Newsflash: substance use, and substance dependence, is not synonymous with substance abuse.
I’ve become increasingly worried about the narrative around stimulant use and abuse in the ADHD community. Mostly because uninformed and very opinionated loudmouths are given a platform to paint Adderall as the driving force behind a new “epidemic.” I’m now seeing articles weekly on the topic floating around the interwebs.
What’s troubling about this isn’t just the framing though, it’s the fact that we are stigmatizing medications that are very much needed for a certain percentage of the population. And what really grinds my gears is that nobody wants to make a distinction between responsible medication use and abuse. It’s all just drug use, right? Ummmm no.
The person who takes a controlled substance because it improves their life, is very different from a person who takes 4x what is prescribed just to see what happens. But somehow we are all treated the same way. I’m guessing it has something to do with American morality. In case you haven’t noticed we have a unique obsession with good and evil, right and wrong, and all manner of binary thinking. From that springs an obsession with self-control and individual responsibility worthy of a dissertation, which I hope somebody has done.
One of the systems we’ve developed in our quest to categorize people into neat little categories, is a way to classify medical and other diagnoses, so let’s start there.
The DSM 4-5
In my book I write specifically about the DSM 5 and the outdated criteria for diagnosing ADHD in women and adults. In general, I do not like talking about the DSM, mostly because it reads a little like a middle school science textbook from the 90s. But it offers a decent starting point for studying the moral judgments we make about how humans engage with substances.
I do not have the brain space to write about how the FDA categorizes “controlled” substances at this moment, so I’ll save that for another time and stick with how the DSM determines the diagnosis of Substance Use Disorders.
Fun fact: In the DSM 4 there were separate criteria for Drug Abuse and Drug Dependency. As a person who has taken a controlled substance for years, this is of great interest to me. I depend on medication, but I don’t actually meet the criteria for dependency or abuse in the DSM 4 or 5.
Hasin DS, O’Brien CP, Auriacombe M, Borges G, Bucholz K, Budney A, Compton WM, Crowley T, Ling W, Petry NM, Schuckit M, Grant BF. DSM-5 criteria for substance use disorders: recommendations and rationale. Am J Psychiatry. 2013 Aug;170(8):834-51. doi: 10.1176/appi.ajp.2013.12060782. PMID: 23903334; PMCID: PMC3767415.
If you look closely, you’ll notice in the DSM 5, which is where we are now, they added “craving” and put all the other criteria under one umbrella that is now called Substance Use Disorders.
There is no longer “abuse” or “dependency”, just Substance Use Disorder.
Unless I’m missing something, it’s much easier to diagnose someone with Substance Use Disorder in the DSM 5.
It feels to me like this opens people up to increased scrutiny.
For example, many ADHD folks are trying to get their meds filled during the ongoing shortage, and they’re calling all over, bugging their prescriber so it’s pretty easy to assume they are “drug seeking.” Whenever someone asks to up their dosage are they assumed to be developing a “tolerance?” At this point I’ve heard numerous stories about women being denied stimulants without much explanation at all so the whole thing is a little sketchy.
Obviously we need to acknowledge that during the pandemic when online prescribing ticked up, that a percentage of those new prescriptions were abused. After all, some people are predisposed to substance abuse. But I highly doubt every single person who got diagnosed online and started taking Adderall between 2020-2022 is abusing the medication.Statistically speaking some will abuse, some will not.
It was socially acceptable to drink at home during the pandemic, but start taking a stimulant ooooh no that’s suspicious. By all accounts many people developed problematic drinking habits during the pandemic. But yet I haven’t seen any news stories on that recently, have you? Hmmmmm Since this is a hot button issue let’s get real about ADHD and substances.
ADHD and Substance Use (lifted from my book)
For better or worse there is a lot of overlap between ADHD and substance use of all kinds. The first theory is the most obvious one, that the nature of ADHD lends itself to impulse control issues, challenges with inhibition, and risk-taking behaviors. The idea is that substance abuse is a medical issue, we are dopamine seeking, and that sort of thing. In some cases that might be true.
Another way to frame substance overuse is as a vulnerability. Getting through the day with ADHD requires every ounce of effort you can muster. Things still inevitably go wrong. When your whole life feels out of your control, including your own mind, it makes sense that you’d want to smooth the edges a bit. This is where terms like “self-medicating” or “checking out” are used.
Also, since most of us have anxiety and/or depression, sleep disorders, and other things going on, looking for relief shouldn’t be stigmatized, but it often is. If you haven’t had a decent night’s sleep in months and a glass of wine helps, you’re going to do what works. The problem for some of us is that when we find something that we feel works, we go all in. People can (and sometimes do) interpret this as abuse.
We also know that adolescents and young adults with ADHD are more likely to develop dependency issues.[1] And one study found that 23% of the subjects in a substance treatment program had untreated co-occurring ADHD.[2] But get this— there’s no way to know what would’ve happened if these folks had been assessed and treated for ADHD earlier. There is some evidence that treating ADHD earlier, decreases problematic substance use later in life.[3]
Just to be clear, ADHD and substance use is a thing and we shouldn’t ignore it.
We need to be aware of how we use substances, and since we aren’t great at self-assessment that means depending on others to tell us when we’re getting off track. We have to be aware of our habits, and if we start to overuse we need to talk to someone who understands. This is why having an ADHD community is essential. But when I say community I do not mean only on social media. I mean real humans who have some sense of your history, and who you feel safe with. Support groups with trained moderators, CHADD, ADDA, that sort of thing.
ADHD and Substance Dependency
I take Concerta, and have done so off and on since the mid 90s.
You could argue that I am dependent on it because when I forget to take it, I run around all day feeling kinda grouchy and overwhelmed at my life.I do not have physical withdrawal symptoms or “cravings,” and I also never take more than I am prescribed.
During the (ongoing) shortage that started with Adderall and then bled over into all stimulant medications, I couldn’t get Concerta for about four months. I never once considered going downtown and buying unidentified pills from a dealer. Because I don’t use the medication to get high. I use medication to make my life better, and to be a more functional human.
People who abuse stimulant meds do not use them the same way.
The people who seek out Adderall prescriptions, then take 4x the prescribed amount are going to develop a tolerance. The people who mix Adderall with alcohol and other drugs are going to have negative outcomes. It’s kinda like putting vodka in your eyeballs to get drunk faster, and then being surprised when you need medical assistance.
Adderall is not the problem in those cases but we blame the Adderall anyway. Why is that?
Americans Have Little Empathy for “mental health”
The uncomfortable truth is we treat people very differently based not only on the substances they use, but on their reasons for using substances.
I found out recently I have inherited a form of familial hypercholesterolemia. My APOB and APOa is ridiculously high and apparently it has nothing to do with my diet or lifestyle. This is ironic because I am semi-obsessed with avoiding chronic disease, but as it turns out I have to take statin medication to control this condition so I don’t up and die in my fifties.
When I tell people about the statin they are very sympathetic. They say things like, “give yourself some grace,” or, “that’s so scary I’m sorry.” Sometimes they even ask me questions like, “do the doctors think it’s working?”
When I talk about ADHD and Concerta they are much less sympathetic. It’s more like, “oh be careful, you don’t want to be dependent on that stuff.” Nobody ever tells me to give myself grace, and they definitely don’t ask if the medication is working for me.
So why are we still having articles being released painting stimulants like Adderall as the boogie man in the war on drugs? I’ll tell you why….
We still believe that self-regulation, or lack thereof, is a personal failure. (in women even moreso)
At the beginning of my book I go deep into the nature of self-control, and how many people attach a moral value to having total self-control. That is the underlying thing that makes everybody so judgey about how others behave and how they choose to live.
Consider the moral judgments we make about substance use. The way we are taught to fear the slippery slope of escaping reality. Anyone who lived through the 80s remembers the “The is your brain on drugs” commercials with the eggs in a frying pan. We do not like the idea of anyone altering their mental state, and if it is perceived as pleasurable….forget about it.
In my opinion, this sort of moral posturing is connected to how we talk about all substance use, not just ADHD medications. We love to trash talk people with substance use disorders and their “choices.” But circumstances play a huge role in how one makes choices.
Americans dislike anyone who is unable to engage tirelessly as a cog in the machine of capitalism. We are suspicious of people who aren’t working themselves to death, we deem them lazy or unmotivated. It doesn’t matter what substance you use – alcohol, pills, powders, or all of the above, if you use substances to cope with your life you are weak.
It also doesn’t matter if you have a verifiable mental health diagnosis. Taking prescribed, effective psychiatric medications is just as stigmatized as anything else. Maybe more. I know women who live in secret with ADHD++, surreptitiously picking up their mood stabilizers at the drive through of the local Walgreens.
I’ve had family members tell me my Concerta is a “crutch.” Putting aside the abhorrent word choice, so what?! Am I not supposed to help myself? No, I’m not. Women seeking help is verboten in a society where we are supposed to serve everyone else no matter the personal cost.
Since we have the same level of disdain for ADHD, mental health, and substance use, it’s no surprise that folks with ADHD who depend on substances are overtly stigmatized.
Adderall is just the current target. My fear is that eventually they will go after all the stimulants. This affects not just ADHD folks but those with narcolepsy, some patients with hypotension, and probably others I don’t know about. I have no clue what that will do to the children and adults living with these conditions, but whatever it is won’t be good.
Ideas:
- Educate prescribers about the difference between use/abuse
- Provide prescribers with data on how to safely prescribe/monitor stimulants
- Trust prescribers to make decisions based on the patient (not misinformation)
- Create protocols to evaluate individual risk of abuse when initiating treatment
- Spread real information about how stimulant overuse/abuse shows up
- Develop support services for ADHD folks who use stimulants/substances
- Stop incentivizing insurance companies (and the FDA) to manipulate the flow
- Stop the fear mongering (who benefits from all this fear? )
References