ADHD and Amphetamines:
> 3/4/2006 6:04:30 PM

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:
      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:

      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



(g) often blurts out answers before questions have been completed


(h) often has difficulty awaiting turn


(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

  1. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  2. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  3. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  4. 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.

Chart of US states and their prevalence rate for children currently medicated with ADHD





























Rhode Island






South Carolina






South Dakota


































New Hampshire






New Jersey


Washington, DC




New Mexico


West Virginia




New York






North Carolina






North Dakota










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


You may have discussed this previously, but I will ask anyway. I have a friend that is concerned about giving his son medication for AHDH, but other than medication, he has not been given any alternatives. He wonders if it is the easy way out. Are there alternatives? Where do you find them?
Posted by: Amy 3/9/2006 10:32:37 AM

Hi Amy.There is Strattera which is not a stimulant medication. It take longer to work and the dosage needs titrating but it is very effective. Their are many psychotherapy interventions that help children learn strategies to cope with and even take advantage of their ADD symptoms. Steer clear of anyone not clinically trained with a lot of ADD experience. Check out this website for some ideas you look for psychtherapy help you will find it. Good Luck,Dr Hapworth
Posted by: 3/10/2006 8:52:58 AM

Dear All,If you would like to understand the reality of what ADD and ADHD are, before haphazardly prescribing drugs of any kind, and harmful drugs at that, take a close look at a laboratory that knows how to truly uncover the issues and treat them, without causing harm to anyone. More recently called: Genova DIagnostics, it has been known in the past as Great Smokies Diagnostic Laboratory, located in North Carolina. Here is the url that will take you directly to the information about ADD and ADHD: have been a patient of theirs and cannot tell you what a blessing this lab is. You can contact Sue Thornbury there for more information. "Concerned Citizen and Pleased Patient"
Posted by: Shari Hoffman 4/7/2006 9:37:42 AM

During my childhood, I noticed with a lot of concern that I was not able to read out loud in class. My mind would just shut down’ and I read words that were not there. On the other side, I was able to graduate as a mechanical engineer, obtained an A in graduate school and became a simultaneous translator in Mexico City as well as the engineering manager for a tire company.As I grew up I was medicating myself with coffee. I had the same problem at work. For example, on the way to work, my mind would be very clear and I would be eager to go to work. Upon arriving and as people came in, my mind would shut down for several hours in the morning and also in the afternoon. One person, that I did some work for asked me ‘why I was not speaking the Queen’s English’ and said he could not understand me. We this just caused allot of psychological distress. I became very aware of my problem. I concluded that that I was born with the problem and it would not go away. I tried over the years to mention my problems to my various general practitioners. No one believed me. One even threatened to report me to the DMV!Well as luck would have it, I was in my son's doctor’s office reading an article, which explained the criteria for ADD or ADHD. Well when I finished reading this article I suddenly realized that my son and I had the symptoms down to the last line. I was still reluctant to bring this up to my doctor.My son’s doctor started my son on Ritalin (20mgs) a day and stated that he did not have experience with ADD/ADHD and we should look for another general practitioner. Well as luck would have it, we found another doctor for John. He spent three hours with John and we had to fill out about 30 pages of questions relating to my son.The doctor decided that indeed John had ADD. He experimented over a year with various medications and finally finding that the combination of an antidepressant and Dexedrine worked the best for John. With this newfound knowledge obtained during the first visit and my own research. I concluded that I might have ADD also. Fortunately the doctor treated some adults for add. He was a children’s doctor but also treated adults. He specialized on the problems of the mind. Well about 20 years ago, I had two frightening experiences. On the way home from work, I noticed a terrible urge to fall asleep with my eyes open. Finally when I was almost killed by a semi, I decided to seek help.My doctor, when I mentioned what happened sent me to UCLA to see a neurologist. The doctor concluded that I had either ADD/ADHD or Narcolepsy brought on by stress or both. He put me on 20 milligrams of Ritalin and stated that, as with the story of my son, that I had to look for a doctor experienced with the possible two disorders. I chose John'’ doctor since I had confidence in him.I went to my son’s doctor and explained to him my problem of my mind closing down to the point that my ability to process information depended only upon luck at work. I also mentioned that upon filling out 30 pages for my son by my wife independently from me, that I had ADD.Armed with this information and a three-hour visit at which point he also concluded that he could help me. He started me out with 220 mgs of Ritalin, yes two hundred and 20 milligrams per day of the medication. My first day, I was ‘flying’ on the medication. It took less than three days to normalize the effects and my mind was normalized. The side effects disappeared. I was then prescribed Xanax at 2 mgs/day, which helped my anxiety but made me addicted to the medication. I reasoned that I would have to be on it for the rest of my life as well as I did with Ritalin.As a result, for the first time I did not have the urge to fall asleep, not experiencing my mind shutting down and not having the urge to multitask without reasonAfter ten years, I decreased myself to 120 mgs per day of Ritalin without any withdrawal symptoms. I am still on 2 mgs per day on Xanax or it’s equivalents.I am now 61 and still on the medications but with a psychiatrist. I monitor my blood pressure daily for my GP since he discovered what I knew but no one wanted to treat it that my systolic blood pressure would fluctuate tremendously up to 200 inches of mercury. With medications, my blood pressure is around 125/80 inches of mercury.SincerelyJoe
Posted by: Joe 5/31/2006 11:48:21 AM

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