Sarah’s mouth is dry. She’s constantly thirsty. The Concerta she took did its job. She finished her paper hours ago. Now, she just has to keep busy.

She cleans her room and organizes the books on her shelf by color and by size. She lies in bed writing letters she will never send to friends she hasn’t talked to in years. She has a lot to say, but no one is awake to listen.

Things will be like this — methodical, obsessive — until the stimulant wears off.

The thing is, Sarah doesn’t have ADHD. She doesn’t have a prescription. But her freshman-year roommate did.

“I took it pretty much before every single test,” the Leawood sophomore says. “Any time I needed to concentrate and get something done. I’m a really big procrastinator, so it was really easy when I took it because I could just knock something out in an hour.”

Sarah’s freshman-year habits are not uncommon. Today, college students across the country rely on stimulants like Concerta and Adderall to increase focus and stave off sleep.

According to a 2002 University of Wisconsin study, 20 percent of college students have used Adderall or Ritalin without a prescription. In a 2004 study, the Partnership for a Drug-Free America found that one in 10 teenagers had taken stimulants (Ritalin and/or Adderall) without a prescription.

Sarah’s use of Concerta has not resulted in any dangerous side effects, but, if abused, prescription stimulants can cause hallucinations and psychotic behavior. And as students report increasingly lax ADHD testing standards, doctors like Stephen Hinshaw, chairman of the psychology department at the University of California-Berkeley, worry that this trend is getting out of hand.

Adderall, Concerta and Ritalin, oh my

Stimulant medications are most often prescribed to treat Attention Deficit Hyperactivity Disorder or ADHD. Some common ADHD medications include Adderall, Concerta, Ritalin, Strattera and Dexedrine. Adderall, however, is the most commonly prescribed ADHD medication on the market. More than 40 million Adderall prescriptions have been written since 1996.

But as the popularity of stimulants rises on college campuses across the country, some psychologists such as Hinshaw, who specializes in childhood and adolescent ADHD, say the dangers increase as well.

“I think it’s a huge issue,” Hinshaw says. “At colleges where students know that (stimulants) can be performance enhancers and that there are brief assessments (to acquire a prescription), and many people with ADHD … don’t like to take the medication everyday, then there becomes a market for it.”

Shire Pharmaceuticals, maker of Adderall, maintains that studies show the drug, which comes in two forms, Adderall and a time-released version called Adderall XR, is safe and does not have addictive capabilities. According to Shire Pharmaceutical’s Adderall XR Web site, www.aderallXR.com, Adderall is thought to work by “restoring the balance of certain neurotransmitters, or chemicals in the brain that send messages between the nerve cells and affect how we function.”

The site goes on to say that scientists believe two of those neurotransmitters, dopamine and norepinephrine, play an important role in focusing and paying attention to tasks and that when those two transmitters are not balanced, ADHD symptoms result. Adderall XR, like other stimulant medications, is thought to restore that balance and promote more normal message transmission, thus increasing the ability to focus and pay attention.

Hinshaw says Adderall is safe when used properly and that anyone — ADHD affected or not – will experience a performance boost when taking a stimulant. However, it is a Schedule 2 drug, which means it is approved for medical use but also has the highest potential for abuse.

“’Why not put stimulants in the water supply?’ Everyone does a little better,’” Hinshaw says. “(You can’t) because stimulants can be drugs of abuse. When they’re used to treat ADHD, they help focus attention, they decrease distractibility and there is not much of a euphoria or a rush. But if you start to get into a pattern of higher use, or particularly if you take them in other forms, such as snorting or injecting, then they can become drugs of abuse.”

Even when taken with a prescription, Adderall, like most stimulants, has side effects, like those Sarah experienced when she took Concerta. The most common side effects are dry mouth, difficulty falling asleep, stomachache, headache, loss of appetite and weight loss.

In February, Health Canada (Canada’s FDA equivalent) banned the sale of Adderall XR after learning from Shire Pharmaceuticals that the medication had been linked to 20 deaths worldwide. In August, however, Canada put Adderall XR (the country still does not sell Adderall in its original form) back on the market with a new label warning people with heart problems about the dangers of taking the medication.

Because Adderall is an amphetamine, the FDA warns those taking the drug that it has a “high potential for abuse.” And if overused or used improperly, Adderall can pose serious health risks, says Dr. Mark Romereim, founder of the Attention Clinic in Wichita.

“If you get more than you need, you are more likely to have side effects. Stimulants will help anybody concentrate,” Romereim says. “But if you get more than you need, you not only have problems with appetite and sleep, you can get depressed, irritable, manic and even psychotic.”

So what is “more than you need?” A June 2005 FDA document says that while individual response to amphetamines varies, toxic symptoms can occur, though rarely, at doses as low as two milligrams. The report says toxic symptoms are rare with doses of less than 15 milligrams, and that doses of 30 milligrams or more can produce severe reactions.

In December, New River Pharmaceuticals filed a new drug application for an abuse-resistant stimulant. The stimulant works through technology that prevents the drug’s active ingredient from being released unless taken as directed and also limits the high patients can get from a stimulant medication.

Getting a Fix

But until that drug is approveD, Romereim and Hinshaw agree that the biggest issue is how easy it can be to get diagnosed with ADHD and, along with the diagnosis, get a prescription for a stimulant medication. Hinshaw says he knows some doctors give people a short test, sometimes as brief as 15 minutes, and that downsizing the diagnosis causes false positives and false negatives.

Both doctors agree an ADHD test needs to have diagnostic and personal evaluations, where the patient’s history is examined and sought from others, such as parents, who have an understanding of the child’s long-term patterns. At UC-Berkeley, Hinshaw says, the ADHD test is eight to 10 hours long.

At the University of Kansas, the Counseling and Psychological Services Center does ADHD testing. CAPS clinician Dr. John Wade says the tests require three to five sessions (one 50-minute session per week) with a CAPS clinician. But before meeting with a clinician, the patient must return a packet of information to CAPS that includes a self-report, a survey with someone who currently knows the person well and information about the patient’s formative years provided by the parents. CAPS also requires elementary, middle and high school transcripts. The rest of the process includes a personality assessment test and clinical evaluations.

At Watkins Health Center, Dr. Myra Strother says students who want to get an old stimulant prescription renewed, or who bring in a diagnosis and want a new prescription entirely, must provide proof of a full evaluation.

“If I see a student who comes in with just a prescription from a family doctor, I will not give them medication,” Strother says.

For those students looking for a study stimulant who don’t want to go through the process of getting a prescription, there is always another way, as in Sarah’s case. Her roommate, who was diagnosed with ADHD and had prescriptions for Ritalin and Adderall was generous with her medication and rarely took all of her prescribed amount (Which Hinshaw says is quite normal for ADHD patients).

“She would give me handfuls,” Sarah remembers.

Amber, Overland Park sophomore, took Adderall she got from friends occasionally her first semester at the University as well. But before the start of her second semester, she was tested for and diagnosed with ADHD. According to her prescription, Amber is supposed to take one 30 milligram pill every morning and one 20 milligram pill every afternoon. Because the severity of ADHD varies from person to person, each ADHD patient’s prescription is different.

Amber says she doesn’t usually take her prescribed dosage and never uses her entire prescription in one month. She usually gives about 10 pills to friends every month, and sometimes sells them as well. Selling, though, is a rarity. Amber says $5 is the most she’s ever made on one pill, and she’s only made about $30 altogether since she started filling her prescription.

Giving away medication, to Amber, is simply a way of helping out her friends. To the federal government, however, it’s a felony. Because Adderall is an amphetamine, it is in the same regulatory category as cocaine and selling it is a class B felony, the same as distributing methamphetamine. In April 2005, a University of Oregon student was arrested for selling legally obtained Adderall and dextroamphetamine sulfate out of his dorm room.

A Prescription Drug World

Sarah’s first experience with stimulants was in eighth grade, when a friend with ADHD who didn’t like to take all her medication gave Sarah Adderall to get rid of the extra pills in her bottle. After that, Sarah continued to take Adderall occasionally throughout high school. Once she got to the University and realized her roommate had excess Concerta, Sarah would occasionally ask for some pills. Throughout her first year at the University, Sarah would sometimes take Concerta as often as every other day, sometimes as infrequently as every other week.

Sarah’s habits are part of a growing trend of prescription drug abuse nationwide. In 2003, the National Center on Addiction and Substance Abuse reported that 15.1 million Americans abused prescription drugs, up from 7.8 million in 1992. The three-year study also found that from 1992 to 2003, prescription drug abuse grew two times faster than the rate of marijuana abuse, five times faster than cocaine abuse and 60 times faster than heroin abuse.

The Center also performed a search for Web sites where a person can buy prescription medication without actually having a prescription. In a one-week window the study found 495 sites advertising prescription drug sales. Only six percent of the sites required a prescription to purchase medication, meaning anyone with a credit card and a mailing address has access to drugs like Adderall, Concerta, OxyContin and Xanax, among others.

“I’ve had people come and tell me that before they came to see me they got Ritalin online from Pakistan and Valium online from Mexico,” Romereim says. “People don’t even think it’s dangerous. I think it’s very foolish. I think it is an ignorance issue.”

The Adderall Advantage

But why go to all this trouble in the first place? Does it really improve your grades that much? Sarah says in certain subjects, such as math, stimulants made a difference. In others, she couldn’t really tell. Out of 28 students surveyed informally in a math class, 13 said they have used a prescription stimulant without a prescription, 11 said they had not and five said they used it with a prescription.

Of the 13 who had taken a stimulant without a prescription, eight said they thought it helped them get better grades and five said it didn’t make a difference.

Amber says at least 30, maybe more, of her friends use Adderall. She agrees with Sarah that taking it with or without a prescription is only dangerous if you take too much. Amber says she once took 60 milligrams to study for a big test and that dosage caused her to throw up. She says she has seen the same effect in others who have taken too much.

Sarah says that when she took Concerta she often wouldn’t sleep for 48 hours or eat for a day and a half. But Sarah says the negative side effects were worth the hours of concentration one Concerta pill could provide.

Amber says stimulants definitely helped her — her GPA went from 2.38 her first semester before being diagnosed with ADHD to 2.88 after she began taking Adderall to help her focus.

For Amber, the use is clearly justified. But are those who don’t really need stimulants, like Sarah, and take them just to get ahead cheating?

According to a nationwide survey of about 11,000 college students published in the January 2005 issue of the journal Addiction, colleges with higher admission standards have the highest rate of prescription drug abuse — up to 25 percent.

“It’s cheating in the same way that when I was in college, kids took speed, or it’s like taking caffeine to stay alert,” Romereim says. “It’s illegal and dangerous, but it’s not on the level of plagiarism.

Ultimately, students like Sarah will keep the stimulant trend alive. She doesn’t have a problem taking them, and hasn’t taken them this year simply because they aren’t as readily available to her now. She doesn’t think there is any real danger in using stimulants as a study aide, an opinion Romereim does not share.

“The goal for treating people with ADHD is not to make them superhuman, it’s meant to make them normal,” he says. “For people who don’t have ADHD, (the drugs are) being used very improperly.”