Misuse & Abuse of ADHD Meds among college students: Updated review of a growing concern

The mis­use and abuse of pre­scrip­tion med­ica­tion is a grow­ing con­cern. I remem­ber speak­ing with col­leagues 15–20 years ago as reports about the non­med­ical use of stim­u­lant med­ica­tions used to treat ADHD (non­med­ical use is defined as use by indi­vid­u­als with­out a pre­scrip­tion) were first appear­ing in the media. At the time, these were gen­er­al­ly thought to be iso­lat­ed inci­dents that were being over-dra­ma­tized in the press.

It has become clear, how­ev­er, that this is not the case today and that the non­med­ical use of ADHD meds, as well as mis­use by indi­vid­u­als for whom med­ica­tion is pre­scribed, is an impor­tant prob­lem. Below is a brief overview and sum­ma­ry of research on these issues.

How com­mon is non­med­ical use of stim­u­lant medications?

Between 2000 and 2011, the annu­al preva­lence of non­med­ical use of amphet­a­mines — this includes drugs used to treat ADHD but is not lim­it­ed to ADHD med­ica­tions — declined from 6.5% to 3.5% among 8th graders, from 11.7% to 6.6% among 10th graders, and from 10.5% to 8.2% among 12th graders. Among col­lege stu­dents, how­ev­er, the rate increased from 6.6% to 9.3%. For non-col­lege adults ages 19–28, the rate also increased — from 5.4% to 7.2%. This data is from the Mon­i­tor­ing the Future Study, an annu­al sur­vey of alco­hol and drug used con­duct­ed with a nation­al­ly rep­re­sen­ta­tive sam­ple. You can find an overview results from the 2011 sur­vey online Here (opens PDF).

These data may under­es­ti­mate non­med­ical use of ADHD stim­u­lants because the MTF sur­vey does not inquire about all wide­ly pre­scribed med­ica­tions and indi­vid­u­als using med­ica­tions not men­tioned may inad­ver­tent­ly fail to men­tion non­med­ical use.

How fre­quent­ly do indi­vid­u­als engage in non­med­ical use?

Pub­lished research on the fre­quen­cy of non­med­ical use has focused on col­lege stu­dents. Results obtained from a nation­al­ly rep­re­sen­ta­tive data base of col­lege stu­dents indi­cat­ed 32% of non­med­ical users had used only once in the pri­or year, 45% used 2–10 times, and 19% used 11 or more times 15. In a study of adults in the gen­er­al pop­u­la­tion, 30% of non­med­ical users report­ed using only 1–2 times per year while 70% report­ed using 3 or more times.

Although most indi­vid­u­als who use non­med­ical­ly do so through oral routes of admin­is­tra­tion only, reports of crush­ing and snort­ing are not uncom­mon. In fact, this was report­ed by near­ly 20% of non­med­ical users in one recent­ly pub­lished study of col­lege students.

Where do those with­out pre­scrip­tions get medication?

The vast major­i­ty of non­med­ical users among col­lege stu­dents obtain med­ica­tion from a friend with a pre­scrip­tion. And, results from sev­er­al stud­ies indi­cate that stu­dents with pre­scrip­tions are com­mon­ly approached by peers ask­ing for their meds. Research with mid­dle school and high school stu­dents makes clear that younger stu­dents are also approached for their meds, although at what appears to be a low­er rate than for col­lege students.

Feign­ing ADHD to obtain med­ica­tion is also a grow­ing con­cern. Stud­ies with col­lege stu­dents sug­gest that many who self-refer for an ADHD eval­u­a­tion exag­ger­ate their symp­toms, per­haps to obt­ian stim­u­lant med­ica­tion. In a study of non-col­lege adults, 20% of those who used non­med­ical­ly report­ed that they had ‘faked’ ADHD to obtain a pre­scrip­tion from a physician.

What are the char­ac­ter­is­tics of non­med­ical users of ADHD medication?

Reports in the pop­u­lar press some­times imply that tak­ing ADHD med­ica­tion with­out a pre­scrip­tion has become almost ‘nor­mal’ behav­ior for col­lege stu­dents, part of a ‘work hard, play hard’ lifestyle. Research does not sup­port this view, however.

Mul­ti­ple stud­ies con­duct­ed with col­lege pop­u­la­tions indi­cate that com­pared to their peers, non­med­ical users:

- have high­er rates of drug and alco­hol use.
— per­form less well academically.
— are more con­cerned about their abil­i­ty to suc­ceed academically.
— report sig­nif­i­cant­ly greater prob­lems with attention.

High­er rates of sub­stance use has also been found among non­med­ical users of ADHD med­ica­tion in the gen­er­al adult population.

Thus, rather than being nor­ma­tive behav­ior, it appears that many indi­vid­u­als engag­ing in non­med­ical use also mis­use oth­er sub­stances and/or feel that atten­tion prob­lems are under­min­ing their abil­i­ty to be successful.

What are the main moti­va­tions for non­med­ical use of ADHD medications?

Most research on the motives for non­med­ical use has been con­duct­ed with col­lege stu­dents. Among stu­dents, the pri­ma­ry moti­va­tion for most non­med­ical users is to enhance aca­d­e­m­ic per­for­mance, espe­cial­ly the abil­i­ty to concentrate/focus while study­ing. How­ev­er, oth­er motives are also report­ed by a sig­nif­i­cant minor­i­ty of indi­vid­u­als, includ­ing using to ‘get high’.

Less is known about motives for use out­side of col­lege pop­u­la­tions. In one study using a nation­al­ly rep­re­sen­ta­tive sam­ple of adults, 40% of non­med­ical users indi­cat­ed that their pri­ma­ry motive was to ‘be more pro­duc­tive’. Anoth­er 13% report­ed that their pri­ma­ry motive was to ‘feel good or get high’.

What are the con­se­quences of non­med­ical use of ADHD medication?

The vast major­i­ty of col­lege stu­dents who engage in non­med­ical use to enhance their aca­d­e­m­ic per­for­mance believe that it is help­ful. In one study, 70% rat­ed the over­all impact of non­med­ical use as being either ‘pos­i­tive’ or ‘very pos­i­tive’ and only 5% rat­ed the over­all impact as ‘neg­a­tive’ or ‘very negative’.

This is strik­ing because there is no data on whether non­med­ical use actu­al­ly improves aca­d­e­m­ic per­for­mance. One recent review con­clud­ed that “…the cog­ni­tive effects of stim­u­lants on healthy adults can­not yet be char­ac­ter­ized definitively…”

Fur­ther­more, most work on this issue is con­duct­ed in lab set­tings and exam­ines the impact of stim­u­lant med­ica­tion on research mea­sures of cog­ni­tive per­for­mance. Whether tak­ing stim­u­lants to pull an ‘all nighter’ improves exam per­for­mance the next day is unknown. In fact, a plau­si­ble hypoth­e­sis is that stu­dents who delay study­ing because they expect stim­u­lants to help them cram the night before would per­form worse than if they pre­pared using a more rea­son­able schedule.

Adverse con­se­quences

Side effects — Although most stu­dents in the study men­tioned above report­ed over­all pos­i­tive effects of non­med­ical use, adverse events were also fre­quent­ly report­ed. These includ­ed sleep dif­fi­cul­ties (report­ed by 72%), irri­tabil­i­ty (62%), dizzi­ness and light­head­ed­ness (35%), headaches (33%), stom­achaches (33%), and sad­ness (25%).

In addi­tion, rough­ly 5% believed that non­med­ical use had con­tributed to their using oth­er pre­scrip­tion drugs and illic­it sub­stances. Approx­i­mate­ly 10% report­ed occa­sion­al wor­ries about obtain­ing stim­u­lant med­ica­tion and about becom­ing depen­dent on it. Over 10% believed that they need­ed stim­u­lants to per­form their best aca­d­e­m­i­cal­ly. This does not seem like a use­ful cog­ni­tion to have.

Abuse and depen­dence — The abuse poten­tial of stim­u­lants when used by indi­vid­u­als with­out ADHD has been doc­u­ment­ed in mul­ti­ple stud­ies, although this is reduced in longer-act­ing for­mu­la­tions. Although infor­ma­tion on how often non­med­ical use of ADHD stim­u­lants meets cri­te­ria for stim­u­lant abuse or stim­u­lant depen­dence is lim­it­ed, data from the 2002 Nation­al Sur­vey on Drug Use and Health showed that near­ly 5% of indi­vid­u­als report­ing past-year use of ADHD med­ica­tions met screen­ing cri­te­ria for these disorders.

Adverse reac­tions — Between 2005 and 2010 the num­ber of emer­gency depart­ment vis­its result­ing from the non­med­ical use of stim­u­lant drugs near­ly tripled, from 5,212 to 15,585. The num­ber of emer­gency depart­ment vis­its linked to adverse reac­tions to pre­scribed ADHD stim­u­lants near­ly dou­bled, from 5,085 vis­its to 9,181 visits.

Thir­ty-sev­en per­cent of all emer­gency depart­ment vis­its relat­ed to stim­u­lant med­ica­tion involved stim­u­lant med­ica­tions exclu­sive­ly; the remain­der involved use in com­bi­na­tion with oth­er drugs – fre­quent­ly oth­er phar­ma­ceu­ti­cals — and alcohol.

What about the mis­use and diver­sion of pre­scribed medication?

The mis­use of stim­u­lant med­ica­tion by those with a pre­scrip­tion is also a concern.

Although most indi­vid­u­als use their pre­scribed stim­u­lant med­ica­tion appro­pri­ate­ly, use in ways that devi­ate from those intend­ed by the pre­scrib­ing clin­i­cian is not uncom­mon. This gen­er­al­ly takes the form of tak­ing med­ica­tion at high­er dos­es or more fre­quent­ly than pre­scribed, which has been report­ed by between 27% and 36% of col­lege stu­dents across sev­er­al stud­ies. How­ev­er, up to 25% of col­lege stu­dents have report­ed using pre­scribed ADHD med­ica­tion to get high and up to 30% have report­ed using in con­junc­tion with alco­hol and/or oth­er drugs.

Sim­i­lar to what has been found for non­med­ical users, aca­d­e­m­ic enhance­ment was the most fre­quent­ly report­ed motive and most col­lege stu­dents mis­us­ing for this pur­pose felt that it was help­ful. Nonaca­d­e­m­ic rea­sons for mis­use, e.g., to feel bet­ter or to lose weight, were report­ed as fre­quent rea­sons for mis­use by rel­a­tive­ly few stu­dents. Data on motives for mis­us­ing pre­scribed med­ica­tion out­side of col­lege sam­ples is limited.

As not­ed above, diver­sion of pre­scribed stim­u­lant med­ica­tion is a sig­nif­i­cant prob­lem. In stud­ies of col­lege stu­dents, giv­ing away or sell­ing med­ica­tion to peers has been report­ed by 26% in the pre­vi­ous 6 months, 35% in the pre­vi­ous 12 months, and 62% in their life­time. Diver­sion of pre­scribed stim­u­lants – gen­er­al­ly to friends and rel­a­tives – was also report­ed by a sig­nif­i­cant minor­i­ty of non-col­lege adults.

Con­clu­sions

Con­cerns about the non­med­ical use of stim­u­lant drugs used to treat ADHD are war­rant­ed, with near­ly 10% of col­lege stu­dents report­ing this is a recent nation­al sur­vey; in some stud­ies, the rates are far higher.

Although rel­a­tive­ly infre­quent use is most com­mon, per­haps 20% of non­med­ical users do so reg­u­lar­ly and engage in intranasal routes of admin­is­tra­tion. Rough­ly 5% of non­med­ical users may meet cri­te­ria for stim­u­lant abuse or stim­u­lant depen­dence and emer­gency depart­ment vis­its asso­ci­at­ed with non­med­ical use are increasing.

In addi­tion to non­med­ical use, many indi­vid­u­als with pre­scrip­tions for ADHD med­ica­tion occa­sion­al­ly mis­use their med­ica­tion by tak­ing it in high­er dos­es or with greater fre­quen­cy than pre­scribed; some also use intranasal­ly to ‘get high’ and/or in con­junc­tion with oth­er drugs or alco­hol. As with non­med­ical use, this is asso­ci­at­ed with high­er rates of oth­er sub­stance use. Divert­ing med­ica­tion to friends and fam­i­ly mem­bers is not uncom­mon and many are approached to do so, plac­ing them at repeat­ed risk for engag­ing in ille­gal behavior.

To address these issues, physi­cians should instruct patients about the abuse poten­tial of their med­ica­tion, the need to store it in a secure loca­tion, and obtain a com­mit­ment not to divert it. Chil­dren and ado­les­cents may need coach­ing on how to respond if approached by peers seek­ing their medication.

Col­leges should con­sid­er revis­ing their con­duct poli­cies to address the mis­use and diver­sion of ADHD med­ica­tion, pro­vide stu­dents with secure stor­age places, and edu­cate stu­dents about the poten­tial dan­gers asso­ci­at­ed with non­med­ical use, espe­cial­ly when used with alco­hol and oth­er substances.
– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Ref­er­ences — Infor­ma­tion pro­vid­ed above is drawn from the fol­low­ing sources among others.

• Arria AM, Gar­nier-Dyk­stra, KM, Caldeira, KM, et al.: Per­sis­tent non­med­ical use of pre­scrip­tion stim­u­lants among col­lege stu­dents: Pos­si­ble asso­ci­a­tion with ADHD symp­toms. J Atten Dis­ord 2011, 15:347–356.
• Dupont RL, Cole­man JJ, Buch­er RH, Wil­ford BB. (2008). Char­ac­ter­is­tics and motives of col­lege stu­dents who engage in non­med­ical use of methylphenidate. The Amer­i­can Jour­nal on Addic­tions 2008, 17:167–171.
• Gar­nier-Dyk­stra LM, Caldeira, KM, Vin­cent, KB, et al.: Non­med­ical use of pre­scrip­tion stim­u­lants dur­ing col­lege: Four year trends in expo­sure oppor­tu­ni­ty, use, motives, and sources. J Am Col­lege Health 2012, 60:226–234. One of the few lon­gi­tu­di­nal stud­ies of non­med­ical use of stimulants.
• John­ston LD, O‑Malley PM, Bach­man, JG, et al.: Mon­i­tor­ing the Future nation­al sur­vey results on drug use, 1975–2011: Vol­ume II, Col­lege stu­dents and adults ages 19–50. Ann Arbor: Insti­tute for Social Research, The Uni­ver­si­ty of Michi­gan. Includes recent nation­al data on non­med­ical use of stim­u­lant medications.
• McCabe SE, Teter, CJ. Drug use relat­ed prob­lems among non­med­ical users of pre­scrip­tion stim­u­lants: a web-based sur­vey of col­lege stu­dents from a Mid­west­ern uni­ver­si­ty. Drug Alco­hol Depen 2007, 91:69–76.
• Novak SP, Kroutil LA, Williams RL, Van Brunt DL. The non­med­ical use of pre­scrip­tion ADHD med­ica­tions: Results from a nation­al Inter­net pan­el. Sub­stance Abuse Treat­ment, Pre­ven­tion, and Pol­i­cy 2007, 2:32.
• Peterkin, AL, Crone CC, Sheri­dan MJ, Wise, TN (2010). Cog­ni­tive per­for­mance enhance­ment: Mis­use or self-treat­ment? J Atten Dis­ord 2010, 15:263–268.
• Rabin­er, DL, Anastopoulus AD, Costel­lo EJ et al.: Motives and Per­ceived Con­se­quences of Non­med­ical ADHD Med­ica­tion Use by Col­lege Stu­dents: Are stu­dents treat­ing them­selves for atten­tion prob­lems? J Atten Dis­ord 2009a, 13:259–270. Care­ful exam­i­na­tion of motives for non­med­ical use and asso­ci­a­tion of non­med­ical use with atten­tion problems.
• Rabin­er DL, Anastopoulus AD, Costel­lo, EJ et al.: The mis­use and diver­sion of pre­scribed ADHD med­ica­tions by col­lege stu­dents. J Atten Dis­ord 2009, 13:144–153.
• Sepul­ve­da DR, Thomas LM, McCabe, SE, et al.: Mis­use of pre­scribed stim­u­lant med­ica­tion for ADHD and asso­ci­at­ed pat­terns of sub­stance use: Pre­lim­i­nary analy­sis among col­lege stu­dents. Jour­nal of Phar­ma­cy Prac­tice 2011, 24:551–560.
• Sul­li­van, BK, May K, Gal­bal­ly L. Symp­tom exag­ger­a­tion by col­lege adults in atten­tion-deficit hyper­ac­tiv­i­ty dis­or­der and learn­ing dis­or­der assess­ments. Appl Neu­ropsy­chol 2007, 14:189–207.
• Upad­hyaya HP, Rose K, Wang W, Brady KT. Atten­tion-deficit/hy­per­ac­tiv­i­ty dis­or­der, med­ica­tion treat­ment, and sub­stance use pat­terns among ado­les­cents and young adults. J Child Ado­lesc Psy­chophar­ma­col 2005, 15:799–809.