Experts concerned about misuse of ADHD drugs

GILLIAN KLAWANSKY

“If drugs in sport is such a huge issue, why are drugs in academia not?” This question was posed by a pharmacist who contacted the SA Jewish Report with his concerns. He wishes to remain anonymous. “We’re following an American trend where it’s almost becoming acceptable in society for people to take amphetamines and tranquilisers to perform better in the workplace. It’s the pressure that society is putting people under – society is basically condoning it.”

What’s most worrying, he says, is that children who don’t suffer from ADHD are using associated drugs to enhance their performance. “You get people, particularly postgrad students, who come into the pharmacy to get Ritalin or Concerta. ‘I’ve got an exam coming up,’ they’ll say.”

Although the pharmacist acknowledges the difficulty in tracking this behaviour in high school students because their parents collect the scripts, he argues that ADHD medication is simply too widely prescribed. 

Psychiatrist Caroline Serebro agrees and says Ritalin should be prescribed with more caution. “There’s demand to script unnecessarily when there is no clear attention deficit disorder or ADHD. You’ve got to meet the criteria. That’s why the prescription of ADHD drugs should always be done in consultation with a psychiatrist,” she says.

Psychiatrist Dr Wendy Duncan agrees and points out the ways in which children work the system. “A lot of kids are faking ADHD,” she says. “They read up on symptoms. There’s also what we call Ritalin diversion, where kids with ADHD are selling their pills. That happens a lot both here and internationally.”

What’s ironic, though, is that the unnecessary use of Ritalin or Concerta will provide little benefit to one’s studying. “If you don’t have a diagnosis of ADHD, the only benefit that a stimulant, be it Ritalin or Concerta, will add is probably wakefulness,” she says. “Studies show that they don’t really improve memory.

“The child may have a sense of being more focused or more concentrated. Yet, in terms of actual cognitive paths and memorising or retaining information, there’s a lot of research to suggest that they don’t work. The risk of using them for this purpose, and them not being effective, is that kids might be tempted to use higher and higher doses.”

The dosage needs to be carefully monitored, Duncan adds. “As with any medication, if you take it in a big enough dose, you face serious risks. These could include psychosis, seizures, and in kids who have a vulnerability towards cardiac problems, you could end up with high blood pressure, arrythmia and the like. That’s only in a child who’s taking a big, big dose, though.”

Parents of children on these drugs need to be aware of risk factors. “If you don’t have ADHD, the medications can interfere with your sleep,” explains Duncan. “That’s particularly problematic when you’re studying, because you retain your information and lay down memory when you sleep. It also could potentially interfere with your appetite. Emotionally, it could elevate levels of agitation and anxiety quite significantly for any child who is already vulnerable to anxiety.

“Parents should also watch out for extreme irritability that’s out of character for the child, or levels of stress that are out of keeping with what’s warranted for the exams. Social withdrawal is also always something to be concerned about.”

Before doctors prescribe ADHD medicine – as with any medication – they’re under obligation to explain any possible side effects. This is particularly vital in terms of medications that come with what’s known as a “black box warning”, as is the case with the ADHD drug Strattera and antidepressants such as Prozac and Zoloft.

“Strattera is a serotonin noradrenaline reuptake inhibitor, or SNRI. It’s more like an antidepressant medication, as opposed to the stimulants like Ritalin,” explains Duncan.  To me, it seems unlikely that a child would be taking Strattera as a quick fix for exams because it takes six to eight weeks to work.

“All SNRIs carry a black box warning to say that adolescents taking these medications may be at higher risks for suicidal ideation behaviour [suicidal thoughts].”

This is where the pharmacist strives to promote awareness. “My concern is how easily these meds are prescribed and how the threats of the issue surrounding suicidality seem to be taken so lightly in South Africa,” he says. He argues that parents are not always adequately warned of these risks when medication is prescribed.

But Serebro disputes this. “I’m very particular about sharing the risks and the black box warnings with every patient. Every patient I see has to sign an informed consent, which means that everything is explained in terms of the most common side effects, including black box warnings. Part of my job, besides formulating a diagnosis and deciding on treatment, is having a discussion around treatment and what the risks around that are.”

A full medical, birth and family – physical and psychiatric – history is taken before prescribing treatment, adds Serebro. “You ask about medication issues and any other medical issues. Especially with stimulants, you ask around cardiac problems and epilepsy. If there was a risk around suicide or other mood-related issues or anxiety, one again would err on the side of caution around scripting certain medications.”

If one’s child is on these medications, they need to be monitored by a psychiatrist. “A parent whose child is about to start on the drug should be fully aware of any ruminations of suicide,” says the pharmacist. “I know of two instances where people have had to take their children off these drugs because they’ve started talking about having suicidal thoughts. It’s hard to get your mind around how a chemical can start doing that to people, but it’s a fact.”

One needs to see the bigger picture, caution the experts. “It’s the anxiety, the pressure, the perceived need for academic excellence that sets these children up for a sense of failure and suicide,” argues Duncan. “It’s not as simple as a pill causing suicide.”

“Fundamentally, the point is that there’s always a risk taking a medication,” she concludes. “Ultimately, it doesn’t make sense that children without ADHD are taking these medications, because they won’t really achieve what they’re hoping to.”