Whenever I write about attention deficit hyperactivity disorder — whether I’m writing generally about the struggles facing these children and their families or dealing more specifically with medications — I know that some readers will write in to say that A.D.H.D. is not a real disorder. They say that the rising numbers of children taking stimulant medication to treat attentional problems are all victims, sometimes of modern society and its unfair expectations, sometimes of doctors, and most often of the rapacious pharmaceutical industry.
I do believe that A.D.H.D. is a valid diagnosis, though a diagnosis that has to be made with care, and I believe that some children struggle with it mightily. Although medication should be neither the first nor the only treatment used, some children find that the stimulants significantly change their educational experiences, and their lives, for the better.
Dr. Mark Bertin, a developmental pediatrician in Pleasantville, N.Y., who is the author of “Mindful Parenting for A.D.H.D.,” said, “On a practical level, we know that correctly diagnosed A.D.H.D. is real, and we know that when they’re used properly, medications can be both safe and effective.” The choice to use medications can be a difficult one for families, he said, and is made even more difficult by “the public perception that they’re not safe, or that they fundamentally change kids.”
He worries, he says, that marketing is really effective, and wants to keep it “at arm’s length,” far away from his own clinical decisions, not allowing drug reps in the office, not accepting gifts — but acknowledging, all the same, that it’s probably not possible to avoid the effects of marketing entirely.
Still, he said, when it comes to stimulants, “the idea that we’re only using them because of the pharmaceutical industry is totally off base,” and can make it much harder to talk with parents about the potential benefits — and the potential problems — of treating a particular child with a particular medication. “When it comes to A.D.H.D. in particular, it’s a hard enough thing for families to be dealing with without all the fear and judgment added on.”
Since many patients will be taking them on a daily basis for years, if not decades, stimulants are a significant category in the pediatric market. According to 2016 data from the Centers for Disease Control and Prevention, 6.1 million children had been given diagnoses of A.D.H.D. and 62 percent were taking medication.
Doctors have in the past tended to think of ourselves as immune to marketing, secure in our training and our science. And repeated studies have shown that not to be true; providing free meals, for example has been shown to influence the likelihood that doctors will prescribe some brand-name drugs over generics (this study did not specifically reference stimulants). That’s why companies spend money on the swag and the samples and the dinners.
Dr. Scott Hadland, a pediatrician and addiction specialist at Boston Medical Center’s Grayken Center for Addiction, recently published a study of stimulant marketing, finding that “pediatricians are the targets of an immense amount of marketing,” most of which was described as “high-frequency, low-dollar value marketing in the form of food or beverage.”
He worries that the marketing could be contributing to a larger public health problem in which more stimulants are prescribed and some are misused, by high school students and especially by college students.
“We’ve seen over a doubling in the use of stimulant-type medications over the past decade,” said Brian Piper, an assistant professor of neuroscience at Geisinger Commonwealth School of Medicine, who was first author on a 2018 study of trends in the use of stimulants in the United States. “How much of this is an expansion of the criteria for A.D.H.D., how much is driven by more girls being diagnosed, by adult A.D.H.D.?”
His research also points to marked regional variations in the use of stimulants, with much less being prescribed in the western United States than in the east. Prescribing patterns may be affected by local custom, by cultural practices and by many other factors. But marketing and incentives in the form of payments or gifts to providers definitely has an impact, he said. “There is a large body of evidence suggesting that there is no such thing as a free lunch.”
Dr. Piper urged patients — and parents — to check whether a prescriber has accepted compensation of $10 or more from a pharmaceutical company or medical device manufacturer, using this government database or through ProPublica, and to bring up the subject with their doctors: “If they chose to accept that ‘free lunch,’ they should be prepared to have a discussion with their patients about why,” he said.
Doctors who actually do the prescribing must balance not only the potential influence of marketing but also the special anxieties and stigmas surrounding stimulants and the challenges of insurance company regulations.
Dr. Doris Greenberg, a developmental pediatrician in Savannah, Ga., who is associate clinical professor of pediatrics at Mercer University School of Medicine, said that although drug development had led to a much broader array of choices, doctors were severely constrained in their ability to choose the best medication by the restrictions imposed by insurance companies. “They can come out with a thousand new innovative medicines and we still can’t use them,” she said. “We now face a monumental number of rejections from insurance companies.”
Dr. Greenberg said that the insurance companies set arbitrary rules about who can take what, and that she spends much of her time on submissions and resubmissions for insurance authorization, not to mention phone calls with “peer reviewers” who are not in her specialty but must approve her decisions. (Recently, to get approval to prescribe a stimulant to a patient, she said, “I had to talk to an orthopedic surgeon.”)
And then there are the effects of direct marketing: “I have to spend 10 or 15 minutes explaining to a family why I’m not going to use the medicine they saw on TV,” Dr. Greenberg said. “We’re just having a mess of a time trying to treat a very treatable disorder.”
Dr. Greenberg also cited the problems with generic versions of some stimulants. Because stimulants are meant to help a child function over some particular part of the day, much of the drug development has gone into extended release formulations, which can be different from one preparation to another. In particular, there have been problems with generic versions of Concerta, which may not release their drugs over time in the same way as the original. “We’ve had to warn our patients, warn the pharmacies,” Dr. Greenberg said.
It all comes back to careful diagnosis, careful consideration of when medications are indicated, and careful consideration of the right medication for the right patient — despite all the other factors.
“As a pediatrician, I think it is important for patients who benefit from stimulants to be on stimulants,” Dr. Hadland said, and “as a pediatrician, I want to make sure we are only prescribing stimulants in cases where they are indicated.”
And because of the potential for misuse of these medications, he said, it’s especially important “to be mindful to follow our patients closely when we do prescribe stimulants for A.D.H.D.”
