ABOVE VIDEO: Adult ADHA - Over or under-diagnosed?
Some years ago, after too many local spirits at a bar in Tanzania, I lay sprawled out across the girl beside me, watching the world move past in double.
One of my perkier comrades, an American, offered a solution in the form of a tiny pink pill.
“This’ll bring ya back!”
I’d seen ecstasy before but this was different. It was smaller and much smoother.
An hour later, I had returned to my accommodation and was drenched in sweat, teaching myself the chords to ‘Gangster’s Paradise’ on the ukulele while deep cleaning the kitchen. My eyes were so wide I thought they might detonate in their sockets. But I felt sharp. Brilliant, even.
I would later find out what I had knocked back with cheap African beer was a central nervous system and cognitive stimulant called Adderall; a pharmaceutical a single chemical compound away from crystal meth and widely prescribed in the United States to treat Attention Deficit Hyperactivity Disorder (ADHD).
The next time I would cross paths with Adderall would be many years later, on a different trip. This time, the experience even more eye-widening.
In 2017, on a writing retreat in Bali, I met Claire.
Claire was from Cincinnati, Ohio. She’d grown up on an alpaca farm, had a loud drawl and the quickest wit in the room. She was my housemate for a month along with 16 other creatives.
One night, over nasi goreng and beer, Claire told me she had been diagnosed with ADHD when she was six years old and her doctor had given her an open-ended prescription to Adderall.
“A teacher told my mum I couldn’t sit still in class.”
It struck me that Claire had been labelled with neurodevelopmental condition by displaying what sounded like fairly commonplace six-year-old behaviour.
My thoughts wandered to my youngest cousin, Tayla, who was in primary school in Australia.
Tayla had never displayed any serious issues with focus – she would read books in their entirety and loved a lengthy chat – but she couldn’t always sit still. She was, after all, a kid.
A paper titled ‘The Assessment of Attention in Preschoolers’, published in the U.S. National Institute of Health’s Library of Medicine claimed that by age four, as many as 40% of children presented with sufficient enough attentional indictors, they were of concern to parents and teachers. Many of these signals, however, were only minor or transient. The paper also acknowledged that inattention was such a common experience in young children that identifying it as ‘disordered attention’ was problematic. Despite this, the Centre of Disease Control and Prevention found the number of American children aged two to five diagnosed with ADHD increased by more than 50% from 2008 survey to 2012.
It dawned on me that Claire wasn’t the only one who hadn’t been sober since the first grade.
Dr. Prash Puspanathan, who works in the psychiatry department of a major metropolitan hospital in Australia, told me that Claire’s narrative was not uncommon, that is was likely the “pathologisation of normal human behaviour.” “Doctors are looking for excuses or different rationale to flatten the bell curve of normal human experience,” he said.
“There is going to be a portion of kids who do see benefit from ADHD medication because their level of impairment is so extreme they are struggling to function, but for the most part, we don’t all mature at the same rate.”
“Personality develops by interacting with the environment. If you start to create that environment internally, pharmacologically, then the environment becomes a relative moot point.”
A week into our retreat, Claire emailed me a lengthy reflection piece she had written for her college finals the year prior. It was about her 16-year relationship with Adderall.
“My body and brain have become wired to perform and release a certain amount of dopamine each day and when they don’t I withdraw and reject any form of willpower to function without Adderall,” she wrote.
I asked her what she did when her prescription ran out.
“It hasn’t yet. My health insurance covers it until I finish college,” she replied. “But I’ve been banned from three chemists for trying to get refills too early.”
In Australia, ADHD medication can only be prescribed by specialists such as paediatricians and psychiatrists. In the United States, however, a prescription can be issued by a physician, dentist, podiatrist, mid-level practitioner or DEA-registered practitioner authorised by the jurisdiction in which they are licensed to practice.
Claire had a few different ticks. She would unconsciously pull out strands of her thick brown hair one at a time, and she never really slept. “When something like this happens from a very young age, over a very long time, your entire biochemical profile changes as a result. Your psychological profile also completely changes."
You then become modulated by the substance… You cease to behave in the way your body was designed to.
Claire and my conversations took a darker turn when she admitted she couldn’t really tell me who she was without Adderall. She didn’t know if certain moments in her life had shaped her, or if the drug had shaped those moments. Comments from family and peers like, “she’s just moody ‘cos she hasn’t taken her Adderall today” had forced Claire to question if she even existed separately to the drug.
Then, one day, she told me about Rose. Rose was Claire’s second-year roommate at college, and the two were inseparable. Rose taught Claire that snorting Adderall was the best way to reach higher peaks and taking lines on an empty stomach was the quickest. Both Claire and Rose had been diagnosed with ADHD when they were children, but by the time Rose was eighteen her dosage was double Claire’s.
The two began using their prescriptions recreationally and when the supply would fall short of their monthly refills Rose would suggest they go in search of different ways to balance the comedown. As Rose’s tolerance began to climb so too did her penchant for mayhem.
Eighty milligrams of Adderall became 160, and 160 became 300. Claire could no longer keep up and soon Rose began requesting that Claire drive her to the outskirts of town to collect her next fix, at which point was no longer dispensed from a pharmacy. If Claire refused to drive, Rose would walk, sometimes on journeys of up to four hours.
Just before her senior year of college, Rose voluntarily entered detox with open charges for Benzo ID, Oxycodone, Cocaine, Ethanol, THC, Opiates, Barbiturates, Benzodiazepines and Adderall. In 2018, she was placed in an induced coma following a stint using Fentanyl.
After being discharged she relapsed immediately and was readmitted to hospital where her arm was amputated due to an infected vein.
Between 2006 and 2011, emergency room visits involving dextroamphetamine-amphetamine (Adderall) rose by 156%. The U.S. Department of Health & Human Services Substance Abuse and Mental Health Services Administration believes prescription abuse to be the fastest growing drug problem in the United States.
Data from the Centers for Disease Control and Prevention showed that illicit and prescription drug overdoses killed 70, 237 Americans in 2017 – a new annual record.
Outwardly, Claire appeared normal; prosperous, even. She had moved out of home and completed a college degree. She had a boyfriend and a good job and enough money for a month-long stay in Bali.
“In the case of cognitive enhancers, like Adderall and Ritalin, often the functional decline isn’t that obvious. If anything, it can look like functional gain because the person is being optimised,” says Dr. Puspanathan.
NSW registered psychologist and private practice owner, Monica Heafey, who works with patients once they are already on medication, told me a great portion of the prescribing is done based on guess work. “The brain is such a complex organ but rarely is there enough education given around how different medications will work [person to person]. If you ask any psychiatrist they’ll say, we don’t really know, but what we think happens is XYZ.”
For two thirds of her life, Claire had carried with her a dark habit. It had informed almost every facet of her existence and driven most of her biggest decisions.
While we were in Bali, Claire had attempted to kick the Adderall but lasted 48 hours before reporting she felt completely “personality-less” without it.
“There is a really big question around what informed consent actually is, and it’s worth reflecting on,” Monica told me when I asked what it meant to be informed about the effects of long-term prescription use in Australia.
“I ask my clients all the time, ‘Do you know what your medication does? Do you know how it works?’ They all say, ‘Nope, I just take it.’”
