Prescription Stimulants for ADHD: Separating Fact from Fiction

Attention deficit/hyperactivity disorder, more commonly known as ADHD, is the most common psychiatric disorder in children and adolescents. According to the American Psychiatric Association, an estimated 8.4% of children and 2.5% of adults have ADHD, and as information about the disorder becomes more widespread, those numbers are expected to increase. 

Prescription stimulants are prescribed to both children and adults with ADHD to manage their symptoms. But despite the frequency at which they’re prescribed - or maybe even because of it - discussions about these drugs are often confusing at best and polarizing at worst. 

There are myriad misconceptions about prescription stimulants.  A quick Google search will tell you that they are either overprescribed or underprescribed; a path to drug abuse or completely harmless; a conspiracy pushed by big pharma or a total cure for ADHD. But buried within the array of opinions, as with many hot-button topics, are small nuggets of truth. 

What are Prescription Stimulants and Who can Get Them?

The most commonly prescribed stimulants, according to the National Institutes of Health, are Adderall (amphetamine/dextroamphetamine), Ritalin and Concerta (methylphenidate), Dexedrine (dextroamphetamine) and Vyvanse (lisdexamfetamine). These drugs increase focus and concentration by upping the amount of dopamine and norepinephrine in the brain. 

Norepinephrine’s effect is physiological - it controls blood pressure, heart rate, blood vessels, breathing and blood sugar. Dopamine plays an important role in the brain’s reward center and is commonly known as the “feel good” chemical.

People with ADHD don’t produce enough dopamine on their own, leaving them feeling tired, unmotivated and even depressed, often engaging in risky, impulsive behaviors to chase the “high” that comes with a rush of dopamine to the brain. At the correct dosage, prescription stimulants are designed to bring these chemicals to a normal level. 

Many people think prescription stimulants don’t work the same way in people without ADHD. But in reality, the drug can’t tell if the person taking it lacks those chemicals–it just supplies them. This is why many refer to prescription stimulants as “study drugs,” as they are often taken by students, athletes and working professionals without a prescription to increase mental and physical performance. 

So, the onus is on the prescriber. But there’s a problem with that. There’s no standardized, physiological test to determine if someone has ADHD or not outside of a research laboratory. The current diagnostic criteria are almost all behavioral.

Sharon Witkin is the chief clinical officer at Polygon, a company that specializes in research and testing for learning disorders like dyslexia and ADHD. One of Polygon’s goals is to provide a clear diagnostic framework for diagnosing ADHD. To that end, she told BioSpace that one of the biggest problems with diagnosis is a lack of standardization. 

“What we understand about brain function and ADHD is still pretty minimal. That means that we're relying almost 100% on behavior to diagnose, and we're trying to diagnose something that happens to everybody,” Witkin said. “Everybody has periods of inattentiveness. Everybody knows what it's like to be distracted. Everybody has some degree of that behavior….so then we have to draw a line in the sand about when it becomes a disorder and when it's merely a normal behavior. And that's a very hard thing to do.” 

The DSM 5 is the current standard for ADHD diagnosis in the U.S. A patient under 17 must report at least six out of nine symptoms to be diagnosed, and those over 17 must report at least five. These symptoms are either self-reported or reported by a guardian, meaning if someone wants to be prescribed stimulants, they can report these symptoms to a physician, who then must decide if the patient is telling the truth. 

“In this moment in the United States, it's very easy to get a diagnosis of ADHD,” Witkin said. “You can find somebody who will give you a diagnosis, and once you have a diagnosis of ADHD, it's not hard to get a prescription.” 

Prescription Stimulant Misuse & Abuse - How Common is it, Really?

This is what many point to as an argument against stimulants – overprescribing. But according to Witkin, one of the biggest problems isn’t that people who don’t need the medication are getting it, but that “sometimes the people who need [the medication] aren't getting it.”

This is because many physicians err on the side of caution to avoid potential abuse or misuse in their patients. But how dangerous is it to abuse these drugs, and how common is it, really? 

A 2018 study published in the American Journal of Psychiatry states that among U.S. adults, 6.6% (annual average) used prescription stimulants overall, 4.5% used without misuse, 1.9% misused without use disorders and 0.2% had use disorders. Drug abuse and misuse occur when a drug is taken without a prescription or used differently than prescribed.

The NIH states that misuse of prescription stimulants can lead to a substance use disorder (SUD), which can turn into an addiction, in some cases. Long-time users can develop a tolerance to the drug, meaning they have to take higher or more frequent doses to get the same effect. 

Tolerance isn’t the same as a SUD - a disorder develops only when continued use of the drug negatively affects the user’s physical health or their ability to keep up with personal responsibilities. Someone with a SUD who stops taking the drugs can experience withdrawal symptoms, including fatigue, depression and problems with sleep.

Because prescription stimulants are controlled substances, they are often compared to other controlled substances like opioids. But though the drugs are in the same class, the risks are much greater for opioids than prescription stimulants. 

For example, someone who abuses or misuses opioids and attempts to stop taking them will experience severe physiological and psychological symptoms. In 2020 alone, there were 68,630 opioid-related deaths recorded in the U.S. 

Dr. Charles Smith, an addictionologist at Recovery First Treatment Center in Florida, told BioSpace that overall, he believes the benefits of prescription stimulants outweigh the risks. 

“Extensive research over the decades has suggested that long-term stimulant use is well tolerated and effective in short-term and long-term treatment plans,” Smith said. “When utilized as prescribed for a prolonged period of time, many studies indicate that adverse neuropsychiatric outcomes are not typical, and some stimulants may even reduce feelings of depression and suicidal ideation in those with ADHD.”

Still, many point to evidence of withdrawal as an argument against prescription stimulants.  A quick scan of r/ADHD on Reddit will show just how many people struggle to cope after they have been taking prescription stimulants for years and try to stop. 

And while this is a valid concern, Erin Knox, Board Certified Psychiatric Pharmacist, director of experiential pharmacy education at the University of California, Irvine School of Pharmacy & Pharmaceutical Science, told BioSpace that for those who take the drug as directed, this may have less to do with the medication and more to do with the user. 

“One of the things that you have to consider is many of the symptoms that people will describe as feelings of withdrawal are also overlapping with the symptoms associated with their ADHD, which now that they are not receiving their stimulant, is essentially being untreated,” Knox said. 

She added, “These medications regulate dopamine, and when you stop [taking them], you go back to this wacky firing, if you will…. And that's where some of the resurgences of the ADHD symptoms can start to come in.” 

Smith agreed. He said that if taken properly, “the potential of developing an addiction to stimulants is exceedingly low.” He added, “someone ending their use of Adderall or Ritalin at therapeutic doses should not experience withdrawal symptoms.”

Benefits, Risks and the Importance of Advocacy 

Still, there are risks that come with taking these drugs. At high doses, they can lead to dangerously high body temperature, an irregular heartbeat, heart failure and seizures. This is why many people turn to non-stimulant options.

In 2002, Strattera (Atomoxetine) became the first non-stimulant medication for ADHD approved by the U.S. Food and Drug Administration. Strattera, along with other approved non-stimulants like guanfacine, clonidine and some antidepressants, touts that its side effects are much less severe than those of prescription stimulants. However, it is also considered to be less effective overall or a second-line treatment.

In April, the FDA approved Supernus Pharmaceuticals’ Qelbree, a non-stimulant, for use in adults with ADHD. This followed a previous approval for its use in children over six and made it the first non-stimulant approved by the FDA in nearly 20 years.

Jack Khattar, president and CEO of Supernus, told BioSpace his company wanted to give people with ADHD a different option. 

“It's been about two decades with no innovation in this space, unfortunately, and we're very pleased to bring something truly different that works well from an efficacy point of view, yet it is not a controlled substance,” Khattar said. “It can be a great alternative for a lot of children, adolescents and adults, and we've proven that, of course, through a very comprehensive clinical study.” 

As both stimulants and non-stimulants are frequently prescribed to children, parents have to weigh the risks versus the benefits and decide what’s best for their child.

Kristin Wilcox is one of those parents. Wilcox is a researcher, pharmacologist and neuroscientist who previously conducted research related to drug abuse behavior and ADHD. When her son was diagnosed, she was conducting a study about the long-term effects of prescription stimulants at Johns Hopkins University. She is also the author of Andrew’s Awesome Adventures with His ADHD Brain, a book based on her experience raising a son with ADHD. 

Wilcox’s son was diagnosed with the inattentive subtype of ADHD, which is more common in girls and women and is diagnosed much less often than the hyperactive subtype. It’s characterized by trouble focusing, being frequently “spacy” or distracted, forgetfulness and lack of attention to detail. This differs from symptoms of the hyperactive subtype, most common in boys, which includes symptoms many picture when they think of ADHD–fidgeting, an inability to sit still, excessive talking and frequent disruptions.

Her son’s official diagnosis came after Wilcox had documented a “paper trail” of comments and reports from teachers with her son’s physician. She said that due to the lack of education and knowledge about ADHD, coupled with the less-common subtype, his reviews from teachers were a mixed bag.

While some teachers recognized that his symptoms were related to ADHD, others thought he was incapable, or worse, lazy. 

“For me, there was a lot of learning involved about what [ADHD] really was…it wasn’t just, you can’t focus, you can’t clean your room, you can’t put your bike away,” Wilcox told BioSpace.

“It took me a long time to understand that. Why can’t you put your bike away? How hard is that? For someone with ADHD, it’s really hard.” 

Wilcox stressed that it’s up to parents to be advocates for their children, and for adults with ADHD, it’s vital for them to advocate for themselves. Stimulants were effective in helping her son manage his symptoms, but finding the right medication took some trial and error. She also emphasized the importance of recognizing the positive traits that coincide with ADHD.

“People with ADHD truly live life. They're fearless. They take bold action. They're outside the box thinkers,” Wilcox said. “These are things I didn't really know and appreciate about my son until I started researching what ADHD really was.”

Wilcox added that because every person with ADHD is different, it’s not uncommon to try a few different treatment methods before finding one that sticks. Above all, the best thing you can do for yourself or your child is drown out the chorus of differing opinions, educate yourself and ultimately, choose the treatment option that’s best for you. 

“Parent education has to be key. They have to know their child, they have to educate themselves and they also have to advocate for their child…they have to do what’s best for them.”