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Medical report: The effects and risks of Adderall use among athletes

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More and more professional athletes are coming under scrutiny and getting suspended for using Adderall. What kind of effect does it have on a player, and what are the risks?

Scott Boehm

There has been a recent flurry of suspensions in professional sports related to the use of Adderall, a stimulant medication typically used for treatment of attention deficit hyperactivity disorder (ADHD). Headlines have brought into focus questions regarding a drug whose prevalence of use in recent years has skyrocketed not only among athletes, but also in the general population as a whole.

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The effects and risks of Adderall use have come under increased scrutiny in recent weeks as a number of players, most recently NFL cornerbacks Brandon Browner, Cedric Griffin and Richard Sherman, as well as MLB catcher Carlos Ruiz, have joined a growing list of athletes earning suspensions due to its use. While the NFL does not require that suspended players specify which banned substance led to their suspensions, at least 10 have blamed Adderall this season alone. The MLB, which recently released its drug testing results for the past season, also identified 10 positive tests for the medication. Which leads to some key questions: what is Adderall, what makes it a tempting option for athletes, and what bodily risks do they face from using the substance?

Adderall is made from a combination of amphetamines and phenylamphetamines ("mixed amphetamine salts"), which stimulate activity of the central nervous system by inhibiting the uptake of two important brain neurotransmitters, dopamine and norepinephrine. While stimulating the central nervous system sounds counterintuitive when treating patients with ADHD, who have difficulty controlling their impulses and maintaining focus, in fact this acts to change the chemical balance in the brain in a manner that results in improved attentiveness and self-control.

It is estimated that approximately 4 percent of individuals above the age of 14 have ADHD, a number that has increased by approximately 20 percent over the past two decades. Even more striking, the number of prescriptions written by physicians for Adderall has more than doubled over that span, which would indicate that many patients are gaining access to the drug for "off-label" uses that are not indicated in the instructions for use.

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Despite the fact that the FDA has specifically indicated Adderall for treatment of ADHD and/or narcolepsy, for years individuals without these conditions have been using Adderall and other stimulants off-label due to the potential benefit derived from the increased focus that comes with their use. Some have described the effect of stimulant medications as being akin to receiving an IV infusion of caffeine, with the classic picture of an individual using a stimulant being a college student looking to get an extra boost while studying for a test or staying up late to write a paper. For this reason, it isn’t difficult to see why Adderall is considered a performance-enhancing drug. While it acts to "calm the nerves" of individuals with ADHD, individuals without this diagnosis report that taking the drug helps them focus their energy and concentration toward accomplishing everyday tasks at levels otherwise unachievable.

In the case of athletes, this may allow them to derive more from workouts and film study sessions, for example, than usual. The increase in attentiveness has potential benefits off the field as well, such as providing increased wakefulness when traveling for road games, or even just returning home after a late contest. Saints kicker Garrett Hartley, for example, who in 2009 tested positive for a banned substance, admitted to using Adderall to prevent him from falling asleep on a late-night drive from Dallas to New Orleans.

In the NFL, MLB, and NBA, Adderall is currently allowed only with a specific medical exemption, and it is banned entirely in the NHL. It is a common misconception that a "medical exemption" simply requires a physician’s letter of necessity, for example one stating that Adderall is being used for treatment of ADHD. However, the process of obtaining a medical exemption requires a full evaluation of each individual case by league-appointed professionals. In one of the more high-profile NFL cases earlier this season, New York Giants RB Andre Brown was suspended for violation of the league’s substance abuse policy, but when he provided documentation indicating that he had been using Adderall for treatment of a medical condition, it was overturned by such a panel.

Outside of the potential performance-enhancing benefits of Adderall, professional leagues as well as the NCAA, which has its own stringent set of rules for use of the drug, have legitimate concerns regarding the potential side effects associated with its use. These range from relatively minor adverse events, such as gastrointestinal effects, decreased appetite, and rash (which typically resolves with discontinuation), to a number of potentially serious and life-threatening conditions, including increase in heart rate, increase in blood pressure, enlargement of heart size, psychotic behavior and even sudden death.

Among the potentially serious adverse effects, changes in mental status, known as amphetamine psychosis, deserves extra consideration. While rare, this is a disorder that can occur when Adderall or other drugs containing amphetamines are used in large amounts for a prolonged period of time, leading to symptoms including hallucinations, delusions, disorders of thought and aggressive behavior. One study estimated that up to 18 percent of chronic amphetamine users experience at least one episode of amphetamine psychosis every year, and that patients with underlying psychiatric conditions may have an even higher risk. While these serious effects are more common with long-term use and high doses, the fact that amphetamines are known to have a high potential for abuse and drug dependence mean that Adderall should be prescribed as sparingly as possible to avoid serious personal risk.

Ultimately, it is this issue of personal risk – even more so than the risk of competitive imbalance – that should make amphetamine use a topic of particular concern in competitive sports. Although not stigmatized to the degree of other PEDs, it is a drug class whose profile is rising, and whose potential for harm deserves this added attention.