Some time ago, the freshman writing program at Harvard published a student essay about the illicit use of stimulants (e.g. Ritalin/methylphenidate, Adderall/amphetamines, Dexedrin/D-amphetamine) among college students. The essay argued that “the current debate about the illicit use of psychostimulant drugs such Ritalin obscures the social context in which drugs are used, stigmatizing those who really need them, and reinforcing the very conditions that encourage their use.”
A recent article by Danielle Ofri, MD, in the NYTimes reminded me of the second point exactly: the controversy over stimulants hurts the patients with ADHD who need them most. In “The Shame of Filling a Prescription,” Ofri tells of a mother who often has to look around pharmacies for weeks to fill her Ritalin prescription for herself and her son. Meanwhile, her job performance and his schooling suffers. She says she is “left feeling shamed, like I’m a criminal in the attempted act of illicit behavior.”
The Ritalin wars creates collateral damage on several levels:
- Medication shortage. Pharma and the FDA accuse the DEA of restricting the supply of methylphenidate in order to minimize illicit use. The DEA accuses pharma (Novartis, Shire) of opting to produce more of the branded versions of drugs than cheaper generics in order to maximize profits. The patients are left behind.
- Stigma at the pharmacy. Doctors prescribe drugs, but they are often unaware of the troubles associated with filling the scripts: “a prescription for a controlled substance is received quite differently from that for a blood pressure medication. Whether it’s a drug for pain, anxiety or A.D.H.D., there seems to be an unspoken perception that the patient is somehow part of the problem, and that there is a chance the patient might be abusing the medication or selling it.”
- Stigma at the clinic. Doctors become immediately careful/suspicious when someone asks for stimulants: “Whenever a patient requests one of these medications from me, the emotional temperature of the clinical encounter is immediately elevated. Almost all doctors — myself included — have been burned by patients who have lied to us about symptoms and then abused or sold the medications we prescribed. And though these cases represent only a tiny percentage of patients, they leave lasting impressions (not to mention legal ramifications) that cause us to scrutinize every future patient, often excessively so.”
- Stigma from peers. Of course, social stigma for those who take stimulants is well-documented. Secrecy, shame, and aversion to social interaction are common to the lived experiences of ADHD patients. I would hazard a guess that it is not the diagnosis of ADHD, but the necessity of taking ADHD medications, that is the more salient and apparent driving force of the stigma.
Ofri concludes, “Shame and humiliation shouldn’t be part of any aspect of medicine.”
How do we accomplish this for ADHD? First, we need to be more accepting of mental health disorders. Second, we need to be more accepting of healthy people who wish to enhance their cognitive performance in safe ways. Third, we need either better data on the abuse potential of ADHD medications. Abuse is defined as taking a drug in large dosages or in non-indicated routes like IV or intranasal, which is different from “misuse/misdirection,” or taking it without a prescription. In the absence of clear data, the regulations on ADHD medications (methylphenidate is schedule II) should be reduced.
To be clear, I haven’t used stimulant drugs, but I am very interested in the pop bioethics issues of transhumanism and cognition enhancement. Read more about the controversy in a series of opinion letters in Nature in 2009. The letters start out with Hank Greely et al.’s idea that society must reject the idea that ‘enhancement’ is a dirty word.
I particularly like Anjan Chatterjee’s position that we should not accept widespread cognitive enhancer use by the healthy until 1) we can minimize socioeconomic disparities in access to enhancers, 2) research in the use, abuse potential, and efficacy of these drugs are complete, 3) pros and cons of enhancer use are widely known, 4) professionals can articulate normative opinions. The first three ideas are consistent with things I value as a humanist: equality, science, and rational and free thinking. The last idea, professional authority, is not perfect but something I will value as a physician. We can reasonably place trust in certain professions if we know they have rational procedures for arriving at some truth and that their work generally produces good in the world.