The non-medical use of prescription psychostimulants or cognitive-enhancing substances among healthy college students is a growing concern. This use appears to be particularly high among medical students. To our knowledge, no literature is available on the non-medical use of stimulants among South African medical students.
To determine the prevalence and correlates of non-medical stimulant use as well as subjective opinion on peer numbers using stimulants and university attitude towards stimulant use among a sample of South African undergraduate medical students.
A descriptive observational study was conducted by means of a self-report questionnaire. Second- and fourth-year medical students (
Of the sample, 44 (18%) reported a lifetime use of stimulants for non-medical purposes and 33 (85%) of this group reported use within the past year. A total of six (2%) students reported a diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD). In the group without a diagnosis of ADHD, non-medical stimulant use was associated with the year of study (
Non-medical use of stimulants to improve concentration and academic performance is prevalent among the South African medical students sampled in this study. Further research at other institutions and under non-medical students would be helpful to assess the scope of this phenomenon.
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.
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.
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%.
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.
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.
This was a descriptive observational study conducted at the medical campus of a South African university.
The sample consisted one class each of second- and fourth-year medical students. There were no exclusion criteria for this study and all students from these classes were included in the survey. We included both junior and more senior students to assess the association between stimulant use and age and/or year of study. These two classes were least involved in research according to the specific university regulations and therefore available for our study.
Data were analysed using Statistica version 11 of 2013. Age was the only continuous variable and was described using means and standard deviations. Furthermore, the analysis of age was stratified according to questions 7 and 18 of the questionnaire (referring to presence or absence of an ADHD diagnosis and non-medical use of sympathomimetics). All other variables were analysed descriptively by means of frequency distributions. Additionally, contingency tables were produced whereby the responses were analysed according to the responses obtained from questions 7 and 18. A histogram was used to graphically present age and bar charts for all other nominal variables. As age was not normally distributed, a non-parametric Mann–Whitney U test was used to compare whether the ages differed with respect to question 18. A comparison of two nominal variables was performed using a contingency table and Pearson’s chi-square test. In the event of small, expected, cell frequencies, a Fisher’s exact test was applied. A significance level of 5% was applied throughout.
Ethical approval was granted by the Health Research Ethics Committee of Stellenbosch University, while lecturers and the appropriate university authorities also granted permission to conduct the study. Ethical standards as put forth by the Health Research Ethical Committee of Stellenbosch University were strictly adhered to. Each student signed a Participant Information Consent Form (PICF) and was handed an anonymous questionnaire in exchange for the signed PICF. Each questionnaire was identified with a research number only and remained completely confidential.
A total of 252 questionnaires were completed. One questionnaire was excluded from the analysis due to contradictory information. The final sample hence amounted to 251 (142 second-year students and 109 fourth-year students). Participants had a mean age of 20.9 (s.d. 1.8, range 19–32), and 184 (73%) were women and 67 (27%) men. Those who lived in residential facilities amounted to 147 (56%), while 103 (41%) lived privately. Most students had a grade average between 50 and 70 (163, 64%).
Of the students, 42 (17%) reported a lifetime use of sympathomimetics for non-medical purposes and 33 of this group (79%) reported use within the past year.
A total of 6 (2%) students reported a diagnosis of ADHD and 3 (50%) were male. Of the students with ADHD, 3 (50%) were diagnosed by a psychiatrist, 2 (33%) by a general practitioner and 1 (17%) by a Grade 6 teacher. Half of the students with ADHD were on treatment. All the students with ADHD were in their second year of study and resided in residential facilities. All of the students diagnosed with ADHD used alcohol in the month prior to completing the questionnaire and 1 student (17%) also reported use of illicit substances concomitantly with stimulant treatment. One student (17%) reported diversion behaviour.
The majority (31; 32%) reported using stimulants to improve concentration (
Reasons for use of stimulants.
Variable | % | |
---|---|---|
To improve concentration | 31 | 32 |
To stay awake | 23 | 24 |
To improve academic performance | 18 | 18 |
For increased energy | 18 | 18 |
To party/for recreational use | 5 | 5 |
To lose weight | 1 | 1 |
To counter effects of other drugs | 0 | 0 |
Students were allowed to choose multiple reasons; values given as percentage of total response.
There was a significant difference between users and non-users in terms of year of study (
Correlates of non-medical stimulant use in undergraduate medical students.
Variable | Stimulant use | ||||||
---|---|---|---|---|---|---|---|
Yes | No | ||||||
% | % | ||||||
0.43 | |||||||
Mean | 21.06 | - | 20.86 | - | |||
s.d. | 1.74 | - | 1.85 | - | |||
Range | 19–32 | - | 19–27 | - | |||
1.00 | |||||||
Male | 11 | 26 | 53 | 27 | |||
Female | 31 | 74 | 147 | 74 | |||
0.03 | |||||||
Second year | 30 | 71 | 103 | 51 | |||
Fourth-year | 12 | 29 | 97 | 49 | |||
0.29 | |||||||
50% – 70% | 31 | 73 | 126 | 63 | |||
70% – 80% | 2 | 22 | 62 | 32 | |||
> 80% | 9 | 5 | 4 | 2 | |||
< 50% | 0 | 0 | 5 | 3 | |||
1.00 | |||||||
Private | 18 | 43 | 84 | 42 | |||
Residential | 24 | 57 | 115 | 58 | |||
1.00 | |||||||
Past year | 33 | 85 | 0 | 0 | 0.31 | ||
Past month | 4 | 10 | 0 | 0 | |||
Past week | 2 | 5 | 0 | 0 | |||
Once | 14 | 30 | 0 | 0 | |||
> 5 times | 12 | 30 | 1 | 0.5 | |||
2–5 times | 16 | 40 | 0 | 0 | |||
0.44 | |||||||
Moderately effective | 30 | 75 | 3 | 60 | |||
Very effective | 7 | 18 | 2 | 40 | |||
Not effective | 3 | 8 | 0 | 0 | |||
0.20 | |||||||
Free from peer | 18 | 44 | 0 | 0 | |||
Bought from peer | 4 | 9 | 0 | 0 | |||
‘Faked ADHD’ | 0 | 0 | 0 | 0 | |||
Family member | 4 | 9 | - | - | |||
Other | 15 | 37 | 3 | 100 | |||
0.29 | |||||||
Yes | 2 | 5 | 4 | 2 | |||
No | 40 | 95 | 191 | 98 | |||
0.75 | |||||||
Yes | 4 | 10 | 16 | 8 | |||
No | 37 | 90 | 179 | 92 | |||
0.002 | |||||||
Yes | 27 | 64 | 74 | 38 | |||
No | 15 | 36 | 121 | 62 | |||
0.07 | |||||||
Yes | 24 | 57 | 105 | 54 | |||
No | 18 | 43 | 92 | 47 | |||
0.01 | |||||||
Yes | 6 | 15 | 7 | 4 | |||
No | 34 | 85 | 187 | 96 |
Students without a diagnosis of ADHD, comparing stimulant users (‘yes’) and non-users (‘no’).
There was no significant difference (
Students’ opinion on frequency of peer stimulant use.
Variable | None | Only a few | Many | Most | Do not know | |||||
---|---|---|---|---|---|---|---|---|---|---|
% | % | % | % | % | ||||||
Students diagnosed with ADHD | 0 | 0 | 3 | 50 | 3 | 50 | 0 | 0 | 0 | 0 |
Using stimulants | 7 | 17 | 25 | 60 | 9 | 22 | 0 | 0 | 1 | 2 |
Not using stimulants | 60 | 30 | 106 | 54 | 25 | 13 | 1 | 0.5 | 6 | 3 |
Students were asked: ‘How many of your fellow students use stimulant mediation to improve cognitive abilities?’.
There was a significant (
Students opinion on university’s attitude.
Variable | Discourage | Prohibit use | Neutral | Encourage | ||||
---|---|---|---|---|---|---|---|---|
% | % | % | % | |||||
Students diagnosed with ADHD | 2 | 34 | 0 | 0 | 4 | 66 | 0 | 0 |
Using stimulants | 11 | 26 | 1 | 2 | 24 | 57 | 6 | 14 |
Not using stimulants | 75 | 38 | 53 | 27 | 65 | 33 | 3 | 1 |
Students were asked ‘What should the university’s attitude be towards the use of stimulants?’
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.
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.
In comparison to other reports,
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.
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’.
Future research should focus on assessing rates of stimulant use at other South African institutions and under non-medical students.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
M.R. was the principle investigator in this study. C.V. was the supervising investigator. Both investigators participated in the conceptualisation, design and completion of the study.