by Alison Hayward, M.D., Sarah M. Lawrence, and Bill Johnson, D.D.S.
SDN Staff Writers
Amanda (not her real name) is a second year health professional student at a major state-funded research institution. Like most students admitted to medical, dental or pharmacy school, Amanda was a top student at her undergraduate institution, used to earning high marks with minimal study time. In professional school, Amanda finds her old study habits put to the test. The material is not difficult, she reports, but the volume of information she’s required to process, coupled with the fast-paced schedule and demands of clinical activities, makes achieving at the level she’s accustomed to a major challenge.
Several of Amanda’s classmates have told her about a “study drug” that allows them to stay awake for days at a time and study for extended periods without rest. The drug, they said, improved their focus and concentration and makes it easier to plow through the mountains of information presented in their classes. One of them offered Amanda a little peach colored tablet, and she accepted but didn’t take it. Worried about the side effects, she placed the tablet on her bookcase and looked at it with curiosity from time to time. Finally, faced with an exam and a paper due and not enough hours in the day, Amanda decided to try the study drug. Immediately she noticed a difference. “I felt great,” she told us. “I was able to stay up all night and finish my work and I didn’t even need to sleep before the exam. It WAS a miracle drug.”
Smart Study Aid or Unfair Advantage?
Like steroids in baseball or track, the use of medication to enhance students’ ability to study is controversial. The most commonly abused stimulant medications among college students are amphetamines and related compounds like methylphenidate. Students obtain these medications by legal prescription through a diagnosis of ADHD, from classmates or by buying them illegally. The ethics of using these medications in this manner are controversial. Students who lack a valid medical diagnosis often use stimulant medications to put in extended study hours and reduce their need to sleep, to facilitate preparing for exams or writing papers. Many students consider this just a part of “getting ahead,” while others liken it to any other form of cheating and point to the perceived unfair advantage drug-taking students may have over peers who lack access to or are unwilling to take medication to help them study.
Stimulant Use and Abuse
The first drug used to treat ADHD was methylphenidate (Ritalin), patented in the 1950s for depression, narcolepsy and fatigue. It then began to be used as a treatment for ‘minimal brain dysfunction,’ as ADHD was known at the time. Ritalin’s popularity exploded with the acceptance of ADHD as a clinical entity, and it is now the most commonly prescribed drug for ADHD in the USA. Methylphenidate is available in numerous preparations, including a transdermal patch and extended release formulations such as Concerta. Ritalin is a CNS stimulant, thought to activate the frontal lobes of the brain by binding to dopamine and norepinephrine receptors.
Other, similar drugs used to treat ADHD include mixed amphetamine salts (Adderall) and dextroamphetamine (Dexedrine), which is one of the components of Adderall. Like Ritalin, these medications all have typical amphetamine side effects like decreased appetite, insomnia, and dry mouth. Dexedrine, the oldest patented amphetamine drug, has been used for its weight loss properties in extreme cases of resistant obesity. All are Schedule II, the most restricted classification for a drug considered to have a legitimate medical use, due to the potential for abuse and addiction. They are close relatives of methamphetamine, an illegal substance that has spawned an epidemic of ‘meth labs’ across the country in recent years.
ADHD: A Difficult Diagnosis
There are several challenging and controversial aspects about the diagnosis of ADHD. The Diagnostic & Statistical Manual of Mental Disorders (DSM), the gold standard for psychiatric diagnoses, identifies 22 diagnostic criteria for ADHD, with characteristics broken into three areas: inattention, hyperactivity, and impulsivity. According to the DSM, a diagnosis of ADHD may be rendered if the patient has six characteristics in either the inattention category or the combined categories of hyperactivity and impulsivity. These criteria must have been present for six months or more and be “disruptive or inappropriate for [the patient's] developmental level.” Critics of the process for diagnosing ADHD claim that the determination of whether a patient’s behavior is “disruptive or inappropriate” is too subjective and vague. The diagnostic and ethical challenge,then, lies in the determination of what constitutes “significant impairment.”
One obvious quandary is the diagnosis of ADHD in the pre-professional or professional health care student population. This demographic is already typically comprised of high achievers and perfectionists. Such individuals often feel pressure to use stimulants to keep up with their peers, whether or not they would be able to achieve a ‘normal’ level of function without the stimulants. For these individuals, the issue is a Machiavellian ethical dilemma — do the ends of successfully pursuing and/or practicing a career in health care justify the means that may be required to achieve them? In debates on the SDN Forums, many decry this type of use of stimulants, which seems to be rampant, and compare it to the use of steroids by professional athletes. Even more disapprove of illegal use of stimulants without a prescription.
Stimulating the Ethical Debate
Widespread abuse of drugs like Adderall and Ritalin on college campuses, however, is well-documented in the literature. One annual government study on the use of Ritalin by college students in 2003 concluded that 5% had used Ritalin without a prescription in the previous year, and broader studies have shown up to 35% prevalence of stimulant abuse, misuse, or illicit sales on undergraduate campuses. Anecdotally, the use of stimulants as “academic steroids” amongst health professions students appears to be similarly frequent.
As the number of patients taking stimulant medications continues to grow, so will the number and complexity of the ethical questions surrounding their use. Such publications as the British Medical Association’s 2007 discussion paper, on the ethical merits and challenges of “cognitive enhancement,” suggest the medical community has begun turning its attention to the matter. In the meantime, the use of stimulants by health students remains a matter of significant controversy.