What is the state of academic performance and achievement in the age of adult ADHD? Recent media publications feature “neuro-enhancement” sought by college students and stressed professionals through the use of prescribed and non-prescribed medications, particularly stimulants, to guarantee focus, concentration and alertness when needed for studying and work demands. It’s as easy as bargaining with a roommate for one of their prescribed stimulant pills for $5. Some campus studies suggest as many as 40% of college students self medicate with non-prescribed stimulants during their college years–in certain settings like fraternities and sororities, it can be much higher. Graduate students certainly partake as well, and that includes medical students.
Approximately 15% of students entering university now have been diagnosed (some very cursorily) with Attention Deficit Disorder and the majority of those students are medicated for their illness. This is a significant increase from twenty years ago when I first started working in a university health center. At that time a diagnosis of adult ADHD was extremely controversial and the incidence of ADHD diagnosis for entering freshmen was less than 1%. In 1991 I attended a college health conference where a Harvard Medical School professor flat out called treating adults with stimulants for ADHD a “clear case of malpractice.” Since then, the diagnosis has gone mainstream in the DSM IV and the criteria are likely to be even more liberalized in the upcoming DSM V revision. Some estimates suggest one in seven adults meet criteria for ADHD. That is a lot of inattention and impulsivity out there. That results in a lot of stimulant out there.
Amphetamines are hardly the new drug on the block. In the 50’s and 60’s they were routinely prescribed for “tired housewives” and became the go-to diet pills to suppress appetite and aid weight loss. My paternal grandmother was one of those tired overweight housewives. She kept a large jar on her kitchen table full of multi-colored capsules that she would pop prior to meals. The appealing looking pills appeared very much like a candy jar to her grandchildren. I remember being warned many times that “those are Grandma’s diet pills and you kids can’t take them because they would stunt your growth”. They didn’t seem to do much for Grandma’s weight problem, but they certainly contributed to her moodiness, anxiety and chronic insomnia, a problem that resulted in prescriptions of sedatives to counteract the stimulant effects. She wasn’t alone in her doctor-prescribed addiction to then uncontrolled substances–thousands of patients were treated with similar drugs that worked at cross-purposes, handed over by well meaning physicians who truly believed they were doing their best to prevent suffering in their patients.
Does that sound anything like the well meaning physicians of today who prescribe stimulants based on “evidence based standards” and “best clinical practices”? Currently the diagnosis of ADHD is difficult to standardize and easy to fake for an adult desperate for that extra edge in a competitive world. No imaging studies have become the gold standard and would bankrupt an already overstretched health care system if they did. Indeed, there are many patients who have legitimate need for the benefit that stimulants offer them–I’ve seen the difference it makes in their chaotic lives. But I know there is no way 40% of college students have legitimate need for stimulants–they are self medicating solely for the extra boost they get from speed. This is no different than the pill popping dieters from the 60’s. And I don’t accept 15% of adults warrant prescribed controlled substances for the rest of their lives. When I see these young adults struggling with insomnia, poor appetite, hypertension, and rapid pulse all thanks to the side effects of their stimulants, it is time to look at other solutions for their learning issues besides amphetamines. Sadly the response from too many doctors is to add on the antianxiety drug, the sleeper, the medical marijuana, the anti-hypertensive. Once again these are well meaning physicians who truly believe they are doing their best to prevent suffering in their patients. It seems we haven’t come far in sixty years. Same overprescribed dependency producing drugs, different diagnostic indications.
It’s time to really take a look at what we physicians are doing in the name of “best clinical practices.” The physical and psychological toll of life long stimulant dependency is clearly understood in street amphetamine addicted patients, what few years they have left because of their snorting and shooting. But we know very little about the ADHD treated individual on routine prescribed amphetamines for thirty, forty, or fifty years or more. In another generation, the health care providers of the future may well shake their heads looking back at our collective ignorance, just as we now shake our heads over the dexedrine- and valium-pushing doctors of fifty years ago.
First, as always, do no harm. It is time to slow down and reduce speed.