Don't flush your Adderall XR.

Health and medicine explained.
May 10 2005 7:22 AM

Blame Canada

Don't flush your Adderall XR.

A few weeks ago, the mother of a patient in my pediatric practice called me and said that her son had abruptly become much more difficult. The boy, who is wonderfully bright and creative but hard to handle, had been seeing an excellent child psychiatrist and was doing well when suddenly things sort of deteriorated. His mother knew what the problem was and told me: Health Canada (the Canadian equivalent of the FDA) had just banned Adderall XR, the medication he was taking, and—though the drug was still available in the United States—she had asked his psychiatrist to discontinue the treatment.


Adderall XR is used to treat Attention Deficit Hyperactivity Disorder, which lumps together all patients with attention problems—those with hyperactivity and those without it, as in the frenetic child and the space cadet. ADHD can be treated without drugs in a couple of ways. Often, though, (perhaps too often) doctors treat this condition with stimulants—drugs that also suppress appetite and interfere with sleep. At the moment, there are two ADHD drugs in the stimulant class: methylphenidate (Ritalin and Concerta) and amphetamine (Adderall). As far as I've been able to tell, the two kinds of stimulants work just about identically and are equally effective. They also have identical drawbacks: In addition to suppressing appetite and interfering with sleep, they can be abused and they're active for a very short period—a morning dose will usually be ineffective by afternoon. To lengthen the short duration, Adderall combines four different amphetamine compounds, each of which dissolves at a different rate. Adderall XR adds a second delayed-release mechanism to alter the time course slightly and, I suspect, to extend the period of patent protection to wall out the competition (the original Adderall is already available generically).

Why, then, did Health Canada ban Adderall XR while the FDA explicitly did not ban it? Between 1999 and 2003, about a million children, most of them in the United States, took Adderall or Adderall XR. In those four years, 12 boys being treated died suddenly and unexpectedly. At autopsy, five of the children were found to have structural heart problems, some surely present since birth. Of the rest, one was dehydrated after severe exercise in 110-degree weather, two might have been overdosed, and one came from a family with a history of abnormal heart rhythms. The rate of sudden unexplained death in children taking Adderall or Adderall XR averaged 4 per 1 million users per year (and none of the deaths occurred in Canada). For approximately the same age range, the annual cardiac death rate was about 6.3 per 1 million children. Given how similar these two rates are, it seems to me that it would be hard to make the case that Adderall adds significantly to the general risk of heart failure for the young people taking it. Unfortunately, however, there is no way to get at the most important datum: the annual rate of sudden, unexplained death in children with ADHD who were not treated with Adderall or Adderall XR. That means we can't compare the death rate between treated and untreated, but otherwise similar, children.

So, again, why did Canada ban Adderall XR? Frankly, it beats me. Probably the decision reflects simple economics: Because it's under patent, Adderall XR is a lot more expensive than generic versions of Adderall. But if Canada just didn't want to pay the extra cost, I wish the health authorities had owned up to that. When public health policy is submerged in other agendas, we can no longer safely turn to oversight agencies for reliable, trustworthy, and nonpartisan advice.

Sydney Spiesel is a pediatrician in Woodbridge, Conn., and clinical professor of pediatrics at Yale University's School of Medicine.


Frame Game

Hard Knocks

I was hit by a teacher in an East Texas public school. It taught me nothing.

Republicans Like Scott Walker Are Building Campaigns Around Problems That Don’t Exist

Why Greenland’s “Dark Snow” Should Worry You

If You’re Outraged by the NFL, Follow This Satirical Blowhard on Twitter

The Best Way to Organize Your Fridge

The World

Iran and the U.S. Are Allies

They’re just not ready to admit it yet.

Sports Nut

Giving Up on Goodell

How the NFL lost the trust of its most loyal reporters.

Chief Justice John Roberts Says $1,000 Can’t Buy Influence in Congress. Looks Like He’s Wrong.

Farewell! Emily Bazelon on What She Will Miss About Slate.

  News & Politics
Sept. 16 2014 4:08 PM More Than Scottish Pride Scotland’s referendum isn’t about nationalism. It’s about a system that failed, and a new generation looking to take a chance on itself. 
Sept. 16 2014 4:16 PM The iPhone 6 Marks a Fresh Chance for Wireless Carriers to Kill Your Unlimited Data
The Eye
Sept. 16 2014 12:20 PM These Outdoor Cat Shelters Have More Style Than the Average Home
  Double X
The XX Factor
Sept. 15 2014 3:31 PM My Year As an Abortion Doula
  Slate Plus
Slate Plus Video
Sept. 16 2014 2:06 PM A Farewell From Emily Bazelon The former senior editor talks about her very first Slate pitch and says goodbye to the magazine.
Brow Beat
Sept. 16 2014 1:27 PM The Veronica Mars Spinoff Is Just Amusing Enough to Keep Me Watching
Future Tense
Sept. 16 2014 1:48 PM Why We Need a Federal Robotics Commission
  Health & Science
Sept. 16 2014 4:09 PM It’s All Connected What links creativity, conspiracy theories, and delusions? A phenomenon called apophenia.
Sports Nut
Sept. 15 2014 9:05 PM Giving Up on Goodell How the NFL lost the trust of its most loyal reporters.