Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
To determine patterns and knowledge of nonmedical use of stimulants among a sample of college students.
Completion of an anonymous survey consisting of 23 questions designed to explore college student use of medications intended to treat attention-deficit/hyperactivity disorder.
A private liberal arts college in New England.
Three hundred forty-seven undergraduate students.
Main Outcome Measure
Nonmedical use of stimulants.
Thirty-one students (9.2%) reported nonmedical stimulant use. Two hundred forty students (71.4%) had peers who used nonprescribed stimulants, 149 (44.3%) knew of peers who made stimulant medication–seeking visits to a physician although they did not believe that they had attention-deficit/hyperactivity disorder, and 178 (53.0%) knew of people who sold stimulants to students. Nonprescription users were significantly more knowledgeable about the effects of stimulants than nonusers, and nonusers whose peers used nonprescribed stimulants were more knowledgeable about the effects of stimulants than nonusers whose peers did not use nonprescribed stimulants. After controlling for age, race, and sex, the variables that predicted nonmedical use of stimulants were beliefs that stimulants help individuals study better, stay awake, and lose weight.
A substantial proportion of college students in this sample were using nonprescribed stimulants. Among nonusers, those whose peers use nonprescribed stimulants were much more knowledgeable about the effects of stimulant use than those whose peers do not use stimulants. This knowledge may confer an increased risk of future nonmedical stimulant use if students become tempted to seek the beneficial effects experienced by their peers.
Attention-deficit/hyperactivity disorder (ADHD) is characterized by symptoms of inattention and/or hyperactivity-impulsivity that cause impairments in executive function and learning ability that generally persist into adult life.1 The effectiveness of stimulants on the behavior of hyperactive children was first observed in the 1930s, and use of these medications has been well established for the treatment of ADHD.2- 4 Between 1990 and 1995, there was a 9-fold increase in the population-adjusted rate of ADHD-related stimulant medication prescriptions.5 During the same period, increased nonmedical use of stimulant medications was also noted. The Monitoring the Future Survey6 found that the annual prevalence of nonmedical use of Ritalin (methylphenidate hydrochloride) among nationally representative samples of high school seniors increased substantially from 0.1% in 1992 to 2.8% in 1998, and then declined slightly to 2.3% in 2003. However, responses to a new question using a different format to ask about Ritalin use on the 2003 version of the Monitoring the Future Survey documented a higher annual prevalence of 4.0%.6 The biological mechanism associated with methylphenidate abuse was established in a review of 60 studies showing that methylphenidate functions in a manner similar to dextroamphetamine or cocaine. Both methylphenidate and cocaine block the dopamine transporter, producing comparable increases in synaptic dopamine levels.7 However, stimulant medications are noteworthy in that individuals without ADHD may experience beneficial effects similar to those of individuals with ADHD.8
Both the abuse and misuse of stimulant medications by normal college students have received a considerable amount of attention in the lay press. Increasing numbers of reports have chronicled student use of stimulants as study aids9- 16 and for recreational purposes.9,11- 14,17 The trend of students giving away and/or selling their prescribed stimulant medications to other students has recently been noted.11- 14,16 College students seeking stimulants inappropriately from college health services has been reported as well.16
The issue of nonmedical use of stimulants has not received as much attention in the medical literature as might be expected. Nevertheless, several reports have documented a problem. Nationally representative samples of 6th through 12th-grade students have shown annual prevalence rates of 4% and 4.5% for nonmedical use of methylphenidate.18,19 Nonmedical use of stimulants among college students has also been demonstrated. More than 16% of students at a public liberal arts college reported trying methylphenidate recreationally,20 and 3% of students surveyed at a large public university admitted to past-year nonmedical use of methylphenidate.21 A recently published study of students at a midwestern university revealed that 17% of men and 11% of women reported nonmedical use of stimulants.22 Student distribution of stimulant medications has been described as well. Samples of students in grade school and high school have demonstrated rates of 16% and 23% for being approached to sell, give, or trade their prescription stimulant medications.19,23 Furthermore, not only are students approached, but some actually engage in the distribution of stimulant medication, with 14.7% reporting having given away medication and an additional 7.3% having sold their medication.24
Such reports are concerning and suggest that further research is needed to examine and address the nonmedical use of stimulant medications among children and young adults. The present study was undertaken to further explore nonmedical use of stimulant medication among college students. This study goes beyond existing work in that it investigates students' beliefs about the effects of stimulant medications and analyzes trends within peer groups.
A survey consisting of 23 questions about college student use of medications intended to treat ADHD was developed and a pilot survey conducted on 15 young people. Face validity was checked during the administration pilot to ensure that the questions were interpreted with the same meanings as we intended. The survey was administered at a private liberal arts college with a student enrollment of approximately 6000. A cover sheet emphasized that participation was voluntary and that the surveys were completely anonymous and could not be traced back to the student. Students were offered candy to thank them for participating.
Participants were recruited from large lecture hall classes. Once the professor concluded the lecture, a brief announcement was made asking for volunteers to complete a survey. Surveys were then distributed to the entire class; 347 surveys were collected. The manner in which the surveys were distributed precluded the calculation of an exact response rate. A stack of surveys was handed to the person seated at the end of each row and passed along the row. Students who did not want to participate could pass the stack without taking a survey. The response rate is estimated at approximately 80%. Both the University of Massachusetts institutional review board and the institutional review board at the participating college approved the protocol for this study.
Demographic questions included age, sex, and race/ethnicity. Students were then asked if they had ever been diagnosed as having ADHD. The next set of questions asked if they had ever visited a physician because they believed that they might have ADHD, to obtain a prescription for ADHD medication because they believed that they had ADHD, or to obtain a prescription for ADHD medication to help them study or for reasons other than believing that they had ADHD. The questions on ADHD medications listed examples including Adderall (amphetamine and dextroamphetamine) and Ritalin and Concerta (methylphenidate). The survey went on to determine if students had ever used ADHD medications without a prescription, if they had knowledge of peers who used ADHD medications to help them study despite not having ADHD or who had visited a physician to obtain a prescription for ADHD medication despite not believing that they had ADHD, and if they had knowledge of individuals selling ADHD medications to students. Finally, students were then asked to indicate if each of 10 statements about ADHD medications was true or false.
Descriptive analyses included frequencies, means, and standard deviations. Bivariate analyses included the Fisher exact test to compare responses among various groups and the Spearman rank correlation. Binary logistic regression models, in which the outcome was coded as nonmedical use vs nonuse, were used to identify predictors associated with nonmedical use of stimulants.
General characteristics of the sample are described in Table 1. Eleven (3%) of the survey respondents reported receiving an actual ADHD diagnosis, and 10 (2.9%) had received a prescription for stimulants. The remaining analyses were performed for the 336 students who did not report having been given an ADHD diagnosis. Thirty-one (9.2%) reported using nonprescribed stimulants. Three students acknowledged visiting a physician seeking ADHD medications although they believed that they did not have ADHD, 240 (71.6%) knew of peers who used nonprescribed stimulants, 149 (44.3%) knew of peers who had visited a physician to get a prescription for ADHD medication despite not believing that they had ADHD, and 178 (53.0%) knew of people selling ADHD medications to students.
Students who identified themselves as white were significantly more likely than students of other backgrounds to know peers who used nonprescribed stimulants (Fisher exact test; P = .001) and to know peers who visited physicians seeking stimulants despite not believing that they had ADHD (P≤.001). There were no significant differences between men's and women's responses to any of the questions, with 1 exception. Women were more likely than men to agree that stimulant medications help people lose weight (P = .004).
Table 2 describes associations between nonmedical use of stimulants and other characteristics. When nonusers were further subdivided into those whose peers used nonprescribed stimulants and those whose peers did not use nonprescribed stimulants, members of the former group were more likely to know peers who sought stimulants from physicians for nontherapeutic uses (P<.001) and to know of people who sold ADHD medications to students (P = .004).
Table 3 includes the 10 statements used in the survey, and participants were divided into 3 subgroups: (1) nonprescription users, (2) nonusers with nonprescription use among peers, and (3) nonusers without nonprescription use among peers. As demonstrated in Table 3, the efficacy of stimulants in helping one study longer, study better, stay awake, and lose weight was endorsed most strongly by nonprescription users, followed by nonusers whose peers used nonprescribed stimulants. Nonusers whose peers did not use nonprescription stimulants provided the weakest endorsement for these statements. The same trend in the reverse direction was found for beliefs regarding stimulant use and relaxation. Nonprescription users were least likely to agree that stimulants promote relaxation, whereas nonusers whose peers did not use nonprescribed stimulants were the most likely to believe that these agents promoted relaxation. No significant trends were found among groups for the endorsement of false statements about stimulant effects, such as stimulants promoting improved sports performance, complexion, or muscle growth.
Table 4 indicates that in the multivariate logistic regression model, after controlling for age, race, and sex, nonprescribed stimulant use was independently predicted by the endorsement of 3 statements about stimulants: that they help one study better, help one stay awake, and help one lose weight. The regression accounted for 8% of the variability in response to nonprescribed stimulant use. The C statistic of 0.771 demonstrated reasonable goodness of fit.
The results of this study demonstrate that nonmedical use of stimulants is occurring among some groups of college students. It is concerning not only that nearly 10% of students reported nonmedical use of stimulants, but also that 71.7% reported nonmedical use of stimulants among their peers and 53.3% knew of people selling ADHD medications to students. These estimates suggest that nonmedical use of stimulants has become a relatively common aspect of student life on this college campus. Although the anonymity of the survey was emphasized to participants, students may have felt more comfortable reporting nonprescription stimulant use by “peers” rather than their own use, so the true percentage of students using nonprescribed stimulants may be even higher than reported.
We were surprised that only 3% of our sample reported having an ADHD diagnosis. Possible explanations for this finding include that surveys were collected in large lecture halls, and perhaps students with ADHD are less likely to attend class or perhaps those who do attend are less likely to stay to complete a survey. It has been reported that young adults with ADHD are less likely to graduate from college,25 which could be due to lower rates of class attendance. Additionally, the public setting in which surveys were filled out may have made students with ADHD self-conscious about acknowledging their diagnosis.
The low rate of reported ADHD diagnoses also raises the possibility that ADHD has been underdiagnosed among this sample of college students. A recent study by Faraone et al26 found that only 25% of adults diagnosed as having ADHD received the diagnosis during childhood or adolescence.
To our knowledge, this is the first study that describes the phenomenon of students seeking stimulant medications from health care professionals for nontherapeutic purposes. Only 1.2% of students acknowledged engaging in this behavior themselves, yet almost half of the students (44.7%) knew of peers who had done so. These figures underscore the importance of health care professionals seeking corroborating data from parents, teachers, and previous health care professionals if at all possible when college students schedule an appointment to discuss symptoms of ADHD. Of course, students must be willing to provide consent to allow disclosure of relevant information to prevent any breach of patient confidentiality.
Our findings also demonstrate that nonprescription users were more likely than nonusers to have visited a physician to obtain stimulant medications for nonmedical uses. However, some of the nonprescription users endorsed a belief that they had ADHD. Therefore, it is possible that a subgroup of the nonprescription users had undiagnosed ADHD. In their study, Faraone et al26 found that more than half of the sample they studied with undiagnosed ADHD had previously discussed their symptoms with health care professionals; furthermore, 7 of their top 10 reasons for self-referral were signs or symptoms of ADHD. This suggests that the nonprescription users in our study may be a heterogeneous group composed of students with untreated ADHD as well as students seeking an unfair advantage. Medical encounters with these students could offer health care professionals the opportunity for education and intervention for both types of students. Given that undiagnosed ADHD and inappropriate stimulant-seeking behavior are potential problems on college campuses that require considerably different treatment responses, the results of this study highlight the need for increased awareness of this issue by college health care professionals.
This study demonstrates that nonmedical use of stimulants clusters within peer groups. Nonprescription stimulant users were more likely than nonusers to know peers with nonprescription use, to know peers who visited a physician to obtain stimulants, and to know people who sell ADHD medications to students. Likewise, nonusers whose peers used nonprescribed stimulants were more likely than nonusers whose peers did not use nonprescribed stimulants to know of peers visiting physicians to seek stimulants inappropriately and to know of people selling ADHD medications to students.
To our knowledge, this is also the first study to examine the beliefs of college students regarding the effects of ADHD medications. Although it may not be surprising that nonprescription users were significantly more knowledgeable about stimulant effects than nonusers, it is interesting that nonusers whose peers use nonprescribed stimulants were significantly more knowledgeable about stimulant effects than nonusers whose peers did not use nonprescribed stimulants. It appears that nonusers whose peers use nonprescribed stimulants are more likely to hold beliefs that may increase their risk for future nonprescribed stimulant use. They may be learning about the effects of stimulants from their peers, either through report or through direct observation. These nonusing students may be at higher risk themselves if they become tempted to try stimulants based on the benefits reported by their peers.
The recent findings of Hall et al22 support our contention that students whose peers use nonprescription stimulants may be at heightened risk for future nonmedical use themselves. Their analysis revealed that for both men and women, knowing peers who used nonprescribed stimulants predicted nonprescription use. Additionally, knowing how to acquire stimulants easily was a factor predicting men's use, and being offered stimulants by another student was a factor predicting women's use.22 Our finding that students whose peers use nonprescribed stimulants were more likely to know of individuals selling ADHD medications to students extends the findings of Hall and colleagues. It is plausible that having peers who use nonprescribed stimulants might increase the likelihood of being offered stimulants by another student.
There are several limitations to this study. The disproportionate recruitment of female respondents (61.3%) suggests that there may have been a sex selection bias. Since other groups have reported higher rates of nonmedical use of stimulants among men than women,22 the disproportionate number of female respondents in this study may have resulted in lower overall rates of students endorsing nonmedical use of stimulants, and it may also explain why we did not find differing rates of stimulant use among men and women.
Although our results may not be generalizable to other colleges or geographic regions, they do complement the results of studies conducted on other college campuses. A study undertaken at another Eastern liberal arts college reported higher rates of recreational methylphenidate use,20 whereas a survey at a midwestern public university found lower rates of nonmedical use of methylphenidate.21 On the other hand, a study from another midwestern university found higher rates of nonmedical use of stimulants but lower rates of students whose peers used nonprescribed stimulants when compared with the results of this study.22 Geographic variation in prescription stimulant use has been recognized27 and may parallel geographic variation in nonmedical use of stimulants given that the latter has been associated with increased numbers of students giving away or selling their prescription stimulant medication.24
Additionally, this study did not address duration or frequency of use. Thus, it is not known whether the nonprescription users in this study were taking stimulants regularly or only on occasion. Also, the circumstances of how students began nonmedical use of stimulants and the sources students used to procure stimulants were not examined.
Finally, the method of survey distribution created some limitations. It would have been preferable to approach students in such a manner that a precise response rate could be calculated. However, the practicalities of distributing surveys in lecture halls quickly enough to encourage participation precluded gathering the necessary data. In addition, as with any study in which potential subjects are offered an incentive to encourage participation, the possibility exists that we inadvertently created bias by offering students candy. Candy was chosen as an incentive because it is inexpensive, portable to lecture halls, and unlikely to be considered coercive. A bowl of candy was placed at the lecture hall exit and was not monitored. Since taking candy was not contingent on completing a survey, and eating candy was not required to participate, it is unlikely that the offer of candy biased our results.
Additional research is needed to better understand the scope of nonmedical use of stimulants among college students nationally and to determine geographic variation. More detailed information from nonprescription stimulant users regarding their decisions to begin using stimulants, their interactions with the medical community, and their sources of stimulants will be helpful in designing interventions to combat this problem. College health services should also consider initiating campaigns to educate undergraduates regarding the potential dangers of inappropriate stimulant use, including the possibility of nonmedical use of stimulants serving as a gateway to other illicit drug use. Such efforts could potentially be helpful in reaching students at heightened risk for nonmedical use of stimulants, such as those whose peers use nonprescribed stimulants, before nonmedical use of stimulants is initiated.
Correspondence: Diane R. Blake, MD, University of Massachusetts Medical School, Department of Pediatrics, 55 Lake Ave N, Worcester, MA 01655 (Diane.Blake@umassmed.edu).
Accepted for Publication: October 9, 2005.
Carroll BC, McLaughlin TJ, Blake DR. Patterns and Knowledge of Nonmedical Use of Stimulants Among College Students. Arch Pediatr Adolesc Med. 2006;160(5):481-485. doi:10.1001/archpedi.160.5.481