Professionalism/Adderall in Academics

Background
Adderall is a prescription stimulant that is used to treat fatigue, attention deficit hyperactivity disorder (ADHD), attention deficit disorder (ADD), and narcolepsy. The drug is an amphetamine, a class of drug that stimulates a person’s nervous system by increasing the release of dopamine. The release of dopamine increases alertness and impulsiveness, thus decreasing inattentiveness. The United States Drug Enforcement Agency (DEA) classifies substances into five schedules based on the drug's medical use and dependency potential with Schedule I as the most dangerous. Schedule I drugs, such as heroin and LSD, are considered the most dangerous because they have no current medical use and have the highest potential for abuse. Adderall is a Schedule II drug, which indicates a current medical use but with a high potential for abuse.

Some of the negative side effects of taking Adderall include loss of appetite, headaches, difficulty sleeping, disrupted heart rhythm, increased blood pressure, long term cardiovascular problems, and strokes. Taking Adderall for prolonged periods may cause withdrawal effects such as fatigue, disorientation, and depression.

Adderall in Universities
During his commencement speech to the University of Virginia class of 2013, comedian Stephen Colbert recited the school's honor pledge with a slight modification: “On my honor, I pledge that I have neither given nor received help on this assignment…so help me Adderall.” This was a reference to the growing trend in the unprescribed use of Adderall on college campuses. A 2011 national Monitoring the Future study reports: “1 in every 10 college students in the United States has engaged in non-medical use of prescription stimulants in the past year.” This number has been increasing with time. Although purchasing or taking Adderall without a prescription is illegal, many students feel as though it is the only option when faced with continuing academic rigors. A 2012 survey from the American College Health Association revealed that 80% of college students have felt overwhelmed by all they had to do in the past year and 45% have felt things were hopeless. These students take various measures to handle the workload of their courses and in order to meet their expectations for success. Many students have turned to Adderall for assistance because it increases concentration and allows them to focus on their work with no distractions, including the need to eat or sleep. Jared Gabay a senior at Auburn University explains the appeal of using the study drug: "I'm more driven. I don't focus on anything else. If I have a paper, that's all I'm doing. No distractions, no socializing, just on with it." He adds that he used to get C's in his classes but with the help of Adderall his grades have improved to A's and B's.

Based on the 2015 National College Health Assessment at the University of Wisconsin, 7.9% of the population reported the use of stimulants with a prescription, being a commonplace at the university and part of student culture. Once finals roll through, many scavenge for the use of Adderall illegally from others who are prescribed the drugs in hopes to do well in exams. Student have been trained to think "hard work and incredibly impressive resumes" leads them to "happiness" which is what the "American Dream is all about". Being the best leads to the high pressure culture of competition between students. Of the students who use Adderall on a recreational basis, 89.5% of students report the involvement in binge drinking and are three to eight times more likely to use marijuana and prescription tranquilizers. The reasons for increased Adderall abuse in universities are the higher diagnoses rates in the past year resulting in higher rates of manufacturing and prescriptions, overprescription, lack of education about contraindications, and the ease of "illicit distribution channels among peers".

Academic Pressure
The term “Academic Doping" was coined to describe the use of stimulants to achieve academic excellence. Usage ranges from active participation to last resort study tactics. Due to immense academic pressures in the university setting, they have become ubiquitous. An economics major from Columbia University says, “If you don't take them, you'll be at a disadvantage to everyone else." Because Adderall usage is so widespread, it not perceived as cheating or even an unfair advantage by many students. A 2011 graduate of Indiana University - Purdue University Indianapolis said: “Adderall was a better option than failing and a better option than actually cheating — the traditional type of cheating." In his research on Adderall at the University of Kentucky, DeSantis discovered reoccurring themes in how students justified their use of Adderall. He found that they often compare Adderall to “party drugs” such as cocaine and marijuana. Since they are using it to perform better in school rather than to get high or buzzed, they believe that the use of Adderall is morally justifiable. One student in the study commented: “Adderall is definitely not a drug. No way. It is a study tool. You don’t get high or anything like that. I take it to do good in school. How can that be bad?”

Moral Obligation
Another perspective supporting the use of Adderall in academics stems from a more philosophical root. According to these pro-Adderall participants, Adderall not only shouldn't be considered cheating, but it also should be used to enhance academic performance. “There is a moral obligation to enhance our capacities for reason, intelligence, and self-control," says James Hughes, the Trinity College director of Institutional Research and Planning. This perspective purports that use of performance-enhancing drugs is a moral obligation of humans as it improves our cognitive capabilities. Henry Greely of Stanford Law School echoes this thought: "We should welcome new methods of improving our brain function...Safe and effective cognitive enhancers will benefit both the individual and society." This opinion maintains that all safe, performance-enhancing methods are positive and ethically sound.

Unsafe Practice
Just because Adderall can be taken safely, does not mean users fully understand the risks. Despite FDA warnings, many users believe that it is not addictive and that it cannot “ruin your life like coke or other drugs like it.” However, users can grow dependent on Adderall. Once users understand the effects, increased procrastination or unhealthy work habits can compensate for the boost in motivation and concentration. In some cases, users become addicted, unable to focus without medication. To combat this, a student group at the University of Colorado at Boulder started a campaign to bring awareness to some of the unexpected consequences associated with abusing Adderall. The campaign consists of a series of memes, or cartoons, printed on cards and distributed around campus. Each meme featured an exasperated cartoon student who has discovered a negative side effect of Adderall with a "#AdderallProblems" caption. Examples included "Sat down at night to crank out a ten-page paper. Ten hours later, I'd color-coded my sock drawer...twice #AdderallProblems", "Stayed up all night studying, slept through the test #AdderallProblems" and "Yelling at yourself to stop talking to yourself #AdderallProblems."

Unfair Advantage
Adderall usage is not seen as conventional cheating, like plagiarism or copying a test. However, if it results in improved performance, even in the short run, it can be seen as a form of cheating. One student from the University of Texas at Austin saw it as "outside aid that wasn't approved for," ultimately "putting somebody else at a disadvantage." Adderall and Ritalin can only be obtained through a prescription and to purchase the drug through illegal means requires connections and money. Furthermore, students that have conditions such as ADHD and Narcolepsy who require these drugs for treatment, feel as though it is a misuse of the prescription. "Adderall allows those students who are given a disadvantage by this disease to keep up and be on the same level academically as those who do not have ADHD." Students are not the only ones who feel as though unprescribed use of Adderall and Ritalin is unfair. Some universities have recognized the use of these study drugs as an honor code violation. In 2010, Wesleyan University decided to add an "Adderall Clause" to their honor code, which states that students must complete their work without "improper assistance", which includes prescription drugs in the definition.

Depression from Adderall
Adderall is used to treat people with ADHD or narcolepsy, which affects certain brain neurotransmitters including dopamine, norepinephrine, and serotonin to reduce symptoms of hyperactivity and improve focus and concentration. For people who don't have these diseases can experience a high, sensing euphoria, energy, increased focus and concentration, and a boost of self-confidence, being the most commonly abused drug. Once the Adderall wears off, it can cause symptoms of withdrawal or a "crash" including sleep problems, sluggishness, anxiety, irritability, panic attacks, and depression. Being a stimulant, it can cause mood disorders when off it since it changes the chemistry of the brain and is a stimulant of the central nervous system. Withdrawal symptoms tend to be more severe for those who abuse the use of Adderall and take it in very high doses.

Students who are correctly diagnosed with ADHD even with the right dosage have a high risk for developing a major depressive disorder. This may be related to the long-term problems from early in life - having trouble in school, with parents and peers, and developing a low self-esteem. The pressures of school and competition are some of the main contributors including the notion of being the model student in school. Among the students who are diagnosed with ADHD from ages 2 -17, 2 out of 3 have at least one other mental, emotional, or behavioral disorder, 1 out of 3 have anxiety, and 17% with depression. Adderall in effect with other antidepressants are considered as a potential treatments for depression to counteract the effects of withdrawal from Adderall. This is only for severe cases and not "standard" depression since it can be an addiction potential, the effects of the antidepressant fades quickly, there's an increased dependency and tolerance, and it can worsen the depression experienced in withdrawal.

Adderall and Professionalism
In the 1970s, psychologist Mihaly Csikszentmihalyi began to explore the idea of a state of complete and effortless focus and attention. He called this state "flow" and described it as a "single-minded immersion" where a person is both highly challenged and highly skilled in the activity they are doing. Csikszentmihalyi argued that those who often experience "flow" in their lives will be the happiest. This feels dissimilar to the immersion of an Adderall user. Adderall induces this immersion artificially, and this immersion is not necessarily driven by some combination of challenge and skill. Instead, it is driven by a deadline.

The Ends Justify the Means
Ignoring the legal aspect of Adderall usage, it difficult to determine whether it is ethical. It is possible that medicinal augmentation is the future of human cognition, but Adderall users appear to have something in common.They want to perform at a more efficient rate. If this is the primary motivation is to finish the current task, then a deeper understanding of self and one's connection to the world may be superfluous. Professor Michael Bishop, Chair of Iowa State University's Department of Philosophy and Religion, states: this "perverts the central mission of a university," because a quality education is so much more than the "temporary acquisition of facts," the "ability to solve problems," or to "articulate views." The questions in the professional world are not answered in the form of multiple choice or short answer essays. The professional world requires judgment, "a critical examination of the assumptions that guide one's life,"and one must be weary when dealing with things that appear both convenient and sustainable.

Over-Diagnoses
With debate of whether ADHD is considered as a "real disease", it is agreed widely that it is over-diagnosed significantly. Medications are not always the best or only option. According to a study in 2010 in the Journal of Health Economics, the youngest of kindergartners were 40% more likely to be diagnosed and twice as likely to take ADHD medications than older students. Physicians making diagnoses for children in early stages of development, thus not distinguishing between normal development immaturity and ADHD. Many doctor visits last 15 to 20 minutes, resulting in a diagnosis without thorough history and examination of the child's case. There is no standardized clinical test to diagnose adequately but rather physicians only ask questions such as "Do you get distracted easily?" or "Is it hard for you to concentrate on one task?" Being distracted from video games or other electronic devices are linked to typical behavior of children with ADHD, which can be fixed with a choice of taking action rather than a pill. Not only is it over-diagnosed, but it is over-prescribed, giving large amounts of dosage which can cause unusual behaviors and addiction.

Over-Prescription
A possibility of the over-prescription of drugs may be from the inadequate training physicians receive while in medical school, residency or continuing medical education. In a survey conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, 57% of doctors believe in the responsibility of preventing prescription drug diversion and abuse, yet only one third of physicians rated the training as adequate. Meaning two out of three physicians currently in practice lack the knowledge and skills to diagnose addictive drugs. The surplus from over-prescription can result in the dealing of Adderall among students illicitly, leading to substance abuse. More than 20% get access through family members or classmates and only 14.8% retrieve from drug dealers but the most common way of attaining prescription drugs for ADHD is through friends who are diagnosed with ADHD at 63%.

Adderall in the Workplace
The gamut of performance enhancing methods in any discipline lie on a spectrum of cheating, from well-accepted practices to serious, punishable cheating. Adderall use's place on the spectrum of academic performance enhancement lies between these extremes and is constantly changing.Students that regularly abuse Adderall in College are continuing their practices in the workforce. The pressure to constantly meet deadlines and fear of job loss enables employees to find methods to stay awake longer and focus more. Because of this, abuse and emergency room visits associated with Adderall have risen dramatically in newly graduated employees.

Misuse in Professional Environments
In an article titled "Workers Seeking Productivity in a Pill Are Abusing A.D.H.D. Drugs", New York Times writer Alan Schwarz reported on the growing trend of stimulant abuse in the workplace. Through interviews, Schwarz found that many of the users cite professional pressure to excel and surpass expectations.

An estimated 4% of the U.S. adult population has diagnosed symptoms of ADHD such as inattention, hyperfocus, and disorganization. Many of these adults are receiving prescriptions for stimulants to combat these symptoms. QuintilesIMS reported that in 2012 roughly 16 million Adderall prescriptions were written for adults between ages 20 and 39. According to ExpressScripts, within that group the largest increase in prescriptions from 2008 to 2012 was in the young professional group aged 26 to 34 which almost doubled to 640,000 from 340,000. These users cite the benefit of Adderall in increasing alertness and preventing fatigue. In one of Schwarz's interview with a dentist in eastern Pennsylvania, the dentist prescribed herself Adderall and other stimulants because she could see 15 patients a day rather than 12.

These benefits come with serious risks as Adderall can cause withdrawal symptoms and affect judgement when combined with fatigue. The health and safety implications of Adderall misuse have motivated organizations like the Federal Aviation Administration to forbid pilots to use amphetamines under any circumstances. While traditional drug screenings catch amphetamine abuse, these screenings may happen once in an employee's hiring process and then never again.

Adderall in Sports
Adderall is also used for athletic performance enhancement. Its perception in the sporting can further help explain its use in academics. Professional athletes use Adderall to improve focus. Because of this, Adderall is regulated as a performance enhancing drug by major US sports leagues. The NBA, MLB, NFL, NCAA, and MLS have all banned Adderall use without a prescription. In the NHL even use with a prescription is prohibited. Still, pressure to perform drives athletes to abuse such stimulants.

National Football League (NFL)
The NFL has handed out a significant number of Adderall related suspensions. In 2012, of 19 players suspended for failed drug test, 8 were linked to Adderall use. However, because NFL confidentiality policy prohibits the discussion of drug test results, players are free to blame any failed test on Adderall. In sports, where Adderall is less stigmatized than steroids or hard drugs, athletes failing tests are inclined to make the "Adderall Excuse." Stimulants remain less stigmatized as the impact of the advantage they provide is debated. Cleveland Clinic sports medicine physician Rick Figler says the advantage is tangible, as "...it parlays into an increased ability to work out harder; or if they're going through testing to perform testing better; if they're studying a playbook to memorize the playbook." NFL Players have also weighed in. Cornerback Richard Sherman was quoted claiming that half the league uses Adderall, and that the league has to allow it. Sherman later denied the statement, saying he was misquoted. Retired NFL punter Pat McAfee tweeted on February 3, 2017: "First day of retirement I tried adderal for my first time... completely understand why it's considered a PED in the league.. #Limitless."

Major League Baseball (MLB)
Major League Baseball faces its own Adderall problem. Baseball not only requires significant focus on both sides of the game, but also demands constant play and frequent travel from its athletes. Stimulants promise to help them stay focused and alert, even when faced with a packed schedule and tiring road trips. While it's estimated that just 4.4% of the population suffers from ADHD or another condition that warrants stimulant treatment, 9.9% of active MLB players in 2013 had a prescription. In 2014, 9.3% had such prescriptions, and still 8 players were suspended for using Adderall without a prescription. While steroids have long held the PED spotlight in the MLB, stimulants are commanding growing attention.

E-Sports
The effects of Adderall have made it a popular for competitive esports, allowing players to stay awake longer for more practice time, and increased their hand-eye coordination and focus. Competitive gamers have been public about using Adderall to improve their sense of awareness. Kory "SEMPHIS" Friesen, a professional Counter Strike: Global Offensive player, admitted during an interview that him and his team were "all on Adderall" during a Counter-Strike: Global Offensive tournament in 2015. The ESL have collaborated with the Nationale Anti Doping Agentur to enforce anti-performance enhancing drug policy in order to maintain a spirit of fair play within esports. However, there is debate regarding how much effort is really going into enforcing players to not take unprescribed Adderall. Some players accuse esport competition holders of ignoring Adderall abuse in order to prevent negative press. Professional Halo 3 player Alex Buck said "Imagine if Halo and other esports titles actually prohibited the use of adderall and similar substances at events and didn't turn a blind eye to it." Esports' revenue has increased 38% from 2017 to 2018, and is expected to increase by 48% in 2018. The risk of adding policies that could prevent popular players from competing may be preventing companies from taking a harder stance on Adderall abuse in esports.

Analogy: Steroids in Sports
Anabolic steroid use in the sports world is analogous and can help explain why Adderall use exists in such gray area. There are socially acceptable performance supplementing substances such as engineered supplements or drinks, such as Gatorade. There is also conventional cheating, such as bribing judges or referees. However, anabolic steroids lie somewhere in between, similar to Adderall. Both steroids and Adderall are drugs with serious potential health consequences, but are used under pressure to succeed to achieve greater performance. Both substances can be used legally with a valid prescription, but use of both is prohibited for performance enhancement. Just as steroids do not make athletes stronger without work, Adderall does not ensure better grades for students. While large sports organizations have officially banned the use of steroids, Adderall presents a new issue for sports organizations, academic communities, and the professional environment.

Adderall in the Military
The military has used amphetamines since World War II to help soldiers fight fatigue and increase focus. The military’s annual spending on stimulants increased to $39 million in 2010, up from the $7.5 million spent in 2001, and over a five-year period Adderall and Ritalin prescriptions written for service members increased from 3,000 to 32,000. In an anonymous survey of fighter pilots, 61% who used stimulants reported them "essential to mission accomplishment", as some squadrons spend thirteen to fourteen hours airborne in a given 24-hour period. Ironically, the military will not accept new recruits who have used ADHD medication within the past year.

Adderall and PTSD
In 2012, the New York Times contended that the rising number of post-traumatic stress disorder (PTSD) cases could in part stem from stimulant usage. Both stimulants and emotional experiences trigger the release of norepinephrine, which helps form long-lasting memories. This explains why people are more likely to remember emotionally arousing events. Because PTSD involves the recollection of a traumatic event, it is possible that stimulants can exacerbate the disorder. Studies suggest that increased norepinephrine levels lead to a higher risk of relapse when reexposed to stressors. Additionally, a study conducted at Harvard showed beta blockers, which weaken the effects of norepinephrine, lessen the symptoms of PTSD in patients compared to placebo treatment. Active-duty service members must remain sharp, but stimulant usage may subject soldiers to dangerous long-term health complications.

Ethics of Adderall Production
When Shire Pharmaceuticals introduced Adderall in the 1990s, the drug came into favor with students, laborers, and the military. Demand grew, but in the early nineties, the Drug Enforcement Administration (DEA) allowed for less than 500 kg of amphetamine to be commercially produced each year. To avoid shortages of stimulants, Congress voted to increase the quota annually. Votes may have been swayed by corporations like Shire, who, in 2017, spent over $3 million lobbying. By 2017, the amount of amphetamine approved for annual production was 42,400 kg. A possible cause of the increasing demand for stimulants is the overdiagnosis of ADHD in children and adolescents, leading to the overprescription of Adderall and other stimulants. 75% of children with ADHD aged 2-5 receive drugs as treatment, whereas only half receive behavioral therapy, and in 2016, the Centers for Disease Control warned that doctors may be overprescribing medication to this younger demographic. Meanwhile, prescriptions stimulant sales in 2012 were reported at $9 billion in the US alone, five times what they were a decade earlier.

In 2014, Shire Pharmaceuticals was fined $56.5 million for violating the False Claims Act. They had stated that Adderall “normalizes” children with ADHD, among other claims not supported by clinical research. Shire was fined again in 2017 in violation of the False Claims Act for $350 million. The False Claims Act allows patients and health care providers to make informed treatment decisions, yet Shire continues to prioritize their economic interests. Recently, Shire partnered with celebrity spokespeople to spread public awareness of adult ADHD, an attempt to capitalize on a growing market. The effectiveness of ADHD treatment with Adderall cannot be denied, but the intentions of Shire Pharmaceuticals are called into question.