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Speed tests – the amphetamine epidemic at US universities

interior-studydrugs3Published in The Age on January 4, 2015.

In the week before university finals, Graham rarely sleeps in his own bed. Some nights, he doesn’t sleep at all. But when he absolutely has to crash, he lies down on a cushioned bench in the campus library, so that he can be certain someone will wake him first thing in the morning. When the lights come on “I get off the couch, go to where my books are, take Adderall, take vitamins, drink water and go again.”

Graham is not his real name, and he does not have attention deficit hyperactivity disorder (ADHD), the condition that the stimulant Adderall is approved to treat. Since his freshman year at Yale, when he obtained a prescription from a doctor back home, he has been taking the drug every day at university. At times of increased stress, he takes double the prescribed dose, or more.

“When I’m under the gun and there’s a big assignment… it gets really unhealthy,” he says. “Every six hours I’m taking another 20mg. It’s brutal. Cognitively you feel fucked, the neurons aren’t really firing but you have no choice.”

Sometimes when he’s been up too long, he needs a sedative to get to sleep. But although he knows that the cycle of uppers and downers is no good for him, he has few doubts and no regrets about his drug use. “I take Adderall with a purpose,” he says. “It’s a productivity drug.” He has an exam to sit and a three papers to finish before Christmas. An entrepreneur since high school, he also has a start-up company to run and social obligations to fulfil. There’s no way he can do it all without the little pink pill.

“I feel like I’m making a deal with the devil, where in exchange for short term productivity and energy and focus now, I’m giving up the last five years of my life,” he says. “I joke about this, but who knows what the long term effects are?” The answer is, nobody does. A vast, unregulated trial of neuro-enhancing drugs is taking place at universities across the United States, and no-one is recording the results.

Adderall is an amphetamine, a class of drugs that people have been taking to stay alert, or to get high, since before the Second World War. Soldiers, workers on assembly lines, housewives trying to lose weight and rock’n’roll bands driving hundreds of miles between shows have all used and abused prescription amphetamines. But in the long history of speed and whizz, dexies and bennies, there has never been an epidemic quite like this one.

In the two most respected academic studies, conducted by researchers at the University of Maryland and the University of Kentucky, 31% and 34% of the students surveyed admitted misusing prescription stimulants at least once. But that data is more than five years old, and the trend is upwards. Between 2007-2011, the number of monthly prescriptions issued to 20-29 year-olds reporting the symptoms of ADHD climbed from 5.6 million to 14 million.

Whatever the true figure, taking stimulants has clearly become routine for a sizable minority. When I called the Columbia university student paper, I expressed surprise that there were no articles about Adderall at the website. “That would be like writing a piece saying students drink alcohol,” an editor told me. The Urban Dictionary’s definition for Adderall is “the only way to finish homework.”

In the United States, Adderall and its competitors Vyvanse, Focalin, Ritalin and Concerta are Class II controlled substances, on a par with cocaine and morphine. In theory, selling a pill can get you a fine of $10,000 and three years in prison. In practice, millions of American college students are using them as study aids, in the belief that they improve concentration and lead to better grades.

Lyndon – another Yale student speaking on condition of anonymity – has a legitimate reason to use stimulants. He was diagnosed with ADHD at the age of six, but at university the more sceptical of his peers sometimes assume he’s using to get ahead. “If you have a diagnosis, people say ‘you paid off some doctor’ which is not what happened with me at all.”

Adderall, in capsule form.

Adderall, in capsule form.

At first, the doctor prescribed Adderall, but when he took it, he bit his nails until his fingers bled, so he switched to Ritalin. “It makes me feel super, super weird, so I only take it on school days when I’m sitting in the classroom,” he says. The drug is a psychostimulant, methylphenidate, the most commonly prescribed ADHD medication of all.

In 2012, more than $9 billion worth of ADHD drugs were sold in the United States, a fivefold increase in a decade. Unless one accepts that American children are five times as fidgety and distracted as they used to be, or that generations of kids needlessly suffered a treatable medical condition, this suggests that the cure has, to an extent, created the disease. According to the Centre for Disease Control and Prevention (CDC), one in five boys currently at high school in the United States has received a diagnosis of ADHD. Last year, around 10,000 children under the age of four were prescribed stimulants, in defiance of medical guidelines.

On campus, it is common knowledge which doctors are pad-happy. Graham had prepared a spiel for his family physician, describing ADHD symptoms that he doesn’t have, but he needn’t have bothered. “He asked me ‘do you have a hard time concentrating?’ I said yes. And that was it. That was the end of the conversation.” The doctor wrote him a script for 40mg of Adderall a day, renewable every three months.

With or without a diagnosis, the pills are easy to get. “I know people that can’t do basic assignments without having some kind of stimulant in their system, which is super alarming,” says Lyndon, adding that there is a “sprawling underground economy” for the drugs on campus. If he has Ritalin leftover at the end of term, he flushes it down the toilet.

When Graham has surplus Adderall, there is always a friend of a friend willing to pay for it. At exam time, the going rate is $1 per milligram. Each time he sells a pill, he is violating university regulations, in addition to committing a felony, but a search of Yale’s public records reveals that no student has ever been disciplined for non-medical use of prescription stimulants.

Eric Stern, who wrote a feature about the subject for the Yale Daily News, believes the university authorities turn a blind eye. “Prescription stimulant use at Yale helps the school’s bottom line. It makes students look smarter and more accomplished and more able to accomplish everything with seeming ease and efficiency,” he says.

Some American universities have forbidden on-campus doctors to prescribe stimulants, punting the responsibility to external physicians. Others, including Fresno State, Marist College and the University of Alabama, require students to sign contracts promising not to sell or share their medication.

From time to time, newspapers publish horror stories about students who killed themselves after abusing amphetamines, but these rare cases are easily ignored. A 2006 study in the Journal of Drug and Alcohol Dependence suggested that around 10% of adolescents and young adults who misuse prescription stimulants become addicted.

“It’s developmentally normal not to see these things are risky or dangerous,” says Professor Amelia Arria at the University of Maryland, who has led several studies of prescription stimulant use. In surveys, students cite the “the casual, benign nature” of the drugs, as if the fact that so many doctors are prescribing them is proof they are safe.

Despite their widespread availability, prescription stimulants are a taboo subject on campus. “I know more people that are willing to admit they snort coke than do Adderall,” Lyndon told me. Guillherme, an economics major who takes Concerta two or three times a month, insisted on being interviewed outside, on a freezing day, because he didn’t feel comfortable discussing it in the Starbucks across the street.

When we met, he was still feeling the effects of the pill he had taken that morning. “I had a data set that I knew was going to be really, really boring, so I took it to get through that,” he said. The drug gives him a mild high, and makes tedious tasks bearable. “It’s like, you’re gonna go party, but you end up with a paper.”

Because Adderall and Ritalin have only been approved by the Food and Drug Administration as treatments for ADHD, there has been little research into their effect on healthy people, both in terms of short term cognitive gains and potential long term harm.
“When it is so clear that a major use is going to be off-label, companies should have to prove safety and efficacy for how they know the drugs are going to be used,” says Professor Hank Greely of Stanford Law School. As a leading advocate of “cosmetic neurology” – healthy adults getting a brain boost from drugs formulated to treat medical conditions – he has long argued for comprehensive trials of Adderall, Ritalin and Provigil, another drug, developed to treat narcolepsy, that is also popular with “mind hackers”.

“The experiment I would love to do, but no-one would ever let me do, is take a couple of hundred students, give half of them drugs and half of them placebo, watch them for two years and see if their grades change, as well as follow them up on health,” says Greely. “And I don’t see any likelihood that that’s going to happen, which is a shame. The National Institutes of Health would be reluctant to fund a study, because what are they going to do if it turns out to be safe and effective?”

A review of the academic literature carried out in 2011 by Professor Martha Farah showed that prescription stimulants can benefit learning, working memory and cognitive control, particularly for people with mental abilities at the lower end of the scale. But in a study of university students the following year, Farah and her colleagues at the University of Pennsylvania found no consistent cognitive improvement. Although the students taking amphetamines believed that their performance had improved, they were kidding themselves.

All the students I met are convinced that the drugs work for them. “I have sleep problems, sometimes I get reading fatigue,” Mark, a second year philosophy student, told me. “[Concerta] is a way of getting to ideas more easily, of being as lucid as I can be.” He estimated that at exam time, nine out of ten members of his fraternity take stimulants and cram round the clock, to make up for missed classes and late nights.

Arria’s team at the University of Maryland found that declining grades and skipped lectures often precede non-medical stimulant use. Of the 38% of students that reported taking stimulants, 89% also smoked marijuana. A small minority used amphetamines as a party drug. Slow-release versions of the drugs, designed to be taken once a day, typically come in formulations that cannot be crushed into powder, to prevent them being snorted.

Graham and Guillherme agreed that it would be wrong to write about Adderall without trying it once. So before sitting down with my notes to plan the article, I unfolded the napkin in my bag, reassured myself that people break the law in small ways every day, and swallowed the pill marked cor 135.

Within minutes, my heart was racing. I began to get a pleasurable tingling in my limbs and, most disconcertingly, to grind my teeth and chew my lips in a way that I last did around fifteen years ago, back when we took drugs to dance for hours, hug strangers and sit around in raptures until sunrise. I constantly caught myself exhaling through my mouth, as if cooling a spoon of too hot soup for a child. When I walked home in late afternoon, I was still high and my lips were chapped.

Did it make me more productive? It’s hard to say. Other than listen to one favourite song on headphones, I did nothing but work, out of a fear of becoming obsessed by some trivial task, a common problem for stimulant users. Read sober, the next day, the work was no better or worse than a typical first draft. I had sore teeth and was slightly irritable. Although the trip down no-memory lane felt great while it lasted, the idea of taking amphetamines all the time, or every time work promised to be complex or dull, horrified me.

The day we met, Graham seemed a bit sped-up. “I am a pretty high-energy person. I speak a little fast. I get excited about things,” he said, but I wondered how much that was the amphetamines talking. “There is a slippery slope,” he admitted. “In my sophomore year it got to the point where I couldn’t clean my room without popping Adderall. But I’ve been able to tone it back and I feel like I have more control now.”

When I asked if he considers himself addicted, he paused, it seemed to me for the first time in the conversation. “Er, no. Because I can stop whenever I want.” We both laughed. “That’s what they say! But here’s the thing. I don’t have withdrawals when I’m not on it. The problem is I’m in a very high pressure environment.”

He would stop taking Adderall over the Christmas holiday. “I’m not proud of it. I don’t enjoy it. But I feel like I don’t have any choice,” he said. Then he rushed off to the library, to make the most of it.
AUSTRALIAN STUDENTS – WHAT THE STUDIES SHOW (published as a sidebar to the main article in print edition)

The first major survey to focus on prescription stimulant misuse at Australian universities, published last year, found that 8% of undergraduates had taken the drugs off-label.

The research team, led by performance psychologist Jason Mazanov of the University of New South Wales school of business in Canberra, polled more than 1,700 students at four large south-eastern universities about their use of cognitive enhancers, illicit drugs, caffeine and natural diet supplements.

Of the 164 students that reported using prescription amphetamines, around two thirds said that they took them to improve their concentration and ability to focus. One third said that they took them to “get high” or “enjoy the feeling”.

Users of illicit substances were more likely to have tried the drugs, suggesting that for some students they represent a “cheaper, more readily available substitute for cocaine”. Women studying law and medicine were also particularly likely to have taken prescription stimulants.

Researchers concluded that while the sample may have been biased towards students who engage in such behaviour “enough Australian university students use substances to enhance academic performance to warrant further investigation.”

“Our interpretation of the results is that the pattern of behaviour could be described as students “self-medicating the massively competing demands they have on their time,” said Mazonov.

“The quaint notion that university students spend all their time partying is no longer relevant (although some still do). The typical full-time student (theoretically forty hours per week studying) is also juggling a job (usually fifteen to twenty hours per week) and trying to figure out who they are… The ones that most concern me in relation to stimulant use are also full-time parents and full-time workers.”

The National Drug and Alcohol Research Centre has commissioned a three year study, due in 2016. That team plans to conduct an online survey of 1,360 students from four universities, followed by in-depth conversations with those that report non-medical use.

Professor Wayne Hall, Director of the Centre for Youth Substance Abuse Research at The University of Queensland, is leading the NDARC research team. “We’ve found it hard to find students who have used the drugs as cognitive enhancers,” he said. “What we’ve tended to find is that people have used these drugs once or twice and either they didn’t see the point or they didn’t like what it did to them.” Although the data is scant, for the time being, Australian students are apparently less inclined than their US peers to use the drugs.