The non-medical use of prescription psychostimulants or cognitive-enhancing substances among healthy college students is a growing concern. Stimulant drugs are generally prescribed for the treatment of Attention Deficit/Hyperactivity Disorder (ADHD), narcolepsy and some cases of depression.¹ Yet, reports show that 5% – 35% of college students use prescription psychostimulants for non-medical purposes.² These drugs are normally prescribed to increase motivation, mood, energy and wakefulness, and include methylphenidate, dextroamphetamine, pemoline and modafinil.¹

Abuse of stimulant drugs can lead to psychological and physiological tolerance and dependence. Common side effects include gastrointestinal discomfort, anxiety, irritability, insomnia, tachycardia, cardiac arrhythmias and dysphoria. Less common adverse effects include induction of movement disorders, Tourette’s disorder and other tics. In addition, high doses of sympathomimetics (which might be the case if stimulants are used non-medically or recreationally) can lead to dry mouth, bruxism, formication, emotional liability, psychosis and seizures.¹ Besides the above concerns, there are multiple ethical considerations involved. In the broader context, these include justifying treatment to healthy or subsyndromal individuals (referring to individuals displaying some symptoms of an illness but not severe enough for diagnosis as a clinically recognised syndrome), as well as offering pharmacological neuro-enhancement for doctors working long shifts and other occupations requiring prolonged attention such as long-distance truck drivers or pilots. Lastly, the possible need for the development of protocols on the use of psychostimulants by academic institutions is another area of possible ethical debate.^3,4

In 2001, a nationwide survey in the United States on the non-medical use of stimulants among a group of 10 000 undergraduate university students revealed a lifetime prevalence of 6.9%, a past year prevalence of 4.1% and a past month prevalence of 2.1%.⁵ This cohort comprised of randomly selected students attending various 4-year courses at 119 American colleges and universities. A cross-sectional assessment was done with the help of a 20-page survey. In 2005, Teter et al.⁶ reported 8.1% lifetime prevalence and a 5.4% past-year prevalence of illicit prescription stimulant use from an Internet survey of 9161 randomly sampled college students. These students were all from a single large public university and were invited via email to complete the Student Life Survey (SLS), developed by the Michigan Substance Abuse Research Centre. Furthermore, reports show that medical students appear to be at higher risk for stimulant use: in 2010, Tuttle et al. reported that 10.0% of medical students used stimulants during their lifetime.⁷ Another report showed that 20.0% of medical students used stimulants during their lifetime and 15.0% used during medical school.⁸ It should, however, be noted that 9.0% of participants in the aforementioned study were diagnosed with ADHD.⁸ In 2013, Emanuel et al.² conducted a multi-institutional census on 2732 medical students and reported a lifetime psychostimulant use of 18.0%, with 11.0% reporting use during medical school and 63.0% of those using stimulants non-medically. This was an online, anonymous, cross-sectional survey about cognitive enhancement drug use and associated factors to all enrolled students at four Chicago-area medical schools, one public and three private institutions, across class year one through to six.

These above-mentioned studies found that the reasons for non-medical use of stimulants are diverse, including coping with the pressure of an academic environment, improving school performance, staying awake to study or complete projects, as well as recreationally to achieve euphoria or lose weight.² Other factors associated with higher rates of use included being male, white, members of fraternities and/or sororities and lower average grades.⁵ Non-medical use was also associated with concomitant high-risk activities, such as use of alcohol and illicit drugs as well as driving while intoxicated.^2,9

To our knowledge, there is no formal information on non-medical stimulant use at South African colleges or universities. A 2011 report in the South African lay press stated that diversion (where a person with a prescription for stimulants will sell or give his and/or her medication to peers) and the non-medical use of stimulants is fairly common at our universities.¹⁰ With this in mind and the fact that the medical fraternity seems to be particularly vulnerable to stimulant use, the aim of this study was to determine the prevalence and correlates of non-medical sympathomimetic use as well as subjective opinion on peer numbers using these drugs and university’s attitude towards this use among a sample of undergraduate medical students at a South African university. Specific objectives included: (1) assessing the reasons for use, source of stimulants, effectiveness and medical, as well as psychiatric comorbidities; and (2) students’ perception on peer frequency of use and the attitude of the university towards stimulant use. Examples of stimulants included methylphenidate preparations, atomoxetine and modafinil, whereas cognitive abilities were defined as the ability to concentrate/think clearly/learn/remember.

This report presents to our knowledge the first findings on rates and correlates of non-medical use of stimulants and related drugs in South African undergraduate medical students. Our results showed that 17% of our sample used stimulants during their lifetime, with only 2% of the sample having a diagnosis of ADHD. The prevalence of use in our sample mirrors international figures obtained by Emanuel et al.² and Webb et al.⁸ The literature however reports a lower average prevalence for stimulant use in non-medical undergraduate students.^5,8 We hypothesise that students possibly used stimulants to increase academic performance, as was reflected in the reasons for stimulant use put forward by students; with very few using it for reasons other than to increase concentration. The extreme academic pressure experienced by the medical fraternity as well as high expectations to perform well might be possible reasons for the higher prevalence of stimulant use in medical students compared with non-medical students.²

We also found an increased prevalence of high-risk behaviour (concomitant use of illicit substances) in the group using stimulants. This finding mirrors results of other international reports on this topic.^5,6 Although there were no statistically significant differences between the user and non-user groups pertaining to psychiatric or cardiovascular disease, it is disconcerting that there are medical students with heart and psychiatric disease using symphatomimetics without a script. This could be deleterious with reference to side effects and drug interactions.

In comparison to other reports,^5,6 we did not find a higher use of stimulants in men, members of residential facilities, or students with lower grade averages. We found that more second-year than fourth-year students used stimulants. Stimulants were mostly obtained from ‘shops’ and ‘house shops’. It is concerning that some students reported obtaining stimulants from pharmacies without a prescription, as well as buying it online via Swiss Guard. It is also clear that many siblings are diverting stimulants to family members.

The authors found the differing opinions on stimulant use interesting. It might be expected that users and non-users would feel different on issues pertaining to non-medical stimulant use, but whether stimulant use per se influenced their viewpoint or vice versa remains to be explored.

Limitations of this study include the use of self-report questionnaires. Given that using stimulants without a valid script as well as selling scheduled medicine as part of diversion behaviour is illegal, the students might have been reluctant to answer honestly. Students may also have been reluctant to self-report a psychiatric diagnosis, hence the low number of participants reporting a diagnosis of ADHD. Although the results of this study may not be extrapolated to other universities or colleges, our results were comparable to other international reports.^2,8

Our study shows that the non-medical use of stimulants among medical students at this South African university is prevalent. This practice is not without risk however and carries ethical and policy-making implications. Duke University in North Carolina, USA, recently prohibited the non-medical use of prescription stimulants for academic purposes, classifying it as ‘cheating’.¹¹ This raises the question whether South African universities and colleges should consider having a policy or protocol on the use of stimulants for cognitive enhancement. A policy such as this would likely be received with diverse responses, as the students in our study had differing opinions on what their university’s approach should be.

Future research should focus on assessing rates of stimulant use at other South African institutions and under non-medical students.