Why I Keep Writing About Stimulants
One reason this topic keeps coming up is simple: I get asked about it constantly.
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Patients, parents, teachers, and exhausted adults sitting in my office all ask roughly the same questions.
What’s the difference between Adderall and Vyvanse?
Why do some people take Ritalin instead?
What about the non-stimulant ADHD medications?
Is this stuff overprescribed?
So consider this a field guide.
The public conversation about ADHD medication is oddly polarized. On one side are people convinced stimulants are handed out like Halloween candy. On the other side are people quietly struggling through school, work, and daily life because they were told ADHD is just laziness in better lighting.
The reality in clinical practice is much less dramatic.
ADHD is almost certainly underdiagnosed in adults and under-treated overall, not the opposite. Millions of people reach their thirties or forties before realizing there was a name for the thing that made school, paperwork, and routine life feel like climbing Everest in Crocs.
Why diagnoses have increased is harder to pin down.
Maybe it is social media making people recognize symptoms.
Maybe the COVID lockdown forced everyone to notice their brains without the scaffolding of daily routines.
Maybe we are simply getting better at recognizing something that has always existed.
Pick your poison.
But stimulant medication is unusual in medicine because when it works, the improvement is often obvious. Not euphoric. Not magical. Just practical.
Bills get paid.
Assignments get finished.
People show up on time.
In other words: ordinary functioning.
This is also why comparisons to recreational drugs miss the point entirely. Robert F. Kennedy Jr. once joked that heroin helped him become an A student. That may be a memorable line, but it is not a model for psychiatry.
The goal of ADHD treatment is not escape.
It is function.
In fact, one reason I prefer stimulant medications over antidepressants when appropriate is that some forms of depression and anxiety improve when people regain the ability to organize their lives, finish tasks, and feel some control over their day.
Momentum itself can be therapeutic.
If your brain finally lets you start the project, answer the emails, and clean the kitchen, mood often follows behavior.
Psychiatry sometimes forgets that.
ADHD medication, when used correctly, does not make people different.
It makes it easier for them to be the person they were already trying to be.
Why Stimulants at All?
The strangest thing about ADHD medication is that it sounds like a paradox: why give a stimulant to someone who already cannot sit still?
The answer goes back to a happy accident in 1937, when Dr. Charles Bradley gave children with behavioral problems a stimulant called Benzedrine. Instead of becoming wilder, many became calmer, more focused, and miraculously actually did their homework¹.
What looked like magic was just chemistry. ADHD brains have weak or inconsistent dopamine signals. Dopamine is the brain’s way of saying:
“Whatever you are doing, keep doing it.”
Without enough dopamine in the right circuits, boring things feel impossible. Stimulants increase dopamine where it matters, which makes life tasks more doable².
And this was not psychiatry’s discovery alone. Armies figured it out long before pediatricians did. During World War II, soldiers were issued amphetamines to march farther and stay awake³. Fighter pilots took them to fly exhausting missions without falling asleep at the controls³.
Even today, military pilots can receive “go-pills” when flying extremely long missions³.
If stimulants sharpen focus in combat and aviation, it should not be surprising that they also help with algebra, taxes, and surviving a PTA meeting.
The Great Stimulant Debate
Psychostimulants (Adderall, Ritalin, Vyvanse) are brain gas pedals. They do not cure ADHD, but they make it possible to pay bills on time, sit for an exam without feeling like your skull is buzzing, or finally open that drawer of six years of loose coupons.
Prescription use has risen sharply since 2016⁴. The fastest-rising group: women aged 15–44⁴.
Translation: mothers, grad students, and burned-out millennials trying to survive late-stage capitalism without becoming memes.
And let us bury the “overprescribed” myth once more.
In 2022, roughly 30% of children with ADHD received neither medication nor therapy⁴. For adults, it is worse, with millions undiagnosed or untreated.
As George Carlin once said,
“Inside every cynical person, there is a disappointed idealist.”⁵
That line describes the ADHD debate surprisingly well.
We have effective treatments.
But stigma still outruns evidence.
• Increase in stimulant prescriptions 2016–2021: sharp⁴
• Fastest-rising group: women 15–44⁴
• Children with ADHD untreated in 2022: 30%⁴
• Adults untreated: millions⁴
• Number of contradictory takes on stimulants: infinite
Coffee, Caffeine, and the Other Stimulant Cousins
Yes, Adderall is a stimulant.
So is coffee.
No, they are not remotely the same thing⁶.
• Caffeine: keeps you awake and jittery
• Ephedrine: once used for asthma and diet pills
• Nicotine: brief focus followed by lifelong regret
• Cocaine and meth: the cousins who burn down the house⁶
The human brain is extremely sensitive to chemicals that influence attention.
Some help.
Some destroy lives.
The difference matters.
Methylphenidates vs Amphetamines
Think of this as the Coke vs Pepsi of ADHD medications.
Methylphenidates (Ritalin, Concerta, Focalin)
• block dopamine and norepinephrine reuptake
• shorter acting
• often smoother⁷
Amphetamines (Adderall, Vyvanse, Dexedrine)
• block reuptake and increase neurotransmitter release
• often stronger
• longer lasting⁷
The folk rule that hyper kids do better on Adderall and inattentive kids do better on Ritalin is about as reliable as astrology⁸.
Medication response is individual.
Trial and adjustment are normal.
Adderall XR vs Vyvanse
Adderall XR is the classic extended-release stimulant.
• mixed amphetamine salts
• onset 30–60 minutes
• duration about 6–8 hours⁹
Vyvanse works differently.
It is a prodrug.
That means it is chemically inactive until metabolized¹⁰.
The drug is amphetamine linked to lysine. Your body must split them apart before the stimulant becomes active.
Because of that:
• onset slower
• duration longer (10–14 hours)
• abuse potential lower¹⁰
Non-Stimulant ADHD Medications
Not everyone takes stimulants.
Some people do not tolerate them. Others prefer alternatives.
Several non-stimulant medications are approved or used for ADHD.
Atomoxetine (Strattera)
A norepinephrine reuptake inhibitor. It is not addictive and lasts all day, but it often takes several weeks to work and tends to be less potent than stimulants¹¹.
Viloxazine (Qelbree)
A newer non-stimulant approved for ADHD that affects norepinephrine signaling and possibly serotonin systems. It does not have abuse potential and can be useful when stimulants are poorly tolerated¹¹.
Guanfacine (Intuniv)
Originally a blood pressure medication that affects prefrontal cortex signaling and can reduce impulsivity and hyperactivity¹¹.
Clonidine
Another blood pressure medication sometimes used in ADHD, particularly when sleep problems or severe impulsivity are present¹¹.
Bupropion (Wellbutrin)
An antidepressant that influences dopamine and norepinephrine and can help some adults with ADHD, particularly when depression is also present¹².
These medications can be extremely useful.
But across many studies, stimulants remain the most effective medications for core ADHD symptoms¹³.
The Punchline
ADHD is real.
Stimulants are not fairy dust.
Diagnoses are rising partly because we stopped writing millions of people off as lazy¹⁴.
These medications help brains that evolved for survival, not spreadsheets.
• Odds ADHD existed in prehistoric humans: high
• Odds ADHD people noticed danger first: also high
• Odds ADHD is caused by sugar or bad parenting: zero
The goal of ADHD treatment is not to make people different.
It is to make ordinary life possible again.
And for many patients, that turns out to be the most radical intervention of all.
Reader Question
Many adults only discover ADHD in their 30s or 40s.
If that was you, when did you first suspect something about your attention or focus worked differently?
I hope you are able to identify with at least something I wrote. Perhaps you have an opinion on the matter of ADHD. I’d love to hear what you have to say. Or, if you are in lovely Boulder, please stop by.
References
- Bradley, C. “The Behavior of Children Receiving Benzedrine.” American Journal of Psychiatry, 94, no. 3 (1937): 577–585.
- Volkow, N. D., Wang, G. J., Kollins, S. H., et al. “Evaluating Dopamine Reward Pathway in ADHD.” Biological Psychiatry, 65, no. 1 (2009): 20–29.
- Rasmussen, N. On Speed: The Many Lives of Amphetamine. New York: New York University Press, 2008, pp. 52–67, 112–135.
- Olfson, M., King, M., & Schoenbaum, M. “Treatment of Young People with ADHD and Trends in Stimulant Prescribing.” JAMA Network Open, 5, no. 6 (2022): e2215561.
- Carlin, G. Napalm & Silly Putty. New York: Hyperion, 2001, pp. 3–5.
- Nehlig, A. “Interindividual Differences in Caffeine Metabolism and Central Nervous System Effects.” Pharmacological Reviews, 70, no. 2 (2018): 384–411.
- Heal, D. J., Smith, S. L., Gosden, J., & Nutt, D. J. “Amphetamine, Past and Present—A Pharmacological and Clinical Perspective.” Pharmacology & Therapeutics, 138, no. 3 (2013): 236–255.
- Biederman, J., Spencer, T., & Faraone, S. V. “Pharmacotherapy of ADHD.” Journal of Clinical Psychiatry, 67, suppl. 8 (2006): 3–8.
- Kollins, S. H. “A Qualitative Review of Issues Arising in the Use of Psychostimulant Medications in Patients with ADHD.” American Journal on Addictions, 16, suppl. 1 (2007): 14–23.
- Pennick, M. “Absorption of Lisdexamfetamine and Its Conversion to d-Amphetamine.” Neuropsychiatric Disease and Treatment, 6 (2010): 317–327.
- Cortese, S., Adamo, N., Del Giovane, C., et al. “Comparative Efficacy and Tolerability of Medications for ADHD in Children, Adolescents, and Adults.” Lancet Psychiatry, 5, no. 9 (2018): 727–738.
- Wilens, T. E., Spencer, T. J., & Biederman, J. “A Review of the Pharmacotherapy of Adults with ADHD.” Journal of Clinical Psychiatry, 67, no. 8 (2006): 113–121.
- Faraone, S. V., Banaschewski, T., Coghill, D., et al. “The World Federation of ADHD International Consensus Statement.” Lancet Psychiatry, 2, no. 12 (2015): 1058–1066.
- Hinshaw, S. P., & Scheffler, R. M. The ADHD Explosion: Myths, Medication, Money, and Today’s Push for Performance. Oxford: Oxford University Press, 2014, pp. 1–18, 65–89.
