- Email: [email protected]
Nonmedical Use of Stimulant Medication: A Concerning Trend
Nonmedical Use of Stimulant Medication A Concerning Trend
a There’s a callout misperception that ADHD medications are harmless because they’re so widely prescribed
As I hung up the phone after speaking to the pharmacist, I carefully emptied the contents of the medicine bottle into the palm of my outstretched hand. How could this be? There were only four methylphenidate (Ritalin) pills left, yet 10 days remained before I could get my 11-yearold son’s prescription refilled. Clearly, this was insufficient to supply his dose of two pills per day; it just didn’t make any sense. Typically, within a given timeframe, there were more than enough pills to meet my son’s needs because he frequently skipped his attention deficit hyperactivity disorder (ADHD) medication on the weekends when he wasn’t in school. I vowed to pay closer attention to his dosing schedule when I picked up his next medication refill the following month.
Missing Pills Equal a Mystery Despite my vigilance, my son prematurely ran out of his methylphenidate for a second month
432
© 2009, AWHONN
Sue A. Woodson, CNM, MSN in a row. With three teenagers in the house, and being cognizant of methylphenidate’s potential for abuse, I began the unnerving task of trying to solve the mystery of the missing medication. During the third month, I kept my son’s methylphenidate in my purse, which was with me at all times. In its customary storage location, I substituted a comparable medication bottle containing a number of similar-appearing placebo pills. Each day, I painstakingly counted the contents of the bottle, documenting the number of pills present and the specific family members who had access to the counterfeit methylphenidate. One by one, I eliminated each family member as a potential suspect. This was no easy task—one son was even forced into the pediatrician’s office to provide a urine specimen to prove he had not consumed methylphenidate
http://nwh.awhonn.org
on a day when I determined he was the only logical person who had access to the drug when a few pills went missing. Thankfully, his test was negative, but that still left me with the other two children (and even my husband, in my increasingly suspicious mind) as potential suspects. Finally, on a day when the majority of family members were out of town and the others had no access to the medication, I discovered that a number of the placebo pills were missing from the “stash.” At this point, realizing that I had reached the limit of my detective abilities, I contacted the local authorities. To be honest, the local police appeared to be quite underwhelmed by my situation, at least initially. I envision the crime report reading something to the effect of, “Middle-aged woman called to report approximately 20 of her son’s prescription pills were stolen; estimated value = $10. No signs of forced entry or vandalism; nothing else missing from home.” When several days passed with no follow-up phone call, I contacted the police department again, this time speaking with an acquaintance who, out of courtesy, promised to send a detective out to meet with me. In addition to being concerned about my son not having medication when he needed it, and worrying that another family member might have a substanceabuse problem, it was quite distressing to me that I couldn’t account for a controlled substance (methylphenidate is a Schedule II drug in the United States [U.S. Department of Justice, 2008]) in my possession. Furthermore, I had no idea what impact this situation could have on my prescriptive authority as a health care provider.
Further Investigation Later that day, a detective arrived at my home to begin his investigation. My meticulous documentation was sufficient to rule out the usual suspects—namely, family members—so we were quickly able to move on to the next level of investigation. As luck would have it, the police department had just received several new surveillance micro-cameras and they were anxious to test them out. Within a few hours, the scene of the crime—my kitchen—was wired via motion detector to initiate video documentation of anyone opening the storage cabinet where the medication was usually kept. Strangely, several weeks passed without any missing pills. Finally, I returned home one
October | November 2009
afternoon to find that the video camera had been activated while the house was supposedly vacant. Waiting anxiously for the police to arrive to review the tape, my mind raced with possibilities. Why would someone enter my home just to steal pills and nothing else? Who was able to pass in and out of my closeknit suburban neighborhood without notice? Who could enter my home repeatedly in broad daylight and in my absence, yet remain unsuspected? After what seemed an eternity, the police finally arrived at my house. The officer placed his eye to the view lens of the micro-camera and began a running commentary: “Here’s you unloading the dishwasher. Here’s your son making a milkshake. Here’s you…oh, wait a minute… that’s not you…(rewinds tape)…Who is this? (hands me the view lens). I stood speechless as my eye tried to convince my brain that what I was seeing was real. There, on the videotape, was a woman I knew—standing in my kitchen— emptying pills from the methylphenidate bottle and pocketing them. I watched the tape as she glanced anxiously around, replaced the medication bottle and wiped it vigorously with a dishtowel. The videotape ended as she closed the kitchen cabinet door. This woman lived a short 2-minute walk from my house. This woman directed the choir at a nearby church. This woman’s son was in the same grade school as my son; our boys were friends and sometimes played together. This woman worked at the same hospital I did. This woman was a licensed health care professional, someone I knew and trusted. This woman didn’t have ADHD! Why was this woman stealing my son’s methylphenidate?
Nonmedical use and abuse of stimulant medications by normal college students has received significant attention in the lay literature
“Cosmetic Neurology”: A Growing Trend Amphetamines, such as Dexedrine and Adderall, and methylphenidate (Concerta and Ritalin) are generally prescribed for children and adults who have been diagnosed with ADHD. In 2004, Anjan Chatterjee, a neurologist at the University of Pennsylvania, introduced the term “cosmetic neurology” to describe the practice of using drugs developed for legitimate medical conditions to improve ordinary cognition (Talbot, 2009). Increasing pressure to be productive in the workplace and competitiveness in the academic setting may persuade some to seek enhancement of their usual abilities through
Sue A. Woodson, CNM, MSN, is a certified nurse midwife and nurse practitioner at Planned Parenthood Health Systems in Charlottesville, VA. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2009.01463.x
Nursing for Women’s Health
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Box 1.
Nonmedical Use of Adderall® in the Past Year among Full-Time College Students and Other Persons Aged 18 to 22, by Age Group and Gender: 2006 and 2007 Source: 2006 and 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).
Enrollment Status
Total Aged 18 to 22
Aged 18 to 20
Aged 21 or 22
Male
Female
Full-Time College Students
6.4%
6.1%
7.0%
6.9%
6.0%
Other
3.0%
3.2%
2.8%
3.2%
2.9%
Source: NSDUH Report retrieved from http://oas.samhsa.gov/2k9/adderall/adderall.htm
nonmedical use of stimulant medications in order to be successful. This cosmetic neurology or “neuroenhancement” is not without precedent. Who among us hasn’t ingested a dose of caffeine in the form of strong coffee to promote insomnia and induce alertness for any number of reasons? Doulas attending a woman during childbirth when the labor turns into a marathon, nurses on 12-hour nightshifts, physicians post-call and so on. Is there anyone who, at one time or another, hasn’t been faced with a situation where they didn’t yearn for augmentation of their usual abilities? How I wish I could remember the names that go with faces, phone numbers I used to know by heart, formulas to calculate medication dosages based on weight or age. However, if
Nonmedical use and abuse of stimulant medications by normal college students has received significant attention in the lay literature (Carroll et al., 2006; Illig, 2009). Despite this attention and the plethora of discussions about it on college message boards, nonmedical stimulant use has received surprisingly little notice in medical literature (Carroll et al.). Articles that do exist in medical journals tend to focus specifically on nonmedical stimulant use in the college population as a means of enhancing study skills. Reports of nonmedical methylphenidate use among full-time college students ages 18 to 22 range from 6.4 percent (National Survey on Drug Use and Health [NSDUH], 2009) (Box 1) to 9.2 percent or higher (Carroll et al.). However, in 2006, the NSDUH (2008)
cosmetic neurology ever were to become a standard practice, what cost would be borne by each individual and exacted on society as a whole? Besides intensification of normal abilities, other motives for nonmedical stimulant use may include the following: (1) recreational use; (2) use as a study aid; (3) use as a means of increasing short-term productivity, (4) concentration or (5) memory enhancement by a person who lacks a medical indication for the drug. Less frequently mentioned reasons for using stimulants nonmedically include performing better in sports, improving mood, staying awake, maintaing a better complexion, losing weight and building muscle (Carroll, McLaughlin, & Blake, 2006).
Box 2.
Estimated ED Visits, by Reason for ED Visit and Drug Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
Methylphenidate Reason for visit
ED visits % of visits
Amphetamine- dextroamphetamine ED visits % of visits
Total ED visits % of visits
Totala
3,601
100
4,272
100
7,873
100
Nonmedical use
1,541
43
2,228
52
3,769
48
Adverse reaction (medical use)
1,322
37
1,320
31
2,642
34
Accidental ingestion
390
11
435
10
825
10
Suicide attempt
348
10
289
7
637
8
aT he total includes only the four types of ED visits shown. This excludes patients who presented to the ED specifically to seek admission to the hospital’s detoxification or substance abuse treatment unit. Source: DAWN Report retrieved from: https://dawninfo.samhsa.gov/files/TNDR09ADHDmeds.htm
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Issue 5
reported that approximately 2 percent of adolescents between the ages of 12 to 17 (estimated to be 510,000 people) also used stimulants, such as methylphenidate, nonmedically during the past year. Specific data regarding nonmedical stimulant use in the adult population (those ages 26 and over) is lacking, but at least one source estimates it to be around 1 percent of the population (NSDUH). How are stimulants acquired for nonmedical use? One means may be through theft, as with the case described above. According to a study conducted by Carroll et al. (2006), some may visit a physician to seek ADHD medications even if they don’t believe they have ADHD. Some who legitimately have a prescription may sell, trade or give their medications to others for nonmedical use. Internet sales may also present an easily accessible opportunity for the motivated user to acquire stimulants for nonmedical use.
Risks The package insert for Adderall, a brand name for generic methylphenidate (U.S. Food and Drug Administration, 2007) lists a number of drug warnings including the risk of sudden death, stroke, myocardial infarction, exacerbation of preexisting psychosis,
emergence of new psychotic or manic symptoms, aggression or hostility, seizures and visual disturbance. Overdosage can result in restlessness, tremor, hyperreflexia, hyperventilation, confusion, hallucinations and panic. Even at therapeutic doses for treatment of ADHD, stimulant medication can cause insomnia, long-term growth suppression and appetite suppression. The National Institute on Drug Abuse (NIDA) has shown that drugs commonly prescribed to treat ADHD can cause physical changes in mouse brain cells resulting in an effect similar to, and in some cases, greater than, cocaine (U.S. Department of Health and Human Services [USDHHS], 2009). As Schedule II drugs, these stimulant medications carry a high risk of abuse, but have safe and accepted medical uses in the United States. Findings by NIDA indicate that people with ADHD do not carry an increased risk of subsequent addiction (2009), but nonmedical use of ADHD medication by normal people can lead to addiction as well as other health consequences (USDHHS). According to the Drug Abuse Warning Network (DAWN, 2006), in 2004, approximately 2 million emergency department (ED) visits in short-term, general, non-Federal hospitals in the United
States were drug-related. Of those visits, methylphenidate and amphetamines were involved in a total of 7,873 encounters (Box 2). Nonmedical stimulant use accounted for 3,769 or 48 percent of these visits. This report categorized nonmedical use as taking a dose higher than prescribed, using a drug prescribed for someone else, or other evidence in the medical record of drug misuse or abuse (DAWN). Polydrug use is typical in patients presenting to the ED as a result of nonmedical stimulant use (Box 3). Thirty-two percent of the time when methylphenidate or amphetaminedextroamphetamine were used, only a single drug was involved in the adverse event. However, 68 percent of the time, the ED patient had also consumed alcohol, an illicit drug or another pharmaceutical in addition to the stimulant (DAWN).
Implications for Nurses Nonmedical stimulant use presents vast implications for nursing care. The dearth of research in this area represents a great opportunity for nurses to generate a body of knowledge regarding the scope of populations who use stimulants nonmedically, their rationale to begin nonmedical stimulant usage, short- and long-term implications of
Box 3.
Nonmedical Use of ADHD Medications in Combination with Other Substances Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
Methylphenidate
Amphetaminedextroamphetamine
Total
%
1,541
2,227
3,768
100
Single drug
597
607
1,191
32
Multiple drugsa
944
1,620
2,564
68
with alcohol
341
413
754
20
with any illicit drug
331
662
993
26
with other pharmaceutical
810
1,329
2,139
57
Total
aC omponents do not sum to total because categories are not mutually exclusive. For example, one multiple-drug visit may include alcohol and another pharmaceutical. Source: DAWN Report retrieved from: https://dawninfo.samhsa.gov/files/TNDR09ADHDmeds.htm
October | November 2009
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References Carroll, B. C., McLaughlin, T.J., & Blake, D.R. (2006, May). Pattern and knowledge of nonmedical use of stimulants among college students. Archive of Pediatric Adolescent Medicine, Vol. 160: 481–485. Retrieved May 21, 2009, from http://archpedi.ama-assn.org/cgi/ reprint/160/5/481.pdf Illig, R. (2009, April 27). Students use Adderall to study for finals. Tennessee Journalist. Retrieved May 18, 2009, from http://tnjn.com/2009/apr/27/ students-use-adderall-to-study/
this practice, and means through which nonmedical users acquire the drug, both legally and illegally. Education regarding the risks versus the perceived benefits of nonmedical stimulant use may serve to discourage this risky practice. ADHD is so commonly diagnosed among adolescent and college-age populations and there’s a misperception that treatment medications are relatively harmless because they’re so widely prescribed. High school and college health nurses should develop educational campaigns to warn students about this practice as a means of prevention. Practitioners need to be aware of nonmedical stimulant use and counsel those seeking medication for this purpose regarding the risks associated with this practice.
Outcome of This Mystery Following her arrest, my neighbor was convicted on two counts of breaking and entering and two counts of illegal possession of a controlled substance. Additional surveillance video footage showed that she was able to enter and exit my house undetected through a side door that did not latch tightly despite appearing to be locked. During the trial, I discovered that she targeted my house based on information she obtained through her son. As it turns out, during the time our sons attended elementary school together, all the children with
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ADHD were called to the nurse’s office simultaneously to take their medication as a group—her son and my son included. She admitted she started taking her own son’s methylphenidate to increase productivity and to promote weight loss and, within a short time, became addicted. To supplement the pills she pilfered from her own son’s prescription, she identified other neighborhood children on methylphenidate by asking her son who else took medication in the school nurse’s office at lunch time. I learned my house was one of several she frequented during her breaking-and-entering-spree.
Conclusion In summary, nonmedical stimulant use, neuroenhancement and cosmetic neurology, whatever the terminology, need to be thoroughly and completely examined so that those diagnosing ADHD and prescribing medications and those engaging in nonmedical stimulant use can totally understand and appreciate the risks versus the benefits of this practice. Nurses can and should take the lead in educating young high school and college students about this practice and the impact it can have on their health and their future. NWH
http://nwhTalk.awhonn.org
National Survey on Drug Use and Health. (2008, February 28). Nonmedical Stimulant Use, Other Drug Use, Deliquent Behaviors, and Depression among Adolescents. Retrieved May 18, 2009, from http://oas.samhsa.gov/2k8/stimulants/ depression.htm National Survey on Drug Use and Health. (2009, April 7). Nonmedical Use of Adderall ® Among Full-Time College Students. Retrieved May 18, 2009, from http://oas.samhsa.gov/2k9/adderall/ adderall.htm Talbot, M. (2009, April 27). Brain Gain. The New Yorker. Retrieved May 18, 2009, from http://www.newyorker.com/ reporting/2009/04/27/090427fa_fact_ talbot The New DAWN Report. (2006). Emergency Department Visits Involving ADHD Stimulant Medications. Retrieved May 18, 2009, from https://dawninfo.samhsa.gov/files/ TNDR09ADHDmeds.htm U.S. Department of Health and Human Services. (2009, February 2). NIDA Study Shows that Methylphenidate (Riatlin) Causes Neuronal Changes in Brain Reward Areas. NIH News. Retrieved May 21, 2009, from http://www. drugabuse.gov/newsroom/09/NR2-02. html U.S. Department of Justice Drug Enforcement Administration. (2008, April). Controlled Substances in Schedule II. Retrieved May 19, 2009, from http:// www.deadiversion.usdoj.gov/schedules/ listby_sched/sched2.htm U.S. Food and Drug Administration. (2007, June 7). Adderall Package Insert. Retrieved May 18, 2009, from http:// www.accessdata.fda.gov/drugsatfda_ docs/label/2007/011522s040lbl.pdf
Volume 13
Issue 5
a There’s a callout misperception that ADHD medications are harmless because they’re so widely prescribed
As I hung up the phone after speaking to the pharmacist, I carefully emptied the contents of the medicine bottle into the palm of my outstretched hand. How could this be? There were only four methylphenidate (Ritalin) pills left, yet 10 days remained before I could get my 11-yearold son’s prescription refilled. Clearly, this was insufficient to supply his dose of two pills per day; it just didn’t make any sense. Typically, within a given timeframe, there were more than enough pills to meet my son’s needs because he frequently skipped his attention deficit hyperactivity disorder (ADHD) medication on the weekends when he wasn’t in school. I vowed to pay closer attention to his dosing schedule when I picked up his next medication refill the following month.
Missing Pills Equal a Mystery Despite my vigilance, my son prematurely ran out of his methylphenidate for a second month
432
© 2009, AWHONN
Sue A. Woodson, CNM, MSN in a row. With three teenagers in the house, and being cognizant of methylphenidate’s potential for abuse, I began the unnerving task of trying to solve the mystery of the missing medication. During the third month, I kept my son’s methylphenidate in my purse, which was with me at all times. In its customary storage location, I substituted a comparable medication bottle containing a number of similar-appearing placebo pills. Each day, I painstakingly counted the contents of the bottle, documenting the number of pills present and the specific family members who had access to the counterfeit methylphenidate. One by one, I eliminated each family member as a potential suspect. This was no easy task—one son was even forced into the pediatrician’s office to provide a urine specimen to prove he had not consumed methylphenidate
http://nwh.awhonn.org
on a day when I determined he was the only logical person who had access to the drug when a few pills went missing. Thankfully, his test was negative, but that still left me with the other two children (and even my husband, in my increasingly suspicious mind) as potential suspects. Finally, on a day when the majority of family members were out of town and the others had no access to the medication, I discovered that a number of the placebo pills were missing from the “stash.” At this point, realizing that I had reached the limit of my detective abilities, I contacted the local authorities. To be honest, the local police appeared to be quite underwhelmed by my situation, at least initially. I envision the crime report reading something to the effect of, “Middle-aged woman called to report approximately 20 of her son’s prescription pills were stolen; estimated value = $10. No signs of forced entry or vandalism; nothing else missing from home.” When several days passed with no follow-up phone call, I contacted the police department again, this time speaking with an acquaintance who, out of courtesy, promised to send a detective out to meet with me. In addition to being concerned about my son not having medication when he needed it, and worrying that another family member might have a substanceabuse problem, it was quite distressing to me that I couldn’t account for a controlled substance (methylphenidate is a Schedule II drug in the United States [U.S. Department of Justice, 2008]) in my possession. Furthermore, I had no idea what impact this situation could have on my prescriptive authority as a health care provider.
Further Investigation Later that day, a detective arrived at my home to begin his investigation. My meticulous documentation was sufficient to rule out the usual suspects—namely, family members—so we were quickly able to move on to the next level of investigation. As luck would have it, the police department had just received several new surveillance micro-cameras and they were anxious to test them out. Within a few hours, the scene of the crime—my kitchen—was wired via motion detector to initiate video documentation of anyone opening the storage cabinet where the medication was usually kept. Strangely, several weeks passed without any missing pills. Finally, I returned home one
October | November 2009
afternoon to find that the video camera had been activated while the house was supposedly vacant. Waiting anxiously for the police to arrive to review the tape, my mind raced with possibilities. Why would someone enter my home just to steal pills and nothing else? Who was able to pass in and out of my closeknit suburban neighborhood without notice? Who could enter my home repeatedly in broad daylight and in my absence, yet remain unsuspected? After what seemed an eternity, the police finally arrived at my house. The officer placed his eye to the view lens of the micro-camera and began a running commentary: “Here’s you unloading the dishwasher. Here’s your son making a milkshake. Here’s you…oh, wait a minute… that’s not you…(rewinds tape)…Who is this? (hands me the view lens). I stood speechless as my eye tried to convince my brain that what I was seeing was real. There, on the videotape, was a woman I knew—standing in my kitchen— emptying pills from the methylphenidate bottle and pocketing them. I watched the tape as she glanced anxiously around, replaced the medication bottle and wiped it vigorously with a dishtowel. The videotape ended as she closed the kitchen cabinet door. This woman lived a short 2-minute walk from my house. This woman directed the choir at a nearby church. This woman’s son was in the same grade school as my son; our boys were friends and sometimes played together. This woman worked at the same hospital I did. This woman was a licensed health care professional, someone I knew and trusted. This woman didn’t have ADHD! Why was this woman stealing my son’s methylphenidate?
Nonmedical use and abuse of stimulant medications by normal college students has received significant attention in the lay literature
“Cosmetic Neurology”: A Growing Trend Amphetamines, such as Dexedrine and Adderall, and methylphenidate (Concerta and Ritalin) are generally prescribed for children and adults who have been diagnosed with ADHD. In 2004, Anjan Chatterjee, a neurologist at the University of Pennsylvania, introduced the term “cosmetic neurology” to describe the practice of using drugs developed for legitimate medical conditions to improve ordinary cognition (Talbot, 2009). Increasing pressure to be productive in the workplace and competitiveness in the academic setting may persuade some to seek enhancement of their usual abilities through
Sue A. Woodson, CNM, MSN, is a certified nurse midwife and nurse practitioner at Planned Parenthood Health Systems in Charlottesville, VA. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2009.01463.x
Nursing for Women’s Health
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Box 1.
Nonmedical Use of Adderall® in the Past Year among Full-Time College Students and Other Persons Aged 18 to 22, by Age Group and Gender: 2006 and 2007 Source: 2006 and 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).
Enrollment Status
Total Aged 18 to 22
Aged 18 to 20
Aged 21 or 22
Male
Female
Full-Time College Students
6.4%
6.1%
7.0%
6.9%
6.0%
Other
3.0%
3.2%
2.8%
3.2%
2.9%
Source: NSDUH Report retrieved from http://oas.samhsa.gov/2k9/adderall/adderall.htm
nonmedical use of stimulant medications in order to be successful. This cosmetic neurology or “neuroenhancement” is not without precedent. Who among us hasn’t ingested a dose of caffeine in the form of strong coffee to promote insomnia and induce alertness for any number of reasons? Doulas attending a woman during childbirth when the labor turns into a marathon, nurses on 12-hour nightshifts, physicians post-call and so on. Is there anyone who, at one time or another, hasn’t been faced with a situation where they didn’t yearn for augmentation of their usual abilities? How I wish I could remember the names that go with faces, phone numbers I used to know by heart, formulas to calculate medication dosages based on weight or age. However, if
Nonmedical use and abuse of stimulant medications by normal college students has received significant attention in the lay literature (Carroll et al., 2006; Illig, 2009). Despite this attention and the plethora of discussions about it on college message boards, nonmedical stimulant use has received surprisingly little notice in medical literature (Carroll et al.). Articles that do exist in medical journals tend to focus specifically on nonmedical stimulant use in the college population as a means of enhancing study skills. Reports of nonmedical methylphenidate use among full-time college students ages 18 to 22 range from 6.4 percent (National Survey on Drug Use and Health [NSDUH], 2009) (Box 1) to 9.2 percent or higher (Carroll et al.). However, in 2006, the NSDUH (2008)
cosmetic neurology ever were to become a standard practice, what cost would be borne by each individual and exacted on society as a whole? Besides intensification of normal abilities, other motives for nonmedical stimulant use may include the following: (1) recreational use; (2) use as a study aid; (3) use as a means of increasing short-term productivity, (4) concentration or (5) memory enhancement by a person who lacks a medical indication for the drug. Less frequently mentioned reasons for using stimulants nonmedically include performing better in sports, improving mood, staying awake, maintaing a better complexion, losing weight and building muscle (Carroll, McLaughlin, & Blake, 2006).
Box 2.
Estimated ED Visits, by Reason for ED Visit and Drug Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
Methylphenidate Reason for visit
ED visits % of visits
Amphetamine- dextroamphetamine ED visits % of visits
Total ED visits % of visits
Totala
3,601
100
4,272
100
7,873
100
Nonmedical use
1,541
43
2,228
52
3,769
48
Adverse reaction (medical use)
1,322
37
1,320
31
2,642
34
Accidental ingestion
390
11
435
10
825
10
Suicide attempt
348
10
289
7
637
8
aT he total includes only the four types of ED visits shown. This excludes patients who presented to the ED specifically to seek admission to the hospital’s detoxification or substance abuse treatment unit. Source: DAWN Report retrieved from: https://dawninfo.samhsa.gov/files/TNDR09ADHDmeds.htm
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Issue 5
reported that approximately 2 percent of adolescents between the ages of 12 to 17 (estimated to be 510,000 people) also used stimulants, such as methylphenidate, nonmedically during the past year. Specific data regarding nonmedical stimulant use in the adult population (those ages 26 and over) is lacking, but at least one source estimates it to be around 1 percent of the population (NSDUH). How are stimulants acquired for nonmedical use? One means may be through theft, as with the case described above. According to a study conducted by Carroll et al. (2006), some may visit a physician to seek ADHD medications even if they don’t believe they have ADHD. Some who legitimately have a prescription may sell, trade or give their medications to others for nonmedical use. Internet sales may also present an easily accessible opportunity for the motivated user to acquire stimulants for nonmedical use.
Risks The package insert for Adderall, a brand name for generic methylphenidate (U.S. Food and Drug Administration, 2007) lists a number of drug warnings including the risk of sudden death, stroke, myocardial infarction, exacerbation of preexisting psychosis,
emergence of new psychotic or manic symptoms, aggression or hostility, seizures and visual disturbance. Overdosage can result in restlessness, tremor, hyperreflexia, hyperventilation, confusion, hallucinations and panic. Even at therapeutic doses for treatment of ADHD, stimulant medication can cause insomnia, long-term growth suppression and appetite suppression. The National Institute on Drug Abuse (NIDA) has shown that drugs commonly prescribed to treat ADHD can cause physical changes in mouse brain cells resulting in an effect similar to, and in some cases, greater than, cocaine (U.S. Department of Health and Human Services [USDHHS], 2009). As Schedule II drugs, these stimulant medications carry a high risk of abuse, but have safe and accepted medical uses in the United States. Findings by NIDA indicate that people with ADHD do not carry an increased risk of subsequent addiction (2009), but nonmedical use of ADHD medication by normal people can lead to addiction as well as other health consequences (USDHHS). According to the Drug Abuse Warning Network (DAWN, 2006), in 2004, approximately 2 million emergency department (ED) visits in short-term, general, non-Federal hospitals in the United
States were drug-related. Of those visits, methylphenidate and amphetamines were involved in a total of 7,873 encounters (Box 2). Nonmedical stimulant use accounted for 3,769 or 48 percent of these visits. This report categorized nonmedical use as taking a dose higher than prescribed, using a drug prescribed for someone else, or other evidence in the medical record of drug misuse or abuse (DAWN). Polydrug use is typical in patients presenting to the ED as a result of nonmedical stimulant use (Box 3). Thirty-two percent of the time when methylphenidate or amphetaminedextroamphetamine were used, only a single drug was involved in the adverse event. However, 68 percent of the time, the ED patient had also consumed alcohol, an illicit drug or another pharmaceutical in addition to the stimulant (DAWN).
Implications for Nurses Nonmedical stimulant use presents vast implications for nursing care. The dearth of research in this area represents a great opportunity for nurses to generate a body of knowledge regarding the scope of populations who use stimulants nonmedically, their rationale to begin nonmedical stimulant usage, short- and long-term implications of
Box 3.
Nonmedical Use of ADHD Medications in Combination with Other Substances Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
Methylphenidate
Amphetaminedextroamphetamine
Total
%
1,541
2,227
3,768
100
Single drug
597
607
1,191
32
Multiple drugsa
944
1,620
2,564
68
with alcohol
341
413
754
20
with any illicit drug
331
662
993
26
with other pharmaceutical
810
1,329
2,139
57
Total
aC omponents do not sum to total because categories are not mutually exclusive. For example, one multiple-drug visit may include alcohol and another pharmaceutical. Source: DAWN Report retrieved from: https://dawninfo.samhsa.gov/files/TNDR09ADHDmeds.htm
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References Carroll, B. C., McLaughlin, T.J., & Blake, D.R. (2006, May). Pattern and knowledge of nonmedical use of stimulants among college students. Archive of Pediatric Adolescent Medicine, Vol. 160: 481–485. Retrieved May 21, 2009, from http://archpedi.ama-assn.org/cgi/ reprint/160/5/481.pdf Illig, R. (2009, April 27). Students use Adderall to study for finals. Tennessee Journalist. Retrieved May 18, 2009, from http://tnjn.com/2009/apr/27/ students-use-adderall-to-study/
this practice, and means through which nonmedical users acquire the drug, both legally and illegally. Education regarding the risks versus the perceived benefits of nonmedical stimulant use may serve to discourage this risky practice. ADHD is so commonly diagnosed among adolescent and college-age populations and there’s a misperception that treatment medications are relatively harmless because they’re so widely prescribed. High school and college health nurses should develop educational campaigns to warn students about this practice as a means of prevention. Practitioners need to be aware of nonmedical stimulant use and counsel those seeking medication for this purpose regarding the risks associated with this practice.
Outcome of This Mystery Following her arrest, my neighbor was convicted on two counts of breaking and entering and two counts of illegal possession of a controlled substance. Additional surveillance video footage showed that she was able to enter and exit my house undetected through a side door that did not latch tightly despite appearing to be locked. During the trial, I discovered that she targeted my house based on information she obtained through her son. As it turns out, during the time our sons attended elementary school together, all the children with
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ADHD were called to the nurse’s office simultaneously to take their medication as a group—her son and my son included. She admitted she started taking her own son’s methylphenidate to increase productivity and to promote weight loss and, within a short time, became addicted. To supplement the pills she pilfered from her own son’s prescription, she identified other neighborhood children on methylphenidate by asking her son who else took medication in the school nurse’s office at lunch time. I learned my house was one of several she frequented during her breaking-and-entering-spree.
Conclusion In summary, nonmedical stimulant use, neuroenhancement and cosmetic neurology, whatever the terminology, need to be thoroughly and completely examined so that those diagnosing ADHD and prescribing medications and those engaging in nonmedical stimulant use can totally understand and appreciate the risks versus the benefits of this practice. Nurses can and should take the lead in educating young high school and college students about this practice and the impact it can have on their health and their future. NWH
http://nwhTalk.awhonn.org
National Survey on Drug Use and Health. (2008, February 28). Nonmedical Stimulant Use, Other Drug Use, Deliquent Behaviors, and Depression among Adolescents. Retrieved May 18, 2009, from http://oas.samhsa.gov/2k8/stimulants/ depression.htm National Survey on Drug Use and Health. (2009, April 7). Nonmedical Use of Adderall ® Among Full-Time College Students. Retrieved May 18, 2009, from http://oas.samhsa.gov/2k9/adderall/ adderall.htm Talbot, M. (2009, April 27). Brain Gain. The New Yorker. Retrieved May 18, 2009, from http://www.newyorker.com/ reporting/2009/04/27/090427fa_fact_ talbot The New DAWN Report. (2006). Emergency Department Visits Involving ADHD Stimulant Medications. Retrieved May 18, 2009, from https://dawninfo.samhsa.gov/files/ TNDR09ADHDmeds.htm U.S. Department of Health and Human Services. (2009, February 2). NIDA Study Shows that Methylphenidate (Riatlin) Causes Neuronal Changes in Brain Reward Areas. NIH News. Retrieved May 21, 2009, from http://www. drugabuse.gov/newsroom/09/NR2-02. html U.S. Department of Justice Drug Enforcement Administration. (2008, April). Controlled Substances in Schedule II. Retrieved May 19, 2009, from http:// www.deadiversion.usdoj.gov/schedules/ listby_sched/sched2.htm U.S. Food and Drug Administration. (2007, June 7). Adderall Package Insert. Retrieved May 18, 2009, from http:// www.accessdata.fda.gov/drugsatfda_ docs/label/2007/011522s040lbl.pdf
Volume 13
Issue 5