A cursory glance at Google search results shows that Attention Deficit Disorder is getting more attention than Anxiety, but not as much as Depression . This is a relative measure of the magnitude of concern and preoccupation about this disorder. Recent FDA data estimate that about 2.5 million children and 1.5 million adults are now taking stimulant medications during any 30-day period, presumably mostly for ADHD. During a public meeting on February 9, FDA officials told members of the Drug Safety and Risk Management Advisory Committee that data show that between 1999 and 2003, 78 million prescriptions were written for ADHD medications for children under 18 and 14 million were written for adults. By contrast, in the 12-year period from 1992 to 2004, 190 million prescriptions for ADHD medications were written for children and adults. ADHD is obviously big business for all those involved in its evaluation and treatment.

The dark side of this trend is that the treatment of choice for this disorder is a group of DEA Class II drugs that are either amphetamines or derivatives of amphetamines. For me the acceptance of these drugs as the “drug of choice” for treatment of the syndrome of ADHD is a disturbing national trend. The most disturbing part is the lackadaisical approach our health care leaders have chosen regarding this use of addictive drugs to treat what has become an epidemic of attention deficit disorder.

When you consider that amphetamines would improve anyone’s performance you don’t have to wonder why these drugs have been selected to treat anyone with the broad range of problems of attention deficit disorder that are diagnosed by the following DSM IV diagnostic criteria:

Either (1) or (2):

1. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
   Inattention
1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities
2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
   
   Hyperactivity
1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
4. often has difficulty playing or engaging in leisure activities quietly
5. is often "on the go" or often acts as if "driven by a motor"
6. often talks excessively

Impulsivity

2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

It is in the realities of ADHD treatment when problems arise. Many studies have demonstrated the benefit of amphetamine treatment.  The willingness of parents and increasingly now adults to enhance scholastic or work performance is a given when one considers the irresistible promise that is made by these results. The trouble with this approach is, in my opinion, similar to prescribing benzodiazepines to patients suffering with anxiety. You are surrendering a patient’s capacity to change by addicting them to the transitory pop of a habit forming drug to treat what ails them. These addictive drug solutions dismiss the powerful capacity that the brain has to reorder its own priorities by the experience of trial and failure and to use the deficits we are born with to reinvent and overcome our inferiorities.  The fact that we prescribe these drugs in childhood and often do so without concomitant psychotherapeutic interventions should further concern all of us. 
 
I used to see patients who have been on amphetamines since childhood who are concomitantly abusing alcohol and other substances. Very often they are uniformly enraged and unwilling to consider other treatment alternatives for their symptoms. I now approach this problem in our New York Center by phone screening these patients and asking them if they are willing to stop amphetamines and look at alternative treatments. They rarely take me up on the offer.

When you consider that a bottle of Adderall can sell illicitly for over $50 on college campuses, you have to be somewhat concerned that sales of Adderall XR grew by 30 percent to $283 million for the first six months of the year, according to company reports. Shire expects the market to keep growing, citing a 1999 federal study that shows that while 8.2 million American adults have attention deficit disorder, only 360,000 receive treatment. It is anecdotally clear that students are using these drugs, selling them and giving them away to friends to enhance performance and write papers etc.

The psychiatric research community also needs to spend more time evaluating what happens to children who have been on these amphetamines for many years. Little to no research exists on the long-term outcomes regarding concomitant substance abuse later in life and what effects the use of these drugs have on brains of users, especially on the limbic and dopaminergic rich areas of the brain. There is strong brain scan evidence that methamphetamine inflicts serious long-term damage to the brains of abusers. Yet fMRI and PETT scanning have not been used to prospectively follow children meeting ADHD diagnostic criteria prior to amphetamine treatment by creating double blind placebo controlled groups and determine in follow-up scans what potential damage these drugs are doing to our youth.

The problem of these drugs on campus is not being surveyed in any coherent manner but here are some results from small studies that should present some alarm:

• A quarter of college-age students have tried stimulants such as Ritalin or Adderall without prescriptions, said Dr. Tim Wilens, a psychopharmacologist at Massachusetts General Hospital.

• Four percent of college students have tried amphetamine compounds, 7 percent Ritalin and 24 percent both types in a survey of undergraduates at Bates College in Lewiston, Maine.

• A fifth of the students prescribed Adderall abused the drug, shared it with friends or sold it, according to a survey of students at the University of Wisconsin-Madison.

• Nearly 5 percent of college students in 2003 said they had tried Ritalin without prescriptions in the previous 12 months, according to the annual, federally financed Monitoring the Future study conducted by the University of Michigan. Abuse among college students was nearly twice that of nonstudents of the same age.
  

The fact that even the new director of the NIDA, Dr. Nora Volkow, has to justify the usage of  slow uptake amphetamine preparations as a better alternative to fast uptake amphetamine only serves to highlight the paradox that the voice of our national drug abuse agency is arguing that this or that preparation of amphetamines is better or worse. Frankly, the Church of Scientology and Tom Cruise make more sense on this issue than the following quote from Dr. Volkow in this month's American Journal of Psychiatry:
“On the basis of these findings from basic research over the past decade, preparations of methylphenidate or amphetamine that lead to slow rates of brain uptake as well as those that cannot be snorted or injected are predicted to have less abuse liability. The paper by Spencer and colleagues in this issue of the Journal provides evidence that even for oral formulations of stimulant medications, delivery by systems that lead to slower rates of release will be less reinforcing than delivery that leads to faster rates of release.”  

I can’t be the only psychiatrist alarmed by this trend. I am at least comforted by the inspired courage that the recent FDA panel took in recommending a black box warning of amphetamine drugs.The following statements from the panel comes as a breath of fresh air:

“A panel of Food and Drug Administration (FDA) advisors last month voted 8 to 7 (with one abstention) to endorse a recommendation for a black-box warning regarding cardiovascular adverse events on the labels of all stimulant medications used to treat attention-deficit/hyperactivity disorder (ADHD). Several advisors said they voted for the warning not because they were particularly worried about safety issues relating to the potential of increased risk of heart attack, stroke, and sudden death, but because they were alarmed about the recent sharp rise in the number of prescriptions for the medications written for both children and adults.”

I particularly credit Dr. Steven Nissan from the Cleveland Clinic for his courage to state the following:

"I want to cause people's hands to tremble a little bit before they write that prescription" for an ADHD medication, said Cleveland Clinic cardiologist Steven Nissen, M.D., a consultant to the advisory committee. Indeed, it was Nissen who suggested the committee consider endorsing a black-box warning because he saw a need "to slow the growth of utilization."

I totally concur with this Cardiologist’s statement and I encourage the research community to define what may be happening to our youth with scientifically sound studies that truly define the risks of these prescriptions to our precious youth.

Percent of Youth 4-17 ever diagnosed and currently medicated for Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2003