Perspective The NEW ENGLAND JOURNAL of MEDICINE

box ” warning describing the cardiovascular risks of stimulant drugs used to treat attention def-icit–hyperactivity disorder (ADHD). This action was unexpected, largely because the FDA had not requested a review of current la-beling for this class of drugs; it had merely asked for recommenda-tions of approaches to studying the cardiovascular risks associated with these drugs. The committee, however, decided to take an inde-pendent course. As a consultant to this committee, I introduced two motions, one recommending the black-box warning and the oth-er proposing the development of a guide for patients, which was approved by a vote of 15 to 0. The guides are handouts that are re-quired to be provided at the time prescriptions are dispensed; they contain information, written in nontechnical language, about the potential hazards of the medi-cation. The drugs under review were primarily amphetamines (Adder-all and other brands) and methyl-phenidate (Ritalin, Concerta, and other brands). These agents are closely related members of the class of sympathomimetic amines, the structures of several of which are shown in the diagram. These com-pounds exert potent stimulant ef-fects on the cardiovascular and central nervous systems. One of the oldest such agents, metham-phetamine, was originally syn-thesized in 1891 and first widely used during World War II in Nazi Germany to enhance the ability of Luftwaffe pilots to stay alert during extended hours of com-bat. Medical use of this agent is now limited, but illicit use has grown rapidly and now represents an increasing public health prob-lem. When smoked or injected in-travenously, methamphetamine (“speed”) is associated with hy-perthermia, rhabdomyolysis, myo-cardial infarction, stroke, and sud-den death — effects well known to coroners in regions of the Unit-ed States where abuse is common. Beginning in the 1950s, the ste-reoisomer dextroamphetamine and related agents were introduced as appetite suppressants. ADHD is a disorder common