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Harvard Crimson, 5/3/06 HARVARD ON SPEED As more students have easy access to study drugs like Adderall and Ritalin, these serious stimulants might be on their way to becoming the new coffee. But is anyone worried? by Liz C. Goodwin Ryan and the other students quoted in this article have asked that their names be changed. In some instances, the students don’t want their peers and their professors to know that they use prescription drugs. In other instances, the students are breaking the law. Ryan is sipping on a Red Bull, about to start studying. He sounds relaxed, happy to have a reason to delay the inevitable late-night cram session that lies ahead of him. But this evening will be fueled by more than just an energy drink. Ryan has something a little stronger in mind -- something he got from his doctor. When he talks about getting diagnosed with Attention Deficit Disorder (ADD) during his freshman year and receiving a prescription for the stimulant Adderall, Ryan sounds amused, even scornful. “I think it’s completely unfair that I have this. I don’t harbor any misconceptions about that,” he says. “The fact is, I pay 10 dollars a bottle for this stuff. What I say to people is, go get tested, you’d be surprised.” Ryan, a senior, sees no reason not to dole out his stash of speed -- slang for the stimulant medications used to treat ADD -- free of charge to friends who ask for it. In fact, Ryan says, it would seem almost selfish not to share, since he is not sure he needs Adderall any more than the next guy. “During exam time, I know I’ve got a steady stream of people who come to me and I don’t turn them away,” he says. “In my experience I’ve found that if people know it’s available, not a lot is holding them back.” Ryan’s cynicism about attention disorders and his carefree attitude toward the medications used to treat them are not uncommon. Like many Harvard students who rely on prescription drugs to study, he doesn’t think his habit is any different from standard staples of late-night college cramming, like coffee, energy drinks, or bottles of Diet Coke. On the “black market” (more often a dorm room than a dark alley), Adderall and Ritalin run between 60 to 80 cents per milligram: a euphoric, amphetamine-fueled all-nighter can be purchased for as little as ten dollars. Alarmed administrators have some theories about why abuse of Adderall and other "study drugs" like Ritalin are on the rise on college campuses across the nation. There’s no consensus on how widespread these drugs actually are -- some studies claim that only 3 percent of students use them, while others say it’s closer to 30 percent -- but most researchers seem to agree that the numbers are going up, not down. A study at the University of Maryland showed that Adderall is the third most accessible drug on campus, right after alcohol and marijuana. Ryan Travia, the College’s director of the Office of Alcohol and Other Drug Services, points to Harvard’s high-stress environment as an explanation for study drug abuse. "Harvard is a pressure cooker," he says. "Students primarily use drugs to get an edge and to stay awake." "I think it’s stress," says Paul Barreira, director of behavioral health and academic counseling at Harvard University Health Services (UHS). "Somebody says ‘I’ve got something to do, and I’ve got to stay up.’" Barreira, who has noticed a rise in study drug abuse at Harvard, calls it "hard to measure" because of how easy it is to access the drugs on the internet and through friends. And even harder to measure is whether or not a student has an attention disorder in the first place. Because there is no absolute litmus test, doctors may be prescribing stimulants to people who don’t actually need them. Yet while the authorities intimately involved with the matter attribute study drug abuse to extreme stress, students -- with and without diagnosed attention disorders -- seem to have a more relaxed view of its use. Many say they don’t see the big deal over popping a few pills, either on a night of a party or a night of a term paper. More students than ever are arriving at Harvard already prescribed some form of stimulant according to Travia, and some of them have no qualms about sharing the goods. Students’ ambiguity about the syndrome and its treatment has led to a proliferation of use and abuse on campus -- but the alarm bells are not sounding. For the Ritalin Generation, "speed kills" sounds like an old wives’ tale, and a prescription slip for Adderall looks no different from a 7/11 energy drink receipt. "No X-ray" Richard D. Kadison, chief of Mental Health Services at UHS, published an article in the New England Journal of Medicine last September entitled "Getting an Edge -- Use of Stimulants and Antidepressants in College." In this article, Kadison laments the rise in perfectly healthy students seeking out a "magical boost" from their doctors. He attributes this rise in "consumer demand" to the overall poor mental state of college students, noting that in a recent survey 94 percent of college students reported feeling overwhelmed with everything they have to do and almost half complained of occasional depression. Steven went looking for this magical boost at UHS last fall. He approached it with persistence and dedication, coming in diligently for checkups and tests over the course of several weeks. Having tried several stimulants that he purchased or received from friends, Steven decided he wanted a more reliable source for the drug. He made an appointment at UHS and, in true Harvard fashion, started doing some research. "I filled out online surveys about it," he says. "All of the questions were like ‘Do you have trouble focusing? Do you feel like you aren’t living up to your potential?’ So because I don’t actually believe very strongly in ADD or ADHD, I didn’t have a problem going in and presenting myself with as little dishonesty as possible as someone who should be diagnosed with ADD or ADHD.” Steven alternately sounds defensive and contrite about his actions obtaining medication at UHS. Occasionally he pokes fun at what he sees as the absurdly vague nature of diagnosing attention disorders. He seems to have no trouble lying to the doctors and nurses at UHS, but he sounds embarrassed when he is asked to go into detail about those lies. “While I think doctors are very useful because of the way that ADD and ADHD are constructed, I feel like I’m just as competent in deciding whether or not I need this drug,” Steven says. Kids like Steven -- smart, informed, and determined to get the drugs they want -- are Dr. Barreira’s worst nightmare. “If someone is really smart and just wants to play the role as someone with a learning attention problem they could do it,” he says. “It’s pretty extreme but they could do it -- learn the script and then play it to the clinician.” But Barreira adds -- “I hope it’s rare. I bet it’s more likely that students use somebody else’s stimulant than it is that a student would come in and lie to get their stimulant.” Kadison and Barreira both confirm that there is no standard test or procedure that all UHS doctors must conduct in order to prescribe a student study drugs. Barreira says that formal psychological testing is not covered by insurance, so he usually doesn’t ask patients to take them. “Our relationships with students are built on trust,” Kadison wrote in an e-mail. “We evaluate each situation on individual issues and symptoms.” Kadison adds that a history of drug abuse is a red flag that might prevent a doctor from prescribing. “It’s always potentially a problem because there’s no x-ray or any way of confirming it, unless one had an assessment done in high school or someone had clearly documented problems in high school,” Barreira says. Yet it is precisely this vagueness that leads students like Steven to write off attention disorder diagnoses as laughably subjective. “ADD and ADHD are syndromes, so people are only diagnosed with symptoms only. There’s no biology around them. Study drugs aren’t made to address any chemical deficiency -- it’s speed,” Steven says. “The whole thing about ADD and ADHD is that almost everyone has trouble focusing at times.” Steven is not the only one who questions the disorder, if not the abuse of its drugs. Ryan, who was diagnosed by a doctor unaffiliated with UHS, says the process is ridiculous. “It’s the most absurd thing in the world. They stuck me in a room for 20 minutes and it was like a 1980s computer and there was a white square and for the next 20 minutes I was supposed to click every time it moved and if I don’t score perfect on that, I have an attention problem,” he says. “I don’t think I should have a drug for that.” Diane, a freshman who was diagnosed with ADD at UHS in the fall, also seems hesitant about her diagnosis. “I think I was honest in what I told [the doctor], but I also definitely know what they would expect to hear,” she says. “There are definitely biases because I know what to say.” "The Same Thing for Less" When Helen left home to start her freshman year at Harvard, several of her friends presented her with a parting gift -- a bottle of Adderall that one of them was prescribed. “I think they thought it was funny,” Helen says. “They were trying to warn me about coming here.” While Helen only ended up taking the pills a few times, after which she cleaned her room more than she studied, for many other students medication received from friends becomes a casual crutch in times of academic need. Greg, an upperclassman who has tried Adderall a few times, more frequently uses over-the-counter ephedrine pills and energy drinks to stay up. He does not make distinctions among the three. “Personally I really do think that taking Adderall to study is the same in theory as taking caffeine and it’s more a matter of legal status of the drug and who controls them,” Greg says. “I think it’s a performance enhancer.” Bob, an upperclassman who uses Adderall occasionally to cram for a test or write a paper, especially during finals, says he gets the drugs from friends. Bob is also unimpressed by the dangers of taking unprescribed Adderall. “In my opinion I don’t think that it’s habit-forming,” he says. “It’s not illegal to have Adderall.” While Adderall obviously isn’t illegal for those who get it from their doctor, it is in fact classified as a Substance II by the Drug Enforcement Administration, which is in the same legal category as cocaine and heroin. The minimum federal sentence for first-time possession of between five and 49 grams is five years. Yet even students who do worry about side effects of taking speed find themselves turning to the drug when the pressure is on. Mike first used a friend’s Adderall when he had three papers due in three days during finals period. “The surprise for me was that the end product was exactly the same, it just takes less time to do it,” he says of his Adderall-fueled paper-writing experience. “Why would you not take something if it allows you to do the same thing for less?” But Mike, unlike many occasional users, also sees the dangers of dependence and over-use. He says the prospect of long-term side effects discourage him from using Adderall on a regular basis. “I’m leery of over-using these things,” he says. “I could stand to be a little more productive every day, but it’s not worth it.” Students run the risk of suffering from a host of potential side effects when they take stimulant drugs prescribed for ADHD -- including cardiac problems, insomnia, high blood pressure, and sexual dysfunction. The Director of the Bureau of Study Counsel, Abigail Lipson, says that students often turn to study drugs, ignorant of their serious nature. “The student is generally trying to solve a legitimate problem...perhaps even an undiagnosed condition that would indeed benefit from medical treatment -- and the student may or may not realize that using prescription medications without medical oversight is both illegal and very dangerous,” Lipson writes in an e-mail. But even some students who are given stimulants with “medical oversight” seem to be confused or ambivalent about their use. Greg’s doctor at UHS thought he suffered from concentration problems when Greg went in complaining of anxiety. He prescribed Wellbutrin, an anti-depressant that is also used to treat ADD or ADHD. But Greg soon decided to stop taking the Wellbutrin on his own. “I just didn’t think it helped me concentrate, instead it made me feel kind of moody and crazy,” he says. “I’d rather not be constantly medicated.” So while Greg says he sees no difference between taking Adderall and caffeine -- “drawing a line between them doesn’t make sense” -- he would rather not take the medication he was diagnosed, and only take pills in extenuating circumstances, like the night before a paper is due. Rick, another student who was temporarily prescribed a stimulant, also decided on his own to stop taking them, opting for a program of occasional self-medication. Rick was prescribed dexedrine -- a form of Adderall -- from a doctor unaffiliated with UHS, after being prescribed a long string of other drugs, many of them antidepressants. He switched back to a non-stimulant anti-depressant after deciding that “it was probably unhealthy to have a prescription.” Rick equivocates when asked if he purposely tried to extract a prescription for a stimulant from his doctor -- “not aggressively,” he says. “It just sort of happened [and] I was content with the situation.” The same level of uncertainty shrouds his decision to stop taking the medication. It was not for fear of addiction, he says, nor from too many people asking him for his pills --although he says friends did ask for them. Since Rick has occasionally taken Ritalin and Adderall to stay awake and work since freshman year, his aversion to having a steady supply, along with his attitude towards concentration disorders, is hard to understand. “When something is boring, I have trouble concentrating on it,” Rick says when asked if he thinks he has an attention disorder. “I don’t really believe in that categorization,” he says. Rick, like so many others, is dismissive of the question of fairness surrounding the use of stimulants. “Does caffeine count? Or when people choose to forego social life to study?” But his decision to forgo a dependable source of the stimulant because it wasn’t “healthy” belies or complicates Rick’s outwardly blasé attitude towards the drug. Perhaps for all his apparent disdain for the disorder, Rick fears the dangers of their all-too-attractive medications. "So Damn Abusable" Elizabeth Wurtzel ’89, author of the drug-addiction memoir “More, Now, Again,” speaks of Ritalin, her one-time drug of choice, with a loathing that could only come from experience. “It’s so damn abusable,” she says. “I think it’s hard to resist abusing it, particularly when you’re in high school and college.” Wurtzel, who would crush and snort the Ritalin pills that were prescribed to her for her attention disorder, lived for months as a drug addict while writing her second book in Florida. She recalls the first time she ever abused Ritalin. “One odd day I cut one in half and it splintered into little pieces and I had snorted cocaine before and I thought ‘I’ll just snort it.’ And then instead of taking four a day I started taking eight a day. It was prescribed and I thought it was safe,” she says. Wurtzel spent four months in a hospital recovering from her addiction. “At heart I really am a nice Jewish girl and I didn’t want to get addicted to drugs,” she says. “I had no idea I couldn’t stop until I got to the point where I couldn’t stop.” Wurtzel, who is also a Crimson editor, now takes Concerta -- a time released version of Ritalin that is harder to abuse because it can’t be crushed up and snorted -- but retains a deep distrust for Ritalin and other ADHD drugs. “I switched from snorting Ritalin to snorting cocaine seamlessly,” she says. “Not too many people would give their children cocaine pills but they give their children Ritalin pills.” In February 2005, Canada pulled Adderall off the market, citing the need to investigate the claims of sudden deaths, heart-related deaths, and strokes in children and adults taking regular recommended doses of Adderall. A few months later, Adderall was back on the market, now marked with a warning about misuse and heart-related side effects. Last month, the FDA rejected the recommendation of its advisory board to label Ritalin and other drugs prescribed for ADHD with a “black box” warning, the most cautionary label used for medications. The suggestion was made in light of an FDA report documenting 25 sudden deaths among children and adults taking ADHD drugs between 1999 to 2003. Meanwhile, doctors wrote more than 31 million prescriptions last year for stimulant ADHD drugs, according to IMS Health, a marketing and strategic consulting firm specializing in the healthcare industry. “When used carefully with appropriate monitoring, they are quite safe and helpful for students who need them,” writes Kadison in an e-mail. “They can make a marked difference in academic functioning and focus for those students with attentional problems.” And this year, Harvard added a question to its drugs and alcohol survey specifically asking about study drug use, according to Travia. “We’ve been hearing more and more about study drugs being an issue, not just here at Harvard, and we want to benchmark where we fit in to all this,” he says. But due to the ease with which these drugs can be attained, use is not likely to be contained. “Since students can purchase almost any medication over the internet and about a third of students with diagnosed ADD are asked to sell or give their medications to friends and classmates, a student who really wants to get access to these medications will probably find a way,” Kadison writes in an e-mail. Abuse in All Forms Amy, an upperclassman, gave away a bottle of Ritalin to a close friend last year after deciding to no longer take the drugs, which she was prescribed at UHS. The friend offered her $50 for 10 pills, but Amy gave him the drugs for free. “I know that he’s into other drugs so I knew if he didn’t get them from me he’d get them from someone,” she says, while shredding napkins onto a dining-hall tray. Amy has struggled with an attention disorder since high school. Her mother, a “crazy foreign mom who doesn’t believe in medication” resisted a high school counselor’s advice that Amy be medicated. But the transition to an unstructured college environment left Amy completely without focus in class or at the library. She sought help at UHS, and was prescribed Ritalin after a 20-minute visit. “To be honest it was very shocking to me,” Amy says. “But what I find about UHS is that they’re very easy to prescribe things.” Her doctor told Amy to beware of friends seeking her drugs. But Amy soon found she had bigger problems. “I get headaches,” she says. “Around five o’clock, when it wears off, I get depressed and I cry.” After telling her doctor about her crashes and insomnia, she was prescribed sleeping pills, which elicited a bad reaction. Frustrated, Amy gave away her remaining Ritalin and tried to live study drug-free. But last semester she could only manage a three-class course load, and found that in class she could only “draw little ponies in my notebook and look at the clock.” She tried going to the Bureau of Study Council, where she learned “to click my pen under the table”, among other techniques, to improve focus. This semester, Amy’s back on Ritalin. “If I have a little crash I’ll just call my mom or do more work,” Amy says of her re-adjustment to the drugs. Her doctor is thinking of switching her to Adderall. Amy is proof that abuse is not limited to the un-prescribed, and that attention disorders can frustrate and confuse even the believers. “I’ll be honest, during finals I totally stockpiled,” she says. “I wouldn’t take any on the weekend so I could take 4 or 5 during the day.” Amy pours some salt onto her tray next to the wreckage of destroyed napkins, arranges it into little clumps, and says apologetically: “I have a paper due at 5 and I’m a little overmedicated right now.” She says this “stockpiling” intensifies the eventual crash. Amy eventually wants to lead a lifestyle where she hopes she won’t need to take study drugs, perhaps through pursuing an active, mobile career. “I don’t want to take it after college,” she says. “There’s just so much pressure here. We’re not forgiving here.” Used to Abuse Steven, the student who receives stimulants from UHS though he does not believe in attention disorders, clings to his belief that study drugs should not be regulated by doctors, since he says not everyone would abuse them. “There’s always issues of addiction and there’s people who are driven to take it because they’re stressed out, but that said I don’t think that doctors necessarily have the authority to judge who needs it or who doesn’t need them,” Steven says. Yet when asked whether he felt a dependency on the stimulants himself, Steven shows less certainty. “No I do not think I’m addicted, but I do find that I have been using more speed than I should be using,” he says. “I use a lot of speed.” Today, Steven has not taken any of his drugs. “I am finding that having taken it for a very long time I have trouble going a day without taking it. Today I’ve been very, very tired. It’s very easy to rely on study drugs all the time. It does take a lot of effort to limit yourself.” But Steven cheers up a bit when a friend stops by with a case of Red Bull for him. When asked why she tried the Adderall given to her by friends, Helen thinks for a second, shrugs, and then says: “Curiosity. I know that the potential costs are not as high. People know you can’t get that hurt.” Helen’s shrug is far from unique, seemingly representative of a generation inured to the seriousness of medication -- the Ritalin Generation. “They don’t know what they’re getting themselves into. They just don’t see it,” Wurtzel says, almost as if she still recognizes herself in the college student of today -- careless, blasé, and immortal. But that was before she graduated, before she started doing 40 lines of Ritalin a day, convinced that nothing she could get from a doctor could possibly hurt her. Wurtzel switched “seamlessly” from cocaine to Ritalin, and many Harvard students make the logical jump between coffee and Adderall with comparable aplomb. And while snorting cocaine is marked by considerable stigma, for those of us fortunate to grow up as members of the Ritalin Generation, little can be more mundane than medication. As students question the disorders that put themselves or their friends on amphetamines to begin with, the attractions of speed in a deadline-filled environment remain. Some are left cynically taking stimulants, as ambivalent to their dangers as they are to the reasons why they are prescribed in the first place. Christina K. Vangelakos contributed to the reporting of this story.

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