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 andpreoccupation about this disorder. Recent FDA data estimate that about2.5 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.

Thedark side of this trend is that the treatment of choice for thisdisorder is a group of DEA Class II drugs that are either amphetaminesor derivatives of amphetamines. For me the acceptance of these drugs asthe “drug of choice” for treatment of the syndrome of ADHD is adisturbing national trend. The most disturbing part is thelackadaisical approach our health care leaders have chosen regardingthis use of addictive drugs to treat what has become an epidemic ofattention deficit disorder.

When you consider that amphetamineswould improve anyone’s performance you don’t have to wonder why thesedrugs have been selected to treat anyone with the broad range ofproblems of attention deficit disorder that are diagnosed by thefollowing DSM IV diagnostic criteria:

Either (1) or (2):

1. six(or more) of the following symptoms of inattention have persisted forat least 6 months to a degree that is maladaptive and inconsistent withdevelopmental level:
   Inattention
1. oftenfails to give close attention to details or makes careless mistakes inschoolwork, 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. oftendoes not follow through on instructions and fails to finish schoolwork,chores, or duties in the workplace (not due to oppositional behavior orfailure to understand instructions)
5. often has difficulty organizing tasks and activities
6. oftenavoids, dislikes, or is reluctant to engage in tasks that requiresustained 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 havepersisted for at least 6 months to a degree that is maladaptive andinconsistent 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. oftenruns about or climbs excessively in situations in which it isinappropriate (in adolescents or adults, may be limited to subjectivefeelings 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. Thesymptoms do not occur exclusively during the course of a PervasiveDevelopmental Disorder, Schizophrenia, or other Psychotic Disorder andare not better accounted for by another mental disorder (e.g., MoodDisorder, Anxiety Disorder, Dissociative Disorder, or a PersonalityDisorder).

Itis in the realities of ADHD treatment when problems arise. Many studieshave demonstrated the benefit of amphetamine treatment.  Thewillingness of parents and increasingly now adults to enhancescholastic or work performance is a given when one considers theirresistible promise that is made by these results. The trouble withthis approach is, in my opinion, similar to prescribing benzodiazepinesto patients suffering with anxiety. You are surrendering a patient’scapacity to change by addicting them to the transitory pop of anaddictive drug to treat what ails them. These addictive drug solutionsdismiss the powerful capacity that the brain has to reorder its ownpriorities by the experience of trial and failure and to use thedeficits we are born with to reinvent and overcome our inferiorities.  Thefact that we prescribe these drugs in childhood and often do so withoutconcomitant psychotherapeutic interventions should further concern allof us. 
 
I used to see patients who have been on amphetaminessince childhood who are concomitantly abusing alcohol and othersubstances. Very often they are uniformly enraged and unwilling toconsider other treatment alternatives for their symptoms. I nowapproach this problem in our New YorkCenter by phone screening these patients and asking them if they arewilling to stop amphetamines and look at alternative treatments. Theyrarely take me up on the offer.

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

Thepsychiatric research community also needs to spend more time evaluatingwhat happens to children who have been on these amphetamines for manyyears. Little to no research exists on the long-term outcomes regardingconcomitant substance abuse later in life and what effects the use ofthese drugs have on brains of users, especially on the limbic anddopaminergic rich areas of the brain. There is strong brain scanevidence that methamphetamine inflicts serious long-term damage to thebrains of abusers. Yet fMRI and PETT scanning have not been used toprospectively follow children meeting ADHD diagnostic criteria prior toamphetamine treatment by creating double blind placebo controlledgroups and determine in follow-up scans what potential damage these drugs are doing to our youth.

Theproblem of these drugs on campus is not being surveyed in any coherentmanner but here are some results from small studies that should presentsome alarm:

• Aquarter of college-age students have tried stimulants such as Ritalinor Adderall without prescriptions, said Dr. Tim Wilens, apsychopharmacologist at Massachusetts General Hospital.

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

• Afifth of the students prescribed Adderall abused the drug, shared itwith friends or sold it, according to a survey of students at theUniversity of Wisconsin-Madison.

• Nearly5 percent of college students in 2003 said they had tried Ritalinwithout prescriptions in the previous 12 months, according to theannual, federally financed Monitoring the Future study conducted by theUniversity 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  slowuptake amphetamine preparations as a better alternative to fast uptakeamphetamine only serves to highlight the paradox that the voice of ournational drug abuse agency is arguing that this or that preparation ofamphetamines 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."

Itotally concur with this Cardiologist’s statement and I encourage theresearch community to define what may be happening to our youth withscientifically sound studies that truly define the risks of theseprescriptions to our precious youth.