Commonly prescribed to treat Attention Deficit Hyperactivity Disorder (ADHD), Ritalin and other stimulants, such as Adderall, have hit the short list of prescription drugs that teens and young adults are using increasingly for non-medical purposes. Less potent than amphetamines but stronger than caffeine, these drugs (a.k.a. study drugs) satisfy the desire to stay awake and be attentive — with the added benefits of appetite suppression, enhanced performance and even a little euphoria. Contrary to the desired therapeutic effect of improved attention and focus among ADHD patients, the non-medical user risks heart symptoms, seizures, and even rage.
One third of all drug abuse today is prescription drug abuse, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). There's even a term for this type of self-medicating: "pharming", whereby one grabs a handful of prescription drugs without necessarily knowing what he or she is getting. In a 2003 Partnership for a Drug-Free America teen study, painkillers were found to be the most common pharmaceuticals abused by teens, especially younger teens, while stimulant abuse is more common among older teens and college students. Twenty-one percent were using prescription painkillers without a doctor's prescription, and 9 percent were using Ritalin and Adderall in the same way. Maybe the anti-drug messages about illegal substances have finally sunk in, maybe prescription drugs are just easier and cheaper to come by, or maybe they're considered safer since they are legal. Whatever the reason, there is cause for concern.
Ellen Morehouse, executive director of Student Assistance Services, an alcohol and drug abuse prevention agency based in Tarrytown and servicing the Westchester school systems, tells of "an unprecedented number of reports of students inappropriately taking over-the-counter drugs ... as well as prescription medications such as Adderall, Klonopin and Ritalin both in and out of school." She accordingly organized a school nurse training session last March with guest speakers from the Hudson Valley Poison Education Center and the New York State Substance Abuse Service. Morehouse attributes the spike in non-medical use of prescription medications to the high level of stress and test anxiety in our communities, with kids staying up late, then being exhausted and needing something to help them stay up for weekend nights, too. She makes a distinction between this pattern and what would be considered recreational use, explaining, "When using a drug for a desired effect it's not recreational any more."
Ritalin is a stimulant
Ritalin is the brand name for methylphenidate, a central nervous system (CNS) stimulant, which has a calming and focusing effect on ADHD by "increasing the dopamine level (a neurotransmitter) and thereby improving attention and focus in individuals with weak dopamine signals," per the National Institute on Drug Abuse (NIDA) website. Research shows that when taken properly, according to form and dosage prescribed by a doctor, individuals with ADHD do not become addicted. The problem lies more with those for whom it is not prescribed but who are taking it for its stimulant properties: appetite suppression, wakefulness, increased focus and attentiveness, and euphoria. The NIDA website explains that "addiction seems to occur when Ritalin induces large and fast dopamine increases in the brain in contrast to the therapeutic effect which is achieved by slow steady increases of dopamine which are similar to natural production by the brain." Because of its potential for psychological dependence, Ritalin is classified by the DEA as a Schedule II drug, with controls on its manufacture, distribution and prescription.
When it comes to taking Ritalin for non-medical purposes, it can be swallowed in original pill form, ground up and snorted for more of a rush, or dissolved in water and injected for even more of a surge. In case the consumer isn't sure how all this is done, he or she can always go to any number of websites that "describe various drugs' effects, tell how much to take and even how to use inappropriately," says Dr. Jonathan Weinstein, director of the Hudson Valley Poison Education Center. Since Ritalin, Adderall, Dexatrine and Concerta are all stimulants, he advises looking for "signs of central nervous system stimulation such as hyper alertness, heart racing and increased blood pressure." Dangerous misuse often occurs when taking too much if the user doesn't feel the desired effect immediately, and in mixing with other substances.
With 3 to 7 percent of school-age kids diagnosed with ADHD, per the NIDA, and prescription of ADHD drugs up 72 percent (2000 vs. 1995 per SAMHSA), they're easy enough to get directly from friends. Morehouse says that the kids with prescriptions are not typically selling because they actually need the medication; they may sometimes be willing to give or sell a few to a friend, but that's not how most kids are getting it. More often, the drugs come from dealers, friends who work at pharmacies, and Internet purchases. There are about 500 websites advertising controlled prescription drug sales, most of which do not require a prescription and none of which place any restriction on sales to kids. "Similar to street drugs, these pills could be cut with anything," warns Dr. Weinstein. As for dealers, one quoted in a recent New York magazine "Generation Rx" article said that Adderall and Ritalin go for $3-$10 per pill.
According to Morehouse, "There's a common misperception of who's abusing. The kids ending up in the emergency rooms are not the ones who had prescriptions." She cites a 1999 Massachusetts General Hospital study to dispel the common fear that prescribing stimulant treatment may result in later drug abuse. In fact, the study found that when taken properly for treatment of ADD/ADHD, it can actually be "protective against substance abuse and other long-term outcomes associated with ADHD."
While this should serve to reassure families of children receiving stimulant therapies for ADHD, it should not lull anyone into a false sense of complacency. Despite all of parents' and doctors' best intentions for the ADHD individual taking prescribed stimulant medication, things can go wrong.
One mother, formerly of Westchester, who spoke to this writer on condition of anonymity, tells of her son's journey through ADHD diagnosis and successful treatment as an elementary school student, to his later drug abuse as a high school student. He was diagnosed in fifth grade because he was fidgety and unfocused in school, and ended up seeing a doctor they later learned was known as the "Ritalin King". The Ritalin helped for about five years, but then her son didn't like how he felt, so they switched to Adderall. Contrary to professional assurances that the kids with prescriptions are not the ones getting into trouble with stimulant abuse, her experience was that parents don't usually realize that kids who are prescribed stimulant medications frequently sell and trade them.
She first learned of the problem when she noticed that a bottle of Adderall was missing. They had an extra bottle because her son's dosage had been changed, and she became suspicious when her son was overly helpful in the search. He had been spending a lot of time with some new friends, also taking Adderall, who made her uncomfortable. She tried to go into his email and decided to call AOL to have his password changed so she could get in. By then it became apparent that her son was abusing prescription drugs, and he entered drug counseling (where he was exposed to kids with even worse problems). He relapsed and ultimately had to be sent away to a treatment facility before finally cleaning up.
There is a happy ending to this story, but it wasn't without scary episodes along the way resulting from combined prescription drugs as well as marijuana use. In retrospect the mother can now identify signs about which she had been clueless at the time: sleeplessness (her son blamed the medication), congestion (he blamed his allergies), irritability, highs and lows, missing medication (he helped look for it), depression (from self-medicating), psychotic episodes, talk of other kids doing drugs (saying he was against drugs). He was able to finish high school at home and even did well, but later admitted he had been smoking pot all year, so even good grades did not guarantee that all was well. He is now away at college, doing well in life, and taking the non-stimulant Strattera for his ADHD.
Elizabeth Wurtzel, author of More, Now, Again: A Memoir of Addiction, wrote of her Ritalin abuse: "It's impossible to say when it went from casual use, to a bad habit, to abuse, to addiction." She marvels over the fact that "a prescription medication that is routinely meted out to children in grade school may well have almost the same effect as cocaine." Granted, that is an addict speaking, but how can we know whether our children have that predisposition?
Advice for parents
Frank Simonelli, Jr., recovering alcoholic, drug counselor and author of Drug Proof Kids: The Ultimate Prevention Handbook for Parents to Protect Children From Addiction, says we can't know for sure who is "drugprone" but there are steps we can take to protect our kids. He writes that "research suggests addicts have more sensitive perceptual systems as well as somewhat defective cognitive and emotional processing systems," but adds that "parents are the most critical factor in their child's learning and development." Kids have to learn how to handle emotions and stress, and it is the job of their parents to teach them sufficient coping skills, which Simonelli notes is apparent in all AA meetings as a key problem.
Parent involvement throughout their children's lives is of paramount importance. Dr. Weinstein says, "The best thing is for parents to be involved in kids' lives and activities, to know them, to talk to them on a regular basis. It may not be true that if kids are doing well they're not on drugs, but it's less likely that there's a problem."
Often when there is a problem, "parents tend to deny it, but they have to look really close," says Ellen Miller, a therapist, social worker and certified empowerment coach in Fairfield County, CT, who works with parents of teens struggling with drug and disability issues. She warns that "it’s important to know that ADHD prescription drugs are stimulants." Some kids will experiment with taking more than their prescribed dose to get high, which they may justify by thinking it's their own medication that was prescribed to them, and "a little helps, but more makes them feel better." Miller adds that parents should not be afraid to look through their kid's things if they suspect a problem; abuse of stimulant medications is much more serious than just a teen acting out. If treatment is needed, it is imperative that parents be comfortable with the chosen treatment.
Almost everyone interviewed for this article recommended parental vigilance over the dispensing of medication and of the contents of medicine cabinets. Prescriptions that are no longer being used should be disposed of so as not to tempt experimentation. Those that must be kept should be hidden or locked up; this applies to alcohol and even over-the-counter drugs.
"There is no foolproof way to be sure there is not a problem," warns Dr. Weinstein, "but the bottom line is to be involved, ask questions, and never ignore your suspicions."
• National Center on Addiction and Substance Abuse: www.casacolumbia.org • National Institute on Drug Abuse: www.nida.nih.gov • University of Michigan Monitoring the Future Study: www.monitoringthefuture.org • Focus Adolescent Services: www.focusas.com • Substance Abuse and Mental Health Services Administration (SAMHSA): www.health.org • Partnership for Drug-Free America: www.drugfreeamerica.org • Poison Control Hotline: 1-800-222-1222