When Paul left home to attend the University of Colorado at Boulder, he took his prescription for the drug Adderall along with him. The medication is normally used to treat attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), but Paul – who now believes he had been misdiagnosed – no longer used it for that purpose.

Instead, the journalism/business student says he took Adderall only occasionally and with a very specific intent: to help him focus on homework, or to stay up all night cramming for an exam. He also shared the pills with other students who did not have prescriptions, but who wanted Adderall for the same reasons he did.

Fellow students “always wanted my Adderall for studying,” says Paul, who asks that his last name not be used. “Certain individuals couldn’t study without it. They figured, ‘If I study all night on Adderall, I’d better take it for the test, too.’ ”

Adderall is the amphetamine most widely prescribed to treat ADD/ADHD. As with other amphetamines, regular users of Adderall can soon become dependent on it to get through the day.

Dubbed “kiddie coke,” Adderall is being used – and abused – by increasing numbers of high school and college students on campuses across the United States.

Although students often take the drug together – sometimes in study groups – their intent is not recreational. Rather, they use the stimulant in an attempt to enhance their powers of concentration and improve their academic performance.

“It’s a performance-enhancing drug,” says Punyamurtula Kishore, president and founder of the National Library of Addictions in Brookline, Mass., and a physician at Beth Israel Deaconess Medical Center in Boston. “They start accessing the drug legally, and then they find they can sell it for five or 10 bucks a pill to college kids.”

Pressure to earn ever-higher grades appears to be a primary motivation in the Adderall craze, say Dr. Kishore and other experts. In Massachusetts, where parents and school officials often have high expectations for students, more prescriptions are written for Adderall than in any other state.

Often, students begin imbibing while still living at home, and sometimes parents – unaware of the dangers involved – tolerate their misuse of the drug.

“A lot of families look the other way so that kids can stay up and study,” says Kishore. “It’s a myth that they’ll do better on exams … [But while on the drug] they feel they can conquer the world. Then they come down and crash.”

Although Adderall is often perceived as legal since physicians and pharmacists are involved in its dispensing, ultimately it is an illegal drug when used by somebody without a prescription. Campus policies on handling student drug users and dealers vary, but range from a warning with counseling to expulsion.

It’s hard to quantify the extent of Adderall abuse among students. Certainly the availability to children of drugs to treat ADD/ADHD has soared in recent years.

In the last 10 years, the number of preschoolers taking ADD/ADHD drugs has tripled; the number of school-age children has multiplied by 20. More than 2 million American children are prescribed drugs for ADD/ADHD. Adderall represents about a quarter of the market.

Statistics on the legitimate use of Adderall, of course, don’t reveal anything about patterns of illegitimate use. However, some experts suggest that the fact that the drug is viewed as a legitimate one may enhance its appeal – and its danger – to youthful users.

When Adderall is passed on from family or friends who have prescriptions to those who don’t, it has an aura of legality that street drugs don’t have. It’s pure, which makes it seem safer than unregulated drugs, where users don’t know what else it may have been cut with.

But in many states it’s a felony to be in possession of drug that has not been prescribed for the person using it. Prosecution, says Robert Goldstein, chief medical officer of Somnia, could be “equally as damning to a student” as addiction. When people see a prescription bottle, they think it’s OK – even when it’s taken inappropriately, says Dr. Kishore.

Students are more likely to take a single Adderall pill than drink 10 cups of coffee because, at least in the short term, it’s “longer acting and has fewer side effects than caffeine,” says Dr. Goldstein. “When used appropriately, it lasts an entire day.”

For 22-year-old Ben, it helped him concentrate for hours on end at the University of Michigan, his alma mater. Ben (not his real name) restricted his Adderall use to study periods.

After about 20 minutes, the drug would kick in. He says that the ability to concentrate intensely “helped time pass by better. I could read for four hours straight without looking up at the clock.”

When Ben describes the widespread use of Adderall at his alma matter, he said many students retained prescriptions from when they were young even though they no longer used the drug themselves. Some had stopped taking Adderall because of headaches or other side effects, yet were willing to going on supplying it to others, either to “help a friend in a crunch,” as Ben puts it, or to make some quick cash.

At Ann Arbor, blue pills (10 milligrams) normally sold for $3, and orange pills (20 milligrams) for $5, says Ben. Prices rose as demand exceeded supply during midterms and finals.

Ben, an English major, would frequently take the drug with his peers during study groups in the library. They also met afterward to share a joint to alleviate the inevitable side effects, which include restlessness, dizziness, and insomnia.

Kishore has counseled a number of such clusters – small groups of friends who have taken Adderall together, and become dependent on it together.

Overcoming the dependency is tough, Kishore says, especially for students who were using Adderall specifically to help them stay up to study and who need to learn to approach their studies in a new way. Treatment is normally done on an outpatient basis and involves teaching new coping behaviors and techniques.

Some also hope a new version of the drug could help reduce its misuse among younger students.

In 2001, Shire Pharmaceuticals, the maker of Adderall, introduced Adderall XR, a time-release version. The new version was developed primarily as a convenience, the company says. But because it is taken as a single daily dose, children don’t need to bring it to school, thus minimizing “any potential misuse or inappropriate transferring of medicine to individuals without a prescription.”

But some experts say that Adderall abuse is still not being taken seriously enough by many parents and adults.

Widespread toleration of Adderall misuse is similar to the blind eye too many adults cast on teenage drinking in the 1980s, says Goldstein.

“People didn’t pay attention or take it seriously, before groups like MADD,” he says. “[Minors drinking] isn’t just bad because they’re underage, it’s dangerous. If somebody gets in a car, they can injure others and themselves. It’s similar to being a parent throwing a party with kids drinking, only to find out you’re responsible for the car crash that happens later on.”

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May 25, 2004
THE CONSUMER
How to Stop Depression Medications: Very Slowly
By MARY DUENWALD

Now that the Food and Drug Administration has warned Americans taking antidepressants to be on the lookout for potentially harmful side effects, including severe restlessness and suicidal thinking, some people may end up stopping the drugs. But going off antidepressants can bring its own problems.

Stopping cold turkey can cause an array of troublesome symptoms, the most common being dizziness, which can last for days on end. Flu-like feelings, including nausea, headache and fatigue, are also common, as are intense feelings of anxiety, irritability or sadness. Some patients experience alarming sensations of tingling or burning in various parts of the body; ringing in the ears; blurred vision; or flashing lights before the eyes. Some people even describe a feeling of shock waves pulsing through their arms and legs, as if they had been zapped with a jolt of electricity, a condition sometimes called lightning-bolt syndrome.

“The feeling can be really abrupt, like a quick jerk of the muscle,” said Dr. Richard C. Shelton, a professor of psychiatry at Vanderbilt University. “It’s not painful, but it can be very frightening to people.”

Internet bulletin boards and Web sites devoted to antidepressant withdrawal chronicle the crying spells, vertigo and nightmares that people sometimes experience.

“I feel like my brain is floating in Jell-O, slamming into the sides of my skull every time I move my head or my eyes,” one person wrote.

Another described palpitations, night sweats and “bloody hideous nightmares.”

To avoid such symptoms, or at least hold them to a minimum, the drugs need to be tapered gradually in most cases, and that means quitting under a doctor’s supervision. Psychiatrists say it is unwise for people who are taking antidepressants simply to quit on their own.

In its warning, issued in March, the F.D.A. urged doctors to closely monitor patients taking antidepressants, especially during the first weeks of therapy or when changing dosage. Signs of trouble, the agency said, could include suicidal thoughts, severe restlessness, anxiety, hostility or insomnia. Though an association between antidepressants and suicidal thinking or behavior has not been proved, unpublished studies suggesting the possibility of such a link in children and adolescents have caused concern. The F.D.A. is still investigating the issue.

The drugs most likely to produce withdrawal symptoms act on the brain chemical serotonin. These drugs work by blocking the action of a protein in the brain that normally transports serotonin out of the synapses, the spaces between brain cells. With the transporter protein blocked, serotonin lingers in the synapses, and that can have a positive effect on mood.

When the drug is taken away, there is suddenly less serotonin in the synapses. Serotonin receptors in the brain, accustomed to a larger supply of the neurotransmitter, may take days or weeks to adjust, said Dr. Ephrain C. Azmitia, a psychopharmacologist at New York University.

“You get a precipitous drop in all the things that serotonin does in the brain, including its effects on appetite, sleep, sensory perception and emotions,” Dr. Shelton said.

Not everyone experiences withdrawal symptoms. Studies suggest that only 10 to 20 percent of patients have significant problems, said Dr. Jerrold F. Rosenbaum, chief of psychiatry at Massachusetts General Hospital in Boston. And some patients find the effects less intense or bothersome than others.

Doctors say people who have been taking especially large doses of a drug for many years may be somewhat more vulnerable. Which drug a patient is taking also makes a difference. Some are stronger than others, and some are metabolized by the body more quickly.

The longer a drug’s half-life – the time it takes for half the amount of drug in the body to be eliminated – the less likely it is to cause withdrawal problems. Eli Lilly’s Prozac, for example, has a long half-life, remaining in the body for days or even weeks after someone stops taking it. As a result, people who take it are less likely to experience withdrawal effects.

“With Prozac, it can take six weeks for any symptoms to occur,” Dr. Rosenbaum said, and even then the effects are mild, with about 5 to 6 percent of people experiencing mild dizziness.

GlaxoSmithKline’s Paxil, on the other hand, generally leaves the body in a day or two. Effexor, made by Wyeth, disappears faster still.

“When you look at these drugs with a very short half-life, almost everybody who quits abruptly experiences at least some symptoms, some dizziness,” Dr. Shelton said. “And about half of people have more significant symptoms.”

For this reason, psychiatrists advise patients taking antidepressants to avoid skipping doses. People who take Paxil or Effexor sometimes experience withdrawal symptoms when they forget to take their pill for a day or two.

“With Effexor, if you miss your morning dose, you can be in withdrawal by the afternoon,” said Dr. Joseph P. Glenmullen, a psychiatrist at Harvard and the author of “Prozac Backlash.”

Zoloft, made by Pfizer, is somewhere in the middle – more likely than Prozac to cause withdrawal symptoms, but much less likely to do so than Paxil and Effexor. Celexa and Lexapro, antidepressants that are made by Forrest Laboratories and that act on serotonin, are also somewhere in the intermediate range, Dr. Rosenbaum said.

Cymbalta, a new antidepressant from Lilly that is expected to win F.D.A. approval later this year, will probably also fall in the middle, he said.

Wellbutrin, an antidepressant also marketed as Zyban, does not work directly on serotonin in the brain. As a result, doctors say, the drug, made by GlaxoSmithKline, does not seem to cause withdrawal symptoms when patients stop taking it.

The withdrawal symptoms do not mean that antidepressants are addictive, experts say. People who are coming off the drug do not crave it, as addicts might crave heroin or cocaine, and they do not seek higher and higher doses over time.

“There’s a lot of misperception about that,” said Dr. Alan F. Schatzberg, a psychopharmacologist who is chairman of psychiatry at Stanford University School of Medicine.

For that reason, many doctors describe the effects produced by stopping antidepressants as a “discontinuation syndrome” rather than as withdrawal.

Yet the symptoms can be troublesome enough to prompt some patients to go back on their medications.

To help patients stop taking an antidepressant, most doctors use a strategy of gradually tapering the drug over time. With Prozac, stepping down the dosage for a week to 10 days may be enough to get patients off it comfortably, Dr. Shelton said.

With Paxil or Effexor, on the other hand, the process may take many weeks or months. Dr. Shelton said he often brings his patients down from the drugs in five-milligram increments, with each stage lasting from five days to a week. A person taking 50 milligrams of Paxil, for example, would be advised to go down to 45 milligrams for one week, then step down to 40 milligrams, and so on.

The riskiest period, Dr. Schatzberg said, comes at the end, when even small increments of tapering can have a big impact on serotonin.

“The taper at the bottom end often needs to go slower than it does at the top end,” Dr. Schatzberg said.

For people who are having difficulty withdrawing from Paxil or Effexor, doctors sometimes prescribe a three-day dose of Prozac toward the end of the withdrawal period. With its longer half-life, Prozac can ensure that serotonin levels readjust more gradually.

Even when patients are entirely off the drugs, they may still experience some symptoms, but usually only for a few days and rarely for more than two weeks, doctors say.

Sadness and anxiety that persist longer than that may be signs that a patient is experiencing a return of the depression. So it is important to distinguish withdrawal from a relapse of illness.

“Just because you’re stopping a drug,” Dr. Rosenbaum said, “doesn’t mean you don’t need it.”