01/28/2016 11:46 am ET Updated Jan 28, 2017

The United States of Adderall (Part III)

(Read The United States of Adderall Part I and Part II)

Amber was a good kid and a rule-follower who did most of her homework most of the time, up until the beginning of high school, when she started to spend more hours thinking about boys than doing schoolwork. She coasted for a while, passing classes and avoiding trouble, but not necessarily excelling. By junior year, she was starting to dream of becoming a doctor, and that motivated her to study a little harder. By the time she was applying for colleges, her grades were steadily improving and she was excited to leave home to get started on her future. At parties during her first semester on campus, she'd usually drink a few beers, maybe slam a tequila shot or two. She had even smoked pot a few times, but didn't like it much. It made her feel weird and out of control. The possibility of addiction never occurred to her when she first tried Adderall. So many of her friends were already taking it. She figured it couldn't hurt to try just one.

Adderall is an amphetamine, a type of stimulant that was first synthesized in the United States in 1929 and released initially as Benzedrine, a drug used to treat depression and low energy. Over the years, drug companies developed new forms of amphetamine, including diet pills like fenfluramine (known as fen-phen) and phentermine, as well as drugs for ADHD like Dexedrine, Focalin, Vyanise and Adderall. Ritalin and Concerta are technically methylphenidate, a derivative of amphetamine that is very similar in chemical structure and physical effects.
Methamphetamine is also approved for use in treating ADHD but the drug, known pharmaceutically as Desoxyn and colloquially as "meth" or "crank," is rarely prescribed, both because of its high price and its dangerous reputation. Instead, methamphetamine is more commonly used as a street drug, alongside other forms of illicit amphetamines, such as ecstasy and purified MDMA, or Mollies.

To the human body, it's irrelevant whether an amphetamine or related drug comes from a pharmacy or off the street. Meth, Adderall, Ritalin, ecstasy: they all work essentially the same way. Inside the brain, within the spaces between nerve synapses, they increase levels of dopamine and adrenaline by preventing these neurotransmitters from getting broken down or re-absorbed by cells. That, in turn, boosts all the feel-good sensations of speed along with a rise in energy levels, heart rate, blood pressure, and wakefulness, with a simultaneous uptick in executive function - the brain's mechanism for controlling learning, self-control, decision-making and more. Over time, as use continues, dopamine levels become depleted, causing fatigue, dissatisfaction with life and a craving for more the drug. No one knows exactly how addiction develops, but in lab studies, rats repeatedly choose amphetamine over food, eventually starving themselves to death.

As early as the 1930s it was clear that humans, too, could become tolerant to amphetamine, causing them to crave progressively more of it to maintain the level of productivity they had grown used to. The risk of addiction was clear enough by 1972 that the U.S. Food and Drug Administration classified amphetamines and methylphenidate as Schedule II medications, the strictest form of control allowed for legal substances. Doctors must write physical prescriptions or with electronic prescribing, supply a six digit code which changes every two minutes The rx cannot be called in to pharmacies or set up with automatic refills - measures that once made a difference in the availability of the drugs for all.

Responsible use of ADHD medications among children can co-exist with rampant abuse among adults. To understand why, it is important to consider an important but often overlooked feature of the drugs: their effects vary greatly with the dose. In small amounts, amphetamine makes anyone who takes it more methodical and deliberate, and better at sticking with activities that might otherwise seem boring or difficult. That's true regardless of age or ADHD status. In the eyes of teachers and parents, this steadiness makes it seem like the drugs have a calming effect on children who are out of control.

If kids took higher doses, they too would become more active, more talkative and hyper. They would appear "tweaked," like overdosed adults. But addiction is unheard of in kids because they complain when they get too much. They feel nervous or strange. Even if they did like how it felt, their parents and teachers dole out the meds, making it impossible for most fifth-graders to see how it might feel to take just a little more. Those safety checks make Adderall safer in children than it is in adults, who often say they feel powerful and grand after taking Adderall and quickly start to want more.

Sixteen years ago, Running on Ritalin focused on concerns about the overuse of prescription stimulants in children. Since then, the teenage years and young adulthood have become a far greater danger zone. That's when users (whether they get the drugs legally or not) start to control their own dosing. There is no one to stop them from taking an extra pill or two. And although Ritalin was once the "it" drug for ADHD, today it's Adderall that has become synonymous with abuse. That's partly because Adderall may give users a slightly more intense high and perhaps even more so because Adderall's manufacturer, Shire Pharmaceuticals, has marketed the drug with particular vigor.

Because of its link to a disorder that affects academic and work performance, Adderall abusers tend to hail from white, middle-class neighborhoods and wealthy families like Amber's. (That sets the drug apart from its close cousin meth, which usually comes through illegal channels, often through Mexico, and tends to attract users who are poor and live in rural areas or the inner city). And while our nation's discussion of prescription drug abuse has focused mostly on opiate painkillers like Vicodin and Oxycontin, addiction to prescription stimulants has steadily grown just below the radar. In many ways, these drugs present similar challenges: How do we balance the legitimate need for a drug (whether it's designed to treat pain or procrastination) with a growing epidemic of misuse, addiction, even overdose and death? Adderall abuse represents something more, too. Unlike drugs that offer a simple escape from discomfort or reality, stimulants often attract people who want to be better versions of themselves, to perform at a higher level, to succeed no matter what it takes. People a lot like Amber.

When she first started taking Adderall, Amber was delighted to find that she had plenty of energy to study all night. She could write a 15-page paper without taking a break or needing to sleep. And then, if she swallowed or snorted another pill, she could stay awake through class the next morning, too. At first, her grades went up. She felt like she could do it all - schoolwork, parties, sorority duties, a part-time job. There were other perks, too. When she took the drug, she didn't feel the need to stop what she was doing to eat. She lost 20 pounds and dropped to a size 2. Guys were asking her out. She liked the alertness, the hyper-focus, the confidence. The highs kept her coming back for more, even though the lows became progressively more miserable. Whenever her supply ran out or she tried to get off the drug, she'd crash hard, sleep for days, binge on ice cream, cry for hours and explode with anger. Her brain felt so foggy that thoughts would dissolve before she had a chance to finish them. The only clear way out of her despair was to take more Adderall, and she always would.

"This never-ending cycle of Heaven and Hell starts to become your life," Amber says. "You take some Adderall, go through withdrawal, build up tolerance, take some more, go through an even worse withdrawal, and so it continues. And possibly the worst part of it all is, the only time you're not worried about your addiction is when you're taking it. That means that the only time you even consider getting help, the hopelessness and depression from withdrawal stops you from doing so. Honestly, I think it is almost impossible not to get addicted to Adderall. It's the perfect drug: motivation, weight loss, better grades, increased dopamine, and it's much easier to get than other drugs."

(The last installment, Part IV, of the United States of Adderall, to follow)