How The American Workforce Got Hooked on Adderall

27:01There'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 all, the technical architecture of the internet is overwhelmingly created by people who are on stimulants.

27:43If 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? So there's that. And then also, if you kind of think about that moment from, let's say, 2005 to 2015, where 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?

28:41Or 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.

29:20Is 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, Wellbutrin, and so on and so forth. In the 90s, 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 that include things like funding patients' advocacy groups to sort of demand recognition and access to these drugs.

30:14And then you have this sort of decline in optimism around these drugs that I would say dates roughly to 2010 and the 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.

31:08But I mean, there's a historian named Norman Oler 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 then with this 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?

31:53The 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 Zas, 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, in the 1980s, with the crackdown on amphetamines, this is one of the conditions for the rise of cocaine usage, for instance.

32:35But 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?

33:13And 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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34:39Complete disclosures available at public.com slash disclosures. Introducing the all-new Adobe Acrobat Studio, now with AI-powered PDF spaces. Do more with PDFs than you ever thought possible. Need AI to turn 100 pages of market research into five insights with a click? Do that with Acrobat. Need templates for a sales proposal that'll close that deal? Do that with Acrobat. Need an AI specialist to tailor the tone of your market report to sound real smart in real time? Do that with the all new Adobe Acrobat Studio. Learn more at adobe.com slash do that with Acrobat. What actually drives the availability of Adderall currently?

35:20Is 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.

36:05I think the first thing to be noted, as you mentioned, is that this is a specifically U.S. phenomenon. And I think that like for all of the activists, and I'm sure like, you know, 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, you know, significant evidence that this is a culturally bound phenomenon just by virtue of the fact that it is essentially a U.S.-bounded phenomenon.

36:40I 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.

37:21Pharmaceutical companies are striking back and saying, know, 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 Wyvance, 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.

38:14And 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 these 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.

38:58That 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.

39:38But 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.

40:13It 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 qui 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.

41:00And 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 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.

41:40I 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. 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 are 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.

42:23I 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. 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.

43:06And so in that sense, assessment is bound to be essentially vibes-based. Now, you know, if you have a clinician who is 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, 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.

43:53Now, 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 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.

44:38But I think that regardless of whether or not they're still slinging like Adderall or Concerta 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 medications 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.

45:24But 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. 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.

46:03Or 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?

46:47And 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.

47:28And 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 and impulse.

48:19And 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.

48:54And 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 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.

49:39But 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 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.

50:28Danielle, 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 Lots. It was a great conversation. and glad we finally got a chance to talk to you. Thank you so much. This was really fun.

50:58Tracy, 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. 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.

51:33Oh, I'm going going to have to censor myself. BS Jobs by David Graeber. And it's sort of like a dystopian studs-turkel 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.

52:16That 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.

52:55Well, 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 don't get if they can't 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. Oh, yeah. 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 U.S.

53:34economy or the health care system that seems to be driving some of this. Yeah. Two things on that. So Danielle 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 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 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.

54:10But 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.

54:42You 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. health care 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, 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.

55:32And 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.

56:04It'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 Oddbots podcast. I'm Tracy Allaway. You can follow me at Tracy Allaway. 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 Armin, Dashiell Bennett at Dashbot, and Kale Brooks at Kale Brooks. Thank you to our producer, Moses Andam. For more Oddbots content, go to bloomberg.com slash oddlots, where you have transcripts, a blog, and a newsletter.

56:40And you can chat about all of these topics 24-7 in the Discord with fellow listeners, discord.gg slash oddlots. And if you enjoy Oddlots, 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 are 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.

57:14Thank you.

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