An espresso at three in the morning is just so last year

March 10, 2006

US students have found a new family of drugs to give them a competitive edge, reports Stephen Phillips

You don't have to frequent the dark corners of campuses to come across a student drug that is fast growing in popularity. "Just stand around the library," advises Eric Heiligenstein, clinical director of psychiatry at the University of Wisconsin's health services department.

Thousands of US students take Adderall, Ritalin, Concerta or any of the other legal medications prescribed to treat the symptoms of attention deficit hyperactivity disorder, including poor concentration and impulsive behaviour. But it is their use by students without ADHD that is causing concern. These students say such drugs enable them to filter out distractions and focus on even the driest of materials for hours on end.

And UK specialists say there is evidence that students here are following the trend.

For many US students, coffee is a strictly old-school way of keeping the brain functioning through the small hours when trying to cram for exams or finish an overdue assignment.

"Students don't want the jittery edge that caffeine produces," says Michael McNeil, health education co-ordinator at Philadelphia's Temple University.

Besides, coffee is a diuretic, notes McNeil, who co-chairs the American College Health Association's (ACHA) Alcohol, Tobacco and Other Drug Committee.

Like caffeine, Adderall, an amphetamine, and Ritalin, a similar-acting stimulant called methylphenidate, keep you alert without any bitter aftertaste or diuretic effect. They also boost concentration, allowing users to slog through onerous assignments, breeze through revision and even, some say, gain an edge in exams.

According to America's National Institute on Drug Abuse, both drugs work by enhancing the effect of key neurotransmitters and "also increase blood pressure and heart rate, constrict blood vessels, increase blood glucose and open up the pathways of the respiratory system". Some US commentators have dubbed them "academic steroids".

Students have invented their own names for these mood-modifying substances.

Adderall, the most popular ADHD drug, which is distributed by British firm Shire Pharmaceuticals, is known as "addaboys", "amps", "addies" or "A-bombs". Ritalin, manufactured by Swiss-based Novartis, is called "vitamin R".

The most comprehensive study of the trend to date was published last January in the journal Addiction by researchers from the University of Michigan and Harvard and Northeastern universities. The extent of abuse varies widely from campus to campus. At some campuses, no students reported taking the drugs; at others, one in four students reported taking the drugs without a prescription. The study, which looked at students at 119 US campuses, found misuse was highest at academically demanding institutions with selective admissions.

Abuse was higher among white males and members of fraternities. Men were twice as likely as women to report misusing the drugs. Members of sororities, the female equivalent of fraternities, were more likely to use the drugs than other female students.

Users were also more likely to be struggling academically. Students with average grades of B or lower were twice as likely to use the drugs non-medically as those with higher grades.

The tablets are either swallowed or ground up and snorted in repeated small doses to prolong the effect, says Bessie Oster, director of Facts on Tap, the student drugs and alcohol education programme at New York-based Phoenix House, America's largest non-profit drug treatment centre.

Officials report that students with legitimate prescriptions often give away excess supplies. But where the drugs are less readily available, black markets develop. Tablets can change hands for $5 (£2.90) each, and prices rise to whatever local demand will bear.

Jessica Hinkson, information services manager at the US Department of Education's Higher Education Centre for Alcohol and Other Drug Abuse and Violence Prevention, says that some students get hold of the pills by feigning the symptoms of ADHD to obtain prescriptions or get them from websites peddling prescription drugs.

Officials trace the phenomenon back to the late 1990s when the first wave of students on Ritalin reached college. Since then, ADHD diagnosis and medication use has mushroomed.

The market for ADHD drugs in the US almost quadrupled to $3 billion between 1999 and 2004, says Lance Longwell of IMS Health, a US firm that tracks the pharmaceutical sector. Sales of Adderall XR, Shire Pharmaceuticals'

bestselling capsule, topped $730 million last year - a 20 per cent increase on 2004. According to US government figures, 2.5 million schoolchildren, including 9.3 per cent of 12-year-old boys, take ADHD drugs.

Officials say that in addition to the increased number of the drugs in circulation, those obtained through prescription is fuelling student abuse.

Heiligenstein says that the fact that students are giving away supplies means they didn't need them in the first place or, at least, not in the dosages prescribed. He cites an encounter with a student who reported being put on medication after a cursory 15-minute examination by his doctor.

In some cases, abuse begins in school. In 2004, 5.1 per cent of sixth-form age students reported abusing Ritalin, according to US government data.

Heiligenstein says that part of the problem is a perception that prescription drugs, as opposed to "street" drugs, are safe because they have been officially approved. "People leave out the fact that they're theoretically safe when prescribed with appropriate medical supervision."

Oster blames the 1997 relaxation of legal constraints on direct-to-consumer prescription drug advertising for making the public feel less worried about "self-prescribing".

McNeil sees ADHD drug abuse as part of the so-called "pharming" phenomenon, in which young people pop pills intended to treat specific ailments, such as chronic anxiety, as mood modifiers.

He suspects abuse is largely "event-driven and time-sensitive", noting that it tends to peak around final or mid-term exams.

Campus officials point out that the misuse remains dwarfed by alcohol abuse among students, but admit it is a growing concern. The problem will be a key issue at this year's ACHA annual conference, McNeil says.

Individual campuses are responding by tightening protocols over ADHD diagnosis at clinics and mounting education initiatives as part of longer-standing alcohol and drug programmes. For example, New York University's Health Promotion and Wellness Services website (www.nyu.edu/nyuhc/owl/index.html) features a section on "Study Drugs" and includes advice for students with ADHD prescriptions on how to resist peer pressure to share their pills.

Other institutions have put filters on campus computers to stop students accessing online pharmacies and have introduced tougher enforcement, including sanctions against students found illicitly taking or dealing ADHD drugs. There have also been crackdowns by campus police.

Nevertheless, "busts" remain rare. The arrest last April of a University of Oregon student caught selling his Adderall made the headlines because it was an exception.

Another issue is whether taking the drugs constitutes cheating.

Heiligenstein says it is unclear whether or not the drugs help students in tests, but adds that this market must be partly driving usage. But, says McNeil, initiatives used to catch those who take performance-enhancing drugs in sport, such as "dope testing", are not being seriously considered as they would raise horrendous legal and logistical problems, not least over dispensations for students with prescriptions.

The perception that the drugs help students get ahead is, however, making it hard for officials to convince students of the dangers of using them without medical supervision. The US Drug Enforcement Administration classes both drugs "Schedule II substances", alongside cocaine and methamphetamine.

The administration says that methylphenidate carries a "high potential for abuse" and can lead to "binge use, psychotic episodes, cardiovascular implications and severe psychological addiction".

Last month, an advisory panel to the Food and Drug Administration, which regulates US prescription drugs, recommended that ADHD drugs carry the sternest possible warning after they were linked to 25 deaths and 54 cases of heart attack, stroke and other heart problems.

Health concerns led Canadian authorities to temporarily suspend sales of Adderall XR last year. The drug is back in circulation but with new labelling that states that patients with heart conditions should not take it and a warning of the dangers of abusing amphetamines. Oster thinks such warnings may not reach students abusing the drugs. "I'm not sure many are getting the drugs in a prescription bottle. They're getting them in tin foil, a plastic bag, whatever."

FDA officials have pointed out that the death or injury rate of both drugs is fewer than one for every million prescriptions, an incidence that Shire says is "generally within the rate that would be expected from the untreated general population".

Meanwhile, students appear willing to overlook the risks. "To them, it's a study aid," reports Anita Barkin, student health services director at Carnegie Mellon University. "If it's going to help them study longer and get a better grade, (they think) that's good. Telling them it isn't a good idea can be a challenge."

McNeil worries that students run the risk of getting psychologically hooked. Amelia Arria, deputy director of research at the University of Maryland's Centre for Substance Abuse Research and principal investigator of the College Life Study, is looking into the question.

"We want to (see) whether people develop a habit of taking them, (and feel that if) they don't have them, they can't perform. It's something that might happen."

Arria says it might be better to tackle the problem by focusing on teaching students better study habits in the first place.

"I don't think students are going to respond to scary messages," she says.

"It might be better to say, 'we know there are people who do well (academically), and this is their way of managing time' - promote positive behaviour, rather than nailing them for negative behaviour."

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