Illegal College ADHD Stimulant Distributors ...

Substance Use & Misuse, 48:446–456, 2013 C 2013 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2013.778281

ORIGINAL ARTICLE

Illegal College ADHD Stimulant Distributors: Characteristics and Potential Areas of Intervention Alan D DeSantis1 , Kathryn E. Anthony2 and Elisia L. Cohen1 Department of Communication, University of Kentucky, Lexington, Kentucky, USA; 2 Communication Studies Program, Columbia College, Columbia SC, USA

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The pervasive increase in prescriptions for these medications has caused some concerns because of the potential for drug abuse and dependency. Recent research has specifically focused on the illicit use of these medical stimulants on college campuses. DeSantis, Webb, and Noar (2008) reported that 34% of their college-student sample had used Adderall and other ADHD medications nonmedically for enhanced academic performance and for recreational use. Similarly, Advokat, Guidry, and Martino (2008) revealed that 43% of the 1,387 undergraduate students in their study had accessed ADHD stimulant medications without a prescription, and 84% of them claimed to do so for improved academic performance. Beyond solely using medical stimulants for improved academic performance, students have also reported using the medications recreationally. In Sepúlveda et al.’s (2011) study of 55 college students reporting past-year prescribed stimulant use, 35% misused stimulants (taking more than prescribed, self-reported misuse, or intentionally using them with alcohol or other drugs). These students were also more likely to divert prescribed stimulants compared to those who did not misuse stimulants (p = .008). This is consistent with Teter, McCabe, Cranford, Boyd, and Guthrie’s (2005) findings that students obtain stimulants for both academic performance and recreational use. Given the pervasive use of ADHD stimulants by nonprescribed users, it should not be surprising that ADHD stimulants are often the most frequently distributed illegal medications on college campuses (Garnier et al., 2010; Wilens, Gignac, Swezey, Monuteaux, & Biederman, 2006). But who is distributing these Schedule II stimulants to nonprescribed college students? The answer is fellow students with medical prescriptions for ADHD stimulants. And while there is a growing body of literature focusing on illegal users that take ADHD medication not prescribed to them, far less is known about these “distributors.” Recent research suggests that the diversion of ADHD

This study identifies indicators of college students, with prescriptions to Attention Deficit Hyperactivity Disorder (ADHD) stimulants, who are most likely to distribute their medication to nonprescribed peers. 2,313 undergraduate students at a large Southeastern University were surveyed from 2009 to 2011. 5.2% (n = 120) were currently taking a prescribed ADHD stimulant. Analyses revealed that distributors are more likely to (1) take their medication less frequently; (2) misuse their stimulants for “off label” purposes; (3) be a member of a fraternity; (4) overestimate the percentages of users; and (5) belong to at-risk peer groups. The work concludes by discussing the study’s implications, limitations and future research. Keywords ADHD, college students, stimulants, prescription drugs, diversion, misuse, Adderall

In the last two decades, there has been an upsurge in the number of prescriptions written for medical stimulants for children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) (McCabe, Teter, & Boyd, 2004; Olfson, Marcus, Druss, & Pincus, 2002). Data analysis from adolescents and children under 19 reported in the Medical Expenditure Panel Survey from 1996 to 2008 found a steady annual increase in the number of patients treated with stimulants, with 3.5% of all U.S. children and adolescents treated with stimulants (Zukevas & Vitiello, 2012). Patients diagnosed with ADHD are typically prescribed Methylphenidate (e.g., Ritalin, Metadate, Concerta, Daytrana), Dextroamphetamine (e.g., Dexedrine, Dextrostat), and Amphetamine (e.g., Adderall), with the latter being the preferred medication to treat ADHD. All of these stimulants have been classified by the U.S. Drug Enforcement Administration (DEA) as Schedule II substances (Woodworth, 2000).

Address correspondence to Dr Alan D DeSantis, Ph.D., Department of Communication, University of Kentucky, 234 Grehan Building, Lexington, KY 40515, USA; E-mail: [email protected]

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ILLEGAL COLLEGE ADHD STIMULANT DISTRIBUTORS

medication is common, with Sepúlveda et al. (2011) reporting 36% of their college student sample had given away, loaned or sold their prescribed ADHD stimulants. For the purpose of this study, we will define these students who either share or sell their prescribed ADHD stimulants with others that do not have prescriptions for these medications as “distributors.” There is a paucity of research that examines the illegal diversion of stimulant use in college student populations (McCabe, Boyd, & Teter, 2006; Sharp & Rosén, 2007). In early investigations of distributors, McCabe et al. (2006) revealed that 54% of subjects medically prescribed for a stimulant reported being approached to distribute their medication to a nonprescribed user. More recent research by Garnier et al. (2010) reported more than one-third (35.8%) of the college students with a prescribed medication diverted it at least once in their lifetime. Additionally, they found that prescribed users had among the highest rates of diversion, with 61.7% (50/81), and that diversion is significantly related to the number of nonprescription drugs the individual uses. As they have asserted, “Each prescription drug used nonmedically in the past year increased the odds of diverting a prescription medication by 52%” (p. 5). Exploring similar questions, Jardin, Looby, and Earleywine (2011) found that distributors were more likely to use a greater number of illicit substances, misuse their medications by taking a higher-than-recommended dose, and mix their medication with other drugs or alcohol to intensify the effects. Most interestingly, they also found that distributors (vs. nondistributors) experience more hyperactivity symptoms with their ADHD and more likely to be high sensation-seekers. While the work of Garnier et al. (2010) Jardin et al. (2011), and Sepúlveda et al. (2011) have contributed to our understanding of the characteristics of ADHD distributors, a more complex and layered profile is needed. Consequently, it is the purpose of this study to identify indicators of students, with current prescriptions to ADHD stimulants, who are most likely to illegally distribute their ADHD medication to their nonprescribed peers. Identifying potential distributors becomes especially important when considering that this relatively small number of “dealers” (3.1% of the student body) is responsible for supplying over 30% of the campus in our study with illegal stimulants (DeSantis, Noar, & Webb, 2009). And this number of illegal users climbs to over 60% when isolating upper-class students (i.e., juniors and seniors) and students that are members of fraternities and sororities (DeSantis et al., 2009; DeSantis & Hane, 2010; Dussault & Wyandt, 2013). Toward this end, we examine indicators that could potentially aid health-care providers, university administrators, and public-health officials in both identifying atrisk distributors and in designing programs and policies that target these potential misusers. Specifically, this study probes this issue by examining the influence of a distributor’s (1) history with stimulants; (2) regularity in taking his/her prescribed ADHD medication; (3) previous

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“off label” misuse; (4) fraternity/sorority membership; (5) sex; (6) perceived normative use of ADHD medication; (7) peer group; (8) self-reported talk with a health-care provider about ADHD medication; and (9) history of illegal substance use. In what follows, we will (a) detail our methods; (b) explain each of these potential indicators of college students’ likelihood of distributing their prescribed ADHD medication; (c) suggest how our findings can be applied to affect illegal distribution; and (d) conclude by discussing future areas of investigation and the limitations of this study.

METHODS Participants

Survey data from 2,313 undergraduate students were collected from a large, lecture-hall “Introduction to Communication Theory” class over the course of four semesters (fall 2009, spring 2010, fall 2010, and spring, 2011). The class is taught at a large Southeastern University and meets the university’s social-science requirement. Consequently, the course provides a sample of students from a wide range of majors from across campus. There is, however, a disproportionate number of first and second year students traditionally enrolled in the class. Procedure

Following the institutional review board’s (IRB) guidelines, students read and approved the consent form before answering any questions. For each of the four semesters that data were gathered, students were informed during class that they would receive 2% extra-credit points for completing an online survey outside of class. For students not wishing to participate in this study, a substitute writing assignment was also available to them for the same 2% extra-credit points. Additionally, the students’ ID numbers, used to award the extra-credit points, were maintained independently of their survey answers, thus guaranteeing their anonymity throughout this process. Approximately 90% of the students participated in taking this 20 to 30 minute survey. Of the 2,313 participants who took the survey, 8.2% (n = 189) had been diagnosed with ADHD in their lifetime while 5.2% (n = 120) were currently taking a prescribed ADHD stimulant at the time they were administered the survey. There were no significant differences in the age of undergraduate with and without active ADHD medication prescriptions, compared to the larger participant survey population (p >.05). This subgroup of 120 (M age = 19.85; Range: 18–27 years old) undergraduates with active prescriptions is the focus of this current investigation. Of these 120 students, 37 (30.8%) females, and 83 (69.2%) were males. Of these, 34 (28.3%) were first year, 45 (37.5%) were sophomores, 31 (25.8%) were juniors, and 10 (8.3%) were seniors. 113 (94.2%) were white, 3 (2.5%) were African American, 3 (2.5%) were Asian/Pacific Islander, and 1 (.083%) identified as “other.”

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A. D. DESANTIS ET AL.

Measures


The DeSantis et al. (2008) survey was modified to address our specific concern of students who illegally distribute ADHD stimulants. This augmented tool consisted of 44 questions divided into five major areas of interest: 6 questions obtained basic demographic information; 25 questions inquired about their specific medication use, side effects, and their relationship with their healthcare provider; 4 questions asked about the morality of distributing ADHD stimulants to other students; 6 questions focused on their perceptions of others’ legal and illegal use; and 3 questions explored their use of other substances (e.g., alcohol, marijuana, pain pills, etc.). Distribution/Diversion of Medications Based on a modified version of Sepulveda et al.’s (2011) measure of diversion of prescribed stimulants, participants completed two items concerning the distribution, or diversion, of prescription stimulant. Participants were asked, “Have you ever given away for free your prescribed medical stimulants” and “Have you ever sold your prescribed medical stimulants?” The two items were combined to create one overall measure of distributors, where 1 = having given or sold prescribed medical stimulants. Type of Prescribed Medication To determine the type of medication taken by prescribed users, participants were asked, “What type of prescription ADHD medication do you currently take?” Participants were asked to select one of the following: Adderall, Concerta, Dextrostrat, Focalin, Methylin, Ritalin, Vyvanse, Daytrana, Desoxyn, Dexedrine, Metadate, and “other.” Nonprescribed Stimulant Use The use of nonprescribed medical stimulants by prescribed users was assessed following the DeSantis et al. (2008) measure: “Have you ever taken nonprescribed ADHD medication?” Participants who had been prescribed ADHD medications were also asked, “Before or after you were diagnosed with ADHD, did you ever take nonprescribed ADHD medication?” Respondents were asked to respond with a yes or no. Fraternities and Sororities Affiliation (aka Greek Affiliation) Fraternity and sorority affiliation has served as a significant predictor of nonprescribed use of medical stimulants in prior research (DeSantis, 2008; Dussault & Wyandt, 2013). To determine whether or not membership in a social fraternity or sorority is also a predictor for stimulant diversion, participants completed the DeSantis et al. (2008) measure of Greek affiliation. Participants were asked “Are you a member of a fraternity” and “Are you a member of a sorority?” to indicate male fraternity or female sorority membership. The two items were also combined to create an indicator of any social fraternity or sorority affiliation.

Use of Stimulants “to Party” Previous research has revealed that beyond academic reasons listed by nonprescribed users, some individuals take the drugs specifically for recreational use (Jardin et al., 2011; Sepúlveda et al., 2011). To assess more fully the off-label usage of the stimulants, participants were asked a modified version of authors DeSantis et al. (2008) and Rabiner et al.’s (2009) measure of motivation for taking nonprescribed medical stimulants: Why do you use prescription ADHD drugs while school is in session? Items included, “To party/socialize longer” and “To prolong the effects of alcohol.” Cronbach’s coefficient alpha for the scale was 0.72 (M = 2.21; SD = 0.540) for while school was in session and α = 0.90 (M = 1.02; SD = 0.98) for when school was out of session. A four-item combined scale measuring the degree to which students used stimulants in and out of school was created (α = 0.80; M = 2.44; SD = 3.77).

Perceived Stimulant Use of Others McCabe (2008) revealed that in a sample of university students, individuals overestimated the number of misusers of nonprescribed stimulants by nearly three times of the actual number of misusers on campus. To assess whether or not the pervasive faulty perceptions are consistent among prescribed users who diverge their medications, participants completed a modified measure of McCabe’s measure of perceived nonmedical stimulant use. Three items asked participants to provide a percentage out of 100 for to estimate their perceptions of other university students’ stimulant use. Participants were asked, “Estimate the percentage of students that are presently taking a nonprescribed ADHD drug” (M = 53.43; SD = 21.91); “Estimate the percentage of students on your campus that are presently taking a prescribed (by their doctor) ADHD drug” (M = 37.21; SD = 18.41); and “Estimate the percentage of your friends at this university that are taking a nonprescribed medical stimulant” (M = 41.49; SD = 28.29).

Physician Talk Garnier et al. (2010) and Sepúlveda et al. (2011) articulated the necessity of meaningful physician-patient communication in curtailing the diversion of prescription stimulants. Based on the importance of the interaction between providers and patients, participants completed a threeitem scale concerning the topics discussed in conversations with their healthcare providers. Scale items were five-point Likert-type questions, ranging from (1) strongly disagree to (5) strongly agree. Sample items from the scale inquired as to whether physicians had discussed certain topics with the patient, including “Whether you take your ADHD medication regularly (as prescribed to you)” and “The dangers of sharing your ADHD medication with others.” Cronbach’s coefficient alpha for the scale was 0.80 (M = 2.87; SD = 1.50).



Use of Other Drugs Previous research has revealed a strong correlation between the misuse of prescribed medical stimulants and the use of illicit drugs (Jardin et al., 2011; Wilens et al., 2006; Sepúlveda et al., 2011). Using a modified measure adapted from Wilens et al. (2006) concerning the use of illicit drugs, participants completed 10 items concerning their use of other drugs, legal and illegal. Participants were asked “Have you ever used alcohol to get drunk?” “Have you ever used. . . marijuana? cocaine? prescription pain killers not prescribed to you? prescription anti-anxiety not prescribed to you? hallucinogens? heroin? ecstacy? methamphetamines?” Frequency of Medication Use McCabe et al. (2004) and Boyd, McCabe, and Cranford (2007) articulated that physicians, but especially parents, should “serve as gatekeepers in monitoring the dosage and frequency of use to detect possible signs of diversion” (p. 279). Based on their observation, and the assumption that individuals who take their prescription less frequently will have additional medication to divert, the frequency with which participants take their prescribed ADHD medication was assessed with one item in which participants were asked to select the days of the week they regularly took their ADHD medication. From these data, a summated variable of these seven days (range: 1–7 days) was created to measure the average number of days the student takes their prescribed ADHD medication. Breaks in Medication Similar to the frequency in which an individual takes his or her medication, breaks in medication (i.e., summer breaks, holidays) may also offer the potential yield of surplus of prescribed stimulants. Just as physicians have been encouraged to pay particular attention to the frequency with which their patients take their medications (Boyd et al., 2007; McCabe et al., 2004), they may also need to be keenly aware of whether or not patients take prolonged reprieves from their medication. The use of prescribed medication during breaks from school was assessed with one item. Participants were asked, “Do you take your prescription ADHD medication when school is not in session (i.e., summer breaks, vacations).” Participants were asked to respond with a yes or no. GPA McCabe et al. (2006), Rabiner et al. (2009), and Sharp and Rosen (2007) revealed that lower grade point averages were significant predictors of nonprescribed users. To assess whether or not this variable also predicts diversion of prescription drugs, participants were ask to self-report their grade point average on a 4.0 scale, where 4.0 was an A, 3.0 was a B, 2.0 was a C, and 1.0 was a D grade point average (M = 2.78; SD = 0.63). University Major Although multiple studies have revealed that nonprescribed users take medical stimulants to improve their aca-

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demic performance (Aikens, 2011; DeSantis et al., 2008), few studies have actually considered whether or not students of particular academic majors are more likely to misuse their prescribed stimulant. Thus, participants were asked to self-report their university major by choosing from the five options of (1) social sciences/education, (2) natural sciences/medical-related, (3) fine arts/humanities, (4) business/economics, (5) engineering/computers, and (6) undecided. Morality of Stimulant Use Through qualitative interviews with nonprescribed users, DeSantis and Hane (2010) revealed that students perceived the taking of nonprescribed medical stimulants as a safe and moral act. To assess this further, participants were asked to indicate their beliefs concerning the morality of nonprescribed stimulant use on a one-item, seven point semantic differential scale ranging from “immoral” to “moral” (M = 4.69; SD = 1.48). RESULTS

Of the 2,139 undergraduate students who took our survey, 120 of them reported currently taking a prescribed ADHD stimulant. Of these, 63 students (52.5%) admitted to giving their prescribed medication away while 47 students (39.2%) admitted to selling their medication to someone without a prescription. Interestingly, every student that reported “selling” their medication also claimed that they had also given away their medication. There were no significant differences between distributors who sold their surplus medication compared to distributors that gave their stimulants away for free. Specifically, both groups were similar in their use of illegal drugs (χ 2 = 14.17, df = 8, p > .078) and their misuse of their stimulants for off-label purposes (e.g., to stay awake and social/party) (χ 2 = 19.97, df = 13, p > .096). Additionally, both groups also over-estimated the percentage of illegal users (χ 2 = 51.31, df = 50, p > .422) and prescribed users (χ2 = 55.22, df = 46, p > .165) on their campus. Finally, those that sold and those that gave their stimulants away for free judged the morality of nonprescribed ADHD stimulant use similarly (χ 2 = 11.14, df = 6, p > .084). We also discovered that a prescribed student’s gradepoint average (GPA) did not matter in predicting their willingness to distribute (selling or giving away). Smarter students are just as likely to “share” medication as their less academically successful peers (χ 2 = 24.70, df = 24, p > .422). Similarly, a prescribed user’s university major did not serve as a predictor (See Table 1, χ 2 = 5.04, df = 5, p > .412). Engineering, communication, and nursing students were as likely to distribute as psychology, pre-med, or art majors. Most strikingly, however, was the discovery that a student’s class standing (i.e., years in college) did not matter (χ 2 = 0.911, df = 3, p > .823). What makes this finding so surprising is that class standing is a significant predictor of illegal use. Juniors and seniors are far more likely to use illegal stimulants than sophomores

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TABLE 1. Differences among ADHD medication users’ by their likelihood to distribute Distributor type No n

%

Yes n

%

X2

16 19 11 4

13.4 16 9.2 3.3

18 26 20 6

15.1 21.8 16.7 5.5

0.911

0.087

.087

No Yes

28 22

23.3 18.3

31 39

25.8 32.5

1.601

0.116

.116

Male Female

35 15

29.2 12.5

48 22

40 18.3

0.028

0.867

.015

No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes

12+ 38− 29+ 21− 48+ 2− 47+ 3− 48+ 2− 45+ 5− 47+ 3− 49 1 49+ 1− 49 1

20.8 32.5 24.2 17.5 40 1.7 39.2 2.5 40 1.7 37.5 4.3 39.2 2.5 40.8 0.8 40.8 0.8 40.8 0.8

2− 68+ 14− 56+ 51− 19+ 39− 31+ 48− 22+ 53− 17+ 47− 23+ 68 2 53− 17+ 68 2

0.9 58.1 11.7 46.7 42.5 15.8 32.5 25.8 40 18 44.2 14.2 39.2 19.2 56.7 1.7 44.2 14.2 56.7 1.7

12.652∗

0.33

.001

18.317∗

0.39

.001

10.820∗

0.30

.001

21.055∗

0.42

.001

13.714∗

0.34

.001

3.976

0.18

.046

12.396∗

0.32

.001

0.088

0.03

.767

−0.31

.001

0.088

0.03

.767

No Yes

6− 43+

5.1 36.4

28+ 41−

23.7 34.7

11.215

−0.31

.001

Class standing freshmen sophomore junior senior Fraternity/sorority

p


Gender

Illegal substance use alcohol marijuana cocaine painkillers anti-anxiety sleeping aids hallucinogens heroin ecstasy methamphetamines

11.361∗

Did you take nonprescribed ADHD Meds before

and freshman. As a general rule, in fact, the more time a student spends on campus, the greater likelihood there is that that student will misuse an ADHD stimulant (DeSantis et al., 2009; DeSantis, Noar, & Webb, 2010). But this finding did not hold true for distribution. First and second year students are as likely to share their prescriptions as third and fourth year students enrolled in our study. Of the indicators we explored as candidates for predicting whether or not a student was likely to distribute their surplus stimulants, the following 10 emerged as significant indicators for distribution. Table 1 reports on the descriptive characteristics of ADHD medication users’ by their likelihood to distribute.

Previous Illegal Use of an ADHD Stimulant Students that illegally used nonprescribed stimulants before being diagnosed and treated by a health-care professional for ADHD were also more likely to share their

currently-prescribed stimulants with nonprescribed peers (X2 = 11.22, df = 1, p = .001).

Frequency of Use per Week Whether a prescribed student is more likely to share is also influenced by how many times per week they take their medication (F = 5.702 p > .019). The mean number of days of the week that distributors take their medication is 4.7 (SD = 0.38); the mean for students that do not distribute is 5.3 (SD = 0.48) times per week. However, whether prescribed users discontinue their medication during school breaks (e. g., winter break, spring break, summer break) did not influence their likelihood of sharing their stimulants. (χ 2 = 0.54, df = 1, p > .462). This also becomes especially interesting when considering that, in most cases, illegally shared stimulants come from surplus medication not used each month by the patient. Consequently, such seasonal breaks in medication



use would logically increase the number of surplus pills available for illegal distribution. This finding may be partially explained by the fact that many of these students return home during such breaks. Within this familial context, there would be less demand for stimulants from their college peer groups (who would also be at home with their families). This reasoning, however, does not account for what happens to the surplus pills accumulated during these intervals once these students return to campus. Off-Label Use of Prescription Medication Distributors are also more likely to use their prescribed ADHD stimulants for off-label reasons than those prescribed users who do not distribute (F = 12.82 p > .001) (i.e., using the medication for reasons not approved by the Drug Enforcement Agency). These off-label indicators include, taking stimulants to party longer when school is in session (F = 12.25 p > .001) and to party longer when school out of session (F = 6.188 p > .014). Additionally, using stimulants to prolong the effects of alcohol while school is in session (F = 6.12 p > .011) and out of session (F = 6.76 p > .011) were also statically significant. Social Fraternity or Sorority Affiliation As with most at-risk behaviors on college campuses, members of social fraternities or sororities are not only (1) more likely to use illegal ADHD stimulants (X2 = 124.701, df = 1, p = .001) (30.8% illegal use by all students versus 46.2% illegal use by fraternity and sorority members), they are also (2) more likely to be diagnosed with ADHD (X2 = 8.679, df = 1, p = .003) (6.92% of nonmembers, 10.48% of members), and (3) be current users of a prescribed ADHD stimulant compared to nonmembers (X2 = 13.825, df = 1, p = .016) (3.9% current use by nonmembers and 7.5% by members). And these “current users” are also 4) more likely to distribute (sell or give) their current prescription for illegal consumption than nonmembers (X2 = 13.71, df = 1, p = .001) (2.1% for nonmembers, 5.0% for members). Sex Men are more likely than women to (1) be diagnosed with ADHD (X2 = 40.662, df = 1, p = .001), (2) currently use a prescribed ADHD stimulant (X2 = 24.673, df = 1, p = .001), and (3) distribute their prescribed ADHD stimulants for illegal use (X2 = 13. 061, df = 1, p = .0001). Fraternity Membership Fraternity men are significantly more likely than sorority women to report (1) being diagnosed with ADHD by a health care provider (16% vs. 6.9%; X2 = 16.779, df = 1, p = .001), (2) illegally using ADHD stimulants (59.6% vs. 37.7%; X2 = 33.733, df = 1, p = .001), and (3) distributing a prescribed ADHD stimulant. (6.9% vs. 3.9%. X = 3.850, p = .03). However, there is no significant difference between fraternity men and sorority women with

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respect to whether they are currently taking ADHD medications (X2 = .147, df = 1, p = .701). Perceived Use Illegal distributors were also more likely to overestimate the percentage of students that illegally take stimulants on campus (F = 8.34 p > .0005). Those that illegally distribute perceive that 60% (SD = 21.1) of their campus illegally uses ADHD stimulants. In contrast, those prescribed users that do not distribute perceive that 46.5% of their campus illegally uses. The actual number found in this study (n = 2,313) of admitted illegal users is 31%. Interestingly, prescribed distributors and prescribed nondistributors equally overestimate the percentage of students diagnosed with ADHD (37%). In truth, 8.2% of their campus reported being diagnosed with ADHD in their lifetime, while only 5.2% admitted to currently taking a prescribed ADHD stimulant. Peer Group Distributors are also more likely to belong to peer groups that illegally misuse stimulants not prescribed to them (F = 21.29, p > .0001). Those subjects that illegally distribute report that 50% (SD = 25.6) of their friends illegally take stimulants. In contrast, those that do not distribute report that only 26% (SD = 26.21) of their friends illegally take stimulants not prescribed to them. Physician Talk The quality of communication exchanged between prescribed users and their health-care providers also played a predictive role in illegal-distribution practices (F = 4.396 p > .0038). Students were less likely to distribute when they reported that their physician frequently asked (1) if they ever “share” their medication with others (18.3%), and (2) if they understand the dangers associated with sharing medical stimulants with nonprescribed individuals (16.8%). Use of Other Drugs Finally, our research highlighted the relationship between ADHD students’ use of certain illegal substances and their willingness to distribute their prescribed stimulants. Specifically, four interesting relationships warrant discussion: First, prescribed ADHD students who did not use alcohol (X2 = 12.487, df = 1, p = .001) or marijuana (X2 = 15.886, df = 1, p = .001) were far less likely to illegally share or sell their prescribed medication than users of alcohol and marijuana. Second, those students that reported using cocaine were less likely to illegally distribute (X2 = 9.881, df = 1, p = .002) than nonusers of cocaine. Third, users of hallucinogens (i.e., psychedelics, dissociatives, and deliriants) and ecstasy (i.e., MDMA 3,4-methylenedioxy-Nmethylamphetamine) were more likely to distribute their prescribed stimulants than nonusers (X2 = 11.556, df = 1, p = .001). The fourth, ADHD prescribed students that illegally use painkillers (e.g., OxyContin, Vicodin,

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Percocet, etc.) are more likely to distribute than those ADHD patients that do not use painkillers (X2 = 19.502, df = 1, p = .001). This final drug-use relationship proved to have the most powerful effect-size and the largest chi square value of the four.


DISCUSSION

The present study sought to identify indicators of ADHD students who are most likely to illegally distribute their prescribed of ADHD stimulants to nonprescribed students. In the section that follows, we will elaborate on a few of these indicators that warrant greater attention. First, the data indicate that students who take their ADHD prescriptions less frequently (less than 7 days a week) are more likely to distribute. When students do not take their 7 pills per week (or 30 pills per month) allotment, that patient is more likely to have surplus pills for sharing or selling to nonprescribed peers. Users of these controlled substances are usually prescribed no more than 30 pills per month (with no “refills”) as a means of regulating and tracking abuses. Consequently, every month patients must re-contact their health-care provider for a new 30-day prescription. This DEA classification is, in part, designed to reduce the number of surplus pills available for illegal distribution. Second, the data also show that students who misused their stimulants for off-label use (reasons other than those approved by their health-care provider) were 2.51 times (SD = 0.38) more likely to illegally share/sell their medication. Of the students (n = 59) that reported never giving away or selling their medication, none reported ever having misused their prescription for off-labeled indications. Therefore, if a student adheres to the medical guidelines dictating usage, they are also more likely to comply with the legal guidelines defining appropriate distribution. Third, like other studies of this kind, we also found that social fraternity or sorority affiliation was a significant predictor of illegal distribution. This relationship can be partially explained by DeSantis et al., (2010) findings that there is a greater demand for illegal stimulants within this tightly bonded community. This situation is exacerbated by the pressure many legal users report feeling from fellow “brothers and sisters” to share their surplus (DeSantis et al., 2010). These data also show that men in fraternities are significantly more likely to distribute ADHD medications than women in sororities. Although fraternity men and sorority women were equally likely to hold a current prescription, the fact that more fraternity men had been diagnosed at one time with ADHD and have had more experiences with these medications may make these college men more likely than their sorority counterparts to share their ADHD medication with their fraternity brothers. In a similar vein, we also found that a student’s peer group also predicts distribution behavior. We may reasonably assume that a student-patient with more friends who illegally misuse is going to be confronted with a

greater number of requests by those friends for his/her surplus stimulants. These greater numbers of requests would logically equate into a greater chance of compliance from the patient. This effect, as Clasen and Brown (1985) have argued, would be even more amplified if misusing friends applied collective “peer pressure” within an intimate-group context. We may also assume that a distributor who is attracted to a peer group that engages in at-risk behaviors (e.g., taking illegal stimulants) may also be more likely to engage in at-risk behaviors him/herself (e.g., illegally distributing stimulants), and vice versa (i.e., at-risk misusers will be attracted to at-risk distributors). As 50 years of research on the Similarity Theory supports, individuals, with similar behavioral patterns and demographic characteristics, are interpersonally drawn to each other (Byrne & Nelson, 1965; Vohs, Finkenauer, & Baumeister, 2011). Fourth, we discovered that more “physician talk” is generally better, regardless of what specific topic associated with ADHD stimulant use is being discussed. We are led to ask, therefore, if the more a health-care provider inquires about a patient’s stimulant regimen, the more likely that the patient will feel that his/her behavior is being more tightly supervised and surveilled. And fifth, our research highlighted the relationship between the use of certain illegal drugs and the studentpatient’s willingness to share his/her prescribed ADHD stimulants (see Table 1, for review). Specifically, we discovered that ADHD students who use cocaine were less likely to illegally distribute their ADHD stimulants. While this finding may seem counterintuitive if one assumes that users of any illegal substances are more likely to distribute drugs, an understanding of the similarities between these two stimulants may provide an explanation. As Rush, Kelly. Hays, and Wooten (2002) have demonstrated, regular users of cocaine assessed the ADHD stimulant, Methylphenidate (e.g., Ritalin), to be strikingly similar to cocaine, and in many cases, more pleasurable and longer lasting. Consequently, we may conclude that the cocaine users in this study were less likely to share their legal doses of stimulants because they also served as a cheaper, more accessible substitute for cocaine. Conversely, we also found that users of hallucinogens and ecstasy were more likely to distribute their prescribed stimulants than nonusers. Unlike cocaine, however, hallucinogens and ecstasy are not primarily taken for their potential amphetamine effect, but rather for their more prominent euphoric effects. Therefore, we may conclude the users of such euphoric-producing drugs will be more willing to share their medication within their social peer groups. We also discovered a similar correlation between the use of painkillers and distribution practices. Specifically, those students that illegally use opiates are significantly more likely to distribute their surplus stimulants than nonopiate users. Additionally, this significance may also be explained by the similarities shared between ADHD stimulants and popular pain killers. Namely, both are


factory-made and pharmacy-distributed. As DeSantis and Hane (2010) have found, such “pharmaceuticals” are perceived to be physically safer and less socially stigmatized. After all, they are prescribed by physicians, made in laboratories, and are purchased at local pharmacies. This common framing practice of pharmaceuticals stands in contrast to the social construction of “street drugs” (i.e., cocaine, PSP, crack, meth) that are not prescribed, regulated, or sanctioned by the medical establishment, the FDA, or the DEA.


RECOMMENDATIONS

While the variables explored in this study supply a more complex and layered profile of those most likely to illegally distribute ADHD stimulants, we ideally seek to apply these findings to practical strategies in stemming the tide of illegal distribution. Toward this end, therefore, we propose a series of practical suggestions for public-health officials, campaign researchers, university administrators, and health-care providers. First, because members of social fraternities or sororities organizations (vs. nonmembers), males (vs. females), and fraternity members (vs. sorority members) are far more likely to distribute than other segments of the student body, this population should be specifically targeted by campaigns and intervention attempts. The ability to identify such at-risk such groups is made even more crucial given that many campuses have limited financial and law-enforcement resources. Consequently, this insight can be helpful in strategically allocating limited resources where they can best be utilized. Additionally, identifying these two at-risk groups can better aid public-health campaign efforts that seek to strategically tailor messages for segmented audiences that pose the greatest public-health threats. In a similar vein, our findings can also aid publichealth campaigns by identifying specific topical or theoretical areas that may be most vulnerable to persuasive efforts. An especially promising area that emerged from our data dealt with the issues of social proof and false consensus. Specifically, we discovered that distributors are more likely to overestimate the percentage of nonprescribed students that illegally take stimulants. This “falseconsensus effect,” (Cunningham, 2007) is especially dangerous since our perceptions of the social prevalence of behaviors are key mechanisms used by humans to evaluate the acceptability and normalcy of their behaviors. It is recommended, therefore, that public-health campaigns highlight the actual, and much lower, number of students that are illegally using nonprescribed stimulants. Such efforts would challenge students’ over-exaggerated perceptions about ADHD stimulants and, in turn, combat the falseconsensus effect on their at-risk decision making. Our third, and most promising, area for effective intervention targets the health-care providers that diagnose, treat, supervise, and write prescriptions for ADHD patients, especially those that are the most at-risk for

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misusing their medication. Our six recommendations are as follows: First, we recommend that health-care providers inquire into how many doses their patients are actually taking every month. Because we and other researchers (Sepúlveda et al., 2011) have discovered that most ADHD patients do not take their medication daily, as is often prescribed, a reduction in the number of doses written for most patients should not have a deleterious effect on the management of their disorder, but simply reduce the number of surplus stimulants on most college campuses. Additionally, health-care providers should inquire if their ADHD patients every share or feel pressure to share their medication with peers or family members. Even if patients are reluctant to affirm either question, our research suggests that the mere act of asking reduces a patient’s willingness to illegally distribute. Third, health-care providers may be wise to ask their patients, perhaps during the diagnostic stage of treatment, if they have ever previously “borrowed” or “experimented” with stimulants before receiving their prescription. This could be done by nonaccusatorially framing the question in clinical, not legal or moralistic, terms. For example, one could say, “We normally have success with stimulants such as Adderall. Have you ever tired anything like Adderall before to see if it works for you?” An affirmative response should alert the physician that the patient has an increased likelihood for illegal distribution, thus warranting more careful monitoring. Along similar lines, physicians should also inquire about their patients’ off-label use of their stimulants. By asking something as seemingly innocuous, as “Do you ever use your medication to fight fatigue or to increase your energy levels?,” health-care providers can isolate yet another variable in helping predict potential illegal distribution. Five, we have found that more talk about the patient’s prescription use, regardless of what specific area is being discussed, is better. Consequently, in an effort to reduce illegal stimulant distribution, it is recommended that health-care providers invest more time in conversation with their ADHD patients, especially those that pose an increased threat of stimulant misuse (e.g., fraternity men, those that use stimulants to fight fatigue, etc.). For these statistically at-risk patents, physicians may consider using their monthly prescription-renewal meeting as an additional opportunity to strategically “talk” about their medication use and the pressure they might feel to share their medication on their campus. Finally, since the at-risk ADHD patient can most effectively be identified by his/her health-care provider, given the nature of the clinical relationship, we suggest that health-care providers maintain an active “profile checklist” to identify which of their ADHD patients are most at-risk for illegal distribution and what indicators make them most likely to distribute. Through a series of simple questions, augmented by some basic observational determinations, physicians could identify which of their

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patients could benefit from increased “talk” and more concerted attention.


AREAS FOR FUTURE RESEARCH

While this study has attempted to give readers a better understanding of the characteristics of potential ADHD distributors, it has also highlighted some areas for future investigation. This research has underscored the need for a multipronged approach to ADHD drug misuse. As we have demonstrated, new programs should be developed to target a myriad of variables, characteristics, and demographics. Specifically, we recommend that efforts focus on (1) the illegal distributors of stimulants, not just on nonprescribed misusers (this later group has garnered the majority of attention in the field’s research); (2) correcting the inflated perceptions of how prevalent the use and distribution of ADHD stimulants are; (3) training health-care professionals in identifying and strategically targeting their at-risk ADHD patients; and (4) potential structural changes to the distribution of ADHD stimulants as well as policy augmentations that could create tighter levels of control over surplus medication and its illegal distribution. To date, the host university of this research has taken no significant steps in policy or structure to reduce the illegal use or distribution of ADHD stimulants. Additionally, future research needs to incorporate multiple university sites, both large and small, public and private, around America so that a more integrated and predictive model of ADHD drug misuse and distribution can be developed. While a few recent meta-analyses have been written attempting to find common themes and issues, there have been few nation-wide investigations since the seminal study by Teter, McCabe, Boyd, and Guthrie (2003). There is also a pressing need to investigate the use of ADHD stimulants misuse and distribution outside of college campuses. While this is a more difficult population to identify and investigate, we are left to wonder how many college misusers, graduate, and continue with the misuse of these “study drugs” in their postcollege lives. Additionally, follow-up studies focusing on the continued behavior of our identified at-risk distributors would also be highly beneficial. Of crucial importance would be to identify what predictors are most significant in identifying long-term distribution behavior and if the patters identified and established in college remain consistent outside of the undergraduate context. And finally, with the growing cultural awareness of ADHD stimulant-abuse (e.g., 60 Min, ABC News, CNN, and the increased growth of academic publications), the need for longitudinal analysis becomes increasingly important. It is crucial that we track the ongoing changes in the awareness, use, motivations, accessibility, and perceptions of ADHD stimulants. We are left to wonder whether the well-intended increased awareness of stimulant use, may have also inadvertently increased collegestudent awareness of ADHD medication, especially with

its well-publicized “positive effects” (e.g., increased attention and cognition). As one of my students commented to me after watching the “60 Min” episode on the topic, “I’ve never tried it before, but the stuff sounds like it really works.” LIMITATIONS AND CONCLUSIONS

As partially highlighted by our suggestions for future research, there are a number of salient limitations to this current investigation. First, our data was taken from a convenience sample that exhibited many characteristic of the campus as a whole; however, given that it is a convenience sample, there is no guarantee that it represents the population from which it was drawn. Our sample also heavily relied on first, second, and third year students. Moreover, all data came from one, large pubic university in the southeast region of the United States, and researchers have found that stimulant use varies according to factors such as region of the country and school competitiveness. Thus, the rates of stimulant use and demographics of distributors we found may be different than those at other universities, and in other populations. In conclusion, with millions of students across America now taking illegal ADHD stimulants (20–30% of most college campuses), our ability to target, reach, and persuade these misusers is becoming exponentially difficult, especially given the financial constraints reported by most universities. Consequently, the efforts to identify and target the much smaller, and more easily identifiable, segment of distributors (comprising 2–4% of most college campuses), may be the best hope public-health officials have in slowing stimulant misuse on college campuses. While this research has not been used by the University where our data was gathered, it is our hope that it will contribute towards constructing a better predictive model of stimulant misuse. Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. ´ RESUM E´ Illégales distributeurs Collège TDAH stimulants: caractéristiques et domaines d’intervention possibles

Cette e´ tude identifie des indicateurs de collégiens, avec des prescriptions de stimulants TDAH, qui sont les plus susceptibles de distribuer leurs médicaments non prescrits a` leurs pairs. 2313 e´ tudiants de premier cycle dans une université du Sud-Est ont e´ té interrogés grande de 2009 a` 2011. 5,2% (n = 120) ont e´ té actuellement un stimulant TDAH prescrit. Les analyses ont révélé que les distributeurs sont plus susceptibles de (1) prendre leurs médicaments moins souvent; (2) abuser de leurs stimulants a` des fins récréatives; (3) eˆ tre membre d’une fraternité, et (4) appartiennent a` des groupes de pairs a` risque.


L’ouvrage se termine par une discussion des implications de l’étude, les limites et la recherche future.

455 Dr. Elisia L. Cohen is an Associate Professor of Communication and Associate Member of the Markey Cancer Center at the University of Kentucky. Her research interests include investigations into communication strategies to reduce health disparities.

Mots-clés: le TDAH, les e´ tudiants, les stimulants, les médicaments, le détournement, l’utilisation abusive, Adderall RESUMEN


Ilegales Colegio Distribuidores estimulantes para el TDAH: Caracter´ısticas y potenciales a´ reas de ´ intervencion

Este estudio identifica los indicadores de los estudiantes universitarios, con las recetas a los estimulantes TDAH, que son más propensos a distribuir sus medicamentos no prescritos a los compañeros. 2.313 estudiantes universitarios en una gran Universidad del Sureste se censada desde 2009 a 2011. 5,2% (n = 120) estaban tomando un estimulante TDAH prescrito. Los análisis revelaron que los distribuidores tienen mayor probabilidad de 1) tomar la medicación con menor frecuencia, 2) mal uso de sus estimulantes con fines recreativos, 3) ser miembro de una fraternidad, y 4) pertenecen a grupos de pares en riesgo. El trabajo concluye con un análisis de las implicaciones del estudio, limitaciones y futuras investigaciones. Palabras clave: TDAH, estudiantes universitarios, estimulantes, medicamentos recetados, la desviación, mal uso, Adderall

THE AUTHORS Dr. Alan D. DeSantis is a Professor of Communication at the University of Kentucky.

GLOSSARY

Adderall: It is the most popular of the ADHD stimulants prescribed to patients. Other ADHD stimulants include Ritalin, Concerta, Metadate CD, Focalin, Dexedrine, Adderall, and Daytrana. Attention deficit-hyperactivity disorder (ADHD): It is a neurobehavioral disorder characterized by either difficulties with inattention or hyperactivity and impulsiveness or a combination of the two. This disorder used to be referred to as Attention Deficit Disorder (ADD). Diversion: It is the term used when an ADHD patient, with a prescription for stimulants, gives or sells any of his/her ADHD medication to nonprescribed users. Fraternities: These are the all-male Greek social organizations found on many American college campuses. Greek social organizations (also known as “Greek-letter organization”): These are social clubs for college students at many American Universities. Interestingly, these clubs have nothing to do with Greek culture. Most of these organizations are gender-segregated groups. Schedule II substances: They are those that have a high potential for abuse that may lead to severe psychological or physical dependence. Sororities: These are the all-female Greek social organizations found on many American college campuses. Stimulants: These are psychoactive drugs which induce temporary improvements in either mental or physical function or both. Due to their stimulant qualities, they are also referred to as “uppers” in nonmedical contexts. REFERENCES

Kathryn Anthony is an Assistant Professor of Communication at Columbia College. She studies health and risk communication.

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