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September
1, 2005
Misuse and Abuse of ADHD Medications |
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In recent years, there has been increasing
concern about the misuse and abuse of stimulant
medication prescribed to treat ADHD, and
this issue has been widely reported in the
media. For example, the following headlines
recently appeared during a single week in
newspapers across the country:
"School Officials Note Student Prescription
Drug Problems"
"Survey: 1 In 5 Teens Getting High
On Medications, Over-Counter Drugs"
"Students Abuse Adderall To Improve
Concentration"
"Emory Limits Prescriptions Of ADHD
Drugs"
"Some U. Miami Students Use Drugs To
Focus On Studying"
"Grades By The Milligram"
Such articles provide an important service
by drawing attention to a problem that parents,
educators, and healthcare professionals
should be aware of. Many such articles provide
little actual data, however, and often contain
nothing more than case histories and include
quotes from students along the lines of
"nearly everyone I know is doing this."
Anecdotal reports like these may convey
incorrect information about the actual rate
of illicit stimulant medication use and
thus scare parents from pursuing what may
be an appropriate treatment option for their
child.
How widespread is the problem of illicit
stimulant medication use? How often are
students with a prescription for ADHD medication
approached by peers to sell or give away
their medication? How often are students
prescribed ADHD medication also taking such
medication illicitly, i.e., taking someone
else's medication in addition to their own,
or using their own medication for purposes
other than for which it has been prescribed?
Answers to these important questions are
found in two recent studies that surveyed
middle, high, and college students about
their use of stimulant medication, as well
as other drugs and alcohol. The first study
- "The use, misuse, and diversion of
prescription stimulants among middle and
high school students" by McCabe, Teter,
and Boyd was published in the journal Substance
Use and Misuse (vol 39, pp. 1095-1116) and
examined these issues in an ethnically diverse
sample of 1536 middle and high school students
from a Midwestern public school district.
This represented approximately 90% of enrolled
students, which is an excellent participation
rate.
Data was obtained using an anonymous, web-based
survey so that participants could feel free
to respond in an honest manner. Students
were asked specifically about the use of
Ritalin, Dexedrine, and Adderall. Because
Concerta, a commonly prescribed stimulant
was not included on the list, the results
are likely to somewhat underestimate rates
of both prescribed and illicit stimulant
medication use. It is also important to
note that the rate of stimulant medication
prescriptions often varies widely from one
area to the next, and because the results
were obtained in only a single location,
they cannot be considered nationally representative.
RESULTS
Here is what the authors found:
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- Just under 6% of students were
either taking stimulant medication
under a doctor's prescription, or
had been prescribed medication in
the past. This figure is consistent
with current estimates of the prevalence
of ADHD.
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- The illicit use of stimulant medication
was reported by approximately 4.5%
of students. This included students
who used stimulants that had not
been prescribed as well as students
with a prescription who were also
using the medication inappropriately.
Unfortunately, information on the
frequency of illicit use, means
of administration (swallowing the
pill vs. crushing and snorting),
and reasons for use (to study better
vs. to "get high") was
not obtained.
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- The rate of illicit stimulant
medication use was about 2.5 times
higher among males than females.
Rates were also higher among white
students compared to black students
and among those without college
plans compared to those planning
to attend college.
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- Of the 99 students who reported
taking stimulant medication prescribed
by a physician, 26 also reported
the illicit use of stimulant medication.
This is a concerning finding in
that it indicates that more than
1 in 4 students prescribed ADHD
meds were either taking other stimulants
in addition to their own, or were
misusing the medication they had
been prescribed. Unfortunately,
specific details on the nature of
this illicit use were not provided.
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- Of students who were prescribed
medication, 23.3% reported being
approached to sell, give away, or
trade their medication. Females
(29.6%) were more likely than males
(20.6%) to be approached in this
manner, as were high school students
(46.4%) compared to middle school
students (13.1%). Students without
college plans were nearly twice
as likely to report being approached
as students with college plans (32.4%
vs. 17.9%).
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| The authors were also interested in learning
about other types of substance use and risky
behavior that were associated will illicit
stimulant medication use. Here is what the
authors reported: |
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- Approximately 50% of illicit
stimulant medication users reported
smoking cigarettes in the past month
or binge drinking in the prior 2
weeks compared to only 10% of non-illicit
users.
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- About 50% of illicit stimulant
users reported marijuana use in
the past year and more than 25%
reported ecstasy use. In contrast,
less than 10% of non-illicit users
reported marijuana use and fewer
than 1% reported ecstasy use.
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- Nearly 50% of illicit stimulant
users reported being a passenger
in a car with a driver who had 5
or more drinks before driving. The
figure for non-illicit users was
less than 25%.
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| Although these results clearly indict that
illicit stimulant medication use often co-occurs
with other risky behavior, two points are
important to emphasize. First, there is no
way to determine whether the illicit use of
stimulants played any role in "causing"
increased rates of other alcohol and substance
use. Instead, it is quite likely that students
predisposed to substance use will include
stimulant medications in the substances they
use. Second, the increased rates of drug
and alcohol use were only found among illicit
stimulant medication users - both those
with and without prescriptions. Students
using their prescribed medications as intended
did not differ from students not receiving
stimulant medication on any type of substance
use or risky behavior. Thus, there is absolutely
no indication that the proper medical use
of prescription stimulants is associated
with greater use of other substances.
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** Study 2 - Non-medical
use of prescription stimulants among US college
students
** How
prevalent is the non-medical use of prescription
stimulants among college students? This
question was addressed in a sample of nearly
11,000 students attending 119 nationally
representative 4-year colleges in the US
(McCabe, et al., 2005, Non-medical use of
prescription stimulants among US college
students: Prevalence and correlates from
a national survey. Addiction, 99, 96-106.
The data from this study was collected in
2001.
Two hundred and fifteen students from each
college were randomly selected and sent
a 20-page survey to complete. The survey
asked questions about students' use of prescription
stimulants, use of other substances, and
other health behaviors. The response rate
across the entire sample was 52%, and ranged
from 22-86% at individual colleges. Participants
were assured that their responses would
remain completely confidential so that they
could respond in an open and honest manner.
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| RESULTS |
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| Results of the survey indicated
the following: |
- Approximately 6.9% of college students
reported non-medical use of prescription
stimulants during their lifetime, 4.1%
reported non-medical use in the past year,
and 2.1% in the past month.
- Non-medical use was twice as high among
males, and was also substantially higher
among white students compared to African
Americans or Asians.
- Fraternity/sorority members reported
more than double the use of non-members.
- Use was higher among those with a GPA
of B or below compared to those with a
B+ or above.
- The rate of non-medical use of prescription
stimulants varied dramatically across
colleges, ranging from 0% to 25%. At twenty
schools, the reported past-year use was
0; at 12 schools, the rate exceeded 10%.
This clearly illustrates how much variability
there is across schools.
- Use was highest at colleges with the
most competitive admissions standards
and lowest at the least competitive schools.
More than 80% of schools with a past year
prevalence rate exceeding 10% had highly
competitive admissions standards and were
located in the Northeast or South. Among
all students attending three historically
black colleges, not a single one reported
non-medical use of prescription stimulants
in the past year.
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| As with middle and high school students,
the illicit use of stimulant medication was
associated with other substance use. Thus,
when reporting on their behavior during the
past 30 days, students who used non-prescribed
stimulants were more likely than other students
to: - use cigarettes (67% vs. 24%)
- engage in frequent binge drinking (69%
vs. 21%)
- use ecstasy (19% vs. 1%)
- use cocaine (17% vs. 1%)
- drive after binge drinking (35% vs. 9%)
- be the passenger of a drunk driver (66%
vs. 21%)
Clearly, the non-prescribed use of stimulant
medications is associated with a range of
other substance use and dangerous behavior.
As noted above, there is no way to determine
whether stimulant use has any causal relation
to the use of other substances, or whether
students who are inclined to use substances
simply choose stimulants as one of the substances
that they use. Although not reported in
this paper, another paper by the same research
group indicates that over 50% of non-medical
users stated that they use prescription
stimulants to get high. Improving concentration
and enhancing alertness were the other two
most commonly cited reasons. |
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| SUMMARY
AND IMPLICATIONS |
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| Data from these studies indicate that the
illicit use of stimulant medications is a
significant problem among students from middle
school through college. Although the rate
of non-prescribed use may be lower than what
some articles in the popular press suggest,
the rates found in these studies are alarming
and translate into thousands and thousands
of students who are engaging in this behavior.
Several findings seem to be especially
noteworthy:
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- Middle and high school students
with a prescription for stimulants
are at risk for being approached
to sell, give, or trade their medication.
Many students may not be able to
resist these overtures, and getting
caught engaging in such behavior
could have serious consequences.
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- Individuals who use stimulants
illicitly are far more likely than
others to use other substances.
At this point, we don't know whether
illicit stimulant use facilitates
the use of other substances, or
is simply part of a general pattern
of substance use. Longitudinal studies
will be required to determine this
and need to be conducted.
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- The rate of illicit stimulant
use is quite high at competitive
colleges and many students report
using stimulants in order to get
high. It is thus worth noting that
some medications used to treat ADHD
are far more difficult to abuse
in this way than others.
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- Among middle and high school
students using stimulant medications
as prescribed, there is no evidence
of increased rates of substance
use.
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- Approximately 25% of middle and
high school students with a prescription
for stimulants were also using medication
in inappropriate ways. This is an
especially concerning finding. However,
the extent to which it is representative
of the general population of students
with a prescription for stimulants
is unclear, as it reflects results
obtained in a single school district.
Additional research on this issue
should be conducted.
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| Perhaps the most important implication
of these results is that parents, educators,
and professionals need to be aware that
the risk for the misuse and abuse of
ADHD medications is quite real. The
authors of the middle and high school
student study note that "Physicians
prescribing medication can play an important
role in explaining the abuse potential
of diverting medication to other children."
Given the findings reported above, this
should be a routine part of what is
conveyed to children and teens who are
prescribed such medication. Parents,
educators, and professionals can and
should also educate children/teens
about the appropriate steps to take
if they are approached by peers asking
for medication so that they are prepared
to deal appropriately with this situation
should it arise. Parents may also
with to speak with their child's physician
about medications for ADHD that have
the lowest potential for misuse and
abuse and take appropriate steps to
make sure that their child's medication
is carefully monitored and is not
freely available to their child.
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