Why Are Prescription Stimulants So Addictive?
The prescription stimulants are very prevalent pharmaceutical agents, frequently used for the management of narcolepsy and Attention Deficit Hyperactivity Disorder (ADHD). Drugs that fall in this category include:
- Dextroamphetamine and amphetamine (Adderall).
- Lisdexamfetamine (Vyvanse).
- Methylphenidate (Ritalin, Concerta).
- Dexmethylphenidate (Focalin, Attenade).
As their name suggests, stimulants can enhance energy, alertness, and the ability to concentrate. Additional physical effects include increases of heart rate, blood pressure, and respiratory rate. They can also induce a pleasant high, especially when taken for non-medical purposes or at doses higher than those prescribed by a doctor.
As a group, the prescription stimulants are very popular drugs of abuse. Some people abuse these medications as so-called study drugs to boost academic performance by increasing their energy and concentration levels, while others abuse prescription stimulants simply as euphoria-producing recreational drugs.
The government’s figures on prescription stimulant use in the National Survey on Drug Use and Health showed that:
- 4 million Americans used them for non-medical purposes.
- 603,000 abused one of these drugs for the first time in 2013.
- 461,000 individuals received treatment for stimulant use in 2013 compared to 268,000 who were treated in 2002.
The number of prescriptions for these drugs has increased dramatically in recent years, which has contributed to the increased levels of abuse reported. According to the Drug Enforcement Administration (DEA), prescriptions for stimulants intended to manage ADHD symptoms increased 39% from 2007 to 2011 to 48.4 million per year.
Addictive Properties of Prescription Stimulants
The brain’s normal system of motivation can be hijacked by addictive drugs.
Amphetamine, methylphenidate and related prescription stimulants produce their psychoactive effects through a biochemical process, or mechanism of action, that is very similar to illicit drugs such as cocaine and methamphetamine. Specifically, stimulants cause a buildup in the brain and spinal cord of a group of neurotransmitters called monoamines, especially dopamine and norepinephrine.
Norepinephrine is important to the body’s fight-or-flight response. High levels of norepinephrine increase heart rate and breathing and trigger the liver to release stores of glucose for a quick energy boost.
Increased dopamine signaling is critical to both the therapeutic effects of stimulants as well as their addictive potential. Dopamine is a key neurotransmitter involved in controlling arousal, the physical and mental state of being alert. Boosting dopamine increases energy, wakefulness, and attention while decreasing fatigue and drowsiness.
Dopamine is also important in brain pathways that determine feelings of reward and motivation. Dopamine signaling is naturally increased by actions that promote survival such as eating good food, spending time with a friend, or having sex. The increase in dopamine activity that accompanies these actions reinforces the motivation to repeat those actions in the future.
Nearly all addictive drugs have been found to increase dopamine signaling in the brain’s reward circuitry either directly (as is the case with stimulants), or indirectly (as seen with opioids). In this way, the brain’s normal system of motivation can be hijacked by addictive drugs or behaviors (e.g., gambling, for some)—eliciting a reinforcing reward signal for activities that harm, rather than benefit, the person.
When an individual abuses a drug for an extended period of time, their body often begins to adapt and develop tolerance to the substance. When someone develops tolerance, they require greater and greater doses of a drug to achieve the desired effect. This need to increase drug use is often one of the first physical signs of drug addiction.
According to the American Academy of Child and Adolescent Psychiatry, the majority of children who take prescription stimulants for ADHD will develop tolerance—eventually requiring increased doses to maintain the therapeutic effects.
In order to minimize the development of tolerance, doctors might periodically change the medications they prescribe to a patient or direct them to take a “drug holiday” for several days or weeks. However, individuals who abuse stimulants on their own are in danger of missing or disregarding the warning sign of tolerance. As they continue to seek more and more of the drug to overcome the effects of tolerance, they are likely to soon find themselves facing another phenomenon inextricably linked with chemical dependency—drug craving.
Because the reward and motivation circuits of the brain are fooled by stimulants and other addictive drugs, long-term abuse can lead the brain to perceive the drug as not just pleasurable, but critical to a user’s well-being. This can lead to intense cravings when an addicted person stops taking the drug suddenly.
These cravings may be similar to feelings of physical need, such as what you’d feel for food or water. Even when faced with the serious negative consequences of their continued drug use – consequences such as the loss of a job, or failed interpersonal relationships – these cravings can overwhelm a user’s desire or resolve to quit. Cravings can also occur unexpectedly when a place or situation reminds an addicted person of drug use. This progression of events is one of the many hazards for people recently abstinent from drugs, potentially increasing their risk of drug relapse.
Methods of Use and Effects
Prescription stimulants are available as pills and tablets that provide controlled, therapeutic doses of the medication when taken as directed. Those abusing these drugs recreationally often take larger doses than recommended in order to increase the euphoric high they experience.
Some stimulant abusers go even further to increase their high by resorting to extremely ill-advised means of taking the drugs. Alternate methods include:
- Crushing and snorting the pills.
- Dissolving them in a drink.
- Dissolving in solution prior to injecting them.
These methods greatly increase the danger of overdose and other side effects. In an effort to reduce abuse and consequent harm, newer medications such as lisdexamfetamine (Vyvanse) have been formulated so that crushing the pills does not release higher doses of the drug.
Although there is little information on whether combining prescription stimulants with other drugs could increase their addictive potential, there does seem to be a link between stimulant abuse and smoking tobacco. A study in the American Journal of Drug and Alcohol Abuse found people who were exposed to smoking at a young age were more likely to become addicted to stimulants.
What Does It Mean to Be Addicted?
When taking a drug for an extended period of time, the body can develop a physical dependence on the drug. This means that the body doesn’t function in the same way when use is paused or ended. Abruptly quitting a stimulant drug after a long-standing period of abuse will almost certainly result in withdrawal symptoms (see below).
Addiction to prescription stimulants is also often marked by severe lifestyle changes. For example, an addict may not feel able to meet simple, everyday responsibilities such as work or family obligations without using the drug. They may also suffer from intense feelings of anxiety or dread at the thought that they might be forced to stop taking the substance.
Beside these anxieties and fears, previously positive activities, like hobbies or spending time with friends, may no longer feel worthwhile. For an addicted person, it may seem that use is essential to daily functioning or even happiness, making it very difficult to stop.
ADHD Medication Diversion
A surprising number of young people can acquire prescription medications used to treat ADHD despite not have a prescription for it. This is a far-reaching problem that enables abuse. Where do these young men and women acquire their prescription drugs? In 2016, a Recovery Brands survey found that an alarming 63% of college-age individuals between 18 and 28 years old get ahold of their stimulant medications by means of their friends.
Almost 20.5% get access to them through a family member, almost 20% via a schoolmate, and merely 14.8% from an illicit dealer. Individuals with a prescription should track their ADHD stimulant medications in order to protect susceptible college-age people from abuse.
The Withdrawal Process
Withdrawal symptoms are variable and depend on factors like how long and how often a person abused stimulants and may include:
- Drug cravings.
- Feeling “flat” or taking no pleasure in daily life (anhedonia).
- Anxiety and irritability.
- Significantly increased appetite.
- Lack of energy.
- Disturbed sleep patterns – insomnia or sleeping excessively.
Individuals who are addicted to stimulants may experience some or all of these symptoms for several weeks to several months after they stop taking these drugs. While these symptoms will often pass in time, medical support and supervision can help to prevent relapse as a response to the unpleasant withdrawal syndrome, as well as safeguard against dangerous, self-harming behavior (including suicide).
Relapse is a particular danger during periods of extended withdrawal. Even though drug cravings become less frequent after several days or weeks of abstinence, they might still be triggered by everyday situations that are linked to drug use in the recovering person’s mind. Such triggers are unique for each person but might include situations such as:
- Unexpected stress at work.
- Conflict with loved ones.
- Being around people or places associated with former drug use.
Treatment for stimulant addiction can help someone trying to quit to understand the factors contributing to their compulsive use and, furthermore, can provide methods of coping with the triggers that will inevitably emerge.
How to Get Help for Prescription Stimulant Addiction
Because of the similarities in the effects of prescription and illicit stimulants, treatments for amphetamine and methylphenidate addiction are based on those used to treat addiction to cocaine and methamphetamine. Because there are no FDA-approved medications for treating stimulant addiction, these treatments rely on various behavioral therapies.
- Contingency Management Interventions – Contingency management interventions use tangible rewards to encourage desirable behaviors such as drug abstinence, for example, by offering vouchers for drug-free urine tests. Such approaches may also involve punishments for undesirable behaviors and have been used successfully to treat stimulant addiction.
- Cognitive Behavioral Therapy (CBT) – CBT encourages people in recovery to recognize and anticipate situations that might cause cravings, think through the consequences of drug use before relapsing, and develop coping strategies to deal with difficult situations. This treatment was developed for individuals addicted to alcohol and has been adapted for use in cases of cocaine dependence.
In addition to the more standard outpatient, inpatient and residential treatment offerings, therapeutic communities and other sober living settings/environments are available to provide long-term support to people in recovery—typically 6 to 12 months, or more. In such a program, clients can learn how to live independently while benefitting from being part of a drug-free community.
Even with completion of a treatment program, continued focus on recovery is needed to minimize the risk of relapse. Many people in recovery find participation in peer and community support groups helpful for long-term abstinence including 12-step groups and secular programs like SMART recovery. These organizations are available across the country, are low-cost or even free, and can play a crucial role in maintaining a long-term, drug-free life.
- Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings.
- U.S. Drug Enforcement Administration, Office of Diversion Control. (2012). National Forensic Laboratory Information System Special Report: ADD/ADHD Stimulants in NFLIS, 2007-2011.
- Pliszka, S., & Issues, A. W. G. o. Q. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry, 46(7), 894-921. doi:10.1097/chi.0b013e318054e724
- Weinberger, A. H., & Sofuoglu, M. (2009). The impact of cigarette smoking on stimulant addiction. Am J Drug Alcohol Abuse, 35(1), 12-17. doi:10.1080/00952990802326280
- National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).