New York Times
POSTED: 1:30 a.m. HST, May 1, 2013
FRESNO, Calif. » Lisa Beach endured two months of testing and paperwork before the student health office at her college approved a diagnosis of attention deficit hyperactivity disorder. Then, to get a prescription for Vyvanse, a standard treatment for ADHD, she had to sign a formal contract — promising to submit to drug testing, to see a mental health professional every month and to not share the pills.
"As much as it stunk, it's nice to know, ‘OK, this is legit,"' said Beach, a senior at California State University, Fresno. The rigorous process, she added, has deterred some peers from using the student health office to obtain ADHD medications, stimulants long abused on college campuses. "I tell them it takes a couple months," Beach said, "and they're like, ‘Oh, never mind."'
Fresno State is one of dozens of colleges tightening the rules on the diagnosis of ADHD and the subsequent prescription of amphetamine-based medications like Vyvanse and Adderall. Some schools are reconsidering how their student health offices handle ADHD, and even if they should at all.
Various studies have estimated that as many as 35 percent of college students illicitly take these stimulants to provide jolts of focus and drive during finals and other periods of heavy stress. Many do not know that it is a federal crime to possess the pills without a prescription and that abuse can lead to anxiety, depression and, occasionally, psychosis.
Although few experts dispute that stimulant medications can be safe and successful treatments for many people with a proper ADHD diagnosis, the growing concern about overuse has led some universities, as one student health director put it, "to get out of the ADHD business."
The University of Alabama and Marist College, like Fresno State, require students to sign contracts promising not to misuse pills or share them with classmates. Some schools, citing the rigor required to make a proper ADHD diagnosis, forbid their clinicians to make one (George Mason) or prescribe stimulants (William & Mary), and instead refer students to off-campus providers. Marquette requires students to sign releases allowing clinicians to phone their parents for full medical histories and to confirm the truth of the symptoms.
"We get complaints that you're making it hard to get treatment," said Dr. Jon Porter, director of medical, counseling and psychiatry services at the University of Vermont, which will not perform diagnostic evaluations for ADHD. "There's some truth to that. The counterweight is these prescriptions can be abused at a high rate, and we're not willing to be a part of that and end up with kids sick or dead."
Changes like these, all in the name of protecting the health of students both with and without attention deficits, involve legal considerations as well. Harvard is being sued for medical malpractice by the father of a student who in 2007 received an ADHD diagnosis and Adderall prescription after one meeting with a clinical nurse specialist.
Still, many student health departments regard ADHD, a neurological disorder that causes severe inattention and impulsiveness, as similar to any other medical condition. Eleven percent of American children ages 4 to 17 — and 15 percent of high school students — have received the diagnosis, according to a survey by the Centers for Disease Control and Prevention.
New college policies about ADHD tend not to apply to other medical or psychiatric conditions — suggesting discrimination, said Ruth Hughes, the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. Such rules create "a culture of fear and stigma," she said, adding that if students must sign a contract to obtain stimulants, they should have to do so for the painkillers that are also controlled substances and are known to be abused.
"If a university is very concerned about stimulant abuse, I would think the worst thing they could do is to relinquish this responsibility to unknown community practitioners," Hughes said. "Nonprescribed use of stimulant medications on campus is a serious problem that can't just be punted to someone else outside the school grounds."
Fresno State officials said a disquieting surge of students requesting ADHD diagnoses — along with news media reports of stimulant abuse and questionable diagnostic practices nationwide — led the university to change several policies last year. Now, students with an outside diagnosis of ADHD can fill their prescriptions at the Student Health Center only after providing documentation of a thorough evaluation by qualified mental health practitioners — which typically involves hours of neuropsychological testing and conversations with parents and teachers to assess impairment and other possible explanations.
Fresno State no longer makes diagnoses, largely because of the substantial time required "to do it right," said Catherine Felix, its director of health and psychological services. Many universities, including North Carolina State, Georgia Tech and Penn State, also said they could no longer handle the volume of requests.
In addition to requiring students to sign the contract, Fresno State does not allow early refills to replace lost or stolen medication. Urine tests can be required should a university clinician suspect that a student is not taking the pills as prescribed.
And in a rare policy among colleges, students receiving prescriptions to treat ADHD must see a Fresno State therapist regularly — not for a cursory five-minute "med check" but for at least one 50-minute session a month.
"It's not just taking a pill every day," said Dr. Daniel Little, who counsels several students with ADHD under this arrangement. "It's about learning coping skills."
Students said little could be done to curb misuse of amphetamines on campus, even as some colleges are tightening their policies.
Many students bring their prescriptions from doctors back home. Pills can not only be used to study but also to generate spending money, usually selling for $5 to $10, depending on the dose. Beach said she was offered up to $150 per pill during finals last year.
Misuse has become common enough for student newspapers to make light of it. The Miami Hurricane at the University of Miami ran an editorial in November that was headlined "Magic Pill Can Enhance Focus, Drive" and said that students "shouldn't look down on those who need — and welcome — the extra push" of Adderall. In another article, an undergraduate encouraged students: "Medicate, Miami. You've earned it." The university responded in a short news release that the articles did not represent its views on the subject.
Some universities go beyond student health to address amphetamine misuse on campus. Two years ago, Duke included "the unauthorized use of prescription medication to enhance academic performance" as a category of academic dishonesty, essentially cheating.
After the 2010 suicide of a student named Kyle Craig — who abused Adderall to keep up his grades, his family said, using prescriptions from a doctor near his New Jersey home — the university devoted part of freshman orientation to highlighting the temptations and perils of stimulant misuse, similar to programs on safe sex and binge drinking.
Several Vanderbilt students maintained that those efforts were futile, partly because they distribute pills themselves. One student, who asked to be identified only by his middle name, Andrew, said he was prescribed 60 pills a month from his hometown psychiatrist, although he needs only 30 or 40. He gives the extras to other students in need.
"I don't think they're doing enough," he said with a laugh, "to stop people like me."