Prescription drug use is the fastest-growing category of drug abuse on college campuses today. Just over 5 percent of Brown students take prescription stimulants once or twice a semester as academic aids, according to last month's Herald poll. More non-first-years, 6.4 percent, reported use than first-years, 2.3 percent.
In 2008, about 12 percent of students reported non-medical use of prescription drugs during their time at Brown, according to a survey conducted that year by the Department of Community Health. Studying was the most commonly reported reason for use.
The use of prescription drugs for late-night studying or finals period stress is not uncommon on any college campus. Six years ago, up to 20 percent of college students had taken Ritalin or Adderall for academic use, according to the New York Times.
The University's Academic Code does not explicitly address the ethics of non-prescribed drug use for studying, coursework or exams. But administrators say non-prescibed use would be considered an unfair advantage, which the code prohibits.
A is for Adderall
It was 11:30 p.m. and Alex '12 had barely begun a comparative literature paper due the next day. ("Alex" is a pseudonym. Like all other students in this article, he spoke on the condition of anonymity.) His roommate, seeing that Alex was stressed, offered him some of his prescription Adderall, an amphetamine used to treat Attention Deficit Hyperactivity Disorder. He showed Alex how to crush up the pill, use his Brown identification card to make a line and fold a $1 bill to snort the powder.
It tasted like sugar, like an orange Tic Tac, Alex said. He became a "highlighter robot," speed-reading and picking out keywords like needles in haystacks. He stayed up all night to finish the assignment, for which he received an A. "I read it over after the effects wore off, and I was like … ‘It sounds like I was on drugs,'" Alex said.
The stream-of-consciousness style reminded Alex of Jack Kerouac's "On the Road" — "quality word vomit," he called it. The Adderall allowed him to express his ideas creatively rather than precisely articulating his thoughts, he said.
After taking Adderall, Alex experienced an increase in the concentration of catecholamines in his prefrontal cortex. Catecholamines are a class of neurotransmitters — chemicals that relay signals between neurons and their target cells — that includes dopamine and norepinephrine. These neurotransmitters are involved in a number of behavioral and cognition processes including reward, motivation, working memory and learning. Though it may seem paradoxical to treat attention problems with stimulants, the drugs have a calming effect on people with ADHD, who are known to have a deficiency of catecholamines. Stimulants reverse this problem by increasing extracellular levels of dopamine, providing the necessary brain stimulation to keep individuals with ADHD focused on one task, rather than shifting their attention in search of engagement. The cause of this deficiency in dopamine is unknown, but studies suggest it may have a genetic origin.
In people who do not have attention deficit disorders, stimulants have the opposite effect. Instead of calming, stimulants increase alertness and wakefulness, as Alex learned from his experience.
For this reason, students who take Adderall and other prescription stimulants may not have elevated focus levels. Rather, the drug keeps them awake, enabling the classic college all-nighter.
From weed to speed
"People text me asking for it, and I'm like, ‘Don't text me about that — come to my room,'" Kelly '11 said. Kelly is diagnosed with ADHD and has a prescription for Adderall, which she refills monthly at Health Services. Her doctor gives her "wiggle room" with the medication, so she often has extra, which she sells to friends for $2 a pill.
"I only sell to people who I really trust," she said.
Kelly has three regulars to whom she sells weekly, in addition to occasional customers who ask for pills when they have a particularly heavy workload. She has a nonchalant attitude about the transactions — she is just doing people a favor and being a good friend, she said. "I know how much it helps me," she said. "Regardless of whether they do or do not have ADHD, I do see how it can help them."
Sarah '11 sometimes buys from Kelly, but only when her regular dealer's supply is short. In the past, when Sarah sold marijuana, she would exchange it for stimulants.
Director of Health Services Edward Wheeler said he worries about his patients selling their prescriptions and warns them that not only is it illegal, but also dangerous. If his patients begin asking for more medication after they have been taking a stable dose for a year or so, he said he becomes skeptical. If he ever found out that his patients were selling their medication, he would cancel the prescriptions, he said, adding that this has never happened.
"People forfeit their right to be on medications if they are abusing them," Wheeler said.
He said he is cautious when prescribing Adderall and Ritalin — patients must be diagnosed with ADHD. Through Health Services, diagnosis is an in-depth process requiring an interview about habits and performance, in addition to neuropsychological testing, often completed through Disability Support Services.
There is a perception that it is more difficult to get diagnosed by doctors at Health Services than by private practitioners, which may explain why many students seek off-campus doctors, Wheeler said. If a student comes in with a prescription written by a non-University doctor, Health Services requires proof from that doctor that a secure diagnosis was completed.
Three percent of prescriptions filled at Health Services are for ADHD medications, according to Wheeler.
Fight or flight
Everyone is familiar with the fight-or-flight response brought on when, for example, a friend unexpectedly jumps from hiding. But the harmless joke turned deadly serious when Sarah entered her dorm room after a night of drinking and smoking marijuana. Her friend sprung from the closet, sending Sarah's heart rate sky high.
She had recently gone cold turkey on stimulants, since it was the end of the semester and she had finished all her academic assignments. She knew that her use of stimulants was irresponsible — she was constantly switching medications and dosages. That night her body retaliated. Her heart started racing, and it would not stop.
"I felt like I had just run a marathon," Sarah said.
Misuse of stimulant medications can lead to serious cardiovascular complications, including increased blood pressure, elevated heart rate, shortness of breath and chest pain. Non-medical use of amphetamines is especially dangerous for those without prescriptions, who may exacerbate an underlying heart condition of which they are unaware, said Frances Mantak, director of health education. Electrocardiograms are recommended before starting use of stimulants to ensure that the medications will not cause heart problems.
An hour later, Sarah's heart was still racing. A friend living on the same hall decided to call Emergency Medical Services.
An ambulance took Sarah to the emergency room, where her systolic heart pressure was measured at 185 beats per minute — average resting heart rate is between 120 and 180 bpm during mild exercise. The medical workers were convinced she was on cocaine.
Sarah was given baby aspirin, and ice packs were placed on her chest. She performed breathing exercises, and after about an hour, her heart rate went down. A friend who had accompanied her to the hospital pulled one of the nurses aside and explained that Sarah had been taking various stimulants for an extended period of time but had recently stopped.
Sarah was diagnosed with amphetamine a
buse. "That's in my medical records now," she said.
After the incident, Sarah went abroad for a year, during which she did not take any stimulants because her course load was less demanding. Upon her return, she resisted resuming her use of stimulants for about a month or two, before finding a friend with a prescription for Adderall. The friend, a Providence local, has now been supplying her with Adderall for about a year and a half. She pays $2 for each pill, which contains 20 milligrams of extended release Adderall. She takes a pill every morning, and said the effects last for about eight to 12 hours.
"I felt that my medical issues happened because I was mixing it with weed, and maybe more likely because I was mixing different kinds, and I wasn't taking it in any kind of regular way," Sarah said. Now that she is taking it regularly, she said she is not worried about negative side effects.
At least one or two students per semester come into Health Services with heart arrhythmias — abnormal beating of the heart — from taking too much Ritalin or Adderall without a prescription, according to Wheeler. "That's probably the tip of the iceberg," he said.
An unfair advantage
According to the University's Academic Code, which prohibits "using unauthorized materials from which one gains unfair assistance during an exam," illicit use of prescription drugs could be considered cheating.
"While you can make the argument that it's cheating, I think you can also make the argument that it is detrimental. They are learning poor study habits. They are not necessarily doing better in their performance," Mantak said.
The use of prescription drugs is also just one of many academic advantages unevenly available to students depending on their ability to pay for it. "Some people are really great at sports and some people aren't. I don't think that using money or social connections to secure an advantage is any different from how anything in our higher education system works," Sarah said.
Kelly expressed a similar sentiment. She said she doesn't view her use as unfair because it brings her "up to the level of everybody else." Nor does she view non-prescription use by undiagnosed students as cheating. "The people that I am selling (Adderall) to aren't breezing through their classes. … They are not doing it to compete with other people."
Kelly said Adderall does not make people smarter or more insightful. It just makes things happen faster, an effect similar to drinking three Red Bulls, she said.
The University has never received reports alleging use of prescription drugs to enhance academic performance, according to Kathleen McSharry, dean for issues of chemical dependency and associate dean of the College for writing and curriculum.
McSharry said she is unsure of how the University would handle such a case should one ever be presented.
"We have to have evidence," she said. "If it is just a verbal report with no concrete evidence, we can't proceed unless the student acknowledges it." But students don't often willingly admit to cheating, she said. "Short of evidence, what are we going to do?"
The use of stimulants is not explicitly prohibited in the academic code — there is an endless list of ways to cheat and the code simply cannot cover them all, McSharry said.
She is more concerned about students' health and safety when it comes to prescription drug use than she is about cracking down on cheating, she said. "I am most concerned about kids' potential to get addicted."
"The last thing they need is me to come down with a hammer on them," she said. The University does have academic standards, she said, but "when there's substance abuse we don't think about right, wrong, bad, good, that kind of thing. We think about: The student is damaging him- or herself."
McSharry is also concerned about how drug sharing and dealing impact the Brown community, she said. "Our philosophy is about the student body and fostering conditions that make it more likely that you all will be able to function effectively and contribute as much as you can. We've got limited time and limited energy. There are some things that we simply just aren't going to be able to do."
‘A cup of coffee'
Though the 2008 University survey indicated that over 88 percent of students have never abused Adderall or Ritalin, perception of the drugs' prevalence persists. People tend to talk the talk rather than walk the walk, Mantak said.
"I do think it's something that most people at Brown have tried at least once or will try at least once during their Brown career," said Sarah, though she acknowledges her perception may be biased by her social group. The vast majority of her friends at Brown have taken Adderall or Ritalin regardless of whether or not they have a prescription, especially around finals time, she said.
Some students take the drug recreationally, often combining it with other substances. Kelly said she takes half of an instant-release Adderall pill before going out because it increases her alcohol tolerance. Another side effect of Adderall is appetite loss, which often results in weight loss.
Of course, the practice is not unique to Brown. Study drugs are used at universities nationwide. But because of Brown's open dialogue about drug use, some students think study drug use may be more acceptable and therefore more prevalent, Sarah said.
At other schools, drug use may be more stigmatized, either leading to less use or more secrecy. Sarah said she thinks people at other schools might view stimulants as "hardcore" drugs, whereas at Brown, "people treat it like a cup of coffee."
Mantak agreed there is a perception that because prescription drugs are legal, they are safe. "They're certainly safer than illegal drugs," she said, but there are still many dangers associated with stimulant medications. The acceptance of drug use reveals a cultural, as well as a University, issue, Mantak said. Questions like "Are we overprescribing in some cases? Is it acceptable to share prescriptions? Are we too reliant on medication?" need to be addressed, she said. At the same time, stimulant medications are important for the people who truly need them, she said.
