Attention Research Update

December 2007

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

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

New Findings on the Misuse of ADHD Medications by College Students

As recently as 10-15 years ago, there was relatively little concern about ADHD medications being diverted, i.e., being given away or sold to those without prescriptions. Currently, however, the misuse and abuse of ADHD medications has become an important concern and it is clear that such diversion is not uncommon.  One setting in particular where the widespread misuse of ADHD medications has been reported to occur is on college campuses, and you have probably seen a number of articles in the media about this issue.

Although such articles can provide an important service by drawing attention to a problem that parents, educators, and health care professionals should be aware of, most offer little actual data may consist of nothing more than case histories and anecdotal reports that can be highly inaccurate. 

Fortunately, there have been several well-conducted studies on the non-medical use of ADHD medications by college students, i.e., the use of ADHD medication by students for whom it is not prescribed,  that have been published over the past several years that have begun to provide solid data on this important issue.  In the largest study of this issue conducted to date, nearly 11,000 students attending 119 nationally representative 4-year colleges in the US were asked about their non-medical use (i.e., use without a prescription) of stimulant medications (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 and participants were assured that their responses would remain completely confidential so that they could respond in an open and honest manner.

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.

* 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%)

- Why do College Students use ADHD Medications Non-Medically? -

In addition to documenting the prevalence of non-medical ADHD medication use by college students, recent studies have examined the reasons why students engage in this behavior.

Results from one study conducted at a large public university in the mid-west found that the motives most commonly reported by students were to help with concentration (58%), to help with alertness (43%), and to “get high” (43%) (Teter, McCabe, Cranford, Boyd, & Guthrie, 2005. Journal of American College Health, 53, 253-262). These results were largely replicated in a second recent study conducted at the same university, where the most commonly reported motives were to help with concentration (65.2%), to help with studying (59.8%), to increase alertness (47.8%) and to “get high” (31%) (Teter, McCabe, LaGrange, Cranford, & Boyd, 2006. Pharmacotherapy, 26, 1501-1510.).  Similar findings from a study conducted at a public university in the northeast have also recently been reported (White, Becker-Blease, & Grace-Bishop, 2006).

Thus, it appears that the majority of non-medical users are motivated to by reasons directly related to enhancing academic performance.  However, use for purely "recreational" reasons is also quite common.

- Limitations of Prior Work -

While these studies have provided important information on the non-medical use of ADHD medications by college students, there are several issues that have not yet been adequately addressed.

First, when inquiring about motives for use, students in these studies were simply asked to check any reason that they had ever taken ADHD medication non-medically, and not to rate the relative importance of different reasons.    Thus, it is hard to know whether using to "get high" is truly a frequent motive for use.

Second, little attention has been paid to how students perceive non-medical use of ADHD medication to affect them and how helpful vs. harmful they perceive this to be.  Such knowledge could be important in efforts to reduce or prevent this behavior from occurring.

Finally, the possibility that at least some students are using ADHD medication non-medically to treat undiagnosed ADHD has not been considered.  Because many individuals with ADHD are never diagnosed or treated, it is possible that some students turn to ADHD medication to address difficulties they experience as undermining their academic success.

- Recent Findings on these Issues -

Recently, my colleagues and I completed a study of these issues at two universities in the southeastern US.  Nearly 4,000 students participated in our web-based survey study, which represented roughly 35% of those invited to participate.  This is a lower participation rate than we had hoped for, but is in the range of other studies of this issue with college students. Students were assured that their responses would remain completely confidential and anonymous so that they could respond freely. Although these results are not yet published, I wanted to share with you some of our preliminary findings.

- Nearly 9% of students reported using ADHD medication without a prescription since beginning college.  About 15% of this group had used more than 10 times during the prior six months.  Most were having it given to them by peers who had a prescription but some were purchasing it from students, not all of who had prescriptions.

- As in the studies noted above, use was higher among whites, among fraternity and sorority members, and among students who engaged in illicit substance use.  Students who used also had lower GPAs.

- By far, the most important reason for taking ADHD medication was to enhance the ability to study outside of class, e.g., to be able to study longer, to be able to concentrate better while studying, and to feel less restless while studying.  Students rarely reported using in order to concentrate better in class. 

- Although roughly 25% of non-medical users had used medication to "get high", this was rated a frequent reason for use by only about 3% of these students.

- Reasons related to enhancing academic performance were the sole reasons for use reported by over 50% of non-medical users.  Over 40% reported using for both academic and non-academic (e.g., to feel better, to get high, to lose weight, to be able to party longer) reasons, and fewer than 10% reported using exclusively for non-academic reasons.

- Most students who use ADHD medication non-medically believe that it is helpful.  Over 70% reported that the overall impact was either "positive" or "very positive" and fewer than 5% rated the impact as negative.  The actual impact on students, however, remains unknown and cannot be answered from our study.

- Reports of adverse effects were common.  About 60% reported that non-medical use contributed to sleep difficulties and appetite reduction and about 50% reported irritability.  More concerning side effects were reported to occur relatively infrequently.  Thus, about 5% believed that using ADHD medication contributed to their use of other substances, and/or resulted in their having to see a doctor, and/or that they sometimes worried about becoming dependent on ADHD medication.

- Are Students Treating their own ADHD Symptoms? -

We were particularly interested to find that students who used ADHD medication non-medically reported significantly higher attention difficulties than other students.  In fact, after controlling for a wide range of factors, including other substance use, students with high rates of self-reported attention difficulties were about twice as likely as other students to report non-medical ADHD medication use.  Nearly 25% reported attention difficulties that were higher than the average score reported by students who indicated a current diagnosis of ADHD.

Interestingly, attention problems did not predict the non-medical use of other prescription medications nor did it predict alcohol use or illicit drug use.  Instead, it was only related to using ADHD medication.

- Summary and Implications -

Data from these studies indicate that non-medical use of ADHD medication is not uncommon among college students.  The most important motives for using ADHD medication is to enhance academic performance, particularly the ability to study outside of class.  Although recreational use also occurs, this is rarely a frequent motive for use.  The majority of students who use ADHD medication non-medically believe that it is beneficial and relatively even though adverse affects are not uncommon. Future studies are needed to try and document what the actual consequences of non-medical use may be.

While it would be an overstatement to suggest that most students who use ADHD medication non-medically are doing so to treat undiagnosed ADHD, our recent data strongly suggests that many non-medical users turn to ADHD medication to address attention difficulties that they experience.  For these students, popular notions of taking ADHD medication in order to "party harder" or to obtain an "academic edge" over their peers do not apply. 

While we cannot determine this from our study, it is very likely that some of these students have undiagnosed ADHD and would benefit from an appropriate evaluation and treatment.  Those who do not actually have ADHD, but who nonetheless experience problems with attention, would also benefit from an evaluation to ascertain the reasons for their attention difficulties so that an appropriate course of action can be undertaken. 

Reducing the non-medical use of ADHD medications by college students is thus likely to require a significant effort to educate students about ADHD, about other problems that can contribute to difficulties with attention, and about the importance of seeking professional assistance for these issues rather than opting for self-medication.  It also points to the ongoing need to develop and test non-medical interventions that can assist children and adults with ADHD.

Finally, given that significant numbers of students seek ADHD medication to enhance their academic performance, as well as for other reasons, the importance of not diverting their medication needs to be emphasized to students for whom it is prescribed.

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.