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Stimulant Drugs – Use and Misuse

Prescription stimulants are controlled substances with potentially serious side effects—and they can be addictive. But some Warfighters and athletes still misuse them. Learn about the real risks and valid uses.

B.L.U.F.

Prescription stimulants can improve attention and alertness, and doctors prescribe them for people with Attention Deficit Hyperactivity Disorder (ADHD) or excessive fatigue. Used improperly and without the supervision of a health provider, these drugs have serious side effects. Some people misuse and/or become addicted to them.

InfoReveal

Stimulants belong to a large class of drugs that increase alertness and energy by increasing arousal of the nervous and endocrine systems. That is, they “speed up” the body and mind.

Illegal stimulants include methamphetamine, cocaine, and MDMA (ecstasy). Legal and widely available (non-prescription) stimulants include caffeine and nicotine. Prescription stimulants include methylphenidate and certain amphetamines. Prescription stimulants usually are used to improve attention and alertness, for example, to treat Attention Deficit-Hyperactivity Disorder (ADHD). These medications also are used to decrease excessive sleepiness or fatigue, such as with narcolepsy.

Claims

People misuse prescription stimulants for a variety of perceived performance enhancements. For instance, many people use them because they think they help with focus, concentration, and staying awake longer. Other people use them to lose weight. Despite bans on such drugs in sports, some athletes still misuse these drugs to gain perceived athletic advantages.

What We Know

Stimulant drugs are very effective at treating the concentration and attention concerns of people with ADHD. They also reduce excess sleepiness for people with narcolepsy. However, there is still much debate about whether these drugs can help generally healthy people enhance their performance, either mental or physical.

It is well known that these drugs can help people stay awake longer. They also seem help improve attention and concentration. It still isn’t clear whether they improve memory, but it seems that they may help improve long-term memory. Because these drugs also decrease appetite and speed metabolism, small doses under the direction of a healthcare provider can help with quick weight loss, but military regulations about this are specific. They also provide energy, which can improve physical performance, but there can be a cost.

Concerns

Prescription stimulants have many serious side effects that can negatively affect the body. There is an increased risk of heart-related concerns such as rapid heart rate or heart attack, as well as body temperature increase and risk of seizure. People misusing prescription stimulants also can develop mental health problems, including anxiety, anger, and psychosis. Stimulants also disrupt sleep and eating. In addition, these drugs are classified as Schedule II drugs by the U.S. government, meaning that they can be addictive.

Debrief (Summary for Military Relevance)

Prescription stimulants have been used in the U.S. military since the mid-1900s. Low doses under the direction of a healthcare provider were found to help service members stay awake during long missions or when sleep is frequently limited. However, these drugs are not considered to be substitutes for regular, good-quality sleep. Recently, the military has been opting for newer drugs such as modafinil and armodafinil, which have fewer side effects, to replace traditional stimulants.

Stimulant drugs are still prescribed in today's military for service members with excess sleepiness (narcolepsy) and ADHD. However, prescription stimulants are highly monitored, and there are regulations about their misuse. Despite this monitoring, some service members continue to misuse these drugs to meet weight standards, increase physical performance, and stay awake for certain types of duty. However, any service member caught misusing these drugs can be subject to an Article 15 or other UCMJ violation.

HPRC's research brief on Prescription Stimulants  provides more detail about what prescription stimulants do, what they are used for, their effects on the mind and body, and military policies on their use.

Research Summary

Key Points

  • Prescription stimulants are used to treat health conditions such as Attention-Deficit Hyperactivity Disorder (ADHD) and narcolepsy (or excess sleepiness).
  • Some people misuse these drugs for perceived performance enhancement properties such as staying awake longer, improving concentration and memory, losing weight, and/or performing better athletically.
  • The military has successfully used these medications for service members who need to stay awake for long missions.
  • Used improperly and without the supervision of a health provider, these drugs have serious side effects such as heart troubles, mental health concerns, sleep problems, and/or addiction.
  • Newer drugs with fewer side effects and chances of addiction are being prescribed in place of some older prescription stimulants.

Background

Stimulants, including prescription stimulants, increase arousal of the nervous and endocrine systems. That is, they “speed up” the body and mind. Prescription stimulants primarily are used to improve attention and alertness (for example, to treat Attention Deficit–Hyperactivity Disorder, or ADHD). These drugs also can be used to decrease sleepiness or fatigue, specifically for people who have trouble staying awake (for example, narcolepsy).

Some people misuse stimulants (that is, without a prescription or not as directed) because they believe these drugs can improve mental and physical performance. There is much debate about whether improper use of prescription stimulants by generally healthy people improves their functioning. Despite their positive effects, long-term and improper use of prescription stimulants can lead to addiction and other negative health effects.

Facts and Evidence

Stimulants belong to a large class of substances that increase alertness and energy. Prescription stimulants (drugs) are used for various health conditions. Some are used for weight loss, excessive sleepiness, and low energy. Other prescription stimulants such as methylphenidate, Lisdexamfetamine, and dextroamphetamine are used to treat concentration difficulties associated with ADHD and other attention disorders.

Stimulants are also found in over-the-counter (OTC) medications, dietary supplements, foods, and tobacco. OTC products that sometimes contain “legal” stimulants include cough and cold medications, laxatives, energy drinks, tobacco, coffee, tea, weight-loss supplements, performance and bodybuilding supplements, and more. The focus of this article is prescription supplements, but much of the information here also applies to these non-prescription sources.

Prescription stimulants "speed up" the brain and body, but each works slightly differently. They prepare the body for action by increasing blood pressure and heart rate, constricting blood vessels, increasing blood sugar, and opening up breathing passages. As a consequence, many people report decreased appetite when taking these drugs. Weight loss may occur because of decreased appetite, increased metabolism, and increased physical activities. The body's senses and mind also become more alert, improving concentration, attention, and memory.

Side Effects of Prescription Stimulants

According to the National Institute on Drug Abuse, these drugs also may have major side effects, especially with long-term use and/or high doses, including:

  • Risks of high body temperature, increased heart rate, heart attack, and seizure.
  • Risks of increased anxiety, hostility, and even psychosis.
  • Risks of insomnia and disruption of the body's natural sleep cycle, which can negatively impact health.
  • Risk of addiction. These drugs are listed by the U.S. government as Schedule II drugs. According to the Drug Enforcement Administration (DEA), “Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, less abuse potential than Schedule I drugs, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous.”

Cautions

Prescription Stimulant Misuse

Sometimes, people with prescriptions for these drugs overuse them. That is, they take more than prescribed. In addition, many people without associated medical concerns misuse prescription stimulants without prescriptions, with the intent of improving mental or physical performance and/or decreasing fatigue. Prescription stimulants may be misused even more often than illegal stimulants such as methamphetamine.1 People who misuse prescription stimulants also are more likely to misuse other drugs. One study reported that 3.4% of people reported nonmedical use of prescription ADHD stimulants.2 Of those people, 95% also reported misusing other prescription drugs (such as tranquilizers and pain relievers) or illicit drugs (such as marijuana, cocaine, and heroin).

Non-Medical Use of Prescription Stimulants

At this point, the research appears mixed on whether any of these drugs actually can improve mental and physical performance in generally healthy people.3 Students have reported misusing these drugs without prescriptions to improve late night studying, focus, and grades.4,5 Prescription stimulants may improve memory by helping to move short-term memories into longer-term memory. They also may improve recall and recognition of information. However, these drugs affect the brains of people without ADHD differently, sometimes with negative side effects.

Some athletes also misuse various prescription stimulants with the aim of gaining competitive advantages in practice, workouts, and competitions (called doping).6 These drugs may boost energy and decrease fatigue during athletic performance7, but it is important to note that both prescription and illegal stimulants are on the World Anti-Doping Agency list of prohibited substances (page 7).

Other people use these drugs or are prescribed these drugs "off label" with the aim of quick weight loss.8 Under proper supervision, short-term use of low-dose prescription stimulants can help with weight loss.

Remember that prescription stimulant misuse can lead to significant side effects such as increased hostility, heart troubles, and other negative health effects.

Military Relevance

History of Prescription Stimulants in the Military

Some stimulants were popularly prescribed in the U.S. during the 1930s through the1960s for a variety of concerns.9 The U.S. military has used prescription stimulants and caffeine to enhance physical and mental performance in certain groups of service members.10,11 These drugs usually are prescribed to promote wakefulness in service members on long missions or needing long-term concentration.12 For instance, the Air Force has used small doses of prescription amphetamines for long flight missions, with increasing use during the Desert Storm conflict.13,14

The overall conclusion has been that small doses during long missions improve mental performance and decrease sleepiness. However, amphetamine use with pilots had the side effects of insomnia and disruption of normal sleep cycles. Therefore, these drugs should not be considered as a replacement for quality sleep.15 They also should not be used without monitoring of side effects by a medical professional.

Recent studies report that healthcare providers are shifting away from amphetamine-related stimulants to newer medications such as modafinil and armodafinil for military operations.16,17 These drugs are not traditional stimulants but still promote wakefulness and may help with concentration and attention. Therefore, they have fewer side effects and are less likely to be misused.

Stimulant Use and Misuse in the Military

The Department of Defense (DoD) Health Related Behaviors Survey (HBRS) anonymously tracks various health behaviors of service members, including prescription and illegal use.

In 2008, the HBRS showed that amphetamine and stimulant misuse among service members increased (5.3% to 8.4%) across all branches; the Marines (3.8%) and the Army (3.8%) had the highest rates of stimulant misuse.

In 2011, the HBRS showed that 2.8% of service members used stimulant medication in the past 12 months, with the Army having the most use (4.4%). Of those individuals, 2.3% were prescribed these medications and 0.5% misused them. The primary reasons for using these medications were to "reduce anxiety or depression," "control stress," and "to help me stay awake." Related to prescription misuse, 1.3% of service members reported prescription drug misuse in the last year. 6.4% of service members reported using someone else's prescribed stimulants, and 5.4% used more than prescribed. Of service members who ever misused any prescription drug, 11.6% reported prescription stimulant misuse at some point with 2.8% using them in the past 12 months.

Military Guidelines for Prescription Stimulants

The DoD has created specific policies that address drug misuse, including prescription stimulant misuse. In the past few years, significant changes have been made to their drug policies. The DoD tests for prescription and synthetic amphetamines. They also have specific drug limitations and monitoring, especially during deployments. Force Health Protection and Readiness has stated the following:

  • All deploying service members are screened with a urine or blood analysis.
  • Service members are given limited supply of Class II stimulants, specifically a 90-day supply, before deployment.
  • The military will use a reporting tool that tracks high-risk medication use by service members.
  • The military will use an overall system that compiles data about providers' prescriptions, including prescription stimulants.

There also are regulations on how long prescriptions are valid (see the “prescribed date” on the bottle). Prescriptions for “commonly misused drugs,” including prescription stimulants, tend to be six months, but this information often can be found on the prescription bottle. Disciplinary actions are not taken when Warfighters take their medications as prescribed and within the time frames of their prescriptions. However, disciplinary action can be taken if it is found that service members take medications not as prescribed or outside the prescription windows.

All Warfighters, regardless of service, must pass a urinalysis test to test for the presence of any controlled substances according to the Drug Demand Reduction Program. For example, the Navy and Marines describe their policy as "zero tolerance" when dealing with prescription drug misuse. Warfighters taking prescription medications outside of their intended purpose, past the prescribed date, in greater dosage than prescribed, or not in the name of the user can be disciplined. The Air Force recently expanded their drug policies to include abuse of commonly abused prescription drugs. Warfighters that have positive urinalyses for a controlled substance “that [they] do not have a current prescription in their medical record, and no other valid reason…are subject to a violation of the Uniform Code of Military Justice (UCMJ).”  Various articles provide some more information on testing for prescription drug abuse in the Army, Air Force, and Navy.

Summary

Prescription stimulants clearly have benefit for people with attention and tiredness/fatigue difficulties. However, there is still much debate about whether prescription stimulants are useful for generally healthy people. There is some evidence that shows a link between prescription stimulants and improvements in some parts of mental and physical performance.3,7 However, these enhancements vary with type of task, dose of the drug, and type of medication. Misusing these drugs with or without prescriptions can lead to serious and potentially fatal consequences.

When administered in small doses and under the proper supervision of a qualified healthcare provider, these medications have been used successfully for Warfighters participating in long missions that require shortage of sleep and increased alertness. However, they can have side effects such as sleep problems. Newer prescribed medications such as modafinil may provide the same benefit with fewer side effects. However, they still should be used only under the direction of appropriate healthcare providers.

References

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  2. Sweeney CT, Sembower MA, Ertischek MD, Shiffman S, et al. Nonmedical use of prescription ADHD stimulants and preexisting patterns of drug abuse. Journal of addictive diseases. 2013;32(1):1-10.
  3. Smith ME, Farah MJ. Are prescription stimulants "smart pills"? The epidemiology and cognitive neuroscience of prescription stimulant use by normal healthy individuals. Psychological bulletin. 2011;137(5):717-41.
  4. Herman L, Shtayermman O, Aksnes B, Anzalone M, et al. The use of prescription stimulants to enhance academic performance among college students in health care programs. The journal of physician assistant education : the official journal of the Physician Assistant Education Association. 2011;22(4):15-22.
  5. Teter CJ, McCabe SE, LaGrange K, Cranford JA, et al. Illicit use of specific prescription stimulants among college students: prevalence, motives, and routes of administration. Pharmacotherapy. 2006;26(10):1501-10.
  6. Angell PJ, Chester N, Sculthorpe N, Whyte G, et al. Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. British journal of sports medicine. 2012;46 Suppl 1:i78-84.
  7. Avois L, Robinson N, Saudan C, Baume N, et al. Central nervous system stimulants and sport practice. British journal of sports medicine. 2006;40 Suppl 1:i16-20.
  8. Jeffers A, Benotsch EG, Koester S. Misuse of prescription stimulants for weight loss, psychosocial variables, and eating disordered behaviors. Appetite. 2013;65:8-13.
  9. Rasmussen N. America's first amphetamine epidemic 1929-1971: a quantitative and qualitative retrospective with implications for the present. American journal of public health. 2008;98(6):974-85.
  10. Babkoff H, Krueger G. Use of stimulants to ameliorate the effects of sleep loss during sustained performance. Military Psychology. 1992;4(4):191-205.
  11. Rasmussen N. Medical science and the military: the Allies' use of amphetamine during World War II. The Journal of interdisciplinary history. 2011;42(2):205-33.
  12. Caldwell JA, Caldwell JL. Fatigue in military aviation: an overview of US military-approved pharmacological countermeasures. Aviation, space, and environmental medicine. 2005;76(7 Suppl):C39-51.
  13. Emonson DL, Vanderbeek RD. The use of amphetamines in U.S. Air Force tactical operations during Desert Shield and Storm. Aviation, space, and environmental medicine. 1995;66(3):260-3.
  14. Caldwell JA. Dextroamphetamine and Modafinil are Effective Countermeasures for Fatigue in the Operational Environment. RTO-MP-HFM-124. Vol Strategies to Maintain Combat Readiness during Extended Deployments – A Human Systems Approach. Neuilly-sur-Seine, France2005:31.1-.16.
  15. Caldwell JA, Caldwell JL, Darlington KK. Utility of dextroamphetamine for attenuating the impact of sleep deprivation in pilots. Aviation, space, and environmental medicine. 2003;74(11):1125-34.
  16. Eliyahu U, Berlin S, Hadad E, Heled Y, et al. Psychostimulants and military operations. Military medicine. 2007;172(4):383-7.
  17. Estrada A, Kelley AM, Webb CM, Athy JR, et al. Modafinil as a replacement for dextroamphetamine for sustaining alertness in military helicopter pilots. Aviation, space, and environmental medicine. 2012;83(6):556-64.