The App for Adderall

“All day every day, people were demanding Adderall.” These words from the Wall Street Journal sounded familiar, like something I once heard in a conversation with a college student I’ll call “Steve.”

Diagnosed with ADHD and prescribed Adderall, Steve had used very similar terms to describe the pressure he sometimes feels during exam periods. Fellow students, without a prescription, hound him for his extra pills. Adderall and other stimulants are popular as both study and recreational drugs on college campuses and much of the circulating supply originates with students like Steve.

But the Journal quote is not from Steve or about students. It’s from a nurse practitioner (NP) who treated adult telemedicine patients for Cerebral, an online mental health company. During the pandemic, the FDA allowed digital start-ups like Cerebral to prescribe Adderall and other potentially addictive (“schedule 2”) stimulants to patients without an in-person medical visit. The companies hired consultants with prescribing privileges, primarily NPs, and launched aggressive marketing campaigns offering “super speedy online diagnoses” to potential ADHD patients. Business soared as people, especially in their 20s and 30s, clamored for the drugs.

But then, almost as quickly, trouble arose. Problems for Cerebral and another telehealth company, Done, began in January 2022 with a media uproar over their TikTok and Instagram ads. One controversial ad linking ADHD to overeating featured objectionable images of a woman surrounded by junk food. “Those who live by impulse,” declared the ad, “eat by impulse.” Other criticized ads described ADHD in terms of symptoms like “spacey, forgetful, or chatty,” “feeling empty,” “overthinking,” and “feeling motivational deficiency.” The watchdog group Media Matters labeled the ads “predatory.” Some were taken down by social media platforms.

Next, former employees of the companies, like the NP quoted above, came forward, claiming that they felt pressured to diagnose ADHD and write prescriptions for Adderall during patient video interviews that were capped at 30 minutes. National pharmacies began refusing to fill Cerebral prescriptions. The Department of Justice launched an investigation of Cerebral for possible violations of the Controlled Substances Act. Meanwhile, the other company, Done, which seems to have escaped relatively unscathed, is currently poaching the Cerebral ADHD customers with a no-cost transfer offer.

The Cerebral troubles have shined a light on the enthusiastic embrace of ADHD and ADHD drugs by adults. Recall that ADHD is considered a childhood order, even if the problem lasts into adulthood. Long controversial, public concern has periodically spiked over the continuously rising rates of stimulant use among youth, typically boys, ranging from preschoolers to adolescents. In a new twist, adult zoomers and Millennials, especially white women, have joined the stampede.

Adult stimulant use has skyrocketed, rising 700% among women aged 25-29 between 2003 and 2015, for instance, and continuing to rise steadily since then. Women ages 19 to 25 have a higher rate of ADHD medication use than girls from 4 to 18. Overall, according to the Journal article, Adderall prescriptions jumped 10% just in 2021. There is every reason to believe the upward trend in first use by adults will continue. The younger generations have also become aggressive proselytizers.

When Cerebral and Done arrived during the pandemic, ADHD was already a massive online phenomenon. The explosion of user-generated content on social media includes videos, newsletters, blogs, and memes designed to share personal experiences, describe signs and symptoms, and find support. On TikTok alone, according to a May 2021 New York Times article, the hashtag ADHD had had 2.7 billion views. A recent study reported that the 100 most popular ADHD videos on TikTok in July 2021 (90% created by laypeople, 10% by people identifying themselves as health professionals) had been viewed a combined 283 million times. The highest engagement was with personal experience videos, averaging nearly 3.9 million views each.

User-generated content is a powerful stimulus to viewer identification with ADHD and so-called “self-diagnosis” is widespread. Enter Cerebral and Done, hot to exploit the “all day every day” consumer demand and stoke it with ads on the same basic theme: personal empowerment through ADHD diagnosis and drugs. Just the message honed earlier in pharmaceutical advertising directed to parents.

Capitalizing on the sheer demand for Adderall appears to have been Cerebral’s undoing. Enticed by the promise of a speedy diagnosis, the “patients” themselves had frequently already decided they had ADHD and needed medication. The only question was whether the gatekeeper, the nurse practitioner, would go along and give them what they wanted.

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According to a Bloomberg story: “At Cerebral, choosing not to prescribe can leave clients irate, triggering bad reviews. When patients ask, the company will often pair them with a new prescriber, nurses and coordinators say.” And should the NP still have the temerity to “deny a patient,” the company was ready to review and reevaluate the decision. Acceding too much to patient demand seems to have been where they crossed the line.

We really shouldn’t wonder at all this. ADHD has always been an ambiguous diagnosis, tied up with impediments to success. Whatever definitional core it might have once had has disappeared and symptoms can include just about any behavior that suggests a lack of individual motivation, self-control, or self-interest. Challenges in these areas don’t end in childhood. If anything, they may intensify in adulthood, as already suggested by the widespread first use of stimulants among college students. Young people I have interviewed, often quite successful through high school, spoke of hitting a wall in their studies or budding careers after college. They spoke of seeking out a diagnosis and finding regular doctors or psychiatrists who acceded to their request, even when the doctor thought they didn’t really meet the diagnostic criteria. Some who were thwarted by one doctor simply shifted to another.

And, as has long been the case, the proof that patients “really do suffer from ADHD,” to quote a Cerebral NP interviewed for the Wall Street Journal article, is in their satisfaction with the drugs. “They tell me,” the NP is happy and seemingly relieved to report, “it’s been life-changing.” Those words too are familiar.

If there is a surprise in this latest scandal, it is that anyone still thinks the ongoing ADHD saga is about health or can be meaningfully evaluated in medical terms.