April 18, 2024 • 52 mins
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.
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Speaker 1 (00:02):
Bloomberg Audio Studios, Podcasts, Radio News.
Speaker 2 (00:17):
Hello and welcome to another episode of The Odd Lots podcast.
Speaker 3 (00:21):
I'm Jolle Wisenthal and I'm Tracy Alloway.
Speaker 2 (00:24):
Tracy, I was gonna ask you a question, but I
already know the answer to it. I was going to say, like, oh,
have you ever tried adderall? But I already know you're not,
so I don't want to like fake the intro 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.
Speaker 3 (00:42):
Drug like coffee, No, something a little stronger than college. 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 one hundred percent sure that you and I,
(01:02):
in the context of this podcast and our day to
day lives, have absolutely spoken to people who have been
on adderall. In fact, a very famous one springs to
mind right now. I don't know who you're talking about,
SBF Sam been Free, There you go, there you go,
but it is an interesting thought experiment. To think about
the proportion of people around you, you know, sometimes highly
(01:24):
productive people who may or may not be on adderall
or something similar.
Speaker 2 (01:29):
So here's my thought, which is that, like, my big
fear with adderall is like, I'm not maybe against trying
it because I don't think I have the most focused
brain in the world. In fact, I know I don't,
and I get scartered. 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
want to stay on this drug forever or do you
just want to go back to your old self knowing
(01:51):
that you have this other potential state in you. Yes,
that's my big fear.
Speaker 3 (01:55):
I feel the same way. 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
(02:15):
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.
Speaker 2 (02:34):
Yeah, I mean, this is not the Olympics. 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 ninety eight, 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 such, And
I feel like I was probably in a slightly different environment.
(02:55):
Maybe if I had been born a couple of years younger,
I might have been prescribed it. I think maybe not
because my parents were hippies and so they didn't really
believe probably and prescribing drugs for that sort of thing.
But then you know, sort of this cultural thing. It's like, oh,
they're giving all these boys.
Speaker 3 (03:11):
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.
Speaker 2 (03:27):
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
(03:47):
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 owne right.
Speaker 3 (04:09):
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.
Speaker 2 (04:24):
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 you know
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.
Speaker 3 (04:43):
I read all of these in one sitting without the
use of adderall. They're very, very good.
Speaker 2 (04:48):
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. She's an assistant professor at
the Institute for Society and Genetics at UCLA, and she's
a history storian 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
(05:09):
our brains or if not, society. So, Danielle, thank you
so much for coming on odd lots.
Speaker 4 (05:14):
Thank you so much. It's wonderful to be here.
Speaker 2 (05:16):
Describe your work in general. You had a great New
York Magazine cover story last year, But talk about like
sort of your from an academic perspective, like what is
your focus? How does adderall fit into your broader research
and work over time?
Speaker 4 (05:28):
So I guess I should say that adderall and tension
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
(05:50):
work is looking at the political, economy and historical emergence
of different types of experimental psychiatric treatments from the twentieth
to the twenty four century.
Speaker 3 (06:01):
I have a really basic question to start out with,
what happened to Riddlin? So no, but honestly, so if
we had been having this discussion in like the nineteen
nineties or the early two thousands, I don't think we'd
be talking about adderall. We'd be talking about Riddlin.
Speaker 4 (06:15):
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, you know,
currently called ADD or ADHD, is that there have been
since nineteen oh two about twenty different names for this
kind of cluster of syndromes. And so Riddlin emerged as
(06:37):
it's methyl fenidate rather than an amphetamine, so it's slightly
different pharmacologically, And it was formulated in the mid nineteen
fifties 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,
(06:58):
by the way, is just methyal fenatic x are. But
there was a period basically in the nineteen seventies when
and I'm sure we'll get into this, there was a
sort of widespread panic over the enormous prevalence of infitamines,
especially to treat children, and riddlin was sort of preferred
as an alternative that had fewer side effects allegedly and
was less addictive allegedly, which accounts for the prevalence of
(07:22):
Riddlin through the sort of mid nineties, at which point
there's a switch when Shire Pharmaceuticals acquires Obatral, which is
rebranded as Adderall, and that's really when the Adderall craze hits.
Speaker 5 (07:35):
Tracy.
Speaker 2 (07:35):
I'm glad you asked that, because I had forgotten all
about Ridlin. 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 Ridlin. So I
mentioned Danielle, I was in high school in the mid nineties.
What was going on then that suddenly there seemed to
(07:57):
be this, you know, the first wave, or maybe the
way you describe it, the second wave of this phenomenon
of let's get all the boys on Ridlin.
Speaker 5 (08:05):
Yeah.
Speaker 4 (08:05):
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 Rusmussen has I
think done a very magisterial job in showing that the
twentieth century was defined in many ways by recurrent waves
of infatimine use. The first wave really began with the
rise of infetamine use during the Second World War, and
(08:27):
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 nineteen seventies,
a sort of moral panic over the extraordinary prevalence of amphetamines,
mostly dexidron and benzydrin, that were being prescribed without any
sort of federal control. It was extraordinarily prevalent across the
(08:49):
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 nineteen seventy one you had Congress tasked deda
with reclassifying amphetamines as being a schedule to substance, that is,
(09:09):
prescriptions needed to be reported to a central government administration,
and there were limits and quotas placed on the quantities
of mphetamines that could be manufactured and then distributed to
pharmaceutical companies, and so used to have this sort of
moral panic around that that actually led to a congressional
investigation in nineteen seventy and there was this sort of
(09:32):
broader crackdown both legally in the nineteen seventies and also
culturally where you had like the sort of countercultural figures
decrying speed freaks, which had also you know, there was
this discourse in this narrative that for instance, like the
heighth Atsbury sort of summer of love had been that
had been destroyed by speed freaks and so on and
so forth, and so in the nineteen seventies you have
(09:52):
a movement away from amphetamines proper, which a creates the
conditions for the rise of things like ritilin, which is
a methyl feenadate, which is you know, it's pharmacologically quite similar,
but it was not subject to exactly the same controls
as emphetamines. And secondly, I think the thing, the very
important thing that happens is that one of the few
(10:13):
medical uses for which amphetamines are going into the late
nineteen seventy is still allowed to be prescribed are child
behavioral disorders. Now, prior to nineteen seventy and fetamines had
been used off label for everything from weight loss to
mood to just like a variety of off label prescriptions.
(10:34):
But you have this sort of concentration after this crackdown
by the DEA to focus amphetamine use medically specifically on
this you know, small cluster of childhood behavioral disorders. This
sets us up for, by the time we get to
the nineteen nineties, the sort of growing market for childhood
applications for m ffetamines. And I guess like the third
(10:56):
intervening factor here would be that in nineteen teen eighty
there was the third publication of the Diagnostic and statistical Manual,
which is 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.
(11:19):
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 nineteen eighties, such that by the nineteen nineties, once
adderall comes onto the market, the stage is set for
(11:39):
a very wide sudden uptick in adderall prescriptions for children.
Speaker 3 (11:59):
So talk to us about what adderall actually does. And
here I have to confess. In preparation for this conversation,
I walked around Union Square in New York and ask
people why they take adderall.
Speaker 4 (12:10):
No.
Speaker 3 (12:10):
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
(12:33):
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 5 (12:54):
Yeah.
Speaker 4 (12:54):
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 nineteen eighty, this was a
(13:16):
document that was created essentially to bring together a bunch
of different stakeholders under a very large tent. These stakeholders
included insurers, clinical researchers, formalcological 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,
(13:39):
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 nineteen eighty,
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
(14:03):
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 let's say,
depression or anxiety neurologically looks like any other case of
depression or anxiety. That's because there are many different ways
to have depressions. Some people might be crying a lot
(14:25):
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
(14:46):
medicine done in a sort of day to day sense,
But once it comes to sort of extrapolating 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
(15:08):
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 rear partake of nopernepherin and dopamine. But I think
(15:31):
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,
(15:55):
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
(16:18):
space in the sort of synaptic space between the axon
and the dendrite and then are reabsorbed. So neurotransmitters are
things like, for instance, nopernethyrine, dopamine. Right there's 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 sort of synapse is
(16:40):
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 no reprodefron. Dopamine is sort
of widely theorized or described as being a chemical that
codes for expectation of reward. So one way that I
like to explain this is that if you go to
(17:00):
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
(17:22):
that hook into this very very motivating dopaminergic system in
the brain. No Ropernaffron similarly controls the body's sort of
readiness for fight or flight, and so it sort of
generally increases a feeling of alertness and readiness. But this
is why you know, it feels really really good to
be on amphetamines, and it sort of increases this general
(17:45):
sense of well being and alertness. And indeed, this is
why you know in the early nineteen thirties, am fetamine
was widely prescribed for antedonia or a lack of pleasure.
In fact, historian Nicholas Rismusin has made the case convincingly.
I think that empetamine was in fact the first antidepressant.
But at a neurological level, that is essentially what amphetamines
(18:06):
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
(18:28):
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.
Speaker 2 (18:47):
So someone like myself who sometimes worries that maybe I
have another level of productivity above me, even I've never
been diagnosed with anything, like, maybe that's true. So you know,
I get like, as you say, okay, it makes internet
gambling you could see or tweeting, tweeting, et cetera. But like,
what is the theory by which like a bunch of
(19:07):
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 eleven pm,
they get one TYPEO wrong, they have to start it
all over. What does ederall do for them in the
(19:27):
sort of corporate context or the work context.
Speaker 4 (19:30):
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 dopinergic chemicals.
So punding was first described in the nineteen seventies by
a psychiatrist who was observing the sort of repetitive behavioral
(19:53):
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 are taking levadopa, 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
(20:16):
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, and amfetamine makes any task that you're
(20:37):
engaged in much more rewarding because it's massively ramping up
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 emphetamine specifically in
sort of knowledge work is that it makes these repetitive
tasks feel more like hunting and gathering. Right, It's more
(21:00):
or it's a more exciting task to do these repetitive tasks.
And this is not something that is specific to the
nineteen nineties. When psychiatrist Abraham Myerson, who is one of
the first psychiatrists to widely use benzydream for a depressed
and antidonic patients in the nineteen twenties, his clinical area
(21:20):
of expertise was the sort of neurosis of what he
called the brain workers of the upper class. So I
think that there is, you know, a robust through line
of amphetamines being used for these emergent forms of work
in the US. That was great.
Speaker 2 (21:34):
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. I
was just looking in sequence, so I guess that person,
you know, there you go, must have been very satisfying
for that person to arrange all of their toys.
Speaker 4 (21:52):
If you think about the sort of phenomenological experience of
what it is like to be online on adderall or
to do research on at there is a sort of
punding like quality to always another real watch, always another
link to open right, and the sort of punding phenomenon
I think is definitely one way to describe the addictive
behavioral loops that are built into this sort of giant
(22:15):
casino called the Internet that we all live in now.
Speaker 3 (22:19):
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
(22:40):
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, 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.
Speaker 4 (23:00):
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
attention crisis, the Internet and aderall. And I think in
(23:20):
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 Done, 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,
(23:43):
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.
(24:06):
One of the arguments that I make in the piece
is that, in fact, if you look at 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
(24:26):
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 amfetines produced than the
extremely boring task of coding. Right. So there's that. And
then also if you kind of think about that moment
from let's say two thousand and five to twenty fifteen,
(24:49):
where you had the proliferation of things like alt lit,
tau l in, Ben Lerner, Jonathan Saffaran Foyer, Vice Pitchfork, right,
if you think about that sort of milange that was
that moment in the culture, I think that one of
the defining features of that zeitgeist was the prevalence of
(25:11):
adderall and the prevalence of millennials who had either been
put on adderall as children, overwhelming the upper middle class
ensured 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.
Speaker 2 (25:27):
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. But before we even get
to the 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
(25:51):
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?
Speaker 4 (26:07):
Yeah, Well, you know, I think that I'm prone to
describe things as a dialectic in that sense, I would
say yes, But you can see this type of pattern
and a variety of psychiatric medications. For instance, if you
think about the emergence of antidepressants SSRIs, SNRIs like prozac, likexepro,
(26:27):
well beutrid and so on and so forth in the nineties,
there is 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
(26:48):
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 dates roughly to twenty ten,
and the sort of fall in optimism because in fact,
(27:08):
most SSRIs and sent arized do not perform very much
better than placebos when looked at in aggregate, that is,
through meta analyzes, 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
(27:30):
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 Ohler has laid out very capably.
(27:54):
I think the argument that, like for instance, Blitzkraig, cannot
be understood apart from the widespread use of 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 the sort of panic around overprescription among children in
(28:15):
the early nineteen seventies, 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,
you know, doing things like suppressing student organizing. Right, the
youth culture comes to be this sort of anti establishment
(28:38):
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, Michelle Fucou, Thomas Zazz,
the wide spectrum of thinkers in the nineteen seventies who
were explicitly making the case that psychiatry was an agent
of social control. The backlash against emphetamines, particularly emphatamines, being
(29:02):
used to treat child behavioral disorders becomes a bit more legible,
and so then, of course, you know, in the nineteen eighties,
with the crackdown on emphetamines, 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,
a sort of dialectic, if you will, between the cultural
(29:22):
meanings of em fetamine, and we're now at 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
(29:42):
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,
(30:03):
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 3 (30:25):
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
(30:48):
access this drug, or is it the companies themselves? 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 demand for its own supply.
So what exactly is driving the availability here?
Speaker 4 (31:07):
Yeah? Okay, 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 activism,
and I'm sure, like you know, I'm going to get
a lot of angry emails after this podcast you always
(31:28):
get about 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 validity of
the ADD or ADHD diagnosis, there is, you know, significant
evidence that this is a culturally bound phenomenon just by
virtue of the fact that it is essentially a US
(31:50):
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 two. In twenty two, because of the classification of
m fatamines as a schedule to substance in the nineteen
seventy one order from Congress to the DEA. This means
(32:10):
that there are quotas that are established for how many
emphatamine salts can be produced and how those are distributed. Now,
there's been a lot of back and forth between pharmaceutical
companies and the DA 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
(32:32):
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
twenty nineteen and twenty twenty two. In twenty nineteen, for instance,
(32:53):
there were sixty six point six million prescriptions for all
ADHD medications that includes things like vibance, concerta riddle and
so on, in forty five million for adderall alone, And
in the first two years of the pandemic there was
six million new prescriptions. So one of the narratives that
you'll hear a lot about this extraordinary rise in stimulant
(33:18):
prescriptions is that this is owing to the proliferation of
telepsychiatry companies like Cerebral Done and so on. And I
think this only gets a 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
(33:39):
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 know that the rise through tele
(34:02):
psychiatry 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 tele psychiatry before, there was not a
huge increase in adderall prescriptions for those types of companies.
(34:22):
It was specifically the emergence of these new types of
companies like Cerebral and Done that were pushing this enormous
increase in diagnosis. And I think that part of this
is just a pretty open and shutcase of like a
company basing its profit model on slinging addictive medications into
this loophole that was created by the pandemic. The Wall
(34:42):
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 no rule MANDATEA that
the number of prescriptions for these stimulants be made publicly
(35:05):
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, that
were basically like do you want some adderall you can
basically have some, it was very hard for reporters to
(35:26):
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
(35:47):
of stays ocurrant. You know, this is also relevant I
think too, 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 que 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.
(36:12):
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 ten hours or you know, or however
long it was, that they must have some sort of
attention deficit diagnosis.
Speaker 2 (36:31):
I find that really fascinating this idea, especially that point
about the gap and the increase in prescriptions from the
sort of vcback startups which we know need growth, growth, growth,
versus the sort of legacy healthcare providers that had been
doing telemedicine for some time that didn't pick up. I
guess I should have just like done a test, But like,
(36:53):
what do you have to demonstrate to get at all?
Presumably you can't just click a button.
Speaker 3 (36:58):
But how simple you can?
Speaker 4 (36:59):
Is it? Like?
Speaker 2 (37:00):
What is there some sort of basic test? And like
do different doctors, like do the ones who worked 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 data prescription.
Speaker 4 (37:18):
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 vibees 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
(37:39):
child psychiatrist who played a board game with me called Stop,
Relax and Think loosely based off of shoots 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 by physiological substrate to this disease entity,
(38:04):
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 out neurological level
what this disease entity quote unquote is and so in
that sense, assessment is bound to be essentially vibespace. Now,
you know, if you have a clinician who is behaving responsibly,
(38:26):
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
(38:46):
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 very high quality
in person pediatric or adult psychiatric care. Now, when it
comes to something like telepsychiatry startups like done in Cerebral,
(39:08):
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 refuse
(39:29):
to prescribe a stimulant, you had to write up a
justification for why you were not doing that, you would
think that responsible medical practice would be the opposite. Cerebral
has since after this series of investigations that prompted a
DJ investigation, stopped prescribing schedule to substances through their platform.
But I think that regardless of whether or not they're
(39:51):
still slinging like adderall or concerto on there, I think
that it bears on, for instance, what kinds of assessments
are being used to prescribe for it antidepressants, which are
also serious, psychoactive medifications that can be very very difficult
to wean off of. But in short, answers to your question, no,
there's no specific diagnostic test that guarantees the appropriateness of
(40:15):
amphetamines for any given patient.
Speaker 3 (40:17):
This is a very wide ranging question. But what are
the implications for society of this increased adderall use? 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
(40:39):
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,
(41:02):
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
the drug or have access to it. In another slightly
more dubious way, it does feel like there might be
(41:23):
some fairness questions tied to this.
Speaker 4 (41:27):
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 twentieth century. So,
for instance, one of the big pushes against the use
of Riddlin for children in the nineteen seventies came from
(41:48):
the Black Panthers, who saw that amphetamines and Riddlin were
being tested on children in residential care facilities, many of
whom were black, right, And so there was a sort
of lower class iffication of amphetamines in the nineteen seventies
because they were being tested on populations in juvenile detention centers,
(42:12):
residential care homes, so on and so forth. There's a
real switch in the nineties, right when suddenly attention deficit
disorders become kind of the explanation for why white, well ensured,
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 emfetamine usage, it has always been considered
(42:36):
an upper middle class competitive edge thing, and I think
in line with this, for instance, I don't think necessarily
that empfetamine 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
(43:00):
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.
Speaker 3 (43:14):
One of the.
Speaker 4 (43:15):
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 in 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
(43:39):
that there is really not that much of a difference
in effectivity for emphetamines 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, all, because we have this robust disease entity,
(44:02):
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
(44:25):
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 and 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
(44:47):
that facilitates that.
Speaker 5 (44:50):
But I think that the.
Speaker 4 (44:51):
Conversation that I hope to see emerged in the coming
years is one that's less focused on sort of who
legitimately has ADHD and who does, because in fact, these
and fetimins have remarkable advocacy for both groups that have
been diagnosed in groups that haven't, and more of a
turn towards thinking about what it is that adderall does
(45:11):
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 sand
(45:34):
Quanon of the Internet as a sort of giant casino
that we all live in.
Speaker 2 (45:39):
Danielle, this was fascinating. We can probably talk for hours
on this subject. I just want to say I'm addicted
to Twitter and Instagram totally naturally, totally clean. But thank
you so much for coming on odd Lauds. There's a
great conversation and glad we finally got a chance.
Speaker 4 (45:54):
To talk to Thank you so much.
Speaker 5 (45:55):
This was really fun, Tracy.
Speaker 2 (46:10):
I really enjoyed that conversation, and there were a number
of things that really are going to 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
(46:31):
online world was also built by the people on these drugs.
Speaker 3 (46:34):
Yeah, it's sort of intertwined. Yeah, 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 going to have to Censor myself
BS Jobs by David Graber, and it's sort of like
a dystopian Studs tircle in the sense that it just
(46:54):
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 points,
So I think there's an aspect of that in there.
The other thing that was very I guess attention grabbing
(47:14):
was the idea of no pun intended was the idea
of some of the venture capital backed health services writing
more prescriptions than perhaps some of the more traditional health
care providers.
Speaker 2 (47:27):
That was totally eye opening for me, and I was,
you know, I'm aware of the proliferation of these telehealth companies.
As a mail 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.
But I hadn't realized the degree to which that specific
(47:48):
combination that Danielle described, which was the relaxation of prescription
drug obligations due to the pandemic and then the simultaneous
explosion of these news services, which it sounds like the
drugs are kind of being given out like candy.
Speaker 4 (48:05):
Well.
Speaker 3 (48:05):
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.
Speaker 4 (48:20):
Which Tracy, Yes.
Speaker 2 (48:22):
What do they do in the UK if they don't
get if they can't get ederall.
Speaker 3 (48:25):
They get their energy. If you work in finance, you
get your energy the old fashioned way. I'm not gonna
say what that. I mean coffee of oh yes, uh no,
it's powdered coffee. Yeah, there we go. But I think
like 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
(48:46):
to be driving some of this.
Speaker 2 (48:48):
Get two things on that. So Daniel 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
(49:09):
pay like ten thousand dollars or whatever just for a
data set who try to aggregate, you know, how many
prescriptions of each 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
(49:31):
in Canada, then you know those numbers in real time
and you can say, oh my god, like these prescriptions
are totally exploding.
Speaker 3 (49:36):
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. But it 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
(49:57):
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 site
geist of the American economy. But wow, there are a
lot of questions that come out of this conversation.
Speaker 4 (50:12):
You know.
Speaker 2 (50:12):
One other thing too about this sort of maybe the
pathologies of the US healthcare system is I don't think
that any of these drugs are as bad as like
addictive painkillers. But it is striking to me that we
did just have this like huge, sort of multi year
realization that the opioid sellers that it was riven with abuse,
(50:34):
a lot of the same things about like so called
like 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 it various books
and documentaries. Is such a disaster, and then we just
like move on to the next drug. And again I'm
not saying it's necessarily comparable, but the speed with which
(50:55):
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?
Speaker 5 (51:02):
Well?
Speaker 3 (51:02):
Danielle made that point to the idea that like it
kind of goes in cycles, all right, And it does
feel like these things kind of come and go in
terms of popularity, in terms of commercialization, as you mentioned
it is. 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 2 (51:22):
Let's leave it there.
Speaker 3 (51:23):
This has been another episode of the All Blots podcast.
I'm Tracy Alloway. You can follow me at Tracy Alloway.
Speaker 2 (51:29):
And I'm Joe Wisenthal. You can follow me at the Stalwart.
Follow our guest Danielle Carr, She's at Underscore Danielle Underscore Car.
Follow our producers Carmen Rodriguez at Carmen Arman, dash Ol
Bennett at Dashbot and Kilbrooks at Kilbrooks. Thank you to
our producer Moses Ondam. For more Oddlots content, go to
Bloomberg dot com slash odd Lots, where we have transcripts,
(51:50):
a blog and the newsletter and you can chat about
all of these topics twenty four to seven in the
discord with fellow listeners Discord dodgg slash Oddlines.
Speaker 3 (51:58):
And if you enjoy All Blots, 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're a Bloomberg subscriber, you can listen
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need to do is connect your Bloomberg account with Apple Podcasts.
Thanks for listening.
Bloomberg Audio Studios, Podcasts, Radio News.
Speaker 2 (00:17):
Hello and welcome to another episode of The Odd Lots podcast.
Speaker 3 (00:21):
I'm Jolle Wisenthal and I'm Tracy Alloway.
Speaker 2 (00:24):
Tracy, I was gonna ask you a question, but I
already know the answer to it. I was going to say, like, oh,
have you ever tried adderall? But I already know you're not,
so I don't want to like fake the intro 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.
Speaker 3 (00:42):
Drug like coffee, No, something a little stronger than college. 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 one hundred percent sure that you and I,
(01:02):
in the context of this podcast and our day to
day lives, have absolutely spoken to people who have been
on adderall. In fact, a very famous one springs to
mind right now. I don't know who you're talking about,
SBF Sam been Free, There you go, there you go,
but it is an interesting thought experiment. To think about
the proportion of people around you, you know, sometimes highly
(01:24):
productive people who may or may not be on adderall
or something similar.
Speaker 2 (01:29):
So here's my thought, which is that, like, my big
fear with adderall is like, I'm not maybe against trying
it because I don't think I have the most focused
brain in the world. In fact, I know I don't,
and I get scartered. 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
want to stay on this drug forever or do you
just want to go back to your old self knowing
(01:51):
that you have this other potential state in you. Yes,
that's my big fear.
Speaker 3 (01:55):
I feel the same way. 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
(02:15):
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.
Speaker 2 (02:34):
Yeah, I mean, this is not the Olympics. 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 ninety eight, 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 such, And
I feel like I was probably in a slightly different environment.
(02:55):
Maybe if I had been born a couple of years younger,
I might have been prescribed it. I think maybe not
because my parents were hippies and so they didn't really
believe probably and prescribing drugs for that sort of thing.
But then you know, sort of this cultural thing. It's like, oh,
they're giving all these boys.
Speaker 3 (03:11):
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.
Speaker 2 (03:27):
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
(03:47):
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 owne right.
Speaker 3 (04:09):
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.
Speaker 2 (04:24):
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 you know
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.
Speaker 3 (04:43):
I read all of these in one sitting without the
use of adderall. They're very, very good.
Speaker 2 (04:48):
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. She's an assistant professor at
the Institute for Society and Genetics at UCLA, and she's
a history storian 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
(05:09):
our brains or if not, society. So, Danielle, thank you
so much for coming on odd lots.
Speaker 4 (05:14):
Thank you so much. It's wonderful to be here.
Speaker 2 (05:16):
Describe your work in general. You had a great New
York Magazine cover story last year, But talk about like
sort of your from an academic perspective, like what is
your focus? How does adderall fit into your broader research
and work over time?
Speaker 4 (05:28):
So I guess I should say that adderall and tension
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
(05:50):
work is looking at the political, economy and historical emergence
of different types of experimental psychiatric treatments from the twentieth
to the twenty four century.
Speaker 3 (06:01):
I have a really basic question to start out with,
what happened to Riddlin? So no, but honestly, so if
we had been having this discussion in like the nineteen
nineties or the early two thousands, I don't think we'd
be talking about adderall. We'd be talking about Riddlin.
Speaker 4 (06:15):
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, you know,
currently called ADD or ADHD, is that there have been
since nineteen oh two about twenty different names for this
kind of cluster of syndromes. And so Riddlin emerged as
(06:37):
it's methyl fenidate rather than an amphetamine, so it's slightly
different pharmacologically, And it was formulated in the mid nineteen
fifties 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,
(06:58):
by the way, is just methyal fenatic x are. But
there was a period basically in the nineteen seventies when
and I'm sure we'll get into this, there was a
sort of widespread panic over the enormous prevalence of infitamines,
especially to treat children, and riddlin was sort of preferred
as an alternative that had fewer side effects allegedly and
was less addictive allegedly, which accounts for the prevalence of
(07:22):
Riddlin through the sort of mid nineties, at which point
there's a switch when Shire Pharmaceuticals acquires Obatral, which is
rebranded as Adderall, and that's really when the Adderall craze hits.
Speaker 5 (07:35):
Tracy.
Speaker 2 (07:35):
I'm glad you asked that, because I had forgotten all
about Ridlin. 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 Ridlin. So I
mentioned Danielle, I was in high school in the mid nineties.
What was going on then that suddenly there seemed to
(07:57):
be this, you know, the first wave, or maybe the
way you describe it, the second wave of this phenomenon
of let's get all the boys on Ridlin.
Speaker 5 (08:05):
Yeah.
Speaker 4 (08:05):
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 Rusmussen has I
think done a very magisterial job in showing that the
twentieth century was defined in many ways by recurrent waves
of infatimine use. The first wave really began with the
rise of infetamine use during the Second World War, and
(08:27):
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 nineteen seventies,
a sort of moral panic over the extraordinary prevalence of amphetamines,
mostly dexidron and benzydrin, that were being prescribed without any
sort of federal control. It was extraordinarily prevalent across the
(08:49):
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 nineteen seventy one you had Congress tasked deda
with reclassifying amphetamines as being a schedule to substance, that is,
(09:09):
prescriptions needed to be reported to a central government administration,
and there were limits and quotas placed on the quantities
of mphetamines that could be manufactured and then distributed to
pharmaceutical companies, and so used to have this sort of
moral panic around that that actually led to a congressional
investigation in nineteen seventy and there was this sort of
(09:32):
broader crackdown both legally in the nineteen seventies and also
culturally where you had like the sort of countercultural figures
decrying speed freaks, which had also you know, there was
this discourse in this narrative that for instance, like the
heighth Atsbury sort of summer of love had been that
had been destroyed by speed freaks and so on and
so forth, and so in the nineteen seventies you have
(09:52):
a movement away from amphetamines proper, which a creates the
conditions for the rise of things like ritilin, which is
a methyl feenadate, which is you know, it's pharmacologically quite similar,
but it was not subject to exactly the same controls
as emphetamines. And secondly, I think the thing, the very
important thing that happens is that one of the few
(10:13):
medical uses for which amphetamines are going into the late
nineteen seventy is still allowed to be prescribed are child
behavioral disorders. Now, prior to nineteen seventy and fetamines had
been used off label for everything from weight loss to
mood to just like a variety of off label prescriptions.
(10:34):
But you have this sort of concentration after this crackdown
by the DEA to focus amphetamine use medically specifically on
this you know, small cluster of childhood behavioral disorders. This
sets us up for, by the time we get to
the nineteen nineties, the sort of growing market for childhood
applications for m ffetamines. And I guess like the third
(10:56):
intervening factor here would be that in nineteen teen eighty
there was the third publication of the Diagnostic and statistical Manual,
which is 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.
(11:19):
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 nineteen eighties, such that by the nineteen nineties, once
adderall comes onto the market, the stage is set for
(11:39):
a very wide sudden uptick in adderall prescriptions for children.
Speaker 3 (11:59):
So talk to us about what adderall actually does. And
here I have to confess. In preparation for this conversation,
I walked around Union Square in New York and ask
people why they take adderall.
Speaker 4 (12:10):
No.
Speaker 3 (12:10):
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
(12:33):
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 5 (12:54):
Yeah.
Speaker 4 (12:54):
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 nineteen eighty, this was a
(13:16):
document that was created essentially to bring together a bunch
of different stakeholders under a very large tent. These stakeholders
included insurers, clinical researchers, formalcological 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,
(13:39):
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 nineteen eighty,
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
(14:03):
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 let's say,
depression or anxiety neurologically looks like any other case of
depression or anxiety. That's because there are many different ways
to have depressions. Some people might be crying a lot
(14:25):
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
(14:46):
medicine done in a sort of day to day sense,
But once it comes to sort of extrapolating 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
(15:08):
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 rear partake of nopernepherin and dopamine. But I think
(15:31):
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,
(15:55):
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
(16:18):
space in the sort of synaptic space between the axon
and the dendrite and then are reabsorbed. So neurotransmitters are
things like, for instance, nopernethyrine, dopamine. Right there's 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 sort of synapse is
(16:40):
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 no reprodefron. Dopamine is sort
of widely theorized or described as being a chemical that
codes for expectation of reward. So one way that I
like to explain this is that if you go to
(17:00):
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
(17:22):
that hook into this very very motivating dopaminergic system in
the brain. No Ropernaffron similarly controls the body's sort of
readiness for fight or flight, and so it sort of
generally increases a feeling of alertness and readiness. But this
is why you know, it feels really really good to
be on amphetamines, and it sort of increases this general
(17:45):
sense of well being and alertness. And indeed, this is
why you know in the early nineteen thirties, am fetamine
was widely prescribed for antedonia or a lack of pleasure.
In fact, historian Nicholas Rismusin has made the case convincingly.
I think that empetamine was in fact the first antidepressant.
But at a neurological level, that is essentially what amphetamines
(18:06):
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
(18:28):
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.
Speaker 2 (18:47):
So someone like myself who sometimes worries that maybe I
have another level of productivity above me, even I've never
been diagnosed with anything, like, maybe that's true. So you know,
I get like, as you say, okay, it makes internet
gambling you could see or tweeting, tweeting, et cetera. But like,
what is the theory by which like a bunch of
(19:07):
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 eleven pm,
they get one TYPEO wrong, they have to start it
all over. What does ederall do for them in the
(19:27):
sort of corporate context or the work context.
Speaker 4 (19:30):
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 dopinergic chemicals.
So punding was first described in the nineteen seventies by
a psychiatrist who was observing the sort of repetitive behavioral
(19:53):
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 are taking levadopa, 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
(20:16):
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, and amfetamine makes any task that you're
(20:37):
engaged in much more rewarding because it's massively ramping up
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 emphetamine specifically in
sort of knowledge work is that it makes these repetitive
tasks feel more like hunting and gathering. Right, It's more
(21:00):
or it's a more exciting task to do these repetitive tasks.
And this is not something that is specific to the
nineteen nineties. When psychiatrist Abraham Myerson, who is one of
the first psychiatrists to widely use benzydream for a depressed
and antidonic patients in the nineteen twenties, his clinical area
(21:20):
of expertise was the sort of neurosis of what he
called the brain workers of the upper class. So I
think that there is, you know, a robust through line
of amphetamines being used for these emergent forms of work
in the US. That was great.
Speaker 2 (21:34):
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. I
was just looking in sequence, so I guess that person,
you know, there you go, must have been very satisfying
for that person to arrange all of their toys.
Speaker 4 (21:52):
If you think about the sort of phenomenological experience of
what it is like to be online on adderall or
to do research on at there is a sort of
punding like quality to always another real watch, always another
link to open right, and the sort of punding phenomenon
I think is definitely one way to describe the addictive
behavioral loops that are built into this sort of giant
(22:15):
casino called the Internet that we all live in now.
Speaker 3 (22:19):
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
(22:40):
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, 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.
Speaker 4 (23:00):
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
attention crisis, the Internet and aderall. And I think in
(23:20):
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 Done, 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,
(23:43):
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.
(24:06):
One of the arguments that I make in the piece
is that, in fact, if you look at 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
(24:26):
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 amfetines produced than the
extremely boring task of coding. Right. So there's that. And
then also if you kind of think about that moment
from let's say two thousand and five to twenty fifteen,
(24:49):
where you had the proliferation of things like alt lit,
tau l in, Ben Lerner, Jonathan Saffaran Foyer, Vice Pitchfork, right,
if you think about that sort of milange that was
that moment in the culture, I think that one of
the defining features of that zeitgeist was the prevalence of
(25:11):
adderall and the prevalence of millennials who had either been
put on adderall as children, overwhelming the upper middle class
ensured 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.
Speaker 2 (25:27):
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. But before we even get
to the 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
(25:51):
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?
Speaker 4 (26:07):
Yeah, Well, you know, I think that I'm prone to
describe things as a dialectic in that sense, I would
say yes, But you can see this type of pattern
and a variety of psychiatric medications. For instance, if you
think about the emergence of antidepressants SSRIs, SNRIs like prozac, likexepro,
(26:27):
well beutrid and so on and so forth in the nineties,
there is 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
(26:48):
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 dates roughly to twenty ten,
and the sort of fall in optimism because in fact,
(27:08):
most SSRIs and sent arized do not perform very much
better than placebos when looked at in aggregate, that is,
through meta analyzes, 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
(27:30):
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 Ohler has laid out very capably.
(27:54):
I think the argument that, like for instance, Blitzkraig, cannot
be understood apart from the widespread use of 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 the sort of panic around overprescription among children in
(28:15):
the early nineteen seventies, 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,
you know, doing things like suppressing student organizing. Right, the
youth culture comes to be this sort of anti establishment
(28:38):
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, Michelle Fucou, Thomas Zazz,
the wide spectrum of thinkers in the nineteen seventies who
were explicitly making the case that psychiatry was an agent
of social control. The backlash against emphetamines, particularly emphatamines, being
(29:02):
used to treat child behavioral disorders becomes a bit more legible,
and so then, of course, you know, in the nineteen eighties,
with the crackdown on emphetamines, 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,
a sort of dialectic, if you will, between the cultural
(29:22):
meanings of em fetamine, and we're now at 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
(29:42):
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,
(30:03):
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 3 (30:25):
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
(30:48):
access this drug, or is it the companies themselves? 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 demand for its own supply.
So what exactly is driving the availability here?
Speaker 4 (31:07):
Yeah? Okay, 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 activism,
and I'm sure, like you know, I'm going to get
a lot of angry emails after this podcast you always
(31:28):
get about 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 validity of
the ADD or ADHD diagnosis, there is, you know, significant
evidence that this is a culturally bound phenomenon just by
virtue of the fact that it is essentially a US
(31:50):
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 two. In twenty two, because of the classification of
m fatamines as a schedule to substance in the nineteen
seventy one order from Congress to the DEA. This means
(32:10):
that there are quotas that are established for how many
emphatamine salts can be produced and how those are distributed. Now,
there's been a lot of back and forth between pharmaceutical
companies and the DA 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
(32:32):
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
twenty nineteen and twenty twenty two. In twenty nineteen, for instance,
(32:53):
there were sixty six point six million prescriptions for all
ADHD medications that includes things like vibance, concerta riddle and
so on, in forty five million for adderall alone, And
in the first two years of the pandemic there was
six million new prescriptions. So one of the narratives that
you'll hear a lot about this extraordinary rise in stimulant
(33:18):
prescriptions is that this is owing to the proliferation of
telepsychiatry companies like Cerebral Done and so on. And I
think this only gets a 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
(33:39):
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 know that the rise through tele
(34:02):
psychiatry 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 tele psychiatry before, there was not a
huge increase in adderall prescriptions for those types of companies.
(34:22):
It was specifically the emergence of these new types of
companies like Cerebral and Done that were pushing this enormous
increase in diagnosis. And I think that part of this
is just a pretty open and shutcase of like a
company basing its profit model on slinging addictive medications into
this loophole that was created by the pandemic. The Wall
(34:42):
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 no rule MANDATEA that
the number of prescriptions for these stimulants be made publicly
(35:05):
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, that
were basically like do you want some adderall you can
basically have some, it was very hard for reporters to
(35:26):
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
(35:47):
of stays ocurrant. You know, this is also relevant I
think too, 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 que 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.
(36:12):
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 ten hours or you know, or however
long it was, that they must have some sort of
attention deficit diagnosis.
Speaker 2 (36:31):
I find that really fascinating this idea, especially that point
about the gap and the increase in prescriptions from the
sort of vcback startups which we know need growth, growth, growth,
versus the sort of legacy healthcare providers that had been
doing telemedicine for some time that didn't pick up. I
guess I should have just like done a test, But like,
(36:53):
what do you have to demonstrate to get at all?
Presumably you can't just click a button.
Speaker 3 (36:58):
But how simple you can?
Speaker 4 (36:59):
Is it? Like?
Speaker 2 (37:00):
What is there some sort of basic test? And like
do different doctors, like do the ones who worked 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 data prescription.
Speaker 4 (37:18):
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 vibees 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
(37:39):
child psychiatrist who played a board game with me called Stop,
Relax and Think loosely based off of shoots 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 by physiological substrate to this disease entity,
(38:04):
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 out neurological level
what this disease entity quote unquote is and so in
that sense, assessment is bound to be essentially vibespace. Now,
you know, if you have a clinician who is behaving responsibly,
(38:26):
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
(38:46):
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 very high quality
in person pediatric or adult psychiatric care. Now, when it
comes to something like telepsychiatry startups like done in Cerebral,
(39:08):
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 refuse
(39:29):
to prescribe a stimulant, you had to write up a
justification for why you were not doing that, you would
think that responsible medical practice would be the opposite. Cerebral
has since after this series of investigations that prompted a
DJ investigation, stopped prescribing schedule to substances through their platform.
But I think that regardless of whether or not they're
(39:51):
still slinging like adderall or concerto on there, I think
that it bears on, for instance, what kinds of assessments
are being used to prescribe for it antidepressants, which are
also serious, psychoactive medifications that can be very very difficult
to wean off of. But in short, answers to your question, no,
there's no specific diagnostic test that guarantees the appropriateness of
(40:15):
amphetamines for any given patient.
Speaker 3 (40:17):
This is a very wide ranging question. But what are
the implications for society of this increased adderall use? 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
(40:39):
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,
(41:02):
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
the drug or have access to it. In another slightly
more dubious way, it does feel like there might be
(41:23):
some fairness questions tied to this.
Speaker 4 (41:27):
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 twentieth century. So,
for instance, one of the big pushes against the use
of Riddlin for children in the nineteen seventies came from
(41:48):
the Black Panthers, who saw that amphetamines and Riddlin were
being tested on children in residential care facilities, many of
whom were black, right, And so there was a sort
of lower class iffication of amphetamines in the nineteen seventies
because they were being tested on populations in juvenile detention centers,
(42:12):
residential care homes, so on and so forth. There's a
real switch in the nineties, right when suddenly attention deficit
disorders become kind of the explanation for why white, well ensured,
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 emfetamine usage, it has always been considered
(42:36):
an upper middle class competitive edge thing, and I think
in line with this, for instance, I don't think necessarily
that empfetamine 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
(43:00):
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.
Speaker 3 (43:14):
One of the.
Speaker 4 (43:15):
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 in 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
(43:39):
that there is really not that much of a difference
in effectivity for emphetamines 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, all, because we have this robust disease entity,
(44:02):
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
(44:25):
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 and 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
(44:47):
that facilitates that.
Speaker 5 (44:50):
But I think that the.
Speaker 4 (44:51):
Conversation that I hope to see emerged in the coming
years is one that's less focused on sort of who
legitimately has ADHD and who does, because in fact, these
and fetimins have remarkable advocacy for both groups that have
been diagnosed in groups that haven't, and more of a
turn towards thinking about what it is that adderall does
(45:11):
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 sand
(45:34):
Quanon of the Internet as a sort of giant casino
that we all live in.
Speaker 2 (45:39):
Danielle, this was fascinating. We can probably talk for hours
on this subject. I just want to say I'm addicted
to Twitter and Instagram totally naturally, totally clean. But thank
you so much for coming on odd Lauds. There's a
great conversation and glad we finally got a chance.
Speaker 4 (45:54):
To talk to Thank you so much.
Speaker 5 (45:55):
This was really fun, Tracy.
Speaker 2 (46:10):
I really enjoyed that conversation, and there were a number
of things that really are going to 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
(46:31):
online world was also built by the people on these drugs.
Speaker 3 (46:34):
Yeah, it's sort of intertwined. Yeah, 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 going to have to Censor myself
BS Jobs by David Graber, and it's sort of like
a dystopian Studs tircle in the sense that it just
(46:54):
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 points,
So I think there's an aspect of that in there.
The other thing that was very I guess attention grabbing
(47:14):
was the idea of no pun intended was the idea
of some of the venture capital backed health services writing
more prescriptions than perhaps some of the more traditional health
care providers.
Speaker 2 (47:27):
That was totally eye opening for me, and I was,
you know, I'm aware of the proliferation of these telehealth companies.
As a mail 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.
But I hadn't realized the degree to which that specific
(47:48):
combination that Danielle described, which was the relaxation of prescription
drug obligations due to the pandemic and then the simultaneous
explosion of these news services, which it sounds like the
drugs are kind of being given out like candy.
Speaker 4 (48:05):
Well.
Speaker 3 (48:05):
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.
Speaker 4 (48:20):
Which Tracy, Yes.
Speaker 2 (48:22):
What do they do in the UK if they don't
get if they can't get ederall.
Speaker 3 (48:25):
They get their energy. If you work in finance, you
get your energy the old fashioned way. I'm not gonna
say what that. I mean coffee of oh yes, uh no,
it's powdered coffee. Yeah, there we go. But I think
like 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
(48:46):
to be driving some of this.
Speaker 2 (48:48):
Get two things on that. So Daniel 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
(49:09):
pay like ten thousand dollars or whatever just for a
data set who try to aggregate, you know, how many
prescriptions of each 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
(49:31):
in Canada, then you know those numbers in real time
and you can say, oh my god, like these prescriptions
are totally exploding.
Speaker 3 (49:36):
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. But it 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
(49:57):
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 site
geist of the American economy. But wow, there are a
lot of questions that come out of this conversation.
Speaker 4 (50:12):
You know.
Speaker 2 (50:12):
One other thing too about this sort of maybe the
pathologies of the US healthcare system is I don't think
that any of these drugs are as bad as like
addictive painkillers. But it is striking to me that we
did just have this like huge, sort of multi year
realization that the opioid sellers that it was riven with abuse,
(50:34):
a lot of the same things about like so called
like 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 it various books
and documentaries. Is such a disaster, and then we just
like move on to the next drug. And again I'm
not saying it's necessarily comparable, but the speed with which
(50:55):
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?
Speaker 5 (51:02):
Well?
Speaker 3 (51:02):
Danielle made that point to the idea that like it
kind of goes in cycles, all right, And it does
feel like these things kind of come and go in
terms of popularity, in terms of commercialization, as you mentioned
it is. 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 2 (51:22):
Let's leave it there.
Speaker 3 (51:23):
This has been another episode of the All Blots podcast.
I'm Tracy Alloway. You can follow me at Tracy Alloway.
Speaker 2 (51:29):
And I'm Joe Wisenthal. You can follow me at the Stalwart.
Follow our guest Danielle Carr, She's at Underscore Danielle Underscore Car.
Follow our producers Carmen Rodriguez at Carmen Arman, dash Ol
Bennett at Dashbot and Kilbrooks at Kilbrooks. Thank you to
our producer Moses Ondam. For more Oddlots content, go to
Bloomberg dot com slash odd Lots, where we have transcripts,
(51:50):
a blog and the newsletter and you can chat about
all of these topics twenty four to seven in the
discord with fellow listeners Discord dodgg slash Oddlines.
Speaker 3 (51:58):
And if you enjoy All Blots, 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're 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.
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