Attention Research Update

May 2005

"Helping parents, professionals and educators stay informed about new research on ADHD"

David Rabiner, Ph.D.  Senior Research Scientist, Duke University


Support for Attention Research Update is provided by Cogmed

Cogmed has developed a computerized training program to improve working memory, which is a frequent problem for children and adults with ADHD.  Research has shown that Cogmed's program can enhance working memory, and that improvements in working memory are associated with reductions in attention and learning problems.  You can learn more at Cogmed.com.  Clinicians interested in learning about the benefits of incorporating working memory training into their practice are invited to request an information package for professionals.

                                    The Abuse and Misuse of ADHD Medications

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:
  • 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 estiamates of the prevalence of ADHD.
  • 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.
  • 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.
  • 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.
  • 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%).

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:
  • 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.
  • About 50% of illicit stimulant users reported marijuana use in the past year and more than 25% reported ecstacy use.  In contrast, less than 10% of non-illicit users reported marijuana use and fewer than 1% reported ecstasy use.
  • 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%

Although these results clearly indicte 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 illict 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. 

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.


RESULTS

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.

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 inclned 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.


SUMMARY AND IMPLICATIONS

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 would translate into thousands and thousands of students nationwide who are engaging in this behavior.

Several findings seem to be especially noteworthy:
  • 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.
  • 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.
  • 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.
  • Among middle and high school students using stimulant medications as prescribed, there is no evidence of increased rates of substance use.
  • 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.

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. 

Thanks again to Cogmed for supporting this issue of Attention Research Update

(c) 2005 David Rabiner, Ph.D.

Information presented in Attention Research Update is for informational purposes only, and is not a substitute for professional medical advice.  Although newsletter sponsors offer products and services that I believe will be of interest to subscribers, sponsorship of Attention Research Update does not constitute a specific endorsement or guarantee of any company's product or services.