The topic here is prescription Adderall. Specifically: Adderall is too often prescribed badly.
Poorly prescribed Adderall can create negative personality changes in people who seek only to treat their ADHD. Trouble is, they might not see this objectively. Unfortunately, their prescribers often don’t ask—or connect the dots.
The topic is not how to illegally obtain and abuse Adderall. Still, if that is your goal, please read this first. It might save your life.
This is a long post. By necessity. I hope the subheads aid scanning. At the end, I’ll offer a preview of what competent prescribing for ADHD looks like.
You will find other articles on this topic ….now. Mine was first, in 2013, and the only until very recently. The reasons for that might be as disturbing as the Madderall Phenomenon itself.
Let’s get this out of the way:
- Prescription Adderall works very well for some people with ADHD.
- For others, Adderall can create more problems than it solve.
- Poorly prescribed Adderall can create or exacerbate anxiety, irritability, grandiosity, tunnel vision, and even rage.
That’s why 20 years ago I started calling it Madderall.
(Note: I’m seeing the term Madderall has been appropriated to describe combining marijuana and Adderall. That’s not the topic here.)
Here’s what you likely won’t hear from your prescriber:
- Poorly prescribed Adderall can ruin lives and ruin relationships.
- The same is sometimes true for Dexedrine, too. Those of you in Australia, where the the national healthcare system (Medicare) has long considered it the stimulant of choice, be aware.
- Individuals experiencing poor results from Adderall often don’t realize it. They believe it’s the price of long-illusive focus. Their loved ones might, too—while they walk on eggshells, frightened.
- Next stop: These adults with ADHD might develop a cannabis or alcohol or benzodiazepine habit to “come down”.
- Or: They love the intense focus too much to let go— no matter if that focus dangerously reduces self-awareness. (In other words, they assume that everyone else has the problem, not them.)
- Adderall is unique among the stimulants in that it has an extra mechanism of action.
The truly tragic part? There are so many less risky options to try first. Prescribers should be making things better, not worse. From my perspective, this is is a long-running public health crisis. It has contributed to a backlash against the diagnosis itself.
Why Has This Been Allowed?
Why do doctors too often insist on prescribing Adderall to newly diagnosed patients? Especially with so little guidance?
Some prescribers misread a meta-analysis based on old, scant data. I will write about that in a future post. This doesn’t let them off the hook, of course.
Three other reasons:
- Its manufacturer is notoriously aggressive in its marketing and fraudulent in its claims.
This company was fined $56.5M in 2014 for its false claims about Adderall and a few other drugs. Read more at the U.S. Department of Justice website: Shire Pharmaceuticals LLC to Pay $56.5 Million to Resolve False Claims Act Allegations Relating to Drug Marketing and Promotion Practices
Stunningly, far too many prescribers still hew to pharma-rep-supplied claims.
2. This manufacturer has long wielded undue influence over most ADHD websites and personalities you see online. Unfortunately, this includes some psychologists and non-profits, including board members and conference speakers. Most people would be shocked at how this one pharma covertly pushes its warped agenda through so many tentacles. I’ll write about this when I retire.
3, Too many prescribers remain clueless, cavalier, and disconnected from consequences. I don’t say this to discourage seeking treatment! Instead, I want you to be a savvy healthcare consumer.
Yes, prescribers often have little time with a patient. That does not excuse this scandalous mess that is happening with Adderall.
Why haven’t other ADHD experts calling this out? Excellent question.
Conflict of Interest
I was an award-winning journalist before falling into ADHD world, in 1999. As such, I naturally avoid conflict of interest. Good journalists know that even accepting a free lunch is a slippery slope. My “pro-medication” stance was exceedingly rare at that time, when the “ADHD Gift” campaign was going full throttle. Taking Pharma support risked muddying my stance.
I’ve rejected all Pharma support—covert and overt. This fact puts me squarely at odds with certain organizations and outlets. People might ask, “Gina, why aren’t you speaking at this or that conference?” I used to, until I understood what was happening and until this one pharma rose to such stunning dominance. Now, I want no part of it.
To be clear: Researchers receiving pharmaceutical funding is a distinctly different matter. Research validity rests on the researchers’ reputations and methods. And they must disclose such funding. By contrast, most of those proclaiming ADHD expertise online are not researchers. A
Moreover, most “ADHD influencers” don’t even disclose this pharma support. That includes licensed psychologists and physicians. I’ve searched unsuccessfully for disclosure of direct or financial payments. The evidence is more clear when it comes to indirect support. This includes public relations efforts on their behalf and being placed (forever) in prominent positions at ADHD non-profits.
- Treating ADHD is not simple. It is a complex syndrome that affects individuals, not clones.
- Genetic differences among individuals affect drug response.
- Prescribing requires expertise and method. Start low, titrate slow. Rating scales. Third-party feedback. And much more.
- To further complicate matters: Adderall is also a popular drug of abuse. Yet, even the story of “Adderall Abuse” is complicated.
No Adderall-Abuse Tips in This Post
Maybe you found this article while seeking to illegally procure or “hack” Adderall. Sorry to disappoint!
Moreover, when you leave in disappointment after 5 seconds, my blog’s “bounce” rate increases. That’s a big Google-search penalty. That means my post will be less likely to turn up in search results. Especially when a slew of paid and promoted articles top the search list.
I leave this post here anyway. Why? You won’t find what you’re looking for, but you might find something better. Please consider this: Chances are good that you actually have ADHD and are attempting to “self-medicate” it. That never ends well.
Which Search Term Brought You Here?
Mostly, readers find this post legitimately, using terms such as these (to name only a few):
- Adderall makes my spouse angry
- Can Adderall make you irritable?
- Why is Adderall making my ADHD worse?
- Depression and anxiety from Adderall?
- Anger outbursts and Adderall
- Does Adderall change your personality?
- Adderall is spiking my blood pressure?
- Why is Adderall dilating my pupils and making me look crazed?
- Irritable after Adderall
- Can Adderall cause bipolar?
- My husband started Adderall and is an angry jerk now
- Can Adderall cause aggression and sexual behaviors in the elderly?
- Why is Adderall making me tired now, after working for 2 months?
This Post Covers Five Points:
- The New York Times has a long history of anti-psychiatry reporting. This was my initial catalyst in writing this post, in 2013.
- Many prescribers are incompetently treating ADHD. This is having devastating consequences. It’s creating a backlash against ADHD, and it causes many people to just give up. Unfortunately, these seem to be the people who write the “I tried ADHD treatment but it went badly, not I am into mindfulness meditation.” (Another hot topic and also, weirdly, promoted covertly by pharma.)
- Why we might best consider prescription Adderall not as a first try but rather a last-stop in stimulant medications
- The importance of ADHD self-education and self-advocacy
- An excerpt from my first book’s chapters on medication
1. More ClickBait From The New York Times?
A back-channel tip came in yesterday. I steeled myself for the next anti-ADHD screed from the paper.
Many reporters seem to view ADHD as rife for an expose. We who know better see transparently traffic-boosting clickbait. As a young journalist many years ago, I was taught to respect The New York Times as an exemplar of journalism. Sadly, that is no longer true.
Make no mistake: The paper still has respectable editor, reporters, and sections. Yet, the front-page editor for several years demonstrated festering personal antipathy toward neuroscience. That and/or the publisher issued orders based on the website’s analytics. Any piece stigmatizing ADHD tends to draw lots of readers—and therefore ad dollars. For years, the ADHD community protested in comments. Then they just mostly gave up.
Bottom line: It’s an SEO (Search-Engine-Optimization) bonanza! After leaving the paper, former Executive Editor Jill Abramson called it “publishing by the analytics.” It is now pervasive online, with virtually every news outlet, amplified in social media. That goes double for ADHD topics.
Over the years, I’ve called out the paper’s negative targeting of ADHD:
- Talking Back to The New York Times’ ADHD Myth-Mongering.
- The New York Times’ Unnatural Opinions on ADHD
- The Truth Behind “10,000 Toddlers Medicated for ADHD” – Parts 1 and 2.
This Time: More Grief—But Also Tiny Relief
Grief , that yet another person fell victim to prescription Adderall—and died by suicide. Again, this is a legitimate medication that, even though helpful for many people, can create severe reaction (including addiction) in many others.
Relief, that finally The New York Times’ grandstanding front page finally got something right about ADHD. Well, at least in tiny part.
The tiny part is this: The manner in which many prescribers treat ADHD largely resembles a giant game of “Pin the Rx on the ADDer.”
All else in the story, unfortunately, is distortion.. It wouldn’t be former sports reporter Alan Schwarz’s last transparent effort to win a Pulitzer Prize. He didn’t, however, and he’s no longer at the paper. Nor is he still a reporter. But he still inflicted immense, perhaps lasting, damage.
Moreover, he went on to write a horribly sensational book on ADHD. Then, Schwarz featured in a Netflix “documentary” from Maria Shriver and her daughter, Christina Schwarzenegger. It’s called Take Your Pills. It’s a one-two punch castigating Adderall and ADHD, as if they are inseparable. Because, in too many prescribers’ minds, they are.(See Netflix’s Take Your Pills: Anti-Science—and Mean)
2. Core Problem: Poor Monitoring of Prescription Adderall
In the early days of my advocacy, the early 2000s, I heard story after story repeated in my Adult ADHD monthly discussion group in Palo Alto. I heard similar in my online group for the partners of adults with ADHD (ADHD partner). That is, they reported reckless prescribing patterns, particularly around Adderall.
What’s Not Happening, Specifically?
To understand the essential problem, we have to start with poor prescribing protocols for ADHD overall.
—Prescribers should track response
That is, they should be using a checklist of symptoms that helps them monitor medication response—and what side effects it might be creating.
—Prescribers should gather reports from family or close friends
Sometimes folks with ADHD lack accurate self-observation. Typically, this improves with medication. The wrong medication, however, risks further clouding self-observation — and worse.
—Too many physicians don’t bother with either
Instead, they rely on a casual, “So, how is that working for you?”
Poor Prescribing Created ADHD Backlash?
To summarize: The prescribing of any stimulant is often done badly. But the problems with Adderall often appear an order of magnitude more serious.
I credit these poor prescribing patterns for much of recent years’ blowback against ADHD. The fact that I publicly predicted and warned about this years ago — verbally collaring this pharma’s reps at conferences, asking “why aren’t you warning prescribers?” — brings me no pleasure in being right.
But I am just one person—without an “authoritative” MD after my name. (Google now actually penalizes this page because it’s not “reviewed” by an MD. Meanwhile, the plethora of “health” sites scrapes the bottom of the barrel for MDs who will slap their “reviewed by” on the article.)
3. Prescription Adderall Works Great Sometimes
Make no mistake: For some people, prescription Adderall works well and with few side effects. It is the best choice for them.
Yet, prescription Adderall has a higher side-effect profile. What does that mean, in practical terms? It means that if you’re just starting treatment, you might want to begin with a less risky choice. In other words, try Adderall only after other stimulants (Ritalin, Focalin, Concerta, Vyvanse, etc.) have not proven effective.
Ideally, a trial should be given of both the amphetamine and methylphenidate classes, as I explain in my book. There is no way to predict beforehand how you will respond to either class of stimulant. It comes down to genetics.
Despite all that, many physicians routinely start new patients with Adderall—and at too high a dose.
Contributing Problems: A Larger View
The issues around prescription Adderall remain only one piece of a problematic puzzle:
A. Physicians who see ADHD as a “simple condition”
“You just throw a stimulant at it!” one psychiatrist told me at a meeting of the American Psychiatric Association. Obviously, he failed to find ADHD treatment interesting and therefore not worth his study. (I saw him later at a presentation on Borderline Personality Disorder. Hundreds of psychiatrists, on the edge of their seats, listening to dramatic stories. But not one presentation on adult ADHD, which has historically been misperceived as BPD.)
In fact, ADHD is a highly complex condition, especially when it is diagnosed later in life. For example, other conditions can complicate medication response. These include sleep and substance-use disorders.
B. Physicians who believe in a “starting” or “average” dose
“There is no starting or average dose!” I’ve emphasized that in my lectures for years. That’s based on advice from the preeminent experts I respect most. Yet still, that seems the status quo. The trouble with this?
—Some people are slow metabolizers: an “average” dose might be too high for them.
In response to the side effects, they might give up on that medication entirely. Yet, if might be that a lower dose would work just fine.
—Some people are rapid metabolizers: an “average” dose might be far too little for them.
They “burn through it” too fast. They need a higher dose in order to get an average effect.
My scientist-husband and I wrote a 7-part series explaining metabolizing issues and more: Genetic Testing for ADHD Medications.
C. Insurance companies reimbursing poorly for psychiatric treatment
Yes, insurance companies share the blame. They do not reimburse psychiatric treatment at a rate commensurate with the kind of expertise and time required. But physicians are responsible, too.
(If you think that single-payer is the solution, think again. The very worst countries when it comes to ADHD medication options are the single-payer healthcare countries. That includes the United Kingdom and Australia. UK residents are waiting years even for an ADHD evaluation. In Australia, adults cannot get Concerta unless they had a diagnosis in childhood. Very handy, as pediatric ADHD was largely ignored except in the most extreme cases.)
D. ADHD impatience for results—want to “feel” it than objectively measure it
Let’s be frank: Some people with ADHD love Adderall because it feels like booster rockets attached to their behind.
The hard truth is, however, is this: You can’t depend on a “visceral feeling” to tell you when the medication is working. In fact, sometimes you won’t realize that the medication is working—or causing problems. But the people around you will!
Moreover, relying on that visceral feeling almost guarantees a bad end. Maybe not today. Maybe not tomorrow. But soon. What if you’re so strung out you don’t even realize it?
Often, patients (or their parents or partners) consider my cautions only after the fact. Meaning, after the typical crash that happens. For many people, in my observation, that’s about two months into Adderall usage.
That’s when they are completely depleted:
- Typically from exhaustion (why go to sleep when for the first time in your life you have “superhuman” focus?)
- But also perhaps due to Adderall’s unique mechanism of action, their very supply of neurotransmitters might be depleted.
E. Parents’ and Loved Ones’ “Denial” of ADHD
Now we turn back to the NYT story for a moment.
Did Richard Fee, the young man featured in the piece, truly not have ADHD, as his parents claim? Was he simply abusing Adderall as a “performance drug.” I’ve seen no evidence of that. It seemed the weakest point of the story.
Reporter Alan Schwarz repeatedly made it clear that he lacks understanding of ADHD’s complexity. He gives lip service to ADHD as a legitimate condition—and then proceeds to rip it apart.
As a former newspaper editor, I have seen the pattern: “Hot Dog” reporters who will do anything to land on the front page, above the fold. They might have had success on one topic (in his case, starting as a sports reporter, concussions from sports) and fancy themselves a rockstar on all brain-related topics.
Schwarz failed to comprehend that ADHD sometimes had a way of “sneaking up” on people later in life. That’s when their innate intelligence and ability to get by in school without good study habits are no longer enough to let them keep up with their goals.
In other words, it might seem that these people are “abusing” stimulants when really they are seeking help. It might also be that they are suffering from poorly titrated and monitored prescription Adderall.
Could it be that Fee’s parents’ own denial systems came into play here? Perhaps Richard felt that at least these doctors believed him.
F. Prescribers Who Fail to Ask for Third-Party Feedback
Please understand: Richard Fee’s parents have my deepest sympathies. It seems they truly tried to warn the physicians of what was happening to their son.
This story is not new to me. The partners of adults with ADHD try desperately to get through to the Adderall-prescribing physicians. They try explain that their partners are turning into rageaholics. (The ADHD adults themselves seldom report increased anger and ability to their prescribers. They don’t want to lose access to their life’s long-missing focus.)
Yes, there are privacy laws. But that does not mean the prescriber cannot request such feedback—nor cannot accept it.
Did Fee have a condition such as bipolar disorder (either instead of ADHD or co-existing to it)? That is, did he have a particular vulnerability to Adderall abuse or addiction? Or, was that particular vulnerability ADHD? Perhaps he was mis-using Adderall to minimize sleep so he could study more and achieve. Thus, he compounded AHDD with sleep deprivation and amphetamine addiction?
We’ll never know. But I suspect that there were red flags throughout his childhood and young adulthood. And the same will be true of many others.
Rest in peace, Richard.
5. Excerpt: My Book’s Chapter on Medication
Now I’ll share with you now the introduction to my first book’s chapter on medication.
Please know: The last thing I want to do is scare you away from seeking treatment that can vastly elevate your life. Just the opposite! You deserve that.
Rather, I am emphasizing: We consumers must be educated, we must self-advocate.
To lack vigilance is to risk a lot. Please don’t let you or your loved one be another casualty. Don’t be passive, thinking that any licensed professional knows better than you or I do. No one cares more about your or your loved one’s life than you do.
Identifying ADHD symptoms and medically addressing them is not, for the most part, rocket science. It’s not even brain science. It’s step-by-step logic and observation. I will be teaching this in Course 2 of my online training, on medication and sleep. Subscribe to this blog to be notified when it’s online.
Chapter 21: RX Treatment Results That Last
It took Alex two grueling years to convince his wife to seek an evaluation and then treatment for her diagnosis of ADHD.
“Now, who knows how long it will take me to convince her to ditch this psychiatrist, who refuses for no logical reason to prescribe stimulants and find one who actually understands ADHD,” he complains. “My wife is skeptical that I or this support group could know something her psychiatrist doesn’t. But trust me, it’s alarming how little this guy knows.”
Looking back, Alex wishes they’d been far more careful in selecting a physician.
In Jeanette’s case, the irony is that she never found her husband’s ADHD a problem—until after he started medical treatment for it.
“I used to go to bed at night thinking I’m the luckiest wife in the world,” she recalls. “Yes, Mike is lousy at paperwork and he doesn’t remember to take out the garbage (or what day it’s collected!). But he is fun, very goodhearted, and rarely gets angry, and loves being with me and the children.”
Then It All Changed
All that changed soon after Mike learned that he might have ADHD and decided to do something about it. He had recognized in himself the traits he didn’t like in his father. That included poor follow-through on promises. He wanted to do a better job with his own family. “His attitude was, ‘If treatment can help me to be a better person, why not?” Jeanette recalls.
Unfortunately, Mike’s personality changed completely after starting medication.
“I went from this perfect marriage to hating my life and being ready to leave him. The worst part was that he didn’t realize that things were getting worse, especially the anger, until we were in major trouble. As far as he was concerned, his focus was better so that was great. But in reality, his focus was unrelenting.”
Jeanette found the support group’s feedback critical to realizing what was happening. He was probably either on the wrong type of stimulant medication or at too high a dosage. She also learned how to find a more qualified physician and, more importantly, convince Frank that he was turning into a father far worse than his own.
Such stories are way too common for the support group’s comfort.
How Do We Navigate This?
Sure, we want to place our faith in our physicians. Yet, one troubling fact remains. Many physicians, including psychiatrists, are poorly trained to treat Adult ADHD. Some know that and respect their limitations. Some don’t.
It’s important that yo know this going in. Smart ADHD healthcare consumers can avoid common pitfalls and come out a success story.
“My message to those embarking on this journey,” Jeanette says, “is don’t be afraid of medication; it can bring great changes. Just be aware.”
Please know that, prescribing for ADHD is a straightforward issue. In fact, ADHD Partner Survey respondents report that when their partner started taking medication, symptoms improved significantly within:
- Hours (15 percent)
- Days (39 percent)
- Weeks (19 percent)
As Jeanette learned, however, the initial “promise” of medications to smooth out the ADHD roller coaster can soon peter out. Support-group members have agonized over this phenomenon for years.
How These Chapters Can Help
The book’s three chapters on medication will support you and/or your partner in creating your own success story by helping you to:
- Avoid common pitfalls that lead to low treatment adherence.
- Understand that goal setting forms the foundation of successful medication treatment.
- Remember that each person has a unique biochemistry — no cookie cutters!
- Recognize that finding the best medication regiment requires a methodical process.
- Know that ADHD commonly coexists with other conditions, which must be considered in any treatment plan.
If you are familiar with this guidelines, you can better recognize competent care when you encounter it. And when you don’t encounter it? You can either keep moving or, if your choices are few, diplomatically help it along.
For more posts related to ADHD medications:
Visit ADHD Roller Coasters Medications category of posts
For more information on my first book: Is It You, Me, or Adult A.D.D.?
The firs version of this post peaked 2013.
—I welcome your comments.