The patient needs a fix, so the routine is simple. Figure out the symptoms. Find a sympathetic doctor. Get a prescription. Enjoy.
It's the tried-and-true formula for landing medical marijuana in California – and, as Major League Baseball has learned over the last three years, for enterprising players who want to skirt the league's drug program that bans stimulants and take them without penalty.
No, not all of the 108 players this year granted baseball's version of a tokin' token – the therapeutic-use exemption (TUE) – are con artists who say they have attention-deficit hyperactivity disorder (ADHD) so they can freely swallow Adderall, Ritalin and other such banned stimulants. But experts say it's inconceivable that 9 percent of MLB players warrant prescription, a number that doubles the ADHD rate in the rest of the country.
"It looks fishy," Dr. Ari Tuckman said. "It doesn't mean it is, but it looks that way."
Tuckman is the vice president for the Attention Deficit Disorder Association and an expert on adult ADHD. Being a scientist, he sees the ridiculousness in baseball – a sport that, to reach the highest levels, requires the sort of single-minded concentration that can so often elude those afflicted with ADHD – somehow ending up with a disproportionate number among its 1,200 players while an estimated 4 to 5 percent of the remaining 300 million Americans suffer from the condition.
The revelation of TUEs is an offseason rite, one of the few gifts delivered by Congressional intervention into baseball's business. The sport has cleaned itself up, steroids no longer the massive pox they once were. It is lingering loopholes like the ability to procure stimulants that renews baseball's title as sport most influenced by drugs, even when football and even hockey match it amphetamine for amphetamine.
The issue, of course, is baseball's culture. From World War II on, stimulants were baseball's version of penny candy. Greenies, beans, speed – the names differed, the effect was the same: a boost for the dog days, or for any day, really, allowing stimulants to weave themselves into the game like any drug that wraps itself around a neighborhood.
Baseball finally began levying suspensions for stimulants in 2007, and the fallout was staggering. In 2006, MLB issued 28 TUEs. In 2007, it allowed 103. Previously, baseball offered TUEs to players after they tested positive for stimulants. Beginning in 2007, it required players to apply before the season – and 75 proved they were worthy in spite of evidence that indicates many weren't.
The majority of ADHD patients taking prescription drugs do so on a daily basis, Tuckman said, and since stimulants stay in the blood for up to three days, drug tests would have exposed most of the regular users in 2006. A handful of the 75 were in the minor leagues then. Others could have tested positive only once, which, at the time, did not trigger any action under the drug plan. Still, those excuses cannot account for such a radical increase. MLB approved the TUEs for the same reasons patients can get an ounce of Purple Kush: doctors gave the go-ahead.
MLB's drug program indicates that a player must receive a "medically appropriate" prescription by a "duly licensed physician." The player or doctor reports the prescription to MLB's independent program administrator, Dr. Bryan Smith, who grants the TUE or denies it. Players who have admitted publicly to having ADHD and take accompanying medicine include pitcher Derek Lowe(notes), first baseman Adam LaRoche(notes) and infielder Nick Green(notes).
Baseball contends its TUE program has gotten more stringent, particularly after the Congressional scrutiny. In 2008, the TUEs rose from 103 to 106, and they jumped by only two this year.
"A healthy percentage of applications for new TUEs was rejected," MLB Players Association director Michael Weiner said Wednesday.
How Smith determines what passes through is not clear. If a player walks in as a 20-something without a history of ADHD and requests a TUE, the likelihood is he will be rejected. Unfortunately, a myriad of shady doctors exist – remember the one who gave Manny Ramirez(notes) a prescription for female fertility drugs? – and with them comes the risk of a stimulant abuser sneaking through the program.
There is only so much MLB can do. ADHD is a controversial condition with a wide spectrum of diagnoses (some are hyperactive, some inattentive, some both) and beliefs (some think it affects up to 10 percent of the population, others believe it's a made-up malady used to peddle pharmaceuticals).
What no one disputes is the effect of stimulants. They aren't steroids. They don't build muscle or stamina. They bring a sense of alertness, an internal calmness belied by external excitement, a focus that borders on relentlessness. It's why students swallow and snort uppers when an all-nighter beckons. It's why 11 players were popped this year for taking Adderall. None were suspended because it takes two stimulant positives for a 25-game ban. It's still bothersome to think the Adderall came as a little pick-me-up from a friend with a TUE.
"In the most general sense, almost everybody does better on a stimulant," Tuckman said, "which is something Starbucks and Coca-Cola figured out long ago."
Baseball's place, then, is precarious. If science can't figure it out, what can MLB do? Something is amiss, certainly, when a representative sample size nearly doubles that of the public. And yet baseball is at the mercy of its players, the same group that nearly torpedoed the sport by willfully deciding to abuse a drug of another kind in the search for an advantage.
"I'm certainly not condoning the use of medications by people who haven't been appropriately prescribed them," Tuckman said. "But professional athletes have to perform at the top of their game every day. For these guys, people notice slight differences. Especially because everyone out there is just as good as they are. It's this culture of hyper-scrutiny on our athletes that pushes this desire for performance-enhancing substances."
The pressure will always be there, and some players cannot live without medicating themselves. Baseball wants to believe they will age and retire and a new, clean generation will arrive without ever having swallowed anything worse than a Red Bull. It's idealistic. It's probably naïve.
Even so, it's something that demands, yes, their full attention.