How The American Workforce Got Hooked on Adderall

This episode explores the rise in Adderall use among the American workforce, examining its impact on productivity and cultural implications.

1. Adderall use has significantly increased among adults, often as a performance enhancer rather than solely for ADHD.
2. The rise of telepsychiatry has facilitated easier access to Adderall, raising concerns about prescription practices.
3. There is an ongoing debate about the fairness of Adderall use in competitive work environments.
4. Regulatory and economic factors significantly impact the availability and distribution of Adderall.
5. The episode discusses the potential societal implications of widespread Adderall use, including its effect on workplace productivity and individual health.

1: Introduction

The hosts introduce the topic of Adderall's role in the American workforce and set the stage for a deep dive into its cultural, medical, and economic facets. Jill Wiesenthal: "Welcome to another episode of Odd Lots!"

2: Historical Context

This section explores the historical shift from Ritalin to Adderall, discussing its medical and cultural trajectory over the decades. Tracy Alaway: "What happened to Ritalin?"

3: Cultural and Ethical Implications

The discussion focuses on the ethical implications of Adderall use in the workplace and its role in the knowledge economy. Danielle Carr: "Adderall makes repetitive tasks much more rewarding."

4: Regulatory and Economic Influences

The chapter delves into the regulatory decisions and economic forces driving the widespread availability and use of Adderall. Danielle Carr: "The current Adderall shortage...is a complex issue involving both production quotas and regulatory measures."

5: Future Outlook

The episode concludes with a discussion on the future of Adderall in society and the potential changes in regulatory and cultural landscapes. Jill Wiesenthal: "What do you see on the horizon for the use of stimulants like Adderall?"

1. Educate Yourself and Others: Understanding the medical and ethical implications of Adderall use can foster more informed decisions in the workplace.
2. Seek Professional Guidance: Always consult with healthcare professionals before considering medications like Adderall for productivity enhancement.
3. Advocate for Fair Workplace Policies: Encourage your workplace to adopt policies that address the use of performance-enhancing drugs ethically.
4. Support Regulatory Reforms: Engage in advocacy for clearer and more responsible prescription practices and regulations.
5. Promote Mental Health Awareness: Highlight the importance of addressing underlying issues like stress and burnout without reliance on medications.

Over the last few years, users of the popular ADHD drug Adderall have been frustrated by regular shortages in getting their prescriptions filled. Various regulatory and supply chain factors have contributed to the inability of producers to keep up with demand. But this raises the question: why is there so much demand in the first place? How did a significant chunk of the labor force -- from tech workers to Wall Streeters -- begin using the drug as an aid for their work and everyday lives? On this episode of the podcast, we speak with Danielle Carr, an assistant professor at the Institute for Society and Genetics at UCLA, who studies the history of politics of neuroscience and psychology. We discuss the history of this medicine and related medicines, what it does for the people who take it, and how market forces opened the drug up to almost anyone.

People

Danielle Carr

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Danielle Carr

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Speaker A
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Speaker B
You know, it can be hard to see the challenges that people we work with every day are going through invisible struggles like stress and burnout, caregiving for a loved one or being misunderstood. But insight, awareness and empathy will help us better see the issues they're dealing with, and that can make us and our companies healthier, too. I'm Holly Robinson. Pete. Join us on the Visibility Gap, a new podcast presented by Cigna Healthcare.

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Speaker C
Hello and welcome to another episode of the Odd Lots podcast. I'm Jill Wiesenthal. And I'm Tracy Alaway. Tracy, I was gonna ask you a question, but I already know the answer to it. I was gonna say, like, oh, have you ever tried Adderall?

But I already know. No, you're not. So I don't want to, like, fake the intro or whatever, but I'm just curious, like, what percentage of our colleagues do you think use some sort of stimulant? Adderall? Something.

Some sort of performance enhancing workplace drug? Like coffee? No. Something that. A little stronger than coffee?

Speaker D
No. Okay. We've had this conversation before, and I think it's such an interesting one because, as you know, I have never tried Adderall. It is a complete cultural blind spot for me. But I am 100% sure that you and I, in the context of this podcast and our day to day lives, have absolutely spoken to people who have been on Adderall.

Speaker B
In fact, a very famous one springs to mind right now. I don't know who you're talking about. SBF. Sam Batemanfree. Yeah, there you go.

Speaker C
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. So here's my thought, which is that, like, my big fear with Adderall is like, I'm not maybe against trying it. Cause I don't think I have the most focused brain in the world. In fact, I know I don't, and I get scattered.

I'm worried that I would be really productive on it. And then for the rest of my life, be faced with this choice of, do you wanna stay on this drug forever? Or do you just wanna go back to your old self, knowing that you have this other potential state in you? Yes, that's my big fear. I feel the same way.

Speaker B
I am deeply concerned that I would start writing a book and be successful at it. No, that's a joke. But I think, like, to me, it opens up kind of interesting questions about fairness and access. And if someone next to you is getting an edge because they either have a prescription that maybe they don't need, or maybe they do need it, and we can get into the degree to which Adderall actually is needed by the population, or they're accessing it illegally. In one 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? Yeah. I mean, this is not the Olympics.

Speaker C
We're trying to all maximize our performance here in the corporate world. So I first heard about Adderall when I was in high school. I graduated in 98, and I wasn't, like, a great student. I got bored a lot in class. I've just been scattered.

I couldn't focus, and so. And I feel like I was probably in a slightly different environment. Maybe if I had been born a couple of years younger, I might have been prescribed it, I think maybe not. Cause my parents were hippies, and so they didn't really believe, probably, in prescribing drugs for that sort of thing. But then, you know, it's sort of this cultural thing.

It's like, oh, they're giving all these boys. Yeah, predominantly boys. I think this is a big issue, that a lot of women weren't diagnosed when they were young, and there are a lot of people right now, in their thirties and forties who are getting late diagnoses, because all the symptoms that people were looking out for were, you know, hyperactive boys, basically. Totally. And so it went from a hyperactive boys in high school thing, and then I sort of forgot about it for a while.

Then I went to college and I found that to be a little easier. And then, 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 own right.

Speaker B
Yes, and I am just going to emphasize this again, cultural blind spot for me. So I'm very interested to hear how, you know, how it works, what the impact might be, and what's driving the boom in usage, as you mentioned. Well, I'm really excited to say we do in fact have the perfect guest, someone I've wanted to talk to for a long time on the show and someone who recently wrote about it. And so there was this great set of essays collected by pioneer works talking about the Adderall phenomenon from various phenomenons. I read all of these in one sitting without the use of Adderall.

They were very, very good. They're very good. Everyone should read all of them. But I'm really excited. We're going to be talking to one of the contributors, Danielle Carr.

Speaker C
She's an assistant professor at the Institute for Society and Genetics at UCLA, and she's a historian of science and psychology. So hopefully we're going to understand how did we get to this point and what is widespread Adderall consumption? How is it rewiring our brains, or if not society? So, Danielle, thank you so much for coming on odd lots. Thank you so much.

Speaker D
It's wonderful to be here. Describe your work in general. You had a great New York magazine cover story last year, but talk about from an academic perspective, what is your focus? How does adderall fit into your broader research and work over time? So I guess I should say that Adderall and attention deficit diagnoses are not my specific realm of expertise.

My dissertation work, and now my first book is looking at the rise of neural implants a la Elon Musk's neuralink to treat psychiatric disorders such as anxiety, depression, PTSD and 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 20th to the 21st century. I have a really basic question to start out with. What happened to Ritalin? So, no, but honestly.

Speaker B
So if we had been having this discussion in like the 1990s or the early two thousands, I don't think we'd be talking about Adderall, we'd be talking about Ritalin. Yeah, I think that that's absolutely right. I mean, one of the interesting things to note about the sort of cluster of names for this behavioral disorder that is currently called ADD or ADHD, is that there have been, since 1902, about 20 different names for this kind of cluster of syndromes. And so Ritalin emerged as it's methylphenidate rather than an amphetamine. So it's slightly different pharmacologically.

Speaker D
And it was formulated in the mid 1950s 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 methylphenidate XR. But there was a period, basically in the 1970s when, and I'm sure we'll get into this, there was a sort of widespread panic over the enormous prevalence of amphetamines, especially to treat children. And Ritalin was sort of preferred as an alternative that had fewer side effects, allegedly, and was less addictive, allegedly, which accounts for the prevalence of Ritalin through the sort of mid nineties, at which point there's a switch when shire pharmaceuticals acquires obitrol, which is rebranded as Adderall, and that's really when the Adderall craze hits. Tracy, I'm glad you asked that, because I had forgotten all about Ritalin.

Speaker C
But now that you say it, that's what people were talking. They weren't talking about Adderall yet. When I was in high school, but I was aware that this was the thing, and, like, CNN and stuff would talk about all these boys being described Ritalin. So I mentioned Danielle, I was in high school in the mid nineties. What was going on then?

That suddenly there seemed to be this, the first wave, or maybe the way you describe it, the second wave of this phenomenon of let's get all the boys on Ritalin. Yeah. So I guess we can start the story in media res, as it were, in the mid nineties. But really, the work of a historian named Nicholas Rasmussen has, I think, done a very magisterial job in showing that the 20th century was defined in many ways by recurrent waves of amphetamines use. The first wave really began with the rise of amphetamine use during the Second World War.

Speaker D
And we can talk about that if you guys would like. But by the mid nineties, one of the major things that had happened was a panic in the 1970s, a sort of moral panic over the extraordinary prevalence of amphetamines, mostly dexedrin and benzedrine, 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 1971, you had Congress tasked the DEA with reclassifying amphetamines as being a schedule two substance. That is, prescriptions needed to be reported to a central government administration.

And there were limits and quotas placed on the quantities of amphetamines that could be manufactured and then distributed to pharmaceutical companies. You had this sort of moral panic around that that actually led to a congressional investigation in 1970. And there was this sort of broader crackdown, both legally in the 1970s and also culturally, where you had this sort of countercultural figures decrying speed freaks, which had also. There was this discourse in this narrative that, for instance, the Hyde Asbury sort of summer of love had been destroyed by speed freaks and so on and so forth. So in the 1970s, you have a movement away from amphetamines proper, which a.

It creates the conditions for the rise of things like Ritalin, which is a methylphenidate, which is, you know, it's pharmacologically quite similar, but it was not subject to exactly the same controls as amphetamines. And secondly, I think the very important thing that happens is that one of the few medical uses for which amphetamines are going into the late 1970s still allowed to be prescribed are child behavioral disorders. Now, prior to 1970, amphetamines 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 small cluster of childhood behavioral disorders. This sets us up for, by the time we get to the 1990s, the sort of growing market for childhood applications for amphetamines.

And I guess, like, the third intervening factor here would be that in 1980, there was the third publication of the Diagnostic and Statistical Manual, which is, or 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 1980s, such that by the 1990s, once Adderall comes onto the market, the stage is set for a very wide sudden uptick in Adderall prescriptions for children.

Speaker A
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Speaker E
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Speaker B
What Adderall actually does. And here I have to confess, in preparation for this conversation, I walked around Union Square in New York and asked people why they take Adderall. No, I asked some people that I know about Adderall and someone explained it to me as this idea that if you do have ADHD, then you don't have the normal level of dopamine in your brain, or your brain handles it slightly differently. And so Adderall basically helps to normalize dopamine and bring it closer to what a neurotypical person 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?

Speaker D
Yeah, so I think the question of what Adderall is and what it does neurologically is very connected to the very contested and open question of what ADD and ADHD are neurologically. So maybe I'll start with what is ADD? What is ADHD? Now, what you have to understand is that with the emergence of the DSM three in 1980. This was a document that created essentially to bring together a bunch of different stakeholders under a very large tent.

These stakeholders included insurers, clinical researchers, pharmacological 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 1980, 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, lets say, depression or anxiety neurologically looks like any other case of depression or anxiety. That's because there are many different ways to have depression. 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 extra 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 repartee of norepinephrine 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, norpornephrine, dopamine. 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 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. Noveprinephrine.

Dopamine is sort of widely theorized, or described as being a chemistry 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. Norepinephrine similarly controls the body as a readiness for fight or flight, and so it generally increases a feeling of alertness and readiness. But this is why 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 1930s, amphetamine was widely prescribed for anhedonia, or a lack of pleasure. In fact, historian Nicholas Rismussen has made the case convincingly, I think, that amphetamine 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. So someone like myself, who sometimes worries that maybe I have another level of productivity above me, even though I've never been diagnosed with anything, like, maybe that's true. So I get, like, as you say, okay, it makes Internet gambling, you could see, or tweeting.

Speaker C
Tweeting, et cetera. But, like, what is the theory by which, like, a bunch of people who have jobs where they have to make PowerPoints about some m and a deal, and they're all, many of them apparently, on Adderall. Like, for that person, they have a job, they're in the office until 11:00 p.m. They get one typo wrong, they have to start it all over. What does Adderall do for them in the sort of corporate context or the work context?

Speaker D
So one of the things that I discussed in my essay was clinical literature around what psychiatrists call punding, which is repetitive behavioral loops that are often observed in patients that are taking drugs that bathe the brain in dopaminergic chemicals. So punding was first described in the 1970s 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 were taking levodopa, 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, an amphetamine makes any task that you're engaged in much more rewarding because it's massively ramping up the.

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 amphetamine specifically in sort of knowledge work is that it makes these repetitive tasks feel more like hunting and gathering. Right. It's a more exciting task to do these repetitive tasks.

And this is not something that is specific to the 1990s when psychiatrist Abraham Myerson, who is one of the first psychiatrists to widely use benzedrine for depressed and anhedonic patients in the 1920s, his clinical area of expertise was the sort of neuroses of what he called the brain workers of the upper class. So I think that there is a robust through line of amphetamines being used for these emergent forms of work in the US. That was great, by the way, I never heard punding before you wrote about it, but if you go to the Wikipedia page for punding, there is a very cute photo of someone who has lined up all of their rubber duckies just looking at that sequence. So I guess that person, you know, there you go. It must have been very satisfying for that person to arrange all of their toys.

If you think about the sort of phenomenological experience of what it is like to be online on Adderall or to do research on Adderall, there is a sort of punding like quality to always another reeled vwatch, always another link to open. Right? And this sort of punting phenomenon, I think, is definitely one way to describe the addictive behavioral loops that are built into this sort of giant casino called the Internet that we all live in now. So this is one of the reasons we wanted to talk to you specifically, because you do write about this in your essay, this idea that, okay, the medication is now available and more people can access it, but at the same time, there might be things actually going on with our society, with our economy that make this medication 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.

Speaker B
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. Yeah, absolutely. And, I mean, I think I want to duck out of coming down on the side of chicken or egg here, right? These things are co constitutive. But the reason that I wrote the piece was that I think that there has been a prevalence of a certain kind of narrative about the relation between the so called detention crisis, the Internet, and Adderall.

Speaker D
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 dawn. 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 but 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 amphetamines produce than the extremely boring task of coding. Right? And then also, if you kind of think about that moment from, let's say, 2005 to 2015, where you had the proliferation of things like Alt lit, Tao, Lin, Ben Lerner, Jonathan Saffron, Fourier, Vice, Pitchfork.

Right. If you think about that sort of melange, 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, overwhelmingly upper middle class, insured 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. I want to get to the rise of telehealth and the pandemic and how that sort of opened up the door to many more people.

Speaker C
But before we even get to that, this sort of broader question, is it a phenomenon when you looking at history, and it certainly sounds like it, where whether it's the government or regulators or the medical profession, it sounds like these things go in waves, and it's like there's a drug gets prescribed popularly, then there's a backlash, and everyone gets concerned. Maybe we're part 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? Yeah.

Speaker D
Well, you know, I think that I am prone to describe things as a dialectic. In that sense, I would say yes, but you can see this type of pattern in a variety of psychiatric medications. For instance, if you think about the emergence of antidepressants, sSRI's, SNRIs, like Prozac, lexapro, wellbutrin, so on and so forth in the nineties, there's a huge amount of optimism about the serotonin hypothesis, that is, that serious mood disorders like depression are caused 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 days, roughly to 2010.

And the sort of fall in optimism because, in fact, most SSRI's and SNRIs do not perform very much better than placebos when looked at in aggregate, that is, through meta analyses. 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 Oller has laid out very capably, I think, the argument that, like, for instance, blitzkrieg cannot be understood apart from the widespread use of meth 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 this sort of panic around overprescription among children in the early 1970s, 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 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, Michel Foucault, Thomas Zsasz, the wide spectrum of thinkers in the 1970s who were explicitly making the case that psychiatry was an agent of social control, the backlash against amphetamines, particularly amphetamines being used to treat child behavioral disorders, becomes a bit more legible. And so then, of course, in the 1980s, with the crackdown on amphetamines, 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 as sort of dialectic, if you will, between the cultural meanings of amphetamine. And we're now in 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.

Speaker A
What do you see on the horizon? Uncertainty or opportunity? Whatever you see at PejM, we can help you rise to the challenges of today, providing outlooks on the market with deep global and local expertise. With over 1400 investment professionals in pursuit of long term returns, our investments shape tomorrow today, pursue your tomorrow with PJim, a leading global asset manager. Hi, I'm Ron Krzyevsky, chairman and CEO of Stifel Financial Advisors.

Speaker E
If you're not growing your practice, you're losing market share. Stifel is a growing entrepreneurial, advisor centric firm built for successful advisors like you. Imagine having the resources of the largest wirehouses and the support of the boutique shops, but none of the bureaucracy to get in the way of you serving your clients. At Stifel, it's your business, your book, your clients. I always tell the advisors we're recruiting, I want you to come to Stifel and double or triple your business.

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Speaker C
Stifel, Nicholas and company incorporated member SIPC and NYSE. What actually drives the availability of Adderall currently? Is it regulation and one thing I didn't realize before I started asking around about this, but Adderall isn't licensed in the UK, so I don't think you can get a prescription for Adderall over there. Is it the rise of prescriptions, the increased use of telehealth, which makes it maybe easier to access this drug? Or is it the companies themselves?

Speaker B
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 create demand for its own supply. So what exactly is driving the availability here? Yeah. Okay.

Speaker D
So I think this is where maybe we talk about what is specific about pandemic telepsychiatry to the recent Adderall boom. I think the first thing to be noted, as you mentioned, is that this is a specifically us phenomenon. And I think that, like, for all of the activists, and I'm sure, like, you know, I'm gonna get a lot of angry emails after this podcast. You always get angry emails, right? I'm.

I mean, honestly, don't email me, but you know what I mean. I think that for all that people want to really double down on the. On the validity of the ADD or ADHD diagnosis, there is 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 2022 because of the classification of amphetamines as a schedule two substance in the 1971 order from Congress to the DEA. This means that there are quotas that are established for how many amphetamine salts can be produced and how those are distributed.

Now, there's been a lot of back and forth between pharmaceutical companies and the DEA, 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 2019 and 2022.

In 2019, for instance, there were 66.6 million prescriptions for all ADHD medications. So that includes things like Vyvanse, Concerta, Ritalin, and so on, and 45 million for Adderall alone. And in the first two years of the pandemic, there were 6 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 Dunn and so on. And I think this only gets at 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 noted that the rise through telepsychiatry 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 telepsychiatry 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 we're pushing this enormous increase in diagnosis.

And I think that part of this is just a pretty open and shut case 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. There's no rule mandating that the number of prescriptions for the 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, they 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 au courant. You know, this is also relevant, I think, to, 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 cui 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 10 hours or, you know, or however long it was, that they must have some sort of attention deficit diagnosis. I find that really fascinating. This idea, especially that point about the gap and the increase in prescriptions from the sort of VC backed startups which we know need growth, growth, growth, versus the sort of legacy healthcare providers that had been doing telemedicine for some time and that didn't pick up. I guess I should have just, like, done a test, but, like, what do you have to demonstrate to get Adderall?

Speaker C
You can't just click a button. But how simple I think you can. Is it really, like, what, is there some sort of basic test? And, like, do different doctors, like, did the ones who work through the legacy providers, have a more, perhaps stringent test or expectations? Like, what do the various types of medical professionals want to see before they'll write that prescription?

Speaker D
I mean, I think the most succinct answer to this question is that it has been and remains essentially vibes based. And the quality of that vibes based assessment basically depends on the quality of the medical care that you're receiving. 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 chutes 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 biophysiological 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 on a neurological level what this disease entity, quote unquote, is.

And so in that sense, assessment is bound to be essentially vibes based. 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 like, 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 refused to prescribe a stimulant, you had to write up a justification for why you were not doing that when you would think that responsible medical practice would be the opposite. Cerebral has since, after this series of investigations that prompted a DOJ investigation, stopped prescribing schedule two substances through their platform. But I think that regardless of whether or not they're still slinging like Adderall or concerta on there, I think that it bears on, for instance, what kinds of assessments are being used to prescribe, for instance, antidepressants, which are also serious psychoactive medications that can be very, very difficult to wean off of. But in short answer to your question, no, there's no specific diagnostic test that guarantees the appropriateness of amphetamines for any given patient. This is a very wide ranging question, but what are the implications for society of this increased Adderall use?

Speaker B
And obviously, there's a physical impact of having a higher proportion of the population dependent in varying degrees on a particular substance. 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 this 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.

Speaker D
Yeah, I think one of the first things to be said about this is, like so many other things in psychiatric treatment, there are a series of strange paradoxes that define how amphetamine treatment have been used over the 20th century. So, for instance, one of the big pushes against the use of Ritalin for children in the 1970s came from the Black Panthers, who saw that amphetamines and Ritalin were being tested on children in residential care facilities, many of whom were black. Right. And so there was a sort of lower classification of amphetamines in the 1970s 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 disorder has become kind of the explanation for why white, well insured, 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, amphetamine usage, 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 amphetamine 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. One of the interesting responses to the club med Adderall essay collection, I thought, was that there was a lot of anger and accusations that some of the arguments that the authors made were prohibitionist and impulse.

And I can see why that would be a concern. But I think that it's misplaced, because, in fact, if you think about the clinically documented fact that there is really not that much of a difference in effectivity for amphetamines between people who have been diagnosed 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 at 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 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. But I think that the conversation that I hope to see emerge in the coming years is one that's less focused on sort of who legitimately has ADHD and who does not.

Because, in fact, these amphetamines have remarkable efficacy for both groups that have been diagnosed and groups that haven't, and more of a turn towards thinking about what it is that Adderall does in terms of setting a sort of pace of freneticism and susceptibility to different forms of behavioral addiction, particularly Internet 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 San quan of the Internet as a sort of giant casino that we all live in. Danielle, this was fascinating. We could probably talk for hours on this subject. I just want to say I'm addicted to Twitter and Instagram.

Speaker C
Totally naturally, totally clean. But thank you so much for coming on odd Lodz. It was a great conversation and glad we finally got a chance to talk to. Thank you so much. This was really fun.

Tracy. I really enjoyed that conversation, and there were a number of things that really are gonna stick with me. But, you know, one thing that sort of I had never really thought about before is the idea that, sure, being on one of these drugs can sort of change the way you consume information or perform tasks online, whether productive or unproductive. But also the idea that the entire online world was also built by the people on these drugs. Yeah, it's sort of intertwined.

Speaker B
Right. The other thing that I thought was really interesting was Danielle's point about the knowledge economy. And part of this is because I've been reading, oh, I'm gonna have to censor myself B's jobs by David Graeber. And it's sort of like a dystopian studs charcoal in the sense that it just details how much dissatisfaction people seem to have with a lot of modern day jobs where you feel like you're not really doing anything, there's a lot of bureaucracy involved, and yet you have to pay attention, per Danielle's point. So I think there's an aspect of that in there.

The other thing that was very, I guess, attention grabbing was the idea, oh, no pun intended, was the idea of some of the venture capital backed telehealth services writing more prescriptions than perhaps some of the more traditional healthcare providers. That was totally eye opening for me. And I was, you know, I'm aware of the proliferation of these telehealth companies. As a male in my mid forties, I constantly get ads for, you know, various pills that I can just go on for, like hair loss and things like that. And so I see them targeted to me all the time.

Speaker C
But I hadn't realized the degree to which that specific combination that Danielle described, which was, is the relaxation of prescription drug obligations due to the pandemic and then the simultaneous explosion of these new services, which it sounds like the drugs are kind of being given out like candy. Well, the other thing that I think is something of a tell is the fact that Adderall is not licensed in places like the UK. This seems, in many respects to be a sort of peculiarly or especially american phenomenon, which. Tracy? Tracy.

Speaker B
Yes. What do they do in the UK if they don't get. If they can't get Adderall? They get their energy. If you work in finance, you get your energy the old fashioned way.

I'm not going to say what that. I mean. Coffee, of course. No, powdered coffee. Yeah, there we go.

But I think it is suggestive as to what's going on here, the fact that there might be something structural or specific about the US economy or the healthcare system that seems to be driving some of this. Yeah, two things on that. So Danielle made this point, and I had realized this six months ago. I remember, out of interest, trying to find some number about, like, finding how much of a drug has been described, how 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 $10,000 or whatever just for a dataset who try to aggregate how many prescriptions of each.

Speaker C
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. Yeah. That point by Danielle. The idea that maybe there are data benefits to have a national healthcare service, that was one I hadn't heard before.

Speaker B
But it may makes some sense to have a sort of centralized body that is actually writing these things, perhaps has a better outlook. Anyway, fascinating conversation. You know, it's going to be good when you ask someone for context on this and they start out with, you know, meth addiction in World War Two. So I really enjoyed that conversation. I feel like I have a better handle on a sort of cultural zeitgeist of the american economy.

But, wow, there are a lot of questions that come out of this conversation. You know, one other thing too, about this sort of, of maybe the pathologies of the US healthcare system is I don't think that any of these drugs are as bad as addictive painkillers. But it is striking to me that we did just have this huge sort of multi year realization that the opioid sellers that was riven with abuse, a lot of the same things about so called 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 various books and documentaries. It was such a disaster.

Speaker C
And then we just 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? Well, Danielle made that point, too. The idea that it kind of goes in cycles and it does feel like these things kind of come and go in terms of popularity, in terms of commercialization, as you mentioned.

Speaker B
Yeah, you're right, it's nuts. But it seems like it is getting a little bit more attention nowadays. We'll see what happens. We'll see. Shall we leave it there?

Speaker C
Let's leave it there. This has been another episode of the all thoughts podcast. I'm Tracy Alloway. You can follow me, racialaway. And I'm Joe Wiesenthal.

You can follow me at hestalwert. Follow our guest Danielle Carr. She's Danielle Carr. Follow our producers, Carmen Rodriguez at Carmenarmon, Dash O. Bennett at Dashbot, and Cale Brooksale.

Brooks. Brooks. Thank you to our producer, Moses Andam for more odd lots content, go to bloomberg.com oddlots. We have transcripts, a blog and a newsletter, and you can chat about all of these topics 24/7 in the discord with fellow listeners. Discord, GG Oddlots and if you enjoy.

Speaker B
Odd lots, if you like it when we do healthcare or pharma themed episodes, then please leave us a positive review on your favorite podcast platform. And remember, if you are a Bloomberg subscriber, you can listen to all of our episodes absolutely ad free. All you need to do is connect your Bloomberg account with Apple Podcasts. Thanks for listening.

Speaker A
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