Stephen looks around the serving area of Davenport Dining Hall and considers: buttermilk or chocolate chip pancakes? Screw it, he thinks, and helps himself to a few of each. When we sit down at a table in the back, Stephen explains: “I kind of need to carb up early, because I don’t always remember to eat again.” He fishes around in his pocket for a moment before pulling out a small orange pill. Then he pops it into his mouth and grins. “Adderall,” he says smoothly. “It’s a hell of a drug.”
Later, I sit with Stephen as he writes a midterm essay, and it isn’t hard to see what he means. While I idle nearby — checking Facebook, texting my brother, munching on a cup of cereal, rechecking Facebook — Stephen does not look up from his computer. Bowed low over the glowing laptop screen, he types fluidly, rarely pausing for more than a second or two to formulate his thoughts. After five hours or so, I ask, “Do you, um, want me to grab you any dinner or something?” It takes Stephen a moment to turn from the screen. “No, no thanks,” he says tersely, his eyes dry and red. “I, um, I’m almost done.”
Stephen does not have a prescription for Adderall, and “Stephen” is not his real name. Because what Stephen does practically everyday — sometimes several times a day — is illegal, he and the other Yale undergraduates I interviewed agreed to speak only on the condition of anonymity. (All of the names in this article are pseudonyms.)
In recent years, The Yale Daily News and The Yale Herald have published articles about the use of study-enhancing drugs on campus. For the most part, these pieces have portrayed what appears to be a small problem, asserting that these drugs are used by a tiny segment of Yale, a niche roughly the size of the Yale College Republicans or fans of tofu apple crisp. A Herald poll in 2011 reported that “10.7 percent [admitted] to having used ‘prescription drugs,’ such as Adderall, Ritalin, and Vicodin, in a non-prescribed setting.”
But nearly all of the students and many of the medical experts I spoke with scoffed at this low number. Various national surveys estimate the number of student users to be as high as 35 percent. A 2010 segment by 60 Minutes concluded that between 50 and 60 percent of college juniors and seniors (and more than four in five fraternity and sorority members) regularly use Adderall or Ritalin.
For many Yale students, Adderall — a medication intended to treat attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy — is an indispensable ingredient for success. As a Yale student, I have no trouble understanding the pressure to succeed on a competitive campus, but I still find something disquieting about Adderall. In order to understand what drives students to take this drug, I contacted 63 Yale undergraduates via email, text, Facebook message, or in person. (I had heard from other students that each of these 63 had taken Adderall at one time or another.) In total, 26 never replied to my inquiries, 10 denied ever using the drug, three responded but later hedged on an interview, and 24 acknowledged using and spoke with me at length.
Through conversations with these two dozen Yalies — freshmen and seniors, men and women, frat stars and science double-majors — I hoped to comprehend the circumstances that make Adderall use so appealing to college students. I hoped to determine whether or not our university stands a chance at combatting the illegal use of a drug that many consider a competitive necessity. I hoped to understand why it unsettled me that, when Stephen’s essay was handed back to him two weeks later, a large scarlet “A” was scrawled across the top.
**
When I spoke to Clyde on a blustery afternoon in March, he was high on Adderall. An athlete who will be working next year at a white-shoe consulting firm, Clyde often finds his Google calendar completely filled — from before the dining halls open for breakfast until after Durfee’s closes for the night. “Without Adderall, there wouldn’t be enough hours in the day,” he told me. “If you want to do everything and do it all well, then you need a little something extra.”
A few days each week, Clyde takes a 20-milligram Adderall capsule with his morning orange juice. The drug, he said, makes him feel wide-awake and, more importantly, makes even the most banal schoolwork interesting. “Maybe not interesting, exactly,” he said, correcting himself. “But it lets you focus 100 percent.” Often when he takes Adderall, his stomach feels scrunched up and empty, but he’s never hungry. Sometimes, his head aches behind his eyes, but he pushes on. “Adderall isn’t a crutch for me,” Clyde said. “It’s a way of life.”
For Clyde and the other students I spoke to, Adderall’s growing presence on campus is a result of Yale’s demand for effortless excellence, for academic and extracurricular distinction, for the ability to binge-watch House of Cards and still ace tomorrow’s exam, for the necessity to do it all with an unworried grin.
Adderall, which contains the stimulant amphetamine and comes in either an instant release (IR) tablet or an extended release (XR) capsule, works by flooding the brain with dopamine and norepinephrine, neurotransmitters that help the user stay alert and focused. Amphetamines have been used pharmaceutically in the United States since 1927; initially, they were available without a prescription and provided free to doctors to treat any and every ailment. “The drug was a cure in search of a disease,” Elaine Moore wrote in her 2010 book The Amphetamine Debate. Today, many users believe that Adderall allows them to perform almost any task with enhanced intensity. A 2012 study funded by the National Institute on Drug Abuse found that a third of student users report taking prescription stimulants to “stay awake to party.”
Bart, a Yale junior, told me that he spent most Friday and Saturday nights last year high on Adderall because “it allowed me to stay up all night and drink a lot more a lot more quickly.” To Bart, partying, like studying, is something for which there is always room for improvement. Adderall, besides allowing us to write more pages and memorize more Chinese characters, could also have the power to enhance our social interactions and experiences. Two athletes told me that taking the drug makes their workouts more intense. But, I wonder, is Adderall actually helping us achieve short-term results? What about long-term success? And what does this need to do it all effortlessly, to break the rules and win anyway, say about the institution we’ve erected around ourselves?
**
As I began to write this article and grow more cognizant of Adderall’s presence at Yale, I was struck most by the reticence that surrounds the drug on campus. Whereas marijuana and alcohol are typically viewed with apathy or amusement, students uniformly hide Adderall use from even their closest friends. One user I spoke with in a New Haven coffee shop earnestly said he didn’t have any close friends who used the drug: “I don’t really hang out with those kinds of people.” Either he is a very convincing liar, or he honestly didn’t know that my next interview — at a café half a block away and with lemon loaf twice as expensive — was with his suitemate, who is a regular user come midterm and finals period.
The silence that surrounds the drug compounds the difficulty that researchers and administrators face in separating the users who take Adderall just to study or party from those who use it to combat a serious attention disorder. In fact, of the 10 students I interviewed who had been formally diagnosed with ADD or ADHD, only half believed that whatever trouble they had concentrating and finishing their schoolwork actually warranted a medical label.
Amos, one of these five students, was formally diagnosed with ADHD as a college senior after years of buying Adderall from dealers to self-medicate. Even now, armed with a legitimate prescription, Amos hides the diagnosis from all but his closest friends. If classmates knew he took Adderall, he said, they would likely view him differently, as an addict or a cheater. But Amos believes the medication simply helps him regulate impulsive behavior, ameliorate a dismal attention span, and improve his admittedly terrible memory. “It’s just, I haven’t lost my coat this year, and I don’t usually make it through winter season without losing my coat,” he said.
According to the National Institutes of Health, ADHD is characterized by impulsiveness, inattention, and excessive motor activity. The disorder first entered the public consciousness in 1844, when Heinrich Hoffmann, a German doctor, published the story of “Fidgety Phil” (“Zappelphilipp”). Little Phil — who “wriggled and giggled, and then, I declare, swung backward and forward and tilted his chair” — is today a popular allegory for a child with attention problems. Phil has been reborn as a number of cultural icons, such as Dennis the Menace and Calvin (of Calvin and Hobbes fame).
Historically, ADHD was estimated to affect about 5 percent of children. In the last decade, however, the numbers have ballooned — climbing to 11 percent nationally in a 2012 CDC study. Of these children, between half and two thirds are put on medication, sometimes as early as age three, a fact that alarms many medical professionals. “Some kids have bona fide ADHD,” said Dr. Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess Medical Center and a professor at Harvard Medical School. “There are other kids who just have shpilkes, Yiddish for ants in your pants.”
A March 2014 report from Express Scripts, the largest pharmacy benefit management organization in the United States, found that the number of young adults taking ADHD drugs doubled between 2008 and 2012. According to Express Scripts, nearly 1 in 10 adolescent boys is currently prescribed ADHD medication, including Adderall. “Using any sort of mathematical common sense, you can see that the suggestion that ADHD is not over-diagnosed is preposterous,” Alan Schwarz, a Pulitzer Prize-nominated New York Times correspondent who has written a series of articles on ADHD, told me.
The students who believe they have genuine ADHD were largely ambivalent about the disorder’s overdiagnosis. “They can have as much of this stuff as they want, as long as it isn’t harder for me to get it,” Karl, a junior who was diagnosed at age 17, said of nonmedical users. But, he continued, “if … I couldn’t get the pills, I don’t know what I would do.”
Even though his closest friends know Karl actually has ADHD, and have seen the difference the drugs make in his day-to-day interactions, many still ask him for the occasional pill. “These are the most proper, toe-the-line sort of people, and they’ll hit you up for it,” he told me in his dorm room, the only place he felt comfortable discussing his condition. Karl recalled one acquaintance who would hang out with him all the time while he was providing her with leftover pills. They would grab a meal, or go to parties together, or just sit around and talk. But once he decided to stop giving her the drug, he rarely saw her anymore. “And I wish I could say she was the only one,” he said.
**
Most of the students I spoke to do not use Adderall to treat a debilitating medical problem. Rather, the drug is a tool that allows them to study late into the night, reading more pages, and writing more flashcards.
For Roy, the transition from high school to freshman year was difficult — classes and extracurriculars dropped, grades far lower than they had been at home. Difficult, that is, until he started taking Adderall. Late into his first fall semester, Roy made an appointment with a New Haven psychologist, whom Roy easily convinced he had an attention disorder. “You just say that you can’t focus and stuff, and that you have ADD,” he told me, although he does not believe he actually has the disorder. The psychologist sent him to a Yale psychiatrist, who wrote him a prescription for two 20-mg XR capsules per day for ninety days. (Federal law requires that a new prescription must be written every three months in an attempt to prevent abuse and large-scale distribution.)
I interviewed Roy the night before a midterm. For the past week, he said, he’d been slowly upping his Adderall dosage in order to study more effectively. A junior and fraternity member, Roy said he remains cautious about using Adderall too regularly — and tries to take breaks after midterm and finals periods. “Let’s not fuck around, it’s meth. It’s a big boy drug,” he told me. “Has it worked for you?” I asked. “Well,” he responded, grinning. “My GPA has gone up.”
For many of the students I spoke with, Adderall functions not so much as a conduit for excellence, but instead as a last resort — a tool they use to just barely keep up with the competition. When I asked Sam, a Yale senior who graduated from public school, whether he thought his Adderall use counted as cheating, he responded: “The rich kids from New York City who went to Collegiate and Dalton and had SAT tutors that get paid more than their high school teachers — are they cheating?” Robin, a junior on full financial aid, felt similarly. “The prep school kids all take Adderall so they can go out and party, fuck around, and still get good grades,” she said. “I’m working twenty hours a week in addition to school. So you better believe I’m taking Adderall too.”
“It used to be that if you went to an elite college like Yale, you basically wrote your ticket. There were a lot of jobs,” said Groopman, the Harvard Medical School professor. “But now … there is a sense that if I don’t get an A in my economics course, then I’ll never go to Goldman Sachs. So I’ll take Adderall to stay up for 24 hours and cram in every fact.”
This point, repeated in different words by all of the Yale students using Adderall without a prescription, made sense to me. I understand the feeling that there are too few jobs and too much competition. For students falling behind, the drug can seem like the only way to keep one’s head above water. But what, exactly, does Adderall do for these students that helps them stay afloat?
Undoubtedly, the drug keeps nonmedical users awake and alert longer, much the same way Red Bull and Five Hour Energy do. “If you think staying awake is a competitive advantage, then yes, it works,” said Dr. Les Iversen, a retired Oxford University professor of pharmacology and chairman of the British government’s Advisory Council on the Misuse of Drugs. “But these drugs are not improving your IQ,” he told me.
What’s more, a 2012 study at the University of Pennsylvania found that Adderall use resulted in no consistent cognitive improvement among college students. On the contrary, students only believed their performance had improved. The users who plug Adderall as an effective study tool are indeed the ones who believe the drug works for them. But according to Dr. Amelia Arria, director of the Center on Young Adult Health and Development at the University of Maryland, Adderall does not improve academic performance at all for many students, and even those who report increased productivity are not actually experiencing enhanced cognition. “It’s not a brain steroid,” Arria told me. “We’re not there yet in terms of brain chemistry. There’s no little blue pill for your brain yet.”
**
Even though the doctors I interviewed unanimously believed that Adderall does not actually improve cognition, I discovered a thriving — albeit underground — market for the drug on campus. One Yale sophomore, Francine, used to sell marijuana, but profit margins were small and interactions with suppliers made her uncomfortable. “Adderall, though … a bottle of thirty pills costs me $5, with insurance. If I can sell pills for $10 each — just think about that for a moment,” she said. Prices on campus run anywhere from a few bucks per pill to a dollar per milligram (pills range from five to 30 milligrams). Because people discuss Adderall less than recreational drugs like marijuana, it is difficult to know the market value and find a reliable dealer, which drives up prices. Francine, who has been dealing for the past year, said that she has between fifteen and twenty “semi-regular” customers. Most of them fit into expected categories: athletes, members of Greek life, and students who use other drugs. “But I also sell to lots of people you wouldn’t suspect: section assholes and girls who go to church all the time and people like that,” she said.
Under the Controlled Substances Act of 1970, Adderall is classified as a Schedule II drug, the same designation as other amphetamines like cocaine and opium. Selling even one pill could be a felony. Still, when I mentioned Adderall’s legal classification to Francine, she laughed. “Something tells me the police aren’t too concerned with a few Yalies studying too hard,” she said.
Sgt. Karl Jacobson, supervisor of the New Haven Police Department’s narcotics and intelligence unit, said that while the officers he oversees occasionally deal with cases of prescription drug abuse, none of their pending cases involve Adderall. “In a city environment where we’re battling street violence and people are dying from gunfire, this isn’t a priority for us,” Jacobson told me.
During the 2012-’13 academic year, a grand total of four students were charged with violating Yale’s drug regulations, for smoking marijuana. The Yale Executive Committee Chair’s Report made no mention of Adderall use. In fact, a careful examination of reports for the last 15 years reveals not a single reference to the terms “Adderall,” “stimulant,” or “amphetamine.”
Pamela George, assistant dean of academic affairs and a member of the Executive Committee, told me via email: “I am not familiar with any cases involving Adderall that have come before the Executive Committee.” She followed up, “Nonmedical prescription drugs are a violation of the Undergraduate Regulations. If they come to our attention, we’d most certainly be concerned about it. The cases we commonly hear involve illicit drugs.” (In response to repeated inquiries, a Yale Health representative told me: “We are not responding to students at this time.”) Still, I was assured in off-the-record conversations with professors and other faculty members that Yale administrators are aware of the drug’s prevalence on campus. But awareness is one thing; stopping nonmedical use is another.
**
Roger Griggs entered the pharmaceutical industry, he said, because his day job as a schoolteacher and a football coach “wasn’t the most lucrative thing in the world.” In 1993, Griggs acquired a small company that produced, among other things, a pill called Obetrol. Only one physician in the entire country was actually using the product, but this doctor found that, while Ritalin worked in calming roughly half of hyperactive children, patients responded to Obetrol 70 percent of the time. Renamed Adderall (a portmanteau of “ADD for all”), the drug was approved by the FDA in 1996 and quickly became one the nation’s most popular prescription medications.
According to Griggs, much of the drug’s success is due to aggressive marketing, including print and television ads aimed squarely at consumers. “A couple of years ago, that drug did about $1.3 billion in sales,” Griggs told me. “It went from $40,000 [a decade before] to $1.3 billion — so that’s probably one of the better success stories out there.”
In 2008, the pharmaceutical industry spent $31.5 billion on research and development. It spent nearly twice as much, $57.4 billion, on marketing. Since 2000, every major drug company has been cited by the FDA for false and misleading advertising, many more than once. “The FDA has rules, but it’s quite clear that the rules are designed to address issues in retrospect,” said Schwarz, the New York Times correspondent. “So if you put out an ad that the FDA doesn’t like, they will slap you on the wrist four months later.”
Of all the things that can make Adderall so appealing, one of the biggest is its seeming legitimacy. After all, it’s prescribed by doctors and even advertised on TV; the high-definition videography and expensive time slots make the drug feel safe and ordinary. Griggs told me he does not believe it is responsible to advertise a drug as powerful as Adderall on television when doctors are still unsure of its effects. “Do you have any idea what the long-term impact of stimulating your brain is?” he asked. “I don’t have a clue. I’ve probably done more studies on this product than anybody and I don’t know what happens after twenty years of stimulation.”
A number of doctors I spoke with repeated this concern. Adderall has existed for just two decades; by comparison, the first epidemiological study to clearly link asbestos with lung problems was published 72 years after the chemical was first mined in the U.S. and used for insulation. It is possible, the experts said, that the consequences of Adderall use could prove much more dire than students believe. “There have been deaths from amphetamines,” said Iversen, the former Oxford pharmacology professor, noting that Adderall is a close cousin of meth and other dangerous drugs. “And there will be even more down the road.”
The side effects that students reported to me were relatively mild. They included anxiety, loss of appetite, and a crash following an initial burst of productivity — one sophomore used the drug to stay up for 24 hours to cram for an exam, but then slept through the test. Even so, most students who experienced side effects continued using because of the drug’s potency. “I took Adderall and my first reaction was, ‘Fuck,’” one freckle-faced freshmen said. “It worked. Like, really well. Like, finished all my readings and p-sets and aced the midterm well. I think I was secretly hoping it wouldn’t work, so I wouldn’t need to use it. Too bad.”
**
When I asked doctors and medical ethicists about how to most effectively combat Adderall abuse, I thought they would all argue for increased public education, advertising restrictions, or a higher bar for ADHD diagnosis. A surprising number, however, said instead that Adderall and other psychostimulants should be made available to all American students. Since so many are already taking the drug, they reasoned, it would be fairer and safer if all students were allowed to use. In 2009, the Ethics, Law and Humanities Committee of the American Academy of Neurology recommended that “the prescription of drugs for neuroenhancement [be] legally and ethically permissible.”
Dr. Hank Greely, director of the Center for Law and the Biosciences at Stanford Law School, told me that pharmaceutical-based neuroenhancement could indeed benefit society — speeding up technological advancements, for example. “If such drugs were proven safe and effective, and issues of fairness and coercion were addressed, I would have no problem with students using cognitively enhancing drugs, just as I have no problem with them using laptops or, in the old days, handheld calculators,” Greely said.
“I’m a liberal Democrat, but I always joke with my friends that there’s a certain amount of libertarian in everyone,” Dr. William Graf, a professor of pediatrics and neurology at the Yale School of Medicine, told me. “So what do I think about Yale students taking a little Adderall around exam time? It comes down to the ethics of autonomy: these are adults that are making informed decisions.”
Many of the doctors argued that bringing Adderall usage out from behind closed doors would allow for regulation and oversight, which would in turn prevent abuse. “This culture of competitiveness and getting ahead isn’t good,” said Dr. Kelly Kelleher, a professor at the Ohio State University College of Medicine. “I would prefer what we did with pot in Colorado — legalize, but intensively tax and monitor; a lot of supervision so we know people don’t do it too much.”
Studies have demonstrated that Adderall (and nearly all drug use, in fact, according to the Substance Abuse and Mental Health Services Administration) is most common among the wealthy and white. Because such students are more likely to know physicians (and because they often have parents who are more comfortable utilizing their resources to boost their children’s academic performance), most have an easier time procuring prescriptions than their poorer peers. In fact, Adderall abuse has spawned a new term: white-collar addiction, the kind of crime acceptable for the young, the white, and the rich.
I suppose that if Adderall were available and affordable for everyone, it would seem less unfair. I can conceive of a Yale in which study drugs are institutionalized and out in the open. And yet, there is something about this image that makes me uncomfortable. Even after hours of conversation with students — and doctors, ethicists, professors, administrators, corporate executives, and police officers — I still can’t quite wrap my head around popping a pill or two to do schoolwork. Perhaps my classes are too easy, or my view of the classroom stuck in the storybook realm of Ms. Frizzle. But I’m not sure I’m ready for a world in which competition is so central, or a few more points on the midterm so essential, or the need for sleep so tangential that drug use is justified.
**
Ethical questions aside, I’ve realized while writing this article that the entire argument surrounding Adderall use may be futile. Ours is a culture of fast fixes — of chemicals to treat every ailment, big or small, real or perceived: from Advil to Xanax to Botox to Viagra. “I think civilization is about enhancement,” said Greely, the Stanford biomedical ethicist. “Everything since we’ve come out of the savannah has been about enhancement.”
While Adderall appears to be the dominant study drug for now, no expert I spoke with thought it would stay that way. Already, a number of other drugs have begun to eat into Adderall’s market share. Vyvanse (another stimulant) contains a more powerful amphetamine compound and lasts up to 12 hours in most patients. Several non-stimulant drugs, such as Intuniv and Strattera, have also been introduced to treat ADHD. Moreover, a number of new neuroenhancers are currently in the pipeline. For instance, ampakines, which target glutamate receptors in the brain and have shown potential to combat Alzheimer’s, may one day improve the cognitive abilities of nonmedical users.
As I watch Christine, a sophomore international student, flip through her chemistry textbook with the rigid efficiency Adderall induces, my mind drifts back to Elaine Moore’s book The Amphetamine Debate and her observation that Adderall was once “a cure in search of a disease.” It seems to me that Adderall has finally found its disease: a student body that prioritizes excellence to the point of sacrificing its own health, of breaking the law, and of alienating classmates who have genuine attention disorders. Watching Christine — the first in her family to attend college — and Stephen, and Clyde, and Roy, and all the rest, I wonder if the cure has actually created the disease, by fostering a society in which people believe they have to do drugs to keep up, and in which such behavior is becoming increasingly mainstream.
Maybe I’m overreacting. Maybe our collective Adderall habit really isn’t a big deal. Maybe it’s on the same level as Sparknotes and a language tutor and the caffeine in Christine’s triple venti Caramel Macchiato with extra cream. But as medicine and technology improve, there is little doubt that drugs and procedures will soon be able to guarantee returns: focus, absorption, perhaps even cognitive enhancement. Is that really what we want?
At the end of our interview, Greely told me: “It is an untested empirical question whether a smarter society is a better society. But it is at least plausible that smarter scientists could lead to better breakthroughs, smarter politicians could lead to better laws.” He paused for a moment, before adding: “Then again, smarter criminals.”