When a parent makes the decision to use stimulants to treat a child’s attention deficit disorder (ADHD or ADD), she never imagines her son or daughter selling or sharing that medication with a friend, risking criminal charges and costly legal fines.
Unfortunately, this practice, known as medication diversion, happens a lot in high schools and colleges, according to the latest research (see “The Numbers on Stimulant Abuse” below). Stimulants are a hot commodity for many young people who don’t have a prescription, making those who do their targets. As academic pressures escalate in college, the misuse of stimulants becomes a temptation.
Stimulants are classified as Schedule II controlled substances by the FDA, due to their high potential for abuse. Most state laws follow federal laws, with criminal penalties for possession without a prescription. The criminal fines and jail time for those caught diverting stimulants are even more severe.
Every Teen Needs a Medication Education Before College
Parents and professionals should not ignore this growing problem. A recent article, published on the ADDitude website, focused on the serious consequences one college student experienced after selling his medication. He began by selling a few pills on campus, which led to his selling his entire prescription. He was arrested by DEA agents and spent time in jail.
I worked on a college campus for 24 years as an ADHD specialist and coach, first in a campus disability office and later in a learning center. Initially, I was naïve about medication diversion. I learned about stimulant abuse late in the game. At a luncheon for a graduating senior, I asked if he had any advice for me. He said, “There’s one topic I wish you’d talk about with all students taking ADHD medication: how to handle the demand they will face to give away or sell their pills!”
I was shocked, but I hid my reaction and listened attentively. He had been open about his use of stimulants, and the news spread quickly among his peers and classmates. He was often approached to sell or hand over “just one pill.”
The biggest challenge came when his best friend begged him for medication. The friend wanted to pull several all-nighters to cram for exams. It was easier to say no to strangers than to his friend. My student had read a New York Times article about a student whose suicide was linked to using a friend’s stimulants. He asked, “What if you have a terrible reaction and end up in the emergency room? I could never live with myself if that happened.”
This young man convinced me to ask all students taking stimulants about their experiences. At his suggestion, I also offered them the opportunity to practice what to say when faced with requests from strangers and, most important, from friends and family members.
A Four-Step Plan to Avoid Medication Diversion
The diversion of stimulant medication has serious legal and health risks for undiagnosed students, and major personal, legal, and financial consequences for those diagnosed with ADHD. We must expand our treatment plans and inform those with ADHD about this important issue. Here are my suggestions for professionals and parents:
1. Physicians should have practices in place to educate and protect young patients using stimulants.
Physicians play a key role in teaching children and teenagers to understand and accept their ADHD, and to value their medication. Researchers David Rabiner, Ph.D., in the department of psychology and neuroscience at Duke University, and William B. Brinkman, M.D., M.Ed., of the Cincinnati Children’s Hospital Medical Center, suggest that physicians are a logical source of information about the problem of medication diversion.
For middle school and high school students, doctors can provide printed or video material explaining the legal and health risks associated with sharing or selling stimulants. Some doctors on college campuses have young adults sign a contract attesting to compliance with taking medication as prescribed, not sharing or selling it, and indicating that they understand the legal and health risks of misusing and diverting it. When physicians take the lead, families and professionals can reinforce warnings that have been heard at medical appointments.
2. Assess a young person’s beliefs about ADHD and stimulant medication, and promote his understanding and acceptance.
Most parents understand and accept the diagnosis of ADHD, and the importance of medical treatment for it, but many young people do not. According to research conducted by Cincinnati Children’s Hospital’s Brinkman and his colleagues, 50 percent of adolescents with persisting symptoms of ADHD refuse to take medication.
In my work, I have observed that when students accept their diagnoses and value medication, they have no desire to give or sell their pills to others. They know the price they’ll pay if they run out of medication. It would seem to follow that those not seeing any benefit to medication, and denying the reality of ADHD, might be more likely to acquiesce when asked for a pill. I didn’t find any research supporting this theory, but I think it is an important topic to study.
To foster the acceptance and understanding of ADHD, it is important to include young people in their healthcare decisions as early and as often as possible. Later in life, they, not their parents, will be the ones who must accept their diagnosis and decide how to use medication. Brinkman and his colleagues suggest that medically supervised trials of medication can be a productive way to promote self-knowledge. They can allow young patients (and families) to become more insightful about ADHD, how it impacts them, and the role medication can play. Many young people do not like some of the effects medication has on their personality and social life. Working through these issues with a physician, rather than strong-arming teens to comply, allows them to weigh the pros and cons, and to find a medication or dose that they can live with.
3. Talk openly about the use, misuse, and diversion of stimulants.
Parents and professionals need to do what my student advised: Talk about the stimulant abuse and misuse culture that teenagers will likely encounter. The premise is simple: ADHD medications are designed to help those with ADHD, and should never be taken by someone without a diagnosis. While this might be plain enough at younger ages, later conversations should include specific information about the health and legal risks of misusing or sharing or selling medication.
Finally, parents and professionals need to offer opportunities to practice what to say if a family member, friend, or stranger asks for pills. Have teenagers rehearse several scripts to prepare them to say “no” and to deal with pressure. Young people need to know that they can turn to us in situations that are awkward, and that they can talk with us about something that they regret having done.
4. Coach teens to manage medication independently and safely before they get out on their own.
In the books Ready for Take-Off and On Your Own, Patricia Quinn, M.D., and I write about how parents of high school students can prepare their teenagers for college. Managing medication on one’s own is an important readiness skill to develop. Parents should collaborate with teens to set goals, so they can gradually hand over more responsibility to their teen. College freshmen encounter so much that is unfamiliar. It may be overwhelming to handle a medication regimen, as well.
Many families help their teens develop a system for taking medication in high school — laying out morning and after-school doses the night before, or filling up a pill case once a week. Cell phone alarms are great for reminding a teen to take medication.
Teens need parental supervision as they learn to take over their medication regimen. As senior year approaches, it can be helpful for the parent to “go cold turkey,” by allowing their teenager full responsibility for her medication regimen. This may be scary, but it allows for supervised learning about the pitfalls while the child is still at home. Parents can help teens evaluate what happens and make adjustments to their medication plan. The final skills to learn are how to order prescriptions and how to use health insurance.
Things to Do Before Heading to Campus
Parents should stress the idea of being discreet in sharing information about stimulant use. They should review information about not diverting medication, and keep tabs on whether their teen is dealing with requests for pills or showing any signs of misuse of her medication. Reconnecting a teen to the prescribing physician when issues arise will allow for continued growth in understanding and acceptance of ADHD and the medication made to treat it.
Even if there are no problems, an appointment with the prescribing physician is useful before a teenager with ADHD goes off to college. Teens can revisit their feelings about taking medication and the effectiveness of their current dosage. The physician can talk about stimulant abuse on college campuses, the risks of diversion and misuse of medication, and ways to handle these challenges.
When a teenager attends a college in another state, or far from home, he will have to find a local physician to manage his prescriptions. If this is done well in advance of moving onto campus, a teenager is set on day one. Find out the campus health center’s policy for prescribing stimulants. Some don’t write prescriptions at all, and only refer to local doctors. Others have strict policies requiring recent, comprehensive, psycho-educational evaluations concluding with a diagnosis of ADHD. Most health centers have lists of local physicians students can consult. Campus doctors may also have suggestions for safe storage of medication — by using locked boxes and carrying one’s daily dose in a pocket or backpack.
During the transition to college, families should map out a plan for dealing with medication. Many students have told me it is best not to discuss one’s stimulant use until they make friends (or maybe not at all). Revisiting the idea of being discreet as new friendships form is critical. Students may value support from parents to be sure they are taking their medications. Some may appreciate texts or phone call reminders at strategic times during the first few months of school. In the end, parents and teens are in this together.
- Sean Esteban McCabe, Ph.D., research professor at the University of Michigan’s Institute for Research on Women and Gender, found that only eight percent of college students admit to taking stimulants without a prescription. Claire Advokat, Ph.D., formerly in the department of pharmacology at Louisiana State University, suggests that the number is upward of 43 percent. Kari Benson, pursuing her Ph.D., in clinical psychology at Ohio University, led a more recent literature review, and reports that approximately 17 percent of the undiagnosed college population admits to using stimulants.
- Studies by Amelia M. Arria, Ph.D., of the Center on Young Adult Health and Development at the University of Maryland School of Public Health, and Duke University’s David Rabiner, Ph.D., suggest that over 30 percent of those diagnosed with ADHD admit to misusing their medication in college by taking higher or more frequent doses.
- Benson and Rabiner have done research indicating that improving academic performance is commonly cited as a key reason for taking or misusing stimulants, along with non-academic reasons: wanting to get high, stay up late, and suppress their appetite. Arria and her colleagues speculate that untreated symptoms of ADHD may also motivate students to seek stimulants.
- A number of researchers — Rabiner, McCabe, Scott Novak, Ph.D., of RTI International, the University of Maryland’s Laura M. Garnier-Dykstra, M.A., and the University of Kentucky’s Alan DeSantis, Ph.D. — conducted surveys to learn where those misusing stimulants obtained their pills. The surveys suggest that anywhere from 66 percent to 91 percent of those misusing stimulants got the medication from a friend, peer, or family member with a prescription. It is very likely that those with prescriptions will be approached to share their pills at some point in their educational career.
- Surveys conducted by Rabiner indicate that 50 percent of college students and 25 percent of middle and high school students diagnosed with ADHD were approached in the past year to sell, trade, or give away their meds. They were approached by strangers and by people they know.
College Success Means More Than Taking Meds
Many students I worked with through the years were insistent that medication was helpful, but it was not enough to ensure their success. Parents can help teenagers connect to campus resources by visiting these offices during freshman orientation or during the summer before the semester starts. All colleges have offices that provide legally mandated accommodations, and most have counseling services. More colleges offer supports, such as academic coaching, writing support, and tutoring services. In addition to regular communication with parents, it can be valuable for teenagers to have a campus community of professionals while adjusting to school and campus life.
Research Cited In This Article
- Brinkman, W.B., Sherman, S.N., Zmitrovich, A.R., Visscher, M.D., Crosby, L.E., Phelan, K.T., & Donavan, E.T. (2012). Academic Pediatrics. Vol. 12, 53-61.
- Advokat, C. D., Guildry, D., & Martino, L. (2008). Licit and illicit use of medications for attention-deficit hyperactivity disorder in undergraduate college students. American College Health, 56, (6), 601–606.
- Arria, A.M., Garnier-Dykstra, L.M., Caldeira, K.M., Vincent, K.B., O’Grady, K.E., Wish, E.D. (2011). Persistent nonmedical use of prescription stimulants among college students: Possible Association with ADHD symptoms. Journal of Attention Disorders, 15, 347-356.
- Arria, A. M., O’Grady, K.E., Calderia, K. M., Vincent, K. B., Wish, E.D. (2008). Nonmedical use of prescription stimulants and analgesics: Association with social and academic behaviors among college students. Journal of Drug Issues, 38, 1045-10
- Benson, K., Flory, K., Humphreys, K. L., Lee, S. S. (2015). Misuse of stimulant medication among college students: A comprehensive review and meta-analysis. Clinical Child and Family Psychology Review, 18, 50-76.
- DeSantis, A. D., Webb, E. M., & Noar, S. M. (2008). Illicit use of prescription ADHD medications on a college campus: A multimethodological approach. Journal of American College Health, 57 (3), 315–323.
- Garnier, L. M., Arria, A. M., Caldeira, K. M., Vincent, K. B.,O’Grady, K. E., & Wish, E. D. (2010). Sharing and selling of prescription medications in a college student sample. Journal of Clinical Psychiatry, 71(3), 262–269.
- McCabe, S. E., Knight, J. R., Teter, C. J., & Wechsler, H. (2005). Non-medical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction, 99, 96-106.
- McCabe, S. E., Teter, C. J., & Boyd, C. J. (2006). Medical use, illicit use and diversion of prescription stimulant medication. Journal of Psychoactive Drugs, 38, 43-56.
- Novak SP, Kroutil LA, Williams RL, Van Brunt DL. The nonmedical use of prescription ADHD medications: results from a national Internet panel. Substance Abuse Treatment, Prevention and Policy. 2007; 2:32.
- Rabiner, D. L., (2013). Stimulant prescription cautions: Misuse, diversion and malingering. Current Psychiatry Reports, 15, 375-402.
- Rabiner, D. L., Anastopoulos, A. D., Costello, E. J., Hoyle, R. H., McCabe, S. E., & Swartzwelder, H. S. (2009a). The misuse and diversion of prescribed ADHD medications by college students. Journal of Attention Disorders, 13, 144-153.
- Rabiner, D. L., Anastopoulos, A. D., Costello, E. J., Hoyle, R. H., McCabe, S. E., & Swartzwelder, H. S. (2009b). Motives and perceived consequences of nonmedical ADHD medication use by college students: Are students treating themselves for attention problems? Journal of Attention Disorders, 13, 259-270.
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