How The American Workforce Got Hooked on Adderall

mind right now. I don't know who you're talking about, SBF Sam been Free, There you go, there you go, but it is an interesting thought experiment. To think about the proportion of people around you, you know, sometimes highly productive people who may or may not be on adderall or something similar.

that you have this other potential state in you. Yes, that's my big fear.

way or another. It just opens up like interesting questions. But then again, I mean, the person next to you can drink ten cups of coffee and that's allowed, right, Like you're allowed to do that.

I might have been prescribed it. I think maybe not because my parents were hippies and so they didn't really believe probably and prescribing drugs for that sort of thing. But then you know, sort of this cultural thing. It's like, oh, they're giving all these boys.

like I forgot all about adderall. And then over the last several years, what we've seen is prescriptions for adderall absolutely explode much more adult use, as you say, people finding out later in life that they're diagnosed with ADHD, which of course has also led to shortages, which have a variety of reasons, some relating to the DEA and manufacturing,

some just related to the absolute booming in demand. And so adderall is just sort of an omnipresent topic of conversation and an angst in its owne right.

so on. But I guess more generally my line of work is looking at the political, economy and historical emergence of different types of experimental psychiatric treatments from the twentieth to the twenty four century.

kind of cluster of syndromes. And so Riddlin emerged as it's methyl fenidate rather than an amphetamine, so it's slightly different pharmacologically, And it was formulated in the mid nineteen fifties as what was hypothesized to be a less addictive alternative to amphetamines, which were at that time being used to treat children with what was being called hyperkinesis Concerta,

by the way, is just methyal fenatic x are. But there was a period basically in the nineteen seventies when and I'm sure we'll get into this, there was a sort of widespread panic over the enormous prevalence of infitamines, especially to treat children, and riddlin was sort of preferred as an alternative that had fewer side effects allegedly and was less addictive allegedly, which accounts for the prevalence of Riddlin through the sort of mid nineties, at which point

there's a switch when Shire Pharmaceuticals acquires Obatral, which is rebranded as Adderall, and that's really when the Adderall craze hits.

What was going on then that suddenly there seemed to be this, you know, the first wave, or maybe the way you describe it, the second wave of this phenomenon of let's get all the boys on Ridlin.

But by the mid nineties, one of the major things that had happened was a panic in the nineteen seventies, a sort of moral panic over the extraordinary prevalence of amphetamines, mostly dexidron and benzydrin, that were being prescribed without any sort of federal control. It was extraordinarily prevalent across the US population, and there really were not very many controls at all in terms of how doctors needed to report

these prescriptions to any sort of federal data collection. And so in nineteen seventy one you had Congress tasked deda with reclassifying amphetamines as being a schedule to substance, that is, prescriptions needed to be reported to a central government administration, and there were limits and quotas placed on the quantities of mphetamines that could be manufactured and then distributed to pharmaceutical companies, and so used to have this sort of

moral panic around that that actually led to a congressional investigation in nineteen seventy and there was this sort of broader crackdown both legally in the nineteen seventies and also culturally where you had like the sort of countercultural figures decrying speed freaks, which had also you know, there was this discourse in this narrative that for instance, like the heighth Atsbury sort of summer of love had been that had been destroyed by speed freaks and so on and

so forth, and so in the nineteen seventies you have a movement away from amphetamines proper, which a creates the conditions for the rise of things like ritilin, which is a methyl feenadate, which is you know, it's pharmacologically quite similar, but it was not subject to exactly the same controls

as emphetamines. And secondly, I think the thing, the very important thing that happens is that one of the few medical uses for which amphetamines are going into the late nineteen seventy is still allowed to be prescribed are child behavioral disorders. Now, prior to nineteen seventy and fetamines had been used off label for everything from weight loss to mood to just like a variety of off label prescriptions.

But you have this sort of concentration after this crackdown by the DEA to focus amphetamine use medically specifically on this you know, small cluster of childhood behavioral disorders. This sets us up for, by the time we get to the nineteen nineties, the sort of growing market for childhood

applications for m ffetamines. And I guess like the third intervening factor here would be that in nineteen teen eighty there was the third publication of the Diagnostic and statistical Manual, which is the DSM, which is widely described as psychiatry's diagnostic bible. This is essentially the list of diagnoses held to be medically viable that insurers will agree to cover, that clinical trials will investigate, and so on and so forth.

And add attention deficit disorder is installed in that version of the DSM, and so I think this really sets the stage for the rise of ADD as a clinical diagnostic entity that receives a lot of research funding in the nineteen eighties, such that by the nineteen nineties, once adderall comes onto the market, the stage is set for a very wide sudden uptick in adderall prescriptions for children.

might have without medication. Could you maybe explain exactly what adderall is doing on someone's brain and the differences between someone who's maybe taking it to boost their productivity versus someone who's taking it because they have been diagnosed with ADHD or something else and they have an actual prescription from a doctor.

of different stakeholders under a very large tent. These stakeholders included insurers, clinical researchers, formalcological companies of course, and of course patients and doctors. And the DSM describes clusters of symptoms, that is, syndromes that tend to occur together. So, for instance, here's a list of ten to twelve behavioral manifestations that tend to cluster together and we're going to call that depression,

so on and so forth. But particularly in nineteen eighty, there was not a robust sense of what the neurological underpinning of each of these diagnoses were. These were descriptions behaviorally of how these syndromes manifest that were presumed to

be disease entities. But I mean, if you ask anyone working at the cutting edge of sort of neurology psychiatry right now, they will tell you quite frankly, that there is no guarantee that any one case of let's say, depression or anxiety neurologically looks like any other case of depression or anxiety. That's because there are many different ways to have depressions. Some people might be crying a lot

and not eating very much. Someone else might not be crying very much and eating a lot, for instance, right, and so there's no guarantee that each instance of the disease entity is going to have the same sort of

biological underpinning behind it. Now, this works fine for things like insurance markets or billing insurers, or sort of getting medicine done in a sort of day to day sense, But once it comes to sort of extrapolating and understanding the neurological basis of diseases, the system does sort of fall apart. This is why increasingly clinical research is moving

towards the ICD system rather than the DSM system. So this is neither here nor there, perhaps generally, but specifically when it comes to add and ADHD, I think it's very important to keep in mind that there is no widely accepted, beyond contestation understanding of what these disease entities actually are on a neurobiological basis. So there are theories that there's some sort of deficit in dopamine production or

the rear partake of nopernepherin and dopamine. But I think it's important to keep in mind that these explanations they might be having prevalence now. But if you think about the rise of, for instance, the serotonin hypothesis when it comes to depression, the serotonin hypothesis dominated theories of depression for quite some time and then has been pretty roundly disproven.

There is not a robust link between depression and serotonin deficits, and so I think that's one important thing to keep in mind, is that we don't necessarily have a robust and agreed upon understanding of what this disease entity quote unquote actually is. Now when it comes to what it is that stimulants actually do in the brain, the brain releases neurotransmitters that then sort of hang out in the space in the sort of synaptic space between the axon

and the dendrite and then are reabsorbed. So neurotransmitters are things like, for instance, nopernethyrine, dopamine. Right there's these are things that your listeners probably have already heard of. Something like an amphetamine decreases the amount of those neurotransmitters that are re uptaken, meaning that the sort of synapse is bathed for a longer period of time by those chemicals. So that's how an amphetamine works, is that it really

bathes the brain. In dopamine no reprodefron. Dopamine is sort of widely theorized or described as being a chemical that codes for expectation of reward. So one way that I like to explain this is that if you go to a gumball and you're expecting to get one gumball, but the machine gives you two for one quarter, you're going to have a huge dopamine spike because that reward is

double what you were expecting. And when you think about the way that, for instance, addictive technologies like video gambling or social media work, they work by introducing variable rewards that hook into this very very motivating dopaminergic system in the brain. No Ropernaffron similarly controls the body's sort of readiness for fight or flight, and so it sort of

generally increases a feeling of alertness and readiness. But this is why you know, it feels really really good to be on amphetamines, and it sort of increases this general sense of well being and alertness. And indeed, this is why you know in the early nineteen thirties, am fetamine was widely prescribed for antedonia or a lack of pleasure. In fact, historian Nicholas Rismusin has made the case convincingly. I think that empetamine was in fact the first antidepressant.

But at a neurological level, that is essentially what amphetamines are doing. They also, because of their dopaminergic action, they increase the rewardingness of a task. It is a common talking point for sort of ADHD advocates that amphetamines only work if you indeed have add or ADHD, and unfortunately this is simply not true. Anyone who takes amphetamines has this burst in heart rate, burst in feelings of well being,

burst in ability to concentrate. This has been documented clinically over and over again that there's not really a perceptible difference between people who have been diagnosed with add or ADHD and people who have not when they take these drugs.

of them apparently on adderall. Like for that person they have a job, they're in the office until eleven pm, they get one TYPEO wrong, they have to start it all over. What does ederall do for them in the sort of corporate context or the work context.

So punding was first described in the nineteen seventies by a psychiatrist who was observing the sort of repetitive behavioral loops like tweezing your eyebrows, or sorting and handling objects, or hunting for things or collecting things, so on and so forth in patients who are taking levadopa, which is a dopamine replacement that is used in patients with Parkinson's.

And I think that this gives us a pretty interesting angle into what it is exactly that amphetamines do, which is to make these repetitive tasks much much more rewarding than they would otherwise be. And so, when you think about the forms of work that predominate in the so called knowledge economy, right where you're on a computer looking for things, searching for information, organizing information, so on and so forth.

First of all, and amfetamine makes any task that you're engaged in much more rewarding because it's massively ramping up the dopamine signals in your brain that are telling you keep doing this. This thing that you're doing is better and better and better than you expected. But I think that what's interesting about the role of emphetamine specifically in sort of knowledge work is that it makes these repetitive

tasks feel more like hunting and gathering. Right, It's more or it's a more exciting task to do these repetitive tasks. And this is not something that is specific to the nineteen nineties. When psychiatrist Abraham Myerson, who is one of the first psychiatrists to widely use benzydream for a depressed and antidonic patients in the nineteen twenties, his clinical area of expertise was the sort of neurosis of what he

called the brain workers of the upper class. So I think that there is, you know, a robust through line of amphetamines being used for these emergent forms of work in the US. That was great.

more desirable or more useful to people. This idea that we're doing more repetitive tasks, that the amount of content available to us is basically endless, and so if we have a drug that makes it more even more enjoyable to sift through all of it. It's sort of like two self reinforcing things here.

attention crisis, the Internet and aderall. And I think in most of the commentary that I've read, even commentary that has been very critical of the proliferation of telehealth startups such as Cerebral or Done, and I'm sure we'll talk

about those in a little bit. Even in these critiques of the overreaches of telepsychiatry and the sudden boom, the latest boom in prescription for ADHD and add stimulant medication, there's this idea that we are medicating an attention crisis that is in fact caused by the prevalence of smartphones in the Internet. So then the causal chain there would be first you have the Internet, then you have the attention crisis, and then we're medicating that attention crisis through adderall.

And I think that that's only one half of the story. One of the arguments that I make in the piece is that, in fact, if you look at the emergence of let's say, millennial Internet culture, which is to say, sort of smartphone CUSP internet culture, first of all, the technical architecture of the Internet is overwhelmingly created by people

who are on stimulants. If you think about the extraordinary prevalence of ADHD medication among coders, you could hardly imagine a job that lends itself better to the sort of jacking up of reward systems that amfetines produced than the

extremely boring task of coding. Right. So there's that. And then also if you kind of think about that moment from let's say two thousand and five to twenty fifteen, where you had the proliferation of things like alt lit, tau l in, Ben Lerner, Jonathan Saffaran Foyer, Vice Pitchfork, right, if you think about that sort of milange that was that moment in the culture, I think that one of the defining features of that zeitgeist was the prevalence of

adderall and the prevalence of millennials who had either been put on adderall as children, overwhelming the upper middle class ensured children who then go on to sort of set the BPM of the culture in the zeitgeist, right or the dissemination of adderall through elite college networks.

of the backlash right now to adderall. Then everyone gets concerned. Then it sort of attenuates for a while, and then suddenly there's a new reason and then it picks back up. Is that a general phenomenon in psychology?

by a deficiency of serotonin in the brain. And this is coterminous with very serious marketing campaigns by pharmaceutical companies that include things like funding patients advocacy groups to sort

of demand recognition and access to these drugs. And then you have this sort of decline in optimism around these drugs that I would say dates roughly to twenty ten, and the sort of fall in optimism because in fact, most SSRIs and sent arized do not perform very much better than placebos when looked at in aggregate, that is, through meta analyzes, and so I do think that there is a kind of push and pull here that is maybe not so dissimilar to this general dynamic in psychiatric

medications more broadly. But what's interesting about amphetamines in particular is that sort of the first wave of amphetamine use really gets going during World War Two, when both Allied and Axis powers are using amphetamines or in the case of the Germans, just meth straight up to fuel wartime activities and to quote unquote boost morale. But I mean, there's a historian named Norman Ohler has laid out very capably.

I think the argument that, like for instance, Blitzkraig, cannot be understood apart from the widespread use of by German troops. So you have the sort of large, large spike in population levels of usage around World War Two, that sort

of rises and rises and rises and rises. And then with the sort of panic around overprescription among children in the early nineteen seventies, I think that that backlash against the sort of psychiatric medication being used on children has to be understood in tandem with, for instance, youth counterculture, with youth suspicion of the way that older generations were,

you know, doing things like suppressing student organizing. Right, the youth culture comes to be this sort of anti establishment suspicion of a variety of different systems, including electoral systems, but also specifically the psychiatric system as an agent of control. Right, So if you think about, for instance, Michelle Fucou, Thomas Zazz, the wide spectrum of thinkers in the nineteen seventies who were explicitly making the case that psychiatry was an agent

of social control. The backlash against emphetamines, particularly emphatamines, being used to treat child behavioral disorders becomes a bit more legible, and so then, of course, you know, in the nineteen eighties, with the crackdown on emphetamines, this is one of the

conditions for the rise of cocaine usage, for instance. But I think that there is this kind of push and pull, a sort of dialectic, if you will, between the cultural meanings of em fetamine, and we're now at a moment where I think there's real tension between a narrative that says, oh, well, when you look at the increase in prescriptions that have been enabled by, for instance, the rise of telepsychiatry, most of those prescriptions are going to women in their twenties

and thirties who may have been, you know, left out of a sort of sexist division of prescribing, whereby their ADHD was not recognized for gendered reasons. So on the one hand, that would be good presumably right. And then you know another line of critique that says that the shocking and enormous rise in stimulant prescription, especially during the pandemic, is maybe more profit driven and not so salutary. And I think like that's the space in which this conversation is unfolding today.

access this drug, or is it the companies themselves? I mean this has been a talking point with the opioid epidemic, this idea that there is a built in incentive for a pharma company to want to demand for its own supply. So what exactly is driving the availability here?

know what I mean. I think that for all that people want to really double down on the validity of the ADD or ADHD diagnosis, there is, you know, significant evidence that this is a culturally bound phenomenon just by virtue of the fact that it is essentially a US bounded phenomenon. I think that people should take that pretty seriously when we think about what is driving the current adderall shortage, which was announced by the FDA in October

of two. In twenty two, because of the classification of m fatamines as a schedule to substance in the nineteen seventy one order from Congress to the DEA. This means that there are quotas that are established for how many emphatamine salts can be produced and how those are distributed. Now, there's been a lot of back and forth between pharmaceutical companies and the DA sort of pointing fingers, and the DEA says that in fact, what's going on is that

pharmaceutical manufacturers are not actually hitting their production quotas. Pharmaceutical companies are striking back and saying no, in fact, the production quotas on the amphetamine salts themselves are too low. I don't actually know which one is true. It seems pretty hard to figure out which one is true. But when we look at the enormous recent spike, even between

twenty nineteen and twenty twenty two. In twenty nineteen, for instance, there were sixty six point six million prescriptions for all ADHD medications that includes things like vibance, concerta riddle and so on, in forty five million for adderall alone, And in the first two years of the pandemic there was six million new prescriptions. So one of the narratives that you'll hear a lot about this extraordinary rise in stimulant prescriptions is that this is owing to the proliferation of

telepsychiatry companies like Cerebral Done and so on. And I think this only gets a part of the story. During COVID, the rule that mandated that Schedule two substances could not be prescribed over telepsychiatry was lifted, which meant, especially that people who had never had an ADHD medication prescription before could suddenly get one. There's been a lot of fighting over whether or not that rule will be extended, but that's certainly a huge part of the proliferation of these

telepsychiatry prescription rates. But what's interesting is that a recent study using CDC data know that the rise through tele psychiatry of these prescriptions are specific to VC backed startups. That is, if you were getting telepsychiatry through a sort of established provider like let's say Kaiser or something who had been doing tele psychiatry before, there was not a huge increase in adderall prescriptions for those types of companies.

It was specifically the emergence of these new types of companies like Cerebral and Done that were pushing this enormous increase in diagnosis. And I think that part of this is just a pretty open and shutcase of like a company basing its profit model on slinging addictive medications into this loophole that was created by the pandemic. The Wall Street Journal has done a pretty magisterial and heroic reporting

job I think of documenting that. But one of the interesting thing that comes out of that type of reporting is that it's very difficult to get national data about levels of prescribing because there is no rule MANDATEA that the number of prescriptions for these stimulants be made publicly available in any way. The CDC has to collect this data by doing reviews of private insurance records, but those tend to lag by about a year to two years.

And so when we all started seeing these advertisements for cerebral which were all over TikTok, all over Instagram, that were basically like do you want some adderall you can basically have some, it was very hard for reporters to sort of track the increase that was actually represented by

those prescribing numbers because they simply aren't federally available. I mean, I think among the many arguments for a national health insurance or Medicare for All as it's called in the United States, is that it's very difficult to track the number of controlled substance prescriptions in a way that sort of stays ocurrant. You know, this is also relevant I

think too, for instance, the opiate crisis. But yes, I think that when you look at this enormous increase in telepsychiatry prescription, there's both this sort of que bono line that you can take of, just like there was an enormous amount of money to be made through these telepsychiatry loopholes that allowed slinging these addictive substances into a pandemic.

And then simultaneously, I think there is the reality that it was enormously difficult to pay attention to anything during the pandemic, which contributed I think to many people feeling that because it was difficult for them to pay attention in zooms for ten hours or you know, or however long it was, that they must have some sort of attention deficit diagnosis.

I mean, I remember that when I was prescribed adderall as an eight year old, I went to like a child psychiatrist who played a board game with me called Stop, Relax and Think loosely based off of shoots and ladders, and at the end of that, I walked out with an adderall prescription, Right, And so, like, the thing is, there's not any sort of blood test or genetic test or brain scan that you could take that would stitch some sort of by physiological substrate to this disease entity,

and to say there's no one to one correspondence between the disease entity and some sort of test that you could take, because it's not actually clear out neurological level what this disease entity quote unquote is and so in

that sense, assessment is bound to be essentially vibespace. Now, you know, if you have a clinician who is behaving responsibly, they will do a variety of tests and sort of ask either the child or the parent, or in the case of adult ADHD diagnosis, the patient themselves about their functioning across a variety of domains, including focus on work organization, ability to sit still for long periods of time, and

so on and so forth. But in reality, there is not really a robust test that differentiates people who do have add from people who don't, even in the best of cases, even in the case of very high quality

in person pediatric or adult psychiatric care. Now, when it comes to something like telepsychiatry startups like done in Cerebral, I think that there's been a lot of reporting and documentation now on the way that providers who were essentially working in this sort of gig economy Uber for psychiatric professionals type of platform were punished if they refused to prescribe stimulants at Cerebral for a while, if you refuse to prescribe a stimulant, you had to write up a

justification for why you were not doing that, you would think that responsible medical practice would be the opposite. Cerebral has since after this series of investigations that prompted a DJ investigation, stopped prescribing schedule to substances through their platform.

But I think that regardless of whether or not they're still slinging like adderall or concerto on there, I think that it bears on, for instance, what kinds of assessments are being used to prescribe for it antidepressants, which are also serious, psychoactive medifications that can be very very difficult to wean off of. But in short, answers to your question, no, there's no specific diagnostic test that guarantees the appropriateness of amphetamines for any given patient.

But also I kind of joked in the intro about unfairness and competitive edges here and then Joe said that it's not the Olympics, but of course life is competitive, and it is in some degree a competition, and you could make a serious argument that, like, some people have access to a drug that increases their productivity and has positive outcomes on their economic lives at the very least, So you have people who have boosted their careers by

being on this particular drug. And maybe they got the prescription when they were younger because their parents had money and health insurance and were able to get it, or maybe they had a network of friends who are on the drug or have access to it. In another slightly more dubious way, it does feel like there might be some fairness questions tied to this.

define how amphetamine treatment have been used over the twentieth century. So, for instance, one of the big pushes against the use of Riddlin for children in the nineteen seventies came from the Black Panthers, who saw that amphetamines and Riddlin were being tested on children in residential care facilities, many of whom were black, right, And so there was a sort of lower class iffication of amphetamines in the nineteen seventies

because they were being tested on populations in juvenile detention centers, residential care homes, so on and so forth. There's a real switch in the nineties, right when suddenly attention deficit disorders become kind of the explanation for why white, well ensured, upper middle class children are not doing as well as

would be expected in class. And so I think I say that to just sort of problematize some of the narratives that like emfetamine usage, it has always been considered an upper middle class competitive edge thing, and I think in line with this, for instance, I don't think necessarily that empfetamine use always gives someone a sort of performance

enhancing edge. One of the arguments that I make in the Adderall essay that I wrote is that in fact adderall makes you more susceptible to different types of digital behavioral loops, these addictive digital behavioral loops like scrolling Twitter infinitely or scrolling TikTok infinitely that sort of directly impact one's ability to lead like a thoughtful, well informed life.

with attention deficit disorders and people who have not, then in fact, the real prohibitionist impulse is to say that because we have this real diagnostic clinical entity, which is you know, in fact, like quite contested and not a robust disease entity, all, because we have this robust disease entity,

we are the only ones who should have adderall. And I think that there's this very serious conversation to be had about equity and distribution and what prohibitionism actually means in terms of the implications, however, for widespread amphetamine use.

I think that when we look at emerging forms and organizations of work, which many theorists have described as sort of just in time production flexible production, when you think about the sort of increased stretching of the worker, the need for different types of flexibility across time and space and so on and so forth, and the sort of ever increasing demands for a sort of infinitely flexible worker.

I think that it makes a lot of sense why adderall or different types of amphetamines would be the drug that facilitates that.

based behavioral addiction. And I guess my closing point here would be that adderall cannot fix the sort of internetified attention crisis because adderall hooks us deeper than ever into the sort of structures of addiction that are the sand Quanon of the Internet as a sort of giant casino that we all live in.

not really doing anything. There's a lot of bureaucracy involved, and yet you have to pay attention, per Danielle's points, So I think there's an aspect of that in there. The other thing that was very I guess attention grabbing was the idea of no pun intended was the idea of some of the venture capital backed health services writing more prescriptions than perhaps some of the more traditional health care providers.

But I hadn't realized the degree to which that specific combination that Danielle described, which was the relaxation of prescription drug obligations due to the pandemic and then the simultaneous explosion of these news services, which it sounds like the drugs are kind of being given out like candy.

many doses prescribed? And you can't find it. And if you look, the only entities that offer that data are these like private for profit collectors, and you have to pay like ten thousand dollars or whatever just for a data set who try to aggregate, you know, how many prescriptions of each and it's sort of this idea for better or worse, and listeners can make up their mind.

But like, if you do have a sort of more national healthcare system and there's only essentially one monopoly prescription writer, whether it's the NHS or whatever it is they have in Canada, then you know those numbers in real time and you can say, oh my god, like these prescriptions are totally exploding.

So I really enjoyed that conversation. I feel like I have a better handle on a sort of cultural site geist of the American economy. But wow, there are a lot of questions that come out of this conversation.

addictive painkillers. But it is striking to me that we did just have this like huge, sort of multi year realization that the opioid sellers that it was riven with abuse, a lot of the same things about like so called like nonprofit patient advocacy groups trying to make these drugs more available and ease the regulations, and then we had this big sort of national reckoning with it various books and documentaries. Is such a disaster, and then we just

like move on to the next drug. And again I'm not saying it's necessarily comparable, but the speed with which we just sort of here's the new drug that we're going to commercialize and promote aggressively, it's like, didn't we just do this?

our producer Moses Ondam. For more Oddlots content, go to Bloomberg dot com slash odd Lots, where we have transcripts, a blog and the newsletter and you can chat about all of these topics twenty four to seven in the discord with fellow listeners Discord dodgg slash Oddlines.