By Elbert Mets
“Finally! Schoolwork that matches his intelligence,” reads the tagline to an advertisement for Adderall, featuring a young, smiling boy in the back- ground. Another ad reads, “In the management of ADHD, reveal his potential. Adderall XR® improves academic performance.” Pharmaceutical companies and popular media often characterize Attention Deficit Hyperactivity Disorder (ADHD) medications such as Adderall as wonder drugs that can supercharge patients’ academic and social lives. Because these drugs can enhance performance in ADHD patients, many people, especially college students, incorrectly assume that these drugs should work in undiagnosed individuals too. It is important for students to gain awareness of the misconceptions surrounding the use and abuse of these drugs in order to avoid health and legal risks.
In recent years, the rate of ADHD diagnosis has risen sharply.1,2 ADHD, a condition marked by inattention, hyper- activity, and impulsive behavior, often appears during childhood and can continue into adulthood.1,2,3,4 In the US, the rate of ADHD diagnosis in children ages 4 to 17 has seen more than a 40% increase from 2003 to 2011.1 By 2011, at least 6.4 million, or 11%, of American children in this age group had been diagnosed with ADHD.2
The prevalence of ADHD treatment has mirrored the rising rate of diagnosis, with 60% of diagnosed children receiving treatment.4 The disorder is typically treated using stimulants such as Adderall (amphetamine-dextroamphetamine), Ritalin (methylphenidate), and Dexedrine (dextroamphetamine).5 A controlled trial comparing stimulant medication, community care, behavioral therapy, and combined medication-behavioral therapy revealed that stimulant medication was a very effective method in mitigating ADHD symptoms.4,6,7 However, it was observed that combining stimulant medication with medication-behavioral therapy resulted in an even stronger social and behavioral improvement compared to the medication alone.7 Despite these observed benefits, pharmaceutical companies have largely disregarded the study’s results, marketing medication alone as the superior ADHD treatment.8
ADHD symptoms are thought to result, in part, from a shortage of dopamine, a neurotransmitter important in the nervous system’s pathways responsible for producing feelings of satisfaction and fulfillment.4,9 This shortage in ADHD patients is caused by a high density of active transporters that remove dopamine from the brain. Prescription stimulants raise dopamine levels in the brain by inhibiting the ability of the transporter to remove the dopamine, thus improving focus in ADHD patients.4,10 Unfortunately, these medications, touted to bolster concentration, are frequently abused by nonprescription users. Improper use of ADHD medications, like Adderall, is especially observed among college students.
Misuse of prescription stimulants on college campuses is a major concern.4 Abuse rates range across colleges; 6.9 to 34% of undergraduate students re- port illicit use of prescription stimulants during their lifetimes.5, 12, 13 Frequently cited reasons for stimulant misuse include improving concentration and alertness when studying and attaining a “high” akin to that of cocaine.4, 13 Despite widespread use in universities, many illicit users of prescription stimulants are unaware of the effects of these drugs.11 Students who use stimulants often rely on friends’ testimonials rather than medical literature in their assessments of the drug’s risks.11 Further- more, the prescription of these medications for ADHD patients by doctors can lead people to falsely believe these drugs are safe for anyone to consume.11
The United States Drug Enforcement Agency rates medications and recreational drugs on a scale of Schedules from 1-5. Schedule 1 drugs (e.g. hero- in, LSD) have the highest potential for abuse and no accepted medical use, while Schedule 5 drugs have defined medicinal purposes and lower potential for abuse.14 Despite the drugs’ benign portrayal, the Drug Enforcement Agency classifies prescription stimulants as Schedule 2, grouping them with the likes of cocaine and methamphetamine.14 This classification underscores the fact that stimulants have a “high potential for abuse” and can lead to “severe psychological or physical dependence.”14 Additionally, the penalty for distribution or possession of these medications without prescriptions can be up to twenty years of imprisonment and up to one million dollars in fines.15 In practice, a conviction for small-scale distribution or possession of these stimulants would likely be less sever, though such a conviction can still be damaging to aspiring professionals.
Despite the consequences of the illegal distribution and possession of these drugs, students report that prescription stimulants are readily available on college campuses.11 Surveys indicate that over 20% of undergraduates with prescriptions for stimulants have sold them to their peers, and more than 50% of these students have been asked to do so.4, 12
Students use prescription stimulants largely for their perceived academic benefits. A survey of 689 undergraduates from the University of Michigan revealed that 58% of stimulant misusers do so to enhance concentration, 43% to increase alertness, and 43% abuse the drugs to achieve a stimulant-induced “high.”13 A Brigham Young University examination of tweets mentioning Adderall use showed an increase in stimulant-related tweets during December and May – college final exam periods.16
Among college students, prescription stimulant misuse differs across demographic groups. It is highest among Caucasian fraternity and sorority members who are struggling academically and attend selective colleges in the northeastern United States.12 Students who abuse stimulants are also more likely to abuse drugs and alcohol.12
Although popular culture often portrays ADHD medication as harmless, prescription stimulant misuse can have significant health con- sequences. Side effects include seizures, heart problems, and trouble sleeping.4, 11 Additionally, the effects of Adderall on the heart are similar to those of cocaine.17 Both drugs can injure the endothelium, the inner lining of the blood vessels, and in combination with several other harmful effects, can cause heart attacks.17 In addition, alcohol consumption coupled with Adderall use can further increase students’ risk for heart attacks.4, 17 The Brigham Young University study also found that the most frequently reported adverse effects of Adderall use on students were sleep deprivation and loss of appetite.16
Nonprescription consumption of stimulants for academic advancement is also of questionable integrity. For this reason, the use of stimulants to height- en performance in academic settings is now seen as being comparable to the use of anabolic steroids in professional sports.11 In line with this thinking, Duke University recently listed “the unauthorized use of prescription medication to enhance academic performance” under “cheating” in its classification of academic dishonesty.4, 18, 19 This ban could reduce the incidence of these medications’ misuse and in turn limit the frequency of negative side effects.
So, does using stimulant medication without an ADHD diagnosis re- ally improve academic performance? The short answer is no. The majority of studies exploring stimulant use by non- ADHD patients have shown little to no performance gains. Recently published research has demonstrated that stimulants are effective primarily in patients with ADHD and serve to bring patients back to “baseline” rather than bolster already normal performance.4 Additionally, studies have shown that there is a placebo effect among nonprescription users of Adderall. According to a 2011 study published in Experimental & Clinical Pharmacology, certain students became more attentive after receiving a placebo, because they believed they were being given stimulants.4
However, a lot remains unknown about the effects of stimulants in non- ADHD patients, largely due to the fact that stimulant abuse for the sake of enhancement has been stigmatized in medical circles.20 There seems to be a common misconception between concentration and performance; while stimulants may increase alertness or concentration, experiments have failed to show a clear correlation to increased performance. Furthermore, the dangers incurred by stimulant abuse seem to far outweigh possible benefits. While possible gains from drug abuse remain hazy, the risks, both medical and legal, are real.
Ultimately, the nonprescription use of ADHD stimulants such as Adder- all is not effective in improving academic performance in individuals without the disorder. Misusing these medications ex- poses students to medical and legal risks with minimal benefit. It is important that students gain insight into the misinformation that circulate on college campuses regarding the use of ADHD stimulants in order to protect their health, avoid potential legal problems, and maintain academic integrity. ■ MD
- Center for Disease Control and Prevention., Increasing prevalence of parent-reported attention-defi- cit/hyperactivity disorder among children — United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep, 2010. 59(44): p. 1439-43.
- Visser, S.N., et al., “Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States,” 2003-2011. J Am Acad Child Adolesc Psychiatry, 2014. 53(1): p. 34-46.e2.
- National Institute of Mental Health. Attention Deficit Hyperactivity Disorder (ADHD). [cited 2014 June 29]; Available from: <http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disor- der-adhd/index.shtml>.
- Lakhan, S.E. and A. Kirchgessner. “Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects.” Brain Behav, 2012. 2(5): p. 661-77.
- DeSantis, A.D., E.M. Webb, and S.M. Noar. “Illicit use of prescription ADHD medications on a col- lege campus: a multimethodological approach.” J Am Coll Health, 2008. 57(3): p. 315-24.
- Wang, S.S., ADHD Drugs Don’t Boost Kids’ Grades, in The Wall Street Journal. 2013.
- A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity dis- order. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry, 1999. 56(12): p. 1073-86.
- Schwarz, A., A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs, in The New York Times. 2013. p. A11.
- Cherkasova, M.V., et al.. “Amphetamine-induced dopamine release and neurocognitive function in treatment-naive adults with ADHD.” Neuropsychopharmacology, 2014. 39(6): p. 1498-507.
- Wilens, T.E. “Mechanism of Action of Agents Used in Attention-Deficit/Hyperactivity Disorder.” Journal of Clinical Psychiatry, 2006. 67(8): pp.37-39.
- Varga, M.D. “Adderall abuse on college campuses: a comprehensive literature review.” J Evid Based Soc Work, 2012. 9(3): p. 293-313.
- McCabe, S.E., et al. “Non-medical use of prescription stimulants among US college students: preva- lence and correlates from a national survey.” Addiction, 2005. 100(1): p. 96-106.
- Teter, C.J., et al. “Prevalence and motives for illicit use of prescription stimulants in an undergradu- ate student sample.” J Am Coll Health, 2005. 53(6): p. 253-62.
- United States Drug Enforcement Agency. Drug Scheduling. [cited 2014 June 29]; Available from: <http://www.justice.gov/dea/druginfo/ds.shtml>.
- The University of Chicago. Table A: Federal Penalties and Sanctions for Illegal Trafficking and Possession of a Controlled Substance. [cited 2014 June 29]; Available from: https://commonsense.uchicago. edu/page/table-federal-penalties-and-sanctions-illegal-trafficking-and-possession-controlled-substance.
- Hanson, C.L., et al. “Tweaking and tweeting: exploring Twitter for nonmedical use of a psychostimu- lant drug (Adderall) among college students.” J Med Internet Res, 2013. 15(4): p. e62.
- Jiao, X., et al. “Myocardial infarction associated with adderall XR and alcohol use in a young man.” J Am Board Fam Med, 2009. 22(2): p. 197-201.
- Carroll, L. “Conduct policy changes reflect drug abuse.” in The Chronicle. 2011.
- Duke University Student Affairs. Student Conduct: Academic Dishonesty. [cited 2014 June 29]; Available from: http://studentaffairs.duke.edu/conduct/z-policies/academic-dishonesty.
- Oremus, Will. “The New Stimulus Package.” Slate (2013): n. pag. Web. <http://www.slate.com/ar- ticles/technology/superman/2013/03/adderall_ritalin_vyvanse_do_smart_pills_work_if_you_don_t_ have_adhd.html>.