Wanting a drug isn’t the same as needing it
It’s 2am here in Pittsburgh, Pennsylvania, and I’ve just finished writing 7,500 words of corporate marketing copy. I then turn my attention to this piece. But my attention is glitching. So, I do something I haven’t done since I took the Pennsylvania bar examination in 2007: I take one of my wife’s bright orange 20 milligram Adderall pills. My jumbled thoughts settle and everything, as the Scientologists might say, goes “clear”.
Neither my wife nor I use Adderall with any regularity. A 60-count “break-in-case-of-emergency” supply might last the Bateman family ‘til death do us part. But the same cannot be said for millions of others who are reliant on the drug: since last August, the world has experienced a shortage of Adderall. This is probably tied to manufacturing and supply chain issues combined with rapidly increasing demand — though nobody knows for sure. It has had a particularly acute effect on the US. A high-income country of 330 million people is bound to have an outsized impact on world affairs. But the numbers related to Adderall beggar belief. America consumes 80% of the drug’s global supply. Back in 2013, there were 18 million Adderall prescriptions in circulation in the United States — a number that exploded to 41.4 million in 2021.
These statistics can be partly explained by another equally astonishing set, relating to the condition for which Adderall is prescribed. According to the US Centers for Disease Control and Prevention, 6.3% of US children aged 5-9 have ADHD, compared to 1.5% of UK children aged between 6-8. Some attribute that to differences in diagnostic principles. The criteria used in the US are considerably more detailed, allowing for diagnosis only if at least five symptoms are present, whereas the globally-accepted standard gives more leeway to the clinician, only stating that symptoms should be “sufficient in number” and cause “significant psychological, social, educational or occupational impairment”.
When I asked one therapist why this leads to a much higher number of ADHD diagnoses in the US — rather than the opposite — she pointed to the laws governing education. Here, the Individuals with Disabilities Education Act mandates that schools provide special education services and accommodations to students with ADHD, while in the UK, there’s no specific legislation for ADHD, and schools have more flexibility to support students with diverse learning needs without a formal diagnosis. American doctors know that parents and students need this diagnosis for paperwork purposes, so they, to borrow a line from Jean-Luc Picard, “make it so”.
In other words, an ADHD diagnosis opens a lot of doors in the US. If you know what to say, it’s not hard to get Adderall. And there are plenty of reasons to want Adderall. It significantly improves cognitive function, increases wakefulness, and enhances mood — temporarily turning poor learners into decent ones, and good ones into rock stars. Longer-lasting than other ADHD drugs like Ritalin, Adderall offers that intense “clear” feeling I mentioned, resulting in higher levels of focus, attention, and motivation.
These stimulants can improve, among other things, performance on various standardised tests that (at least for now) still have an outsized impact on admission to the most prestigious academic programmes. Unsurprisingly, there’s plenty of evidence that rich parents and their kids are working with willing doctors to secure easy access to Adderall, and other so-called “smart drugs”. A 2016 study found that 10.7% of high school students who had used Adderall in the past year had obtained it from a doctor. Meanwhile, 13.2% had obtained it from a friend or family member, indicating that these drugs circulate widely in certain academic and social circles — a fact many of us may know all too well.
I’ve watched a number of friends and relatives game the system to receive legal prescriptions for ADHD, visiting physicians and uttering the magic words needed to meet diagnostic criteria. Their motivations varied: one cousin likes to be “amped up” on stimulants at all hours of the day, while a friend from college uses it to improve his performance as an esports athlete. And I’m willing to admit that the drug has benefited me in small and very infrequent doses. But there are obvious ethical concerns here. Adderall, like Ozempic (for weight loss) or testosterone (for muscle building), gives some people an unfair advantage over others.
The US Drug Enforcement Administration acted last month to rein in what some now consider a “Wild West” environment. Adderall prescriptions in the US rose 16% during the pandemic, with telehealth appointments a main driver. The DEA’s proposed rule would require at least one in-person visit to the physician prescribing controlled substances such as Adderall. But it faces stiff resistance from clinicians and users, who argue that remote consultations increased access to life-changing medications. People whose lives and identities are tied up in ADHD have been lamenting that their condition, defined by an inability to focus without Adderall, becomes doubly hellish when they’re required to actually go somewhere to get prescriptions filled; the complaint of one legal aid attorney, representative of thousands of others, was that the “nationwide adderall shortage means I skipped my doses this weekend and f*cking fought for my life to do the dishes”.
And yet, the rate at which Adderall is prescribed in the US must mean that the majority of diagnosed cases of ADHD are not life-destroying, merely life-affecting. Moreover, even long-tenured experts on ADHD, including Remembering Ritalin author Lawrence Diller, have serious qualms about the “realness” of the “disease”. In his book, Diller reflects on the various young patients — “Generation Rx”, he calls them — with whom he worked during the Eighties and Nineties, probing the extent to which ADHD is a legitimate diagnosis or an oversimplified, harmful label that could be applied to anyone in certain conditions. “For patients, if ADHD truly exists, risking their health by taking a drug to treat the condition or disease makes a lot more sense… [but] if it doesn’t exist, then perhaps they’re just using it as a crutch… and setting themselves up to abuse it,” he writes. Adderall, like other stimulants, presents numerous dangers: side effects that run the gamut from high blood pressure, increased heart rate, panic attacks, psychosis, agitation and irritability. And of course, there’s the horrific feeling of crashing when one doesn’t have regular access to the stimulant.
Diller’s concerns are echoed by my neurologist acquaintance. ADHD, like most diseases of the mind, are “all in one’s head”: the symptoms are not verifiable by any methods beyond the claims of the patient. Physicians have a duty to take these claims seriously, but it’s difficult to gauge the roots of a symptom from the outside. Is lack of concentration, far from being a “disease”, merely a sign that someone is a poor student — a sad but unavoidable fact of life that one must confront in the ordinary course of existence? And if so, would liberally prescribing this now-scarce drug be the ethical thing to do? Or would that be unfair on those who use Adderall to get through the day, rather than excel?
These are loaded questions, but important ones. In response to the Adderall crisis, the media has pumped out nuts-and-bolts policy proposals. A recent New York Times column, for instance, argued for maintaining full telehealth physician availability and boosting Adderall production by shifting regulation and oversight from the DEA — which is primarily interested in drug interdiction — to the FDA — which is more concerned with drug safety and access. There is certainly much to recommend such arguments. The libertarian, “government is the problem” side of me favors wide latitude with regard to drug access, but that doesn’t acknowledge the core cultural questions fueling all of this feverish pill-popping.
It’s hardly surprising that increasing numbers of people are struggling to concentrate. We are bombarded with stimuli, which naturally leads to difficulty focusing and increased impulsivity in day-to-day life — symptoms of ADHD — and the subsequent prescription of Adderall. If assigned, a diagnosis can become a core plank in an individual’s sense of self; as Freddie deBoer has written for UnHerd, our very online culture encourages people to turn diagnoses into identities. Viewed this way, Adderall’s is a toxic, “ouroborotic” cycle of consumption — the culture fosters the behaviors that result in an ADHD diagnosis, Big Pharma sells you the medication needed to address it, and the various social media platforms that monetize your freely-provided content offer you space to earn attention by #ShoutingYourStigma.
Are you your disease — as a young influencer might proclaim on TikTok — and therefore entitled to Adderall access as some sort of fundamental human right? By extension, is someone who has the attention span of a feral cat that’s locked onto its prey not entitled to this “smart drug”? Or should everyone have access to Adderall, since it’s a tool that might encourage further human flourishing, before we’re forced to insert neural implants and merge with AI? Or should no one, since our “human essence” is sacred and must remain unsullied by chemical interventions?
These are the questions we will need to answer. But for now, all we can be sure of is that fewer people will get Adderall, particularly cheaper generic-brand Adderall, than want it. Those that do will probably be the richest — who may use it to get richer — rather than those who most need it. We can only hope that these dynamics will encourage us to reflect on whether wanting and needing, like our illness and ourselves, are inextricably linked, or merely connected because “thinking makes it so”.