June 2009 - AAMC Reporter

"I Don't See It as a Problem": More Medical Students Taking Prescription Stimulants, Few See Cause for Concern

Back in the eighth grade, Milton Moore was diagnosed with attention deficit hyperactivity disorder (ADHD). After doctors prescribed the stimulant Adderall, a common treatment for ADHD and similar disorders, Moore immediately noticed a difference in his concentration levels and his academic performance.

Moore is now in his twenties, and it is clear that Adderall has served him well. Now a second-year student at Meharry Medical College in Nashville, he takes Adderall to keep pace with the informational deluge that is a medical student's life—the unyielding inrush of chapters to read, notes to review, visuals to memorize, study groups to attend, exams for which to prepare.

"It makes a world of difference," Moore said of his Adderall prescription. "Without it, I can read 10 pages in a sitting, but with it, I can read maybe 100 pages."

In the ultra-competitive world of medical school, where students are conditioned to seek almost any means of gaining an advantage, stimulants like Adderall are viewed by some as a passageway to almost superhuman levels of concentration and productivity.

Perhaps that is why Moore does not bat an eye when classmates approach him seeking a pill or two.

"Even in high school, people were trying to get it," Moore said. "So I'm not surprised."

He even keeps a well-honed, polite refusal at the ready.

"You want to help them out, but they may have heart conditions or something," he said. "That's what I tell them to avoid giving it to them."

In bygone eras, strong coffee or a caffeine tablet was the stimulant of choice for medical students working into the wee hours. But now, the pressure to perform coupled with a greater number of ADHD students entering medical school might be making Adderall and other stimulants like Ritalin and Concerta more available—and acceptable—on medical school campuses. Adderall, the stimulant of choice for many students, is the most popular ADHD medication. According to the National Institute on Drug Abuse (NIDA), Adderall was prescribed to 21.8 million Americans in 2005.

"More and more people are getting test accommodations because of their ADD diagnoses," said Diane B. Gottlieb, M.D., director of student mental health service at Drexel University College of Medicine. "And more people are being diagnosed with ADD in general. So that means more students are going to medical school who may not have had the chance before."

This logically translates to more widely available stimulants on campus. And, according to experts, more medical students are taking advantage.

The improper use of prescription stimulants on college campuses is not a new revelation. The National Center on Addiction and Substance Abuse at Columbia University has estimated that prescription stimulant abuse among college students increased 93 percent between 1993 and 2005. Last year, a NIDA survey found that 10 percent of 17- to 25-year-olds nationwide had used prescription amphetamines for nonmedical reasons. A 2006 study conducted by the University of Michigan's Substance Abuse Research Center and published in the journal Pharmacotherapy revealed that 6.9 percent of U.S. college students—and as many as 25 percent at some schools—had illegally used prescription stimulants. The most commonly reported motives for illicit use, according to the Michigan report, were help with concentration and help with studying.

No studies have specifically targeted medical students, but some now say the problem is increasing there. That medical students are more savvy about health care than the average college student may exacerbate the problem.

"I have noticed more classmates getting prescriptions," Moore said. "They are just going to the psychiatrist and telling them what they want to hear."

Mental health professionals who treat medical students support this claim.

"During the last two or three years, the number of requests for ADD evaluations has hugely increased," Paula Stoessel, Ph.D., director of mental health services for physicians in training at the University of California, Los Angeles (UCLA), David Geffen School of Medicine. "We make them [medical students] go through a lot before we hand out medication, but I've heard them talk about [obtaining Adderall prescriptions] in passing."

UCLA requires that students who complain of attention deficit work through the school's disability office and undergo a series of tests and evaluations before a prescription is issued. Gottlieb, who along with Stoessel said they each see about 10-20 students a year who complain about attention deficits or similar issues, said the threshold in some places can be very low.

"People have said they walk right into the campus health centers or psychologist's office and get stimulants just by saying they have attention problems," Gottlieb said.

Anxiety and depression can also cause concentration problems, according to Gottlieb, which in turn can drive students to seek an incorrect ADHD diagnosis or selfmedicate rather than pursue counseling, which many fear can stigmatize a would-be physician. No student who had illegally used, distributed, or obtained prescription stimulants volunteered to speak on the record for this article. "If they are getting [stimulants] outside of me, they're not going to say anything to me about it," Stoessel said.

Students pointed to stress as the primary culprit.

"There is too much pressure on students," Moore said. "They're about to take the Step 1 [USMLE 1 assessment test], and we're told that holds the key to residency. There is huge stress placed upon students every day. I think the pressure to do well is causing an increase in this."

But the increase might also have an even simpler root. Many medical students simply do not view stimulant use—illicit or otherwise—as a major problem.

"I know students who self-diagnosed, and were able to get someone to prescribe it for them," said Monique, a third-year medical student at the University of Maryland School of Medicine who asked that her last name be withheld. "I honestly don't see it as a problem right now. Even if students are doing it, it is still their brain. It's not cheating. And I don't notice any belligerent behavior with students who take them. So I don't know that it's a big issue."

Those who are taking prescription stimulants for legitimate medical reasons seem sympathetic to those needing or seeking extra help.

"I have a classmate who is struggling, and I think he has ADD. So I offered to give him one, but he didn't want it," said Vittoria DeLucia, a first-year University of Maryland medical student with ADHD. "But I can relate to people who do want it. I don't think it's right, but I wouldn't judge them too harshly."

Internet discussion vehicles such as Facebook and Medical School Forum are rife with armchair Adderall experts and informal question-and-answer sessions on the drug. On February 24, a prospective medical student identified as Eric B wrote in Medical School Forum's MCAT discussion area that he was planning to take the MCAT exam in the spring and asked "if I should take Adderall on test day" and if so, "when should I take the drug?" Eric B went on to add that "I don't want an answer [that] drugs are not the answer or [I am] better off doing bad on the MCAT than to die of side effects...this test is going to determine if I even get into medical school, so yeah it is a big deal, and I will do anything to do well on this test."

Experts caution, however, that the side effects should not be taken lightly. Like any stimulant, Adderall and similar medications can raise heart rate and blood pressure. In some cases, headaches, tics, and even serious mental illness can result.

"For the most part, students don't see any negative effects," Gottlieb said. "If you use them a lot, you can become tolerant to them. It's something that requires a lot of monitoring."

On the flip side, the drugs' benefits may be romanticized or exaggerated by students hoping for a miracle pill.

"It may keep you awake, but it doesn't make you smarter," Stoessel said. "They think that the focus is better, and it may feel that way, but how much do you really get done if you stay up all night?"

Students may not see a problem, but increasingly, medical school officials do.

"I think it is a problem," said Samuel K. Parrish, M.D., Drexel's associate dean for student affairs. "I don't believe that many studies have been done on medical students and inappropriate use of this type of prescription. We are learning that it is unrealistic to believe that people are doing this in college but not in medical school."

Stoessel suggested that anonymous exit interviews with graduating students could uncover more information about stimulant use, as well as related issues like concentration, depression, and anxiety.

"I wonder why they feel they have to do this," Stoessel said. "Getting into UCLA is really hard, and I feel bad that they don't believe in themselves. With the quality of the people we accept, we're saying 'You can do this.' It shouldn't have to be this way."

Nevertheless, for many students, it is.

"I hear lots of stories about people who took them and stayed up all night," said Monique. "I could see how it is something that could be abused. You have to spend a lot of hours and a lot of time, and you just get tired. And when you're on it, you're not tired."

—Scott Harris