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Psychostimulant Use Disorders in Young Adults: Running on Fumes
By John Dyben, DHSc, MCAP, CMHP
Social Work Today
Vol. 18 No. 4 P. 24

Nonmedical use of prescription stimulants is a growing concern among young people, especially college students who believe the drugs will improve their school performance.

Today, alcohol remains the primary chemical leading to substance use disorders (SUDs), but it is often used concurrently with other drugs (Hedden, 2015). Among college students and other young adults, nonmedical use of prescription stimulants (NPS) may be the most common form of drug use following alcohol (Benson, Flory, Humphreys, & Lee, 2015).

Commonly misused psychostimulants include dextroamphetamine (Dexedrine), dextroamphetamine/amphetamine combination (Adderall), and methylphenidate (Ritalin, Concerta). Sometimes referred to as speed, uppers, skippy, kibbles-and-bits, vitamin R, and other names, these drugs are powerful. When they lead to addiction, they can encourage use of illicit substances such as cocaine and methamphetamine if a person cannot obtain the prescription drug.

Research indicates that NPS is most common among college students, with more than 10% of these young adults engaging in NPS regularly, and more than 30% reporting having done so at some point in their lives (Weyandt et al., 2013). Unfortunately, there are indicators that the problem may be even more widespread. In 2018, The Michigan Daily conducted a survey of more than 1,300 college students. Nearly one-fourth of the surveyed students reported using psychostimulants, even though fewer than 10% reported having a prescription (Norris, 2018). This suggests greater than 15% ongoing student NPS in this particular population.

Sources
According to Norris, students without prescriptions for stimulants can purchase them from other students for a few dollars per dose. Many students, though, have no need to even purchase the drugs as those with prescriptions often share them as they might share anything else with friends.

Drugs picked up at pharmacies are often perceived by young adults as having little to no cost, especially if they are being provided through parents. So, most of the NPS that occurs is not students finding street dealers and buying drugs from them; rather, it begins with a prescriber writing for the drug for a student who then provides it to many others for NPS.

Multiple Potential Consequences
These prescription stimulants are Schedule II drugs in the same category as cocaine. What can happen at high doses is potentially deadly: seizures, heart failure, high body temperature, and irregular heartbeat. Repeated NPS can cause anger, paranoia, convulsions, impulsivity, impaired judgement, and even psychosis (National institute on Drug Abuse [NIDA], 2018). They work primarily by increasing the activity of dopamine and norepinephrine in the brain.

Increased norepinephrine affects blood vessels, blood pressure, heart rate, blood sugar, and breathing. The user may feel focused and energetic, while physiologically the body will experience increased blood pressure and heart rate, increased blood sugar, changes in breathing, and vasoconstriction (narrowing of blood vessels).

Increased dopamine causes heightened feelings of pleasure and mood elevation. This process sends strong signals through the reward pathways of the brain (particularly the ventral tegmental area and the nucleus accumbens) causing a powerful reinforcement that leads to repeated administration. In some people, this will lead to a change in the brain that manifests in addiction.

The risk of addiction with NPS is real and devastating. As a person develops tolerance and needs more and more of the drug to achieve results, the risk for addiction increases, as do all other potential deleterious consequences. When a person becomes addicted, the brain changes. It begins to operate in a type of survival state in which it drives a person to continue to use the drug despite negative consequences.

What about children who have been prescribed psychostimulants for ADHD? So far, studies have found that when people have a diagnosis of ADHD and use prescription psychostimulants monitored by a physician, it does not seem to significantly increase or decrease their risk for future SUDs (NIDA). However, as with most drugs commonly used for psychiatric conditions in children, the research is far from comprehensive.

Reason for Use, Normalization
Given the potential risks, why do young adults, often college students, take psychostimulants nonmedically? Arria et al. (2017) found that an overwhelming majority of college students engaged in NPS believe that it helps improve their school performance and that this will ultimately result in improved grades. Their work also revealed that this belief is likely erroneous and NPS does not result in improved grades or provide any other advantage compared with students who do not use psychostimulants.

Unfortunately, clinical experience has shown that patients with SUDs that include NPS often continue to believe that they cannot perform intellectual tasks without psychostimulants. This hurdle to recovery is often further complicated by parents and siblings who want to see their loved one free of other drugs but maintain an ingrained belief that psychostimulants are harmless, a belief that is in many ways reinforced by cultural norms.

The feeling of focus that one may experience when engaged in NPS can create false impressions of being effective, and families can become enamored with the idea of improved performance. A college student reported that as a freshman she took Dexedrine once for a long night of cramming for a test. She bought it from another student. When she got on the campus shuttle to get to the class, she couldn't sit down: "My neck felt like a giraffe—I was way up high, looking down. Then I wrote what I thought was a decent essay, and it was crap." Her perception while writing the essay was altered from reality. Only when looking at it later did she realize that she wasn't doing better; she simply felt like she was doing better.

Another decades-old reason that young adults, especially women, take prescription stimulants is to reduce their appetite with the goal of losing weight. Jeffers and Benotsch (2014) surveyed 707 college students and found that 4.4% reported they had engaged in NPS specifically for the purpose of losing weight. These behaviors also highly correlated with higher concerns about body image and greater risk for eating disorders.

When alcohol is added to this mix, the combination becomes even more dangerous. A trend referred to as "drunkorexia," particularly prominent in college students, involves restricting calories in order to be able to drink without gaining weight. One recent study of 4,275 individuals between the ages of 18 and 26 found that an astounding 34.1% of respondents reported having engaged in this practice (Lupi, Martinotti, & Di Giannantonio, 2017). This behavior combines all the consequences of drug use with the consequences of malnutrition. One essentially starves the body of what it needs while saturating it with elements that tax the body's systems to a point of poisoning it.

Zach: Play Hard, Work Hard
Young adults often engage in NPS to study and play hard at the same time. Zach's is a story of how psychostimulants, such as Adderall, nearly cost him his life.

Zach was in high school when he sustained a sports injury. Opioids were prescribed, and he liked the high. His years of addiction began, but his was a life of success in school and sports. "In some ways, the pressure to succeed was self-imposed," he says. "It was real, and I felt it."

In college, Zach realized that Adderall had a magic charm: He could play and study and get through classes. In fact, he found he could drink exhaustively in the evening because he took Adderall the next morning. Voilà. No hangover. Energy, focus. "It was easy to get prescriptions," he says, knowing his attention-deficit disorder claims could win over the prescriber.

Still, there were times when the prescription drugs weren't available, so he turned to methamphetamine, which was easy to obtain. "Meth has the same results," he says. "You know at the time it's dangerous, but you don't care because you have to have it, and there is no rationale."

Zach knew he was chemically dependent, so he sought therapy. He thought he had his addictions under control; he graduated from college and went on to teach. But he continued to drink and take prescription stimulants or methamphetamine and became increasingly nonfunctional. Instead of feeling energetic in the morning after an alcohol-infused evening and a morning dose of Adderall, he became frazzled and frenetic. He found it hard to concentrate and lost significant weight. At first he got compliments on the weight loss, then concern. He couldn't sleep.

More methamphetamine. More alcohol. He missed days at work, then scrambled to make it up. Until one day, the day of his annual work review, he overslept. He considered suicide. "I seriously considered it, because of my misery, [my] inability to get my life in balance, and my failures, including to even show up for my review. The pressures to succeed didn't pan out. But then I got a call from my parents, who were on their way to see me. I couldn't let them down."

When Zach agreed to treatment again, he had to come face to face with his addiction to alcohol. And he was terrified of giving up psychostimulants. During primary residential care, everything seemed to be a blur. Focusing was difficult. "If I knew how hard it was going to be, I don't know if I could have done it," he says. But he had made the decision.

What made the difference for Zach? The psychotherapies and peer support were tailored to him as an individual. Cognitive behavioral therapies, mindfulness, biofeedback, motivational interviewing to dissipate his ambivalence, sober peer "play," and group therapy were all part of the recovery puzzle. What also made the difference, he says, were the spiritually focused, peer support, self-care, and actionable practices he derived from study and practice of the 12 Steps. The empathetic support of peers gradually supplanted cravings and pressures to succeed synthetically.

Treatment and the Individual
Assessment of NPS usually reveals that other drugs or alcohol are involved. For this reason, medical detox and withdrawal must be closely monitored. Withdrawal from psychostimulants alone involves factors such as fatigue, insomnia, confusion, weakness, and often the serious physical depletion of weight loss and nutrient depletion. Additional substances including alcohol further complicate the withdrawal process and can be dangerous.

There are no prescription medications available for the specific treatment of psychostimulant use disorder (NIDA), but considering that SUD has psycho-bio-social-spiritual elements, treatment must address these aspects holistically. This includes the need to treat common co-occurring conditions such as anxiety, depression, and thought disorders.

For treatment to be effective, young adults, especially millennials, need to be leveled with, listened to, and engaged in the plan of treatment. Initial moments of contact with treatment professionals can be vital, because relationships that most effectively facilitate lasting change will be those based on trust and therapeutic rapport.

Empathy can be the counselor's best tool. This does not mean taking on the individual's trauma or experiences nor sharing details of one's own experiences. Empathetic treatment at its core is authentic, nonpatronizing, and involves informed listening. It involves acknowledging where the person is right now, being able to ask the question "What is it you really want?" and being ready for the answer "I want my Adderall, that's what I want!"

Addiction nearly always involves ambivalence, particularly in early stages of change. Initially, patients will tend to present the motivation they have to keep using, but there is always a motivation to get well somewhere in there, too. Effective therapists will provide a space for patients to unpack that ambivalence and, if effective rapport has been developed, can help patients increase their own motivation to move toward health.

Family involvement in the treatment process is vital for several reasons. Most importantly, families are systems; addiction, like all other chronic health conditions, affects everyone within the system. Families often develop maladaptive behaviors dealing with their loved one's issues, and these behaviors tend to be both enabling and self-damaging. Everyone in the system deserves the possibility of being healthy in body, mind, and spirit.

Also, families tend to provide recovery environments postresidential treatment. Families do not cause addiction and so they cannot cure it. However, they can be intentional in developing an environment where healthy living is possible and where each member can flourish.

Prevention
We have a cultural understanding as a nation that cocaine and heroin are dangerous, but we put similar substances into pharmaceuticals and suddenly convince ourselves that they are benign. This is not to say that we need to go to the opposite extreme and vilify all drugs. However, we do need to see them for what they are and recognize each drug's benefits and dangers.

What can deter a young adult from using psychostimulants nonmedically? Since a major challenge to treating NPS lies in the multiple internal and external reinforcers of the use of these drugs, we need broader-based education that reaches families, educators, prescribers, and the general public.

Education is sometimes marginalized because it is insufficient in and of itself to address the problems of substance misuse. This is true in the same way that a carburetor is not enough to make a car run. Education alone is not enough, but proper education to everyone in the chain is an imperative element of prevention that must not be undervalued.

Another important element of prevention is early intervention. Keeping youths away from drugs including alcohol for as long as possible helps to decrease the likelihood that they will develop any form of SUD. This does not mean parents should be trying to scare their kids about drugs or watching their every move. Simply having nightly family dinners decreases the likelihood that children will develop SUDs, and it increases the likelihood of kids talking to their parents about their lives (Elgar, Craig, & Trites, 2013).

According to the Drug Enforcement Administration (2017), deaths from psychostimulants (excluding cocaine) have been rising steadily. In 2015, there were 5,716 deaths attributed solely to psychostimulant poisoning. That is more than 15 people per day. This is a trend that cannot be allowed to continue. Providing education at all levels, prevention, and treatment when it is needed can turn the tide.

— John Dyben, DHSc, MCAP, CMHP, is chief clinical officer of Origins Behavioral HealthCare.

References
Arria, A. M., Caldeira, K. M., Vincent, K. B., O'Grady, K. E., Cimini, M. D., Geisner, I. M., et al. (2017). Do college students improve their grades by using prescription stimulants nonmedically? Addictive Behaviors, 65, 245-249.

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(1), 50-76.

Elgar, F. J., Craig, W., & Trites, S. J. (2013). Family dinners, communication, and mental health in Canadian adolescents. Journal of Adolescent Health, 52(4), 433-438.

Hedden, S. L. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, Department of Health & Human Services. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.

Jeffers, A. J., & Benotsch, E. G. (2014). Non-medical use of prescription stimulants for weight loss, disordered eating, and body image. Eating Behaviors, 15(3), 414-418.

Lupi, M., Martinotti, G., & Di Giannantonio, M. (2017). Drunkorexia: An emerging trend in young adults. Eating and Weight Disorders — Studies on Anorexia, Bulimia and Obesity, 22(4), 619-622.

NIDA. (2018, June). Prescription stimulants. Retrieved from https://www.drugabuse.gov/publications/drugfacts/prescription-stimulants.

Norris, M. (2018, March 25). Survey finds that 24 percent of University students use Adderall. The Michigan Daily. Retrieved from https://www.michigandaily.com/section/research/adderall-used-24-university-students.

US Department of Justice, Drug Enforcement Administration (2017). 2017 national drug threat assessment. Retrieved from https://www.dea.gov/docs/DIR-040-17_2017-NDTA.pdf.

Weyandt, L. L., Marraccini, M. E., Gudmundsdottir, B. G., Zavras, B. M., Turcotte, K. D., Munro, B. A., et al. (2013). Misuse of prescription stimulants among college students: A review of the literature and implications for morphological and cognitive effects on brain functioning. Experimental and Clinical Psychopharmacology, 21(5), 385-407.