The Next Deadly Epidemic: Adult ADHD and Stimulants?

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I’ve sometimes wondered how guilty I’d feel if I was a doctor who had started liberally prescribing opiates when we were all heavily urged to do so, now that we have a deadly epidemic as a result. This isn’t just idle musings. I’m being urged to promote what I fear might become the next deadly epidemic — stimulants. I work as a college psychiatrist, arguably ground zero for the emerging ADHD/stimulant crisis. This week I was given a big shove… and I’m angry.

I was at the American Psychiatric Association annual conference in New York alongside 15,000 psychiatrists from around the world. Hundreds and hundreds of us overflowed a session called “Adult ADHD: An Evidence-Based Psychopharmacology Treatment Algorithm” presented by Drs. David Osser, Robert Patterson, and Bushra Awidi from Harvard. We were looking for informed guidance as we struggle with increasing numbers of patients looking for stimulants to deal with the ADHD they’ve been helped to become aware of. We got a simpler answer than we could ever have hoped for: give them all high dosages of stimulants, oftentimes even higher than the FDA recommended dosages. Use some caution if they have bipolar disorder or substance abuse or alcoholism or abuse stimulants, but go ahead and give them all stimulants.

Really?

If you don’t believe me, contact them or check out psychopharm.mobi where they say they’ll post their ADHD algorithm soon for everyone to see.

How could they come to such a clearly irresponsible recommendation?

Because it’s “evidence-based” on randomized controlled studies. I should point out that virtually all randomized controlled studies are drug studies, so they can’t recommend anything besides pills based on “the evidence.” They are either short-term studies to get FDA approval for a new drug or a new indication, or sometimes studies — directly or indirectly financed by drug companies and their allies — targeted to make advertising points. There are no serious long-term studies, either of efficacy or dangerousness, nor are there studies of how to get off medications.

Within those “limitations of the data,” the studies show that new stimulants are very effective over the short run and are reasonably safe. Aside from Strattera, no other treatments — including older off-patent medications like Wellbutrin or clonidine, or coping skills or accommodations — have been studied, so they aren’t included in the algorithm.

Thus, our modern, scientific, methodological blinders, intentionally or not, lead us to shortsighted prescribing practices, as, in my opinion, they usually do.

So, what are you going to do?

Short answer: I’m not prescribing any student stimulants until someone can tell me what the odds are that if they start taking stimulants daily as a freshman they’ll lose control and end up psychotic before they graduate. I know it’s not zero because I’ve seen people it’s happened to, but I don’t have any idea how many it is. Someone, please do the study at some college — then we can talk about how much is an “acceptable risk.” (By the way, I think it’s likely that the way most students “abuse” stimulants, taking them only when they’ve procrastinated enough that they’re behind or have to take a hard test, is safer than “using” them daily in high dosages the way these Harvard doctors recommend.)

Long answer: ADHD (or often more accurately ADD), even more than most DSM 5 diagnoses, conflates people who have attention problems and “meet criteria” with people who actually have the underlying mental illness. When they say that 80% of people with ADHD have other co-occurring disorders (and I don’t know what population or methodology they got that figure from), what that means to me is that the vast majority of the time, people diagnosed with ADHD actually have some other condition that is interfering with their attention rather than ADHD. If we add in trauma — for example “developmental trauma disorder,” childhood sexual abuse, and rape victims, all of which are very common but aren’t in DSM 5 — the number of misdiagnosed (and, in my opinion, mistreated) people goes up even higher. Many responsible clinicians want to take a careful childhood history and even collect records to find underlying, often treatable causes of attention problems before making a diagnosis of ADHD and prescribing stimulants, even though DSM 5 doesn’t require it.

For people without other underlying things interfering with their attention (like a recent breakup), we can “normalize” their problem as a mismatch between their attention spans and the required attention of their lives. We all have a range of attention spans — and that range is steadily getting shorter, making more and more people problematic and therefore “diagnosable.” If we look back across the last 100 years, we can see a progression from a generation who listened to the radio and tracked the leisurely pace of baseball as the national sport, moving on to my generation who grew up training our brains to watch TV and Sesame Street’s short attention span segments and we respond to the pace of football, and now we’re being replaced by a generation raised on video games, surfing the internet, and iPhones, for whom even basketball isn’t stimulating enough.

While we have been able to change the pace of our sports, entertainment and music to adapt to our ever-decreasing attention spans, we really have not fundamentally altered the pace of school, so that’s where most people struggle. In addition, short attention spans have made several really important things more difficult — including being able to commune with nature, paying attention to our romantic partners and other relationships enough to connect and share our lives, attending to our children closely enough to give them the “mirroring” they need to develop, and spending time connecting to God either in group or individual prayer.

When I meet someone who has been at the lower end of the attention spectrum throughout their lives, without other treatable causes, and they are distressed by their resultant struggles even though they made it to college, I offer them: 1) coping skills, adaptations, and accommodations (usually through the disabled students office), 2) a trial of Wellbutrin (which doesn’t work nearly as well as stimulants, but isn’t nearly as dangerous and isn’t addictive), and 3) a long, difficult program of retraining their brain to pay attention better, commonly called meditation (I tell them that it took me 1 ½ years to count to 10 breaths without getting distracted when I began meditating).

I also tell them that even though stimulants help almost everyone concentrate better, I’m too cautious to risk their brains and their lives by prescribing stimulants.

I refuse to be one of the doctors that contribute to the next deadly epidemic. If you think I’m overcautious, I hope you’re right, but I see too many similarities between stimulants and opiates. They’re both strongly psychologically and physically addictive, stimulate our pleasure centers, are often “abused” by otherwise normal people (we’ve tried to create less abusable formulations, while the street dealers create stronger, more abusable, more dangerous formulations), and have long-term dangerous mental and physical effects even at prescription strengths. And perhaps most importantly, they both “work” in the short term without actually fixing anything.

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55 COMMENTS

  1. You might also mention that long-term consumption of ADHD drugs also opens up the possibility of future opioid addiction, once the stimulant consumption has made the user dysperceptive and he/she finds out that narcotics are vaguely therapeutic for this altered (paranoid) states. That was how the earlier “speed” craze of the late 1960’s died out- the speedsters largely became junkies.

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  2. Hi, Mark,

    I am glad that you recognize the chances of psychosis or “manic states” being brought on by stimulant use at accepted dosages. What I wonder is this: since you don’t seem to think that “ADHD” is really a disease state at all, it’s confusing that you talk about people who “actually have the underlying mental disorder.” Do you actually believe there are people who “have ADHD”? If so, how are they differentiated from those have “a mismatch between their attention spans and the required attention of their lives?” Or is that what “the underlying mental disorder” actually means in your observation?

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    • Hi,
      You’re right, I’m equivocating a little. After we “rediagnose” the majority of people with attention deficits as being caused, or “secondary” to something else, and then we assess the majority of the rest as “mismatches” along the normal spectrum, are there a few people who actually have a “primary” disorder that should be called ADHD? My sense is that there are, buried under the avalanche of all these other people, a few people, mostly children, who have some kind of neurodevelopmental disorder, perhaps of the timing of myelination, that causes attention problems, often transiently as their brain further develops. I’ve met a handful of adults who I thought had that and hadn’t outgrow it. Child psychiatrists may have a different experience. When I shared this article with my college psychiatrist list serve, they generally agreed with my sentiments, but almost all thought I shouldn’t refuse to ever use stimulants, that there are a few people who should be prescribed them – this same group. Coincidently, or maybe not, last week I met a woman whose older brother was violent to her every day of her life, until at age 18 her parents were pressured into giving him stimulants and his severe hyperactivity, agitation, and violence all disappeared and he went on to college, marriage, having kids and she was able to begin her recovery. Its still hard for me to prescribe stimulants even in that setting, without really knowing what the risks really are, but they’re probably right, I shouldn’t say never.

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      • One is labeled an antipsychiatrist when stating that there is no such thing as ADHD. But lets face it. The whole condition of ADHD is a marketing strategy. All anyone ever knew was that there were children who were incorrigible in class and became calm on amphetamine products.

        Judging by all the amphetamine seeking people who call my office, the stimulant epidemic is already here. The Netflix documentary ‘Take Your Pills’ does a good job at explaining that stimulants have become acceptable performance enhancers in an increasingly competitive society.

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        • It’s obvious that inattention and the like are real. Some of the behaviours subsumed under the “ADHD” label can very well apply to an individual. You will get some very angry dads, moms and individuals alike if you say “ADHD isn’t real” because they will construe it as you dismissing the problems their kids have, supposedly have, or the problems they have with their kids, or the problems individuals have with themselves.

          If a person wants to take a stimulant as a performance enhancer, that’s up to him, and as long as he isn’t harming anyone (except himself), it is none of our business. Of course, if he is directly or indirectly being forced (even in a subtle manner) to take them, then that brings up a different issue.

          But selling stimulants under the guise of “treatment” for “ADHD” is what is fraught with complications.

          There was some mom here a while ago saying “my child’s ADHD is as much a part of her as *insert some other trait*”. I also remember a guy who used to viciously troll Phil Hickey’s site, hurling abuses, quoting paragraphs from citations, and basically being angry at the fact that “antipsychiatry individuals” are going to prevent people from getting the kind of help that he found enormously useful (which was getting the “ADHD” tag and taking stimulants).

          Let’s not even get into “comorbidities” in behavioural professions. Note the, “be careful with stimulants if they have ‘bipolar disorder'” line in the article. The stimulants themselves can cause mania in some individuals with no prior history of such an occurrence and then it will become a “comorbid” condition (“ADHD” + the newly “uncovered” “bipolar disorder”). This is how it starts. The descent into having multiple labels (“comorbities”) and ending up on multiple drugs and becoming a revolving door “patient”. At least, for some individuals.

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          • First, ADHD isn’t real, sorry mom.

            “Inattention” is in the eye of the beholder. Who gets to determine what should capture another’s attention? Teachers who think 6 year olds should be doing “low-grade clerical work” instead of smelling the daisies? Wives who pay attention to their own needs instead of their husbands’ expectations? Etc. etc.

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      • Of course, labeling this whole group “ADHD” would prevent us ever finding out if there are a very small number of people who actually have something wrong with them biologically, since the “ADHD” group is wildly heterogeneous. The serious problem with allowing stimulants for a theoretical small group who can’t be differentiated from the masses so diagnosed is that once you do, “diagnostic drift” takes over and you get what we have today. Until there is some way to actually determine who has this ostensible disorder in some objective way, protests to “never say never” come across as avoiding the issue.

        Thanks for your reply!

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    • True, Wellbutrin is not safe. But the “illegal false advertising” that it is the “happy, horny, skinny drug” does have some truth to it. It does also cause antidepressant discontinuation syndrome when you are taken off of it, which the doctors misdiagnose as a plethora of DSM disorders.

      I am glad you’re not mass drugging our children with the amphetamines though. Why the medical community believes mass drugging our children, with drugs chemically identical to cocaine, is wise is beyond me. It’s insane, and evil.

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  3. You’d wonder how they get away with it!

    When I was at school there were pupils labelled as “un academic”, but they weren’t limited when it came to knowing the names of all the football club’s and the footballers and their form (and the same with the horses).

    Drugs are for Mugs!

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  4. They are all deadly, and you go willingly, trusting your GP and psychiatrist.

    From Brian:

    “Margaret River is a small town, situated in Western Australia, about 250 km south of Perth and about 10 km from the Indian Ocean. It is known for its craft breweries, boutiques and surrounding wineries.

    But, from now on, it will also be known as the place where, on May 11th this year, 61-year-old Peter Miles shot dead his wife Cynda (left), as well as his daughter Katrina and her four children (bottom of page) – Taye (13), Rylan (12), Arye (10) and Kayden (8) – on their farm outside the town. Then, after making an emergency triple zero call, he shot himself.”

    http://antidepaware.co.uk/margaret-river-massacre/

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  5. Dear Doctor,
    It’s good to hear of your restraint.
    Back when I worked as a speech pathologist in an mostly-immigrant children elementary school, we were serving as a factory farm for ADHD drugs. I refused to participate in any referral until we had tried at least two interventions (moving the student’s desk, changing teachers). Believe me, the willy nilly handing out of the Connors scale dried right up.

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  6. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” (Marcia Angell, MD, “Drug Companies and Doctors: A story of Corruption.” NY Review of Books, Jan. 15, 2009.)

    You may have seen this statement before. The fact that it was made in 2009, so many years ago, is telling because of what’s happened since then. Upwards of 10’s of thousands dying from Opiate addiction every year most caused by prescribed meds. The professionals involved in this, act concerned and look around for solutions, unfortunately no one takes responsibility for whats happened. When in fact the people of this country know full well who is responsible. The medical profession, which includes the so called treatment facilities.

    Those that become addicted to Opiates, have the difficult time of finding treatment. Usually the prescriber sends them to a facility, and realistically facilities have about a 1% success rate. They don’t even offer detox for stimulants, because they are taught that they don’t require medically monitored withdrawals. Yet the severe depression the accompanies withdrawal from stimulants, is likely to lead back to use. Its also true that facilities and treating medical directors, prescribe anti depressants, and other meds some time which further potentiate drug triggered psychiatric symptoms. With facility treatments costing as much as a $100,000 dollars a month for high end facilities, even though treatment doesn’t really have much to offer it is quite lucrative for those that own and operate treatment centers many of these are psychiatrists or medical corporations. The bottom line is that psychiatry exploits illness, purely for profit. There are many people who have been to rehab, literally 100’s of times, and who are not any better. A stimulant epidemic, likely will result once again, in lots of disinformation while people, are strung out to die.

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  7. I think this latest round in America’s on again/off again love affair with Rx uppers is going to (wait for it, wait for it….) crash. Ha!

    Seriously. This time around, the pills are already in Schedule II, so its not as if the docs can plead ignorance. I just don’t know what will replace Adderall and friends…I guess that’s Big Pharma’s job?

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  8. “odds are that if they start taking stimulants daily as a freshman they’ll lose control and end up psychotic before they graduate”, This is a given! These stimulants steal the spirit from the soul and stick it in a little bottle. As human beings increasingly look inward, life begins to seem more like a problem to be solved than a process to be fully experienced. There are no shortcuts to life…

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    • “As human beings increasingly look inward, life begins to seem more like a problem to be solved than a process to be fully experienced.”
      Prescient, or “spot on”, as the Brits say.
      This tendency is greatly exacerbated by corporate medicine, prescription drug ads, and the media.

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  9. I’d say we’ve got quite an uphill battle ahead of us. NBC news, for instance, this evening did a story about this district attorney who after much success in the battle against tobacco companies was taking on the pharmaceutical companies over the opioid crisis. This story, without so much as a blink or a set of raised eyebrows, was followed by a story on the “need” to diagnose (label) and treat (drug with amphetamines) more kids “ADHD”. I imagine the irony completely escaped the reporters doing the stories. The fact that the pharmaceutical industry through advertising finances NBC Dateline news, I would expect, has a great deal to do with these kind of selective blinders of convenience.

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    • I just saw some “news,” don’t know if it was the same network, where they were talking about young children needing brain scans to “confirm” whether they have “ADHD,” with a shrink “explaining” that this is biological, not mental.

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      • Yes, they were showing brain scans and talking biology as an explanation for un or under developed brains (instead of youth, of course). You know where that has to be going (treatment, that is, drugs). Theory has it, you see, under developed brains cause distraction (formally considered a “mental disorder”) in the classroom setting, therefore, drug the kids, and someday they will develop into “normal” unscrupulous and money grubbing businessmen (and women) anyway.

        As I pointed out above, the story I saw followed a story about what was being done to punish the drug industry over the current practice of prescribing addictive (and potentially deadly) opioids. This story is followed, although there is no mention of drugging, with a story about going after kids to get treatment for “ADHD”, and I really don’t see a lot of difference between giving ailing people opioids for pain relief, and giving children speed (all “ADHD” drugs contain it) as a ‘performance enhancer’. Also, not the slightest acknowledgement of the hypocrisy involved in running these two stories side by side, the message from the one, in effect, cancelling out the message of the other.

        ‘Cognitive dissonance’ in the NBC studios? You betcha! I’d say their news team is definitely “deficit” in something having to do with morality, PR effects aside.

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    • Another reason network news on television would want to praise drugs as a cure for short attention spans is one obvious solution for restless kids who can’t concentrate is ditching the boob tube!

      Pitch the thing! Let the kids listen to the radio or read or learn to play musical instruments. Get the really restless ones outside engaging in physical play. Most “ADHD” kids are just healthy, energetic ones if you take them off the plug in drug and get them moving so all that pent up energy has somewhere to go.

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  10. Well, let’s see how the weak-kneed professionals who know the truth yet hold their tongues respond to this:

    Oliver North — yep that one — is the new president of the NRA. As such he is currently blaming school shootings on RITALIN. So, as with Justina Pelletier, what all the “progressive pros” should have been shouting from the rooftops instead of whispering on MIA is being taken up by the right wing. This is good, as all publicity is important due to the extent of the coverup, but if this is allowed to be seen as primarily a right wing issue it will be destructive to the anti-psychiatry cause.

    Dr. Breggin is sending around a link to Red State about this development; the following link is to the HuffPost coverage. Let’s see if the “liberal” response is to defend psychiatry:
    https://www.huffingtonpost.com/entry/oliver-north-school-shootings_us_5b018dece4b0a046186d22be

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    • “but if this is allowed to be seen as primarily a right wing issue it will be destructive to the anti-psychiatry cause.”

      Yes, you could see it coming, but why didn’t NRA grasp the drug cause sooner. Be very interesting to see how it plays out.

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    • Even one political part questioning psychiatry is good. The “Cures Act” or Murphy’s Law went through almost unanimously. No one had any doubts that it was a good thing. Even the sick crazies would prosper. Who doesn’t want safe and effective treatments?

      Who indeed? But we’re talking about psychiatry here. Lol.

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  11. Why didn’t the NRA grasp the situation sooner?

    In a word–selfishness.

    Too busy defending their right to bear arms to care about the rights of others denied due process. The rights to life and liberty and blah, blah, blah. Stuff that crazies don’t need after all. “They’re not real people like us.”

    As someone who has always supported the 2nd Amendment I’m hurt and angry.

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      • It is, indeed, the criminal Oliver North, returned from notoriety to head the NRA. The NRA is in a strange way a natural ally, in that they want to distract any attention from gun control. However, being supported by the NRA may be as helpful as an endorsement from NAMBLA (the North American Man-Boy Love Association) the way their reputation is sinking lately!

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        • No way their reputation is sinking from what I can see — remember that the media IS controlled by out-of-touch neoliberals, the same ones who blame “the Russians” for Trump.

          Why they would make North their prez eludes me, he’s such an obvious right-wing fascist bugaboo. I know this doesn’t apply to the rank & file; there are many Black NRA members in the inner city. You would think they’d want to draw in more “mainstream” support. Guess that never stopped them before, considering Charlton Heston.

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          • There are stats showing a recent severe decline in public opinion regarding the NRA, starting from when they made such rude and degrading comments about the teenage survivors of the Parkland shooting massacre. Their stock is most definitely down, at least for the moment. I can’t see how having Ollie North as their “face” could possibly help matters, though I know he’s a “hero” in certain very irrational circles.

            http://www.businessinsider.com/nra-poll-popularity-favorability-more-americans-dislike-2018-3

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          • Anyway the NRA is the least of my concerns, as their focus is very specific despite the Clint Eastwood imagery. And without the 2nd Amendment this would be a hopeless dictatorship by now, despite how bad it may already seem.

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          • Hey, I have no problem with the second amendment. But I do have a problem with people who have been proven violent being allowed to own firearms. Most gun owners are AOK, but just like if you drive drunk or drive on the sidewalk, you lose your car, if you’re unsafe with your firearms, you should lose them. Not sure why anyone would disagree with that concept.

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          • The NRA appears to consistently oppose any form of gun control, no matter how focused or practical it may be. Two recent examples are straw purchases and the “gun show loophole.” The NRA would be far better served if they simply looked at current gun control laws and people’s objections to them and proposed their own form of legislative fix that would protect honest peoples’ right to own firearms while preventing them from getting into the hands of people with known histories of violence. I have not seen any effort in this direction. Instead, they seem to want to create maximum alarm in the public toward any sort of gun control proposal, equating any efforts at resolving current issues with an attempt to disarm legal gun owners. Choosing Ollie North as their leader says a lot.

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          • We need a new thread here I think. Anyway, you seem to be agreeing with the narrative that school shootings are primarily being done by people with histories of violence who have slipped through some background check and illegally obtained a weapon. How often is this actually the case? Some no doubt but I don’t think this is a pattern.

            Not pushing the NRA, just looking for some perspective.

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  12. Politifact posted an article titled, “No links between Ritalin and school shootings, as NRA’s Oliver North claimed” (http://www.politifact.com/truth-o-meter/statements/2018/may/22/oliver-north/no-connection-ritalin-school-shootings-nra/). It made it to the top page of Reddit politics (https://www.reddit.com/r/liberalgunowners/comments/8ldxls/no_links_between_ritalin_and_school_shootings/). Some quotes from the Politico article:

    “The short answer is that this is nonsense,” said Katherine S. Newman, Torrey Little professor of sociology at the University of Massachusetts and author of Rampage: The Social Roots of School Shootings.

    For Rampage, Newman and her fellow researchers studied medication as a precipitating factor in the school shootings that took place between 1970 and 2000. They found no evidence drugs played a role.”

    and

    “A minor percentage of school shooters studied had been medicated, not “many.” The notion that many have specifically been on the drug Ritalin since kindergarten has no factual basis. More broadly, causation has never been established between the medication and violence. We found no specific ties between ADHD medication and school shootings, either.”

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    • Childrens metabolising CYP enzymes are not fully developed and all have different phenotypes, which makes them liable to toxicity plus withdrawal from ritalin/cocaine = akathisia. Give the ones who’s actions have caused the deaths a Cytochrome P450 pharmacogenetics gene test and look at all the food stuffs they consumed at the time, correlate to those that inhibit the enzymes and we will get a better picture of the truth of this matter and where the crime really is.

      Have sent Katherine S. Newman an email re the above with reference links, let’s see if she replies. Doubt it.

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      • Sounds like some sinning by omission may be going on here, as in the phrase no “specific” ties; does this mean there are “general ties”? Plus most of the well known cases are linked more to “antidepressants.” But to imply that speed of any sort has not been shown to “cause” (how about “predispose to”?) violence is ridiculous.

        So as I intimated previously, are any professionals here going to publicly challenge this woman’s statements and provide Reddit & Politico w/documentation?

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        • Sounds as bogus as arguing that, “SSRIs help people greatly and save lives. While they have been shown to cause suicidal thoughts there is no direct link to suicide established.”

          So…suicidal thoughts don’t cause suicide. And if greater numbers of folks commit suicide on these drugs that’s just the mental illness at work. Quit pill shaming. 😛

          Move along folks. Nothing but a few hundred corpses to see.

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  13. Another potential political ally – the unions. I was in touch with the Teamsters in D.C., who were out and out challenging opioid manufacturers due to having lost so many members, or family members of members, to the drug(s). I don’t know where, if anywhere, these challenges have gone. The woman I spoke with had not heard of the connection between drugs and violence/shootings, etc.

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  14. It is mind boggling how many unproven assumptions all this “epidemic” and “addiction” rhetoric. Institutionalized medicine and psychiatry have created this “fiction” of ADHD to promote use of stimulants, which is silly on its face. If individuals are seeking stimulants, then they should be available without having to be “diagnosed.” The healthcare provider should merely educate the user. There are millions of people who enjoy a variety of stimulants, be it coffee, modifinal, amphetamines, etc. Likewise, there are millions of people who use opiates in a responsible manner, and it enhances their lives. Big Pharma has never forced anyone to take anything against their will. Opiates, Stimulants, depressants, do not have human agency. Drugs do not produce drug addicts..our society creates the need for speed and performance…until you address that underlying dynamic, there will be a huge demand for stimulants…

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    • “Big Pharma has never forced anyone to take anything against their will.” Well, yes, but they have mind bent the medical profession – bribes, falsified clinical trial and medical journal data, and so on, to prescribe potions that are often harmful, if not fatal. And the industry continues to work on “us” as well through endless and mind-numbing pharmaceutical ads.

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