A Little Consistency Check

This morning, or noon, or whatever, I read Jonah's post at The
Frontal Cortex, href="http://scienceblogs.com/cortex/2007/02/the_nfl_and_mental_illness.php">The
NFL and Mental Illness.  It is a tragic story, but there is
one thing about it that I want to comment upon, regarding the reported
Adderall prescription.



But first, a digression.  Reporters are expected to do at least a
little fact-checking.  But in addition to checking facts,
sometimes it is appropriate to check for consistency. 

href="http://www.nytimes.com/2007/02/02/sports/football/02concussions.html?ei=5090&en=ceccf2dfd8ebf740&ex=1328072400&partner=rssuserland&emc=rss&pagewanted=print">Dark
Days Follow Hard-Hitting Career in N.F.L.

By ALAN SCHWARZ

February 2, 2007



"Welcome to the glamorous life of a former N.F.L. player," he said. A
half-hour later, he stepped into his Range Rover and drove to his local
CVS to pick up another bottle of Adderall. The 72 pills of 30
milligrams each are supposed to last nine days, but he knows he will
blow through them in four or five.

That may be 100% accurate, but is it consistent with what one would
expect?  And if not, what does the inconsistency tell us?

First of all, who ever writes a prescription for nine days' worth of
medication?  I know that in some rare cases, if a patient is known
to have a tendency to use medication too quickly, the doctor will write
for one week at a time, e.g. seven days with three refills, for a total
of one month.  But nine?  Perhaps there are some antibiotic
regimens or steroid bursts that last nine days, but it is very odd for
an ongoing prescription to be given in nine-day allotments. 



Second, what about the dose?  The FDA-approved labeling calls for
a maximum daily dose of 60mg for Adderall.  72 pills, divided by 9
days would give a dose of eight 30mg pills per day.  That's 240mg
per day, four times the recommended maximum!  If he takes all of
them in four days, that would be 540mg per day, which is an
astronomical amount, even for someone with an addiction. 



I did once know of a person who manufactured methamphetamine (not the
same, but comparable to, Adderall), who took something like a gram
(1,000mg) per day.  That shows it is not unheard of, but still,
540mg is a breathtaking amount. 

One of his most maddening frustrations, Mr. Johnson said,
is that no tests -- from M.R.I.'s to other scans of his brain -- have
confirmed his condition, causing some people in his life to suspect
that he is wallowing in retirement blues. "That's ridiculous," he said,
"because I always treated football as a steppingstone for the rest of
my life. I used to have incredible drive and ambition. I want to get my
M.B.A. But I can't even let myself have a job right now. I don't trust
myself."

He's right, he can't trust himself.  I will say another thing, if
he's "wallowing" in blue, he needs to get off that drug.  His
brain is probably so depleted of dopamine, he can't even think unless
he takes the stuff.  And if he blows through his entire supply in
four days, and has to wait five more days to get more, he's on an
mind-bending emotional roller coaster. 



Now, to keep this in perspective, there are times when it is
appropriate to exceed the FDA guidelines for dosing.  There are
times it is appropriate to use medication off-label (i.e. for a
condition other than those for which the drug was specifically
approved).  There are even times when it is appropriate to provide
an abusable drug to someone with a known substance abuse problem
(Admittedly, this is controversial, but I think I can make a case for
that position).   But I find it highly doubtful that it is
appropriate to give someone 240mg of Adderall a day under any
circumstances.



The newspaper article focuses on the danger of head trauma.  The
author does not develop what I think is the real story here, which is
the addiction problem. 



Sure brain injury is a serious issue, and it is something that probably
ought to be studied more thoroughly.  And not just in professional
sports, but high school and college as well.  In the unfortunate
case of Mr. Johnson, it appears that there is more to the story than
the brain injury.