You Can't Be an Alcoholic If You're in College, Right?

Have you heard this one before? It's not uncommon to find it on the lips of college students. For some it's almost a rallying cry.

The sheer prevalence of binge drinking and the youth of college drinkers can mislead students into thinking that heavy drinking is just a college thing, a rite of passage that they'll mature out of, and that it therefore poses little risk to them in the short or long term.

For many students that may be true. But some students won't outgrow their dangerous drinking habits, while others are already suffering the negative consequences of excessive drinking.

Young Adults and Alcohol Dependency

Contrary to college lore, there is no minimum age for alcoholism. Sadly, many young adults do meet the criteria for alcohol dependency and abuse. A 2002 study found that 31% of college students abused alcohol and 6% could be diagnosed with alcohol dependency.

A 2007 study identified five "subtypes" of alcohol dependency: young adult, young antisocial, intermediate familial, functional, and chronic severe. Only the chronic severe abusers fit into popular stereotypes of what most of us associate with alcohol abuse, yet they are the smallest percentage of problem drinkers.

Shockingly, young adults made up the largest subtype (31.5%), according to the study. They are also the least likely to seek help for their drinking.

In an interview with Psychiatric News, the researchers themselves expressed surprise with their finding "that so many of the individuals who met diagnostic criteria for alcohol dependence were young adults [in their early 20s]."

Young adult drinkers drank less frequently than other subtypes, but when they drank, they tended to binge (73% of the time). Since over a third of young adult drinkers are still in school, the researchers suggested that "they may be an unrecognized part of the college drinking problem."

More recently, the American Psychiatric Association (APA) has changed how they define substance use disorder.

Previously, the APA treated substance abuse and dependency as an either/or scenario: either you had a problem or you didn't. In contrast, the newest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) treats substance use disorders on a continuum from mild or moderate to severe.

As Dr. Charles O'Brien explained, "In DS- 4, we had essentially two diagnoses: one was abuse and the other, dependence...By doing a lot of research, we've discovered addiction doesn't work that way. It starts off mild at the beginning and becomes gradually more severe."

There was some controversy over the new standards. Critics claimed as many as 40% of college students could end up being labelled as alcoholics if the DSM 5's new diagnoses are followed.

This increase in diagnoses, critics argued, could do more harm than good. Rather than encouraging students to seek help, the diagnosis might lock them into the identity of an alcoholic or addict, causing them to act and think accordingly.

"And that poses a huge problem," wrote Maia Szalavitz for Time,  "particularly for adolescents and young adults with mild problems who may be pushed to adopt an addict identity and to see themselves as having no way to control their drinking or drug use if they ever 'relapse'. Rather than empowering those who do have control to use it, these programs essentially tell kids that if they ever have just one drink or puff on a joint, they’re lost."

But if telling students that they're problem drinkers doesn't work, then what other solutions are available?

Drinking Problem versus Problems with Drinking

Some researchers have suggested another approach that avoids the labels associated with substance use disorders. The Harvard School of Public Health, for example, has recently released a series of books that addresses the grey area between normal and problem drinking.

The series is called the "almost effect" and discusses circumstances where individuals may experience negative consequences from their drinking, such as poor sleep, depression, a drop off in work performance, or relationship troubles, but may not qualify for a formal diagnosis of alcohol dependency. They call these individuals "almost alcoholics."

Though they may not be formally diagnosed for a substance use disorder, they may nonetheless benefit from counseling or a brief intervention in order to help them see the connection between their drinking and its consequences.

Dr. Joseph Nowinski, one of the series' authors, explains that the decision that your drinking is a problem "does not imply that you admit to having a 'diagnosis', or that you are 'mentally ill'. Rather, it simply means that you have decided to make some changes in your lifestyle in the interest of your overall health."

In other words, perhaps the problem isn't that students think you can't be an alcoholic in college, but that they're thinking in terms of alcoholic or not alcoholic. Such binary thinking prevents them from seeing how their drinking is beginning to cause them problems and from doing something about it. Even if it's not an official diagnosis and even if it doesn't lead to problems later in life, college drinking can still be a problem now.

Why Are Students So Unhealthy during Finals Week?

It's that time of the year: the trees are all bare, a coat of frost shines on the sidewalk, the smell of  anxietys hangs in the air, and sleep-deprived students lumber around campus unshowered and unshaven. Ah, finals season!

Most of us intuitively understand that stress is connected to students' failure to fulfill even the most basic self-care during finals, but why? After all, students usually don't have class or other commitments during finals week, so they should be able to focus exclusively on studying without ignoring the basics like brushing their teeth and getting enough to eat.

Indeed, one might think that faced with the intense pressure of finals, students would renew their focus and effort. In fact, research suggests otherwise, demonstrating how stress alters the way we make decisions.

When stressed out we tend to focus on short-term rewards and pleasurable outcomes of a decision while ignoring the less savory and long-term consequences. That's why it's so hard to resist eating that pint of ice cream in your freezer after a tough day or to forgo buying that new pair of shoes you covet but can't afford after a miserable meeting at the office.

In other words, it is exactly because students have to study for five finals that a friend's invitation to party tempts them so much. The stress causes them to focus on the immediate reward of going to the party (socializing and drinking) and not the downside of losing a night's sleep to late night carousing (hang over and poor grades).

Stress also makes it more difficult for students to connect bad decisions to their consequences. Even if students go out the night before a test, stress will help them remember the pleasurable experience of socializing and drinking and forget the fact that they were horribly hung over for the exam. This is one reason why researchers also link stress to substance abuse and addiction. Under stress, you focus on the pleasures of the drug and lose sight of the negative consequences.

Am I saying that stress makes us short-sighted and irresponsible? Not quite. Another recent study shows that under stress some people are actually more likely to sacrifice their time to help someone they care about. The research supports the uplifting hypothesis that humankind's default setting is to self-sacrifice (when it comes to close relationships). This is well and good for our species, but it also explains why some harried students take on big social commitments during finals week when they should be making more time for themselves.

All this rather paradoxically suggests that exactly when we need to buckle down and get the most done, we have the fewest cognitive resources to do so because stress saps our willpower. Given this fact, a nudge in the right direction might help students keep their cool and improve their grades.

A few common tips worth reminding students about:

Exercise (like walking) has long been touted as an important stress reliever and memory aid. Recent studies suggest that regular exercise also boosts creativity.

Mindfulness and meditation are also good ways to decompress and still the turbulent waters of daily life.

Also remind students to wait until after finals to make big decisions. The simple act of waiting can help students make better, more reflective choices.

Court Rejects Ban on Alcohol Advertising in College Papers

Until the U.S. Court of Appeals for the Fourth Circuit's recent decision limited its reach, the Virginia Alcoholic Beverage Control Board's (ABC) regulations banned all college newspapers from running alcohol advertising. The ban is part of a comprehensive strategy aimed at reducing underage drinking.

Many colleges and universities take a similar "environmental" or "community-level" approach to combat high-risk drinking. These interventions often enlist retailers and advertisers as allies in prevention efforts. 

But in 2006 two college newspapers affected by the regulation, The University of Virginia's Cavalier Daily and Virginia Tech's Collegiate Daily, sued the ABC, claiming the ban violated their First Amendment free speech rights.

The newspapers pointed out that a majority of their readership were over 21 (59-60% of the Collegiate Times' and 64% of The Cavalier Daily's readers). Therefore, while Virginia had a government interest in preventing underage drinking, the papers' wide distribution to people over 21 meant that the scope of the regulation was too broad.

In its decision, the Court sided with the college newspapers, acknowledging the state's interest but rejecting the regulation's overbroad reach.

"While commercial speech is protected by the First Amendment, there is a 'commonsense distinction' between commercial speech and other varieties of speech...[therefore] a regulation of commercial speech will be upheld if (1) the regulated speech concerns lawful activity and is not misleading; (2) the regulation is supported by a substantial government interest; (3) the regulation directly advances that interest; and (4) the regulation is not more extensive than necessary to serve the government’s interest."

Under this analysis, the Court concluded, "the challenged regulation fails...because it prohibits large numbers of adults who are 21 years of age or older from receiving truthful information about a product that they are legally allowed to consume...Accordingly, the challenged regulation is unconstitutionally overbroad."

The court also rejected the ABC's rejoinder that the regulation was justified by the state's more general interest in combatting abusive drinking, whether by underage or of-age drinkers. The Court cited a previous case that determined "states may not 'seek to remove a popular but disfavored product from the marketplace by prohibiting truthful, non-misleading advertisements.'"

The ruling, however, did not overturn the regulation itself. It only rejected the regulation as applied to these four-year college newspapers. As commentators have pointed out, where a paper's underage readership is the majority of its readership, the ban might still apply. A paper at two-year college, for instance, might still be subject to the regulation.

Critics of the ban have lauded the decision as a victory for free speech. Indeed, because school papers operate under tight budgets, the ban had a significant impact on the papers' finances and thus affected their primary mission of news reporting. According to estimates in The Cavalier Daily, lifting the prohibition would raise advertising revenue by 5 to 8%.

And while harm-reduction specialists may lament the loss of another valuable tool, the research is still divided on the effects of advertising on alcohol consumption. 

Study Drug and Party Aid: Prescription Stimulant Abuse on College Campuses

In June 2007, freshman Johnny Edwards went to Harvard University's Health Services clinic complaining about trouble concentrating and studying. A nurse practitioner diagnosed him as suffering from attention deficit and hyperactivity disorder (ADHD) and prescribed Adderall, a stimulant. Six months later Edwards killed himself.

Edwards's father is now suing Harvard for wrongful death, alleging that the diagnosis of ADHD and the Adderall prescription did not meet medical standards.

For two years, Richard Fee struggled with an addiction to Adderall that doctors prescribed him to treat attention ADHD. He had been in an out of psychiatric care, and kicked out of his house by his parents who feared his violent outbursts.

Fee had been introduced to Adderall in college as study aid, only obtaining a prescription for himself after he graduated to help him with medical school applications.

In late 2011, Fee hanged himself in his bedroom closet. His mother found the body.

These tragic cases highlight the dangers of prescription stimulants.

Like Fee and Edwards, many young people are first introduced to these drugs in college. And like Fee, many students' first experience with the drug is not under a doctor's order but under academic pressure. Unlike Fee and Edwards, many students obtain the drugs illegally.

Because of their widespread abuse and potentially dire consequences, schools need to develop policies that directly address the use of prescription stimulants on campus.

 

"I Feel Like a Genius on It"

Students who don't have a legitimate medical need often take stimulants to get a leg up academically. Though untested on individuals without ADHD, students claim prescription drugs like Adderall and Ritalin help them concentrate, study longer, or simply stay up later to finish a project. They usually take the drugs during finals week or other times of "high academic stress."[1]

"Adderall has become to college what steroids are to baseball," explains Roger Cohen in a NY Times column, "an illicit performance enhancer for a fiercely competitive environment."

In one study, students described the drugs' effects glowingly. "I get everything done, quickly. I am crazy on it that way," said one student. Another insisted he was "so much more productive...It's just a different level on Adderall." For other students "stuff just registers better" or "I grasp everything so much easier...I feel like a genius on it."[2]

Given these drugs' reputations as academic miracle workers, it's unsurprising that college students are more likely than their non-college peers to have abused prescription stimulants.[3] The estimates vary, but studies have found as many as 34% of college students use prescription stimulants for non-medical reasons.[4]

The medications are easy to get. Friends and acquaintances are the most common suppliers. Nor does there seem to be much of a stigma attached to the drugs. Instead students often see them as safe alternatives to "illegal" drugs.[5]

That they're legal, however, does not mean that the drugs are safe, especially when used without a doctor's supervision. The federal government classifies Adderall, Ritalin, and Concerta (all used to treat ADHD) as schedule II drugs, the same classification as cocaine, methadone, and methamphetamines. According to federal guidelines, schedule II substances have "a high potential for abuse which may lead to severe psychological or physical dependence." 

Indeed, the Food and Drug Administration warns that Ritalin, Adderall, and Concerta can cause heart problems, aggressive behavior, and even psychotic symptoms in children and teenagers.

To make matters worse, students often ingest them in ways that are not prescribed, such as snorting them or taking higher dosages. As one student explained to researchers, Adderall often comes in time release capsules, but "if you mash it up, you get it all at once, like a rush."[6]

"Cheap Coke"

Some students are less coy about prescription stimulants' potential for recreational and not just academic abuse. One described Adderall to researchers as "cheap coke. You know you get the same high, but you can get it for like 5 bucks."[7]

Indeed, while most students cite academic reasons as their motive for abusing prescription stimulants, 22.5% reported they used the drugs to party -- not study -- longer.[8] Sadly, the consequences of abusing these stimulants as party drugs are now appearing in emergency rooms.

According to the Drug Abuse Warning Network, in 2005 the number of emergency room visits related to "nonmedical" use of central nervous system stimulants like Ritalin, Adderall, and caffeine pills was 5,605. In 2012, it was 22,949. Thirty percent of those visits in 2012 -- over 6,800 -- involved alcohol.

Studies show that college students who used non-medical prescription stimulants while drinking are more likely than other drinkers to experience alcohol-related consequences. Some researchers speculate that this is because the stimulants hide the depressive effects of intoxication, leading users to drink more.[9]

Users of illicit prescription stimulants are also more likely than other drug users to report taking several drugs, often simultaneously, a dangerous and potentially fatal practice.[10]

Preventing Abuse

Stimulants such as Adderall and Ritalin have important, legitimate medical uses.

But these drugs also lend themselves to abuse by students looking for an academic edge or cheap high. And the potential for abuse will only grow as more students with prescriptions to Adderall or Ritalin (and hence more pills) arrive on campuses.

According to the CDC, between 1997 and 2006, rates of ADHD diagnosis increased by 3% every year. As of 2007, 9.5% of children 4 to 17 years old were diagnosed with ADHD. 66.3% of those children received medication for the disorder.

In fact, studies have shown that colleges students can effectively fake ADHD symptoms based on information available on the web, which might mean that motivated college students are dishonestly obtaining prescriptions.[11]

Unfortunately, abusers of prescription stimulants end up hurting students with legitmate reasons to take the medications. On College Confidential, an online forum for college students, one poster complained that abusers of medications damaged the reputations of students with ADHD:

I have some serious gripes about these bad practices. First of all, we don't take meds to get ahead. We take meds to level the goddamn playing field by controlling our symptoms and making our minds like one of yours, and these people are just messing it up for us. Secondly, all of this is giving us a bad reputation and personally I'm sick of hearing how kids with AD(H)D are all frauds and cheaters. Abusing medication is repulsive to me.

Cracking down on abuse might help remove the label of "fraud" or "cheater" that also sticks to legitimate users of the medications.

Several schools have already put policies in place to prevent abuse.  Duke University, for instance, includes "the unauthorized use of prescription medication to enhance academic performance" as a form of cheating in its policy on academic dishonesty. Other colleges and universities have begun to require a more rigorous diagnosis before any medication is prescribed.

Regardless of the approach, colleges and universities need to be actively addressing this issue in a sensitive and effective manner.

Works Cited

[1] DeSantis, A.D., Webb, E.M., Noar, S.M. (2008). "Illict Use of Prescription ADHD Medications on College Campus: A Multimethodological Approach." Journal of American College Health, 57, 315-323, esp. 319.

[2] Ibid.

[3] McCabe, S.E., Teter, C.J. (2007). "Drug use related problems among nonmedical users of prescription stimulants: A web-based survey of college students from a Midwestern university." Drug and Alcohol Dependence, 91, 69-76.

[4] DeSantis 2009.

[5]Bavarian, N., Flay, B.R., Ketcham, P.L., Smit, E. (2013). "Illicit use of prescription stimulants in a college student sample: A theory-guided analysis." Drug and Alcohol Dependence, 132, 665-673. DesSantis 2009, 322. Bavarian 2013.

[6] DeSantis 2009, 320.

[7] Ibid.

[8] Bavarian 2013.

[9] Egan, K.L., Reboussin, B.A., Blocker, J.N., Wolfson, M., Sutfin, E.L. (2013). "Simultaneous use of non-medical ADHD prescription stimulants and alcohol among undergraduate students. Drug and Alcohol Dependence, 131, 71-77.

[10] McCabe 2007.

[11] Sollman, M., Ranseen, J.D., Berry, D.T.R. (2010). "Detection of Feigned ADHD in College Students." Psychological Assessment, 22, 325-335.