WEBVTT - How The American Workforce Got Hooked on Adderall 0:00:02.440 --> 0:00:15.640 Bloomberg Audio Studios, Podcasts, Radio News. 0:00:17.840 --> 0:00:21.520 Hello and welcome to another episode of The Odd Lots podcast. 0:00:21.600 --> 0:00:23.840 I'm Jolle Wisenthal and I'm Tracy Alloway. 0:00:24.120 --> 0:00:26.079 Tracy, I was gonna ask you a question, but I 0:00:26.120 --> 0:00:28.600 already know the answer to it. I was going to say, like, oh, 0:00:28.640 --> 0:00:30.400 have you ever tried adderall? But I already know you're not, 0:00:30.440 --> 0:00:32.600 so I don't want to like fake the intro whatever, 0:00:32.760 --> 0:00:35.159 but I'm just curious, like, what percentage of our colleagues 0:00:35.200 --> 0:00:39.320 do you think use some sort of stimulant adderall something, 0:00:39.400 --> 0:00:42.960 some sort of performance enhancing workplace. 0:00:42.440 --> 0:00:46.520 Drug like coffee, No, something a little stronger than college. Okay, 0:00:47.120 --> 0:00:50.479 We've had this conversation before, and I think it's such 0:00:50.520 --> 0:00:53.800 an interesting one because, as you know, I have never 0:00:53.840 --> 0:00:58.600 tried adderall. It is a complete cultural blind spot for me. 0:00:59.280 --> 0:01:02.240 But I am one hundred percent sure that you and I, 0:01:02.520 --> 0:01:05.480 in the context of this podcast and our day to 0:01:05.560 --> 0:01:08.600 day lives, have absolutely spoken to people who have been 0:01:08.720 --> 0:01:11.560 on adderall. In fact, a very famous one springs to 0:01:11.600 --> 0:01:14.160 mind right now. I don't know who you're talking about, 0:01:14.319 --> 0:01:16.720 SBF Sam been Free, There you go, there you go, 0:01:17.400 --> 0:01:20.920 but it is an interesting thought experiment. To think about 0:01:20.959 --> 0:01:24.560 the proportion of people around you, you know, sometimes highly 0:01:24.600 --> 0:01:27.880 productive people who may or may not be on adderall 0:01:28.040 --> 0:01:28.880 or something similar. 0:01:29.400 --> 0:01:32.080 So here's my thought, which is that, like, my big 0:01:32.160 --> 0:01:35.559 fear with adderall is like, I'm not maybe against trying 0:01:35.560 --> 0:01:37.640 it because I don't think I have the most focused 0:01:37.640 --> 0:01:39.199 brain in the world. In fact, I know I don't, 0:01:39.200 --> 0:01:41.800 and I get scartered. I'm worried that I would be 0:01:41.880 --> 0:01:44.600 really productive on it and then for the rest of 0:01:44.640 --> 0:01:47.120 my life be faced with this choice of do you 0:01:47.160 --> 0:01:49.160 want to stay on this drug forever or do you 0:01:49.200 --> 0:01:51.560 just want to go back to your old self knowing 0:01:51.920 --> 0:01:54.400 that you have this other potential state in you. Yes, 0:01:54.400 --> 0:01:55.160 that's my big fear. 0:01:55.240 --> 0:01:58.240 I feel the same way. I am deeply concerned that 0:01:58.320 --> 0:02:00.840 I would start writing a book and be successful at it. No, 0:02:01.080 --> 0:02:04.080 that's a joke, but I think, like to me, it 0:02:04.200 --> 0:02:07.880 opens up kind of interesting questions about fairness and access 0:02:08.200 --> 0:02:11.960 and if someone next to you is getting an edge 0:02:12.080 --> 0:02:15.919 because they either have a prescription that maybe they don't 0:02:15.919 --> 0:02:17.520 need or maybe they do need it, and we can 0:02:17.560 --> 0:02:21.480 get into the degree to which adderall actually is needed 0:02:21.480 --> 0:02:25.200 by the population, or they're accessing it illegally. In one 0:02:25.200 --> 0:02:28.000 way or another. It just opens up like interesting questions. 0:02:28.040 --> 0:02:30.080 But then again, I mean, the person next to you 0:02:30.080 --> 0:02:32.560 can drink ten cups of coffee and that's allowed, right, 0:02:32.639 --> 0:02:33.640 Like you're allowed to do that. 0:02:34.000 --> 0:02:36.400 Yeah, I mean, this is not the Olympics. We're trying 0:02:36.400 --> 0:02:39.280 to all maximize our performance here in the corporate world. 0:02:39.520 --> 0:02:41.760 So I first heard about adderall when I was in 0:02:41.880 --> 0:02:44.919 high school. I graduated in ninety eight, and I wasn't 0:02:45.040 --> 0:02:48.560 like a great student. I got bored a lot in class. 0:02:48.919 --> 0:02:51.400 I've just been scattered. I couldn't focus and such, And 0:02:51.480 --> 0:02:55.040 I feel like I was probably in a slightly different environment. 0:02:55.160 --> 0:02:57.160 Maybe if I had been born a couple of years younger, 0:02:57.639 --> 0:03:00.240 I might have been prescribed it. I think maybe not 0:03:00.320 --> 0:03:02.399 because my parents were hippies and so they didn't really 0:03:02.400 --> 0:03:06.160 believe probably and prescribing drugs for that sort of thing. 0:03:06.639 --> 0:03:09.080 But then you know, sort of this cultural thing. It's like, oh, 0:03:09.080 --> 0:03:11.960 they're giving all these boys. 0:03:11.080 --> 0:03:13.720 Yeah, predominantly boys. I think this is a big issue 0:03:13.760 --> 0:03:16.880 that a lot of women weren't diagnosed when they were young, 0:03:16.919 --> 0:03:18.799 and there are a lot of people right now in 0:03:18.840 --> 0:03:21.840 their thirties and forties who are getting late diagnoses because 0:03:21.880 --> 0:03:24.640 all the symptoms that people were looking out for, were, 0:03:24.800 --> 0:03:27.280 you know, hyperactive boys basically. 0:03:27.000 --> 0:03:30.120 Totally, and so it went from a hyperactive boys in 0:03:30.200 --> 0:03:32.600 high school thing, and then I sort of forgot about 0:03:32.600 --> 0:03:34.000 it for a while. Then I went to college and 0:03:34.040 --> 0:03:35.920 I found that to be a little easier, and then 0:03:36.040 --> 0:03:38.600 like I forgot all about adderall. And then over the 0:03:38.640 --> 0:03:42.680 last several years, what we've seen is prescriptions for adderall 0:03:42.960 --> 0:03:47.040 absolutely explode much more adult use, as you say, people 0:03:47.200 --> 0:03:50.440 finding out later in life that they're diagnosed with ADHD, 0:03:50.760 --> 0:03:53.920 which of course has also led to shortages, which have 0:03:53.960 --> 0:03:58.880 a variety of reasons, some relating to the DEA and manufacturing, 0:03:59.040 --> 0:04:02.320 some just related to the absolute booming in demand. And 0:04:02.400 --> 0:04:06.240 so adderall is just sort of an omnipresent topic of 0:04:06.360 --> 0:04:09.320 conversation and an angst in its owne right. 0:04:09.480 --> 0:04:12.040 Yes, And I am just going to emphasize this again 0:04:12.800 --> 0:04:16.599 cultural blind spot for me. So I'm very interested to 0:04:16.760 --> 0:04:20.200 hear how you know, how it works, what the impact 0:04:20.279 --> 0:04:23.600 might be, and what's driving the boom in usage as 0:04:23.600 --> 0:04:24.560 you mentioned. 0:04:24.240 --> 0:04:26.440 Well, I'm really excited to say we do, in fact 0:04:26.560 --> 0:04:30.080 have the perfect guest, someone I've wanted to talk to 0:04:30.440 --> 0:04:33.919 for a long time on the show. And you know 0:04:34.040 --> 0:04:36.360 someone who recently wrote about it, And so there was 0:04:36.400 --> 0:04:40.600 this great set of essays collected by pioneer works talking 0:04:40.600 --> 0:04:43.279 about the adderall phenomenon from various phenomenons. 0:04:43.400 --> 0:04:46.440 I read all of these in one sitting without the 0:04:46.520 --> 0:04:48.240 use of adderall. They're very, very good. 0:04:48.400 --> 0:04:50.520 They're very good. Everyone should read all of them. But 0:04:50.560 --> 0:04:52.360 I'm really excited. We're going to be talking to one 0:04:52.360 --> 0:04:55.960 of the contributors, Danielle Carr. She's an assistant professor at 0:04:56.000 --> 0:04:59.560 the Institute for Society and Genetics at UCLA, and she's 0:04:59.600 --> 0:05:03.320 a history storian of science and psychology. So hopefully we're 0:05:03.360 --> 0:05:05.839 going to understand how did we get to this point 0:05:05.960 --> 0:05:09.800 and what is widespread adderall consumption? How is it rewiring 0:05:09.800 --> 0:05:12.680 our brains or if not, society. So, Danielle, thank you 0:05:12.720 --> 0:05:14.680 so much for coming on odd lots. 0:05:14.480 --> 0:05:16.240 Thank you so much. It's wonderful to be here. 0:05:16.600 --> 0:05:19.200 Describe your work in general. You had a great New 0:05:19.279 --> 0:05:22.320 York Magazine cover story last year, But talk about like 0:05:22.360 --> 0:05:25.000 sort of your from an academic perspective, like what is 0:05:25.080 --> 0:05:27.840 your focus? How does adderall fit into your broader research 0:05:27.880 --> 0:05:28.640 and work over time? 0:05:28.839 --> 0:05:31.560 So I guess I should say that adderall and tension 0:05:31.600 --> 0:05:35.800 deficit diagnoses are not my specific realm of expertise. My 0:05:35.880 --> 0:05:39.080 dissertation work and now my first book is looking at 0:05:39.120 --> 0:05:43.080 the rise of neural implants a la Elon Musk's neuralink 0:05:43.200 --> 0:05:47.200 to treat psychiatric disorders such as anxiety depression PTSD and 0:05:47.240 --> 0:05:50.160 so on. But I guess more generally my line of 0:05:50.200 --> 0:05:54.680 work is looking at the political, economy and historical emergence 0:05:54.800 --> 0:05:59.320 of different types of experimental psychiatric treatments from the twentieth 0:05:59.400 --> 0:06:00.560 to the twenty four century. 0:06:01.480 --> 0:06:03.839 I have a really basic question to start out with, 0:06:04.160 --> 0:06:08.280 what happened to Riddlin? So no, but honestly, so if 0:06:08.320 --> 0:06:11.240 we had been having this discussion in like the nineteen 0:06:11.320 --> 0:06:13.479 nineties or the early two thousands, I don't think we'd 0:06:13.520 --> 0:06:15.440 be talking about adderall. We'd be talking about Riddlin. 0:06:15.920 --> 0:06:18.560 Yeah, I think that that's absolutely right. I mean, one 0:06:18.600 --> 0:06:21.400 of the interesting things to note about the sort of 0:06:21.440 --> 0:06:26.200 cluster of names for this behavioral disorder that is, you know, 0:06:26.279 --> 0:06:29.880 currently called ADD or ADHD, is that there have been 0:06:29.920 --> 0:06:33.120 since nineteen oh two about twenty different names for this 0:06:33.240 --> 0:06:38.159 kind of cluster of syndromes. And so Riddlin emerged as 0:06:37.960 --> 0:06:42.440 it's methyl fenidate rather than an amphetamine, so it's slightly 0:06:42.760 --> 0:06:46.200 different pharmacologically, And it was formulated in the mid nineteen 0:06:46.240 --> 0:06:50.040 fifties as what was hypothesized to be a less addictive 0:06:50.240 --> 0:06:53.840 alternative to amphetamines, which were at that time being used 0:06:53.839 --> 0:06:58.040 to treat children with what was being called hyperkinesis Concerta, 0:06:58.160 --> 0:07:01.200 by the way, is just methyal fenatic x are. But 0:07:01.320 --> 0:07:04.279 there was a period basically in the nineteen seventies when 0:07:04.320 --> 0:07:05.960 and I'm sure we'll get into this, there was a 0:07:06.000 --> 0:07:11.040 sort of widespread panic over the enormous prevalence of infitamines, 0:07:11.120 --> 0:07:14.440 especially to treat children, and riddlin was sort of preferred 0:07:14.920 --> 0:07:17.880 as an alternative that had fewer side effects allegedly and 0:07:17.960 --> 0:07:22.160 was less addictive allegedly, which accounts for the prevalence of 0:07:22.280 --> 0:07:25.720 Riddlin through the sort of mid nineties, at which point 0:07:25.800 --> 0:07:30.360 there's a switch when Shire Pharmaceuticals acquires Obatral, which is 0:07:30.640 --> 0:07:34.640 rebranded as Adderall, and that's really when the Adderall craze hits. 0:07:35.040 --> 0:07:35.360 Tracy. 0:07:35.360 --> 0:07:37.200 I'm glad you asked that, because I had forgotten all 0:07:37.240 --> 0:07:40.160 about Ridlin. But now that you say it, that's what 0:07:40.280 --> 0:07:42.920 people were talking. They weren't talking about adderall yet when 0:07:42.960 --> 0:07:44.840 I was in high school, but I was aware that 0:07:44.880 --> 0:07:47.040 this was the thing, and like CNN and stuff would 0:07:47.080 --> 0:07:50.120 talk about all these boys being described Ridlin. So I 0:07:50.200 --> 0:07:53.280 mentioned Danielle, I was in high school in the mid nineties. 0:07:53.680 --> 0:07:57.640 What was going on then that suddenly there seemed to 0:07:57.680 --> 0:08:00.040 be this, you know, the first wave, or maybe the 0:08:00.040 --> 0:08:02.960 way you describe it, the second wave of this phenomenon 0:08:03.120 --> 0:08:04.880 of let's get all the boys on Ridlin. 0:08:05.480 --> 0:08:05.760 Yeah. 0:08:05.800 --> 0:08:08.160 So I guess we can start the story in media 0:08:08.240 --> 0:08:10.960 res as it were in the mid nineties. But really 0:08:11.040 --> 0:08:13.280 the work of a historian named Nicholas Rusmussen has I 0:08:13.280 --> 0:08:16.240 think done a very magisterial job in showing that the 0:08:16.240 --> 0:08:20.320 twentieth century was defined in many ways by recurrent waves 0:08:20.440 --> 0:08:24.040 of infatimine use. The first wave really began with the 0:08:24.120 --> 0:08:27.280 rise of infetamine use during the Second World War, and 0:08:27.400 --> 0:08:28.920 we can talk about that if you guys would like. 0:08:29.360 --> 0:08:32.240 But by the mid nineties, one of the major things 0:08:32.280 --> 0:08:35.119 that had happened was a panic in the nineteen seventies, 0:08:35.120 --> 0:08:39.680 a sort of moral panic over the extraordinary prevalence of amphetamines, 0:08:39.760 --> 0:08:45.000 mostly dexidron and benzydrin, that were being prescribed without any 0:08:45.040 --> 0:08:48.960 sort of federal control. It was extraordinarily prevalent across the 0:08:49.040 --> 0:08:52.280 US population, and there really were not very many controls 0:08:52.320 --> 0:08:55.640 at all in terms of how doctors needed to report 0:08:55.760 --> 0:09:00.160 these prescriptions to any sort of federal data collection. And 0:09:00.160 --> 0:09:03.720 so in nineteen seventy one you had Congress tasked deda 0:09:04.240 --> 0:09:09.320 with reclassifying amphetamines as being a schedule to substance, that is, 0:09:09.760 --> 0:09:14.840 prescriptions needed to be reported to a central government administration, 0:09:15.040 --> 0:09:18.479 and there were limits and quotas placed on the quantities 0:09:18.480 --> 0:09:21.800 of mphetamines that could be manufactured and then distributed to 0:09:21.960 --> 0:09:25.640 pharmaceutical companies, and so used to have this sort of 0:09:26.040 --> 0:09:29.160 moral panic around that that actually led to a congressional 0:09:29.200 --> 0:09:32.040 investigation in nineteen seventy and there was this sort of 0:09:32.440 --> 0:09:36.360 broader crackdown both legally in the nineteen seventies and also 0:09:36.440 --> 0:09:39.840 culturally where you had like the sort of countercultural figures 0:09:39.960 --> 0:09:43.079 decrying speed freaks, which had also you know, there was 0:09:43.120 --> 0:09:45.520 this discourse in this narrative that for instance, like the 0:09:45.559 --> 0:09:47.839 heighth Atsbury sort of summer of love had been that 0:09:47.920 --> 0:09:50.040 had been destroyed by speed freaks and so on and 0:09:50.160 --> 0:09:52.600 so forth, and so in the nineteen seventies you have 0:09:52.679 --> 0:09:57.400 a movement away from amphetamines proper, which a creates the 0:09:57.520 --> 0:10:00.920 conditions for the rise of things like ritilin, which is 0:10:01.000 --> 0:10:04.800 a methyl feenadate, which is you know, it's pharmacologically quite similar, 0:10:04.840 --> 0:10:07.800 but it was not subject to exactly the same controls 0:10:07.840 --> 0:10:11.120 as emphetamines. And secondly, I think the thing, the very 0:10:11.120 --> 0:10:13.679 important thing that happens is that one of the few 0:10:13.960 --> 0:10:19.040 medical uses for which amphetamines are going into the late 0:10:19.120 --> 0:10:22.400 nineteen seventy is still allowed to be prescribed are child 0:10:22.520 --> 0:10:26.800 behavioral disorders. Now, prior to nineteen seventy and fetamines had 0:10:26.800 --> 0:10:29.920 been used off label for everything from weight loss to 0:10:30.320 --> 0:10:34.120 mood to just like a variety of off label prescriptions. 0:10:34.360 --> 0:10:37.439 But you have this sort of concentration after this crackdown 0:10:37.559 --> 0:10:42.160 by the DEA to focus amphetamine use medically specifically on 0:10:42.200 --> 0:10:47.160 this you know, small cluster of childhood behavioral disorders. This 0:10:47.200 --> 0:10:48.640 sets us up for, by the time we get to 0:10:48.640 --> 0:10:52.520 the nineteen nineties, the sort of growing market for childhood 0:10:52.960 --> 0:10:56.160 applications for m ffetamines. And I guess like the third 0:10:56.320 --> 0:11:00.559 intervening factor here would be that in nineteen teen eighty 0:11:00.720 --> 0:11:04.160 there was the third publication of the Diagnostic and statistical Manual, 0:11:04.200 --> 0:11:07.800 which is the DSM, which is widely described as psychiatry's 0:11:07.840 --> 0:11:12.200 diagnostic bible. This is essentially the list of diagnoses held 0:11:12.200 --> 0:11:15.679 to be medically viable that insurers will agree to cover, 0:11:15.960 --> 0:11:18.839 that clinical trials will investigate, and so on and so forth. 0:11:19.200 --> 0:11:24.480 And add attention deficit disorder is installed in that version 0:11:24.559 --> 0:11:27.400 of the DSM, and so I think this really sets 0:11:27.400 --> 0:11:30.439 the stage for the rise of ADD as a clinical 0:11:30.600 --> 0:11:33.960 diagnostic entity that receives a lot of research funding in 0:11:33.960 --> 0:11:37.240 the nineteen eighties, such that by the nineteen nineties, once 0:11:37.280 --> 0:11:39.640 adderall comes onto the market, the stage is set for 0:11:39.679 --> 0:11:43.480 a very wide sudden uptick in adderall prescriptions for children. 0:11:59.160 --> 0:12:02.600 So talk to us about what adderall actually does. And 0:12:02.800 --> 0:12:06.559 here I have to confess. In preparation for this conversation, 0:12:06.720 --> 0:12:09.240 I walked around Union Square in New York and ask 0:12:09.280 --> 0:12:10.720 people why they take adderall. 0:12:10.760 --> 0:12:10.840 No. 0:12:10.920 --> 0:12:13.960 I asked some people that I know about adderall, and 0:12:14.040 --> 0:12:17.000 someone explained it to me as this idea that if 0:12:17.000 --> 0:12:20.960 you do have ADHD, then you don't have the normal 0:12:21.280 --> 0:12:24.760 level of dopamine in your brain, or your brain handles 0:12:24.800 --> 0:12:28.720 it slightly differently, and so adderall basically helps to normalize 0:12:28.880 --> 0:12:33.680 dopamine and bring it closer to what a neurotypical person 0:12:33.880 --> 0:12:39.240 might have without medication. Could you maybe explain exactly what 0:12:39.360 --> 0:12:43.640 adderall is doing on someone's brain and the differences between 0:12:43.720 --> 0:12:47.000 someone who's maybe taking it to boost their productivity versus 0:12:47.000 --> 0:12:49.600 someone who's taking it because they have been diagnosed with 0:12:49.679 --> 0:12:52.800 ADHD or something else and they have an actual prescription 0:12:52.880 --> 0:12:53.480 from a doctor. 0:12:54.400 --> 0:12:54.720 Yeah. 0:12:54.760 --> 0:12:57.040 So I think the question of what adderall is and 0:12:57.080 --> 0:13:01.000 what it does neurologically is very connected to the very 0:13:01.000 --> 0:13:05.880 contested and open question of what ADD and ADHD are neurologically. 0:13:05.960 --> 0:13:10.240 So maybe I'll start with what is ADD what is ADHD. Now, 0:13:10.320 --> 0:13:13.040 what you have to understand is that with the emergence 0:13:13.120 --> 0:13:16.120 of the DSM three in nineteen eighty, this was a 0:13:16.160 --> 0:13:19.440 document that was created essentially to bring together a bunch 0:13:19.480 --> 0:13:22.760 of different stakeholders under a very large tent. These stakeholders 0:13:22.800 --> 0:13:28.600 included insurers, clinical researchers, formalcological companies of course, and of 0:13:28.600 --> 0:13:35.000 course patients and doctors. And the DSM describes clusters of symptoms, 0:13:35.280 --> 0:13:39.400 that is, syndromes that tend to occur together. So, for instance, 0:13:39.880 --> 0:13:44.160 here's a list of ten to twelve behavioral manifestations that 0:13:44.280 --> 0:13:47.319 tend to cluster together and we're going to call that depression, 0:13:47.600 --> 0:13:50.240 so on and so forth. But particularly in nineteen eighty, 0:13:50.280 --> 0:13:54.080 there was not a robust sense of what the neurological 0:13:54.200 --> 0:13:58.640 underpinning of each of these diagnoses were. These were descriptions 0:13:59.080 --> 0:14:03.880 behaviorally of how these syndromes manifest that were presumed to 0:14:03.960 --> 0:14:07.240 be disease entities. But I mean, if you ask anyone 0:14:07.320 --> 0:14:09.720 working at the cutting edge of sort of neurology psychiatry 0:14:09.800 --> 0:14:11.480 right now, they will tell you quite frankly, that there 0:14:11.520 --> 0:14:14.880 is no guarantee that any one case of let's say, 0:14:14.920 --> 0:14:20.200 depression or anxiety neurologically looks like any other case of 0:14:20.280 --> 0:14:23.080 depression or anxiety. That's because there are many different ways 0:14:23.080 --> 0:14:25.480 to have depressions. Some people might be crying a lot 0:14:25.520 --> 0:14:27.600 and not eating very much. Someone else might not be 0:14:27.640 --> 0:14:30.640 crying very much and eating a lot, for instance, right, 0:14:30.680 --> 0:14:34.960 and so there's no guarantee that each instance of the 0:14:35.000 --> 0:14:37.560 disease entity is going to have the same sort of 0:14:38.080 --> 0:14:43.360 biological underpinning behind it. Now, this works fine for things 0:14:43.400 --> 0:14:46.480 like insurance markets or billing insurers, or sort of getting 0:14:46.480 --> 0:14:48.520 medicine done in a sort of day to day sense, 0:14:48.560 --> 0:14:51.520 But once it comes to sort of extrapolating and understanding 0:14:51.520 --> 0:14:54.800 the neurological basis of diseases, the system does sort of 0:14:54.920 --> 0:14:58.160 fall apart. This is why increasingly clinical research is moving 0:14:58.200 --> 0:15:02.440 towards the ICD system rather than the DSM system. So 0:15:02.680 --> 0:15:05.520 this is neither here nor there, perhaps generally, but specifically 0:15:05.520 --> 0:15:07.920 when it comes to add and ADHD, I think it's 0:15:08.000 --> 0:15:10.800 very important to keep in mind that there is no 0:15:11.120 --> 0:15:17.400 widely accepted, beyond contestation understanding of what these disease entities 0:15:17.440 --> 0:15:22.880 actually are on a neurobiological basis. So there are theories 0:15:23.080 --> 0:15:27.560 that there's some sort of deficit in dopamine production or 0:15:27.560 --> 0:15:31.080 the rear partake of nopernepherin and dopamine. But I think 0:15:31.120 --> 0:15:34.680 it's important to keep in mind that these explanations they 0:15:34.760 --> 0:15:37.360 might be having prevalence now. But if you think about 0:15:37.400 --> 0:15:40.760 the rise of, for instance, the serotonin hypothesis when it 0:15:40.800 --> 0:15:45.760 comes to depression, the serotonin hypothesis dominated theories of depression 0:15:46.040 --> 0:15:49.640 for quite some time and then has been pretty roundly disproven. 0:15:49.680 --> 0:15:54.840 There is not a robust link between depression and serotonin deficits, 0:15:55.200 --> 0:15:57.480 and so I think that's one important thing to keep 0:15:57.480 --> 0:16:01.160 in mind, is that we don't necessarily have a robust 0:16:01.280 --> 0:16:05.800 and agreed upon understanding of what this disease entity quote 0:16:05.840 --> 0:16:09.520 unquote actually is. Now when it comes to what it 0:16:09.640 --> 0:16:13.200 is that stimulants actually do in the brain, the brain 0:16:13.240 --> 0:16:17.920 releases neurotransmitters that then sort of hang out in the 0:16:18.040 --> 0:16:20.920 space in the sort of synaptic space between the axon 0:16:21.000 --> 0:16:25.080 and the dendrite and then are reabsorbed. So neurotransmitters are 0:16:25.080 --> 0:16:28.360 things like, for instance, nopernethyrine, dopamine. Right there's these are 0:16:28.360 --> 0:16:31.480 things that your listeners probably have already heard of. Something 0:16:31.760 --> 0:16:36.680 like an amphetamine decreases the amount of those neurotransmitters that 0:16:36.720 --> 0:16:40.000 are re uptaken, meaning that the sort of synapse is 0:16:40.080 --> 0:16:43.640 bathed for a longer period of time by those chemicals. 0:16:44.160 --> 0:16:47.680 So that's how an amphetamine works, is that it really 0:16:47.840 --> 0:16:51.680 bathes the brain. In dopamine no reprodefron. Dopamine is sort 0:16:51.720 --> 0:16:55.560 of widely theorized or described as being a chemical that 0:16:55.640 --> 0:16:59.120 codes for expectation of reward. So one way that I 0:16:59.240 --> 0:17:00.680 like to explain this is that if you go to 0:17:00.680 --> 0:17:03.840 a gumball and you're expecting to get one gumball, but 0:17:03.880 --> 0:17:06.280 the machine gives you two for one quarter, you're going 0:17:06.359 --> 0:17:10.199 to have a huge dopamine spike because that reward is 0:17:10.320 --> 0:17:13.119 double what you were expecting. And when you think about 0:17:13.160 --> 0:17:17.359 the way that, for instance, addictive technologies like video gambling 0:17:17.600 --> 0:17:22.400 or social media work, they work by introducing variable rewards 0:17:22.800 --> 0:17:27.840 that hook into this very very motivating dopaminergic system in 0:17:27.880 --> 0:17:31.800 the brain. No Ropernaffron similarly controls the body's sort of 0:17:31.840 --> 0:17:34.879 readiness for fight or flight, and so it sort of 0:17:35.160 --> 0:17:39.439 generally increases a feeling of alertness and readiness. But this 0:17:39.600 --> 0:17:42.560 is why you know, it feels really really good to 0:17:42.640 --> 0:17:45.320 be on amphetamines, and it sort of increases this general 0:17:45.359 --> 0:17:49.040 sense of well being and alertness. And indeed, this is 0:17:49.040 --> 0:17:52.080 why you know in the early nineteen thirties, am fetamine 0:17:52.119 --> 0:17:55.680 was widely prescribed for antedonia or a lack of pleasure. 0:17:55.760 --> 0:17:59.359 In fact, historian Nicholas Rismusin has made the case convincingly. 0:17:59.400 --> 0:18:02.639 I think that empetamine was in fact the first antidepressant. 0:18:02.640 --> 0:18:06.920 But at a neurological level, that is essentially what amphetamines 0:18:06.920 --> 0:18:10.120 are doing. They also, because of their dopaminergic action, they 0:18:10.160 --> 0:18:14.560 increase the rewardingness of a task. It is a common 0:18:14.640 --> 0:18:19.240 talking point for sort of ADHD advocates that amphetamines only 0:18:19.359 --> 0:18:24.080 work if you indeed have add or ADHD, and unfortunately 0:18:24.280 --> 0:18:28.680 this is simply not true. Anyone who takes amphetamines has 0:18:28.800 --> 0:18:32.440 this burst in heart rate, burst in feelings of well being, 0:18:32.760 --> 0:18:36.480 burst in ability to concentrate. This has been documented clinically 0:18:36.560 --> 0:18:39.679 over and over again that there's not really a perceptible 0:18:39.720 --> 0:18:43.520 difference between people who have been diagnosed with add or 0:18:43.560 --> 0:18:46.600 ADHD and people who have not when they take these drugs. 0:18:47.000 --> 0:18:50.520 So someone like myself who sometimes worries that maybe I 0:18:50.680 --> 0:18:54.640 have another level of productivity above me, even I've never 0:18:54.680 --> 0:18:58.399 been diagnosed with anything, like, maybe that's true. So you know, 0:18:58.480 --> 0:19:01.040 I get like, as you say, okay, it makes internet 0:19:01.080 --> 0:19:05.479 gambling you could see or tweeting, tweeting, et cetera. But like, 0:19:05.800 --> 0:19:07.879 what is the theory by which like a bunch of 0:19:07.880 --> 0:19:11.280 people who have jobs where they have to make powerpoints 0:19:11.320 --> 0:19:14.840 about some m and a deal and they're all many 0:19:14.880 --> 0:19:19.040 of them apparently on adderall. Like for that person they 0:19:19.080 --> 0:19:22.440 have a job, they're in the office until eleven pm, 0:19:22.760 --> 0:19:24.680 they get one TYPEO wrong, they have to start it 0:19:24.720 --> 0:19:27.560 all over. What does ederall do for them in the 0:19:27.920 --> 0:19:30.119 sort of corporate context or the work context. 0:19:30.440 --> 0:19:32.320 So one of the things that I discussed in my 0:19:32.520 --> 0:19:37.440 essay was clinical literature around what psychiatrists call punding, which 0:19:37.480 --> 0:19:41.840 is repetitive behavioral loops that are often observed in patients 0:19:41.840 --> 0:19:45.560 that are taking drugs that bathe the brain in dopinergic chemicals. 0:19:45.840 --> 0:19:49.880 So punding was first described in the nineteen seventies by 0:19:49.880 --> 0:19:53.320 a psychiatrist who was observing the sort of repetitive behavioral 0:19:53.320 --> 0:19:58.199 loops like tweezing your eyebrows, or sorting and handling objects, 0:19:58.440 --> 0:20:01.239 or hunting for things or collecting things, so on and 0:20:01.240 --> 0:20:04.760 so forth in patients who are taking levadopa, which is 0:20:04.760 --> 0:20:08.320 a dopamine replacement that is used in patients with Parkinson's. 0:20:08.920 --> 0:20:11.920 And I think that this gives us a pretty interesting 0:20:12.040 --> 0:20:16.360 angle into what it is exactly that amphetamines do, which 0:20:16.400 --> 0:20:21.160 is to make these repetitive tasks much much more rewarding 0:20:21.240 --> 0:20:23.400 than they would otherwise be. And so, when you think 0:20:23.400 --> 0:20:26.199 about the forms of work that predominate in the so 0:20:26.359 --> 0:20:29.879 called knowledge economy, right where you're on a computer looking 0:20:29.920 --> 0:20:34.520 for things, searching for information, organizing information, so on and so forth. 0:20:35.080 --> 0:20:37.800 First of all, and amfetamine makes any task that you're 0:20:37.800 --> 0:20:41.520 engaged in much more rewarding because it's massively ramping up 0:20:41.600 --> 0:20:44.560 the dopamine signals in your brain that are telling you 0:20:44.840 --> 0:20:47.160 keep doing this. This thing that you're doing is better 0:20:47.160 --> 0:20:49.600 and better and better than you expected. But I think 0:20:49.600 --> 0:20:53.199 that what's interesting about the role of emphetamine specifically in 0:20:53.280 --> 0:20:56.439 sort of knowledge work is that it makes these repetitive 0:20:56.480 --> 0:20:59.960 tasks feel more like hunting and gathering. Right, It's more 0:21:00.040 --> 0:21:04.880 or it's a more exciting task to do these repetitive tasks. 0:21:05.119 --> 0:21:07.679 And this is not something that is specific to the 0:21:07.720 --> 0:21:11.480 nineteen nineties. When psychiatrist Abraham Myerson, who is one of 0:21:11.520 --> 0:21:17.160 the first psychiatrists to widely use benzydream for a depressed 0:21:17.280 --> 0:21:20.920 and antidonic patients in the nineteen twenties, his clinical area 0:21:20.960 --> 0:21:23.879 of expertise was the sort of neurosis of what he 0:21:23.960 --> 0:21:26.800 called the brain workers of the upper class. So I 0:21:26.840 --> 0:21:29.400 think that there is, you know, a robust through line 0:21:29.440 --> 0:21:33.119 of amphetamines being used for these emergent forms of work 0:21:33.240 --> 0:21:34.880 in the US. That was great. 0:21:34.920 --> 0:21:37.520 By the way, I never heard punding before you wrote 0:21:37.520 --> 0:21:39.520 about it, but if you go to the Wikipedia page 0:21:39.640 --> 0:21:42.000 for punding, there is a very cute photo of someone 0:21:42.040 --> 0:21:44.119 who has lined up all of their rubber duckies. I 0:21:44.200 --> 0:21:47.160 was just looking in sequence, so I guess that person, 0:21:47.520 --> 0:21:50.159 you know, there you go, must have been very satisfying 0:21:50.200 --> 0:21:52.200 for that person to arrange all of their toys. 0:21:52.440 --> 0:21:55.359 If you think about the sort of phenomenological experience of 0:21:55.400 --> 0:21:58.640 what it is like to be online on adderall or 0:21:58.680 --> 0:22:01.280 to do research on at there is a sort of 0:22:01.320 --> 0:22:05.520 punding like quality to always another real watch, always another 0:22:05.600 --> 0:22:08.879 link to open right, and the sort of punding phenomenon 0:22:08.920 --> 0:22:12.000 I think is definitely one way to describe the addictive 0:22:12.040 --> 0:22:15.800 behavioral loops that are built into this sort of giant 0:22:15.880 --> 0:22:18.400 casino called the Internet that we all live in now. 0:22:19.200 --> 0:22:21.239 So this is one of the reasons we wanted to 0:22:21.280 --> 0:22:24.680 talk to you specifically, because you do write about this 0:22:24.800 --> 0:22:28.399 in your essay. This idea that, Okay, the medication is 0:22:28.880 --> 0:22:32.560 now available and more people can access it, but at 0:22:32.560 --> 0:22:35.240 the same time, there might be things actually going on 0:22:35.560 --> 0:22:40.159 with our society, with our economy that make this medication 0:22:40.600 --> 0:22:44.560 more desirable or more useful to people. This idea that 0:22:44.600 --> 0:22:47.960 we're doing more repetitive tasks, that the amount of content 0:22:48.080 --> 0:22:51.159 available to us is basically endless, and so if we 0:22:51.240 --> 0:22:54.080 have a drug that makes it more even more enjoyable 0:22:54.440 --> 0:22:56.879 to sift through all of it. It's sort of like 0:22:57.000 --> 0:22:59.240 two self reinforcing things here. 0:23:00.119 --> 0:23:01.800 Yeah, absolutely, And I mean I think I want to 0:23:01.880 --> 0:23:04.000 duck out of coming down on the side of chicken 0:23:04.160 --> 0:23:07.439 or egg here. Right, these things are co constitutive. But 0:23:07.920 --> 0:23:09.720 the reason that I wrote the piece was that I 0:23:09.720 --> 0:23:12.080 think that there has been a prevalence of a certain 0:23:12.200 --> 0:23:15.600 kind of narrative about the relation between the so called 0:23:15.640 --> 0:23:20.359 attention crisis, the Internet and aderall. And I think in 0:23:20.440 --> 0:23:22.800 most of the commentary that I've read, even commentary that 0:23:22.840 --> 0:23:26.639 has been very critical of the proliferation of telehealth startups 0:23:26.680 --> 0:23:29.479 such as Cerebral or Done, and I'm sure we'll talk 0:23:29.520 --> 0:23:33.480 about those in a little bit. Even in these critiques 0:23:34.080 --> 0:23:37.800 of the overreaches of telepsychiatry and the sudden boom, the 0:23:37.920 --> 0:23:42.840 latest boom in prescription for ADHD and add stimulant medication, 0:23:43.520 --> 0:23:48.080 there's this idea that we are medicating an attention crisis 0:23:48.119 --> 0:23:51.000 that is in fact caused by the prevalence of smartphones 0:23:51.000 --> 0:23:53.600 in the Internet. So then the causal chain there would 0:23:53.600 --> 0:23:57.000 be first you have the Internet, then you have the 0:23:57.040 --> 0:24:02.840 attention crisis, and then we're medicating that attention crisis through adderall. 0:24:02.880 --> 0:24:06.120 And I think that that's only one half of the story. 0:24:06.520 --> 0:24:09.159 One of the arguments that I make in the piece 0:24:09.359 --> 0:24:12.240 is that, in fact, if you look at the emergence 0:24:12.400 --> 0:24:15.280 of let's say, millennial Internet culture, which is to say, 0:24:15.320 --> 0:24:18.960 sort of smartphone CUSP internet culture, first of all, the 0:24:18.960 --> 0:24:23.160 technical architecture of the Internet is overwhelmingly created by people 0:24:23.200 --> 0:24:26.600 who are on stimulants. If you think about the extraordinary 0:24:26.720 --> 0:24:31.920 prevalence of ADHD medication among coders, you could hardly imagine 0:24:31.960 --> 0:24:36.080 a job that lends itself better to the sort of 0:24:36.400 --> 0:24:39.720 jacking up of reward systems that amfetines produced than the 0:24:39.760 --> 0:24:43.359 extremely boring task of coding. Right. So there's that. And 0:24:43.400 --> 0:24:46.159 then also if you kind of think about that moment 0:24:46.240 --> 0:24:49.200 from let's say two thousand and five to twenty fifteen, 0:24:49.760 --> 0:24:53.080 where you had the proliferation of things like alt lit, 0:24:53.280 --> 0:24:58.600 tau l in, Ben Lerner, Jonathan Saffaran Foyer, Vice Pitchfork, right, 0:24:58.640 --> 0:25:01.600 if you think about that sort of milange that was 0:25:01.920 --> 0:25:05.480 that moment in the culture, I think that one of 0:25:05.520 --> 0:25:10.960 the defining features of that zeitgeist was the prevalence of 0:25:11.000 --> 0:25:13.640 adderall and the prevalence of millennials who had either been 0:25:13.640 --> 0:25:17.080 put on adderall as children, overwhelming the upper middle class 0:25:17.160 --> 0:25:19.720 ensured children who then go on to sort of set 0:25:19.800 --> 0:25:23.240 the BPM of the culture in the zeitgeist, right or 0:25:23.400 --> 0:25:26.640 the dissemination of adderall through elite college networks. 0:25:27.560 --> 0:25:30.280 I want to get to the rise of telehealth and 0:25:30.320 --> 0:25:32.639 the pandemic and how that sort of opened up the 0:25:32.640 --> 0:25:34.440 door to many more people. But before we even get 0:25:34.440 --> 0:25:37.640 to the sort of broader question, is it a phenomenon 0:25:37.720 --> 0:25:40.119 when you looking at history, and it certainly sounds like 0:25:40.119 --> 0:25:44.280 it where whether it's the government or regulators or the 0:25:44.320 --> 0:25:47.360 medical profession, it sounds like these things go in waves, 0:25:47.440 --> 0:25:51.239 and it's like there's a drug gets prescribed popularly. Then 0:25:51.280 --> 0:25:53.840 there's a backlash and everyone gets concerned. Maybe we're part 0:25:53.840 --> 0:25:56.440 of the backlash right now to adderall. Then everyone gets concerned. 0:25:56.600 --> 0:25:59.560 Then it sort of attenuates for a while, and then 0:25:59.680 --> 0:26:01.919 suddenly there's a new reason and then it picks back up. 0:26:02.200 --> 0:26:06.160 Is that a general phenomenon in psychology? 0:26:07.359 --> 0:26:10.520 Yeah, Well, you know, I think that I'm prone to 0:26:10.560 --> 0:26:13.760 describe things as a dialectic in that sense, I would 0:26:13.800 --> 0:26:16.280 say yes, But you can see this type of pattern 0:26:16.359 --> 0:26:20.439 and a variety of psychiatric medications. For instance, if you 0:26:20.520 --> 0:26:27.639 think about the emergence of antidepressants SSRIs, SNRIs like prozac, likexepro, 0:26:27.920 --> 0:26:30.960 well beutrid and so on and so forth in the nineties, 0:26:31.040 --> 0:26:35.720 there is a huge amount of optimism about the serotonin hypothesis, 0:26:35.760 --> 0:26:39.200 that is that serious mood disorders like depression are caused 0:26:39.240 --> 0:26:42.199 by a deficiency of serotonin in the brain. And this 0:26:42.400 --> 0:26:48.119 is coterminous with very serious marketing campaigns by pharmaceutical companies 0:26:48.480 --> 0:26:52.960 that include things like funding patients advocacy groups to sort 0:26:52.960 --> 0:26:56.840 of demand recognition and access to these drugs. And then 0:26:56.880 --> 0:27:00.520 you have this sort of decline in optimism around these 0:27:00.600 --> 0:27:03.960 drugs that I would say dates roughly to twenty ten, 0:27:04.359 --> 0:27:08.240 and the sort of fall in optimism because in fact, 0:27:08.600 --> 0:27:11.920 most SSRIs and sent arized do not perform very much 0:27:11.960 --> 0:27:15.439 better than placebos when looked at in aggregate, that is, 0:27:15.520 --> 0:27:17.800 through meta analyzes, and so I do think that there 0:27:17.880 --> 0:27:20.720 is a kind of push and pull here that is 0:27:20.800 --> 0:27:25.840 maybe not so dissimilar to this general dynamic in psychiatric 0:27:25.880 --> 0:27:30.240 medications more broadly. But what's interesting about amphetamines in particular 0:27:30.760 --> 0:27:33.480 is that sort of the first wave of amphetamine use 0:27:34.040 --> 0:27:38.120 really gets going during World War Two, when both Allied 0:27:38.200 --> 0:27:42.760 and Axis powers are using amphetamines or in the case 0:27:42.800 --> 0:27:46.960 of the Germans, just meth straight up to fuel wartime 0:27:47.359 --> 0:27:50.399 activities and to quote unquote boost morale. But I mean, 0:27:50.480 --> 0:27:54.120 there's a historian named Norman Ohler has laid out very capably. 0:27:54.160 --> 0:27:57.399 I think the argument that, like for instance, Blitzkraig, cannot 0:27:57.440 --> 0:28:01.520 be understood apart from the widespread use of by German troops. 0:28:01.640 --> 0:28:04.800 So you have the sort of large, large spike in 0:28:04.920 --> 0:28:08.800 population levels of usage around World War Two, that sort 0:28:08.800 --> 0:28:11.320 of rises and rises and rises and rises. And then 0:28:11.760 --> 0:28:15.719 with the sort of panic around overprescription among children in 0:28:15.760 --> 0:28:19.760 the early nineteen seventies, I think that that backlash against 0:28:19.800 --> 0:28:23.120 the sort of psychiatric medication being used on children has 0:28:23.160 --> 0:28:27.120 to be understood in tandem with, for instance, youth counterculture, 0:28:27.560 --> 0:28:31.480 with youth suspicion of the way that older generations were, 0:28:31.560 --> 0:28:34.639 you know, doing things like suppressing student organizing. Right, the 0:28:35.080 --> 0:28:38.240 youth culture comes to be this sort of anti establishment 0:28:38.760 --> 0:28:43.320 suspicion of a variety of different systems, including electoral systems, 0:28:43.320 --> 0:28:47.160 but also specifically the psychiatric system as an agent of control. Right, 0:28:47.200 --> 0:28:50.680 So if you think about, for instance, Michelle Fucou, Thomas Zazz, 0:28:51.080 --> 0:28:53.680 the wide spectrum of thinkers in the nineteen seventies who 0:28:53.720 --> 0:28:56.600 were explicitly making the case that psychiatry was an agent 0:28:56.640 --> 0:29:02.480 of social control. The backlash against emphetamines, particularly emphatamines, being 0:29:02.600 --> 0:29:06.680 used to treat child behavioral disorders becomes a bit more legible, 0:29:07.120 --> 0:29:09.520 and so then, of course, you know, in the nineteen eighties, 0:29:09.680 --> 0:29:13.000 with the crackdown on emphetamines, this is one of the 0:29:13.000 --> 0:29:16.800 conditions for the rise of cocaine usage, for instance. But 0:29:16.840 --> 0:29:19.000 I think that there is this kind of push and pull, 0:29:19.360 --> 0:29:22.800 a sort of dialectic, if you will, between the cultural 0:29:22.880 --> 0:29:25.800 meanings of em fetamine, and we're now at a moment 0:29:25.880 --> 0:29:30.360 where I think there's real tension between a narrative that says, oh, well, 0:29:30.480 --> 0:29:33.280 when you look at the increase in prescriptions that have 0:29:33.400 --> 0:29:36.880 been enabled by, for instance, the rise of telepsychiatry, most 0:29:36.880 --> 0:29:39.760 of those prescriptions are going to women in their twenties 0:29:39.760 --> 0:29:42.840 and thirties who may have been, you know, left out 0:29:42.920 --> 0:29:46.920 of a sort of sexist division of prescribing, whereby their 0:29:46.960 --> 0:29:51.560 ADHD was not recognized for gendered reasons. So on the 0:29:51.600 --> 0:29:54.800 one hand, that would be good presumably right. And then 0:29:54.960 --> 0:29:57.920 you know another line of critique that says that the 0:29:57.960 --> 0:30:03.360 shocking and enormous rise in stimulant prescription, especially during the pandemic, 0:30:03.520 --> 0:30:06.520 is maybe more profit driven and not so salutary. And 0:30:06.600 --> 0:30:09.080 I think like that's the space in which this conversation 0:30:09.160 --> 0:30:23.920 is unfolding today. 0:30:25.680 --> 0:30:31.960 What actually drives the availability of adderall currently? Is it regulation? 0:30:32.240 --> 0:30:35.240 And one thing I didn't realize before I started asking 0:30:35.280 --> 0:30:38.560 around about this, but Adderall isn't licensed in the UK, 0:30:38.960 --> 0:30:41.080 so I don't think you can get a prescription for 0:30:41.080 --> 0:30:44.360 adderall over there. Is it the rise of prescriptions, the 0:30:44.440 --> 0:30:47.920 increased use of telehealth which makes it maybe easier to 0:30:48.080 --> 0:30:51.800 access this drug, or is it the companies themselves? I 0:30:51.840 --> 0:30:55.160 mean this has been a talking point with the opioid epidemic, 0:30:55.240 --> 0:30:58.040 this idea that there is a built in incentive for 0:30:58.200 --> 0:31:02.720 a pharma company to want to demand for its own supply. 0:31:02.920 --> 0:31:06.360 So what exactly is driving the availability here? 0:31:07.120 --> 0:31:09.240 Yeah? Okay, So I think this is where maybe we 0:31:09.280 --> 0:31:14.320 talk about what is specific about pandemic telepsychiatry to the 0:31:14.360 --> 0:31:17.440 recent adderall boom. I think the first thing to be noted, 0:31:17.520 --> 0:31:20.920 as you mentioned, is that this is a specifically US phenomenon. 0:31:21.000 --> 0:31:24.080 And I think that, like for all of the activism, 0:31:24.080 --> 0:31:25.959 and I'm sure, like you know, I'm going to get 0:31:26.000 --> 0:31:28.480 a lot of angry emails after this podcast you always 0:31:28.520 --> 0:31:33.480 get about I mean, honestly, don't email me, but you 0:31:33.520 --> 0:31:35.680 know what I mean. I think that for all that 0:31:35.680 --> 0:31:38.960 people want to really double down on the validity of 0:31:39.000 --> 0:31:43.240 the ADD or ADHD diagnosis, there is, you know, significant 0:31:43.280 --> 0:31:46.479 evidence that this is a culturally bound phenomenon just by 0:31:46.600 --> 0:31:50.400 virtue of the fact that it is essentially a US 0:31:50.480 --> 0:31:52.840 bounded phenomenon. I think that people should take that pretty 0:31:52.840 --> 0:31:56.160 seriously when we think about what is driving the current 0:31:56.240 --> 0:31:59.680 adderall shortage, which was announced by the FDA in October 0:31:59.680 --> 0:32:03.480 of two. In twenty two, because of the classification of 0:32:03.600 --> 0:32:06.560 m fatamines as a schedule to substance in the nineteen 0:32:06.600 --> 0:32:10.600 seventy one order from Congress to the DEA. This means 0:32:10.600 --> 0:32:14.480 that there are quotas that are established for how many 0:32:14.520 --> 0:32:17.959 emphatamine salts can be produced and how those are distributed. Now, 0:32:18.000 --> 0:32:20.880 there's been a lot of back and forth between pharmaceutical 0:32:20.920 --> 0:32:23.960 companies and the DA sort of pointing fingers, and the 0:32:24.000 --> 0:32:26.800 DEA says that in fact, what's going on is that 0:32:27.120 --> 0:32:32.600 pharmaceutical manufacturers are not actually hitting their production quotas. Pharmaceutical 0:32:32.640 --> 0:32:35.760 companies are striking back and saying no, in fact, the 0:32:35.800 --> 0:32:39.600 production quotas on the amphetamine salts themselves are too low. 0:32:39.800 --> 0:32:42.240 I don't actually know which one is true. It seems 0:32:42.280 --> 0:32:44.720 pretty hard to figure out which one is true. But 0:32:44.800 --> 0:32:49.080 when we look at the enormous recent spike, even between 0:32:49.320 --> 0:32:53.800 twenty nineteen and twenty twenty two. In twenty nineteen, for instance, 0:32:53.880 --> 0:32:57.560 there were sixty six point six million prescriptions for all 0:32:57.840 --> 0:33:02.480 ADHD medications that includes things like vibance, concerta riddle and 0:33:02.520 --> 0:33:06.000 so on, in forty five million for adderall alone, And 0:33:06.120 --> 0:33:09.000 in the first two years of the pandemic there was 0:33:09.040 --> 0:33:12.920 six million new prescriptions. So one of the narratives that 0:33:13.040 --> 0:33:18.080 you'll hear a lot about this extraordinary rise in stimulant 0:33:18.160 --> 0:33:20.960 prescriptions is that this is owing to the proliferation of 0:33:21.000 --> 0:33:25.600 telepsychiatry companies like Cerebral Done and so on. And I 0:33:25.600 --> 0:33:29.160 think this only gets a part of the story. During COVID, 0:33:29.360 --> 0:33:33.640 the rule that mandated that Schedule two substances could not 0:33:33.800 --> 0:33:39.520 be prescribed over telepsychiatry was lifted, which meant, especially that 0:33:39.560 --> 0:33:44.080 people who had never had an ADHD medication prescription before 0:33:44.320 --> 0:33:47.800 could suddenly get one. There's been a lot of fighting 0:33:47.880 --> 0:33:50.520 over whether or not that rule will be extended, but 0:33:50.560 --> 0:33:53.760 that's certainly a huge part of the proliferation of these 0:33:53.760 --> 0:33:57.640 telepsychiatry prescription rates. But what's interesting is that a recent 0:33:57.680 --> 0:34:02.400 study using CDC data know that the rise through tele 0:34:02.440 --> 0:34:08.520 psychiatry of these prescriptions are specific to VC backed startups. 0:34:08.560 --> 0:34:12.080 That is, if you were getting telepsychiatry through a sort 0:34:12.120 --> 0:34:16.080 of established provider like let's say Kaiser or something who 0:34:16.160 --> 0:34:18.719 had been doing tele psychiatry before, there was not a 0:34:18.800 --> 0:34:22.680 huge increase in adderall prescriptions for those types of companies. 0:34:22.880 --> 0:34:25.640 It was specifically the emergence of these new types of 0:34:25.640 --> 0:34:30.400 companies like Cerebral and Done that were pushing this enormous 0:34:30.400 --> 0:34:32.880 increase in diagnosis. And I think that part of this 0:34:33.000 --> 0:34:35.279 is just a pretty open and shutcase of like a 0:34:35.360 --> 0:34:40.280 company basing its profit model on slinging addictive medications into 0:34:40.280 --> 0:34:42.920 this loophole that was created by the pandemic. The Wall 0:34:42.920 --> 0:34:47.000 Street Journal has done a pretty magisterial and heroic reporting 0:34:47.080 --> 0:34:49.600 job I think of documenting that. But one of the 0:34:49.640 --> 0:34:52.160 interesting thing that comes out of that type of reporting 0:34:52.680 --> 0:34:56.239 is that it's very difficult to get national data about 0:34:56.320 --> 0:35:00.799 levels of prescribing because there is no rule MANDATEA that 0:35:01.080 --> 0:35:05.040 the number of prescriptions for these stimulants be made publicly 0:35:05.080 --> 0:35:07.520 available in any way. The CDC has to collect this 0:35:07.600 --> 0:35:10.959 data by doing reviews of private insurance records, but those 0:35:11.040 --> 0:35:13.400 tend to lag by about a year to two years. 0:35:13.400 --> 0:35:16.719 And so when we all started seeing these advertisements for 0:35:16.800 --> 0:35:20.239 cerebral which were all over TikTok, all over Instagram, that 0:35:20.280 --> 0:35:23.239 were basically like do you want some adderall you can 0:35:23.280 --> 0:35:26.840 basically have some, it was very hard for reporters to 0:35:26.880 --> 0:35:31.120 sort of track the increase that was actually represented by 0:35:31.160 --> 0:35:34.279 those prescribing numbers because they simply aren't federally available. I mean, 0:35:34.320 --> 0:35:37.439 I think among the many arguments for a national health 0:35:37.480 --> 0:35:39.640 insurance or Medicare for All as it's called in the 0:35:39.760 --> 0:35:43.279 United States, is that it's very difficult to track the 0:35:43.440 --> 0:35:47.560 number of controlled substance prescriptions in a way that sort 0:35:47.560 --> 0:35:50.400 of stays ocurrant. You know, this is also relevant I 0:35:50.440 --> 0:35:53.239 think too, for instance, the opiate crisis. But yes, I 0:35:53.280 --> 0:35:56.680 think that when you look at this enormous increase in 0:35:56.840 --> 0:36:01.680 telepsychiatry prescription, there's both this sort of que bono line 0:36:01.719 --> 0:36:03.520 that you can take of, just like there was an 0:36:03.640 --> 0:36:06.240 enormous amount of money to be made through these telepsychiatry 0:36:06.560 --> 0:36:11.600 loopholes that allowed slinging these addictive substances into a pandemic. 0:36:12.000 --> 0:36:15.480 And then simultaneously, I think there is the reality that 0:36:15.640 --> 0:36:19.719 it was enormously difficult to pay attention to anything during 0:36:19.760 --> 0:36:22.520 the pandemic, which contributed I think to many people feeling 0:36:22.600 --> 0:36:25.040 that because it was difficult for them to pay attention 0:36:25.120 --> 0:36:27.640 in zooms for ten hours or you know, or however 0:36:27.680 --> 0:36:29.640 long it was, that they must have some sort of 0:36:29.640 --> 0:36:31.439 attention deficit diagnosis. 0:36:31.719 --> 0:36:35.920 I find that really fascinating this idea, especially that point 0:36:35.960 --> 0:36:39.960 about the gap and the increase in prescriptions from the 0:36:40.000 --> 0:36:43.240 sort of vcback startups which we know need growth, growth, growth, 0:36:43.600 --> 0:36:46.879 versus the sort of legacy healthcare providers that had been 0:36:46.920 --> 0:36:51.000 doing telemedicine for some time that didn't pick up. I 0:36:51.000 --> 0:36:53.560 guess I should have just like done a test, But like, 0:36:53.600 --> 0:36:55.239 what do you have to demonstrate to get at all? 0:36:55.280 --> 0:36:58.640 Presumably you can't just click a button. 0:36:58.320 --> 0:36:59.520 But how simple you can? 0:36:59.680 --> 0:37:00.400 Is it? Like? 0:37:00.440 --> 0:37:02.960 What is there some sort of basic test? And like 0:37:03.000 --> 0:37:06.160 do different doctors, like do the ones who worked through 0:37:06.200 --> 0:37:13.360 the legacy providers have a more perhaps stringent test or expectations, 0:37:13.440 --> 0:37:16.080 like what do the various types of medical professionals want 0:37:16.080 --> 0:37:17.800 to see before they'll write data prescription. 0:37:18.400 --> 0:37:20.960 I mean, I think the most succinct answer to this 0:37:21.080 --> 0:37:25.840 question is that it has been and remains essentially vibes based, 0:37:26.040 --> 0:37:30.160 and the quality of that vibees based assessment basically depends 0:37:30.280 --> 0:37:33.640 on the quality of the medical care that you're receiving. 0:37:34.120 --> 0:37:36.920 I mean, I remember that when I was prescribed adderall 0:37:37.000 --> 0:37:39.239 as an eight year old, I went to like a 0:37:39.320 --> 0:37:43.320 child psychiatrist who played a board game with me called Stop, 0:37:43.400 --> 0:37:46.640 Relax and Think loosely based off of shoots and ladders, 0:37:46.880 --> 0:37:48.319 and at the end of that, I walked out with 0:37:48.320 --> 0:37:51.080 an adderall prescription, Right, And so, like, the thing is, 0:37:51.320 --> 0:37:54.720 there's not any sort of blood test or genetic test 0:37:55.239 --> 0:37:58.880 or brain scan that you could take that would stitch 0:37:59.239 --> 0:38:04.280 some sort of by physiological substrate to this disease entity, 0:38:04.280 --> 0:38:07.960 and to say there's no one to one correspondence between 0:38:08.160 --> 0:38:10.480 the disease entity and some sort of test that you 0:38:10.520 --> 0:38:13.359 could take, because it's not actually clear out neurological level 0:38:13.800 --> 0:38:17.839 what this disease entity quote unquote is and so in 0:38:17.840 --> 0:38:22.399 that sense, assessment is bound to be essentially vibespace. Now, 0:38:22.680 --> 0:38:26.000 you know, if you have a clinician who is behaving responsibly, 0:38:26.480 --> 0:38:29.480 they will do a variety of tests and sort of 0:38:29.560 --> 0:38:32.480 ask either the child or the parent, or in the 0:38:32.480 --> 0:38:36.640 case of adult ADHD diagnosis, the patient themselves about their 0:38:36.640 --> 0:38:41.080 functioning across a variety of domains, including focus on work organization, 0:38:41.719 --> 0:38:43.920 ability to sit still for long periods of time, and 0:38:43.920 --> 0:38:46.560 so on and so forth. But in reality, there is 0:38:46.680 --> 0:38:53.480 not really a robust test that differentiates people who do 0:38:53.600 --> 0:38:56.680 have add from people who don't, even in the best 0:38:56.840 --> 0:39:00.840 of cases, even in the case of very high quality 0:39:00.880 --> 0:39:04.440 in person pediatric or adult psychiatric care. Now, when it 0:39:04.480 --> 0:39:08.360 comes to something like telepsychiatry startups like done in Cerebral, 0:39:08.480 --> 0:39:10.880 I think that there's been a lot of reporting and 0:39:10.960 --> 0:39:15.320 documentation now on the way that providers who were essentially 0:39:15.360 --> 0:39:19.799 working in this sort of gig economy Uber for psychiatric 0:39:19.800 --> 0:39:24.880 professionals type of platform were punished if they refused to 0:39:24.920 --> 0:39:29.160 prescribe stimulants at Cerebral for a while, if you refuse 0:39:29.280 --> 0:39:31.920 to prescribe a stimulant, you had to write up a 0:39:32.040 --> 0:39:35.520 justification for why you were not doing that, you would 0:39:35.520 --> 0:39:39.680 think that responsible medical practice would be the opposite. Cerebral 0:39:39.719 --> 0:39:43.480 has since after this series of investigations that prompted a 0:39:43.560 --> 0:39:48.840 DJ investigation, stopped prescribing schedule to substances through their platform. 0:39:49.200 --> 0:39:51.359 But I think that regardless of whether or not they're 0:39:51.360 --> 0:39:54.359 still slinging like adderall or concerto on there, I think 0:39:54.360 --> 0:39:57.880 that it bears on, for instance, what kinds of assessments 0:39:57.920 --> 0:40:01.440 are being used to prescribe for it antidepressants, which are 0:40:01.480 --> 0:40:05.080 also serious, psychoactive medifications that can be very very difficult 0:40:05.480 --> 0:40:08.600 to wean off of. But in short, answers to your question, no, 0:40:08.840 --> 0:40:15.239 there's no specific diagnostic test that guarantees the appropriateness of 0:40:15.440 --> 0:40:17.240 amphetamines for any given patient. 0:40:17.960 --> 0:40:20.040 This is a very wide ranging question. But what are 0:40:20.080 --> 0:40:25.040 the implications for society of this increased adderall use? And 0:40:25.160 --> 0:40:30.120 obviously there's a physical impact of having a higher proportion 0:40:30.280 --> 0:40:35.680 of the population dependent in varying degrees on a particular substance. 0:40:36.000 --> 0:40:39.040 But also I kind of joked in the intro about 0:40:39.239 --> 0:40:43.000 unfairness and competitive edges here and then Joe said that 0:40:43.040 --> 0:40:45.520 it's not the Olympics, but of course life is competitive, 0:40:45.560 --> 0:40:49.040 and it is in some degree a competition, and you 0:40:49.080 --> 0:40:52.520 could make a serious argument that, like, some people have 0:40:52.719 --> 0:40:57.320 access to a drug that increases their productivity and has 0:40:57.600 --> 0:41:02.080 positive outcomes on their economic lives at the very least, 0:41:02.080 --> 0:41:06.040 So you have people who have boosted their careers by 0:41:06.080 --> 0:41:08.279 being on this particular drug. And maybe they got the 0:41:08.280 --> 0:41:11.800 prescription when they were younger because their parents had money 0:41:11.880 --> 0:41:14.400 and health insurance and were able to get it, or 0:41:14.480 --> 0:41:17.719 maybe they had a network of friends who are on 0:41:17.880 --> 0:41:20.960 the drug or have access to it. In another slightly 0:41:21.000 --> 0:41:23.640 more dubious way, it does feel like there might be 0:41:23.680 --> 0:41:26.399 some fairness questions tied to this. 0:41:27.360 --> 0:41:29.279 Yeah, I think one of the first things to be 0:41:29.320 --> 0:41:32.279 said about this is, like so many other things in 0:41:32.320 --> 0:41:36.160 psychiatric treatment, there are a series of strange paradoxes that 0:41:36.640 --> 0:41:41.719 define how amphetamine treatment have been used over the twentieth century. So, 0:41:41.880 --> 0:41:45.480 for instance, one of the big pushes against the use 0:41:45.520 --> 0:41:48.440 of Riddlin for children in the nineteen seventies came from 0:41:48.520 --> 0:41:52.839 the Black Panthers, who saw that amphetamines and Riddlin were 0:41:52.880 --> 0:41:56.960 being tested on children in residential care facilities, many of 0:41:57.000 --> 0:42:00.719 whom were black, right, And so there was a sort 0:42:00.760 --> 0:42:06.719 of lower class iffication of amphetamines in the nineteen seventies 0:42:06.840 --> 0:42:11.960 because they were being tested on populations in juvenile detention centers, 0:42:12.200 --> 0:42:15.239 residential care homes, so on and so forth. There's a 0:42:15.280 --> 0:42:18.960 real switch in the nineties, right when suddenly attention deficit 0:42:19.000 --> 0:42:24.560 disorders become kind of the explanation for why white, well ensured, 0:42:24.640 --> 0:42:26.879 upper middle class children are not doing as well as 0:42:26.880 --> 0:42:29.080 would be expected in class. And so I think I 0:42:29.160 --> 0:42:31.920 say that to just sort of problematize some of the 0:42:32.000 --> 0:42:35.960 narratives that like emfetamine usage, it has always been considered 0:42:36.000 --> 0:42:40.479 an upper middle class competitive edge thing, and I think 0:42:40.680 --> 0:42:45.080 in line with this, for instance, I don't think necessarily 0:42:45.160 --> 0:42:49.000 that empfetamine use always gives someone a sort of performance 0:42:49.440 --> 0:42:52.480 enhancing edge. One of the arguments that I make in 0:42:52.520 --> 0:42:55.440 the Adderall essay that I wrote is that in fact 0:42:55.520 --> 0:42:59.960 adderall makes you more susceptible to different types of digital 0:43:00.040 --> 0:43:04.960 behavioral loops, these addictive digital behavioral loops like scrolling Twitter 0:43:05.080 --> 0:43:09.880 infinitely or scrolling TikTok infinitely that sort of directly impact 0:43:09.960 --> 0:43:13.920 one's ability to lead like a thoughtful, well informed life. 0:43:14.640 --> 0:43:15.160 One of the. 0:43:15.719 --> 0:43:21.000 Interesting responses to the club Med Adderall essay collection I 0:43:21.040 --> 0:43:22.880 thought was that there was a lot of anger and 0:43:23.000 --> 0:43:27.040 accusations that some of the arguments that the authors made 0:43:27.239 --> 0:43:31.960 were prohibitionist in impulse, And I can see why that 0:43:32.000 --> 0:43:35.479 would be a concern, but I think that it's misplaced, because, 0:43:35.520 --> 0:43:39.479 in fact, if you think about the clinically documented fact 0:43:39.520 --> 0:43:41.880 that there is really not that much of a difference 0:43:42.320 --> 0:43:46.120 in effectivity for emphetamines between people who have been diagnosed 0:43:46.160 --> 0:43:49.319 with attention deficit disorders and people who have not, then 0:43:49.360 --> 0:43:51.799 in fact, the real prohibitionist impulse is to say that 0:43:51.880 --> 0:43:56.120 because we have this real diagnostic clinical entity, which is 0:43:56.160 --> 0:43:58.759 you know, in fact, like quite contested and not a 0:43:58.840 --> 0:44:02.520 robust disease entity, all, because we have this robust disease entity, 0:44:02.800 --> 0:44:05.640 we are the only ones who should have adderall. And 0:44:05.719 --> 0:44:08.080 I think that there's this very serious conversation to be 0:44:08.120 --> 0:44:13.480 had about equity and distribution and what prohibitionism actually means 0:44:14.040 --> 0:44:18.239 in terms of the implications, however, for widespread amphetamine use. 0:44:18.800 --> 0:44:21.920 I think that when we look at emerging forms and 0:44:22.040 --> 0:44:25.680 organizations of work, which many theorists have described as sort 0:44:25.680 --> 0:44:29.200 of just in time production flexible production, when you think 0:44:29.200 --> 0:44:33.239 about the sort of increased stretching of the worker, the 0:44:33.320 --> 0:44:36.280 need for different types of flexibility across time and space 0:44:36.360 --> 0:44:37.920 and so on and so forth, and the sort of 0:44:38.280 --> 0:44:41.600 ever increasing demands for a sort of infinitely flexible worker. 0:44:42.000 --> 0:44:43.759 I think that it makes a lot of sense why 0:44:43.840 --> 0:44:47.760 adderall or different types of amphetamines would be the drug 0:44:47.880 --> 0:44:49.239 that facilitates that. 0:44:50.040 --> 0:44:51.200 But I think that the. 0:44:51.200 --> 0:44:53.960 Conversation that I hope to see emerged in the coming 0:44:54.080 --> 0:44:57.399 years is one that's less focused on sort of who 0:44:57.480 --> 0:45:01.680 legitimately has ADHD and who does, because in fact, these 0:45:01.680 --> 0:45:05.680 and fetimins have remarkable advocacy for both groups that have 0:45:05.760 --> 0:45:08.520 been diagnosed in groups that haven't, and more of a 0:45:08.560 --> 0:45:11.880 turn towards thinking about what it is that adderall does 0:45:11.960 --> 0:45:14.879 in terms of setting a sort of pace of freneticism 0:45:15.400 --> 0:45:20.880 and susceptibility to different forms of behavioral addiction, particularly Internet 0:45:20.880 --> 0:45:24.000 based behavioral addiction. And I guess my closing point here 0:45:24.000 --> 0:45:27.080 would be that adderall cannot fix the sort of internetified 0:45:27.160 --> 0:45:31.240 attention crisis because adderall hooks us deeper than ever into 0:45:31.440 --> 0:45:34.480 the sort of structures of addiction that are the sand 0:45:34.520 --> 0:45:38.160 Quanon of the Internet as a sort of giant casino 0:45:38.200 --> 0:45:38.920 that we all live in. 0:45:39.480 --> 0:45:42.880 Danielle, this was fascinating. We can probably talk for hours 0:45:43.040 --> 0:45:45.320 on this subject. I just want to say I'm addicted 0:45:45.400 --> 0:45:49.399 to Twitter and Instagram totally naturally, totally clean. But thank 0:45:49.480 --> 0:45:51.799 you so much for coming on odd Lauds. There's a 0:45:51.800 --> 0:45:54.400 great conversation and glad we finally got a chance. 0:45:54.239 --> 0:45:55.640 To talk to Thank you so much. 0:45:55.680 --> 0:46:10.080 This was really fun, Tracy. 0:46:10.239 --> 0:46:13.239 I really enjoyed that conversation, and there were a number 0:46:13.239 --> 0:46:14.920 of things that really are going to stick with me. 0:46:15.239 --> 0:46:17.839 But you know, one thing that sort of I had 0:46:17.960 --> 0:46:21.320 never really thought about before is the idea that sure 0:46:21.640 --> 0:46:24.200 being on one of these drugs can sort of change 0:46:24.239 --> 0:46:27.359 the way you consume information or perform tasks online, whether 0:46:27.400 --> 0:46:31.040 productive or unproductive, but also the idea that the entire 0:46:31.120 --> 0:46:34.080 online world was also built by the people on these drugs. 0:46:34.280 --> 0:46:37.319 Yeah, it's sort of intertwined. Yeah, right. The other thing 0:46:37.320 --> 0:46:40.120 that I thought was really interesting was Danielle's point about 0:46:40.120 --> 0:46:42.759 the knowledge economy. And part of this is because I've 0:46:42.760 --> 0:46:46.000 been reading Oh I'm going to have to Censor myself 0:46:46.160 --> 0:46:50.360 BS Jobs by David Graber, and it's sort of like 0:46:50.400 --> 0:46:54.239 a dystopian Studs tircle in the sense that it just 0:46:54.360 --> 0:46:58.200 details how much dissatisfaction people seem to have with a 0:46:58.239 --> 0:47:01.120 lot of modern day jobs where you feel like you're 0:47:01.160 --> 0:47:03.920 not really doing anything. There's a lot of bureaucracy involved, 0:47:03.960 --> 0:47:07.360 and yet you have to pay attention, per Danielle's points, 0:47:07.400 --> 0:47:09.440 So I think there's an aspect of that in there. 0:47:09.760 --> 0:47:14.280 The other thing that was very I guess attention grabbing 0:47:14.760 --> 0:47:18.400 was the idea of no pun intended was the idea 0:47:18.480 --> 0:47:22.440 of some of the venture capital backed health services writing 0:47:22.480 --> 0:47:25.799 more prescriptions than perhaps some of the more traditional health 0:47:25.840 --> 0:47:26.640 care providers. 0:47:27.000 --> 0:47:29.319 That was totally eye opening for me, and I was, 0:47:29.520 --> 0:47:33.480 you know, I'm aware of the proliferation of these telehealth companies. 0:47:33.920 --> 0:47:36.839 As a mail in my mid forties, I constantly get 0:47:36.880 --> 0:47:39.040 ads for you know, various pills that I can just 0:47:39.080 --> 0:47:41.200 go on for like hair loss and things like that, 0:47:41.320 --> 0:47:44.360 and so I see them targeted to me all the time. 0:47:44.719 --> 0:47:48.759 But I hadn't realized the degree to which that specific 0:47:48.840 --> 0:47:54.160 combination that Danielle described, which was the relaxation of prescription 0:47:54.400 --> 0:47:58.600 drug obligations due to the pandemic and then the simultaneous 0:47:58.680 --> 0:48:03.320 explosion of these news services, which it sounds like the 0:48:03.400 --> 0:48:05.320 drugs are kind of being given out like candy. 0:48:05.600 --> 0:48:05.799 Well. 0:48:05.880 --> 0:48:08.480 The other thing that I think is something of a 0:48:08.600 --> 0:48:12.080 tell is the fact that adderall is not licensed in 0:48:12.280 --> 0:48:15.480 places like the UK. This seems in many respects to 0:48:15.560 --> 0:48:21.319 be a sort of peculiarly or especially American phenomenon. 0:48:20.880 --> 0:48:22.560 Which Tracy, Yes. 0:48:22.360 --> 0:48:23.879 What do they do in the UK if they don't 0:48:23.920 --> 0:48:25.840 get if they can't get ederall. 0:48:25.960 --> 0:48:28.279 They get their energy. If you work in finance, you 0:48:28.320 --> 0:48:30.759 get your energy the old fashioned way. I'm not gonna 0:48:30.800 --> 0:48:34.399 say what that. I mean coffee of oh yes, uh no, 0:48:34.520 --> 0:48:37.440 it's powdered coffee. Yeah, there we go. But I think 0:48:37.560 --> 0:48:40.799 like it is suggestive as to what's going on here, 0:48:40.920 --> 0:48:44.160 the fact that there might be something structural or specific 0:48:44.280 --> 0:48:46.920 about the US economy or the healthcare system that seems 0:48:46.960 --> 0:48:48.200 to be driving some of this. 0:48:48.600 --> 0:48:51.759 Get two things on that. So Daniel made this point, 0:48:51.800 --> 0:48:55.080 and I had realized this six months ago. I remember, 0:48:55.200 --> 0:48:58.080 out of interest, trying to find some number about like 0:48:58.280 --> 0:49:00.840 finding how much of a drug has been described, how 0:49:00.880 --> 0:49:03.960 many doses prescribed? And you can't find it. And if 0:49:03.960 --> 0:49:07.200 you look, the only entities that offer that data are 0:49:07.239 --> 0:49:09.520 these like private for profit collectors, and you have to 0:49:09.520 --> 0:49:11.640 pay like ten thousand dollars or whatever just for a 0:49:11.719 --> 0:49:14.520 data set who try to aggregate, you know, how many 0:49:14.560 --> 0:49:18.239 prescriptions of each and it's sort of this idea for 0:49:18.360 --> 0:49:21.160 better or worse, and listeners can make up their mind. 0:49:21.440 --> 0:49:23.160 But like, if you do have a sort of more 0:49:23.600 --> 0:49:29.120 national healthcare system and there's only essentially one monopoly prescription writer, 0:49:29.239 --> 0:49:31.400 whether it's the NHS or whatever it is they have 0:49:31.440 --> 0:49:33.879 in Canada, then you know those numbers in real time 0:49:33.880 --> 0:49:35.680 and you can say, oh my god, like these prescriptions 0:49:35.680 --> 0:49:36.560 are totally exploding. 0:49:36.760 --> 0:49:39.200 Yeah, that point by Danielle, the idea that maybe there 0:49:39.200 --> 0:49:42.840 are data benefits to have a national healthcare service, that 0:49:42.960 --> 0:49:45.719 was one I hadn't heard before. But it makes some 0:49:46.000 --> 0:49:48.200 sense to have a sort of centralized body that is 0:49:48.239 --> 0:49:51.680 actually writing these things, perhaps has a better outlook anyway, 0:49:51.800 --> 0:49:54.680 fascinating conversation. You know it's going to be good when 0:49:54.760 --> 0:49:57.320 you ask someone for context on this and they start 0:49:57.360 --> 0:49:59.799 out with, you know, meth addiction in World War Two. 0:50:00.239 --> 0:50:03.080 So I really enjoyed that conversation. I feel like I 0:50:03.160 --> 0:50:06.960 have a better handle on a sort of cultural site 0:50:07.080 --> 0:50:09.800 geist of the American economy. But wow, there are a 0:50:09.840 --> 0:50:12.320 lot of questions that come out of this conversation. 0:50:12.680 --> 0:50:12.880 You know. 0:50:12.960 --> 0:50:15.799 One other thing too about this sort of maybe the 0:50:15.840 --> 0:50:19.520 pathologies of the US healthcare system is I don't think 0:50:19.600 --> 0:50:22.200 that any of these drugs are as bad as like 0:50:22.520 --> 0:50:25.520 addictive painkillers. But it is striking to me that we 0:50:25.880 --> 0:50:28.799 did just have this like huge, sort of multi year 0:50:29.000 --> 0:50:34.240 realization that the opioid sellers that it was riven with abuse, 0:50:34.400 --> 0:50:36.560 a lot of the same things about like so called 0:50:36.680 --> 0:50:40.760 like nonprofit patient advocacy groups trying to make these drugs 0:50:40.800 --> 0:50:43.400 more available and ease the regulations, and then we had 0:50:43.400 --> 0:50:47.000 this big sort of national reckoning with it various books 0:50:47.040 --> 0:50:50.480 and documentaries. Is such a disaster, and then we just 0:50:50.480 --> 0:50:52.560 like move on to the next drug. And again I'm 0:50:52.560 --> 0:50:55.600 not saying it's necessarily comparable, but the speed with which 0:50:55.640 --> 0:50:57.560 we just sort of here's the new drug that we're 0:50:57.560 --> 0:51:01.239 going to commercialize and promote aggressively, it's like, didn't we 0:51:01.360 --> 0:51:01.879 just do this? 0:51:02.280 --> 0:51:02.520 Well? 0:51:02.800 --> 0:51:05.080 Danielle made that point to the idea that like it 0:51:05.200 --> 0:51:07.439 kind of goes in cycles, all right, And it does 0:51:07.520 --> 0:51:09.880 feel like these things kind of come and go in 0:51:09.960 --> 0:51:13.760 terms of popularity, in terms of commercialization, as you mentioned 0:51:14.000 --> 0:51:17.040 it is. Yeah, you're right, it's nuts, but it seems 0:51:17.080 --> 0:51:20.680 like it is getting a little bit more attention nowadays. 0:51:20.719 --> 0:51:22.880 We'll see what happens. We'll see shall we leave it there? 0:51:22.960 --> 0:51:23.719 Let's leave it there. 0:51:23.920 --> 0:51:26.640 This has been another episode of the All Blots podcast. 0:51:26.719 --> 0:51:29.680 I'm Tracy Alloway. You can follow me at Tracy Alloway. 0:51:29.800 --> 0:51:32.600 And I'm Joe Wisenthal. You can follow me at the Stalwart. 0:51:32.800 --> 0:51:37.480 Follow our guest Danielle Carr, She's at Underscore Danielle Underscore Car. 0:51:37.719 --> 0:51:41.000 Follow our producers Carmen Rodriguez at Carmen Arman, dash Ol 0:51:41.000 --> 0:51:44.440 Bennett at Dashbot and Kilbrooks at Kilbrooks. Thank you to 0:51:44.480 --> 0:51:47.600 our producer Moses Ondam. 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