Smacked

by Eilene Zimmerman

  In 1980, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, introduced the category of ADD—attention deficit disorder, either with or without hyperactivity. In 1987 it was replaced by attention deficit/hyperactivity disorder, or ADHD, today the most common childhood behavioral health problem leading to medical and behavioral interventions. According to the CDC, about 11 percent of American children age 4–17 have received a diagnosis.

  The disorder is treated with stimulants, the most well-known among them being Adderall, which came on the market in 1996. There were 91 million prescriptions for ADHD drugs worldwide in 2017, according to an industry report from market research firm IBISWorld, and adults recently overtook children in terms of their share of that market. It’s estimated that as much as 35 percent of college students use ADHD medication without a prescription, and there is usually a supply of it “on any given dorm floor at any time,” write Stephen P. Hinshaw and Richard M. Scheffler in their book The ADHD Explosion.

  Few people in the world know more about ADHD than Hinshaw, a clinical psychologist and psychology professor at the University of California, Berkeley, and a psychiatry professor and vice-chair for child and adolescent psychology at the University of California, San Francisco. I asked him if he thinks we are seeing the emergence of a generation dependent on stimulants. “That’s the sixty-four-zillion-dollar question, isn’t it?” he says. “Part of the increased use of these medications is the legitimate recognition of a disorder. However, the skyrocketing rates of increase go beyond recognition of a condition—unless there is an epidemic, and ADHD isn’t contagious.”

  Hinshaw says the vast majority of pediatricians diagnose the disorder “in twelve minutes.” ADHD is diagnosed based on a set of symptoms; there is no blood test or brain scan to confirm its existence. “If you want a formula for creating unacceptably high rates of diagnoses, incentivize academic performance in kids above all else and make sure that standards for assessing and diagnosing ADHD are lax,” says Hinshaw.

  Young children may be misdiagnosed, but they rarely fake ADHD symptoms; adults, however, often do—about one in four, according to several studies, including a well-cited one published in 2010 in the journal The Clinical Neuropsychologist. Many of the adults in the study that faked symptoms wanted medication because they were having a tough time dealing with their workloads and their lives. “A lot of people think they have it because they are struggling, but it’s not because of ADHD,” said the study’s lead author, clinical neuropsychologist Paul Marshall, in an interview. “Oftentimes, it’s simply depression, anxiety, or lack of sleep.”

  Hinshaw and his research team have been following and interviewing hundreds of people with and without ADHD about their drug use and mental health over the past two decades. (Hinshaw says other research teams have followed even larger groups.) For those without ADHD, he says, “We hear over and over again, ‘I feel like I’m a better person when I’m on these drugs.’ ”

  * * *

  —

  IT’S A TUESDAY NIGHT in March 2018, and I am at the Williamsburg Hotel in Brooklyn, speaking to a private gathering of the NYC Salon, a speaker series started a few years ago by two Millennials, Tarun Chitra, who left graduate school (he was studying theoretical physics at Cornell) to work on creating artificial intelligence software used by finance companies, and Ruth Nachmany, a software engineer at Warby Parker, an online retailer of prescription glasses. They started inviting people with novel insights or interesting projects in art, economics, science, technology, and comedy to give talks about their work and process. The group got so large (more than 3,000 members, according to NYC Salon’s Facebook page) it had to be closed to new members. Meetings occur every other Tuesday night at different locations.

  About thirty-five young men and women are here to listen to me speak about my research for this book and to talk to me about drug use, both their own and in their social circles. I have agreed not to use people’s names or identify the companies for which they work. One man in his late twenties who has his own tech company tells me he popped an Adderall right before this event. “It’s been a long day and I needed something to help stay focused,” he explains. A woman sitting next to him turns to me and elaborates. “It’s not like it’s an escape. It’s coping,” she says. “You’d be surprised how many people are still riding off the Adderall high they have been riding all day long, and you’ve just never seen them in their natural state.”

  I make my way over to the next group. A man in a gray sweater introduces himself. “I’m twenty-nine and I worked in finance out of college and now I’m in med school. I worked for many years in investment banking, researching pharma companies. I’ve used drugs my entire life. Weed and MDMA [also known as ecstasy or Molly, a stimulant and hallucinogen] in college. When I started working I did stimulants on and off prescription. I bought some today, actually. It’s all about the risk-benefit ratio, and the benefits for me outweigh the risks,” he says. “The human brain didn’t evolve to be staring at numbers all the time. I think part of the reason we use drugs in cognitively demanding fields is because humans haven’t been able to evolve fast enough to meet the demands of modern society.” I think he may be onto something.

  The use of stimulants to enhance memory, concentration, and overall performance increased 180 percent, on average, from 2015 to 2017, in fifteen countries that took part in the Global Drug Survey, an online survey that has collected data from more than 100,000 people. The United States had the highest rates of stimulant use both years.

  Many of the people in this room use the drug ketamine for partying (they call it Special K). It’s actually an anesthetic (used, for example, in hospitals and on the battlefield) but at low doses produces hallucinations and mood changes, and can make users feel dissociated both from their body and reality. (Research shows ketamine may be effective in treating depression that isn’t responding to other treatments. In March 2019, the FDA approved a new drug from Johnson & Johnson based on ketamine that is administered via a nasal spray.)

  Two other drugs mentioned frequently tonight are modafinil (the stimulant that treats narcolepsy) and LSD, used in very small doses. A thirty-year-old physician tells me he regularly microdoses LSD and uses Adderall and small amounts of fentanyl too. “Look, a doctor’s job is to give medication to patients, so we are very good at dosing medication,” he says, adding that he often doses himself while working. I ask if he feels at all ethically compromised, treating patients after he has taken medication himself. “Doctors can get overconfident, of course. I have a hard line against benzos and opiates. I do enjoy them but I also know they are very addictive. I had an attending [physician] that died last month from an opiate overdose. He was using alcohol and benzos and opiates.”

  * * *

  —

  WHAT DOES ALL THIS mean for the future? I’m not sure. I wanted to learn more about what was driving drug use and abuse among some of the most privileged people in America. What I have found is that the reasons people use are complicated and individual, and there is rarely just one reason. Peter’s personal history and the culture and time in which he lived, the profession he chose, his genetics and personality, all of it in all of its complexity informed his decision to start down a road he likely thought of as a way to chemically enhance his life. Or chemically escape it. It’s too late for me or anyone else to help him see that it would not lead to feeling better, that it would not solve his problems. I can, however, sound a warning for those who may inadvertently follow in his footsteps. Right now, some of the youngest members of society are involved in a giant chemistry experiment, the results of which have yet to be seen.

  It’s unclear how the brain’s prefrontal cortex—which is involved in planning, attention, problem-solving, error-monitoring, and decision-making—will be affected by exposure to the doses of amphetamines used by many college and high school students.

  In a
2017 article on psychostimulants, researchers at Children’s Hospital of Philadelphia and Drexel University College of Medicine wrote that the drive for cognitive enhancement is unlikely to decrease, and they expressed concern that the lack of knowledge about what happens to children and adolescents using psychostimulants like Adderall “may be perpetuating a perception of these drugs as ‘safe’ for any age when that might not be true.”

  And what about the use of marijuana? A recent Gallup poll found that one in four young adults under thirty now uses it on a regular or occasional basis. There are very few studies of cannabis use during adolescence, a time when the brain may be particularly vulnerable to the effects of THC (tetrahydrocannabinol, the ingredient in marijuana that makes a user feel high). A study published in The Journal of Neuroscience in January 2019 found that the brains of adolescents who smoked one or two joints before they were fourteen had more gray matter than teens who didn’t use marijuana. The increase was seen mostly in the amygdala, an area of the brain that processes emotions, and the hippocampus, which affects memory development and spatial abilities.

  What this might mean isn’t clear yet, but one of the study’s lead authors, University of Vermont psychiatry professor Hugh Garavan, said that at around age fourteen the adolescent brain is typically undergoing a pruning process, where it (that gray matter) gets thinner—not thicker—as it refines its synaptic connections. The teens using marijuana, he said, may be disrupting that process.

  Judith Grisel, a psychology professor at Bucknell University and author of Never Enough: The Neuroscience and Experience of Addiction, says marijuana “can change the course of brain development and have long-lasting effects on brain pathways having to do with mood and cognition and susceptibility to addiction.” Cannabis use also appears to increase—rather than decrease, as is commonly assumed—the risk of misusing and overusing prescription opioids.

  Sam Ball, the addiction psychologist, is deeply concerned about adolescents using marijuana. “If you take the developing adolescent brain and what may be a fully accessible drug, the rates of kids starting to smoke pot at twelve or thirteen will absolutely go up,” he says. “And you’re not going to have overdose deaths like you do now—maybe some drug-driving fatalities, but you aren’t going to have 70,000 people die of an overdose of marijuana in a year. You will, however, see the more insidious effects over the course of this adolescent’s development. It will impair their schoolwork, family relationships, work functioning. And some people will become psychotic. I think it is going to grow as a problem much more quietly than opioids, but it will be far-reaching,” he says.

  Beverly Roesch, the addiction therapist at Cirque Lodge, told me the treatment center sees many clients who used a lot of marijuana and kicked off a psychotic disorder (like schizophrenia). “If you’re predisposed to a psychotic illness, marijuana fast-tracks you to it,” she says. “It may have medicinal value, but it is also a powerful psychoactive agent.” And it’s more powerful than it has ever been. An analysis of marijuana samples seized during drug busts from 1995 to 2014 showed THC concentrations increased from about 4 percent in 1995 to 12 percent in 2014. Three years later, in 2017, High Times magazine ranked the twelve strongest cannabis strains in the world. The top four had a THC content of more than 30 percent—that’s more than seven times as strong as marijuana was in 1995. Long-term use is also associated with health and psychiatric problems later in life, cognitive difficulties, and lifetime alcohol problems.

  If these drugs aren’t safe but are used for decades, I wonder what these kids will be like when they are thirty or forty or fifty. Will their maturity be delayed because of how the drugs affected their prefrontal cortex? Will it impact their decision-making ability, reasoning, memory? If people under thirty become dependent on amphetamines and other stimulants, cannabis and tiny doses of acid to cope with the productivity and creative problem-solving requirements of their professions, what drugs will they require to cope with the rest of their lives?

  After all the research I’ve done about addiction, all the studies and books I’ve read, all the experts I’ve interviewed, this question remains. Are we coping with the difficult parts of life by distracting ourselves with addictions—to our phones, streaming video, work, food, porn, news, shopping, drugs? Many of the people I spoke with about their current or past drug use said they felt disconnected and lonely. In 2000, Facebook didn’t even exist; today it is the largest and perhaps loneliest “community” in the world.

  Harvard professor and political scientist Robert Putnam, in his 2000 book Bowling Alone, chronicled that growing feeling of isolation in writing about the decline of American communities. According to the 2018 American Time Use Survey, people in the United States spend about thirty-eight minutes a day socializing and communicating—face-to-face—with others.

  The world around us may be changing dramatically, but I believe our needs as human beings aren’t. A series of studies done back in 1993 found that when a person’s central aspirations are “self-acceptance, affiliation and community feeling” they feel less distress in life and more well-being. It’s as if the digital age has made us think of human connection and support as more an option than a necessity. Yet isn’t it critically important to feel truly—not virtually—connected to something bigger than ourselves, even if that something is just our neighbors? “It’s in relationships that we find recovery,” Dan Lukasik, the founder of Lawyers With Depression, told me. “We can be damaged by relationships, but we are also resurrected by them.”

  Sam Quinones, the author of Dreamland: The True Tale of America’s Opiate Epidemic, perhaps the definitive book on the evolution of the opioid crisis, testified before Congress in January 2018, answering questions and giving his thoughts on how the crisis might be addressed. At the end of his testimony, Quinones said, “This scourge is about issues far deeper than drug addiction. It’s about isolation, [the] hollowing out of small-town America and the middle class, of the silo-ization of our society, and it’s about a culture that acts as if buying stuff is the path to happiness. This epidemic shows us no matter how high the stock market rises, how rich some Americans have grown, that neither we, nor they, can isolate ourselves from the world. Problems will find them, and us. I believe therefore that the antidote to heroin is not naloxone. It is community. Community is the response to a scourge rooted in our own isolation.”

  But building a social support system—a brick-and-mortar one, not a virtual one—takes time. It takes more time and effort to call someone and have a conversation with them, or make plans to see them and execute those plans, than it does to send a text. And likewise, it’s easier to take a pill or buy something new to make sadness or anxiety disappear or, at least, distract us from it, rather than just sitting still and actually processing what is going on in our lives. That is difficult. I know. Like so many others I struggle each day to resist the temptations that invite me, at every turn, to distract myself. For better or worse, I am part of a consumption-fueled society that keeps seeking what it thinks will finally make it feel okay: more.

  Psychiatrist Judson Brewer told me, “People like Peter think, ‘just this much more and then I’ll be happy.’ But it will never be enough. The problem is that we are not comfortable with ourselves, with being ourselves. And we can’t bear to spend ten minutes with that discomfort,” he says. “That’s why we’re always looking for something else.”

  PART IV

  ■ FIFTEEN

  April 2018

  EVAN AND I ARE in Ann Arbor, Michigan, to attend Anna’s college graduation tomorrow. It is nearly six P.M. and all the restaurants in town are overflowing with visiting families. We decide to make dinner at Anna’s apartment: risotto with chicken, asparagus, and peas. I pour chicken broth into a large pot and start heating it while Evan chops up shallots and garlic, adding them to a pan of rice, olive oil, and white wine. Next to him I sauté small pieces of chicken. Anna connects her phone
to speakers in the living room and starts flipping through playlists on Spotify to find a song she wants us to hear.

  Her roommate is in and out, packing up and getting ready to move on, both physically and metaphorically. I look around the apartment as I cook, at the IKEA throw pillows, the string of lights carefully positioned over an Indian-print wall hanging, the collection of burned and beat-up pots and pans in the kitchen, the mismatched mugs and glasses—many sporting the school’s signature slogans, Go Blue and Hail. She will miss this, I think. The late nights hanging out with her roommate, talking boys and friends and politics and the future. Pregames, sorority date parties, hungover breakfasts, the red Solo cups scattered on frat house lawns, your best friends just around the corner, all of it.

  After dinner, Evan and I head to the Ann Arbor Regent Hotel. I’m not sure how I originally found this place, but it is where Peter, Evan, and I stayed during move-in weekend four years ago. We were on the first floor then; this weekend we’re on the second, at the opposite end of the hotel. Late on Friday night I leave the room to get a cup of tea from the little dining area downstairs. The hotel is quiet, which makes sense, as graduation is early tomorrow morning. It looks exactly the same as it did the first time we stayed here. I lift the lid of my paper cup to blow on the tea, trying to cool it, then walk down the hallway looking for the rooms we had four years ago. I stand in front of the one I think I shared with Evan. Several feet farther down is the one where Peter stayed. I don’t know what I’m hoping for, other than to remember how it felt to be here then, the four of us together for the weekend.