He could be the emblematic Duke freshman: self-assured, well-spoken, goal-oriented. Early in the spring semester, Andrew shows up at one of the numerous campus cafés that peddle an enticing array of caffeinated concoctions. He's there to talk about a different stimulant—a so-called "study aid" drug.
Back in December, he had to review an entire chemistry textbook and related problem sets. In the tradition of students who are proud procrastinators, he had left the task to a couple of nights before final exams. After a grueling practice for a club sports team, he got back to his dorm room late, grabbed his chemistry materials, sank into a chair, and popped a capsule of Concerta, an extended-release drug that he had mooched off a friend. The drug is prescribed for attention-deficit hyperactive disorder (ADHD)—which Andrew doesn't happen to have.
He didn't leave the chair until 8 or 9 the next morning. His roommate fell asleep watching the studying Andrew; the roommate woke up to the still-studying Andrew.
"You do what you have to do," Andrew says about resorting to the drug. "I don't see a problem with it." He adds that he's sure other students find themselves drawn to other stimulants—caffeine pills, maybe, or Red Bull, the energy-boosting drink that he finds distasteful and maybe dangerous.
Competition is clearly part of his life, as it is for many Duke students: He was a high-school valedictorian, is taking a premed curriculum, and sticks with an intense daily workout at Brodie Gym on East Campus. "If you have to put in that much work," he says, "it's worth it" to be a Concerta consumer at critical times in the school year. For him, this particular episode of chemistry cramming was indeed worth it, he insists, although he declines to be specific about his final grade. His goal was to recover from a weak performance earlier in the semester. And he managed that, he says.
Andrew (not his real name) fits a profile outlined in a Duke study released in December. The study, led by researchers from the department of psychology and neuroscience, found that 9 percent of the Duke student body illicitly used ADHD medication such as Ritalin, Adderall, and Concerta during college. Nearly 20 percent of the group of users had done so ten or more times in the past six months. All of those stimulants are Schedule II drugs, as defined by the Drug Enforcement Administration, meaning they have a high potential of abuse but also have a considerable clinical benefit.
That arsenal of drugs, widely used in combating a medically recognized disability, increasingly has become a thorny issue for student-life officials across the nation. "If we look at well-conducted epidemiological studies, there hasn't really been an increase in the prevalence of ADHD," says Scott Kollins '82, director of the ADHD program at Duke Medical Center and associate professor of psychiatry. "What's happened, though, is that there certainly has been an increase in people's awareness of it. The good consequence is that kids get referred and diagnosed. The bad consequence is that any behavior problem suddenly becomes ADHD."
More awareness of ADHD may not be a bad thing. But just as students are drawn to a substance—alcohol—thought to enhance social interactions, so might they be drawn to a substance thought to enhance academic performance. And like drinking excessively, resorting to study-aid drugs is an activity fraught with medical, legal, and ethical concerns, particularly in an academic setting.
The Duke study found that 90 percent of those who reported using ADHD medication during the past six months without benefit of a prescription were aiming for a basic goal: greater success with their studying. And almost all the users felt it was effective. Only a small percentage considered the experience negative, brushing aside side effects like loss of appetite, difficulty in sleeping, and irritability. Such expressions of satisfaction suggest, says David Rabiner, the lead author of the study, that for Duke or any other university, mounting a more aggressive campaign against stimulants would mean fighting students' inclinations to indulge in an easy fix for academic challenges—a fix whose effectiveness is widely assumed and whose dangers aren't well understood.
"Students who are doing this to enhance their ability to study in many cases are students who are simultaneously reporting high levels of academic concerns and high rates of attention difficulties," says Rabiner Ph.D. '87, A.H.C. '87, an associate research professor and director of undergraduate studies in the department of psychology and neuroscience.
That presents "a different picture than your typical high-achieving Duke kid who wants to be even more high-achieving," Rabiner says. "It really looks like many students are doing this not so much to enhance their efforts but almost to remediate deficits that they perceive themselves as having. They're concerned about their ability to succeed academically. And it looks like they're turning to this as a way to address their problems. That's different from their trying to become super-students." They may not be aiming for super-student status, but 40 percent of the user group said they felt they needed ADHD medication to do their best academically. (Despite common belief, he adds, "There are very few students who are doing it regularly, at least as they report, for recreational reasons.")
Rabiner's study is based on a Web survey taken in the spring of 2007 at Duke and the University of North Carolina at Greensboro. The survey group was reasonably representative of the undergraduate population of two schools that appeal to quite different demographics. Other studies have suggested that the illicit use of ADHD medication is more common at colleges and universities with tougher admission standards. Rabiner's findings highlight the fact that it's more common among students struggling to earn top grades—and among students who are white, belong to a fraternity or sorority, and engage in other types of substance abuse and risky behavior.
But whether those students are actually benefiting from consuming drugs presumed to boost academic performance is a question without a clear answer, according to Rabiner. "What we found is that overwhelmingly they think it's helpful. They feel it often helps them to concentrate or that it always helps for that purpose. Whether it makes an objective difference in how they do, we have no idea."
Objectivity is hard to find when it comes to diagnosing ADHD. "It would be nice if we could do a blood test, but it's just not that black and white," says Student Health physician Lauren Johnson. She says an ADHD diagnosis entails a comprehensive evaluation, including a family history and a record of childhood symptoms. "We're sticklers for having documentation before we're willing to initiate medication or refill medication." The condition "is genetic, it's biological," she adds. "It's not something that just showed up last week."
At Duke Student Health and at other institutions, the number of ADHD students is on the rise, says Johnson, both in the categories of students seeking an initial ADHD diagnosis and those aiming to maintain treatment after having been diagnosed before beginning college. Kollins observes that a hike in the number of students seeking a diagnosis is one thing; an actual increase in prevalence would be something else. "It means that there are more people who have heard about the disorder and/or the treatment. And they think it could explain the impairments they are facing." That is, students not succeeding as they anticipated might arrive at the conclusion that ADHD issues—and not, say, bad study habits—are holding them back. "Or," he concedes, "it might be a quick way to get some cognitive-enhancing drugs."
If students are diverting those drugs to their peers, they're violating the terms of the Duke Student Health "Controlled Medication Contract." Among other terms, the contract provides that students "will not ask for or accept" medications from other providers while receiving medication from Student Health; that they will "not share, sell, or trade" medications; and that they understand that excuses of running out early, losing a prescription, or spilling medication won't entitle them to a prescription refill.
Even with such strict language, diversion is hardly uncommon. According to Rabiner's survey, in the past six months 65 percent of ADHD students at Duke were asked by other students for their medication; most were asked multiple times. Some gave or sold their ADHD medication to a peer—a few on multiple occasions—and two students reported having their medication stolen.
Sarah, a 2008 Duke graduate, who was diagnosed with an attention disorder in her junior year, can identify with many of those scenarios—including the sense that she was lagging behind her peers in a high-pressure Duke environment. "In contrast to high school, getting good grades at Duke required a more complete understanding of the material, not only memorization," she says. "I had no clue how to manage my time. I would spend the majority of my time sitting in front of books, but daydreaming or thinking about other things. I would also spend excessive amounts of time making to-do lists or trying to catch up and get organized."
Sarah (not her real name) takes Adderall almost daily. It's useful for her, she says, because it allows her to exist in a distraction-free zone. Now and again, she notes, she needs to get off the Adderall to escape the zone and to follow a more easygoing routine.
To college students, for whom odd sleeping and eating habits are the norm, the side effects are no big deal, Sarah says. And illicit pill-popping is no big deal either. "You'll hear people say, 'I have a huge paper due tomorrow. This is going to be an Adderall night.' People don't feel guilty about it. It's not hidden." Sarah says that as a student, she was "asked a lot" to give out some of her Adderall; she was offered $15 for just one pill. She says she's refused the offers but jokes, "I could have made a lot of money."
The drugs prescribed for a diagnosed ADHD condition, counterintuitively, help slow down hyperactive individuals. In ADHD brains, says Kollins, dopamine function is abnormally inactive. Dopamine largely controls someone's ability to inhibit responses; the lack of that ability translates into impulsivity, hyperactivity, and inattention. For ADHD individuals, at least in theory, elevating levels of dopamine "normalizes" attention and inhibitory control. So, far from replicating the caffeine buzz of coffee or an energy drink like Red Bull, ADHD medication places the ADHD individual in a zone where he or she is calmer and more focused.
The main differences among the various medications hinge on whether they are based on amphetamine or methylphenidate. According to Kollins, these compounds operate slightly differently on the brain. Amphetamine is more potent, so physicians prescribe more controlled doses. There's no evidence that any one compound works better than another for treating ADHD. A number of the stimulants are designed for slow release, with the effects lasting six to twelve hours. Others are in and out of the body's system in three or four hours.
There's a lot of debate around the question of whether the drugs work in the same way for those with and without ADHD, Kollins says. Either population, though, will see side effects. "If you take a reasonable dose of an amphetamine or methamphetamine product, you are going to be able to stay awake longer; in fact, it might impair your sleep. It's going to decrease your appetite. If you reach a certain point with a dose, it is going to make you jittery. You are going to get a bump in your heart rate and your blood pressure. The magnitude of the change is going to depend on how much you take and exactly what product you take."
Beyond concerns over side effects, there's reason to doubt, according to Rabiner, whether ADHD students find their medications helpful in terms of the ultimate aim—success in college. In another Web survey, still unpublished, he and his colleagues found that while "most students with ADHD appeared to be making satisfactory adjustments in college," they also reported having "lower GPAs, heightened concerns about academic performance, and … more depressive symptoms, social concerns, emotional instability, and substance use."
The medications probably do improve attention and reduce impulsivity in children and adults with ADHD, Rabiner says. And they probably promote short-term gains in children's academic performance—the basis on which they are prescribed. "What has been harder to document at the group level is that this treatment leads to improvements in meaningful real-world outcomes. As a crude analogy, it is sort of like studies showing that certain medications may reduce blood pressure but have no impact ultimately on mortality rates."
Rabiner's earlier survey shows that a lot of students who use ADHD drugs illicitly are also drawn to other substances: 24 percent reported using cocaine and 67 percent, marijuana. Problem drinking, too, is linked with the use of the drugs.
"The feeling is that if you take Adderall, you can stay up longer and you are not going to pass out when you are out drinking," says Kollins. "Well, that may be a perceived benefit, but then we get mentions of Adderall being in somebody's system when they show up with alcohol poisoning at the emergency room." Officials involved with student health worry that the illicit use of ADHD drugs can mask other problems, including depression, sleep disorders, and drinking to excess, that should be addressed in other, more medically sensible, ways.
Musing about the case of Andrew and his chemistry preparations, Kollins says, "If it's freshman chemistry, it's probably lots and lots of rote memorizing of formulas. And so there probably is a chance that he was able to, on a short term, study, stay up longer, stay focused longer, maybe get a better score on the test. But when he gets to organic chemistry next semester, how much of that learning is going to stick? That's what we don't know."
The Chronicle thinks it knows enough to dislike the pill-popping practice. In January, the student newspaper adopted a rare scolding tone in an editorial aimed at students like Andrew. According to the editorial, "Say No to Study Drugs," taking ADHD medication without a medical diagnosis and prescription is not just illegal, it is also "a morally reprehensible means to get ahead in class," "exacerbates the real academic pressures that exist in any competitive university," and "replaces a culture of learning with an environment in which getting the task done in as little time as possible is the only focus." The editorial declares that abuse of ADHD medication should be considered akin to "plagiarism, cheating, and lying."
A more nuanced view was expressed a few weeks earlier in a Nature commentary by Henry Greely of Stanford Law School and Barbara Sahakian of the University of Cambridge. Students who illicitly take Ritalin, Adderall, and Concerta are "early adopters of a trend that is likely to grow," write the authors. Such drugs, they add, "along with newer technologies such as brain stimulation and prosthetic brain chips, should be viewed in the same general category as education, good health habits, and information technology—ways that our uniquely innovative species tries to improve itself."
They call for more research in areas like the precise effects of the drugs and the risk of dependence: Are users getting merely transient, short-term boosts, or do the drugs promise long-lasting significant changes in the ability to learn? Lacking research findings that place cognitive-enhancing drugs in a danger zone, they argue that the drugs "seem morally equivalent to other, more familiar, enhancements."
"Human beings have been enhancing their capacities from time immemorial," says Allen Buchanan, James B. Duke Professor of philosophy and public policy. "You can think of literacy and numeracy as fantastic cognitive enhancements; computers are fantastic cognitive enhancements. And the most popular cognitive-enhancement drug so far is caffeine. Nicotine is also a cognitive-enhancement drug; it's just that it has very bad side effects."
There's not a clear boundary between one form of enhancement and another, or between treatment of a disease and enhancement of a normal person's capacities, Buchanan says.
"You might take Adderall in the hope that you'll do better than someone else and end up in the highest percentile of scoring on the test. But perhaps I'm a researcher working on a cure for cancer, and I want to be able to assimilate vast amounts of literature and then integrate it into my research." What if he took Adderall to enhance his assimilating ability on such a consequential project? That might produce an individual benefit beyond the realm of competition, says Buchanan. It might also produce a benefit for society.
"There's some evidence that some of the cognitive-enhancement drugs that are now being used are most effective for people at the lowest end of the cognitive-performance range," Buchanan says. "That's actually sort of good news, because it means that these drugs could be used to help level the playing field." A good analogy, he says, is the use of calculators in providing a performance boost for those who are mathematically challenged.
"You could imagine a situation where fifty years from now, 100 years from now, there's a wide range of enhancements that lots of people are using: enhancements to their immune system, so they're not as prone to the common cold; mood enhancements, so fewer people suffer from depression; sleep enhancements, so they can sleep fewer hours and get as much out of it psychologically and physically; and cognitive enhancements, so they have better memories and better mental acuity. And if using all these things becomes the norm, then in the extreme case, you can imagine that a person who didn't use them would be regarded as disabled. That is, they wouldn't be able to function in the dominant cooperative scheme. They would look like people who just aren't up to being productive members of society."
The lesson from older drugs like Prozac, says Buchanan, is that "enhancements aren't generally going to come through the door with 'enhancement' stamped on them. They are going to come through the back door as treatments of diseases first. Prozac was used to treat clinical depression; it was considered a disease condition. And then there was pressure from people who weren't clinically depressed but who just wanted to feel a little better. And that's what's happening with cognitive-enhancement drugs. First they were developed for narcolepsy or for treating symptoms of Alzheimer's dementia or for attention-deficit disorder, defined pretty narrowly and rigorously."
It would be more sensible to bring enhancement drugs more out in the open instead of relegating them to "the back door of treatment," Buchanan says. That would allow better research into the drugs' effects on normal people, and from there the developing of safety standards. "It's a little like the people who just say no to globalization. It's not going to happen. People are going to use these things if they have some reasonable prospect of safely increasing their cognitive capacity."
His generation, Buchanan says, is going to have a lot of body parts replaced, from heart valves to every joint imaginable. "We've already enhanced ourselves in ways that make us live longer. But one consequence of that is that we may have, as it were, enhancement gaps. We're living longer physically, but parts of our brains aren't able to keep up. We may need enhancements of the brain, just to take advantage of this increase in longevity and to avoid a social disaster, like the bankrupting of the Social Security system and the health-care system."
There are bound to be risks with the magic bullet or the quick fix, Buchanan says. But the demand is out there and, as he puts it, "it's going to be satisfied, one way or another." He mentions the laser surgery he had to sharpen his eyesight. "I had an enhancement when I had Lasik surgery. I had my vision improved a little bit better than normal." No one is accusing him of seizing an unfair advantage because he's improved his ability to consume information. Though, of course, he's done just that.
Are laser surgery and pill-popping just two sides of a many-sided, and open-ended, quest for enhancement? Society, Buchanan acknowledges, isn't yet comfortable with the concept. The Chronicle reflected that resistance in its critical editorial, which asked: "For the rest of your life, will you reach for a pill before every major assignment?"
Andrew, the freshman, wonders about the question posed by the Chronicle editorial as well. He hopes to be a surgeon someday. And if he succeeds in that career ambition, he'll be cutting out drug-based study aids, he says. He imagines himself preparing for a delicate procedure: "I wouldn't want to be under the influence of anything."
The illicit use of drugs prescribed to treat attention disorders is fraught with medical, legal, and ethical concerns. At the same time, it may be an expression of the human imperative to work with ever-greater efficiency.
April 1, 2009