This morning, the New York Times has a blockbuster front-page article on how healthy teenagers are misusing stimulants like Adderall and Ritalin, usually used to treat attention deficit hyperactivity disorder, in order to focus on studying and perform better on tests. The story does a fantastic job tracking the personal stories of high school and college kids who use these medicines to get an academic edge.
But it’s worth looking at the science and medicine behind this trend, because it shows how our cultural misunderstanding of what these medicines do is leading to more — and more dangerous — stimulant use. The biggest question is this: how do we as a society decide how we want these medicines to be used?
There is no evidence in the article that this problem is brand new or even that it is on the rise. I remember abuse of these drugs being fairly common ten years ago. A 2006 study based on a 2002 survey indicated that 7 million Americans have misused these medicines. So this is a long-standing problem. And using stimulants to focus certainly dates back further — look at all the benzedrine Sal Paradise and Dean Moriarty took in Jack Kerouac’s On The Road.
The article perpetuates the idea that these drugs calm kids with ADHD down, but have a different effect on health people. Actually, the drugs do exactly the same thing in people whether they are hyperactive, have problems paying attention, or are healthy. They improve focus by increasing the levels of the neurotransmitters norepinephrine and dopamine in the prefrontal cortex, the front part of the brain that regulates attention and behavior. Basically, light that up and everything else gets controlled. But your heart still races.
To get a little technical, here’s an article from Neuropsychopharmacology:
For years, it was assumed that stimulants had paradoxical calming effects in ADHD patients, whereas stimulating ‘normal’ individuals and producing locomotor activation in rats. It is now known that low doses of stimulants focus attention and improve executive function in both normal and ADHD subjects. Furthermore, the seminal work of Kuczenski and Segal showed that low, oral doses of methylphenidate reduce locomotor activity in rats as well.
Often you hear that if stimulants like Ritalin, Vyvanse, or Adderall help people stay calm, that means that they must have ADHD. This isn’t true. These drugs will help anyone focus and pay attention. Giving stimulants to a kid with ADHD is more like giving a child with a learning disability more time on a test — and advantage that might help anybody, but helps that child more — than fixing his brain.
Given that, it’s understandable that kids desperate for an academic advantage would turn to stimulants. Why shouldn’t they?
One reason is safety. The effect of long-term stimulant use on people’s cardiovascular health remains an issue of pretty heated debate. A 2006 article in the New England Journal of Medicine seemed to show an increased risk; A 2011 NEJM study seemed to dismiss them. For the kids who are getting pills from their buddies instead of their psychiatrists, things are more dangerous, partly because they use too much, often snorting them instead of taking them by mouth. It doesn’t take a huge dose of stimulant to increase focus, but a high school kid isn’t likely to ramp up slowly. And these drugs can be addictive.
Another is simply that we as a society don’t like the idea of someone using a drug to get an advantage. It might actually be that in one way the test-takers, not the psychiatric profession, have the right idea about these medicines: maybe they do work best for short-term use, not as a daily pill given over a lifetime. But that still leaves the question of whether people should take medicines with risks and the potential for addiction in order to do well on tests. When is the risk worth it? What if it does result in a better life down the road? A 2008 article in Nature argued that this position is incorrect, and that society need to reject the idea that “enhancement” is a dirty word.
I tend to disagree. I worry that we’re over-using these stimulants, both as a medical treatment and as a performance enhancer. There are other ways to learn to focus. A dose of Ritalin is not the same as a cup of coffee.
But it also often seems we manage to get this one wrong on both sides. The concern that too many people, particularly children, are being pushed toward brain drugs is a real one. So, too, though, is the concern that lots of kids who are illicitly taking stimulants are getting such a big benefit that maybe they should have access to the medicines on a regular basis. There are probably lots of people taking stimulants who should not be, and there also may be many who could use them who are not getting them. It’s the central problem of medicine: the wrong people get a treatment; the right people don’t.
At the end of the day, there’s one culprit that probably can’t take the blame for our confused and contradictory approach to these drugs: the pharmaceutical industry. Shire, the maker of Adderall, and Johnson & Johnson, the maker of Concerta, may have benefited in the past from kids who gave away their pills. But increasingly, these are drugs that are cheap generics that companies will have little interest in promotion. Ritalin, originally made by Novartis, has been a cheap generic for years. If we keep overusing them, we’ll only have ourselves to blame.