THE JOYFUL REDUCTION OF UNCERTAINTY

Adderall Risks: Much More Than You Wanted To Know

[Previously in series: Antidepressant Pharmacogenomics: Much More Than You Wanted To Know; SSRIs: Much More Than You Wanted To Know, etc. This is all preliminary and you should not take it as a reason to change successful medical care. None of this necessarily applies to your particular case and you should talk to your doctor if you have questions about that.]

I. Confessions Of A Gatekeeper

I didn’t realize how much of a psychiatrist’s time was spent gatekeeping Adderall.

The human brain wasn’t built for accounting or software engineering. A few lucky people can do these things ten hours a day, every day, with a smile. The rest of us start fidgeting and checking our cell phone somewhere around the thirty minute mark. I work near the financial district of a big city, so every day a new Senior Regional Manipulator Of Tiny Numbers comes in and tells me that his brain must be broken because he can’t sit still and manipulate tiny numbers as much as he wants. How come this is so hard for him, when all of his colleagues can work so diligently?

(it’s because his colleagues are all on Adderall already – but telling him that will just make things worse)

He goes on to give me his story about how he’s at risk of getting fired from his Senior Regional Manipulator Of Tiny Numbers position, and at this rate he’s never going to get the promotion to Vice President Of Staring At Giant Spreadsheets, so do I think I can give him some Adderall to help him through?

Psychiatric guidelines are very clear on this point: only give Adderall to people who “genuinely” “have” “ADHD”.

But “ability to concentrate” is a normally distributed trait, like IQ. We draw a line at some point on the far left of the bell curve and tell the people on the far side that they’ve “got” “the disease” of “ADHD”. This isn’t just me saying this. It’s the neurostructural literature, the the genetics literature, a bunch of other studies, and the the Consensus Conference On ADHD. This doesn’t mean ADHD is “just laziness” or “isn’t biological” – of course it’s biological! Height is biological! But that doesn’t mean the world is divided into two natural categories of “healthy people” and “people who have Height Deficiency Syndrome“. Attention is the same way. Some people really do have poor concentration, they suffer a lot from it, and it’s not their fault. They just don’t form a discrete population.

Meanwhile, Adderall works for people whether they “have” “ADHD” or not. It may work better for people with ADHD – a lot of them report an almost “magical” effect – but it works at least a little for most people. There is a vast literature trying to disprove this. Its main strategy is to show Adderall doesn’t enhance cognition in healthy people. Fine. But mostly it doesn’t enhance cognition in people with ADHD either. People aren’t using Adderall to get smart, they’re using it to focus. From Prescription stimulants in individuals with and without attention deficit hyperactivity disorder:

It has never been established that the cognitive effects of stimulant drugs are central to their therapeutic utility. In fact, although ADHD medications are effective for the behavioral components of the disorder, little information exists concerning their effects on cognition…stimulant drugs do improve the ability (even without ADHD) to focus and pay attention.

I cannot tell you how much literature there is trying to convince you that Adderall will not help healthy people, nor how consistently college students disprove every word of it every finals season.

That makes “only give Adderall to people with ADHD” a moral judgment, not a medical one. Adderall doesn’t “cure” the “disease” of ADHD, at least not in the same way penicillin cures syphilis. Adderall will give everyone better concentration, and we’ve judged that it’s okay for people with terrible concentration to use it to overcome their handicap, but not okay for people with already-fine concentration to use it to become superhuman.

We could still have a principled definition of ADHD. It would be something like “People below the Nth percentile in ability to concentrate.” Instead, we use the DSM, which advises us to diagnose people with ADHD if they say they have at least five symptoms from a list. The list has things like “often has difficulty sustaining attention” and “often has difficulty organizing tasks”. How often? You know, often! And if you work as a Senior Regional Manipulator Of Tiny Numbers, you’re going to have attention problems a lot more “often” than the rest of us.

So the DSM criteria are kind of meaningless, but that’s fine, because people can just lie about them anyway.

There are whole websites for this: How To Convince Your Shrink You Have ADHD, How To Get Your Doctor To Prescribe You Adderall In Five Easy Steps, et cetera. But I can’t imagine most people need them. Just talk about all the times in your life that you had attention and concentration problems, and if your doctor asks you a more specific question (“Do you often lose things?”) you give the obvious right answer (“Wow, it’s like you’ve known me my whole life!”).

Aren’t psychiatrists creepy wizards who can see through your deceptions? There are people like that. They’re called forensicists, they have special training in dealing with patients who might be lying to them, and they tend to get brought in for things like evaluating a murderer pleading the insanity defense. They have a toolbox of fascinating and frequently hilarious techniques to ascertain the truth, and they’re really good at their jobs.

But me? At best, I can have a vague suspicion you’re not telling the truth. And how many patients genuinely in need of treatment do I want to risk accidentally rejecting just so I can be sure of thwarting you? A lot of 100% honest psychiatric patients’ stories are pretty unbelievable, really, and I don’t want to have to treat every patient like a convicted murderer. Unless you give me some specific reason to doubt you, I start with the assumption that you’re telling the truth.

Think about how wasteful all of this is. We throw people in jail for using Adderall without a prescription. We expel them from colleges. We fight an expensive and bloody War on Drugs to prevent non-prescription-holders from getting Adderall. We create a system in which poor people need to stretch their limited resources to make it to a psychiatrist so they can be prescribed Adderall, in which people without health insurance can never get it at all, in which DEA agents occasionally bust down the doors of medical practices giving out Adderall illegally. All to preserve a sham in which psychiatrists ask their patients “Do you have ADD symptoms?” and the patients say “Oh, yeah, definitely,” and then the psychiatrists give them Adderall. It’s like adding twenty layers of super-reinforced concrete to a bunker with a wide-open front door.

(Also, if by some chance a psychiatrist doesn’t give a patient Adderall, that patient practically always goes to another psychiatrist, and that next psychiatrist does. Trust me, no matter how unsuitable a candidate you are, no matter how bad a liar you are, somewhere there is a psychiatrist who will give you Adderall. And by “somewhere”, I mean it will take you three tries, tops.)

Psychiatrists’ main response to this perverse and unwinnable system is to give people Adderall, but feel guilty about it. Somebody should do an anthropological study on this, but my preliminary observations:

Some people will lecture their patients on how Medication Can Never Address The Root Cause Of A Problem, and the patient will agree that Medication Can Never Address The Root Cause Of A Problem, and then the psychiatrist will give them Adderall and feel good about it.

Some people will discuss alternative options, like behavioral treatments, or non-stimulant medications, and the patient will come back in a month and say that the behavioral treatments didn’t work, and then the psychiatrist will give them Adderall and feel good about it.

Some people will give their patients a formal test where they have to answer questions like “I often have trouble concentrating – strongly disagree, disagree, neutral, agree, or strongly agree?” Then the patient will give whatever answers get them Adderall, the psychiatrist will add up all the answers and score the test and find that it means the patient needs Adderall, and then the psychiatrist will give the patient Adderall and feel good about it.

Some people will occasionally find some little issue with one patient’s story, deny them Adderall, and then ride out the moral high for weeks, feeling so virtuous that they can give the next few people Adderall and feel good about it.

Some people will demand multiple evaluation sessions, lots of laboratory tests, make a patient tell them their whole life story. And after learning that they had a bad relationship with their stepfather in 8th grade and still have sexual hangups over that time they ejaculated prematurely with Sally one time in freshman year, the psychiatrist will give the patient Adderall and feel good about it.

I have been guilty of all of these at one time or another. I still wrestle with these issues a lot. The latest step in my evolving position was reading Kelsey’s blog post about having ADHD and trying to get Adderall. Her doctor gave her a list of things she had to do before he would give her Adderall, and she – having ADHD – got distracted and never did any of them.

(by my calculations, that decreased Kelsey’s effectiveness by 20%, thus costing approximately 54 billion lives.)

So lately I’ve been trying to be smarter about all this. What about good old consequentialism? Most people will get some benefit from Adderall, but it’s a powerful drug with a lot of potential risks. Maybe I should figure out exactly how bad the risks are, and then I can figure out how bad people’s concentration problems would have to be for the risks to be outweighed by the benefits.

Trying to discover the risks of Adderall is a kind of ridiculous journey. It’s ridiculous because there are two equal and opposite agendas at work. The first agenda tries to scare college kids away from abusing Adderall as a study drug by emphasizing that it’s terrifying and will definitely kill you. The second agenda tries to encourage parents to get their kids treated for ADHD by insisting Adderall is completely safe and anyone saying otherwise is an irresponsible fearmonger. The difference between these two situations is supposed to be whether you have a doctor’s prescription. But what if you are the doctor, trying to decide who to prescribe it to? Then what? All they tell you in medical school is to give it to the people who actually have ADHD – which, I repeat, is kind of meaningless.

This post records my attempt to figure out something better. Apologies for the length.

II. Medical Risks

Most people on stimulants will have some minor side effects. Feeling jittery, feeling cold, feeling sick, leg cramps, arm cramps. Some will feel “like a robot” or otherwise psychologically uncomfortable. But these don’t discourage me from giving stimulants to people who need them. If someone needs the drugs, let them try them, see how many side effects they get, and decide for themselves whether it’s worth it.

I’m much more concerned about side effects that are permanent and dangerous. These people give us a list:

Sounds pretty bad. On the other hand, I’ve prescribed Adderall to lots of people and none of them have ever gotten any of these things, except mild hypertension. How common are these, really?

The best source for exact numbers is the guidelines by sinister-sounding European organization EUNETHYDIS. I’ll use US medical database UpToDate as a secondary source. Both lump together Adderall and Ritalin – something I’ll be doing too throughout most of this essay, except where it becomes important to distinguish them.

Seizures: EUNETHYDIS doesn’t believe this happens at normal doses. They write:

There are occasionally concerns that, as with other psychotropics, ADHD medications may lower the seizure threshold so as to cause seizures in previously seizure-free individuals. However, in prospective trials, retrospective cohort studies and post-marketing surveillance in ADHD patients without epilepsies, the incidence of seizures did not differ between ADHD pharmacotherapy and placebo [relative risk (RR)] for current versus non-use for methylphenidate, 0.8; RR for atomoxetine, 1.1

UpToDate is so unimpressed by this that they don’t even mention it. If you ask them about seizure risk for ADHD medications, they start telling you about bupropion. Overall I wouldn’t give these medications to people with a known seizure disorder without a neurologist’s approval, but they seem pretty okay otherwise.

Hypertension: Broad agreement from both sources that stimulants cause hypertension. EUNETHYDIS says 1-4 mm systolic, UpToDate says 3-8 mm.

The main problem with hypertension is that it increases risk for things like heart attacks. I calculated an average 40 year old’s risk of heart attack and got 1% over 10 years. Adding on an average Adderall-related increase in blood pressure, I got 1.1%.

What about in high-risk adults? I calculated risk for a 60 year old smoker with high cholesterol and high blood pressure. He has a 30.5% base risk of heart attack. Then I added in a typical Adderall-related rise in blood pressure, and he ended up at 32.0%. So Adderall only increased risk by about 1/1000 per year, even in this worst case scenario. Also, I never meet 60 year old smokers asking for Adderall. Overall this seems not too interesting.

I haven’t looked into other hypertension-related problems like kidney disease as much, but these seem like things you’ll hopefully have a lot of warning about and be able to talk to your doctor about whether to stop stimulants over.

Heart Attack and Stroke: My usual sources fail me here, but BioMed Central Cardiovascular Disorders comes to the rescue. They review three major studies on stroke and heart attack in stimulant patients.

Study #1 finds that stimulant users have 3x more risk of transient ischaemic attack (a small mini-stroke that does no lasting damage), but no increased risk of stroke.

Study #2 is the best and biggest study, and finds that stimulants actually reduce heart attack and stroke. They suspected “healthy-user bias”; that is, only healthy people would use such a supposedly-dangerous medication.

Study #3 is the most recent, and found no increased risk of heart attack or stroke.

UpToDate writes:

Patients receiving stimulant therapy visited the emergency department or clinician office more frequently than those who were not treated with medications because of cardiac symptoms (10.9 versus 9.1 events per 1000 patient-years, adjusted hazards ratio 1.2, 95% CI 1.04-1.38) [26]. The cardiac symptoms included syncope, tachycardia, or palpitations. However, the group that received stimulant therapy was more likely to receive other psychotropic medications (antidepressants and antipsychotic agents), be male, and be non-Hispanic. The incidence of fatal and serious cardiac abnormalities was low and not different between the two groups, and was similar to the rates seen in the general pediatric population.

The 1/1000 extra ER visit per patient year sounds bad, but “palpitations” means “your heart feels like it’s beating in a weird way”, and Adderall clearly causes this, so my guess is this is mostly just people feeling this and freaking out. I have had patients call me after feeling this and freaking out, and we dealt with it, and they were fine. If I hadn’t been available, maybe they would have gone to the ER and turned themselves into a statistic.

There might be some bias in these studies, but overall there doesn’t seem to be much evidence this is worth worrying about unless your risk of heart attack or stroke is already really high.

Psychosis: I saw this a lot when I worked in inpatient. Somebody would take five times the recommended dose, or take more Adderall every time they felt tired until they hadn’t slept for a week, and then they would start hearing voices or feeling like something was crawling on their skin. After a day or two off Adderall, and a night or two getting a normal amount of sleep, they’d be fine. Take enough stimulants and you will become psychotic – but it’s rare on prescribed doses, and it usually resolves pretty quickly.

What dose can cause psychosis? Amphetamine-Induced Psychosis says:

Early studies demonstrated that amphetamines could trigger acute psychosis in healthy subjects. In these studies, amphetamine was given in consecutively higher doses until psychosis was precipitated, often after 100–300 mg of amphetamine. The symptoms subsided within 6 days.

Compare this to the standard daily dose of Adderall of about 10 – 60 mg.

Can psychosis ever happen at normal doses? EUNETHYDIS is skeptical. They write:

Data from population-based birth cohorts indicate that self-reported psychotic symptoms are common and may occur in up to 10% of 11-year-old children. In contrast, the prevalence of psychotic symptoms in children treated with ADHD drugs from RCTs is reported as only 0.19%. While this very low observed event rate in trials is likely to reflect a lack of systematic assessment and reporting, there is no compelling evidence to suggest that the observed event rate of psychotic symptoms in children treated with ADHD drugs exceeds the expected (background) rate in the general population. In the US FDA analysis, ADHD drug overdoses did not contribute significantly to reports of psychosis adverse events.

So basically, “kids are always kind of weird, studies say kids aren’t weird on Adderall, clearly they’re not paying attention, but it doesn’t look like things got any worse.”

UpToDate links these people, who say:

We analyzed data from 49 randomized, controlled clinical trials in the pediatric development programs for these products. A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In approximately 90% of the cases, there was no reported history of a similar psychiatric condition. Hallucinations involving visual and/or tactile sensations of insects, snakes, or worms were common in cases in children.

I think their use of “psychotic events per person-year” is misleading. Their study includes 5717 people, which means that for them to have 743 person-years each person must have been monitored for two months or so. But if you’re going to get psychotic on stimulants, usually it’s right after the stimulant is started. That means it might be better framed as “11/5717 patients had a psychotic event”, or even “one in every five hundred patients had a psychotic event”. Note that this matches the 0.19% number given by EUNETHYDIS. And the most common psychotic event was a feeling of snakes or insects on the skin which resolved after the drug was stopped, so we’re not talking “person is forever schizophrenic” here.

Also, I feel like EUNETHYDIS makes a good point with the “kids are always weird” thing. Here’s one of the psychotic events mentioned in the paper:

A spontaneous report from the manufacturer of Strattera (atomoxetine) described a 7-year-old girl who received 18 mg daily of atomoxetine for the treatment of ADHD. Within hours of taking the first dose, the patient started talking nonstop and stated that she was happy. The next morning the child was still elated. Two hours after taking her second dose of atomoxetine, the patient started running very fast, stopped suddenly, and fell to the ground. The patient said she had “run into a wall” (there was no wall there). The reporting physician considered that the child was hallucinating. Atomoxetine was discontinued.

Have these people ever seen a child?

The methylphenidate prescribing information suggests an 0.1% risk of psychosis, which matches the other two studies pretty well.

Does stimulant psychosis always get better after the stimulant is discontinued? My strong impression is “yes”, but I am told that this study claims 5% to 15% of stimulant psychosis patients do not recover. I cannot find the full text to figure out exactly what they mean, and it looks like it was done on chronic meth addicts rather than prescription users.

So a few lines of evidence converge on 0.1% – 0.2% of children who use prescription stimulants become psychotic. I don’t know numbers for adults, but a few people who have read drafts of this article mention they have personally seen someone get psychotic on Adderall, which seems anecdotally to argue for a higher rate. I don’t know if those people were using it correctly or using anything else alongside it. Of people who get psychotic on Adderall, perhaps 5-15% stay psychotic after discontinuation (I predict this is about meth-heads and exaggerated).

Aggressive Behavior: This is just going to be the same as psychosis. Adderall isn’t going to magically turn gentle old grandmothers into killing machines. If you’re already a kind of violent guy, and you take a lot of Adderall, maybe it’ll push you over the edge.

Sudden Death: This is usually cardiovascular – something goes very wrong with your heart and it stops beating without warning. But UpToDate writes:

Reports of unexpected deaths of children receiving stimulant therapy have led to concerns that these medications increase the risk of cardiovascular (CV) adverse events, including sudden unexpected deaths (SUD) [1,2]. However, large cohort studies have not shown an increased risk of serious CV adverse events in children treated with stimulant therapy compared with the general pediatric population…

Among adult patients who are either current or new users of stimulant medications, there appears to be no increased risk of serious CV events. This was illustrated in a large retrospective cohort study of adults (age range 25 to 64 years) based on data from four large health plans that was done in parallel with the study performed in children discussed above [3,16]. Multivariant analysis demonstrated a lower risk of serious CV events (defined as myocardial infarction, stroke, and sudden cardiac death) in individuals who were current users of stimulant therapy versus nonusers (relative risk [RR] 0.83, 95% CI 0.72-0.96). In new users of ADHD medications compared with controls, the risk of serious CV events was even lower (RR 0.77, 95% CI 0.63-0.94). However, there may be a modest amount of healthy-user bias that favored the current users of stimulant therapy. To adjust for this potential bias, a multivariant analysis that compared current users with individuals who had used stimulant therapy more than one year ago (defined as remote use) found no difference in the risk of serious CV events (RR 1.03, 95% CI 0.86-1.24). The crude incidence of serious CV events in the overall cohort was 1.34 per 1000 person-years. These results showing no increased risk of serious CV events are consistent with previously discussed studies in pediatric patients.

And EUNETHYDIS:

when the number of patient-years of prescribed medication was incorporated into the evaluation, the frequency of reported sudden death per year of ADHD therapy with methylphenidate, atomoxetine or amfetamines among children was 0.2–0.5/100,000 patient-years [99]. The analysis of 10-year adverse-event reporting in Denmark resulted in no sudden deaths in children taking ADHD medications [5]. While it is recognised that adverse events are frequently under-reported in general, it is likely that sudden deaths in young individuals on relatively new medications may be better reported. Death rates per year of therapy, calculated using the adverse events reporting system (AERS) reports and prescription data, are equivalent for two ADHD drugs (dexamfetamine and methylphenidate): 0.6/100,000/year [37]. (The accuracy of these estimates is limited however, for instance because in moving from number of prescriptions to patient-year figures assumptions must be made about the length of each prescription). It seems likely, using these best available data, and assuming a 50% under-reporting rate, that the sudden death risk of children on ADHD medications is similar to that of children in general.

Despite this, I am always very wary prescribing stimulants to anyone with any history of heart problems. I always make these people go see a cardiologist. The cardiologist always says yeah, sure, whatever, but it makes me feel a lot better.

In General: Probably the most informative passage I’ve seen on the medical risks of stimulants is this one from Misuse Of Study Drugs:

In 1990, there were about 271 emergency room reports involving methylphenidate, 1,727 in 1998, and 1,478 in 2001 [32]. The total number of emergency department visits resulting from use of all psychotherapeutic CNS stimulants was 4091 in 1998, 3644 in 1999, 3336, in 2000, 3146 in 2001 and 3275 in 2002 [33]. There are approximately 25 emergency room deaths per year among up to 3 million users of prescription stimulant drugs (including both those medically prescribed and not prescribed these drugs). Thus, the likelihood of dying from such drugs appears to be approximately 1 in 120,000.

But isn’t 25 deaths per year still bad?

Here’s another passage from the same source:

Intravenous use of prescription stimulants is particularly dangerous. In particular, intravenous (IV) abuse of methylphenidate may result in talcosis. Talcosis is a reaction to talc, a filler and lubricant in methylphenidate and other oral medication. This inflammation reaction occurs in the lungs and related consequences include lower lobe panacinar emphysema.

People aren’t dying because their psychiatrist gave them Adderall 10 mg bid. They’re dying because they ground it up, injected it into their bloodstream, and had their lungs turn into talc. The people dying of stimulant use are doing things so horrifying you could not possibly imagine them even if you took ten times your prescribed dose of Adderall and used all of it to focus on writing a report on the most horrifying ways you could possibly use Adderall. Did you know that 13% of Massachusetts college students have ground up Ritalin and snorted it up their nose? Did you know the first case report of Ritalin abuse involved a patient who was taking 125 Ritalin pills daily? All of these people are out there, and still only 25 people die of stimulant-related causes per year!

My impression is that, in particularly at-risk people, stimulants may add +1/1000 to the risk of heart attacks per year, and +1/10,000 risk of long-term psychosis. Everything else in this category can be rounded down to zero.

III. Addiction

What about addiction risk?

The data on this are really poor because it’s hard to define addiction. If a prescription stimulant user uses their stimulants every day, and feels really good on them, and feels really upset if they can’t get them…well, that’s basically the expected outcome.

Wilens et al finds that over ten years, 10% of adolescents surveyed got high on their medication, and 22% sometimes used more than prescribed. Does that mean those 10% or 22% are “addicted”? Not really – some of them probably have a tough day one time, so they take two Adderall that day and no Adderall the day after. As for getting high – well, a lot of people get high on alcohol who aren’t alcoholics, and a lot of people get stoned who nobody would call addicted to marijuana.

A lot of studies in this area ask the kind of different question of whether children put on stimulants are more likely to be addicted to drugs in general as adults. Most of them find these children are less likely, which is hypothesized to be an effect of successfully treating their ADHD.

And there’s a book on narcolepsy which apparently claims that between less than 1% and 3% of people taking stimulants for that condition get addicted, but I can’t track down their methodology or really anything beyond one reference. And narcoleptics are a different population than ADHD patients and results might not generalize (though that number sounds kind of right).

I don’t think there are good data here, but my intuitions and personal experience is that “addiction” of the sort you get with heroin or tobacco is very rare, at least when responsible people without a personal or family history of addictive behavior take stimulants as prescribed. Most people agree the risk is lower for extended-release stimulants (eg Adderall XR), and very low for Vyvanse.

IV. Tolerance

Tolerance is when you keep needing more and more of a drug to get an effect. In the worst cases, your baseline changes so that you need the drug to feel normal. The concern is that long-term use of Adderall will make your attention naturally worse, so that medicated-you is only as good at concentrating as unmedicated-you was before, and unmedicated-you is even less attentive.

We know tolerance occurs over the short-term, and we encourage patients to take a few days off Adderall every week or two to let their bodies reset. More concerning is whether it happens over the space of years, where people’s bodies adjust in a more permanent way.

The best study of this phenomenon was the Multimodal Treatment of ADHD (MTA) study, which randomized children to be treated with stimulants or “behavioral therapy” (eg learning coping skills, etc). Behavioral therapy for ADHD is not very good and I interpret it as a nice way of saying placebo.

For the first year, the kids getting stimulants did much better on all metrics than behavioral-therapy-only. For the second year, they did a little better. By the third year, they were the same. In the eighth year, which was as long as anyone kept checking, they were still the same.

This is pretty concerning. It sounds like over three years people’s bodies built up some tolerance to stimulants, after which they provided no further benefit. The only saving grace is that there’s no evidence of stimulants ever making people worse than normal (even on people who stopped the medications later).

People have critiqued this study on the grounds that although they started off giving the experimental group stimulants vs. the control group behavioral therapy, any patient could switch treatments at any time and many of them did. By year three when the groups equalized, only 66% of the medication group was on medication, and a full 43% of the therapy-only group was. So maybe this just drowned out any original effect?

The authors of the study are not convinced:

It is tempting to conclude that intensive medication management beyond 14-months could have resulted in continued differences between the randomly assigned treatment groups…In a previous multimodal treatment study where medication was carefully titrated and monitored for two years, treatment gains were maintained for the entire period. However, after 14 months the MTA became an uncontrolled naturalistic follow-up study and inferences about potential advantages that might have occurred with continued long-term study-provided treatment are speculation. Moreover, with one exception (math achievement), children still taking medication by 6 and 8 years fared no better than their non-medicated counterparts despite a 41% increase in the average total daily dose, failing to support continued medication treatment as salutary (at least, continued medication treatment as monitored by community practitioners)…Finally, a previous analysis of the MTA data through 3 years did not provide evidence that subject selection biases towards medication use in the follow-up period accounted for the observed lack of differential treatment effects.

Thus, although the MTA data provided strong support for the acute reduction of symptoms with intensive medication management, these long-term follow-up data fail to provide support for long-term advantage of medication treatment beyond two years for the majority of children—at least as medication is monitored in community settings.

As far as I can tell, pretty much everyone has ignored this, using the usual range of meaningless excuses like “Well, treatment must be individualized to the patient”.

This is very tempting, because for example I have a lot of patients who have been on stimulants for decades, are still very excited about them, and think they’re doing great. Every so often these patients go off their stimulants, are very unhappy, and insist on going back on them again. They say that pre-stimulant, they were scatterbrained and always losing things and missing appointments and failing to do work, and now, after ten years of stimulant treatment, they feel great.

We can imagine ways these people are wrong. Maybe the stimulants worked for the first three years, stopped working so gradually they didn’t notice, and now they only notice the difference between being on stimulants (baseline), and immediate post-stimulant withdrawal (very bad). But this would require a lot of people to be really wrong about their internal experience.

I asked a question on the Slate Star Codex survey about this. People on Adderall more than one month were asked to tell me whether they had no tolerance problems, some tolerance requiring dose escalation, or high tolerance that made the medications stop working entirely. The preliminary results:

Adderall for between one month and one year: (n = 124)
62 (50%) No tolerance, worked as well as ever
57 (46%) Some tolerance, or required dose escalation, but still worked well in general
5 (4%) High tolerance, stopped working

Adderall for one to five years: (n = 117)
33 (28%) No tolerance, worked as well as ever
78 (67%) Some tolerance, or required dose escalation, but still worked well in general
6 (5%) High tolerance, stopped working

Adderall for more than five years: (n = 59)
23 (39%) No tolerance, worked as well as ever
33 (56%) Some tolerance, or required dose escalation, but still worked well in general
3 (5%) High tolerance, stopped working

All three categories were evenly divided between “no tolerance” and “some tolerance but still worked well”, with only about 5% saying the tolerance became a big problem. This matches my clinical experience. So either I’m right, or the problem where they get confused and forget their baseline is affecting my survey-takers.

There are occasional claims that magnesium or some other substance can help reverse Adderall tolerance. As far as I know these have never really been investigated.

So: there’s no good evidence that taking Adderall will actively make your ADHD worse in the long run. There is good evidence from clinical trials that benefits will decrease to zero over the space of a few years, apparently contradicted by the personal experiences of doctors and patients. Overall not sure what to do with this one.

V. Neurotoxicity

There’s some evidence that amphetamines can cause permanent cellular damage, but it’s not clear whether this happens in humans at typical therapeutic doses.

If you give rats very high doses of IV amphetamines, they accumulate so much dopamine in the cytoplasm of their neurons that it causes oxidative stress and destroys dopaminergic nerve terminals. This doesn’t happen to rats at doses matching human doses of Adderall. But it does happen at those doses to squirrel monkeys. At least this is the claim:

Adult baboons and squirrel monkeys were treated with a 3:1 mixture of D/L–amphetamine similar to the pharmaceutical Adderall for 4 weeks. Plasma concentrations of amphetamine (136±21 ng/ml-1) matched the levels reported in human ADHD patients after amphetamine treatment lasting 3 weeks (120–140 ng/ml-1) or 6 weeks in the highest dose (30 mg/day-1) condition (120 ng/ml-1). When the animals were killed 2 weeks after the 4-week amphetamine treatment period, both non-human primate species showed a 30–50% reduction in striatal dopamine, its major metabolite (dihydroxyphenylacetic acid (DOPAC)), its rate-limiting enzyme (tyrosine hydroxylase), its membrane transporter and its vesicular transporter. These consequences are similar, if not identical to the effects of neurotoxic doses in rodents.

I’m not really sure what they’re getting at here – surely they’re not saying just one month of Adderall permanently decreases striatal dopamine by 50%? But it sounds like something bad is happening, and since humans are more like monkeys than rats, maybe there’s cause for concern.

What would it look like if people got this kind of brain damage? One likely possibility is Parkinson’s disease, a condition caused by poor dopaminergic function in the brain. If you were going to tell a story about how Adderall could cause long-term neurotoxic damage, it would look like gradual decrease of brain dopaminergic function without obvious effects through most of the lifespan (since most people have dopaminergic function to spare). As the patient got older and started naturally losing brain function, Parkinson’s would appear. This happens to genetically and environmentally predisposed people anyway (which is why old people get Parkinson’s so often), but in this scenario amphetamine use would present an extra risk factor.

Several studies have shown that meth addicts do have higher rates of Parkinson’s disease. This one says people hospitalized for meth addiction are 60% more likely to get Parkinson’s than people hospitalized for other reasons. This one finds Parkinson’s rates three times higher in meth addicts compared to non-drug-users.

What about at therapeutic doses? This article claims there was a study that found people who used Benzedrine and Dexadrine (early forms of prescription amphetamine) in the 1960s have rates of Parkinson’s Disease about 60% higher than non-users today, but I can’t find the study itself and I don’t know the methodology. Another study finds similar results. Since both ADHD and stimulant addiction are very hereditary, you could make an argument that people who already have problems with their dopamine system are more likely to get Parkinson’s later on. There’s a little bit of conflicting evidence for this. Also, ADHD patients might have three times the rate of dementia with Lewy bodies, a condition closely related to Parkinson’s. On the other hand, there doesn’t seem to be any genetic connection. Overall my guess is this is not what’s going on.

About 1-2% of people will get Parkinson’s if they live long enough. If Adderall increases that risk 60%, then presumably it could cause a 1% absolute increase in risk.

Some people claim various substances (magnesium, minocycline, etc) will protect your brain from amphetamine neurotoxicity. None of these have been studied in anywhere near the depth they would need to be to make me feel comfortable with this.

The good news is that as far as anyone can tell, Ritalin doesn’t cause these problems, even if you give it to rats at super-high doses. It seems to be a difference in the mechanism of action. I’ve been talking about Adderall this whole post because it’s the most commonly-used stimulant and some studies have suggested it’s more effective for a few people, but this might be a strong argument in favor of starting with Ritalin and only switching to Adderall if Ritalin fails.

So overall there is plausible, but not incontrovertible, evidence linking Adderall to a somewhat increased risk of Parkinson’s disease in old age.

VI. Summary

My impression is that the risks of proper, medically supervised Adderall use are the following:

1. High risk of minor short-term side effects that might make you want to stop taking the medication with no long-term issues
2. Extremely low risk of serious medical side effects like stroke or heart attack, except maybe in a few very vulnerable populations
3. Maybe one percent risk, but not literally zero risk, of addiction if patients are well-targeted by their doctors and use the medication responsibly.
4. Perhaps one in five hundred risk, but not literally zero risk, of psychosis. Some anecdotal evidence suggests it is more common than this. Most of these cases will be mild and resolve quickly. Some people find a very small number of cases of stimulant-induced psychosis may be permanent, though I still find this hard to believe.
5. Some evidence for tolerance after several years, though most patients will continue to believe it is helping them. No sign of supertolerance where it actually makes the condition worse.
6. Plausibly 60% increased relative risk (+~1% absolute risk) for Parkinson’s disease with long-term use; this is unlikely with Ritalin.
7. Unknown unknowns.

Of these, I find the psychosis, tolerance, and Parkinson’s to be the most concerning. My most likely change after doing this research is to prescribe my patients who need stimulants Ritalin instead of Adderall. Most people find both stimulants work about equally well, and it seems potentially slightly safer. Given that the increased risk is only 1% in absolute terms, is still unclear, and may be incurred after only a few weeks of use, I’m not planning to force my patients who are currently happy on Adderall to switch to Ritalin right now.

I am pretty upset about the overall terrible state of this research. In particular, nobody except the MTA takes the possibility of tolerance seriously, and the MTA results really ought to have inspired a lot more soul-searching and hand-wringing than they actually did. The numbers on addiction and psychosis are inexcusably terrible given how easy they would be to collect. Getting good data on the Parkinson’s risk would be harder, but one so-far-unexplored possibility would be to compare past prescription Adderall history to past prescription Ritalin history in Parkinson’s patients to adjust for the potential ADHD confounder. I really think somebody should do this.

Despite all this, I compare these risks to the risks of eating one extra strip of bacon per day and decide that overall this is not enough for me to stop prescribing stimulants to patients who I think might benefit from them. These are about the standard level of side effects for a powerful medication and I think there’s a major role for these in ADHD treatment as long as patients are well-informed about the risks they’re taking.

PS: I don’t accept blog readers as patients, and I won’t prescribe you Adderall just because you liked this post.

This entry was posted in Uncategorized and tagged , , . Bookmark the permalink.

242 Responses to Adderall Risks: Much More Than You Wanted To Know

  1. Sniffnoy says:

    Broken-link nitpicking: Your “How to convince your shrink you have ADHD” and your “Some people claim” link are both broken due to the use of smart quotes rather than ASCII quotes.

    Edit: The first of these is now fixed but not the second?

  2. stephenmalina says:

    Having never taken Adderall, I’ve always wondered how taking it would compare to having more than my normal amount of caffeine, sleeping well, and not eating for between 16 and 20 hours. I’d describe the feeling I get from this combination as over-confidence (things I’d rightfully assess as hard seem easier), high ability to focus and get into flow, but lower ability to synthesize “interesting” thoughts without a clear external goal or prompting. These effects like a toned down version of Adderall’s effects but I obviously can’t know without having experienced them and, being all too wary about the problems associated with introspecting on my own mental states, would hesitate to draw conclusions even if I had.

    On the flip side, the minor side effects of Adderall sound very similar to how I feel in the caffeine plus fasted state.

    Most people on stimulants will have some minor side effects. Feeling jittery, feeling cold, feeling sick, leg cramps, arm cramps.

    Add occasional twitches in arms and legs and these match exactly.

    • maxaganar says:

      I’ve noticed similar mental changes when fasting. And to a lesser extent even when not fasting but eating very little, and sometimes simply when ketogenic and eating a normal amount of calories. This wasn’t why I started experimenting with fasting but it might be the strongest reason I have now to continue.

    • crybx says:

      I have also experienced what you described with caffeine and fasting and wonder how it compares to ADHD medications. However, I dislike the side effects I experience with caffeine. I think my brain easily interprets the jitters and extra awareness of my heart beating as anxiety. So I limit my caffeine to about 1 cup of coffee a week, and I drink it strategically when a state of high flow would help me get a lot done. That way I still occasionally get the effect of “more than my normal amount of caffeine” without daily side effects.

      In the past, I’ve compared how I feel drinking a large amount of caffeine after a long time drinking none to how I imagine the main character in Limitless feels taking NZT. But with daily use, the boost drops off to almost nothing within a few days.

      • jnp says:

        Tolerance is inevitable with caffeine, can’t help you there. But anxiety and jitteriness are not: try taking L-theanine with your caffeine. It’s a compound found in tea, is available over the counter (in the US, at least), and is an effective anxiolytic, promoting calm focus alongside the caffeine’s energy. After good sleep, solid diet, and adequate exercise, the caffeine + L-theanine combination is generally the number one nootropic recommendation.

    • Mercy Vetsel says:

      I would describe Adderall as a caffeine buzz but with calm energy rather than nervous energy. I have serious cottonmouth, problems sleeping and initially the crawling skin sensation, but I’ve never felt jittery.

      However, having taken it for as much as one month, I’m in the 5% who develop a tolerance to the point where it’s useless and so now I generally only take it when I need a little boost.

      Incidentally, during my entire 20’s I had the same problem with caffeine, drinking 7 to 10 cups per day until I finally went cold turkey and switched to decaf. Now I do the same thing with caffeine as with Adderall — only when I need a boost.

  3. Taymon A. Beal says:

    So overall this sounds pretty low-risk, but I’m curious how you apply this conclusion to the question you raised at the beginning of the post, about who Adderall should be prescribed to given that “people who really have ADHD” is not really a natural category.

    Presumably it would be bad for it to be made available to everyone who wants it, because lots of people (like college students and the Senior Regional Manipulator Of Tiny Numbers) are using it primarily to gain an advantage in the pursuit of positional goods, so if they’re all taking it (as is the case in the Senior Regional Manipulator’s department), they’re all exposed to the side effects and medical risks and none of them is better off. (Although the costs of prohibition might plausibly be even worse—but that’s really a separate issue.)

    Of course, making that kind of judgment is out of scope for your job as a doctor, but it’s also the whole reason you started looking into this in the first place, so…

    • actinide meta says:

      This view, that economic and technological progress, art, science, and all other human activities and aspirations are worthless, because positional goods exist, is so absurd to me that I can’t even find a way to engage with it.

      I’m very skeptical of “better living through chemistry”, because evolution should already have taken any biochemically low dimensional pure wins. But if everyone in the world is smarter and more focused and has four extra hours a day to live, that is not just a wash because it doesn’t help you climb some dumb status ladder!

      • simon says:

        Some level of distractability was arguably useful in the past because, e.g., getting eaten by tigers less often makes up for somewhat less productivity in making arrowheads. Nowadays we might want a lower level of distractability (fewer tigers in office buildings) so in principle it could be a pure win from a modern perspective.

        • actinide meta says:

          Yes, that’s possible. Or maybe these drugs reduce creativity, lateral thinking, and reevaluation of instrumental goals. Which are pretty important to software engineers.

          But I guess it’s easy for me to say, since I’m probably unnaturally focused already.

          • Ozy Frantz says:

            It seems like that is best solved through a combination of (a) observing the effects of Adderall on yourself and (b) choosing whether to take Adderall on any given day depending on what you’re doing that day.

          • Aceso Under Glass says:

            What evidence do you have that stimulants reduce creativity et al? I find I’m effectively more creative because I can follow a train of thought until the end, instead of needing a steady drip of Accomplishment.

          • Desertopa says:

            Ozy, the trouble with that approach is that an inconsistent dosing schedule may interfere with the therapeutic effects of Adderall (I haven’t done anything like Scott’s depth of research on it, but I’ve experienced this issue myself and a number of psychiatrists have told me it’s not uncommon.)

            I had wanted to take that approach myself, using Adderall only when I felt a particular need for it to focus on otherwise difficult activities. But after an extended dosing lapse, I no longer seem to get any therapeutic effect whatsoever.

      • Doctor Locketopus says:

        > I’m very skeptical of “better living through chemistry”, because evolution should already have taken any biochemically low dimensional pure wins.

        The ability to write code for 16 hours per day, all the while keeping an intricate pattern of dozens of interacting mechanisms in your head, has only been advantageous for about the last 50 years, and only advantageous on a society-level scale for maybe 25.

        That’s far too short a time for evolutionary effects to manifest themselves.

        Pleistocene Hacker, who got engrossed by the patterns of raindrops flowing down the cliff wall, would likely have been eaten by a cave bear.

        One can think of a few activities that have been around for longer that require similar levels of concentration (for example, composing classical music for an entire orchestra or some religious disciplines), but it’s worth noting that there are an awful lot of sad stories in the lives of the great composers, and that many religious disciplines require celibacy.

      • InferentialDistance says:

        because evolution should already have taken any biochemically low dimensional pure wins

        Not how evolution works. Evolution has already taken any easily reachable, organically feasible pure wins that are adaptive to the environment we evolved in. We live in very different environments: highly sedentary information-crunching in atomized urban centers vs. foraging and persistence hunting in small close-knit tribes. The chemicals may not be easy for primate mammals to organically produce. And, even if it is reasonable for them to be naturally created, the path between where we have been, historically, and any of those bodies may require passing through intermediate steps that are a net loss. Evolution is a local optimizer, so it can’t get to any improved configurations that require leaving the local maximum.

        • MNH says:

          Evolution is a local optimizer, so it can’t get to any improved configurations that require leaving the local maximum.

          Not entirely true. There’s lots of stochasticity in the process (e.g. genetic drift), and stochastic versions of local optimizers actually do break free from local optima, and tend to do a better job breaking free of worse local optima.

          • markk116 says:

            Until you get really enthusiastic and turn all the mutation knobs to full power after which the population “genetically drifts” to extinction….

          • quanta413 says:

            It’s probably also worth mentioning that people tend to envision a very low dimensional space with lots of local optima that aren’t global optima. But on a physical level evolution operates on an extremely high dimensional space (~10^6-10^9 baseapairs of DNA i.e. dimensions) which means there aren’t really many local optima. There is an enormous space of neutral “ridges” that populations can wander along due to things like genetic drift. And these ridges may eventually connect to higher optima.

          • publiusvarinius says:

            @quanta413:

            The usual intuition is that local optima are rare on differentiable high-dimensional search spaces (it’s very unlikely that the derivative is zero in every direction, because there are lots of directions).

            I am not going to debate whether evolution is “differentiable” or not, in any sense. The heuristic fails even if everything is differentiable, assuming that the support of the function is small. And that is certainly the case for evolution: extremely large areas of the space of all possible genetic configurations are completely non-viable.

      • Sniffnoy says:

        This is more of a reply to the various replies, but as a way of centralizing the discussion here I think it’s useful to link to Gwern’s page on the matter (which is in turn quoting Bostrom and Sandberg), which has this to say about ways in which the Algernon argument — “If the proposed intervention would result in an enhancement, why have we not already evolved to be that way?”, in Bostrom and Sandberg’s formulation — can fail to apply. They list three ways:

        1. Changed tradeoffs. Evolution “designed” the system for operation in one type of environment, but now we wish to deploy it in a very different type of environment. It is not surprising, then, that we might be able to modify the system better to meet the demands imposed on it by the new environment.

        2. Value discordance. There is a discrepancy between the standards by which evolution measured the quality of her work, and the standards that we wish to apply. Even if evolution had managed to build the finest reproduction-and-survival machine imaginable, we may still have reason to change it because what we value is not primarily to be maximally effective inclusive-reproductive-fitness optimizers.

        3. Evolutionary restrictions. We have access to various tools, materials, and techniques that were unavailable to evolution. Even if our engineering talent is far inferior to evolution’s, we may nevertheless be able to achieve certain things that stumped evolution, thanks to these novel aids.

        I think that basically covers it, really. So — if you can find a way that one of those three applies, you can get around the Algernon argument. If you can’t… you probably can’t.

        It looks like the people replying to you so far are trying to suggest ways that #1 (simon, Doctor Locketopus) or #3 (InferentialDistance) might hold. I have nothing really to say about the object-level here, but I thought it would be useful to collect this together and put it in Bostrom and Sandberg’s terms.

        • actinide meta says:

          I agree with all three of these in the abstract, and I tried (apparently unsuccessfully) to allude to 1 (“pure wins”) and 3 (“low dimensional”) in my original statement. But this puts it much better.

          I remain skeptical at the object level, at least with respect to software engineering, in which field I have had considerable success as a leader. Usually by reminding people to step back and think about and talk about what they are doing, rather than spend 16 hours a day doing it harder. But again, I can’t rule out that I’m only working with people who already have exceptional attention spans naturally or through medication.

      • Baeraad says:

        Considering that most human activity today seems to be aimed at selling people things they don’t need, I’d say that that view is pretty close to the truth, actually. Most people serve no meaningful purpose, but they still have to compete against hordes of other people who serve no meaningful purpose in order to earn their share of the actual necessities of life (along with their share of crap they don’t need, of course).

        Let the brain surgeons and fire fighters have as many performance enhancers as they need, by all means – but forcing regular people to cram down pills to make their pointless make-work hold the same standard as the pointless make-work of their pill-popping colleagues sounds like a net loss for humanity to me, yes.

        • Jessica says:

          Excellent point.
          David Graeber makes a similar argument about the non-utility of most jobs.
          The exact mechanism by which a society keeps so many people in bullshit jobs without overt acknowledgement that this is what it is doing is a question worth investigating, even worth using Adderall to resolve.

    • Ozy Frantz says:

      At least in theory the college students that use it would additionally learn more about the subjects they’re studying.

    • jonathanpaulson says:

      Presumably it would be bad for it to be made available to everyone who wants it, because lots of people (like college students and the Senior Regional Manipulator Of Tiny Numbers) are using it primarily to gain an advantage in the pursuit of positional goods

      This seems like a really bad argument. The Tiny Numbers would be manipulated better! And the students would learn more! Are you saying all human activities requiring focus are zero-sum? I think they’re almost all positive-sum.

      Scott, did you ever change your view that most human activity is socially useless competition over positional goods?

      • phil says:

        Isn’t that what the money is for though?

        There is a certain economic value to having the numbers counted well

        Whoever counts those numbers the best will capture that value

        I’m not that convinced that many number counting activities meaningfully expand the pie out economic value

        (I don’t discount that it’s theoretically possible, I just don’t take it as a given)

        • jonathanpaulson says:

          Isn’t that what the money is for though?

          I don’t know what point you’re trying to make.

          There is a certain economic value to having the numbers counted well

          Whoever counts those numbers the best will capture that value

          I’m not that convinced that many number counting activities meaningfully expand the pie out economic value

          It sounds like your model is that there is a fixed pie of work to be done, and whoever is the best will get to do that work and reap the rewards, and everything else will be sad and unemployed. This is not at all accurate; instead, there is an enormous pile of work that is not done because it is not cost-effective to do it. Lower costs, and it is.

          For instance: I play a lot of video games. If all game developers had 4 more productive hours a day, game companies wouldn’t just make the exact same games and profit off the reduced labor costs. They would add more features to games. Games would be done faster. There would be more (and better) games because it would be faster and cheaper (in labor-hours) to try out new ideas. As a video game consumer, I pretty clearly benefit (and hence, the pie of economic value expands).

          • phil says:

            The market for cool video games with neat features is neither fixed nor infinite. To the degree that you know have more interesting games to buy, and spend money you wouldn’t have previously spent in the video game market, that’s likely to come out of your larger entertainment budget (or some other budget, either way, it’s not infinite, it’s coming from somewhere)

            If game programmers take performance enhancing drugs, you’re totally correct that they can do work that’s not marginally profitable to do currently, let not pretend this doesn’t come without costs though.

            It’s absolutely the case that they will push out developers who don’t take the PEDs and were previously on the margins of the industry

          • To the degree that you know have more interesting games to buy, and spend money you wouldn’t have previously spent in the video game market, that’s likely to come out of your larger entertainment budget (or some other budget, either way, it’s not infinite, it’s coming from somewhere)

            The objective isn’t to have money spent, it’s to produce useful goods and services. If the result of a game programmer doing a better job is a better game that’s a net plus, even if the amount of money spent remains the same.

          • phil says:

            Do you feel the same about Steroids in baseball? Players taking steroids can hit more HRs w/ steroids for the same cost, so more consumer entertainment, so a net plus.

            Is it simply neo-Ludditism to care about the all players who decided to follow the rules and didn’t get to have baseball careers?

            I legitimately curious your answer in a non-judgements sense. To me this strikes me as a truly toxic concept of progress when progress demands we have to chemically alter ourselves, or poo poos the idea of saying, you know what, lets not, let’s experience humanity the way millions of years of evolution programmed is to experience it, and maybe we’re crossing ethical boundaries by participating in a system that economically penalizes people for not altering their chemistry

          • Do you feel the same about Steroids in baseball?

            Good question. The answer depends on what gives value to the fans.

            If what the fans value is seeing people do something difficult very well, so that the better the players are the more the fans enjoy the game, then the same argument applies. If what they value is a hard fought game, so that watching two teams of quality X play is just as good as watching two teams of quality Y>X play, then the argument does not apply.

          • CatCube says:

            @DavidFriedman

            The situation that many professional athletes (and high-end amateurs) end up faced with is “If you want to actually continue in your career, you’re going to have to take drugs that will shrivel your balls and turn you into a violent lunatic.” Then the leagues tend towards being filled with people who looked at that tradeoff and said, “OK!”

            What we’re starting to look at here with taking Adderall for keeping up with the Joneses at white-collar jobs is, “Instead of taking out tens of thousands of dollars in student loans to get a sheepskin permitting you to get hired, you’re going to have to take out tens of thousands of dollars in student loans to get a sheepskin permitting you to get hired AND you’re going to have to start doing crank.” I’m not sure that this is an improvement.

    • deciusbrutus says:

      I don’t think that “being objectively better at certain tasks” is a purely positional good.

      • phil says:

        ‘Purely’ is doing too much work here.

        An interesting thing to think about, what are the factors inherent to a given task, where, if you chemically enhance yourself, the resulting improvements are likely to be positional in nature vs nonpositional.

        Some primative thoughts about it, it’s probably runs opposite of the economic reward for the task, highly compensated white collar work is going to get done whether you do it or not, if you dropped dead of a heart attack, the work wouldn’t stop, they’d find someone else to do it, and the show would go on.

        If you’re an especially accomplished white collar worker you probably have a grounds to complain about that analysis. ‘You see, I’m marginally better than my heart attack replacement, otherwise they wouldn’t have needed the event of my heart attack to get my job.’

        And that’s almost certainly true, but the amount of work that ‘marginally’ does in that sentence should be troubling to us.

        How marginal exactly is the difference? 10%? 5%? 1%? a fraction of 1%?

        Exactly how well oiled is the machinery of the system we exist in? What does that mean about the meaningfulness of our existence?

        —–

        In contrast many jobs are not well compensated, to pick a genaric stereo type that I don’t actually know that much about, social workers are not well compensated, if taking adderall lets you be an especially dedicated social worker, and then you die of a heart attack, it’s actually pretty likely that it’ll be pretty difficult to replace what you were contributing.

        The margins seem much better.

        ——–

        I’ve never taken Adderall, though I have often wished my ability to concentrate was better.

        Never have experienced it I can’t speak to whether taking it is a pleasurably experience in and of itself, or merely a means to an end.

        But to the degree to which it’s a means to an end, we should examine the how large the margins of the activity we’re using it for really are.

        It’d suck if we’re taking adderall just so we can afford to send our kids to a good school, which only has jobs that our kids will have to take adderall to compete at… in a loop, let’s step out of that loop.

        • if you dropped dead of a heart attack, the work wouldn’t stop, they’d find someone else to do it, and the show would go on.

          That someone would then no longer be doing the slightly less valuable thing he was previously doing. That’s a cost.

          You seem to be analyzing the problem in a world with an infinitely elastic supply of white color labor.

          • phil says:

            I’m sure theoretically I’m wrong, but practically at high white collar wages, that seems like the observable universe

          • Then why are white collar wages high? If there is an infinite supply of people willing to do the same work at the same quality for the same pay, wouldn’t you expect some of them to be willing to do it for a little less pay? And then others for still less?

            And so on until pay reached a level at which there was not an infinite supply of people willing to … .

          • phil says:

            That’s a good point, why are actors well paid? Do you truly feel there is a shortage of people who can act in movies?

            Maybe a better example would be why are professional athletes well paid, the answer there is pretty obvious, because tiny marginal differences in the world are valuable. Especially in winner take all systems.

            I actually don’t see how it refutes my point.

            If the 100 best baseball players in the world disappeared.

            Do you think any actual value would disappear?

            Or would the next 100 best players suddenly be the new 100 best players, and we would get into all the drama about which of them could win which games?

            I’d suggest that at that level, the actual talent level, unless you have an exceptionally gifted eye for it, is nearly imperceptible.

            Instead it’s the meaning fans give to what they’re doing that creates the value.

          • quanta413 says:

            @phil

            I’m stunned that you’re comparing white collar labor markets to acting and sports markets. White collar labor markets are definitely not winner takes all. There’s no obvious place to set a cutoff between highly compensated and less compensated white collar work that won’t be far more unnatural than the distinction between pro athlete and not pro athlete. I guess you could maaaybe define “highly compensated white collar work” as “Fortune 500 CEO” (which is a rather extremely small subset of highly compensated white collar work since most people would include engineers, mid level managers, bankers, doctors, etc. etc.) but I’ll bet there’s still a much smoother transition than in professional athletics.

            And the size of these markets could hardly differ more. My extremely ballpark estimate is that the total number of athletes in professional sports markets is on the order of thousands to ten thousands while the number of white collar workers is on the order of almost the entire rest of the U.S. economy (i.e. tens to hundred million). We’re talking a 3 to 4 orders of magnitude fold change. Not to mention differences in age structure of the people who dominate these job markets, etc.

          • phil says:

            I mean, some white collar work is winner take all and some isn’t.

            Making partner at large law firms seems pretty winner take all.

            The point was more that high wage don’t neatly map onto the supply of the people who would like to do that work.

            Lots of white collar work (especially the high paid variety) has lots of people who would like to do it, and could do it very nearly as well as the people who actually get to do it.

            (I’ll grant that there can be a lot of value in the thin margin between the people who do it well enough to do it, and those who could very nearly do it, but that model tends to suggest a winner take all market, and winner take all markets suggest that the overall good is largely positional)

          • Andrew Cady says:

            Then why are white collar wages high? If there is an infinite supply of people willing to do the same work at the same quality for the same pay, wouldn’t you expect some of them to be willing to do it for a little less pay? And then others for still less?

            Only if they can prove that they can do the same work quality, which they cannot.

            Also, at a certain point, lowering the wages lowers the quality of the work, because the worker becomes overloaded with obligations and problems outside of work, which end up affecting their work quality. (Just like the wages for a blue collar worker need to be enough to keep them alive and in attendance, those for a white collar worker need to be enough to keep them work-focused.) So you can’t just go lower and lower forever, no matter whether there are people willing.

          • Careless says:

            why are actors well paid

            they’re not. They’re mostly very low income.

        • deciusbrutus says:

          If we were to improve everyone’s productivity 10%, we increase production 10%.

          Whether or not the marginal productivity is positional is independent of whether it is increased productivity.

          That’s not to mention that math researchers report scale-changing effects.

        • Andrew Cady says:

          I’m marginally better than my heart attack replacement, otherwise they wouldn’t have needed the event of my heart attack to get my job

          Sadly you’re probably not even better. They just have more information about you.

          Nevertheless, real resources will be wasted acquiring the information about your replacement.

    • thetitaniumdragon says:

      You’re viewing it as positional rather than absolute, but nootropics cause an increase in absolute performance as well; people would, in fact, do better using amphetamine in a judicious manner than they would not using it at all.

      I’m in favor of legalization because, frankly, at theraputic doses there’s little evidence that it is very risky. It is probably less bad than things like alcohol and tobacco, which are already legal, and marijuana, which is being legalized.

      Does it really matter if some people use it?

      I think the real issue is that it is likely that people who use it persistently over time will in fact acclimate to it; that’s honestly the biggest long-term “risk”, that in the end, it will only grant a temporary boost.

      But hey, it’s up to people as to whether or not that boost is worth it, I think.

      • cuke says:

        I find myself vacillating between supporting the idea of legalization because I lean that way about most substances taken recreationally (and then plough enforcement costs into education/treatment) and feeling wary of the performance arms race that amphetamines specifically seem to entail. They seem more like steroids than pot or alcohol, in that there are a lot of “legitimate” external pressures for people to use them, rather than people opting to use them for their own fun.

        The dystopian view I get of adolescent guys being under pressure (in certain socio-economic classes) to take amphetamines to get through school and hold onto jobs they hate seems very grim to me and I’d rather we figure out as a society how to make school and work more sustainable for adolescent guys (and everyone else too of course).

  4. crybx says:

    I don’t accept blog readers as patients

    Do you have some sort of process for screening if your patients are (or become) readers? I am nowhere near you, so this is me asking purely out of curiosity.

    • Le Maistre Chat says:

      Yeah, I’m VERY curious how he tracks the legal names of his blog readers so that he never accepts one as a new patient.

      • albertborrow says:

        I think it’s more like, he never accepts blog readers who a) know it is him and b) made the motivated decision to seek him out for help. He’s said something along this line several times on tumblr, at least.

      • Nornagest says:

        My guess would be that when he gets a youngish nerdy-looking patient out of the blue, he asks them “do you read my blog by any chance?”, and his readers, being nerds, either say “yes” (if they’re the scrupulous kind of nerd), or blush and stammer for a bit before saying “no” (if they’re the unscrupulous kind of nerd), whereupon he says thanks for coming in and gives them a referral.

        At least, that’s what I’d do if I were in his shoes.

        • Taymon A. Beal says:

          It can’t be quite this, because “Scott Alexander” isn’t his real name.

          • Nornagest says:

            Yeah, that’s why “do you read my blog”, not “hi, I’m Scott Alexander, do you read my blog” (as a previous version of my post read before I remembered he’d be inadvertently doxxing himself). He doesn’t have to say which blog, he just has to watch for the reaction.

            Out of respect for our host’s anonymity I won’t give details of how one might seek him out as a blog reader, but it wouldn’t be hard.

      • Vamair says:

        Scott didn’t mention that he doesn’t accept readers of his blog. Just “blog readers”. An unsuspecting patient is probably asked if they read blogs, and if they do, they’re not accepted.

        • roystgnr says:

          To be honest, if you’re treating attention deficit, and you want to have a decent success rate, “patients who don’t read any blogs” is probably a great group to practice on.

    • carvenvisage says:

      I didn’t read it that literally. (maybe ‘propositionally’ is a more precise word).

      And I can’t imagine that he hassles all of his patients with questions about blogs just to avoid the possibility of someone seeking him out.

      -It’s probably more like ‘he doesn’t accept patients as blog readers’.

  5. publius76 says:

    Once had a craigslist roommate who had Adderall-caused addiction/paranoia/aggression. He had been to an immersive treatment thing for it, but it failed, and he was back on Adderall, and still addicted/paranoid/aggressive.

    It was clear that it was destroying (perhaps largely already had destroyed) his personal life. Was a good guy and I wish him well but I wouldn’t be optimistic.

    Anyway, it might be worth double-checking the 1-in-1000 estimate on this… are the clinical data sources really reliable? I imagine this addiction is something that happens over longer periods of time, and, of course, with more-than-normal doses (but intentionally overdosing is undoubtedly very common for a performance drug like this.)

    What about looking at other sources… what do Google Trends search data for Adderall addiction/paranoia show, compared to other drugs? (See book “Everybody Lies” for extensive use of that method.)

    I haven’t done such a comparison, but based on my anecdotal impression from that experience I think it may be worth looking for some other data sources to check robustness of that finding.

    • Rick Hull says:

      How did you determine the medication was causing the destruction of his personal life and paranoid aggressive behavior? Did he have these tendencies inherently?

  6. apollocarmb says:

    Psychiatry is just bunk anyway. It’s just social conservatism and discrimination masquerading as something else.

    • Nornagest says:

      I think I’ve said this before, but you need to work on your bait.

      • herbert herberson says:

        The thing about psychology/psychiatry is that it’s really half a dozen things, most of which are accurate in some situations and bullshit in others. Freudianism, behaviorism, cognitivism, pharmacology, humanistic/Rogersian therapies, existential/Szaszianism.. the history of psychology is a parade of schools and paradigms that do an excellent job explaining some things and are often total bullshit when applied to others (altho I’d argue that Carl Rogers and CBT’s error modes are more around the lines of “trite” than “bullshit”).

        Are there any other fields that do this sort of blind man and the elephant kind of thing?

        • kaakitwitaasota says:

          Theoretical linguistics is kind of like this, particularly the various strains of generativism (the field Chomsky started). Government and Binding, X̄, Minimalism, Optimality Theory, are all very good at explaining some aspect of some language, but often fail horribly elsewhere. Usually, the creators try to patch them up by introducing yet more epicycles–e.g. generative tree-drawing started out proposing that morphology always plays second fiddle to syntax, which is the really important structure. Example of an English sentence modeled in X̄.

          That’s an easy conclusion to come to with the Germanic and Romance languages, and languages like Chinese, Japanese or Persian can be shoehorned into it, but it crashes and burns in the Americas and Australia. North American languages in particular tend to be extremely morphology-heavy, and syntax is often something of an afterthought–in many North American languages word order is used more for rhetorical effect and has little bearing on core meaning. (There are exceptions–e.g. the languages of California tend to give syntax a greater role than the Iroquoian or Athabaskan languages, and the Muskogean and Siouan languages have strictish word order. But for much of the continent, this holds true).

          So the generativists came up with Distributed Morphology, where you cut a twenty-morpheme-long Iroquoian/Athabaskan/Caddoan/Algonquian verb up into its pieces, hang those on a tree, and…well, here’s an analysis of the internal structure of a single verb in Wampanoag (an Algonquian language also known as Massachusett). The generativists come up with a new model every so often, but it’s been rather epicyclic so far: come up with a model (usually based on something from Western Europe or at least Eurasia), find a language that doesn’t fit (Arapaho, Navajo, Wichita…), try to fit the language into the model…

      • apollocarmb says:

        No bait. Why can’t people just be expressing controversial opinions?

        I have never even spoken to you before.

        • CheshireCat says:

          Because your “controversial opinion” is a sweeping generalization and you have done nothing to substantiate it. The easy heuristic is to dismiss assertions of this kind, and it is a heuristic that has justified its existence countless times.

          Besides, bait is bait, whether the fisherman put it there or not.

          • CheshireCat says:

            The issues I can see with your manifesto are numerous, so I will try to keep this short.

            A few of your criticisms are wholly valid. Namely, the societal nature of some definitions of mental illness, and historical bad practices in this realm. But these are not novel criticisms. They have been the subject of debate for decades, and are addressed in every Intro to Psych class. Much care has been taken to address this.

            Almost everything else here aren’t critiques, but open-ended questions that, again, have been either answered or hotly debated time and time again. Most of it boils down to “How can you define a mental illness”, which can be answered by a quick scan of the 4 D’s.

            Your point about paraphilias is completely off the mark, because paraphilias and fetishes are not considered illnesses in and of themselves. They only cross that line when they cause the individual discomfort or harm, or if they cause discomfort or harm to others. A dude and a double amputee getting it on in the privacy of their own home would not be considered evidence of mental illness by any legitimate practitioner. A dude spying on somebody changing or flashing a random person on the street would. The DSM-V’s sections on paraphilias focus on a forensic (criminal) setting.

            Frankly, this criticisms are nowhere near as damning as you seem to think they are. I could level most of them at the field of medicine as a whole, and they would be just as valid. (That is to say, not very)

            You seem so intent with throwing out the baby with the bathwater that I have to wonder: Have you ever had, or known somebody who has had, a serious mental illness? Because I very, very much doubt you be making most of these points if you did. I encourage you to read up on the experiences of people who have severe OCD, Schizophrenia, Agoraphobia. Ask yourself if they would tell you that they’re not mentally ill.

          • apollocarmb says:

            Well as I already said in the “manifesto”. I don’t deny schizophrenia etc can be harmful. I deny that there is any need for the mental ilness-non mental ilness dichotomy.

    • TheEternallyPerplexed says:

      Although there is a strong constructivist element in its diagnoses, they are not fully made up for sinister purposes… (interesting paper)

  7. Paul Crowley says:

    If they just want to be more productive, how come they’re asking for Adderall rather than Provigil?

    • toastengineer says:

      Possibly a combination of never having heard of it (I’ve only heard of modafinil from the rationalist-sphere, whereas Ritalin/Adderall is (was?) as much of a cultural phenomenon as “mother’s little helper” was back when) and, as Scott implied, possibly genuinely believing they have ADD because they’re surrounded by other number-manipulators who are either naturally super-attentive or already on Adderall.

    • Nornagest says:

      I think Provigil is only prescribed on-label in the US for certain sleep disorders. That seems like the kind of thing that’d be harder to fake than ADHD, or at least rarer and therefore more suspicious if someone comes in the door and starts asking for the drug.

      • 57dimensions says:

        There was at least one or two patients at the primary care office I worked at who were prescribed modafinil/Provigil for ADHD/attention problems, but the insurance companies really hated it and it took a crazy amount of paperwork to get them to approve it in the first place, and every time the prescription needed to be renewed the insurance would give us a hard time, requesting more paperwork. I think there were a few other patients who tried to get modafinil but their insurance wouldn’t allow it.

        • That raises a question that hadn’t occurred to me before. Suppose your insurance won’t cover a drug but your doctor thinks you should have it. Can he prescribe it for you to buy with your own money? Or is part of the deal, explicit or implicit, that insurance has to cover whatever he prescribes and he agrees not to prescribe what they won’t cover?

          • Gazeboist says:

            Yes, your doctor can write out a prescription for you. The prescription is permission for you to buy / the pharmacist to sell you the drug in question, and is generally purpose-agnostic.

            (I’m always confused when people talk about getting prescribed OTC meds. Is that just the doctor recommending you the drug in question? Is ibuprofen a prescription drug in Germany?)

          • Doctor Mist says:

            people talk about getting prescribed OTC meds

            A number of OTC drugs like ibuprofen are available in larger doses by prescription. Yes, you could just take more of the OTC drug, but the higher-dose prescription version may be covered by insurance and therefore (if your insurance is good) cost you less. I presume the reason for this weirdness is that the FDA thinks the large dose is risky enough that they want a doctor to be observing the result; I don’t know how many patients figure this out and just start taking the big dose OTC to save themselves a doctor’s appointment.

          • cuke says:

            In the US anyway, my understanding is that doctors often prescribe, order tests, and perform procedures that are not covered by insurance.

            Deplin is the pharmaceutical version of L-methylfolate, often prescribed as an augmenter (or stand-alone treatment) for depression. You need a prescription to get Deplin (though not OTC L-methylfolate), but insurance (last I checked) considers it a nutritional supplement or “food item” or something like that and they don’t cover it. I think it’s pretty arbitrary where the lines fall — there’s a pharmaceutical version of fish oil that some insurance covers, but obviously the kind you buy OTC is not covered. HRA and HSA cards have changed things somewhat because if you have one of those, you can (depending on the rules) spend some of that insurance money on things like supplements or not-usually-covered medications.

            Some of this can be nudged by doctors calling and talking to insurance companies to make the case for why this or that drug or lab test should be covered in this situation because alternatives aren’t workable for that patient. The insurance company still gets to say no if they want to.

            My husband just got Lyme disease for the second time in two years. Our insurance company paid for the Lyme test last year and they refuse to pay for the identical Lyme test this year because they said it’s “experimental” — no idea why. He tested positive unequivocally both times and was prescribed Doxycycline both times, which insurance paid for both times. Our insurance company sent us this year a 30-page list of changes in what drugs are covered and not under our plan — there’s no way a doctor can keep track of all that even for one patient.

            As a provider in my tiny corner of the mental health world, I’ve not encountered a system as broken as health insurance in my lifetime. It makes the DMV seem entirely efficient and stress-free. Just one small example: insurance companies often pay more (to the insured or the provider) for the same procedure if the provider is not in-network for their company. Insurance companies thus create an incentive for the provider to get out of their network and to require the patient covered by their plan to submit receipts for reimbursement, even though that costs the insurance company more money. Maybe a health economist could explain how that perverse incentive developed.

    • Douglas Knight says:

      1. They probably don’t know about it. 2. If they do know about it, they doubt Scott knows about it. Asking a new doctor for an exotic drug is probably not a good idea. 3. The lower schedule is a big deal. It’s easy to get black market modafinil by mail order.

      But the flip side is why isn’t Scott suggesting modafinil to these patients? Maybe he is, but it isn’t relevant to this blog post.

      (As 57 says, the label isn’t relevant to the law, only to the insurance companies. But these patients probably have gold-plated insurance and probably wouldn’t mind paying out of pocket, even before the generic was available. Plus they can legally order from India with a prescription in hand.)

    • Scott Alexander says:

      Provigil isn’t FDA-approved for ADHD, which means insurances won’t cover it. If you go for the legitimate stuff as opposed to buy-from-sketchy-online-vendors stuff, it’s too expensive for most people’s out-of-pocket budget.

      • Douglas Knight says:

        Where do you get drug prices? You once used goodrx. Does that still work? It says ~$60/month with coupon. Does that coupon require insurance coverage?

      • Eric Rall says:

        This probably depends on the insurance. I’m taking modafinil for ADHD, and it’s covered for me (Premera Blue Cross PPO, through my employer (Microsoft)). If I haven’t hit my deductible, it’s about $30/month from Costco and about the same from ExpressScripts home delivery pharmacy. I’m located in the Bay Area.

        One tip for prescribing it is that the per-pill price seems to be about the same for 100mg or 200mg pills, so if a patient only needs 100mg, their out-of-pocket is only half as much if you write the prescription for half a 200mg pill per day instead of a whole 100mg pill.

      • Don_Flamingo says:

        The sketchy-online-vendor/darknet-stuff is the legitimate stuff, though. It’s too cheap to produce and too easily available in patent-agnostic India (where it’s OTC) to be a good candidate for counterfeiting. And vendors can maintain their accrued good reputation even if any particular market gets shut down (as they often do).

      • bean says:

        I’m considering trying to switch, as Oklahoma limits you to a 30-day supply of Concerta (and apparently other ADD meds). I’m not sure modafinil isn’t covered, but it’s a lot cheaper if I can get my insurance to pay for it, and it’s Schedule IV, so I should be able to get a 90-day supply. Will report back with results.

      • cuke says:

        Remind me, how does this off-label prescribing work? I know I’ve been prescribed drugs for off-label uses and my insurance has covered it every time. For instance: mirtazapine for insomnia, low-dose naltrexone for mystery auto-immune condition.

        If doctors frequently prescribe off-label uses and insurance covers it, how can they not cover Provigiil for ADHD?

        • AKL says:

          Insurance companies maintain lists of the drugs they cover called formularies. If a drug is not listed on the formulary, it will not be covered unless the patient / doctor contact the insurance company for prior approval. MOST drugs on formulary can be prescribed for any use (on / off label). However, some drugs have restrictions: step therapy (patient must try and fail drug A before drug B will be covered), quantity limit (Rx cannot be greater than 30 days, e.g.), and prior authorization (insurance company must review the Rx and approve it or the drug will not be covered) are the most common.

          Most drugs with abuse potential will require prior authorization, and one of the criteria might be “only covered with a diagnosis of ADHD” or whatever. So while off-label prescribing is common and frictionless (at least vs. on-label prescribing) in most cases, for most stimulants, most insurance companies will require a specific diagnosis.

    • rosvicl says:

      In some cases, they may have tried it already. There are neurologists who will try it off-label for fatigue in patients without those sleep disorders. If the insurer says okay (after too many phone calls), and it doesn’t help, Ritalin or Adderall is the obvious next step. Doctors really don’t like to look at a patient and say “I agree you have a problem, but I can’t help you” even when that’s true.

  8. AndyMcKenzie says:

    Great post. A few thoughts:

    1) I think another key question in re: tolerance is whether people can go off them long-term and be basically OK after an initial washout period, without any psychologic dependence. If you’re starting people on the drugs when they are young and healthy it might make sense, but what happens when they get older and aren’t as healthy? If they aren’t able to stop it without losing their jobs, that seems to me like a big problem. But if they are able to stop, great.

    2) As you know, the issue with hypertension is definitely not just heart attacks. Kidney disease, peripheral vascular disease, stroke, and risk of dementia later in life all come to mind. 3-8 mmHg is not nothing; for example, when it comes to stroke, one meta-analysis of 100+ RCTs found that a “blood pressure reduction of 10 mm Hg systolic and 5 mm Hg diastolic was associated with a 41 % (33 % to 48 %) reduction in stroke for all trials” [PMC3838588].

    I know you posted links claiming a paradoxical lower risk of stroke in patients on stimulants, but I’d be really wary of relying on retrospective studies because of the massive confounding effects (healthy-person bias, etc). I basically wouldn’t trust them.

    3) What do you think about the role of equity? If people need good insurance and/or cash to get access to the one or more psychiatrists who will prescribe them the stimulants, it seems to me that this makes it more likely that “the rich get richer” insofar as they will do better in school and in their careers. This is troubling. Of course there’s pretty much nothing you can do about it as an individual psychiatrist.

    None of this is to criticize you or this important post — if I were in your shoes, I think I’d probably act the same way. The main exception being that I think I’d be a little bit more worried about effects on blood pressure if stimulants really do cause an increase of 3-8 mmHg systolic, and maybe try to choose one that causes less of an increase in blood pressure (although from a quick search, I couldn’t find a clear difference between Ritalin and Adderall).

    I’d also want to think about the long-run consequences for both the patient (getting off the stimulants eventually) and for society (equity across socioeconomic classes) — which I’m sure you have, and you can’t discuss everything here.

    • Gazeboist says:

      Tolerance is not dependence. Scott mentions both.

    • CheshireCat says:

      Re: Point 3, speaking as an ADHD person whose insurance stopped covering the meds: Adderall can be surprisingly affordable. I went down to Costco with a coupon for $40 for a month’s supply and discovered that their basic asking price is *even lower*: 26 dollars for a month’s supply of 20mg twice daily!

      To be fair, I shopped around and nobody has it anywhere near as cheap as Costco does. Usual quotes were in the $80 range. I am also fortunate enough to only have to take about 10mg once a day, so I’m stockpiling a little in case this low pricing is short lived somehow. I asked my doc to prescribe 20mg even though I only take 10, because it works out to be a little cheaper and more convenient that way.

      I don’t know about you, but paying ~$13 a month in order to actually function seems like a really good deal to me.

      • AndyMcKenzie says:

        Interesting, thanks. I meant in terms of access to >= 1 psychiatrists to do the original prescribing, though; hadn’t really thought about the cost of the drugs themselves.

        • CheshireCat says:

          Oh, right. Well at least in California, insurance is provided for free by the state to people below a certain income level. That’s what I use. Though in my experience, all 3 psychiatrists I’ve had to see had no problems prescribing the meds. I almost felt guilty to not be scrutinized at all, they just prescribed them after asking a few questions.

          • AndyMcKenzie says:

            I’m glad to hear that it worked out for you and thanks for the details. I’ve read that in some other areas, especially rural ones, getting access to a psychiatrist can be difficult. It seems unfair that people in these parts of the country wouldn’t have the same access to the meds. But I’ve also read that ADHD meds can be prescribed by primary care physicians too, which I imagine may be more common in areas where patients have less access to psychiatrists.

  9. ksvanhorn says:

    Any plans to do a similar write-up on modafinil?

  10. James Miller says:

    I took Adderall for around a year about seven years ago. It made me happier, more productive, and reduced my need for sleep. Tolerance definitely set in and eliminated a lot of the early advantages. I stopped taking the drug because a primary goal became to live long enough to live forever and I figured Adderall probably slightly reduced my chance of surviving to a singularity. I figured that consistently needing less sleep was probably a bad sign. Interestingly, since Adderall reduced how much I slept it probably increased my expected waking lifespan if you ignore the possibility of radical life extension within my lifetime.

  11. The Nybbler says:

    Also, I never meet 60 year old smokers asking for Adderall.

    Of course not. Who needs amphetamines when you have cigarettes? Side effects seem to be generally worse for cigarettes, though.

    Maybe suggest methamphetamine to these patients. This will weed out those who have enough dignity left to not want to be tweakers. Though perhaps that’s filtering out precisely the wrong set. And you’d probably not be able to ethically prescribe it anyway.

    Seems to me it would save a lot of everyone’s time and hassle to sell this stuff next to the No-Doz.

    PS: I don’t accept blog readers as patients, and I won’t prescribe you Adderall just because you liked this post.

    Meh, I get it the old fashioned way, through daring midnight raids on chemical supply companies for precursors, then a synthesis lab hidden in industrial parts of New Jersey. All financed by also producing pseudoephederine (known on the street as “Red P”) and selling it for cash to people with stuffed-up noses who have exceeded their legal allotment.

    • Doctor Locketopus says:

      > Of course not. Who needs amphetamines when you have cigarettes?

      The combination of the nicotine and MAOIs in tobacco (with the latter being quite important — vaping and nicotine gum just aren’t the same) and caffeine is damned near perfect for inducing the focus state.

      Too bad it kills you.

    • Dahlen says:

      You’re joking, right? If you chain smoke, you feel like the room is spinning with you and you want to puke. If you abuse amphetamines, you can’t sleep for a week. They’re not remotely comparable.

      • The Nybbler says:

        I’m joking about “Red P” (though racemizing legally-available levomethamphetamine and producing ephederine/pseudoephederine from it using the classic synthesis from the Journal of Apocryphal Chemistry sometimes seems like a good idea) and kinda half-joking about suggesting meth (as Desoxyn) to test drug-seeking patient’s self-respect, but I think certainly cigarette smoking can provide the same focusing effects as other stimulants, and some people may be using cigarettes to self-medicate for ADHD.

  12. abstract gradient says:

    a lot of people are really, really wrong about their internal experience http://elephantinthebrain.com/ ? and this sounds like the sort of thing people would be wrong about

    substances with this dynamic aren’t in the ancestral environment, right?

    • caryatis says:

      I had that thought too. Why should we assume that people who believe Adderall continues to work for them are correct?

      • Alsadius says:

        Subjective experiences are Bayesian evidence. Whatever expectation we have of their effects before hearing from users, hearing “It works really well!” from users as a whole should increase that expectation relative to baseline. It may not increase them a lot, if you think they’re unreliable narrators, but it should increase it at least a little bit(unless you’d use “This doesn’t work for me at all!” as evidence of its success?).

        • caryatis says:

          Yes, this would be a valid point if self-reports were all the evidence we had. But compared with the RCT data we have, self-reports are of very little value. I’m surprised Scott gives them so much weight.

      • bean says:

        What if others close to them confirm this? My parents were married for a dozen years before my dad started medication, and I’m very sure that my mom would have noticed if the ritalin had stopped working in the past 18. Regression to the mean is all well and good if the person doing the regressing is still growing, but it’s not that likely when the person starting the pills is past 40.

  13. Jeremiah says:

    Audio version done. MP3 Here Or you can get it in the podcast feed. Apologies if I butchered any pronunciations.

  14. Garrett says:

    A few comments from a sample-size of 1:

    I was diagnosed with ADHD at age 27, well after getting 2 degrees, my second job, house, car, etc. Great finances, with the only part missing (then as now) being the relationship side of my life. I was initially prescribed methylphenidate. It changed my life.

    I could actually stop and enjoy the breeze and the clouds. It was fantastic. Unfortunately, there were certain side-effects. Pretty much all desires were suppressed while it was active. This meant that food was pretty unappetizing. At the end of the day, the come-down was horrible. In addition to having a day’s worth of hunger come at me, there was also a day’s worth of lust. So I’d find myself furiously masturbating with an ice-cream tub.

    At some point, I was switched to amphetamine. In addition to the tablets tasting better, it didn’t seem to have nearly the side-effect profile and so I find it a much better choice.

    Finally, observations, having taken amphetamine for a long time:
    The “life feels fantastic and now I know why this is a schedule II drug” feeling subsided after about 4 months of constant/prescribed use. I no longer have anything that resembling a “high” from the drug.
    The “this is better than any coffee” wake-up feeling (no, seriously, it’s amazing) only worked for about the first 3 days.
    The “I get improved focus and am less likely to say offensive things” experience seems to keep working 5+ years on.

  15. melboiko says:

    Classic The Last Psychiatrist post on the topic: “How to take Ritalin correctly” (“about Adderall, Dexedrine and others”). Choice quote:

    First, a disclaimer: you should only get Ritalin for indicated disorders by prescription from a physician. Ok? Because the doctor will rigorously apply artificial and unreliable diagnostic categories backed up by invalid and arbitrary screens and queries to make a diagnosis. So after this completely subjective and near useless evaluation is completed, your doctor should be able to exercise prudent clinical judgment to decide if Ritalin could be of benefit. In other words, he will ultimately decide based on little else but his own prejudices and/or consult the Magic 8 Ball. That’ll be $250, please. Cash appreciated.

  16. Squirrel of Doom says:

    Remind me, is “Meth” and Adderall…

    -A- The same thing?
    -B- Technically different but practically the same?
    -C- Related but substantially different?

    • Douglas Knight says:

      B. The two big differences are (1) if you smoke it, it’s a fast rush and it’s addictive, compared to pills; and (2) whether you take it to go on a binge, vs take in conjunction with regular food and sleep. Compared to ways of using the drugs, the chemical differences are irrelevant.

      There are subtle differences. There are even multiple formulations of amphetamine, such as benzedrine, dexedrine, and adderall. Meth is yet another thing, but compared to ritalin, meth is just another form of amphetamine. And Scott isn’t even bothering to distinguish ritalin from amphetamine.

      (Some details: Adderall is a mixture of different salts, to dissolve at different rates and spread out the rush, to discourage recreational use and/or addiction. The other difference is the effect on the central vs peripheral nervous system. d-methamphetamine is said to have the most pure central effect, followed by d-amphetamine, l-amphetamine, and finally l-methamphetamine, which is available over the counter as a nasal decongestant. The peripheral effects can be unpleasant and discourage large doses. The original was benzedrine, a 50/50 mixture of d- and l-amphetamine, just because it’s easy to make. Dexedrine is purified d-amphetamine, hence the name. Adderall is a 75/25 mixture of d- and l-. I think it’s cut with l- just for the negative effects.)

    • The Nybbler says:

      Related but substantially different. If you’re looking for prescription meth the brand name is Desoxyn; pure D-methamphetamine. Adderall is 75% D-amphetamine, 25% L-amphetamine, in three different forms. The levo form has different effects, and the methyl group which gives “meth” its name changes the effects significantly.

    • MNH says:

      It’s C. They’re both amphetamines, but the differences are definitely substantial in effects, side effects, addicitivity, etc. The most salient difference, probably, being that meth is directly neurotoxic.

  17. Thibaut says:

    The full text of ‘Relapse of Paranoid Psychotic State in Methamphetamine Model of Schizophrenia’ is online here as a PDF: https://academic.oup.com/schizophreniabulletin/article/18/1/115/1905631

  18. Deiseach says:

    I am genuinely curious to ask this: how do you think that prescribing Adderall (or similar) compares in Europe (or the British Isles to be more particular if “Europe” is too big a canvas) as against the USA?

    I’m years removed from formal education, and back when I was in secondary school dsylexia wasn’t even a thing yet – you were just stupid. Maybe in this year of 2017 Irish university students are all doped to the eyeballs on stimulants prescribed by doctors but I really don’t get the same sense of that.

    Then again, reading posts about US education systems, plus the kinds of hours and work-weeks you expect out of your college-educated white-collar professionals, are insane by European standards, so there isn’t perhaps the same pressure for “I need to concentrate with unblinking focus for eight hours of study per night to get the all As in my tests to get the results I need to get into a good university where I will dope myself to the eyeballs to study for the tests that will get me a good degree that will get me a good job”. (We were expected to study for several hours a night, particularly when coming up to the national exams, when I was in school but we were also expected to do it unmedicated).

    • Tracy W says:

      I think the US education system is quite different – e.g. A’s are much easier to get than in NZ or the UK. Calculus is a university level course. My friends who went to US universities for post-grad thought the German students were the best prepared and American students were about average.

      • Nornagest says:

        Calculus can be a university-level course in the US, but it’s not uncommon for college-bound students to take it in high school (generally in their final year).

        • Tracy W says:

          In NZ we started learning calculus when we were 15 in the ordinary maths classes. So three years before end of high school.

    • Creative Username 1138 says:

      Drug prescriptions in the US seem to be much more relaxed in general. In another thread I was pretty surprised to read that people get opioids after wisdom teeth removal in the US. Here (Germany) you don’t get anything stronger than ibuprofen.

      • Garrett says:

        I had my wisdom teeth out when I was living in Canada. I was given Tylenol with Codeine (T3) for pain after removal. And boy did I need them.

        Ibuprofen has the problem of encouraging bleeding, so my understanding is that is discouraged perioperatively here.

  19. Mammon says:

    FYI: ritalin mostly just gets me extremely high, it’s a great party drug. Meanwhile Adderall makes me feel particularly normal.

  20. Paul M. Rodriguez says:

    Sci-Hub is not working for me at the moment, so I can’t cite any papers, but I think it’s well-established that narcoleptics are resistant to addiction. A 1-3% rate of addiction among narcoleptics might suggest a higher rate in the general population.

  21. Alsadius says:

    You discuss taking a few days off every couple weeks to reduce tolerance. I’ve been on methylphenidate for about a year and a half now, and I’m starting to wonder if I may be developing a tolerance. Is taking breaks recommended for Ritalin as well? My doctor had me phase it in gradually over a couple weeks when I started, which made me think it’s one that you should not be taking breaks from, but tbh I trust you more than my GP on this stuff(he’s good as GPs go, but not a specialist).

  22. caryatis says:

    Scott says:

    >I don’t think there are good data here, but my intuitions and personal experience is that “addiction” of the sort you get with heroin or tobacco is very rare, at least for responsible people taking stimulants as prescribed without a personal or family history of addictive behavior.

    Thing is, there are actually a lot of us with a history of addictions, or family members with addictions. And a lot of the people for whom that is true are going to avoid disclosing it to a doctor, especially when they are actively trying to get drugs from that doctor. So, I come out a bit more cautious than Scott.

    On another topic, I’d love to see a discussion like this of potential benefits of benzos for anxiety.

  23. MarginalCost says:

    How does the relative ease (or gameability if you prefer) of getting an ADHD diagnosis for medication purposes compare to the difficulty of getting approved for extra time on school tests?

    • Fossegrimen says:

      No idea about the US, but around here the stupid thing is that it’s the same criteria, which means that you can get none or both, but not one or the other.

      • Gazeboist says:

        Same in the US (roughly), in my experience. Both require a diagnosis and a specific signoff from a doctor. I feel a lot better asking my psychiatrist to sign off on extra time than asking for meds, though.

        • At a slight tangent, the fact that some students got extra time on exams is one of the reasons I started trying to give exams that most students could finish before the time was up.

  24. hshhh says:

    As an academic, I’ve encountered numerous colleagues taking adderall, and it’s usually been followed by pretty negative outcomes – failed exams, subpar manuscripts, intense bursts of writing that go nowhere. It’s scared me off ever trying it. That said, I rationally realise there must be a HUGE selection effect here: the moment when you think “hmm, I’m going to contact a bunch of random people to see if they have Adderall” is not likely to the moment in your academic career when things are going just great.

    Still, I do harbor (perhaps without good reason) a suspicion that Adderall might boost linear analytical abilities only at the expense of certain kinds of holistic or creative thinking, and in a field like mine (philosophy), the latter are arguably as important as the former. I say this based on no hard data (and I am very open to hearing others’ experiences), but on the fact that introspectively I generally find there to be a quite deep (maybe even conceptual) tradeoff between the two kinds of thinking.

    • Gazeboist says:

      “Intense bursts of writing that go nowhere” sounds a lot like what happened to me when my dose was too high. I might be able to take a couple of those ideas somewhere if I had the time, but at that time I was just desperate to get everything written down, and I also drifted a bit out of the field where I could be said to have some expertise. It certainly didn’t make me less creative though.

    • Dahlen says:

      Still, I do harbor (perhaps without good reason) a suspicion that Adderall might boost linear analytical abilities only at the expense of certain kinds of holistic or creative thinking

      It’s not just a hunch. Stimulants seem to do this by decreasing the activity of what is known as the default mode network (or, as I like to call it, the idling system of the brain) while increasing the activity of its complementary system, the task-positive network. The default mode network is the reason why random thoughts pop into your head unprompted, which can be very useful in a wide array of activities, such as writing. OTOH, this is also why I can’t read a book without needing to take a “thinking break” when something in the book gives me a thought I’d like to ruminate on. Other people with ADHD face similar difficulties. That’s why stimulants are often experienced as creativity blockers.

  25. blacktrance says:

    Data point: I’ve been taking Vyvanse (which is metabolized into Adderall) daily for a year and a half, supplementing it with magnesium. I developed some tolerance in the first few months, but there were no noticeable changes after that, and it continues to be effective at the same dosage. I did develop some dependence – missing a dose feels like getting a cold – but I consider it worth it overall and I’m still happier and more productive on it than before I started it.

    • outis says:

      I was prescribed Vyvanse for ADHD. Very low dose. The first time I used it, it gave me a sort of high, and increased my focus enormously pretty much instantly. The second time, I did not get any high, but my focus still increased. Because I am scared of neurotoxicity, and of drugs in general, I try to only take it when I really feel that I’m spinning my wheels and can’t make any progress. This happens every few months.

      The same low dose I started out with still gives me enhanced focus, but I often end up focusing on a slightly different task than what I’m really trying to do. Also, it seems to be less effective than the first time I took it. And I never got the “high” again after the first time.
      I think I’ve taken less than 50 doses since I started it, more than a year ago.

      • blacktrance says:

        For me, it started out producing a significant high, but it gradually diminished and went away after three months, though even now it continues to produce a good mood about 1-2 hours after I take it.

        I often end up focusing on a slightly different task than what I’m really trying to do.

        I think that’s how stimulants work in general: they give you the ability to focus, but you still have to point it in the right direction.

  26. adaldrida says:

    How about withdrawal? Does physical dependence fall under “addiction” as you’re thinking of it?

    I took Ritalin from about age 15 or 16 to 22, although I only managed to take it consistently by age 21 or so. Before Ritalin, I was really bad at focusing. When I was 22, I was moderately bad at focusing on the days I took it, and on the days I didn’t take it I was extremely bad at focusing, depressed, and had an awful headache. (The withdrawal was bad enough that I never skipped a day on purpose, but I sometimes lost my medication or didn’t manage to refill it on time.)

    Now I’m 27 and the way I function without Ritalin is the way I used to function with it. But I’m never in withdrawal, so life is way better now.

  27. 57dimensions says:

    I really don’t get the Adderall/Ritalin hype. I was prescribed Ritalin for excessive daytime sleepiness and it was not great. On 10mg I felt nothing, but on any more than that my heart felt like it was going to beat out of my chest, which although I knew it wasn’t dangerous, it felt terrible and would last for like two hours. They switched me to XR and that helped with the palpitations. I never felt more focused and I definitely did not get more school work done, which is why its use as a study drug confuses me–I wish it worked for me that way, because at the time I was nearly failing high school. I also didn’t get any kind of pleasurable high from it, and would never have tried to take more to achieve that since I already had unwelcome side effects at a therapeutic dose. Oh and it also made me sweat like crazy, a side effect that I’m some what paranoid remained after I stopped taking it because it feels like I still sweat a lot more than I used to before. But because of this I did find the best antiperspirant ever: Certain Dri. I highly recommend it to anyone, it is unbelievably effective.

    • Incurian says:

      People can react differently to drugs. I had a similar experience with Ritalin, but found Adderall to be highly effective.

  28. Some Troll's Serious Discussion Alt says:

    Does anyone else get/is there any literature on weird perception effects from adderall? It definitely has some sort of weird effect on my vision sometimes.

    • Gazeboist says:

      Not that I’ve noticed. What’s the actual effect you’re seeing?

      • Some Troll's Serious Discussion Alt says:

        Individual objects all stand out and get really distinctly separate from each other. Instead of seeing ‘a pile of clutter’ on my desk, I’ll see a stapler, a calculator, a pad of sticky notes, payroll schedule, and a pair of ear buds” on my desk, if you know what I mean.

        Its like the difference between taking a picture of a room versus taking a picture of every object in the room, printing them all out, then cutting them up and meticulously reconstructing them into a 1:1 collage of the room. Everything is still there, but none of it quite fits together anymore and you can tell that it was all assembled together from totally separate images.

        I’m not perfectly happy with this explanation or the analogy, but I think they are the best I can do.

        • Dahlen says:

          That’s not a perception effect, I thought you meant stuff like blurred vision or paresthesia or altered colour perception. It ties directly into the attention-enhancing effects of stimulants. This means that, if you went looking for your stapler, you’d actually be able to notice it on your desk instead of staring blankly into space and going “Uhhhh…”

          One of the tests I was given to see if I really had ADHD consisted of ordering all the numbers from 1-100 that were jumbled together into a 10×10 matrix. If you can’t find the 42 in there, this is exactly for the same reason why you can’t see your stapler in your “pile of clutter”. (Spoiler warning: I failed the test.)

        • Gazeboist says:

          I’ve never experienced anything like that. It sounds like the kind of thing that people might not always mention unless you prompt for it specifically, though, in which case it might be difficult to study.

  29. userfriendlyyy says:

    I’ve been on Adderall for over a decade. Started at 30mg/day now up to 60 (not XR) but, as you mentioned some days more, other days I don’t take it. The main point I wanted to bring up regarding tolerance is that I try to take at least 1 day a week off of it, but on that day I’m lucky if I get out of bed. You only mentioned a tolerance to attention regulation; which I haven’t experienced at all. I do have a HIGH tolerance to the amount of energy stimulants give me and unfortunately have a dependence on that aspect of the meds too. I suspect that is the more common case.

  30. Candide III says:

    The rest of us start fidgeting and checking our cell phone somewhere around the thirty minute mark.

    I think this is a normal reaction. Evolution hasn’t equipped our brain for staring at spreadsheets of tiny numbers or pages of code. Speaking from experience, once this reaction hits, it’s already too late, you’ve lost the beginnings of concentration and must start over. One has to catch the preliminary phase — so to speak, when you are not yet fidgeting but only starting to feel the itch — and suppress or re-channel it. If you succeed, you “catch the wave” and bang out the code for as long as nobody interrupts you with something irrelevant, or until exhausted. It helps if you feel really interested in what you’re trying to do, but it’s neither necessary nor sufficient. Probably there are techniques for such suppression or re-channeling, but I don’t know what they are.

    • Garrett says:

      > as long as nobody interrupts you with something irrelevant

      And yet tech companies persist with open-planned offices.

  31. Clegg says:

    What about the possibility of managing the Parkinson’s risk with nicotine? There are population and animal studies suggesting that smoking/nicotine reduces the risk of Parkinson’s. And now this study finds that nicotine reduces meth-induced Parkinson’s-like dopamine deficits in rats.

    Possibly related: Nicotine has similar effects to Adderall. The rise of widespread prescription stimulant usage roughly overlapped with the decline of smoking, especially among professionals of the sort Scott talks about here, right? It would be interesting to see if declines in smoking correlate with increases in ADHD diagnoses.

    • Douglas Knight says:

      Actually, this is the second rise of amphetamine. We only caught up to 1970 usage about a decade ago. The previous wave was more recreational, but it was also substantially professional.

  32. Petja Ylitalo says:

    “5. Some evidence for tolerance after several years, though most patients will continue to believe it is helping them. No sign of supertolerance where it actually makes the condition worse.”

    This was a bit unclear to me. Is there evidence against supertolerance, or is there just no evidence on the subject in either direction?

    Also, Kelsey/UnitOfCaring mentioned forgetting to do things like it would be part of ADHD, is this common?
    Would´ve thought it should be the other way around, focusing on a thing -> forgetting to do other things.

    • Gazeboist says:

      When you have ADHD, it’s less that you can’t focus than that your focus lands randomly among things you could be focusing on, so the moment your mind starts to wander, you’re gone. There’s actually a symptom of ADHD called hyperfocus, which is pretty much what it sounds like. Some people differentiate between hyperfocus and “flow” and some don’t.

      Regardless, yes, memory issues are a thing with ADHD, both in terms of forgettimg to do things you committed to ahead of time (which to me always felt symptomatic of my inability to sense time passing) and short term things like “why am I in this room again?”

  33. chucko says:

    I think the view of only taking the (small) risks into account when people ask for Adderall is a little bit too short sited. What about the anticipated advantages? As is mentioned, cognitive abilities don´t get enhanced by it. And where is the evidence that it enhances fokus or attention in otherwise healthy adults? There are studies about that and they don´t seem to suggest any positive effect on objective markers of attention. The best one I found is this dissertation: http://trace.tennessee.edu/cgi/viewcontent.cgi?article=4811&context=utk_graddiss
    They also controlled for subjective markers (perceived Alertness, Focus, Energy and Motivation) where the stimulants group had an advantage over the placebo group, but that did not lead to better performnce in tasks where concentration is needed (fo example the D2 test):

    “participants who reported greater changes in these positive symptoms did not actually perform any better or worse on the four primary performance measures across time. Thus, despite feeling as though they had increased alertness, focus, energy and motivation, these enhancements did nottranslate to improved neurocognitive functionin”

    Adding this to the cost-benefit analysis, it seems to me that any possible risk is too much for someone who is otherwise healthy and will not have his focus actually elevated through this

    • MuncleUscles says:

      The claim is not that it lets you focus better, but that you can focus for longer on normally boring tasks. The increased motivation is the desired effect, and I don’t think you can dispute it does that. Whether it is worth it depends on the task at hand

      • chucko says:

        Can you name any studies supporting that claim? I cant really find RCTs supporting that…

        • MuncleUscles says:

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3489818/

          One function, which is reliably improved by stimulant medications, is sustained attention, or vigilance.

          Though they do not provide a source for that, or at least I cannot find it.

          But really, while you can question people when they self-report feeling smarter, I think ‘ability to focus for an extended period of time’ is something that can be reliably self-reported, since everyone can reliably measure time.

          • chucko says:

            I am not questioning that they report that. They certainly feel more motivation (more than induced by placebo), whether that leeds to actual higher ability to keep your attention up for a longer timer (more than would be induced by placebo), that I am questioning. But there is certainly a lack of good research about that whole problem.

          • Gazeboist says:

            Actually, one of the effects of stimulants that I experienced was that I developed a sense of time, which I didn’t previously know I lacked. All of a sudden I could anticipate when a timer or an alarm would go off without looking at it. This ability mostly stayed with me when I was off medication, though, so take it with a grain of salt.

  34. as1018 says:

    There is a rare side effect that you didn’t mention. New research shows an increased risk of pulmonary arterial hypertension in both amphetamine and metamphetamine users. It is thought that they increase release of serotonin that then constricts the arteries in the lungs and causes remodeling of the lining of the arteries. There may also be damage to the mitochondria in the lining of the arteries.

    This is a serious disease that is often overlooked until it is fairly advanced. The primary symptom is shortness of breath which can be attributed to many factors, such as just being out of shape. It takes an echocardiogram and a heart catheterization to make the diagnosis. The disease has a high mortality rate and is very expensive to treat. It is a different type of hypertension from the one you mentioned.

    The risk of pulmonary arterial hypertension with amphetamine use is not currently known. It may increase in proportion to dose and the length of time the drug is used. All of this its currently being investigated but it appears to be a very serious risk. Perhaps future studies in genetics will help identify the people who are most at risk of this side effect.

  35. Saint Fiasco says:

    RE: the study on tolerance in children, I think it’s important to take into account that children often perform to meet expectations.

    Suppose for example that a child, through lots of sweat and tears, has very mediocre grades in school. Then they start taking Aderall and their grades improve for a year. The next year, even if their grades go back to being mediocre, it might be that they got those grades with much less sweat and tears.

    The study only looked at “grades earned in school, arrests, psychiatric hospitalizations, or other clinically relevant outcomes”, the latter of which does not seem to include things like happiness and life satisfaction. If we consider that children’s lives are meaningful for more than just getting good grades, a drug that helps them get the same mediocre grades with less effort should not be considered to have “tolerance” issues.

    As an analogy, consider that even though many people drive faster when they wear seat-belts, they are not necessarily irrational for doing so. They really are able to get to places faster (for a given level of risk) than they would without seat-belts.

  36. brentdax says:

    Aggressive Behavior: This is just going to be the same as psychosis. Adderall isn’t going to magically turn gentle old grandmothers into killing machines. If you’re already a kind of violent guy, and you take a lot of Adderall, maybe it’ll push you over the edge.

    I think you might be treating this too lightly. The first time I drove while using Adderall, I noticed that I was changing lanes more often and leaving less space between my car and others. I’ve noticed other small behavior changes too. This is fine for me—I’m probably still not as aggressive on average as other people in these areas—but if Adderall shifts all patients slightly towards “asshole”, that means the average Adderall patient will probably be slightly more of an asshole than the average non-patient.

    • carvenvisage says:

      *than they are off adderall.

      Also, is ‘asshole’ the right word for your cutting things close on the road? That sounds more like e.g. ‘reckless’, ‘confident’, ‘impatient’, or ‘aggressive’. Unless you were doing it specifically to stress people out or something?

    • Dahlen says:

      Not necessarily, and not with any ADHD drug. This seems to be more of an effect of amphetamine as opposed to methylphenidate, and both (I think) make me considerably less of an asshole than in my unmedicated state, mostly through increasing my patience reservoir. I really can’t believe how Zen-like I can be when medicated. Sure, this is one of the matters in which people with “real” ADHD are said to differ from “healthy” people, but perhaps the average change in aggressiveness may even be negative.

  37. John Schilling says:

    On the question of tolerance and whether survey respondents can remember their baselines from many years in the past: Caffeine tolerance is as I understand it both substantial and extensively studied, at least compared to Adderall and Ritalin. Perhaps asking identically-worded questions regarding both caffeine and adderall, and comparing the former to the known or CBE tolerance curve for caffeine, would allow calibration for baseline shift?

    He says, just after this year’s study is complete.

    • Incurian says:

      Caffeine tolerance may come on too quickly to be a good comparison. It takes me a month or two to need to double my caffeine intake for the same effect, it’s easy to notice. If adderall takes years to develop tolerance, it may happen so gradually that you wouldn’t notice.

      • John Schilling says:

        Good point. Still, people who have been drinking coffee for years presumably have not been doubling their dosage every few months, so the comparison may be useful at the asymptote. And of course we (by which I mean Scott) can ask the question across a range of time scales to see if there is a trend.

  38. Deiseach says:

    Okay, having looked online, I found this article.

    Bones of it: yes, these kinds of drugs are being used by Irish university students (estimation around 9%). How do they get them? Most buy them online (there’s not the same “go to the doctor and say you can’t concentrate and get a prescription” route as Scott describes). Attitudes of students? Great to let you cram in a short time before the exam. Attitudes of the medical profession and university administrations? This is not something desirable.

    I do think there is (as yet) a big difference in attitude over here: the dosing up of children from a young age to let them focus in school is not as routine, if it happens it’s for very serious and definite ADD/ADHD (and not just “Johnny fidgets in class”), and it’s not normal(ised) for third level students and adults to use as routine to help them work.

    That may change. If students are buying them off the Internet (presumably copying American students whose stories they can read online about the use of these kinds of drugs) and if they’re perceived as “you can party the year away, then load up on these, study for twenty-four hours straight, and pass your exam” then people will take them. And if mid-twenties young adults are going into work, having developed this habit in college, I assume they’ll carry it over. So Irish attitudes may come to resemble American ones: I need this to be able to pass my exam/do my job, if I have to fake having ADD to get a prescription, I will, and doctors will become more accustomed to writing prescriptions for these drugs for people who walk in to the surgery and go “I’ve become terribly scatter-brained recently and it’s affecting my personal and work life”.

  39. fortaleza84 says:

    Does this drug create feelings of pleasure or euphoria? If so, it’s highly dangerous and anyone who thinks otherwise is fooling himself.

  40. maintain says:

    >(it’s because his colleagues are all on Adderall already – but telling him that will just make things worse)

    Really, what percentage of successful people rely on stimulants, and would not be successful without them?

    • A Definite Beta Guy says:

      Now, this is an excellent question. I got the impression in HS and College that many high-achievers used something like Adderall/Ritalin. Like the heavy marijuana use, this was not something I was privy to until Senior year (cause I was insanely unpopular).

      When I was in college (mid-tier state school) my classmates were legitimately surprised that I did NOT ever take any Adderall. Not all of THEM did, but I’d say the proportion was around 1/3?

      Post-college, a lot of the kids who went into Public Accounting started up Adderall. Public Accounting is a lot like Investment Banking where you might be regularly working 80-100 hour weeks.

      My impression is that the prevalence is less than marijuana and recreational ecstasy, but higher than cocaine.

      Is it necessary to succeed? I honestly cannot tell you. I don’t think so, but I’m biased because I have an easy time staring at spreadsheets all day long. Apparently some people struggle with this? I mean, I get pissed when I am trying to debug something and might have to step away, but I never get distracted. I just get pissed as I become more exhausted.

      I will say that using Abraham Wald logic, that I come across plenty of successful people who use Adderall. There is no one in my friend group that uses heroin or meth. I therefore have a strong prior that these drugs are EXTREMELY destructive. I realize that this has no relation to your question, but I find it interesting.

  41. roystgnr says:

    Some people will discuss alternative options, like behavioral treatments, or non-stimulant medications

    Oh, wow! I’m pretty sure I don’t suffer from ADD/ADHD/whatever, but as a Regional Manipulator of Tiny Greek Letters a Computer will Turn Into Numbers, I’ve got to admit that anything which improves my focus would be an invaluable…

    Behavioral therapy for ADHD is not very good and I interpret it as a nice way of saying placebo.

    Damn it. Never mind.

  42. alwhite says:

    Having only read part 1 so far…

    I had a co-worker who claimed to have ADHD. He was diagnosed as a child and put on medication (didn’t tell me the name). He hated the medication and sometime in high school he stopped taking it. Then for the next 10-15 years he had a happy and successful career with a diagnosis of ADHD but no treatment for it.

    This is where I think a lot of push back needs to happen. The diagnosis of children with ADHD is very often an attempt to solve a different problem that adults don’t want to deal with. In the instance of my co-worker, it was very probable that he was higher intelligence than his classmates and bored out of his mind.

  43. Ozy Frantz says:

    I’m puzzled that behavioral treatment for ADHD is basically placebo, because I have known a lot of people with ADHD and the successful ones almost always use techniques I would call behavioral to manage their ADHD. (Examples: buy trash cans until you have so many you successfully throw all your trash away; own fewer things; have exactly one place for everything and never allow it to go anywhere else; social media blocking software; calendars; accountability partners.) I had assumed behavioral treatment for ADHD was basically helping people develop those techniques. Is it not?

    • Gazeboist says:

      Behavioral treatments are good for what I’d call large-scale executive function (on the scale of a week or more), and for fixing certain classes of simple, stupid problem like the trashcan thing.

      What they don’t provide is an ability to stay on task voluntarily, or to fight the tendency to do things like “snooze or turn off the alarm” instead of “do the task the alarm was a reminder for” (this is why beeminder didn’t work for me – I would just lie instead of following what the incentive was supposed to be). I’ve also found that it’s harder to come up with things like the trashcan fix you mentioned when I’m not medicated, so I wind up waiting for solutions to appear instead of coming up with them myself.

    • rahien.din says:

      Anyone can CMIIW but : not as I understand it. “Behavioral treatment of ADHD” is basically “train yourself not to be ADHD.” Not all that effective. You can’t remember not to forget.

  44. aj says:

    “Height is biological! But that doesn’t mean the world is divided into two natural categories of “healthy people” and “people who have Height Deficiency Syndrome“.”

    Am I missing something? Isn’t this called dwarfism?

  45. Gazeboist says:

    (23 year old cis man)

    I’ve been taking extended release adderall for a bit more than a year, minus several months where I ran out because of various problems filling the perscription and subsequently lacked the executive function to fix. The main effect was the usual magic focusing powers that most people with ADHD describe, plus generally being less sleepy (my sleep cycle is normally awful; I’m not sure which way the causation goes but the drugs fix both so whatever). I also developed a sense of time for the first time in my life. I had previously taken the adadge that time flies when you’re having fun as a complete and total explanation of the fact that I didn’t know what ten minutes was.

    I’ve noticed the following effects in addition to the ones above:

    – Minor hypertension, as stated in the main post.
    – Reduced appetite. More annoying than it sounds, because I still get hungry.
    – Some bad dreams similar to the anxiety below. This comes and goes.
    – A vague, sourceless anxiety that regularly showed up about 8 hours after taking my meds and lasted half an hour to an hour. As with all negative emotions, I found this fairly annoying and requested a solution. My psychiatrist perscribed wellbutrin (an antidepressant I may have misspelled), which may or may not have replaced the anxiety with a vague feeling that I’m about to cry. I’ll probably talk to him about reducing/eliminating the wellbutrin.
    – Exactly once, I was (I think) Actually High, rather than just magically able to focus, be awake, etc. While in that state I wrote down a lot of ideas on any surface I could find, which was … ok, but I have absolutely no desire to reenter that state because of the constant feeling that I couldn’t keep up with my own body/mind. My psychiatrist reduced the dose and it hasn’t happened since.

  46. dickwheybrew says:

    There are, for sure, side-effects that are not published probably because discussing them is still slightly outside over the overton window and embarassing. I took Adderall, Adderall XR, Ritalin, Concerta and Vyvanse over a period of about 8 years.

    I swear to you during the washout period following a dose of Adderall or Vyvanse if I had not slept well before, I would reach levels sexual compulsive thoughts that were super difficult to control. Like I really wanted to do some freaky, embarrassing S&M stuff, but only in those circumstances. It didn’t occur with Concerta.

    With the short-acting Ritalin, during the washout period I would get so depressed that I couldn’t see straight. That didn’t occur with the short acting Adderall, Adderall XR, Concerta or Vyvanse.

    I also want to link to to this rant from a (then) homeless man on Youtube that I’ve followed for some time (before and after being homeless), just because I feel like it belongs here. https://www.youtube.com/watch?v=X2STBVdiG7M

  47. Don_Flamingo says:

    Anyone has an opinion and/or experience on cycling different kinds of stimulants to keep dependencies low?
    Say 10 days of Armodafinil, 10 days of Ritalin, several days of rest?

    • __phoenix13 says:

      Personally, I just take tolerance breaks. I assume you can take at least a week off from work and take a vacation? Sometimes I find coffee useful for counteracting the rebound sleepiness on the first day or two, though.

  48. Dahlen says:

    Here’s one data point for more heart weirdness caused by stimulants: postural orthostatic tachycardia syndrome (POTS). In English, your heart rate is normal while lying in bed, but jumps up by at least 30 bpm when you get up (and doesn’t get back down). I got it suddenly, after 1 week on lowest-dose Concerta; I discontinued the meds and it took me about a month to exercise it away. This isn’t mentioned anywhere in the literature, in fact methylphenidate is listed as a treatment for POTS, because its hypertensive effects are supposed to compensate the tachycardia-inducing effects through the baroreflex in POTS patients. Or something. Normally POTS is either a matter of peripheral neuropathy, manifesting without hypertension and possibly with hypotension, or hyperadrenergic, where there’s hypertension alongside tachycardia because your body is flooded with too much norepinephrine, because of the NET (norepinephrine transporter) being affected or deficient in some way. Strattera is known to cause some cases of POTS. But not Concerta.

    I’m pretty sure I’m not imagining it because it was persistent, strongly associated with stimulant use, met the clinical criterion, went away (with some effort) after discontinuing the meds, and theoretically plausible through possible damage to the sympathetic peripheral nerves or the NET itself, which methylphenidate blocks. I’d report this somewhere if I knew who’s responsible for pharmacovigilance in my country.

    I also have some pharmacokinetic weirdness on the side where all sympathomimetic substances, from MAOIs to epinephrine dental anesthetic, induce tachycardia abnormally quickly and considerably more (in bpm) than expected. From the moment I gulp down my lowest-dose, extended-release, properly administered Concerta, it takes about 30 seconds tops for my heart rate to climb up to as high as 140 bpm (on the first day, then ~90 bpm on the second, then 75 and so on as I build up tolerance), after which it decreases to baseline in a matter of minutes. (It’s not anxiety, it happens repeatedly and expectedly and then again anxiety doesn’t increase HR that much.) That’s also weird as fuck, but the POTS was what really killed it for me. Too bad. Such a smooth medication. I miss being able to keep my desk clean, focus on fine motions, not have a short fuse etc.

    Oh! And one possible drawback of stimulants, for people who like to “go out for drinks”: it’s really hard to choose a drink that goes with the meds. Alcohol reacts with your Ritalin to form ethylphenidate which seems to be much more potent, acidic juices of all kinds interfere with absorption, caffeinated drinks will make you even more jittery, hot chocolate has PEA… And water is kind of lame. But let that be the least of anyone’s worries 🙂

    • Anonymous12345 says:

      I had a similar experience to this, where the use of a particular stimulant caused a relatively mild POTS-like condition that cleared up pretty quickly. I then used the same stimulant again, and it caused a much more dramatic and severe syndrome that included POTS symptoms, fainting spells even while lying down, extreme blood pressure fluctuations, arrhythmias, etc. This lasted for about 5 years, and I have still not completely recovered. Those 5 years were hellish, and I thought I was going to die on several occasions.

      Your situation sounds very similar to mine (e.g. I also now overreact to sympathomimetics). My best guess is that the stimulant precipitated some kind of immune response, and my immune system is now primed for similar reactions. I strongly recommend you avoid any stimulants in the future.

      • Dahlen says:

        Oh, good to hear that I’m not some one-in-a-billion circus freak in that respect. Although it’s awful that this happened to you too. Mind telling what stimulant you took, and for how long? My experience was: 1 week of 18 mg Concerta every day -> POTS; took it again after ~1 week -> I felt normal, though the POTS didn’t fully remit; took it a second time after ~2 weeks -> HR went crazy for about an hour, couldn’t do anything safely except lying in bed, didn’t take it ever since. My HR is now normal, around 65 at baseline, standing up.

        In your place, I’d be considerably more worried if this happened after occasional use, like no more than 3 days in a row, with some breaks in between.

        I think I overreacted to sympathomimetics since forever, because the first time I took any serious stimulant-like substance was with selegiline, a MAO-B-selective inhibitor which metabolizes to levo-methamphetamine (not at all a negligible factoid), usually used to treat Parkinson’s disease, which I took in half the minimum dose that the pills came in (~2.5 mg). Surprisingly, it was about as effective as Concerta, possibly a bit less in terms of sheer focus, but with a much tougher side effect profile. I had prolonged angina with tachyarrhytmia for about 16 hours since intake, again with a very quick onset, of no more than 5 minutes after administration. (As opposed to Concerta, which at first didn’t give me trouble past the first several minutes after intake.) After a while, with once weekly use, it mellowed down to mere mild tachycardia, but I got no POTS and still judge Concerta to be a much smoother medication by comparison. Selegiline seemed to have some effect on me for about a week after intake, since it’s an irreversible MAOI, and it could be seen in my resting heart rate. So I needed to take it much more rarely. But the risk seemed greater.

        I don’t think I can really risk giving up stimulants completely. They help me function normally and I don’t think I can hold a serious job without them. One possible way out would be to do cardio exercise until I lower my baseline HR to such a low value that I don’t have to be worried about stimulant-induced tachycardia ever again. It’s true that I barely got out of the house during my first round of treatment; lack of exercise is bad in and of itself. That’s sort of my backup strategy in case tests show that I can’t take them safely as it is currently.

        I very much doubt that it has anything to do with the immune system. An allergy, as it were, manifests itself very differently. You may get tachycardia, yes, but it’s usually a histamine problem, not a dopamine/norepinephrine problem. You get rashes on your skin and edema and sneezing. It’s a very different experience.

        In any case, I’m strongly inclining towards reporting my experience to some researcher and discovering WTF is wrong with me biologically. Maybe you should do the same. There must be some sort of abnormality in terms of pharmacokinetics that may be discoverable by some sufficiently adept scientist. Perhaps in the future such stuff may appear on some patient information leaflet and the exact biochemical causes could show up in the scientific literature. As far as I can tell such cases aren’t usual.

        • Anonymous12345 says:

          If you’ve always over-reacted to stimulants, I’m guessing the root causes of our experiences may be different? I was never particularly sensitive to them prior to this event, then extremely sensitive afterward. I think in my case the whole syndrome was an autoimmune reaction (not immune as in allergies, immune as in dysautonomia / lupus / etc) precipitated by the stimulant, for various reasons:

          *POTS is believed to often be an autoimmune syndrome
          *My own symptoms followed a relapsing/remitting course, which is common for autoimmune conditions
          *Symptoms of systemic inflamation, etc.

          Mainly I wanted to warn you in case you were in a similar situation to me, where subsequent use of stimulants made things much much worse.

  49. inquisitive_cactus says:

    Both lump together Adderall and Ritalin – something I’ll be doing too throughout most of this essay, except where it becomes important to distinguish them.

    Were your questions about Adderall on the SSC survey intended to be about both Adderall and Ritalin, or were they intended to explicitly exclude Ritalin?

  50. Bram Cohen says:

    Your main point seems to be that *at standard prescription doses* adderall is fairly safe and that when people get it from a doctor they mostly take the prescribed dose, which would seem to be an argument in favor of handing it out freely because it’s better than people taking street meth. Also if you prescribe ritalin instead because of the risk of parkinsons that’s another benefit over street meth.

  51. bean says:

    Very long-time ritalin/concerta taker here. (Slightly over 18 years at this point.) Never taken Adderall, tried Vyvanse for about a week earlier this year. Didn’t see a big difference in behavior or side effects, so I switched back to concerta.

    Every time I see a questionaire on ADD/ADHD, I jokingly ask who’s been spying on me. I wonder if we’ve seen the same thing you’ve described with depression, where we’ve seen it creep from people who are clearly and definitely way out on the edge to anyone who sometimes has trouble concentrating. My dad and sister are both medicated, and my dad didn’t start until he was in his 40s. He clearly has the same thing that I do, even if not as badly, so regression to the mean as you get older makes no sense in his case. And my mom (who we joke is the only one in the family addicted to ritalin, namely to us having ours) says that she’s seen no signs of tolerance/regression.

    Personal story: The day I first took ritalin was the day I learned to read. It was the summer before 1st grade, and reading had still not quite clicked for me. Half an hour after the first dose, I sat down and read a stack of books. And I remember telling my mom that I’d tell my kids about that being the day I learned to read. It was that dramatic, and I was soon devouring every book in sight. Within a year, I was venturing into the adult section of the library. My brother, who doesn’t have ADD, taught himself to read in preschool.

    Medical thought: Would it be possible to check for tolerance by switching drugs? If the mechanism of action is different, wouldn’t a low dose of the new stuff be fairly effective? Or would you spend a bunch of it countering withdrawal symptoms, and have it look like high dose required, no tolerance?

  52. Good post. Some thoughts cross-posted from tumblr:

    One thing I’m curious about that was not addressed in the post is the role, in all of this, of computerized tests — specifically, “continuous performance tests.”

    I had to take one of these — the TOVA (Test of Variables of Attention) — when I went in to get tested for ADHD in 2014. (I was in grad school at the time, and wanted to get tested for the same reasons as the “Senior Regional Manipulators Of Tiny Numbers” Scott talks about.) The tester said I didn’t have ADHD, and at the time I assumed my normal TOVA results weighed heavily in her decision, and (also) that this was normally how such things were decided.

    But Scott’s post makes it sound like the usual procedure is a lot more of a human judgment call. He mentions a variety of things that prescribers do to make themselves feel better about their decisions, but none of them are “administer a computerized test with no human oversight and always follow what it says (or always do so unless you can think of a really good reason not to).” If nothing else, this would certainly reduce worries about human biases.

    I say “if nothing else” there because the same thing would be true of any such test, even if it had no diagnostic value at all. (Then your decisions would suck — but even then, not because of your biases!) However, tests like the TOVA may indeed have a lot of diagnostic value. That is, they may have good sensitivity and specificity in discriminating controls from people with ADHD diagnoses***.

    (There are even some studies showing it can discriminate these groups from people who are “faking bad,” i.e. malingering. This makes some sense if the distribution is light-tailed, e.g. normal, so that that if you overdo your faking by just a little bit you’ll stray from a region where 5% of the population lives to a region where 0.01% of it does.)

    For one thing, if this is true, it means that we could just automate the whole process and get roughly the same results we were getting before, but without worries about human factors getting in the way.

    Additionally, if true this is scientifically interesting, in part because of what it says about existing (non-computerized) diagnostic techniques. Scott’s post describes a very fuzzy, human process with a lot of variation between clinicians. But apparently this process has enough reliability to agree with a computerized test a lot of time, which would not be a priori obvious.

    Moreover, if (as Scott says) ADHD is one extreme of a continuous/unimodal distribution, then we could use the TOVA to figure out where clinicians are already implicitly setting the cutoff. Scott writes:

    We could still have a principled definition of ADHD. It would be something like “People below the 5th percentile in ability to concentrate, as measured by this test.”

    We aren’t doing this, but what we are doing may be accidentally similar to it. The Schatz et. al. 2001 study, discussed further below, includes an ROC curve showing us how many false and true positives we get for various thresholds. The thresholds are for “T scores,” which are apparently like z-scores except the mean is set to 50 and the SD to 15, so that e.g. a threshold of 65 (the recommended one) means you say everyone who’s 1.5 SDs or more above the mean of the reference population has ADHD.

    If everything were normally distributed, you could get quantiles out of this, and translate clinical behavior into cutoffs separating X% of the population from (100-X)% of it. (Well, sort of — the “reference population” here is neither the full population nor the non-ADHD population, it’s sort of a mixture determined by the selection criteria used to make the normative stats.) Of course, as usual, the people who made the reference stats don’t say anything about whether the distribution was normal. But this kind of analysis could be done by someone, in principle, anyway.

    (***Caveat: the most widely cited study I could find on this was is Forbes 1988, which — astonishingly — was not blinded. That is, the TOVA was administered in the process of making the diagnostic decisions against which it was later compared, and were [Forbes’ words] “usually known before the final diagnosis was made.” Forbes goes on to claim that different TOVA results would not have flipped any of the diagnoses, to which my reaction is “okay, great, so if that was true, why did you show them to the clinicians at all?

    However, there are also studies like Schatz et. al. 2001 that give the TOVA to people who have already had a formal diagnosis done before the study started, and also to controls. There are still worries like “are we sure the original diagnoses didn’t use the TOVA or a similar test?” and “given our screening procedures for controls, what base rate of undiagnosed ADHD should we expect in our control population, i.e. how sure are we that some of our control ‘false positives’ weren’t true positives?”, so I still am not impressed with the evidence quality I’ve seen. That said, if you grant for the sake of argument that Schatz et. al. did things right, they get good sensitivity/specificity results too. Oddly, they interpret their results as bad news for the TOVA, on the basis that it does worse than a test based on parent ratings, but since the original diagnoses themselves involved parent ratings, this doesn’t seem like a fair/useful basis for comparison.)

  53. raj says:

    After reading this, I’m slightly more inclined to pursue a scrip. You didn’t really make it sound all that bad. Still unsure as occasional modafinil use has been working well for me.

    In the course of our careers most of us surely trade our precious QALYs for productivity (wake up to an alarm and get inadequate sleep, eat poorly and get too little exercise because we’re tired from work – perhaps more directly, spending our best hours on things we don’t really want to) – isn’t it possible that pharmaceuticals represent a tradeoff that is actually really worthwhile?

    Which is to say, can’t we rationally conclude: yes this drug is killing you, but what is a job if not killing yourself for money, on the margin? And why can’t doctors see it that way also – surely it’s better if you’re not keeping secrets from your healthcare provider?

    But the hard question remains, how do we actually quantify the costs versus the benefits

    • Hyzenthlay says:

      isn’t it possible that pharmaceuticals represent a tradeoff that is actually really worthwhile?

      I think yeah, they often do, which is why so many people are medicated. It’s just a matter of weighing the benefits against the side effects, and given that it is hard to quantify it often comes down to what works for the individual and their temperament and lifestyle, and finding something that works often just takes a lot of research and trial and error.

      But I suspect that a lot of people have a bad reaction to the idea of “modern life is just impossible for the human brain to cope with so we need drugs on a society-wide level.” It feels dystopian, and most people are still fairly bioconservative and see taking drugs as something that should only be done when absolutely necessary (though, weirdly, people are willing to make exceptions for legal recreational drugs like alcohol/caffeine/tobacco). Hence the need for the concept of ADHD as a disease which requires a specific “treatment,” rather than the more realistic and nuanced approach of “people fall along a spectrum as far as natural ability to concentrate, and for those on the lower ends of the spectrum, the concentration boost from stimulants is well worth the negative side effects.”

      It comes down to whether a person’s life is better or worse when they’re on stimulants, and there’s naturally a certain amount of subjectivity in that.

  54. rahien.din says:

    As far as I can tell, the increased risk of seizure is a myth.

    • habu71 says:

      For amphetamines, maybe. For Bupropion, not so much. Trust me on this one.

      • rahien.din says:

        Well yeah.

        (Are people using bupropion to treat ADHD? I don’t treat that disease, but that is still news to me.)

        • _sciurus_ says:

          Yes: it apparently works by being a stimulant, but a weak enough one that you can pretend it’s not and then feel virtuous. I didn’t know this when I got it for depression but its effects on me included, in addition to making me bizarrely happy all the time, stuff I was very much not expecting that helped hugely with ADHD-ish problems (which I’d assumed were human universals and therefore not problems). It increased my attention span from about 2 minutes to about 2 hours and made it easy to be far more organized than I’d ever been in my life. So I’m personally very impressed with it.

          • It’s not just about feeling virtuous. I maxed out on the safe stimulant dosages with only moderate size effects, then tried bupropion and it did a much better job.
            (I now take it with low doses of vyvanse, and the combo makes me normal-functioning enough to complete grad school, so that’s a real win compared to what I was like in middle school. And yes, I’ve been on the combo for about that long.)

          • habu71 says:

            It was working well for me right up until the point I woke up on the floor of my high school science class with a bunch of faces staring down at me after having my first seizure. And with it went any chances of my flying the F-22.
            Actually, to be fair, my poorish high school grades and complete lack of respect for authority had already pretty much killed that prospect, but I much prefer to blame the Bupropion.

          • CatCube says:

            @habu71

            You’re not even allowed to fly a Cessna as a civilian pilot if you’re on ADHD meds, so it wasn’t the seizure that stopped you. The diagnosis itself would have given you a 3 in your PULHES and probably stopped a military career.

          • quanta413 says:

            Bupropion made you bizarrely happy? Weird, I took it for moderate depression and didn’t feel any happier so I had assumed that I had misunderstood the internal effect of a lot of antidepressants. Bupropion did make me more able to get up though; it felt like I had increased willpower but maybe that was the weak stimulant effect you speak of.

            I don’t remember my focus changing at all, but I could usually already focus for hours at a time if other people didn’t interrupt me too much.

          • Incurian says:

            You’re not even allowed to fly a Cessna as a civilian pilot if you’re on ADHD meds

            The stuff they give to pilots to help them stay alert on long missions disqualifies you from being a pilot?

          • John Schilling says:

            Taboo “they”, but yes.

          • The Nybbler says:

            Wow, another reason to hate the FAA (and avoid psychiatrists). Get diagnosed once, be barred from piloting for life unless you can pass what I assume (since it’s six hours long) is a prohibitively expensive battery of tests.

          • John Schilling says:

            unless you can pass what I assume (since it’s six hours long) is a prohibitively expensive battery of tests.

            Probably not prohibitively expensive for someone who can afford e.g. the minimum forty hours of training necessary for a private pilot’s license in the first place, but certainly an annoyance at the very least. If you were diagnosed in adolescence but have been off medication for years and want to be a pilot, talk to an AME but this shouldn’t be a dealbreaker. If you’re still on medication, and benefiting from it, the FAA’s stance is going to be much more than an annoyance.

          • bean says:

            Wait. The FAA bans anyone on ADD meds from being a pilot? First, how did I now find out about this years ago. Second, this is insane. I wasn’t a big fan of theirs before, but words are failing me.
            Well, guess there goes my chances of ever getting anything more than a light sport license.

          • CatCube says:

            @bean

            I’m starting to not be thrilled about it, either. After reading some stuff about ADHD here, I’m realizing that I might need to talk to a psychiatrist. I’m really having trouble keeping up with a lot of administrative requirements at work, my desk is always a disaster and I lose pencils despite the fact that I haven’t moved since using it and so it MUST be within arms reach, and I’ve ended up delinquent on some bills because it turns out the autopay wasn’t working and I didn’t catch it. Then, after finding out about the screwed up autopay, I sort of didn’t fix it for another two months, despite having more than enough money to pay it off.

            I’ve got my pilot’s license, and an ADHD prescription would mean I can’t get a medical, but those things do me no good if I can’t afford to fly because I’m living in a cardboard box, either.

          • John Schilling says:

            @CatCube: If you have a pilot’s license, you presumably had a medical at some point in the past. If this was within the past 10 years, you may be able to privately fly aircraft up to 6000 lbs gross weight under the new BasicMed system. I haven’t looked into it in detail, but ADHD isn’t on the short list of automatic disqualifiers and there doesn’t seem to be a list of absolutely prohibited medications. This won’t be any help for bean or anyone else who has never held an FAA medical system.

            And in the FAA’s defense, they aren’t set up to do an independent review of the entire pharmacopeia. If some overly-cautious bureaucrat at the FDA says a drug sometimes causes people to pass out (freak out, spazz out, whatever), the FAA is mostly going to defer to that ass-covering ruling and say “…and since you can’t pull over to the side of the road when that happens, No”. If the FDA says that the only people allowed to have Modafinil are the ones who have been diagnosed with a disease that makes them randomly fall asleep and the only people who are allowed to have Adderall are the ones with the disease that makes them randomly not pay attention to critical tasks, ditto. If 90% of these people are exaggerating their symptoms because the FDA refuses to recognize that Adderall now fills the role nicotine used to, that’s a much bigger problem than the FAA can be expected to deal with.

            Still sucks if you’re in the fuzzy border where an ADHD diagnosis is legitimately merited but effectively and reliably controlled by the appropriate meds. I find myself wondering just how many fields are experiencing that particular brand of suckage.

          • CatCube says:

            @John Schilling

            I’m actually not very down on the FAA about this. I mean, at the end of the day, their job is aviation safety. Fulfilling everybody’s dream is a distant second. And psychological problems are a very, very real concern. I mean, it was only what, two years ago when a pilot was told that he wasn’t fit to fly because of his suicidal tendencies, and his response was to fly a plane full of passengers into the side of a mountain. So, y’know, score one for psychiatry and regulatory caution there.

            As far as my interaction with AMEs, my third-class medical expired a little while back. My BFR is expired, as well.

            Separate from the “Do I have ADHD?” question–dicey, since “Oh, I recognize these symptoms in myself while reading the Internet!” is, shall we say, not a very reliable method of diagnosis–I’ve been thinking recently about how I’ve been approaching my flying. I’ve had a pattern with hobbies where I’ll get super into it, then back off for a long time (maybe even years) and then get back into it. I’d have to look at my logbook, but I don’t know that I flew more than an hour or two in 2017, and if I did it was really early in the year. I’ve maintained my membership in a flying club all that time, because I always intend to go out flying, just never make the time for it.

            With that pattern of “streaks” in hobbies, if I continue, that means that I’ll be spending months knocking the rust off, then getting bored and drifting away, then repeating. That could turn out to over 25% of my flying time being in a “rusty” state. That’s…probably not a super-great way to approach aviation.

            I started thinking about this after some dinner conversations about an Instrument Rating. That’s always been kind of a long-term goal, especially once I finished my PE license. It’s also a lot more useful in the Pacific Northwest, due to the climate that doesn’t have a huge number of VMC days. However, one guy I was talking with said that he made the decision to not get his instrument rating, since didn’t know how much he’d be doing it, and that’s the kind of thing you probably don’t want to be not-terribly-current on when you need it. I’ve been thinking that may apply to all of my flying.

            So it’s cool to hear the new medical system may not disqualify me, but thinking about it in total, I might still have to think seriously about hanging it up.

          • John Schilling says:

            So it’s cool to hear the new medical system may not disqualify me, but thinking about it in total, I might still have to think seriously about hanging it up.

            Understood, and I agree that flying a few hours of Pacific-Northwest hard IFR every year is a Bad Plan. On the other hand, maybe treatment for possibly-ADHD would let you take a more consistently disciplined approach to flying (or to whatever hobby takes flying’s place). If so, it looks like you’ve got until ten years after your last 3rd class medical to slide into the less restrictive BasicMed system for the rest of your flying life.

            Important thing is to not fail a third-class medical, ever, so if there’s anything that might be an issue do a pre-consultation with the AME before showing up for the formal exam. There’s no penalty for letting it (or your BFR) lapse, as long as you don’t actually fail.

          • _sciurus_ says:

            quanta413: To be fair, I think my current happiness level is human-normal or maybe a little below that. Bizarre for me, though – feeling like this was unprecedented except for a one-week period after I took mushrooms for the first time. Stuff like wanting to smile and say hello to strangers, losing the constant sense of doom at the back of my mind, and beginning to suspect that acquaintances who have seemed vaguely friendly for years might not secretly hate me.

            Overall it’s nice, but maybe too far out of character, so I keep thinking maybe I should quit, and then finding excuses not to do that for a while. Also I haven’t been able to get good info on tolerance and how/whether taking it long-term will fuck me over.

            Now I have adderall too (apparently “far more organized than I’d ever been in my life” was still bad enough to indicate ADHD once depression couldn’t explain it anymore), so maybe I should switch to just using that.

  55. loriphos says:

    All three categories were evenly divided between “no tolerance” and “some tolerance but still worked well”, with only about 5% saying the tolerance became a big problem. This matches my clinical experience. So either I’m right, or the problem where they get confused and forget their baseline is affecting my survey-takers.

    Or maybe people for whom the tolerance became a big problem are less likely to have the attention span to read SSC or take long surveys. 😉

    (More seriously, were the survey questions about Adderall for people who have been taking it for at least a month or who have ever taken it for at least one month? I’m assuming the latter, but in case it was the former, it seems like people for whom it stopped working are likelier to have stopped taking it).

  56. Brad says:

    If there’s some lifetime limit of some small number of years of effectiveness, what’s a good strategy for picking the years?

  57. habu71 says:

    While I am certainly not the sharpest tool in the shed, I’m currently about to finish my PhD in Nuclear Engineering so I’m not a complete idiot. That being said, if it wasn’t for the dextroamphetamine I have taken for the past 15 years I doubt I would have even graduated high school. The stuff is indeed magical. While I have been on Ritalin, Adderall, Stratera, Bupropion, and dextroamphetamine at different points in my life, my only recent experience – that is, pretty much all of the past 10 years in which there was not a national shortage of dextroamphetamine – is with dex.
    I usually take two doses per day, each of which last almost precisely 5 hours. Some days when I need more than 10 hours of work time I will take 3 doses, and on the days when I don’t need to work or be around people I care about liking me I won’t take any at all. Its effect is entirely predictable in both intensity and duration.
    I say all this to emphasize that I have never encountered tolerance with this drug and that, if others experience of its effects are similar to mine, decreasing effectiveness would have been highly noticeable. Especially, as amphetamines are a very effective appetite suppressant. On any given day I will know exactly when the meds are wearing off because I will suddenly start becoming hungry. And while I am sure that it is possible that the appetite suppressant effects of dex could have a different rate of tolerance build up than the increased focus effects, this sure doesn’t seem to be the case for me.

    TLDR, the effects of amphetamines seem to be so significant that if a tolerance did build up, people would notice. Sure, it might be difficult to quantify focus, but it’s much easier to quantify hunger, and easier still to quantify weight. Thus, what I am trying to say in a long and rambling manner that would be far more succinct and elegant if I was currently on my meds is that, on this particular issue, if a large group of people say that tolerance isn’t an issue, I would absolutely believe that, for them, it isn’t.

  58. adhdssc says:

    Scott, thank you so much for writing this post. I’m a long time reader and I actually met you once at an SSC meetup. I’ve been taking Adderall for over 10 years now (parents took me to a doctor and got me prescribed when I was in middle school and it did wonders). It has been a very positive thing for me in life, but whenever I get something weird like a heart palpitation like you mentioned, I find myself going down hours long rabbit holes because I’m terrified I might die of a heart attack or something before I turn 30. I always felt like I couldn’t get further in my understanding because every website you find is very black and white.

    When I saw this post in my RSS feed I just gasped and dropped what I was doing to read it. Thank you so much for writing this post. I think this will really give me a bit more peace of mind in the future.

  59. skef says:

    I think it is fair to say that among recreational drug users and those familiar with them, speed use is a) associated with increased shallowness and self-centeredness and b) speed users do not generally recognize those changes of personality unless or until forced to by extenuating circumstances (loosing friends, constant arguments, etc.)

    Typical Adderall dosages are lower than typical recreational dosages, but the evaluative criteria above don’t seem to take personality changes into account unless they are so extreme as to have legal ramifications. Do we know whether these prescriptions are making people slightly jerkier? Are there any studies tracking, for example, relationship outcomes? Is the question something that modern psychiatry considers relevant?

    • bean says:

      That sort of thing is going to be heavily confounded by the changes you get due to the direct effects of the drugs. Almost everyone considers me more pleasant to be around when I’m medicated. I’m less likely to pace, interrupt, or generally get distracted. I find it hard to see it being a net drain on the relationship.

      • skef says:

        Actual tweakers are well known to say similar things.

        The phenomenon is also plausibly a threshold thing. Someone who is unusually distracted may be nicer to be around on a small amount of Adderall, while someone who is normally distracted and taking it for work may be less nice to be around.

  60. andrewducker says:

    Counterpoint on ADHD just being part of a spectrum of attention:
    A friend was prescribed medication for it, and it had the opposite effect it had when I tried a pill. To me, it provided energy and “sped me up”. When she first took it she slept 16 hours a day for the first three days. Because it relaxed her.

    I don’t see how “people who don’t have much concentration” would be relaxed by the drug when it has the opposite effect on the vast majority of the population.

    • Seppo says:

      From my experience trying Adderall under similar circumstances: I felt more “energetic” in one sense—my hands got sort of tingly and I think I was probably thinking a bit faster than normal. But, when it was time to sleep I was content to think faster than normal about things like “this pillow is real soft”, so that just lying in bed in the dark actually felt nice rather than excruciatingly boring as it often does for me. I slept longer and better as a result. (My doctor insists I do not “have” “ADHD”, though.)

  61. Andrew Cady says:

    If one of your patients finds your blog, will you “fire” them as a patient?

  62. Reziac says:

    I see the list of Adderall side effects, and I immediately want to see a full before-and-after thyroid profile, and related stuff like blood calcium levels. And I want to see another set of tests in about six weeks.

    A whole lot of nasty side effects are probably secondary to subclinical hypothyroidism.

  63. Manx says:

    For more anecdotal evidence of the link between stimulants and psychosis being more prevalent than reported – I personally know 4 doctors who describe having psychotic symptoms precipitated by stimulant use – 2 from my medical school class and 2 from my residency program, which seems far more than 1 in 1000. All of the people involved were using the stimulants to stay up for studying as opposed to using them regularly for ADHD and report having used a low to average dose. None of them had symptoms for more than a day, and only one of them went to the ED for their symptoms. In addition, I have seen 3 cases of adderall induced psychosis severe enough to require hospitalization and heard at least 2 patients report that they ‘cannot take stimulants’ due to these side effects in the outpatient setting, and I have seen less than 1000 cases of ADHD. The numbers seem very fishy to me.

  64. __phoenix13 says:

    This is largely consistent with my review of the literature.

    That said, this article cites the infamous squirrel monkey study without noting that:

    (a) there were no signs of neural death or neurite retraction anywhere, and

    (b) reduced baseline dopamine levels are exactly what you would expect as part of the mechanism of tolerance.

    In my view, that study did not establish the existence of neurotoxicity. It merely established the existence of tolerance.

    There is evidence of outright neurotoxicity and very protracted withdrawal symptoms (e.g. months or more) among _methamphetamine addicts_, but nothing of the sort for ordinary amphetamine (a week or two being typical, even for long-term chronic use at therapeutic dosages). Methamphetamine is a different compound, with different metabolic pathways, different receptor affinities, and much more oxidative stress in vitro (and presumably in vivo).

    The only significant negative claim that I see here is about the increased risk of Parkinson’s disease, most likely due to more cumulative dopamine production and catabolism over the course of the person’s life. This could potentially be counteracted to some degree with e.g. a mild MAO-B inhibitor to shift the equilibrium toward the dopamine->3-MT->HVA pathway for dopamine catabolism via COMT, rather than the dopamine->DOPAL->DOPAC->HVA pathway via MAO. (DOPAC appears to cause most of the oxidative stress involved in dopamine catabolism.) As a side benefit, this would also likely lead to a lower necessary therapeutic dose of amphetamine in the first place.

    I am so tired of misleading claims of alleged ‘neurotoxicity’ from therapeutic doses of amphetamine. They are usually followed by either scaremongering or attempts to ban it and substitute some newly patented inferior alternative.

    • Dahlen says:

      The only significant negative claim that I see here is about the increased risk of Parkinson’s disease, most likely due to more cumulative dopamine production and catabolism over the course of the person’s life. This could potentially be counteracted to some degree with e.g. a mild MAO-B inhibitor to shift the equilibrium toward the dopamine->3-MT->HVA pathway for dopamine catabolism via COMT, rather than the dopamine->DOPAL->DOPAC->HVA pathway via MAO. (DOPAC appears to cause most of the oxidative stress involved in dopamine catabolism.) As a side benefit, this would also likely lead to a lower necessary therapeutic dose of amphetamine in the first place.

      You know, this can kill some people. It’s not very advisable to take two medications that act to the same end through different mechanisms. It probably overloads the COMT, too.

  65. Scott, what do you have against Bupropion for ADD/ADHD?

    Also, I’m assuming the risks are all similar for XR formulations, Vyvanse, etc. – Is that correct?

    Edit: Also, re: “Behavioral therapy for ADHD is not very good and I interpret it as a nice way of saying placebo” – I found (self-administered) CBT very helpful in addition to the medication. I also found going to a group and sharing strategies very helpful. I suspect these types of activities would be somewhat helpful in place of medication, but I don’t see a reason not to do both.

    • cuke says:

      I did a tiny bit of research on this question (of CBT type interventions without medication for ADHD) and my sense is that it’s really hard for a lot of people with ADHD to get traction with the behavioral interventions without the support of the medication.

      I’m not someone who says the same thing about mild to moderate depression or anxiety, where I think CBT on its own can be quite effective.

      Effective CBT type therapy depends on the person being able to set up new routines and do assignments between sessions with some consistency, and that consistency thing is so hard for the people I’ve worked with who have ADHD and aren’t taking meds. Once on meds, of course all kinds of CBT type strategies are helpful for getting tools on board to increase functioning.

      I would be interested to hear from therapists, doctors, or people with ADHD who have found a non-medication approach effective.

      • Dahlen says:

        Yeah, one item often mentioned in ADHD CBT workbooks is a mention of whether the patient has taken their medicine on a given day, as part of the tasks they must perform. It made me very bitter during the times while I was still fighting to get medication and therapists and so on suggested CBT routines.

        Managing ADHD without medication is tough. Meds make a qualitative difference. Nothing can ever substitute them. Your brain just doesn’t have the same inclinations that it has otherwise.

        That said, there are little nudges you can hand yourself so that life becomes a bit easier. I’ve detailed above why I can’t use my meds for treatment; here’s what I do instead. I use my memories of how focus felt like on meds as a sort of guideline for how I am supposed to be focusing. If, let’s say, I’m washing dishes and I notice that I just sloppily rub the sponge onto the plates without paying any heed to exactly which parts I am cleaning, I remember how I used to do it while on meds and try to correct, to go through the motions at least.

        I’ve also succeeded in quitting bad habits (not gonna lie here, commenting on SSC is one of them) and filling my time with stuff I don’t regret doing, but is still somewhat rewarding, like that kind of instant-feedback learning websites like Duolingo or Codecademy.

        I used to have a problem with keeping a thousand browser tabs open at the same time, which I’ve quit. I’ve solved my hangups about reading actual books, namely my preconception that it’s a hard and unenjoyable thing to do. I’ve switched to, you know, Just Doing It.

        Other than that? Without meds, nothing is going to stop you from procrastinating. Nothing is going to stop you from losing your temper or your patience with people (except utmost respect for the person in question). Nothing is going to stop your brain from making instinctively bad decisions. Specifically CBT-like techniques are useful if you have some beliefs that need debugging, but if otherwise you’re doing everything as you know you should, to the extent that your brain agrees, the usual techniques don’t work for your kind of problem. Medications are still fundamental.

  66. Seppo says:

    Her doctor gave her a list of things she had to do before he would give her Adderall, and she – having ADHD – got distracted and never did any of them.

    This exact thing happened to me (Tom said, attitudinally)

  67. sarahmarri7 says:

    Above information is truly amazing I am searching it for a couple of days. Do share more information like that especially about Morocco travel experiences.

  68. philipkd says:

    What is the angels-and-clockwork reference? I found it by following down the rabbit hole of Slate Star links here to The Virtue of Silence post.

  69. Dragor says:

    I did notice adderall and modafinil made me more “aggressive,” but only in a normal irritable way. My take on this was stimilants increase impulsivity, and irritation is an impulse. It was enough to make me stop taking medication when I stopped needing it, but at the time it wasn’t a big deal.

  70. Conor says:

    I’d be curious to know the actual scientific reasons why meth would be more addictive than adderall.

    • Douglas Knight says:

      I gave 3 reasons here.

      (1) Smoking and snorting are more addictive than pills. (2) Adderall is less addictive than other formulations of amphetamine. (3) Meth is more addictive than amphetamine.

      I describe two mechanisms. One is that faster onset creates habits faster, though maybe not addiction in the technical sense. This is the mechanism in (1) and one of the mechanisms in (2). The other mechanism is that the peripheral stimulation of d-amphetamine compared to d-methamphetamine discourages larger doses, contributing to (3). Similarly, the peripheral stimulation of l-amphetamine contributes to (2).

      There may be other effects. When I search “methamphetamine neurotoxity” I find people talking about developing a tolerance to dopamine faster and longer on meth than on amphetamine.

  71. Steve Sailer says:

    What are some of the cultural effects of amphetamines?

    The cultural effects of LSD and marijuana on, say, famous 1960s musicians have been discussed endlessly. Amphetamines, however, don’t have as extensive of a literature. For example, I only recently realized that a big reason late 1970s British bands tended to play faster than American bands is because British working class kids had been heavy into amphetamines since WWII.

  72. Steve Sailer says:

    “About 1-2% of people will get Parkinson’s if they live long enough. If Adderall increases that risk 60%, then presumably it could cause a 1% absolute increase in risk.”

    Sounds like a certain beloved former TV and movie star who made his best movie in the mid-1980s by staying up all night after appearing in his hit TV show all day.

  73. johnjohn says:

    Any ideas why Ritalin seem to be the preferred drug of choice for treating ADHD in Europe, while Adderall reigns supreme in the states?

  74. iamthad says:

    I’m interested in the assertion that “‘ability to concentrate’ is a normally distributed trait, like IQ.” While this seems like a reasonable assumption given the Central Limit Theorem, has this been studied?

  75. Mercy Vetsel says:

    Wow! Thanks you so much for that excellent post. This makes more sense then everything I’ve read and been told about ADHD put together, although I must admit potential confirmation bias because as a patient and layman, I’ve been long convinced that certain claims made by just about every shrink I ever talked to — “Adderall doesn’t ‘work’ for non-ADHD people” or “ADHD is a discretely identifiable and treatable disorder” — are nonsense.

    Of course, I generally only feel motivated to post objections and I think you have it a bit wrong on the nature of Excel workers needing more Adderall than Word workers. I’m an Excel worker who has had severe problems with focus and procrastination my whole life (along with 60% of my siblings, parents and children) and I can tell you it’s definitely not that quant work is uniquely boring. In fact, if I had to do all of the tedious writing and documentation that I imagine you do, I’d have to triple my dose! My guess is that all of the ADHD people you see are more drawn to Excel fields and never would have made it through med school or law school.

    The description of ADHD that rings most true to my experience came from the shrink who first convinced me to take the meds. He said we live in a world that rewards being on the opposite end of the ADHD spectrum, which he called OCD. I’m not sure if that’s clinically the right tail of the attention curve, but the analysis makes sense either way. While left-tail high-crisis threshold concentration genes (ADHD) were almost certainly advantageous at some point in our evolutionary history, spending large amounts of time doing tedious tasks is really important for just about every successful occupation today.

    My worst problems actually have to do with important but tedious tasks that tilt away from numerical analysis, namely taxes, expense reports, resumes, presentations and papers — followed by tedious but less important tasks like paying bills, sorting mail, following up, making appointments, remembering periodic tasks and so on. In fact, I’ve often immersed myself in intense numerical analysis like death penalty regression models or some other utterly useless Excel, coding or R work as a means of procrastinating the tasks that I really have a hard time cranking up my concentration levels to tackle.

    That brings me to another ADHD topic that I’ve never heard addressed intelligently. What is the difference between ADHD and JPL (just plain laziness)? While I clearly have all of the classic ADHD traits, I feel that my bigger problem is JPL and specifically procrastination. Okay, so right now I should be filling out TPS reports and returning phone calls but my severely late todo list isn’t at a crisis level yet and I’d rather do something more fun like posting on an interesting blog. That seems like JPL to me. Part of the reason why Adderall has mixed results for me is that it can make my unproductive detours even more severe.

  76. Calvin says:

    Very interesting. The only thing I would add is that the same arguments for Adderall are also used for Testosterone (as an anabolic steroid) for people claiming to have low testosterone.

  77. John Richards says:

    If you have trouble continuing medication because you procrastinate on calling in the prescription, that’s a good sign that you legit have reason for it. Source: personal experience (inattentive type).

  78. jameverywhere says:

    I am very worried about Adderall tolerance… if anyone reading this has suggestions for where I can go from here, please let me know.

    I have been taking Adderall for a little over a year for idiopathic hypersomnia/pathological excessive daytime sleepiness. My MSLT score was like 6.7 minutes. At my worst, pre-diagnosis, I was uncontrollably sleeping up to 18 hours a day, and whenever I took measures to force myself to stay awake, I would lose so much cognitive function it wasn’t even worth it.

    After my sleep study and diagnosis, I was first medicated with Ritalin. It seemed to work for about a month, but then stopped working. My doctor upped my dose, but it didn’t help; I was napping during the day again and the brain fog was back. When she gave me Adderall, it was a life changer. I actually had motivation? to do things? and I didn’t feel like i needed to just crawl back in bed and go back to sleep 24/7? Also, wouldn’t you know it, the Adderall completely erased the depression I’d been suffering for ages, which no anti-depressant could ever touch (in fact, several made it worse). It only makes sense that being permanently exhausted no matter what I did would make me depressed…

    Anyway, over the course of the past year, I’ve had to up my Adderall dose twice, from 10mg XR/day to 20mg to 30mg… I’ve been taking one 24-hour period off the meds per week and whenever I can go 2 or more days in a row, I do that too. I also have been reducing my dose on my days off work… previously, that just meant it would wear off faster and I’d go to bed earlier, but nowadays if I take only 20 mg, I end up taking a nap in the middle of the day, which never used to happen before.

    I’m pretty small (120 lbs), so I don’t want to continue increasing my dose all that much more. I’ve been tried on modafinil, and it was like taking nothing at all.

    If taking a drug holiday once a week doesn’t work, and I need the drug in order to work any kind of day job whatsoever, what can I do to prevent or reverse tolerance?

    Have there been any studies on Adderall tolerance for those with narcolepsy/hypersomnia, as opposed to ADHD?