Letter to the Editor: Your meds are problematic – Adderall edition

Re: "The Adderall age"

I am a 5th year whose ADHD was diagnosed in June 2017. In what I assume was some sick joke, I got the call to arrange my UofT ADHD assessment the day everyone else in my class was graduating. I had emailed Health & Wellness in February, desperate for help, after years of filling out the same intake forms about basic anxiety symptoms and not being deemed troubled enough. I am absolutely going to die furious over that negligence, but it’s not why I’m writing today.

Nouran Sakr’s recent article about amphetamine use among students without ADHD gets a lot right, but in attempting to educate herself, her “both sides” critical approach does not refute many common stigmatizing misconceptions about the condition and its treatment. These must be addressed.

Despite never having been suicidal, my symptoms resembled severe depression. I couldn’t stay awake in my favourite classes, but had incessant, repetitive daydreams. I had no extracurriculars, dying hobbies, and almost no social life, and couldn’t stop picking at my skin. I lacked the wherewithal to put together emails that made sense, but tweeted fifty times a day. Multiple days a week, I was not organized enough to get up, eat, shower, put clothes on, and then walk outside. Beneath my veneer of laziness was a woman who loves being alive, screaming at herself to move.

The process I am describing is executive dysfunction. ADHD is a disability caused by deficient dopamine signaling. Dopamine’s reputation as a “pleasure” chemical fails to describe its role in performing regular actions like, “I should get a drink and go pee and catch the TTC so that I will not be late to my job and get fired and die”. It’s impulse control. In a person with ADHD, stimulants restore this normal “go” function, so describing how amphetamines induce euphoria at high doses in regular people does nothing to inform people on ADHD.

The implication that people with ADHD are addicted to their meds is false, stigmatizing, and easy to disprove. People with ADHD are twice as likely as the average person to develop addictions, and 14-23% of people with a substance use disorder are thought to have ADHD. Addiction can be an attempt to compensate in the wake of no official diagnosis. Last February, I started taking Benadryl to help me sleep. I know that sounds tame but my symptoms were ruining my life. I knew the risks and I knew it could escalate anyway, because I didn’t want to live in a black hole anymore. What does a person without this knowledge do?

The implication that people with ADHD are addicted to their meds is false, stigmatizing, and easy to disprove.

Treating ADHD with stimulant medication, meanwhile, has been shown to lower this risk of developing addictions by restoring brain function in a controlled manner. It is much more dangerous to people with ADHD, who are already heavily stigmatized, to insinuate its most common and effective treatment method will hurt them. 75-90% of ADHD patients respond positively and safely to either amphetamines or the stimulant methylphenidate (Ritalin). By “positively”, I suggest you reread my symptom paragraph and imagine what it might be like for those to go away. A stranger’s issues with Big Pharma are not worth me living as a corpse.

If all that sounds too scary and dangerous, it’s worth noting psychiatrists do not ignore patient risks related to cardiac conditions or side effects. ADHD does not need to be treated with stimulants in every case. They’re just usually what works.

Therapeutic doses of stimulants aren’t high enough to make you high. I am not sitting around railing 120mg of crushed Adderall or selling pills to desperate overachievers (though given the level of public ignorance, it’s a hilarious prospect). If I stop taking Vyvanse, I stop functioning, not because I’m addicted, but because it’s my medicine. If I don’t eat or sleep enough, it doesn’t even work! Non-ADHDers complaining about focusing on the wrong things on stimulants don’t realize that’s my entire life. They’re tourists. But I don’t blame them; some doctors can’t even recognize ADHD. Countless women go undetected well into adulthood. I was lucky it only took me 22 years.

I got help when I got too angry to care whether a doctor would think I was lying about my symptoms to cheat my way into a 3.3. That shouldn’t be normal. Some students who buy amphetamines illicitly may have ADHD and have merely fallen through the cracks of our broken mental health system. Making people feel ashamed of a possible disability, or scared they’ll be arrested, while not informing them on how ADHD works, is irresponsible. Our illness is not a secret club. I hope I’ve set the record straighter, and I hope any undiagnosed people reading feel seen.

I love my amphetamines and I’m not sorry.

The Adderall age

A student with ADHD explores the science behind ‘study drugs’

The Adderall age

I have ADHD. After receiving my diagnosis a year ago, the first person I told was my mother, who happens to be a physician. She wasn’t nearly as surprised as I was, mainly because my excessive distractibility, impulsiveness, and restlessness could hardly go unnoticed. The need for a diagnosis, however, was masked by my high marks in school, which hit rock bottom when I started at U of T.

When I informed my mum, the first thing she told me was not to take the medications my doctor suggested. “You know [ADHD medications] are highly addictive and classified as a Schedule III drug, right?” she told me. “It’s basically a descent into drug addiction.”

While she strongly advised me to avoid these meds due to their highly addictive nature, the psychiatrist who diagnosed me — and whose opinion I highly valued — was quick to suggest I start taking the medication. He told me that if I followed my prescription exactly, I would be unlikely to form a dependency on it.

Unsure of what to do, I decided to research. After rummaging the internet for hours, I discovered that ADHD medications were commonly abused by students and employees when working under pressure. Curious, I decided to learn what prompted those who don’t have ADHD to take these highly addictive pills.

‘SPEED’ IN SCHOOL

The main type of ADHD medication is stimulants of the central nervous system (CNS), which are also used to treat narcolepsy. Stimulants fall into two main categories: amphetamines and methylphenidates. Amphetamine brands include Adderall, Dexedrine, Vyvanse, and others, while Ritalin and Concerta are common methylphenidate brands.

Since U of T is a competitive and highly stressful environment, I looked to find people who had tried these drugs among my peers. Finding students who had taken ‘speed’ pills at least once was easy, but not many were willing to have their stories published. All the students I talked to had used Adderall, Vyvanse, or both.

Sara*, a fourth-year student, experimented with Adderall twice. The first time, she obtained the pill from her friend’s boyfriend. After keeping it in her wallet for a while, she decided to use it one night when she had to write an essay on deadline. She found she was able to focus on her readings more than usual. “It was a class I really hated,” she said.

It was only the next day that she decided to research the chemical she had ingested the night before.

Unlike Sara, Nate*, also a fourth-year student, did not have a very productive experience with Vyvanse. He tried it in his third year, after his friend suggested it. He decided to test the drug in hopes of finishing his 2,000-word essay the night before it was due. But it was a counterproductive experience. “I was scrolling through Twitter,” he said, “I’d suddenly look up and three hours have passed.”

“I was really zoned out; it was an out of body experience. I was almost too focused. It was too much.”

DIAGNOSING ADHD

In my pursuit of students who had used these pills, it seemed common for people to justify their actions by thinking, ‘Everyone has a little bit of ADHD anyway, so why not just take these meds?’

Dr. Paul Sandor, a psychiatrist at Toronto Western Hospital and a professor in the Department of Psychiatry at U of T, was quick to contest this belief. “Although some people have the ability to stay on task [and are] not distracted for long periods of time, others may be less so, but still within normal limits.”

The diagnosis of ADHD requires that symptoms impair normal activity and have been present for a long time in more than one setting. A student who recently started to notice an inability to focus in a classroom does not necessarily have ADHD.

Dr. Michelle Arnot, an associate professor who teaches a course about drug misuse in society and the Undergraduate Coordinator at U of T’s Department of Pharmacology and Toxicology, agrees. She said that a little inattention is normal, adding that our bodies are not designed to “sit in front of a screen for five hours.” However, she mentioned that people with ADHD have trouble controlling their attention or behaviour even when they want to. Arnot believes that drug therapy is only acceptable if there is a significant impairment or an inability to control behaviour and pay attention, and a formal diagnosis has been received.

YOUR BODY ON ADHD DRUGS

In your brain, neurons communicate with one another by releasing chemicals called neurotransmitters. Dopamine and norepinephrine are two neurotransmitters whose release is affected by ADHD medications. Amphetamines inhibit and sometimes reverse the reuptake of dopamine and norepinephrine; as a result, communication between these cells is prolonged.

Feeling anxious on amphetamines is not uncommon, and most of the students I talked to also reported a loss of appetite, sleeplessness, and an increased heart rate. In addition to the CNS, amphetamines also stimulate the sympathetic division of the peripheral nervous system, which is responsible for the fight-or-flight response. As a result, the body is tricked into thinking that it needs to respond to a life-threatening situation — blood vessels tighten, heart rate increases, and blood flows to the limbs. The digestive and urinary systems are also suppressed.

Once the drug is out of their system, a person starts to experience withdrawal effects, which are the opposite feelings they had on the drug. For amphetamines, sleepiness and agitation are common.

Kalai*, who took 10-milligram pills of Adderall throughout his first year as a Life Science student, said that the day after he took Adderall, he felt anxious, sluggish, and unmotivated. His withdrawal symptoms would disappear around two days after taking the pill.

A DANGEROUS DEPENDENCE

With time, a person on amphetamines may become desensitized to the dose they’re used to taking and need to increase it to achieve the same effects. This tolerance is one of the three aspects of drug dependence. The other two are the ‘reward pathway’ and the speed of the drug’s onset and offset.

The reward pathway is a dopamine pathway that involves the mesolimbic system of the brain — an area that reinforces learning and behaviour. Food and sex are both activators of the mesolimbic system. “It is important because it provides a sense of euphoria,” said Arnot. “It makes us want to do something again.”

“I don’t like to use this term but drugs ‘hijack’ that pathway,” she explained. The artificial increase of dopamine in the space between neurons caused by amphetamines and other stimulants results in an above-average euphoria, which the brain associates with this drug. As a result, the person may seek this ‘high’ again by taking more of the drug.

Additionally, the speed at which the drug reaches and affects the brain — called the onset of the drug — is a factor that affects the potential of addiction. The faster this euphoria is achieved, the more addictive the drug will be. For example, injected heroin has a faster onset and offset than methadone taken orally because it goes straight into the bloodstream rather than the digestive system. Thus, due to its very slow onset and offset, methadone has a lower abuse liability.

Vyvanse has a duration of 10–12 hours. It has an onset of two hours, meaning that its speed is slower than Adderall, which has a duration of only four to five hours and an onset of 30 minutes to an hour. When injected, methamphetamine — or meth — has an onset of a few seconds to a minute and is the most addictive of its drug family.

Although Vyvanse and Adderall XR — a version of Adderall that lasts approximately 12 hours — have slow onset and offset speeds, they are still controlled substances and have adverse effects at high doses. They may cause psychotic episodes, insomnia, and cardiovascular complications.

Since they may be fatal for people with cardiovascular diseases and other medical conditions, a physician should know a patient’s medical and family history, especially pertaining to strokes, hypertension, hyperthyroidism, heart and blood circulation diseases, seizures, substance use disorders, and mood or mental disorders. Medical tests must also be conducted before prescribing these drugs. Without the consent of a physician, taking Vyvanse or Adderall can be extremely dangerous for someone whose family has a history of medical conditions.

“There’s a lot of energy spent right now looking for that magic nootropic, cognitive enhancer, whatever you want to call it,” said Arnot. Amphetamines are studied because of their ability to increase dopamine and norepinephrine between neurons in the areas of the brain responsible for controlling attention, memory, and learning. Research suggests that amphetamines have no significant effect on the performance of people without ADHD. Although they slightly increase alertness and focus, they have mild to moderate impacts on memory.

Arnot said that the results may also have been linked to a placebo effect. “If you took [the drug] and thought you were going to do well because of taking it, you did better than if you think you were getting the null drug.”

Amphetamines also shorten the rapid eye movement (REM) stage of sleep. REM is crucial for forming and consolidating memory. Due to its sleep-altering ability, this agent is used to help students stay up at night to cram for a test or finish an essay. “It doesn’t suppress the need [for sleep], it artificially stimulates the release of neurotransmitters which overrides those driving forces of sleep,” emphasized Arnot. As a result, the misuse of amphetamines is counterproductive and worsens memory.

UNDERSTUDIED AND OVERRATED

I was surprised to learn that the Centre for Addiction and Mental Health (CAMH), Canada’s largest mental health and addiction teaching hospital and one of the world’s leading research centres in its field, had not conducted any research specifically relating to the impacts of ADHD medications as cognitive enhancers among students. I contacted them to ask for any Canadian studies on this topic, but there weren’t any.

“That would be part of the problem,” said Sean O’Malley, Senior Media Relations Specialist for CAMH. “I think it’s just an understudied issue.” The Canadian Centre on Substance Use and Addiction also had no experts to speak about stimulant misuse among university students.

Besides the obvious health disadvantages associated with taking Adderall, Vyvanse, or other stimulants to advance studies, consuming these substances without a medical reason is not as effective or appealing as it might seem. Methylphenidates are classified as Schedule III drugs in Canada. They have a high potential for abuse and may lead to severe psychological and physical dependence.

According to the Controlled Drugs and Substances Act, and depending on the specific drug, possession of amphetamines or methylphenidates without a prescription or license is an indictable crime and may result in up to seven years in jail, while offenders found trafficking, importing, exporting, or producing these drugs could receive life imprisonment.

While the urge to cram in some extra study time may be strong, science is saying that these drugs don’t improve performance for non-ADHD brains, are dangerous for your health, and are illegal — the cons far outweigh the pros.

* Names have been changed at individuals’ request