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But insight, awareness, and empathy will help us better see the issues they're
dealing
with. And that can make us and our companies healthier too. I'm Holly Robinson-
Pete. Join us
on The Visibility Gap, a new podcast presented by Cigna Healthcare. Download it
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Hello and welcome to another episode of the Odd Lots podcast. I'm Joe Weisenthal.
And I'm Tracy Alloway.
Tracy, I was going to ask you a question, but I already know the answer to it. I'm
Joe Weisenthal. And I'm Tracy Alloway. Tracy, I was going to 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 or
whatever.
But I'm just curious, like what percentage of our colleagues do you think use some
sort of
stimulant, Adderall, something, some sort of performance enhancing workplace drug?
Like coffee? No, something a little stronger than coffee.
Okay. We've had this conversation before, and I think it's such an interesting one
because,
as you know, I have never tried Adderall. It is a complete cultural blind spot for
me,
but I am 100% sure that you and I, in the context of this podcast and our day-to-
day lives,
have absolutely spoken to people who have been on Adderall.
In fact, a very famous one springs to mind right now.
I don't know who you're talking about.
SPF.
Sam Bingman-Fried.
Oh, yeah, there you go.
There you go.
But it is an interesting thought experiment to think about the proportion of
people around you,
sometimes highly productive people who may or may not be on Adderall or something
similar.
So here's my thought, which is that, like, my big fear with Adderall is like, I'm
not maybe
against trying it because I don't think I have the most focused brain in the
world. In fact,
I know I don't and I get scattered. I'm worried that I would be really productive
on it. And then
for the rest of my life, be faced with this choice of, do you want to stay on
this drug forever?
Or do you just want to go back to your old self, knowing that you have this other
potential
state in you?
Yes.
That's my big fear.
I feel the same way.
I am deeply concerned that I would start writing a book and be successful at it.
No, that's a joke.
 But I think, like, to me, it opens up kind of
interesting questions about fairness and access. And if someone next to you is
getting an edge,
because they either have a prescription that maybe they don't need, or maybe they
do need it,
and we can get into the degree to which Adderall actually is needed by the
population,
or they're accessing it illegally in one way or
another. It just opens up like interesting questions. But then again, I mean, the
person
next to you can drink 10 cups of coffee and that's allowed, right? Like you're
allowed to do that.
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 98. And I wasn't like a great student. I got bored a lot in class.
I've just been scattered. I couldn't
focus. And I feel like I was probably in a slightly different environment. Maybe
if I had
been born a couple of years younger, I might have been prescribed it. I think
maybe not because my
parents were hippies. And so they didn't really believe probably in 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. 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 30s and 40s who are getting late diagnoses because all the
symptoms that
people were looking out for were,
you know, hyperactive boys, basically. Totally. And so it went from a hyperactive
boys in high school thing. And then I sort of forgot about it for a while. Then I
went to college and I found
that to be a little easier. And then, like, I forgot all about Adderall. And then
over the last
several years, what we've seen is prescriptions for Adderall absolutely explode,
much more adult use.
As you say, people finding out later in life that they're diagnosed with ADHD,
which, of
course, has also led to shortages, which have a variety of reasons, some relating
to the
DEA and manufacturing, some just related to the absolute booming in demand.
And so Adderall is just sort of an omnipresent topic of conversation and an angst
in its
own right.
Yes.
And I am just going to emphasize this again, cultural blind spot for me.
So I'm very interested to hear how, you know, how it works, what the impact might
be and
what's driving the boom in usage, as you mentioned.
Well, I'm really excited to say we do, in fact, have the perfect guest,
someone I've wanted to talk to for a long time on the show and, 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. I read all of these in one
sitting without the use of Adderall.
They were very, very good.
They're very good.
 Everyone should read all of them.
But I'm really excited.
We're going to be talking to one of the contributors, Danielle Carr.
She's an assistant professor at the Institute for Society and Genetics at UCLA.
And she's a historian of science and psychology.
So hopefully we're going to understand how did we get to this
point and what is widespread Adderall consumption? How is it rewiring our brains
or if not society?
So Danielle, thank you so much for coming on OBLOT. Thank you so much. It's
wonderful to be here.
Describe your work in general. You had a great New York Magazine cover story last
year, but
talk about 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?
So I guess I should say that Adderall and attention deficit diagnoses are not my
specific
realm of expertise. My dissertation work and now my first book is looking at the
rise of
neural implants, a la Elon Musk's Neuralink, to treat psychiatric disorders such
as anxiety,
depression, PTSD, and so on. But I guess more generally, my line of work is
looking at the
political economy and historical emergence of different types of experimental
psychiatric
treatments from the 20th to the 21st century. I have a really basic question to
start out with. What happened to Ritalin?
So no, but honestly, so if we had been having this discussion in like the 1990s or
the early
2000s, I don't think we'd be talking about Adderall. We'd be talking about
Ritalin.
Yeah, I think that that's absolutely right. I mean, one of the interesting things
to note about
the sort of cluster of names for this behavioral disorder that is, you know,
currently called ADD or ADHD is that there have been since 1902 about 20 different
names for this
kind of cluster of syndromes. And so Ritalin emerged as its methylphenidate rather
than
an amphetamine. So it's slightly different pharmacologically, and it was
formulated in the
mid-1950s as what was hypothesized to be a less addictive alternative to
amphetamines, which were
at that time being used to treat children with what was being called hyperkinesis.
Concerta,
by the way, is just methylphenidate XR. But there was a period basically in the
1970s when, and I'm sure we'll get into this,
there was a sort of widespread panic over the enormous prevalence of amphetamines,
especially
to treat children. And Ritalin was sort of preferred as an alternative that had
fewer
side effects, allegedly, and was less addictive, allegedly, which accounts for the
prevalence of
Ritalin through the sort of mid-90s,
at which point there's a switch when Shire Pharmaceuticals acquires Obitrol,
which is rebranded as Adderall.
And that's really when the Adderall craze hits.
Tracy, I'm glad you asked that because I had forgotten all about Ritalin.
But now that you say it, that's what people were talking.
They weren't talking about Adderall yet when I was in high school.
But I was aware that this was the thing and like CNN and stuff would talk about
all these boys being described Ritalin. So I mentioned, Danielle, I was in high
school in the mid 90s. What was going on then that suddenly there seemed to 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 Ritalin?
Yeah, so I guess we can start the story in media res, as it were, in the mid-90s.
But really,
the work of a historian named Nicholas Rasmussen has, I think, done a very
magisterial job in
showing that the 20th century was defined in many ways by recurrent waves of
amphetamine use.
The first wave really began with the rise of amphetamine use during the
Second World War, and we can talk about that if you guys would like. But by the
mid-90s, one of
the major things that had happened was a panic in the 1970s, a sort of moral panic
over the
extraordinary prevalence of amphetamines, mostly dexedrine and benzadrine, that
were being prescribed without any sort of federal control.
It was extraordinarily prevalent across the U.S. population, and there really were
not very many
controls at all in terms of how doctors needed to report these prescriptions to
any sort of federal
data collection. And so in 1971, you had Congress tasked the DEA with
reclassifying amphetamines as being a schedule two substance.
That is, prescriptions needed to be reported to a central government
administration.
And there were limits and quotas placed on the quantities of amphetamines that
could be manufactured and then distributed to pharmaceutical companies.
manufactured, and then distributed to pharmaceutical companies. And so you had
this sort of moral panic around that that actually led to a congressional
investigation in 1970. And there was this sort of
broader crackdown, both legally in the 1970s, and also culturally, where you had
like,
this sort of countercultural figures decrying speed freaks, which had also, you
know,
there was this discourse in this narrative that,
for instance, like the Hyde-Atsbury sort of summer of love had been destroyed by
speed freaks and so
on and so forth. And so in the 1970s, you have a movement away from amphetamines
proper, which
A, creates the conditions for the rise of things like Ritalin, which is a
methylphenidate, which
is, you know, it's pharmacologically quite similar,
but it was not subject to exactly the same controls as amphetamines. And secondly,
I think the very important thing that happens is that one of the few medical uses
for which amphetamines
are going into the late 1970s still allowed to be prescribed are child behavioral
disorders.
still allowed to be prescribed are child behavioral disorders. Now, prior to 1970,
amphetamines had been used off-label for everything from weight loss to mood to
just like a variety of off-label prescriptions. But you have this sort of
concentration after this crackdown
by the DEA to focus amphetamine use medically specifically on this, you know,
small cluster
of childhood behavioral
disorders. This sets us up for, by the time we get to the 1990s, the sort of
growing market for
childhood applications for amphetamines. And I guess, like, the third intervening
factor here
would be that in 1980, there was the third publication of the Diagnostic and
Statistical
Manual, which is, or the DSM, which is widely described as psychiatry's diagnostic
bible.
This is essentially the list of diagnoses held to be medically viable that
insurers will agree to cover, that clinical trials will investigate, and so on and
so forth.
And ADD, attention deficit disorder, is installed in that version of the DSM.
And so I think this really sets the stage for the rise of ADD as a clinical
diagnostic
entity that receives a lot of research funding in the 1980s, such that by the
1990s, once
Adderall comes onto the market, the stage is set for a very wide, sudden uptick in
Adderall
prescriptions for children.
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www.choosestifel.com. they take Adderall. No, I asked some people that I know about
Adderall and someone explained it to
me as this idea that if you do have ADHD, then you don't have the normal level of
dopamine in
your brain or your brain handles it slightly differently. And so Adderall
basically helps
to normalize dopamine and bring it closer to what a neurotypical person might have
without medication. Could you maybe explain
exactly what Adderall is doing on someone's brain and the differences between
someone who's maybe
taking it to boost their productivity versus someone who's taking it because they
have been
diagnosed with ADHD or something else and they have an actual prescription from a
doctor?
Yeah. So I think the question of what Adderall is and what it does neurologically
is very connected
to the very contested and open question of what ADD and ADHD are neurologically.
So maybe I'll
start with what is ADD, what is ADHD? Now, what you have to understand is that
with the emergence
of the DSM-3 in 1980, this was
a document that was created essentially to bring together a bunch of different
stakeholders
under a very large tent.
These stakeholders included insurers, clinical researchers, pharmacological
companies, of
course, and of course, patients and doctors.
And the DSM describes clusters of symptoms, that is syndromes, that tend to occur
together.
So for instance, here's a list of 10 to 12 behavioral manifestations that tend to
cluster
together and we're going to call that depression, so on and so forth.
But particularly in 1980, there was not a robust sense of what the neurological
underpinning
of each of these diagnoses were.
These were descriptions behaviorally of how these syndromes manifest that were
presumed
to be disease entities.
But I mean, if you ask anyone working at the cutting edge of sort of neurology
psychiatry
right now, they will tell you quite frankly that there is no guarantee that any
one case of, 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 depression.
Some people might be crying a lot and not eating very much.
Someone else might not be crying very much and eating a lot, for instance.
And so there's no guarantee that each instance of the disease entity is going to
have the same sort of biological underpinning behind it.
Now, this works fine for things like insurance markets or billing insurers or sort
of getting medicine done in a sort of day-to-day sense.
But once it comes to sort of 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 very important to keep in mind that there is no
widely accepted,
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 reuptake of norepinephrine and
dopamine.
But I think it's important to keep in mind that these explanations, they might be
having prevalence now. But if you think about the rise of, for instance, the
serotonin hypothesis when it comes to depression, the serotonin hypothesis
dominated theories of depression for quite some time and then has been pretty
roundly disproven. There is not a robust link between depression and serotonin
deficits. And so I think that's one important
thing to keep in mind is that we don't necessarily have a robust and agreed upon
understanding of
what this disease entity, quote unquote, actually is. Now, when it comes to what
it is that stimulants
actually do in the brain, the brain releases neurotransmitters that then sort of
hang out in the space, in the sort of synaptic space between the axon and the
dendrite,
and then are reabsorbed. So neurotransmitters are things like, for instance,
noprenephrine,
dopamine, right? 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 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
and norepinephrine. 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
a gumball
and you're expecting to get one gumball, but the machine gives you two for one
quarter,
you're going to have a huge dopamine spike because that reward is double what you
were expecting.
And when you think about the way that, for instance, addictive technologies like
video gambling or social media work, they work by introducing
variable rewards that hook into this very, very motivating dopaminergic system in
the brain.
Norepinephrine similarly controls the body'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 sense of well-being
and alertness.
And indeed, this is why, you know, in the early 1930s, amphetamine was widely
prescribed for
anhedonia or a lack of pleasure. In fact,
historian Nicholas Rismussen has made the case convincingly, I think, that
amphetamine was in
fact the first antidepressant. But at a neurological level, that is essentially
what amphetamines are
doing. They also, because of their dopaminergic action, they increase the
rewardingness of a task.
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 fortunately, this is simply not true.
Anyone who takes amphetamines has this burst in heart rate, burst in feelings of
well-being,
burst in ability to concentrate.
This has been documented clinically
over and over again that there's not really a perceptible difference between
people who have
been diagnosed with add or adhd and people who have not when they take these drugs
so someone
like myself who sometimes worries that maybe i have another level of productivity
above me even
i've never been diagnosed with anything.
Like, maybe that's true.
So, you know, I get like, as you say, OK, it makes Internet gambling.
You could see or tweeting, tweeting, etc.
But like, what is the theory by which like a bunch of people who have jobs where
they have to make PowerPoints about some M&A deal?
And they're all many of them them apparently, on Adderall. Like,
 for that person, they have a job, they're in the office until 11 p.m., they get
one typo wrong,
they have to start it all over. What does Adderall do for them in the sort of
corporate context or
the work context? So, one of the things that I discussed in my essay was clinical
literature around what psychiatrists call punting, which is repetitive behavioral
loops that are often observed in patients sorting and handling objects or hunting
for things or collecting things, so on and so
forth, in patients who were taking levodopa, which is a dopamine replacement that
is used in patients
with Parkinson's. And I think that this like gives us a pretty interesting angle
into what it is exactly that amphetamines do, which is to make
these repetitive tasks much, much more rewarding than they would otherwise be. And
so when you
think about the forms of work that predominate in the so-called knowledge economy,
right, where
you're on a computer looking for things, searching for information, organizing
information, so on and
so forth, First of all,
an amphetamine makes any task that you're engaged in much more rewarding because
it's
massively ramping up the 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 amphetamines specifically in sort of knowledge work
is that it makes these repetitive tasks feel more like hunting and gathering,
right?
It's a more exciting task to do these repetitive tasks. Abraham Meyerson, who was
one of the first psychiatrists to widely use benzadrine for
depressed and anhedonic patients in the 1920s, his clinical area of expertise was
the sort of
neuroses of what he called the brain workers of the upper class. So I think that
there is,
you know, a robust through line of amphetamines being used for these emergent
forms of work in
the U.S. That was great. By the way, I never heard Punding before you wrote about
it,
but if you go to the Wikipedia page for Punding,
there is a very cute photo of someone
who has lined up all of their rubber duckies.
I was just looking at that.
In sequence.
So I guess that person, you know, there you go.
It must have been very satisfying for that person
to arrange all of their toys.
If you think about the sort of phenomenological experience of what it is like to
be online
on Adderall or to do research on Adderall, there is a sort of punding-like quality
to
always another reeled 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 casino
called the internet that we all live in now. So this is one of the reasons we
wanted to talk
to you specifically, because you do write about this in your essay, this idea
that, okay,
the medication is now available and more people can access it. But at the same
time,
there might be things actually going on
with our society, with our economy, that make this medication more desirable or
more useful
to people. This idea that we're doing more repetitive tasks, that the amount of
content
available to us is basically endless. And so if we have a drug that makes it more,
even more
enjoyable to sift through all of it, it's sort of like two self-reinforcing things
here.
Yeah, absolutely. And I mean, I think I want to duck out of coming down on the
side of chicken or egg here, right? These things are co-constitutive.
But the reason that I wrote the piece was that I think that there has been a
prevalence of a certain kind of narrative about the relation between the so-called
detention crisis, the internet, and Adderall. And I think in most of the
commentary that I've read,
even commentary that has been very critical of the proliferation of telehealth
startups such as
Cerebral or Dunn, and I'm sure we'll talk about those in a little bit, Even in
these critiques of the overreaches of telepsychiatry and the sudden
boom, the latest boom in prescription for ADHD and ADD stimulant medication,
there's this idea
that we are medicating an attention crisis that is in fact caused by the
prevalence of smartphones
in the internet. So then the causal chain there would be first you have the
internet,
then you have the attention crisis, and then we're medicating that attention
crisis through Adderall.
And I think that that's only one half of the story. One of the arguments that I
make in the
piece is that, in fact, if you look at the emergence of, let's say, millennial
internet
culture, which is to say sort of smartphone cusp internet culture, first of 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
prevalence of ADHD medication among coders, you could hardly imagine a job that
lends itself better to the sort of jacking up of reward systems that amphetamines
produce than the extremely boring task of coding, right? you had the proliferation
of things like Alt-Lit, Tao Lin, Ben Lerner, Jonathan Safran Foyer,
Vice, Pitchfork, right? If you think about that sort of melange that was that
moment in the
culture, I think that one of the defining features of that zeitgeist was the
prevalence of Adderall
and the prevalence of millennials who had either been put on Adderall as children,
overwhelmingly upper middle class insured children who then go on to sort of
set the BPM of the culture in the zeitgeist, right? Or the dissemination of
Adderall through
elite college networks. I want to get to the rise of telehealth and the pandemic
and how that sort
of opened up the door to many more people. But before we even get to that, this
sort of broader question, is it a phenomenon when you, looking at history,
and it certainly sounds like it, where whether it's the government or regulators
or the medical
profession, it sounds like these things go in waves. And it's like there's a drug
gets
prescribed popularly, then there's a backlash and everyone gets concerned. Maybe
we're part
of the backlash right now to Adderall, then everyone gets concerned, then it sort
of attenuates for a while,
and then suddenly there's a new reason and then it picks back up. Is that a
general phenomenon
in psychology? Yeah, 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 in a variety of psychiatric medications. For instance, if you think
about the emergence of
antidepressants, SSRIs, SNRIs like Prozac, Lexapro, Welbutrin, and so on and so
forth.
In the 90s, there's a huge amount of optimism about the serotonin hypothesis.
That is that serious mood disorders like depression are caused by a deficiency of
serotonin in the brain.
And this is coterminous with very serious marketing campaigns by pharmaceutical
companies that include things like funding patients' advocacy groups to sort of
demand recognition and access to these drugs.
And then you have this sort of decline in optimism around these drugs that I would
say
dates roughly to 2010 and this sort of fall in optimism because, in fact, most
SSRIs and SNRIs
do not perform very much better than placebos when looked at in aggregate, that
is,
through meta-analyses. And so I do think that there is a kind of push and pull
here that is maybe not
so dissimilar to this general dynamic in psychiatric medications more broadly. But
what's interesting about amphetamines in particular is that sort of the first wave
of amphetamine use really gets going during World War II,
when both Allied and Axis powers are using amphetamines, or in the case of the
Germans,
just meth straight up, to fuel wartime activities and to quote-unquote boost
morale. But I mean,
there's a historian named Norman Oller has laid out very capably, I think, the
argument that, like, for instance, Blitzkrieg cannot be understood apart from the
widespread use of meth by German troops.
So you have the sort of large, large spike in population levels of usage around
World War II that sort of rises and rises and rises and rises.
and rises and rises. And then with the sort of panic around overprescription among
children in the early 1970s, I think that that backlash against the sort of
psychiatric medication being
used on children has to be understood in tandem with, for instance, youth
counterculture,
with youth suspicion of the way that older generations were, you know, doing
things like
suppressing student organizing, right? The youth culture comes to be this sort of
anti-establishment suspicion of a variety of
different systems, including electoral systems, but also specifically the
psychiatric system as
an agent of control, right? So if you think about, for instance, Michel Foucault,
Thomas Zsasz,
the wide spectrum of thinkers in the 1970s who were explicitly making the case
that psychiatry
was an agent of social control, the backlash against amphetamines, particularly
amphetamines
being used to treat child behavioral disorders, becomes a bit more legible. And so
then, of course,
you know, in the 1980s, with the crackdown on amphetamines, this is one of the
conditions for
 the rise of cocaine usage,
for instance. But I think that there is this kind of push and pull, a sort of
dialectic,
if you will, between the cultural meanings of amphetamine. 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 20s and
30s who may have
been, you know, left out of a sort of sexist division of prescribing whereby their
ADHD was
not recognized for gendered reasons. So on the one hand, that would be good,
presumably, right? And then, you know, another
line of critique that says that the shocking and enormous rise in stimulant
prescription,
especially during the pandemic, is maybe more profit-driven and not so salutary.
And I think, like, that's the space in which this conversation is unfolding today.
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What actually drives the availability of Adderall currently? Is it regulation? And
one thing I
didn't realize before I started asking around about this, but Adderall isn't
licensed in the UK.
So I don't think you can get a prescription for Adderall over there. Is it the
rise of
prescriptions, the increased use of telehealth, which makes it maybe easier to
access this drug? Or is it the companies
themselves? I mean, this has been a talking point with the opioid epidemic, this
idea that
there is a built-in incentive for a pharma company to want to create demand for
its own
supply. So what exactly is driving the availability here?
Yeah, okay. 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 U.S. phenomenon. And I
think that
for all of the activists, and I'm sure I'm going to get a lot of angry emails
after this podcast.
You always get angry emails, right?
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 significant evidence that this is a culturally
bound phenomenon just by virtue of the fact that it is essentially a U.S.-bounded
phenomenon. I
think that people should take that pretty seriously. When we think about what is
driving
the current Adderall shortage, which was announced by the FDA in October of 2022,
because of the classification of amphetamines as a Schedule II substance in the
1971 order from Congress to the DEA. This means that there are quotas that are
established for how many amphetamine salts can be produced and how those are
distributed. Now,
there's been a lot of back and forth between pharmaceutical companies and the DEA
sort of
pointing fingers. And the DEA says that, in fact, what's going on is that
pharmaceutical
manufacturers are not actually hitting their
production quotas. Pharmaceutical companies are striking back and saying, no, in
fact,
the production quotas on the amphetamine salts themselves are too low. I don't
actually know
which one is true. It seems pretty hard to figure out which one is true. But when
we look at the enormous recent spike, even between 2019 and 2022, in 2019, for
instance,
there were 66.6 million prescriptions for all ADHD medications. So that includes
things like
Vyvanse, Concerta, Ritalin, and so on, and 45 million for Adderall alone. And in
the first
two years of the pandemic, there were 6 million new prescriptions. So one of
the narratives that you'll hear a lot about this extraordinary rise in stimulant
prescriptions is
that this is owing to the proliferation of telepsychiatry companies like Cerebral,
Dunn,
and so on. And I think this only gets at part of the story. During COVID, the rule
that mandated that
Schedule II substances could not be prescribed over telepsychiatry was lifted,
which meant
especially that people who had never had an ADHD medication prescription before
could suddenly get
one. There's been a lot of fighting over whether or not that rule will be
extended,
but that's certainly a huge part of the proliferation of the telepsychiatry
prescription
rates. But what's interesting is that a recent study using CDC data noted that the
rise through
telepsychiatry of these prescriptions are specific to VC-backed startups. That is,
if you were getting telepsychiatry through a sort of
established provider like, let's say, Kaiser or something, who had been doing
telepsychiatry
before, there was not a huge increase in Adderall prescriptions for those types of
companies. It was
 specifically the emergence of these new types of companies like Cerebral and Dunn
that were pushing
this enormous increase in diagnosis.
And I think that part of this is just a pretty open and shut case of like a
company basing its
profit model on slinging addictive medications into this loophole that was created
by the
pandemic. The Wall Street Journal has done a pretty magisterial and heroic
reporting job,
I think, of documenting that. But one of the interesting
things 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 mandating that the number of
prescriptions
for these stimulants be made publicly available in any way. The CDC has to collect
this data by
doing reviews of private insurance records,
but those tend to lag by about a year to two years. And so when we all started
seeing these
advertisements for Cerebral, which were all over TikTok, all over Instagram, that
were basically
like, do you want some Adderall? You can basically have some. It was very hard for
reporters to sort
of track the increase that was actually represented by those prescribing numbers
because they simply aren't federally available.
I mean, I think among the many arguments for a national health insurance or
Medicare for all, as it's called in the United States, is that it's very difficult
to track the number of controlled substance prescriptions in a way that sort of
stays au courant.
You know, this is also relevant,
I think, to, for instance, the opiate crisis. But yes, I think that when you look
at this enormous
increase in telepsychiatry prescription, there's both the sort of cui bono line
that you can take
of just like there was an enormous amount of money to be made through these
telepsychiatry
loopholes that allowed slinging these addictive substances into
a pandemic. And then simultaneously, I think there is the reality that it was
enormously difficult to
pay attention to anything during the pandemic, which contributed, I think, to many
people feeling
that because it was difficult for them to pay attention in Zooms for 10 hours, or,
you know,
or however long it was, that they must have some sort of attention deficit
diagnosis. I find that really fascinating, this idea, especially that point
about the gap and the increase in prescriptions from the sort of VC-backed
startups, which we know
need growth, growth, growth, versus the sort of legacy healthcare providers that
had been doing
telemedicine for some time and that didn't pick up.
I guess I should have just like done a test.
But like, what do you have to demonstrate to get Adderall?
Presumably, you can't just click a button, but how simple.
I think you can.
Is it really like what is there some sort of basic test and like do different
doctors
like do the ones who work through the legacy providers have a more perhaps
stringent test or expectations?
Like, what do the various types of medical professionals want to see before
they'll
write that prescription? I mean, I think the most succinct answer to this question
is that it has
been and remains essentially vibes-based. And the quality of that vibes-based
assessment basically depends on the quality of
the medical care that you're receiving. I mean, I remember that when I was
prescribed Adderall as an
eight-year-old, I went to like a child psychiatrist who played a board game with
me called Stop,
Relax, and Think loosely based off of chutes and ladders. And at the end of that,
I walked out with
an Adderall prescription, right? And so like, the thing is, there's not any sort
of blood test or genetic test or brain scan
that you could take that would stitch some sort of biophysiological substrate to
this disease
entity. And to say, there's no one-to-one correspondence between the disease
entity
and some sort of test that you could take because it's not actually clear at a
neurological level what this disease entity, quote-unquote, is.
And so in that sense, assessment is bound to be essentially vibes-based. behaving
responsibly, they will do a variety of tests and sort of ask either the child or
the parent, or in the case of adult ADHD diagnosis, the patient themselves, about
their functioning
across a variety of domains, including focus on work, organization, ability to sit
still for long
periods of time, and so on and so forth. But in reality, there is not really a
robust test that differentiates people who do have
ADD from people who don't, even in the best of cases, even in the case of like
very high
quality in-person pediatric or adult psychiatric care.
Now, when it comes to something like telepsychiatry startups like Dunn and
Cerebral, I think that
there's been a lot of
reporting and documentation now on the way that providers who were essentially
working in this
sort of gig economy, Uber for psychiatric professionals type of platform were
punished
if they refused to prescribe stimulants. At Cerebral for a while, if you refused
to prescribe stimulants. At Cerebral, for a while, if you refused to prescribe a
stimulant,
you had to write up a justification for why you were not doing that, when you
would think that
responsible medical practice would be the opposite. Cerebral has since, after this
series of
investigations that prompted a DOJ investigation, stopped prescribing Schedule II
substances through
their platform. But I think that regardless of
whether or not they're still slinging like Adderall or Concherta on there, I think
that it bears on,
for instance, what kinds of assessments are being used to prescribe, for instance,
antidepressants, which are also serious psychoactive modifications that can be
very,
very difficult to wean off of. But in short answer to your question, no, there's
no specific diagnostic
test that guarantees the appropriateness of amphetamines for any given patient.
This is a very wide-ranging question, but what are the implications for society of
this increased
adderall use? And obviously, there's a physical impact of having a higher
proportion of the population dependent in varying degrees on a particular
substance. But also, I kind of joked in the intro about unfairness and competitive
edges here. And then Joe said that it's not the Olympics. But of course, life is
competitive, and it is in some degree a competition.
competitive and it is in some degree a competition. And you could make a serious
argument that like some people have access to a drug that increases their
productivity and has positive outcomes on
their economic lives at the very least. So you have people who have boosted their
careers by
being on this particular drug and maybe they got the prescription when they were
younger because their parents had money and health insurance and were able to get
it. Or maybe they
had a network of friends who are on this drug or have access to it in another
slightly more dubious
way. It does feel like there might be some fairness questions tied to this. Yeah,
I think one of the
first things to be said about this is,
like so many other things in psychiatric treatment, there are a series of strange
paradoxes that define how amphetamine treatment have been used over the 20th
century. So,
for instance, one of the big pushes against the use of Ritalin for children in the
1970s came from the Black Panthers, who saw that
amphetamines and Ritalin were being tested on children in residential care
facilities,
many of whom were Black, right? And so there was a sort of lower classification of
amphetamines
in the 1970s because they were being tested on populations in juvenile detention
centers,
residential care homes, so on and so forth. There's a real switch in the 90s,
right,
when suddenly attention deficit disorder has become kind of the explanation for
why white,
well-insured, upper-middle-class children are not doing as well as would be
expected in class.
And so I think I say that to just sort of problematize some of the narratives that
like amphetamine usage has always
been considered an upper middle class competitive edge thing. And I think in line
with this, for
instance, I don't think necessarily that amphetamine use always gives someone a
sort of
performance enhancing edge. One of the
arguments that I make in the Adderall essay that I wrote is that, in fact,
Adderall makes you more
susceptible to different types of digital behavioral loops, these addictive
digital
behavioral loops like scrolling Twitter infinitely or scrolling TikTok infinitely,
that sort of directly impact one's ability to lead
like a thoughtful, well-informed life. One of the interesting responses to the
Club Med Adderall
essay collection, I thought, was that there was a lot of anger and accusations
that some of the
arguments that the authors made were prohibitionist 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 that there is really not that much of a difference
in effectivity
for amphetamines between people who have been diagnosed with attention deficit
disorders and
people who have not, then in fact, the real prohibitionist impulse is to say that
because we have this real diagnostic
clinical entity, which is, you know, in fact, like quite contested and not a
robust disease
entity at all, because we have this robust disease entity, we are the only ones
who should
have Adderall.
And I think that there's this very serious conversation to be had about equity and
distribution and what prohibitionism actually means.
of sort of just-in-time production, flexible production, when you think about the
sort of increased stretching of the worker, the need for different types of
flexibility across time 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 that facilitates that. But I think that
the conversation that I hope to see emerge in the coming years is one that's less
focused on sort of
who legitimately has ADHD and who does not, because in fact, these amphetamines
have remarkable
efficacy for both groups that have been diagnosed and groups that haven't, and
more of a turn
towards thinking about
what it is that Adderall does in terms of setting a sort of pace of freneticism
and susceptibility
to different forms of behavioral addiction, particularly internet-based behavioral
addiction.
And I guess my closing point here would be that Adderall cannot fix the sort of
internetified
attention crisis because Adderall hooks us deeper than ever
into the sort of structures of addiction that are the sine qua non of the internet
as a sort of
giant casino that we all live in. Danielle, this was fascinating. We could
probably talk for hours
on this subject. I just want to say I'm addicted to Twitter and Instagram totally
naturally,
totally clean. But thank you so much
for coming on Odd Lodge. It was a great conversation and glad we finally got a
chance to talk to you.
Thank you so much. This was really fun.
Tracy, 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 online world was also built by the people on
these drugs.
Yeah, it's sort of intertwined, 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, B.S. Jobs by David Graeber. And it's sort
of like a dystopian
studs turkle in the sense that it just details how much dissatisfaction people
seem to have
with a lot of modern day jobs where you feel like you're not really doing
anything. There's a lot of
bureaucracy involved, and yet you have to pay attention per Danielle's point. So I
think there's an aspect of that in there. The other thing that was very, I guess,
attention grabbing was the idea of, no pun intended,
was the idea of some of the venture capital backed telehealth services writing
more prescriptions
than perhaps some of the more traditional healthcare providers.
That was totally eye opening for me. And I was, you know, I'm aware of the
proliferation of these telehealth companies. As a male in my mid 40s, 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 combination that Danielle described,
which was the relaxation of prescription drug obligations due to the pandemic,
and then the simultaneous explosion of these new services,
which it sounds like the drugs are kind of being given out like candy.
Well, the other thing that I think is something of a tell is the fact that
Adderall is not licensed in places like the UK. This seems in many respects to be a
sort of peculiarly or especially American phenomenon.
Tracy, Tracy.
Yes.
What do they do in the UK if they can't get Adderall?
get Adderall. They get their energy. If you work in finance, you get your energy
the old-fashioned way. I'm not going to say what that... I mean coffee, of course.
Oh, yeah. Powdered coffee.
Yeah, there we go. But I think it is suggestive as to what's going on here, the
fact that there
might be something structural or specific about the U.S. economy or the healthcare
system that
seems to be driving some of this. Yeah, 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 in a given year. And you can't find it. And if
you look,
the only entities that offer that data are these like private for-profit
collectors,
and you have to pay like $10,000 or whatever just for a 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 health care system and there's
only essentially
one monopoly prescription writer, whether it's the NHS or whatever it is they have
in Canada,
then you know those numbers in real time and you can say,
oh my God, like these prescriptions are totally exploding.
Yeah, that point by Danielle, the idea that maybe there are data benefits
to have a national health care 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
out with, you know, meth addiction in World War II.
So I really enjoyed that conversation.
I feel like I have a better handle on a sort of cultural zeitgeist of the American
economy.
But wow, there are a lot of questions
that come out of this conversation.
 You know, one other thing too about this sort of,
maybe the pathologies of the U.S. 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 was riven with abuse, a lot of the same things about like so-called like non-
profit
patient advocacy groups trying to make these drugs more available and ease the
regulations.
And then we had this like big sort of national reckoning with it, various books
and documentaries,
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
we just sort of, here's the new drug that we're going to commercialize and promote
aggressively.
It's like, didn't we just do this? Well, Danielle made that point to the idea that
like,
it kind of goes in cycles, 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?
Let's leave it there.
This has been another episode of the All Thoughts Podcast.
I'm Traci Allaway.
You can follow me at Traci Allaway.
And I'm Joe Weisenthal. You can follow me at Traci Alloway.
And I'm Joe Weisenthal. You can follow me at The Stalwart. Follow our guest,
Danielle Carr. She's at underscore Danielle underscore Carr. Follow our producers,
Carmen Rodriguez at Carmen Arman,
Dashiell Bennett at Dashbot, and Cale Brooks at Cale Brooks. Thank you to our
producer,
Moses Andam. For more OddLots content, go to Bloomberg.com slash OddLots, where
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