In the United States of Adderall

The current national Adderall shortage has inadvertently brought to the nation’s attention the potential over and misdiagnosis of attention deficit hyperactivity disorder (ADHD) and the possible over-prescription of Adderall and similar medications like Ritalin, Concerta, and Vyvanse, all prescription stimulant drugs.

As an M.D., who wrote his first Ritalin prescription in 1978, I’ve never been against using these medications in children. But beginning in the mid-1990s, when doctors began prescribing these drugs to adults, I grew concerned because I had studied the history of these substances here and throughout the world.

Since its synthesis in 1929, amphetamine, the active ingredient in Adderall and Vyvanse, and its virtually identical twin, methylphenidate (in Ritalin and Concerta) cycled through new indications (in the past used for problems as varied as asthma, depression, and obesity). Misuse, abuse, and addiction problems invariably followed, so much so that ultimately the cycle ends with society rejecting these medications (usually due to tightened government regulations and high negative publicity).

The Adderall shortage highlights the great demand for these products in our country. American manufacturers of prescription stimulants must apply for an annual production quota from the Drug Enforcement Administration (DEA) by law because these drugs are categorized as Schedule II (the strictest control for legally prescribed drugs). In 2022, the DEA approved a total of 133,525 kilograms or about 31 tons of legal stimulants for the U.S. This translates to 405 mg. of the stimulant drug for every man, woman, and child in America (or about 20–20 mg. Adderall pills).

This may seem like a lot of legal speed. It is–if you also compare American use rates of prescription stimulants to other developed countries. The U.N.’s International Narcotics Control Board (INCB) maintains annual consumption data of countries signatory to a 1972 treaty. Thus in 2020 (the last year of data collected), the average German used 4 percent of what Americans used daily, those in the United Kingdom, 3 percent, and France, 2 percent.

There are now 30 different varieties of prescription stimulants available in the U.S. There are different lengths of action ranging from three to sixteen hours. They come as pills, capsules, different chewable tablets or liquids flavors, and even a transdermal skin patch. Most other countries get by with only five varieties, a short and long-acting generic amphetamine and methylphenidate pill, and lisdexamphetamine (Vyvanse).

There are many reasons for this vast difference in how these Europeans and Americans cope with attention, distractibility, and performance. But we as a nation should be concerned because the dark side of our current use of prescription stimulants is the misuse, abuse, and addiction problem.

The National Institute on Drug Abuse (NIDA) was the last agency to closely examine the stimulants in 2015-2016. Sixteen million adults (6.6 percent of American adults) had tried a prescription stimulant. Five million had obtained the medication illegally (1.9 percent). Four hundred thousand (0.2 percent) met the criteria for abuse and addiction. Rates for all three categories were higher in the 18-29 year age group.

Maybe only 400,000 people with a substance use disorder doesn’t sound like much. At the time, this was about a quarter of those who reported prescription opiate addictions. But since then, in the wake of the opiate crisis and the consequent negative publicity, opiate prescriptions have plummeted. In contrast, prescription stimulants have greatly risen (a 10 percent increase in just the past year).

A historical inevitability will likely create a major backlash to Adderall and the diagnosis of A.D.H.D. that will also affect its use in children, which paradoxically is safer than in adults. Children don’t have access to the medication and don’t like the higher dosages. They complain and say, “I feel weird.” Adults can access their pills and say, “I feel grand,” when taking higher dosages. I don’t know what it will take for America to wake up to this growing public health crisis. Certainly, please not more Adderall.