Is this the next drug problem?
We all know about the opioid epidemic. Hopefully, we’re starting to make some progress in combating it. Did you know that we are also in the midst of a stimulant epidemic? How is this the case? Why is this so concerning? What should we be doing about it?
While the opioid epidemic is front and center on the news, it’s not the only drug epidemic sweeping across America. The abuse of stimulants, like methamphetamine, cocaine, Adderall and Ritalin, is rapidly increasing. Information from government surveys on drugs show that stimulant use is rising and is actually surpassing opioid use. During 2016, it’s estimated 2.3 million people started using opioids for the first time. Also, during that year, 2.6 million people started using stimulant drugs for the first time. A survey of people in 2016 showed that an estimated 3.8 million people said they used opioids to get high within the last month and 4.3 million said the same about stimulants. The problem isn’t just the abuse of stimulants, but the number of people dying is also mounting. In 2017, the Center for Disease Control (CDC) said that overdose deaths from stimulants rose 30% from the previous year, which means it’s passing the volume of opioid abuse and deaths at an alarming rate. Despite all of this information, no one is paying attention to the epidemic.
In order to understand why this is a huge problem, we need to look at what stimulants do to our bodies. They act in the brain on a group of monoamine neurotransmitter systems, such as norepinephrine and dopamine. The stimulants enhance the effects of these chemicals. This results in increase alertness, attention and energy, but also elevates blood pressure, heart rate and respirations. In the past, they were used to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other conditions. Nowadays, they are used to treat something entirely different. Our attention spans are steadily getting shorter, which is becoming more and more problematic for many people. While we’ve adapted the things we enjoy doing, such as what sports we watch and activities we do, to fit our shortened attention span, we have not changed the pace of school or most workplaces. This is where people are struggling. Stimulant medications are prescribed to treat individuals with ADHD, who have shorter attention spans, which increases their ability to focus and function. When taken appropriately, these medications can greatly improve an individual’s quality of life. Some of these medications main ingredient is amphetamine, such as Adderall, Dextroamphetamine and Mydasis. Others are based off of methylphenidate, like Concerta, Daytrana, Metadate, Methylin and Ritalin. All of them can increase wakefulness, motivation, and aspects of cognition, learning, and memory. Some people take them when they don’t have a medical need, but to get high, to boost energy and alertness or to keep their weight down. Using stimulants for nonmedical purposes poses significant health risks, including addiction, feelings of hostility or paranoia, psychosis, a dangerous rise in body temperature, irregular heartbeats, heart failure, seizures and even death. As the potential for misuse and addiction became clear, the number of conditions treated with stimulants has decreased. Stimulant abuse is actually worse for your body than opioid abuse because it affects your cardiovascular system by causing high blood pressure and damage to organs so significant that you develop long-term problems with your heart, lungs, and brain. Also, it’s more challenging to treat than opioid addiction because there is no rescue drug for people who overdose and there currently aren’t medications to help curb the abuse of stimulants. Both of these are available if you’re addicted to opioids. If someone is addicted, when they stop using, they are likely to have withdrawal symptoms including fatigue, depression, and disturbed sleep patterns.
Without a doubt, stimulants and opioids are both strongly psychologically and physically addictive. They stimulate the pleasure center of your brain, which leads to them being abused because you want to have that same high. The problem is that they only work in the short-term, but have long-term hazardous mental and physical effects. It’s important to note that these effects can occur at prescription strength doses. People who abuse stimulants desire a different kind of high from those who abuse opioids. Opioids create a sense of calm and euphoria, whereas, stimulants produce bursts of energy and focus. Occasionally, there is overlap between the two groups because people addicted to opioids have a hard time staying awake since these drugs depress their central nervous system. In order to function every day, they use stimulants.
Our country’s “War on Drugs” has been the longest war we’ve been continuously involved in. The sad thing is that it’s unwinnable. The opioid epidemic is a direct result of doctors overprescribing opioids to their patients. This started in the early 2000s and has led to a staggering increase in the number of people abusing the drugs. There has been a considerable reduction in the prescribing and manufacturing of opioids causing patients to start using heroin and fentanyl that they buy on the street. This goes back to the old concept of supply versus demand. When a market exists for willing buyers and sellers, prohibiting the legal consumption of the product sends that market underground. Policymakers continue to focus on restricting prescriptions of opioids. This isn’t fixing the problem because people who are abusing them are no longer getting them from their doctor since it has become too difficult. In the meantime, this restriction of prescriptions is making patients who actually need the medication suffer. During the same time period of the rise of the opioid epidemic, the abuse of stimulants prescribed for ADHD has increased, but receives little attention. You might see the occasional story about college students using stimulants to study for their exams, but no one is covering the fact that the number of emergency room visits due to stimulant overdoses has increased by almost 400% in the past several years. This increase mirrors the rise in recreational use of stimulants by adults between 2006 and 2014. Recently, as the crackdown on prescribing stimulants to patients who don’t medically need them has begun, more and more people are turning to purchasing their stimulants from the streets. The production of street amphetamines is being done in Mexico where it’s made with a potent chemical normally found in products used to clean swimming pools called phenyl-2-propanone (P2P). Not only does this makes the meth purer, it also makes it cheaper to produce in larger quantities. This purer meth can bring on psychotic reactions. So, not only are more people are using it and they are using more of it. The street names for amphetamines include bennies, black beauties and speed. For methylphenidates it’s called MPH, R-ball, Skippy, the smart drug or vitamin R. Governmental figures show in approximation that for every kilogram of heroin seized in the past several years, 15 kilograms of stimulants have been seized. When you put all of this together, it’s easy to see why stimulant abuse and overdose should not be viewed as its own problem, but should be combined with the opioid issue under the context of substance abuse being present due to drug prohibition. Until we address true source of the problem, it will only continue to grow.
In addition to the illegal suppliers, legal supplies of stimulants have never been greater. While there have been some recent improvements, prescriptions for stimulant medications is up in all age groups. In the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) that was published in 2013 and is used by psychologists as guidelines, the number of symptoms required to make a diagnosis of ADHD decreased from six to five and change the requirement of ADHD symptoms needing to be present before the age of seven to 12. It’s estimated that ADHD affects 3 to 5% of children and adolescents with at least half of those going on to develop adult ADHD. The ambiguity of the symptom criteria means that adult ADHD can be easy to fake. This is why it’s thought one in four diagnoses of adult ADHD isn’t real. The study examining this concept was completed before the diagnostic criteria was changed, so it would be safe to assume that the number of faked adult ADHD cases is higher now than in the past. At one of the more recent conferences of the American Psychiatric Association, the question of adult ADHD came up and the approved response was to give high dosages of stimulants and if it needed to be more than the Food and Drug Administration’s (FDA) recommendation, then so be it. According to those recommending it, the endorsement is thanks to evidence from randomized controlled studies. The problem with this is that randomized controlled studies are usually drug studies, so they tend to be biased towards the medications. This sounds a great deal like what happened with opioids. The other issue is that no serious long-term studies in relation to the efficacy, dangerousness or how to get off medications has been done.
In the 1990s, the CDC introduced the “pain is the fifth vital sign” movement. The bottom line was that opioids were safe and effective, especially for chronic pain, and they didn’t cause addiction if used for legitimate pain. As we now know, none of this was true and are having to go back to retrain doctors. Trying to help with the shift in thought, the CDC did something recently that it rarely does, they issued a prescribing guideline. Since they don’t have any enforcement authority over these guidelines, there action is one of the most important moments in our modern public health history. These guidelines list recommendations that doctors can follow when considering the use of opioid pain relievers in adults with chronic pain. However, as we know, opioids aren’t the only drug that our country is having a problem with. When you look the guidelines in relation to stimulants, there are some notable similarities. One of these guidelines is when making the decision to prescribe any controlled substance to a patient for long-term therapy, it shouldn’t be done without careful consideration. All efforts to maximize non-addicting and non-pharmacologic, evidence-based treatments, like non-stimulant medications, Cognitive Behavioral Therapy and peer support groups, should be made first. Good communication with the patient where the risks, expected side effects, possibility of cravings and the risk of misuse or relapse to previous drug use are reviewed is essential. Prior to starting the medication, realistic goals should be established, objective measures to monitor for improvement should be set and discussion of how the medication will be discontinued if goals are met should be completed. Treatment should only move forward if, after the discussion, the expected benefits outweigh the risks. Doctors also need to look at their state’s Prescription Drug Monitoring Program (PDMP) to make sure that the patient has not received prescriptions from other providers. To make sure that the individual isn’t using illicit drugs, urine drug testing should be done prior to starting therapy and occasionally during treatment. The initial follow-up should occur within a month of starting the medication and then be every three months thereafter. In order to decrease the risk of abuse of the medications, the doctor should discuss with family members doing pill counts and potential side effects. If a patient has behaviors consistent with drug abuse, the doctor should refer the patient for substance abuse treatment program. All of this seems like common sense, so the guideline is really just a document encouraging doctors to practice good medicine.
Our country definitely has multiple drug epidemics going on. We need to not only be aware of them, but address all of them. The only way to do that is to keep working towards laws and changing mindsets of prescribers. Also, we need to expand our focus beyond the legal way to obtain these drugs by addressing the purchase and use of illegal drugs. Remember, none of these medications are not dangerous by themselves, it’s our abuse of them that that makes them so.