Who Gets to Medicate Me?

Part 2 of the Adderall series: biocertification, self-determination, and drug use solidarity

a 1930’s ad for amphetamine, marketed under the name Benzedrine

Last week in Part 1, I wrote about a YouTube video by How to ADHD that argues we should fight the stigma against stimulant medication by reinforcing the line between Adderall and meth — a line which, chemically at least, is very thin.

Culturally and politically, this line was drawn in order to determine who deserves access to certain drugs, and who should be criminalized and targeted for using the same drugs without a doctor’s approval.

The “medicine-drug divide,” as drug historian David Herzberg calls it, is possible due to a process called biocertification, which takes many forms: the determination of federal disability benefits through a bureaucratic maze of doctor’s notes and court appeals, genetic tests that claim to prove Native American ancestry for tribal membership, and, of course, a psychiatric diagnosis that gets a person access to certain kinds of healthcare.

In their book Health Communism, Beatrice Adler-Bolton and Artie Vierkant explain that biocertification is a way for authorities to ration care based on the expertise of state-certified medical professionals. It’s “assumed to be a necessary gatekeeping mechanism or checkpoint to prevent the ‘wasting’ of resources on fakers” — a threat, they explain, was mostly invented by a statistician at the Prudential Insurance Company in the early 1900’s to argue against socialized medicine.¹

The medicine-drug divide was being constructed around the same time, and it was led by doctors who saw an opportunity to expand their authority. Herzberg writes:

“They pushed for stronger state licensing laws; increased educational standards; and more robust enforcement of ethical codes for physicians, pharmacists, and the pharmaceutical industry. An addiction crisis blamed on poorly educated physicians and pharmacists dramatized the need for such reforms, casting them as a noble social good rather than an elite’s selfish grab for power.”

The FDA we know today was built out of a 1906 law called the Pure Food and Drug Act, a consumer protection bill that was pushed through by arguing that white women were accidentally getting addicted to drugs because they didn’t know what was in their products.

According to Herzberg, the justification was that “native-born white consumers were innocent (they had no desire to experience pleasure from drugs and wanted to avoid addiction) but also ignorant (they needed expert guidance to avoid drug dangers).”

These assumptions show up in How To ADHD’s video when they interview a psychiatrist who says:

“What I see in my own clinic is young people coming to me vaping nicotine, smoking weed or vaping THC in particular, to self-medicate for their ADHD but also to self-medicate for the depression and the anxiety that is developed from their ADHD either going untreated or not being ideally treated. And I've got to tell you, trying to help them, trying to get them off of those substances, so that we can best manage their ADHD, is really hard.”

The message here is that “self-medication” is bad, regardless of whether it helps you, because only doctors are supposed to have the authority to medicate. As a former ADHD patient who’s been “self-medicating”² with various substances for most of my life, I think ADHDers and drug users actually have a lot in common.

Adler-Bolton and Vierkant point out that drug users, disabled people, and the poor were all pathologized as having a contagious disease that caused crime and the dreaded dependency, and to address these social ills, authorities turned to carceral solutions like asylums and prisons.

Research is currently being funded to suggest that ADHD causes crime — last year The Guardian described “a new report drawn up by the ADHD Foundation, a panel of experts in the disorder and the drug company Takeda” that found one in four incarcerated people in the UK qualified for an ADHD diagnosis, and that “the failure to spot prisoners with ADHD when they arrive to start their sentence contributes to difficulties managing jails”.

Authorities, experts, and corporations do not care about us — they care about managing us, and biocertification is a crucial strategy for this. Sometimes the strategy is to deny people their agency altogether by calling them crazy, a common tactic used against the psychiatrized and the criminalized alike.

In a podcast episode on harm reduction for Undark, journalist Zachary Siegel³ quotes Elinore McCance-Katz, the Trump-appointed former US Assistant Secretary for Mental Health and Substance Use, who criticized the life-saving use of fentanyl test strips by writing:

“The entire approach is based on the premise that a drug user poised to use a drug is making rational choices, is weighing pros and cons, and is thinking completely logically about his or her drug use. Based on my clinical experience, I know this could not be further from the truth.”

This prohibition logic assumes that people who use drugs can’t make their own decisions about their bodies and need authorities to save them — but that’s just not true. Members of the street economy have been implementing their own safety protocols for decades in the face of a state that would rather punish than help them.

In Saving Our Own Lives, activist and artist Tourmaline writes:

“Harm reduction happens in the pockets of exquisite care we show our loved ones, without questioning or judging their life choices, or imagining that we know better than they do. It’s extending a belief system of true autonomy and self-determination: I trust you, I’m not afraid of you, here are tools that might be useful to you, do with them what you will.”

Liberatory harm reduction is a philosophy that starts with presuming competence — a tenet of disability rights. Self-determination is a struggle shared by drug users and disabled people alike, and when we look through this lens, “self-medication” is just medication.

That doesn’t mean just passing out drugs with abandon. It means fully explaining the benefits and the risks, and allowing people to decide for themselves. It’s not like we don’t have any idea how this approach could work for drugs — we already have an informed consent model around hormones and cannabis, as my friend Devon Price pointed out this week, describing his experience with both:

“My nurse practitioner is not there to decide what is best for me, or to limit which kinds of care I can access, only to inform me of the benefits and risk of my decisions, and help guide me through the process I’ve initiated. Under informed consent, I get to hold onto nearly all of my power and dignity. I am trusted as the authority on my own experience and feelings. I am informed, and the future of my body is in my own hands.”

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There’s one thing I can’t stop thinking about: Herzberg wrote that during the deliberation over the Pure Food and Drug Act, the desire to experience pleasure from drugs was argued to be what distinguished “addicts” from deserving patients. Now, doctors are still wary of “drug-seekers” coming to their office, “faking” ADHD to get stimulants.

When they use the term drug-seeking, is what they really mean pleasure-seeking? We’ve been told that we can’t have a drug just because it feels good — it has to be treating some kind of “legitimate illness.” You can’t want it, but you can need it, if a doctor bio-certifies you for it.

I think about posts I’ve seen by ADHDers on their first day of stimulants that say something like, Is this how it feels to be normal? Does everyone just feel this good all the time? The answer to which is: no, they don’t, and there’s no such thing as normal. Stimulants feel good because they increase confidence, dull emotional response, and make mundane tasks more enjoyable.

There’s a reason they were used extensively by militaries in both World Wars, sold as a treatment for everything from housewives’ depression to asylum residents’ catatonia, and got so popular in the US that the fear of “thrill pills” was used to pass the Controlled Substances Act in 1971.⁴

A Ritalin ad from 1967

I get the impulse to defend your access to a stimulant that makes the activities of daily living possible, especially when that access has been hinged on the denial of pleasure. It is terrifying to be faced with the proposition that a drug you rely on could suddenly be ripped away, so it makes sense that people lean into medicalizing amphetamines and denying any affinity with drug users.

But after what I've learned about drugs by "self-medicating" with them, I can't accept that mixed amphetamine salts work by “fixing” my neurology, just like I don’t consider alcohol to be balancing my neurotransmitters when it helps me cope with loud parties, or Xanax to be curing a benzodiazepine deficiency when it stops my panic attacks.⁵

Psychoactive drugs have direct effects on us, and sometimes those effects feel good, which can be helpful in itself. Puritanical thought and anti-drug propaganda have led us to think of pleasure as destructive, but pleasure can be therapeutic, too. That should be reason enough to have safe access to a substance, but due to the past century of power struggles and profit motives, we’re no longer allowed to see it that way.

“Recovering” from a “legitimate illness” is not supposed to have anything to do with pleasure. It’s just about tuning the body like a machine, getting back to that mythical state of normal, productive, efficient worker — a standard both people with ADHD and people who use drugs fall short of. We are not so different, and we could demand so much more together.

As an extra for paid subscribers, I put out a podcast episode this week critiquing the claim that Adderall prevents car crashes — check it out here.

In Part 3, I explore why Adderall shortages happen.

1. I cannot overstate how important this book is! READ IT. !!! “Malingerers of the world unite” !!!

2. The more I say this word the more ridiculous it sounds. Save for when you’re in a hospital and being administered drugs directly, aren’t we always, technically, “self-medicating” ??? I’m being too literal I know but it just sounds like bullshit to me.

3. He co-writes a Substack with Tana Ganeva called

Substance

which I highly recommend if you’re interested in independent reporting on drugs and crime

4. See: On Speed by Nicolas Rasmussen for more about this history. This part, in particular, makes my head explode:

“Congressional committees considering the bill in 1969 heard alarming testimony from top medical experts that the amphetamines were truly addictive; that amphetamine and methamphetamine were now proven ineffective treatments for weight loss and depression, and that newer, similar drugs such as Ritalin were no different; and that if these popular uses were banned, the legitimate demand for the drugs would decline from the 8–10 billion doses sold by drug firms to only a few tens of thousands of doses per year. This amount would suffice to treat the few hundred patients suffering narcolepsy, and also the children with an unusual hyperactivity syndrome, nearly as rare as narcolepsy according to some expert witnesses, amounting to perhaps a thousand cases in the entire nation. (Under a new name, Attention Deficit/Hyperactivity Disorder or AD/HD, diagnoses of childhood hyperkinesis would surge a few years later, after amphetamine’s other legitimate uses were blocked.)”

5. This example comes from Joanna Moncrieff and her drug-centered model of drug action