November 28, 2012
The Truth About Adderall
Let's talk about Adderall. For those who haven't heard, Phillies catcher Carlos Ruiz has been suspended for the first 25 games of the regular season after testing positive for an amphetamine, widely reported to be the prescription drug Adderall. Adderall is commonly prescribed for the treatment of Attention Deficit/Hyperactivity Disorder (ADHD) and, less commonly, narcolepsy. As someone who has treated a number of kids and teens with ADHD, I want to talk a little bit about the medication and why someone might misuse it.
First off, let's talk about the word "amphetamine." Amphetamines are a class of drugs with certain chemical properties, and Adderall is in this class, along with other drugs such as methamphetamines and greenies. However, Adderall acts on the brain differently than do other amphetamines. This is not to say that Adderall is harmless. It's just different.
There are legitimate reasons that an adult might have a prescription for Adderall. There is a great misperception that ADHD is only a disorder of childhood. Indeed, clinicians used to believe that people "outgrew" ADHD, although it seems that what they're really doing is getting better at adapting to it. They take jobs that are high stimulation and where they can be up and moving a lot, but the ADHD never really goes away. Some people need Adderall to control their ADHD symptoms in adulthood, and yes, some of them are professional baseball players. There's a therapeutic exemption in MLB for players who are using the drug under the guidance of a doctor. Reports have suggested that approximately nine percent of MLB players have such an exemption.
The fact that the rate is so high compared to the national average has drawn some suspicion, and recently MLB has gone from a single-person review panel for these exemptions to a three-person committee. There is no blood test to diagnose ADHD. Most of the criteria for ADHD are behavioral observations (person has trouble staying organized, makes a lot of careless mistakes, has trouble remaining in his or her seat) and the only stipulation is that symptoms have to be present before the age of six. Of course, this leaves open the possibility that players might fudge the truth to get a diagnosis. On top of that, there are few adults who have a comprehensive and accurate memory of what they were like at age six. There’s not usually another source for corroboration. Major leaguers don’t often bring their parents to doctor’s appointments.
Another issue is that “trouble paying attention” can be caused by depression, anxiety, PTSD, poor diet and/or sleep habits, sensory processing disorders, certain endocrine problems, or an undiagnosed learning disorder. There are measures that can look more objectively at performance on a sustained attention task, as well as standardized behavioral inventories to look both at ADHD symptoms and at symptoms more globally. A good diagnostician will want to rule out many of the above problems before assigning a diagnosis of ADHD. The problem is that to do a proper differential diagnosis for ADHD takes a couple of hours. I’m left to wonder how stringent the diagnostic procedures are for MLB players.
The reason that Adderall is so effective for people with actual ADHD is that it is a low-level stimulant that mostly affects the pre-frontal cortex, which is the part of the brain right behind the forehead. It's also the part of the brain that regulates attention, impulse control, and higher functions like reasoning, learning, and planning. People often wonder why one would give a stimulant to a child who is hyperactive and has impulse control problems. The reason is that ADHD seems to be a problem not with too much energy, but with not enough activity in the part of the brain that reins in that energy and impulsivity. Adderall specifically brings the level of activity in the pre-frontal cortex up to normal rates. For those who need this extra activity, that's a very good thing.
There are, of course, ways to misuse Adderall or other medications for ADHD. Some people crush the pills and snort them (with effects much like those that stem from snorting many other amphetamines). Others take the drug in pill form, and sure enough, it goes to the pre-frontal cortex, where it stimulates the parts of the brain that regulate focus and reasoning. College students are known to use the drug when pulling all-nighters. The result is increased focus and clarity of thought—perfect for finishing that term paper.
And maybe perfect for that game of baseball, because baseball is a game where attention is at a premium. You have to be able to focus on the field for each pitch, even though nothing might happen that involves you for 10 minutes. That's rough. You have to be able to make split-second decisions about that fastball coming at you, and that's easier when the part of the brain that figures out patterns and plans a response is operating in high gear. And maybe some guys take a pill to try to capture that. For catchers like Ruiz, there might be an extra incentive. Calling a game is like a three-hour final exam where you are constantly trying to balance what is working for the pitcher, what he can throw, what the batter is vulnerable to, and what he might be expecting on this next pitch. I’ve never done it, but I have to assume that it’s mentally exhausting. I can imagine the temptation that a “gramme is better than a damme.” (A billion points for catching that reference.)
There will, of course, be negative side effects for someone who takes Adderall, even if it isn't needed. When neurons are stimulated beyond what they should be, there's a greater chance that they will burn out. What's sad is that there is a perfectly legal, safe, and effective way to get the pre-frontal cortex of the brain to work at peak efficiency and still be able to beat a drug test. Get a good night of sleep. When you sleep, the brain prunes away neurons that aren't needed (making the rest of them more efficient), builds new connections to encode new skills, and gets a chance to rest.
So, if you're a major-league player who wants all of the effects of Adderall, but who doesn't want the whole 25-game suspension thing, may I recommend that you skip the pills and instead grab a pillow.