Overview of the Usage of Adderall for the Treatment of ADHD

Abstract

This paper explores research about the drug Adderall, a stimulant medication that is prescribed for the treatment of ADHD. Adderall has become an increasingly popular way to treat the focus and attention problems associated with ADHD, a condition which is thought to be caused by a deficiency of dopamine in brain circuits that depend on dopamine for communication. Adderall helps manage the cognitive problems related to ADHD through its ability to attach to nerve endings and block the reabsorption of dopamine so that it may accumulate in the brain and improve neural communications in the nucleus accumbens. However, Adderall has also earned the reputation of working as a cognitive enhancer, which has made it increasing popular among students on college campuses who do not have ADHD. This illicit use has put Adderall under a lot of speculation and criticism about the rate it is being prescribed and how those prescriptions are being used.

Overview of the Usage of Adderall for the Treatment of ADHD

Adderall is a drug that is commonly prescribed for the treatment of Attention-deficit hyperactivity disorder (ADHD), a condition that currently affects about one out of every five children in the United States. ADHD is defined as a condition in which individuals experience difficulties maintaining focus while often struggling with hyperactive or impulsive behavior simultaneously. As a result, individuals with ADHD experience significant impairment in academic performance, occupational achievements, low self-esteem, and maintaining positive relationships with their peers and family members (Biederman, Lopez, Boellner, & Chandler, 2002). The most effective treatments for ADHD are stimulant medications such, which are thought to boost activity in the areas of the brain that are responsible for regulating attention and self-control (Higgins, 2009). Currently, the two most popular medications prescribed for the treatment of ADHD are Ritalin and Adderall (Chau, 2007). However, Adderall has become much more popular than Ritalin recently because many patients who do not benefit from the effects of Ritalin have benefitted by taking Adderall instead.

Introduction

Adderall is comprised of a mixture of neutral salts. These include dextroamphatamine sulfate, amphetamine sulfate, the dextro isomer of amphetamine saccharate, and l-amphetamine aspartate (Biederman et al., 2002). It was initially approved for unrestricted use in the treatment of ADHD by the United States Food and Drug Administration in 1996 (Higgins, 2009). The United States Drug Enforcement Administration (DEA) classifies Adderall as a Schedule II substance, which makes it only legally available with a prescription that can only be filled for up to 30 days’ worth of doses without any refills. As a Schedule II drug, Adderall is also subject to production quotas set by the DEA (DeSantis & Hane, 2010). There are two different forms of the drug currently available. The immediate release form takes effect about an hour after ingestion, and typically has a duration of approximately 4-6 hours. Comparatively, the extended-release formulation of Adderall is designed to produce a pulsed- released of amphetamine salts so that their therapeutic effects are able to last throughout the entire day (Biederman et al., 2002). This formula makes it easier for ADHD patients to use because it only has to be taken once a day and is associated with fewer side effects.

How Does Adderall Work?

The cognitive problems associated with ADHD have been found to correlate to an underactive frontal cortex. In some ADHD patients, the frontal cortex has also been found to be smaller than average. The frontal cortex is the area of the brain, which resides just behind the forehead and is responsible for controlling executive functions such as making decisions, predicting future events, and suppressing emotions and urges. In order to function, the frontal cortex depends heavily on a neurotransmitter, or signaling chemical, known as dopamine. Dopamine is released by the frontal cortex by neurons originating from deeper structures in the brain. Another set of dopamine-releasing neurons extends to an area called the nucleus accumbens, which is a critical mediator of motivation, pleasure, and reward (Higgins, 2009). When there is less dopamine in the prefrontal cortex, cognitive ability declines.

As a stimulant, Adderall is able to enhance communication in these brain circuits controlled by dopamine. It is able to bind to the proteins on nerve endings, known as dopamine transporters, which usually are responsible for sucking up any excess dopamine. By binding to these transporters, Adderall is able to deactivate them so that dopamine is then able to accumulate outside the neurons (Higgins, 2009). Consequently, the increased level of dopamine is then thought to improve the functionality of the neuronal circuits imperative for motivation and impulse control. Adderall also increases arousal in the nucleus accumbens, which helps improve task saliency. Therapeutic doses of Adderall have been shown to improve performance on working memory tests.

Prescribing Trends

Over the course of the last 15 years, doctors have been making continuously larger numbers of ADHD diagnoses and prescribing stimulants to treat this rapidly growing number of people. This increase has led to the speculation that Adderall is being overly-prescribed to individuals who do not suffer from the cognitive deficits of ADHD (Chau, 2007). As observed in some cases, doctors are even prescribing Adderall to patients with very moderate to mild inattention problems that are usually attributed to normal difficulties in maintaining focus. One possible explanation for this trend is a lower tolerance in society for anyone experiencing mild cognitive or behavioral problems (Higgins, 2009). Similarly, all of the recent changes to federal special education laws, more commonly known as the ‘Individual’s with Disabilities Education Act’ enacted in 1991 made special education services and operant conditioning available to children diagnosed with ADHD (Chau, 2007). These changes most likely motivated more people to seek out psychiatric services and subsequently caused an increase in the diagnosis of ADHD.

An additional explanation for the greater amounts of people diagnosed with ADHD is that the diagnostic criteria for ADHD has undergone several changes in the last two decades. These changes may have slightly relaxed some of the previous necessary criterion for receiving an ADHD diagnosis. On the other hand, these changes to the diagnostic criteria have become more comprehensive in their ability to identify cases of ADHD due to a constant increase in research findings about the condition. For instance, about 20 years ago, the term ‘ADHD’ was considered to be the only way of labeling the condition. Additionally, anyone being evaluated for ADHD had to present both significant issues maintaining focus and hyperactivity in order meet the criterion necessary for receiving a diagnosis. However, as research findings in the last 20 years continued to provide new information and advance understanding of the condition, ADHD was broken down into three different subtypes (Higgins, 2009). One of these subtypes, known as inattentive ADHD has no associations with hyperactivity, but individuals receiving this diagnosis are still prescribed Adderall for their treatment.

New information about ADHD has also contributed to the longevity of the problem. ADHD was previously thought to only affect individuals during childhood and then eventually subside on its own as the individual matures into an adult. Therefore, Adderall was only prescribed for a few years during grade school. However, research has found that ADHD can persist into adulthood, and as a result many current patients are encouraged to keep taking their medications for much longer durations of time (Higgins, 2009). Unfortunately, another possible explanation for the increase of Adderall prescriptions is abuse of the drug. Many people who have no cognitive deficits perceive Adderall as a quick and easy way to increase their productivity and academic performance, which causes them to seek out doctors they believe they can deceive into giving them a prescription.

Adherence Issues and Abuse

Drugs that improve cognitive performance, such as Adderall, have become the subject of a lot of controversy due to their high risk for abuse. While the medication is very helpful to those suffering from the adverse cognitive deficits of ADHD, they are even more helpful to those who do not suffer from any cognitive impairment (DeSantis & Hane, 2010). Individuals with relatively normal brain functionality can also benefit from taking the drug. This is because it merely acts as a cognitive enhancer for them (Chau, 2007). These cognitive benefits are what have earned Adderall its’ popular nickname ‘study buddy’ among students on college campuses who seek to boost their academic performance without having to substantially increase the effort they are currently putting forth (DeSantis & Hane, 2010). However, when Adderall is taken by individuals who have no medical need for the drug, the observed effects work very similarly to illegal drugs such as speed or cocaine.

The increased number of individuals who have received an ADHD diagnosis and are prescribed Adderall has also played a role in abuse of the drug. Widespread use and availability has created a lot of opportunities for the medication to fall into the wrong hands of those who use it illicitly as a cognitive enhancer (Chau, 2007). Many college students who do have ADHD resort to selling their prescriptions to other students when they have extra pills (DeSantis & Hane, 2010). In 2005, a national survey of college students in the United States found that non-medical use of prescription stimulants, such as Adderall, was as high as 25% at some colleges. The study also reported that non-medical usage rates were higher in students who were male, white, have lower grade point averages, and/or members of sororities or fraternities (McCabe, Knight, Teter, & Wechsler, 2005). Additionally, rates were also higher in colleges located in the north-eastern region of the United States and at colleges that have more competitive admission standards (Teter, McCabe, LaGrange, Cranford, & Boyd, 2006). Another survey of a mid-western university was conducted to determine what the motivation behind the high rate of illicit use of Adderall and found that students turned to the drug when feeling overwhelmed with pressure from time commitments and fatigue (Hall, Irwin, Bowman, Frankenberger, & Jewett, 2005). These factors can make it hard for them to study keep up with their stressful workloads.

While Adderall is considered safe by the United States Food and Drug Administration, it is also classified as a high with a high abuse potential because its stimulating effects can easily become addictive. Occasional users who take Adderall to help them perform better academically might eventually feel that they cannot study or perform as well without taking the drug to help them, which may have negative consequences for their self-esteem and cognitive drive (DeSantis & Hane, 2010). The abuse appeal of Adderall beyond cognitive enhancement is for recreational use. Some people use it as an alternative to cocaine and methamphetamine because they believe it to be more safe since it is produced and controlled by pharmacists and the government (Chau, 2007). Since it is technically a prescription drug, people also belief that it is safer than drugs like cocaine, which are illegal and never prescribed because of their harmful health effects (DeSantis & Hane, 2010). Other illicit users justify their abuse by arguing that since it does not cause the ‘high’ associated with most recreational drug use that is it not bad and should not be considered a ‘real drug.’.

Common Side Effects

The physical and mental side effects of Adderall can vary widely between each individual and depend slightly on age. The most frequently experienced side effects of Adderall usage are anorexia, abdominal disturbances, headaches, and insomnia. For some individuals, these side effects are so severe and unpleasant that they are unable to continue taking the drug and resort to trying out different medications. Other relatively common and innocuous side effects are abdominal pain, vomiting, nausea, pharyngitis, increased cough, and nervousness. Episodes of emotional lability, which are defined as involuntary or uncontrollable displays of emotion, such as laughing or crying, sometimes also occur as a side effect. Therapeutic doses can also cause mood swings, irritability, restlessness, and repetitive or obsessive behaviors (Biederman et al., 2002). In order to experience as few adverse effects as possible, patients should try to keep their dosage as low as possible.

Adderall also has some physiological effects on the body’s cardiovascular system including irregular heartbeat, increased heartbeat, hypertension, hypotension, and Raynaud’s phenomenon. Adderall should not be taken by individuals who have pre-existing heart conditions, which would significantly increase the risk for instances of sudden cardiac death, a condition where the heart suddenly stops beating (Biederman et al., 2002). Additionally, Adderall does increase the risk of having a stroke or heart attack as well as developing permanent heart defects. Other side effects include acne, blurred vision, teeth grinding, a fast heart rate, tremors, increased perspiration, dry mouth, constipation, diarrhea, and difficulty urinating (Vitiello, 2008). Fortunately, increases in the dosage of Adderall has not been found to cause an increase in any of its side effects (Biederman et al., 2002). Dosages have to be frequently increased with most stimulatory medications after the body slowly becomes tolerant of the effects.

Amphetamine Psychosis

One of the most severe and rare side effects is amphetamine-induced psychosis, which closely resembles schizophrenia. Episodes of this are very rare and usually indicate that an individual is abusing their Adderall or taking too much of it. Before the onset of the psychotic state, individuals who continue to take Adderall start to exhibit a flattening of affect and anhedonia, which is an inability to derive any pleasure from activities that are usually found enjoyable. Symptoms of amphetamine-induced psychosis include flight of ideas, tangential thought, a flat affect, psychomotor retardation, waxy flexibility, loss of short-term memory, magical thought, as well as visual and auditory hallucinations. Of the most common hallucinations is the sensation of bugs crawling under the skin, which is known as delusional parasitosis. Researchers believe that this state of psychosis is brought on by the way Adderall affects the brain. Amphetamines like Adderall inhibit the uptake of norepinephrine and directly release dopamine from newly synthesized pools. Studies vary in their reports of how long this state of amphetamine-induced psychosis persists. For some individuals, the effects are very short lived and quickly subside once the medication is stopped. However, others seem to have more chronic episodes of which their psychotic symptoms persists for almost a week (Surles, May, & Garry, 2002). In one case, a participant for a study on Adderall induced psychosis continued to experience psychotic symptoms intermittently for 26 days.

Long-Term Effects

While the side effects that occur during the use of Adderall are well known and documented, there is a growing concern about what long-term effects the drug might have on the brain. Recent studies conducted with animal test subjects have hinted that Adderall could alter the structure and function of the brain in ways that result in depressed moods, increased anxiety, and lead to potentially significant cognitive deficiencies (Higgins, 2009). Currently, there are no studies that have examines the long-term effect of taking these Adderall over the course of one’s lifetime. There are a lot of concerns about how this medication could affect the adult brain as the brain continues to develop throughout childhood and adolescence (Chau, 2007). Furthermore, the stimulant nature of drugs like Adderall has been compared to the harmful long-term effects of other illegal drugs that have a very similar chemical composition such as cocaine and methamphetamine (Higgins, 2009). Abuse of cocaine and methamphetamine is correlated to permanent health problems, especially heart conditions, and there is some speculation that users become more prone to experiencing psychological and cognitive problems even well after stopping their use of the drug.

Interactions with Other Drugs

Adderall can interact with monoamine oxidase inhibitors (MAOIS) even if it is administered two weeks after the last dose of the MAOI. This interaction is associated with a very high risk of hypertensive emergencies, which is a cause of very high blood pressure with the acute impairment of at least one organ system such as the central nervous system or cardiovascular system. Even when taken in only very low doses under direct supervision of prescribing physicians, it is not recommended that these drugs be taken together. Adderall can also interact with selective serotonin reuptake inhibitors (SSRI’s), which are normally prescribed for the treatment of depression (Broadley, 2010). In rare cases, this combination can cause serotonin syndrome, which is an excess and dangerous buildup of serotonin. When norepinephrine reuptake inhibitors are taken with Adderall, noradrenergic ac activity is enhanced and the effects of Adderall are more intense and last longer. Adderall should also not be taken with Bupropion, a CYPSD6 inhibitor, which has pro-convulsant properties that can be enhanced if taken with a stimulant (Biederman et al., 2002). Additionally, Adderall is not recommended for patients who already have pre-existing cardiac conditions, other mental illnesses, or a history of prior drug abuse.

Conclusion

Adderall is a stimulant medication that is prescribed for the treatment of ADHD, a condition in which afflicted individuals suffer from cognitive problems in attention, hyperactivity, motivation, and working memory. It primarily targets the central nervous system to affect specific chemicals, in the brain, such as dopamine, that are associated with hyperactivity and impulse control. Adderall binds to nerve endings in order to block dopamine transporters from sucking up excess dopamine, which allows dopamine to accumulate in the brain and subsequently increases activity in the nucleus accumbens. Adderall is currently classified as a Schedule II drug by the Drug Enforcement Administration because of its addictive nature and high potential for abuse. Recent prescribing trends have shown a sharp increase in the last two decades of people receiving a diagnosis for ADHD and being treating with Adderall, which unfortunately has also led to a lot of abuse of the drug. Most of the abuse tends to occur on college campuses, where students who do not suffer from the cognitive impairments of ADHD are stressed under the pressure to perform well academically see the drug as an easy and safe way to enhance their cognition. However, while Adderall is safe to take under a physician’s care, it has many concerning side effects, which are much more acute when taken by those who do not have ADHD.

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