The brain on steroids: Abuse of prescription stimulants
This post reviews prescription stimulants, especially stimulants prescribed for those diagnosed with ADHD, for the use of enhancing brain functioning in healthy individuals. As the availability of stimulants has increased so has the abuse. The abuse has also lead to further research by investigators at universities and drug companies. A new wave of brain research is underway to enhance the functioning of those with a psychiatric diagnosis and those without.
Adderall and Ritalin are central nervous system stimulants that affect the brain and nerves that contribute to hyperactivity and impulse control. These drugs, along with psychotherapy, are generally used in the treatment of Attention Deficit Disorder with Hyperactivity (ADHD). ADHD is a developmental disorder typically first identified in childhood that has been demonstrated to persist into adulthood (Brown & Rosa, 2002). It is a disorder of inadequate response inhibition, a problem of performance (not skills) and of inconsistency (not inability) (Goldstein & Naglieri, 2008).The prevalence of the disorder is estimated to range from 2% to 18% in US children and adolescents (Meaux et al., 2006). Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity) (NIMH, 2008). Children often struggle with following through on their homework and can be disruptive during classroom activities. As ADHD persists into adulthood many adolescents and young adults are may become discouraged by doing poorly in school. Teens may choose tasks or activities that have a quick payoff, rather than those that take more effort, but provide bigger, delayed rewards, thus they may struggle with school and other activities in which they are expected to be more self-reliant (NIMH, 2008).
Although hyperactivity tends to decrease as a child ages, teens who continue to be hyperactive may feel restless and try to do too many things at once. Furthermore, daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD (NIMH, 2008). The most common and frequently prescribed psychotropic drugs for ADHD are stimulant medications. Between 1987 and 1996, the overall annual rate of prescription stimulant medication use by children and adolescents increased over 250%, from 1.4 per 100 persons to 3.9 per 100 persons (Meaux et al., 2006). Results from double-blind, placebo controlled studies have consistently demonstrated that stimulants are superior to placebo in decreasing hyperactivity and impulsivity and increasing attention in individuals with ADHD (Brown & Rosa, 2002). The stimulant medications are believed to exert their action through the enhancement of dopamine and norepinephrine neurotransmission, although the precise mechanism of action is unknown (Brown & Rosa, 2002).
Adderall is a short-acting dextroamphetamine. Adderall is frequently and effectively employed in the clinical management of children with ADHD short-acting dextroamphetamine agents have increased in popularity due to ease in once-daily administration, which enhances adherence and decreases the stigma associated with twice-daily dosing at school (Brown & Rosa, 2002). The only long-acting preparation of amphetamine is Adderall-XR. The delivery of Adderall-XR is unique because it allows for delivery over the course of 12 hr (Brown & Rosa, 2002).
The effects of the stimulants are exemplified through the of sustained attention, impulsivity, and over activity. Laboratory tasks as well as on parent and teacher ratings show these impressive effects (Brown & Rosa, 2002). There is also evidence suggesting that the stimulants can enhance academic productivity and performance, decrease aggressive behaviors in the short-term, and improve social skills, peer relationships, and even mother-child interactions (Brown & Rosa, 2002).
Although evidence supporting stimulants for ADHD appear impressive there are short-term adverse effects that include: insomnia, anorexia, nausea, abdominal pain, headaches, lability of mood, anxiety, nightmares, weepiness, tachycardia, and blood pressure changes (Brown & Rosa, 2002). The long-term effects typically include the possibility of weight loss or stunting growth, adverse cardiovascular effects, and drug dependence or abuse (Brown & Rosa, 2002). The efficacy and safety of stimulants has been proven by extensive data and some medical doctors have concluded that stimulants are perhaps underutilized in the management of children and adolescents with ADHD (Brown & Rosa, 2002). However, research indicates that fewer than one in five children who are prescribed stimulant medication for ADHD continue taking the medications beyond 1 year (Meaux et al. 2006). Some may conclude that ADHD is over diagnosed and stimulants are inappropriately used for many children. As the debate over whether or not stimulants are overly prescribed to those suffering from ADHD, a new debate has arisen: should those without ADHD be allowed to use (or abuse) prescription ADHD medication-Adderall or Ritalin-recreationally? Twenty-six percent of college students surveyed admitted using prescription stimulant medications illicitly for academic and recreational reasons (Meaux et al. 2006). Illicit use of prescription stimulant medications on college campuses is second only to marijuana and is thought to be a “gateway” drug to cocaine and methamphetamine use (Meaux et al. 2006).
Setlick et al. (2009), conducted a study to show the rise in abuse of ADHD stimulants among teens and young adults. An inquiry was made through the American Association of Poison Control Center’s National Poison Data System for the years of 1998-2005 for all cases involving people aged 13 to 19 with intentional abuse or misuse of ADHD medication (Setlick et al., 2009). They compared these trend s to the data on the total number of exposures, as well as, teen and preteen ADHD medication sales data from IMS Health’s National Disease and Therapeutic Index database. Results showed that over 8 years estimated prescriptions for teenagers and preteens increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both together (Setlick et al., 2009). Substance-related abuse calls per million adolescent prescriptions rose 140%. Setlick et al. (2009), suggests that due to the increase there is rising problem with teen ADHD stimulant medication abuse.
Wilens et al. (2008), conducted a literature review of the misuse of stimulants in ADHD and non-ADHD populations across a range of developmental stages. The studies reported rates of past year nonprescribed stimulant use to range from 5% to 9% in grade school- and high school-age children and 5% to 35% in college-age individuals (Wilens et al., 2008). Lifetime rates of diversion ranged from 16% to 29% of students with stimulant prescriptions asked to give, sell, or trade their medications (Wilens et al., 2008). Recent work suggests that whites, members of fraternities and sororities, individuals with lower grade point averages, use of immediate-release compared to extended-release preparations, and individuals who report ADHD symptoms are at highest risk for misusing and diverting stimulants (Wilens et al., 2008).
In the current fast paced and demanding society, students may feel required to achieve high academic scores, volunteer, and engage in extracurricular activities. Students need to adapt to their surrounding environment. To manage problems, cope with challenges and demands many individuals may engage in new behaviors and coping strategies when adapting to their environment. Individual adjustment may be tested for university students (Dyson & Renk, 2006). Freshmen may doubt whether they will be able to meet the expectations of society, parents, and friends in addition to the expectations that they have for themselves (Dyson & Renk, 2006). Due to the unfamiliarity of university life students must make choices about when and how to study, make new friends, engage in extracurricular activities, or work. This may prove to be a very stressful for many students. Individual stress may occur when the demands individual experiences or perceives are exceed his or her coping capabilities (Dyson & Renk, 2006). As reported by DeSantis et al. (2009), college students tend to use ADHD medications without prescriptions for mostly purposes to “help with concentration,” to “help study,” and to “increase alertness.” Other students did report recreational reasons such as, “to get high,” (DeSantis et al., 2009).
The case study of Alex by Margaret Talbot exemplifies the misuse of ADHD stimulants for highly functioning individuals in a university setting. A young man I’ll call Alex recently graduated from Harvard. As a history major, Alex wrote about a dozen papers a semester. He also ran a student organization, for which he often worked more than forty hours a week; when he wasn’t on the job, he had classes. Weeknights were devoted to all the schoolwork that he couldn’t finish during the day, and weekend nights were spent drinking with friends and going to dance parties. “Trite as it sounds,” he told me, it seemed important to “maybe appreciate my own youth.” Since, in essence, this life was impossible, Alex began taking Adderall to make it possible. Alex took fifteen milligrams of Adderall most evenings, usually after dinner, guaranteeing that he would maintain intense focus while losing “any ability to sleep for approximately eight to ten hours.” (Talbot, 2009).
Competitive schools have an overwhelming number of white male undergraduates using neuroenhancers. College students tend to consider Adderall and Ritalin benign, in part because they are likely to know peers who have taken the drugs since childhood for ADHD (Talbot, 2009). DeSatntis et al. (2009) reported, in a study conducted in 2008, that 34% of college students at a large public institution in the American Southeast claimed to have ever used ADHD medication nonmedically. DeSantis et al. (2009) further investigated these finding to the more specific population of fraternity members to investigate determine the pattern of prescription stimulant misuse. They found 55% of fraternity members reported using ADHD stimulants, and these figures were significantly higher among upperclassmen, those who live off campus, and those who use marijuana. The current study also found that fraternity members primarily reported using ADHD stimulants for academic reasons. In fact, only a minority of students reported taking the drug for social purposes, (DeSantis et al., 2009). The study found that the vast majority of students viewed ADHD stimulants as posing little or no danger and that obtaining these stimulants was effortless (DeSantis et al., 2009). Pills are reported to cost between three to five dollars each (Cetta & Bourg, 2010). However, some students do feel it is unfair to take pills even if the risk may seem minimal. “I definitely [see it as wrong]. I feel that it is an unfair advantage. If the person next to me that has the exact same schedule takes an Adderall they can stay up the entire night knowing the material and come in and make a grade better than me,” a student told Katie Couric on a CBS 60 Minutes episode.
Studies that prove the positive effects of stimulants on the healthy brain add to the security many students feel about taking prescription medication. At the Brookhaven National Laboratory in New York, psychiatrist Nora Volkow study on the effects of Ritalin on sleep deprivation shows that Ritalin works in a healthy brain the same way it does in the brain of someone with an attention disorder (Cetta & Bourg, 2010). Although she is researching the effects of Ritalin on healthy individuals, Volkow is the director of the National Institute on Drug Abuse and cautions that stimulants like Adderall and Ritalin can be addictive (they are in same class of drugs as cocaine).
In April 2008, Nature magazine ran its own informal online poll that surveyed 1,400 people from 60 countries. The survey included three drugs: methylphenidate (Ritalin); modafinil (Provigil), prescribed to treat sleep disorders but also used off-label to combat general fatigue or overcome jet lag; and beta blockers, drugs prescribed for cardiac arrhythmia that also have an anti-anxiety effect (Maher, 2008). A majority of the fourteen hundred readers who responded said that healthy adults should be permitted to take brain boosters for nonmedical reasons, and sixty-nine per cent said that mild side effects were an acceptable risk (Talbot, 2009). Though a majority said that such drugs should not be made available to children who had no diagnosed medical condition, a third admitted that they would feel pressure to give “smart drugs” to their kids if they learned that other parents were doing so, (Talbot, 2009). The internet has made the availability of these drugs very accessible. The Nature poll found that one-third of the drugs being used for non-medical purposes were purchased over the Internet, while the rest were obtained from pharmacies or on prescription (Maher, 2008). Because the drugs are easy to buy online it would be difficult to stop their spread: “The drive for self-enhancement of cognition is likely to be as strong if not stronger than in the realms of ‘enhancement’ of beauty and sexual function” (Talbot, 2009).
In 2007, Dr. Anjan Chatterjee described, “Cosmetic neurology as the practice of intervening to improve cognition and affect in healthy individuals.” He broaches the subject of the need for cosmetic neurology and the ethics and moral issues that arise from this debate. By the age of 85 between a quarter and a half of the population may have a brain-againg illness and cognitive disorders in younger people (such as ADHD, learning disabilities, and the spectrum of autistic disorders) are increasingly recognized, (Chatterjee, 2007). The clinical need for treatments for cognitive and affective disorders is accompanied by scientific developments that make neuroenhancement possible and have included: motor, cognitive, and affective systems. For example insulin-like growth factor increases muscle mass and prevents decline associated with aging (Chatterjee, 2007). Chatterjee asserts that attention, memory, and learning can also be modulated in healthy people, but most neuroenhancement drugs are developed to treat disorders. Noradrenergic-blockers, such as Proprananol, may be useful in attenuating traumatic memories, even in well consolidated old memories, in PTSD (Debiec & LeDoux, 2006). Serotonin reuptake inhibitors are used widely and seem to promote affiliative behavior in healthy people (Chatterjee, 2007). Using neuroenhancers to treat disorders is not widely debated. However, using with these brain-enhancements for those are not suffering will inevitably be a source of great debate. Should we be able to enhance the brain, just like some would enhance their features by getting a facelift?
Chatterjee, 2007, discusses some of the ethical implications and cultural factors associated with neuroenhancers. First is a concern about safety. As new medications are developed, some will have undesirable side effects. In a disease state, we weigh the potential risks against the potential benefits. In a healthy state are any risks are worth taking? Second is a subtle concern about the erosion of character. If struggle is important to the development of character, does the use of pharmacological interventions to improve cognition or modify affect undermine this process? Third is a concern about distributive justice. If cosmetic neurology succeeds in making people smarter and happier, will these enhancements be available disproportionately to the affluent? Finally, there is a concern about coercion. Can healthy individuals be forced to take medications either because it would serve a greater good or because of competitive pressures? Despite these considerable ethical concerns, I propose that the advent of cosmetic neurology is inevitable. My point is not to trivialize these concerns, but to argue that they are unlikely to halt the development of cosmetic neurology. he workplace has only become more competitive over the years. Many sectors of society have winner-take-all conditions in which small advantages produce disproportionate rewards. The usefulness of being stronger and smarter, require less sleep, learn more quickly, and not be bothered by psychological trauma is abundantly clear. Older workers risk being replaced by younger workers because they are less able to learn and adapt to a rapidly changing technological environment. Finally, psychological problems can be treated directly in the brain rather than distantly at the body, (Chatterjee, 2007).
Chatterjee recognizes that it may be unlikely to halt the development of cosmetic neurology. The Air Force has even approved Provigil for fighter pilots on extended combat missions (Cetta & Bourg, 2010). In 1998, Cephalon, the pharmaceutical company that manufactures it, received government approval to market the drug only for “excessive daytime sleepiness” due to narcolepsy. In 2004, Cephalon had obtained permission to expand the label to includ sleep apnea and “shift-work sleep disorder.” Net sales of Provigil climbed from a hundred and ninety-six million dollars in 2002 to nine hundred and eighty-eight million in 2008 (Talbot, 2009). Cephalon has recently released Nuvigil, a longer-lasting variant of Provigil. Candace Steele, a spokesperson, said, “We’re exploring its possibilities to treat excessive sleepiness associated with schizophrenia, bipolar depression, traumatic injury, and jet lag,” (From Talbot, 2009).
As sales are increasing for prescription drugs, drug companies are entering the race for neurohancements. Last year alone there were more than two million Provigil prescriptions filled, some for truck drivers on long hauls and doctors working around the clock (Talbot, 2009). Some researchers are placing a greater emphasis on researching the effects of neuroenhancers on the brain. Talbot reported a study conducted by Cambridge University researchers in 2002, “[Researchers] gave sixty healthy young male volunteers a battery of standard cognitive tests with one group received modafinil (Provigil); the other got a placebo. The modafinil group performed better on several tasks, such as the “digit span” test, in which subjects are asked to repeat increasingly longer strings of numbers forward, then backward. They also did better in recognizing repeated visual patterns and on a spatial-planning challenge known as the Tower of London task.” The view of the brain will change as neuroenhancers become more publicly acceptable and accessible. The question of whether neuroenhancers increases potential and ability or enhancement changes brain structure will arise. The age old question of nature versus nurture is bound to be revisited on the question of human nature. Before elusive and relatively untouched, the topic of the brain’s capacity and ability may be uncovered. Talbot reported, “A 2007 discussion paper published by the British Medical Association also makes this point: “Equality of opportunity is an explicit goal of our education system, giving individuals the best chance of achieving their full potential and of competing on equal terms with their peers. Selective use of neuroenhancers amongst those with lower intellectual capacity, or those from deprived backgrounds who do not have the benefit of additional tuition, could enhance the educational opportunities for those groups.’”
Determining the future of brain power will be the cutting edge of research. Debates over the natural abilities versus enhanced abilities of students may come into question. Will there be drug tests before tests? Or will there be a new super focused and super productive generation?
References
Brown, R., and Rosa, A. (2002). Recent developments in the pharmacotherapy of attention-deficit/hyperactivity disorder (ADHD). Professional Psychology: Research and Practice, 33(6), 591-595. doi:10.1037/0735-7028.33.6.591.
Cetta, D. and Bourg, A. (2010). Popping pills a popular way to boost brain power. 60 Minutes: Among Upper Classes, 50-60 Percent Using ADD/ADHD Drugs Ritalin, Adderall. CBS Interactive Inc. <http://www.cbsnews.com/stories/2010/04/22/60minutes/main6422159.shtml?tag=currentVideoInfo;segmentTitle>
Chatterjee, A. (2007). Cambridge Quarterly of Healthcare Ethics, 16(2), 129-137. Cambridge University Press.
Debiec, J and LeDoux, J. (2006 ) Noradrenergic Signaling in the Amygdala Contributes to the Reconsolidation of Fear Memory Treatment Implications for PTSD. Ann. N.Y. Acad. New York Academy of Sciences. Sci. 1071: 521–524. doi: 10.1196/annals.1364.056
Desantis, A., Noar, S., & Webb, E. (2009). Nonmedical ADHD stimulant use in fraternities. Journal of Studies on Alcohol & Drugs, 70(6), 952-954.
Dyson, R. and Renk, K. (2006). Freshmen adaptation to university life: Depressive symptoms, stress, and coping. Journal of Clinical Psychology. 62(10); 1231–1244
Maher, B. (2008). Poll results: look who’s doping. Nature. 452, 674-675. doi:10.1038/452674a
Meaux, J., Hester, C., Smith, B., & Shoptaw, A. (2006). Stimulant medications: A trade-off? the Lived experience of adolescents with ADHD. Journal for Specialists in Pediatric Nursing, 11(4), 214-226. doi:10.1111/j.1744-6155.2006.00063.x.
National Institute of Mental Health. (2008). Attention Deficit Hyperactivity Disorder. National Institutes of Health. 08-3572. <NIMH.nih.gov>
Talbot, M. (2009). Brain gain. New Yorker, 85(11), 32-43.
Setlik, J., Bond, G., & Ho, M. (2009). Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics, 124(3), 875-880. doi:10.1542/peds.2008-0931.
Wilens, T., Adler, L., Adams, J., Sgambati, S., Rotrosen, J., Sawtelle, R., et al. (2008). Misuse and diversion of stimulants prescribed for ADHD: A systematic review of the literature. Journal of the American Academy of Child & Adolescent Psychiatry, 47(1), 21-31. doi:10.1097/chi.0b013e31815a56f1.
