Do Stimulants Work If You Don't Have ADHD?

"Work" how, and for whose benefit?? PLUS: recommended readings on space colonizer mythology, attention beyond the self, and two autism memoirs I'm enjoying

Welcome back to the slug town round-up, today I have some great readings for paid subscribers on science mythology, transcendental attention, autism memoir, and prescription stimulant history, but first we’re going to do a little psy-ence communication analysis on a study that has captivated the news media this month.

Unfortunately, everyone seems to have gotten it extremely wrong!

Here’s the headline on CBS News:

"Our results suggest that these drugs don't actually make you 'smarter,'" — says one author of the study and professor of NEUROECONOMICS?? —“Because of the dopamine the drugs induce, we expected to see increased motivation, and they do motivate one to try harder. However, we discovered that this exertion caused more erratic thinking."

In the press release, lead author Elizabeth Bowman adds that stimulants “may actually be leading to healthy users working harder while producing a lower quality of work in a longer amount of time." Obviously the word “healthy” is very loaded pathology paradigm language, but we’re just gonna have to roll our eyes and bear with it, because that’s the basis of pretty much all research like this!

CBS put this article out on June 15th, one day after the study’s press release was published, but it was in the Guardian, Forbes, and New Scientist almost immediately. 

As someone who monitors ADHD news on a daily basis, that’s really fast for a press release to make the jump to mainstream news outlets, and I’m fairly certain it’s a combination of timing (ongoing Adderall shortage) and sensational narrative (you mean the drugs those ADHD fakers are stealing don’t even work for them?!)

It's Not "ADHD Fakers" Taking All the Adderall

These headlines fit really nicely into the conservative malingerers-stealing-all-the-drugs narrative, providing a cautionary tale to these supposed medicine thieves and a satisfying schadenfreude to everyone else, but the framing is totally misleading if you actually read the study. 

So let’s do that!

Researchers took forty people age 18-35 without ADHD diagnoses and made them do something called the Knapsack Optimization Problem, which is like a virtual test of how good you are at packing a backpack. Travelers on budget airlines and gamers will probably be familiar with this “inventory Tetris,” but basically, every item has a value and a weight assigned to it and you’re supposed to fit the most value in the bag in the shortest amount of time. 

The first thing we have to point out here is that there was no ADHD group. It was placebo-controlled, but researchers were not comparing results between ADHDers and non-ADHDers. Second of all, knapsack optimization is a very specific kind of problem, and I really don’t think you can say it applies to “productivity” in general, because what kind of productivity do you mean? 

For this study, the researchers say: “Productivity is measured as average increase in value of knapsack per item move.” (It’s neuroeconomics, remember.)

They found that the drugs didn’t affect their ability to solve the problem, but did have a negative effect on value for some, meaning they did not make their backpacks expensive enough. They also found “quality of effort reversals,” which means if someone did above-average on the test when they took the placebo, then they tended to do worse on the drugs. But, if someone was below-average on the placebo, then they did better on the drugs. 

The reason they give for this is that the drugs made the above-average group make more random choices, but they helped the below-averages do better simply because the drugs helped them spend more time — which resulted in more effort — on the task. 

Maybe these “below-average performers” were more easily bored or overwhelmed or tired, and stimulants gave them motivation and energy? And the people who were already expending a lot of effort on the task didn’t need any more energy or motivation, so stimulants actually just threw them off?

In pharmacology, there is something called “the ceiling effect” — the point at which a drug stops being beneficial and either plateaus or actually starts to make things worse. This is true for everyone — ADHDers have a ceiling for drug effects, too, and there are huge within-group differences.

The prescription process involves careful trial-and-error because baselines and sensitivities to drugs vary widely, but this media framing confirms the reductive notion that there is a clear binary between “normal” and “abnormal” brains, suggesting that stimulants “fix” a deficit in ADHDers and have some kind of physiological opposite day effect on everyone else.

And I guess I can’t blame them for that because, culturally, we are deep into Chemical Imbalance: Dopamine Edition right now, but this is the part of the study that made me scream, because it is absolutely not as straightforward or exciting as what all the news articles are saying: 

Translation: previous studies looking at drug effects on cognition in people with ADHD have had mixed results, and when they have found them, the effects are all really different, which appears to be the case in studies on people without ADHD diagnoses as well!

They cite a previous paper from 2011 which states that “it is still uncertain whether the medical use of stimulants enhances academic achievement” and calls for a way of measuring behavior in these studies that looks at strengths and weaknesses on an individual basis rather than using the categorical approach of diagnosing a person as either ADHD or not.

This is because the criteria for ADHD is pretty vague and non-specific, so it includes lots of people who are all very different from each other. You know that thing they say, if you’ve met one autistic person, you’ve met one autistic person? The same is true here — not all of us with this diagnosis find stimulants helpful with our productivity, because again, it depends what kind of productivity you mean.

Writing a novel requires very different skills to filling out a spreadsheet or teaching a class of kindergarteners. This study was specifically looking at a test of economic optimization. Can you pack the most value into the smallest space really fast? (Can you do The Capitalism??)

If I take Adderall, I can get repetitive tasks like laundry, dishes, and grocery shopping done pretty easily, but I actually find that my creative writing skills get worse. Stimulants put my brain in a tunnel, which makes reaching outside the tunnel to weave disconnected ideas together a lot harder. 

Creativity requires spiraling around, getting distracted, and coming up with weird connections — referred to as “divergent thinking” — and hindering this process is a well-known effect of amphetamines (despite their historic popularity with artists). The drugs did help me in school, though, because that tunnel vision blocked out a lot of the stuff that was overstimulating me, and they made me feel more confident in class and more able to focus on boring stuff like taking tests.

Increased motivation, energy, and confidence are effects of stimulants we’ve known about since their invention, and this study has not really given us any new revelations. Militaries passed out stimulants to their soldiers during the World Wars, and the US and UK governments studied their effects extensively, finding, for instance, that they helped pilots stay awake and feel like they were performing better, but they didn’t actually improve their flying skills. 

And I have to put an obligatory disclaimer here that none of this means ADHD isn’t “real,” or there’s no reason to take drugs, or that we should make drugs that help people manage the basic tasks of daily life and survive their workday harder to get. (Do not use my critiques for your prohibitionist agenda! I have joined the war on drugs on the side of the drugs!!)

The only reason it’s controversial to say that maybe stimulants “work” because they make us feel good is because pleasure is totally demonized in Western medicine, where treatment is supposed to be strictly rational and mechanical. Thanks to a century of anti-drug propaganda, we’re forced to justify the use of certain psychoactive drugs with reductive chemical imbalance ideas in order to legitimize their medical use. It’s a real rock and hard place situation, and I recognize that it’s complicated.

But the idea that stimulants don’t “work” if you don’t have ADHD is an old misconception that has been disproven for decades, and we need to move past it. Also, what does “work” even mean? Work how, and for whose benefit?? Maybe a bit more history will be helpful here.