Study drugs "don't make you smarter": acceptability evaluations of nonmedical prescription stimulant use among undergraduate students.
Competitive university environments became the focus of major media attention across North America as fears aired about the prevalence of "cognitive enhancement" and "academic doping" practices among students, in the face of high rates of prescription for attention-deficit hyperactivity disorder (ADHD) conditions (e.g., A. D. DeSantis & Hane, 2010; McCabe, West, & Wechsler, 2006; Racine & Forlini, 2010; Wilens et al. 2008; Wolff & Brand, 2013; Vrecko, 2015). Medical professionals are asking universities to make efforts to "denormalize" the nonmedical use of prescription stimulants (herein referred to as "NM-stimulant use") by educating students on harms and to gather data on the sparsely researched issue (Rosenfield, Hebert, Stanbrook, Flegel, & MacDonald, 2011). The Government of Canada recently announced an intention to enlarge the scope of its National Anti-Drug Strategy to include the misuse of prescription drugs (Governor General of Canada, 2013). The United States illustrates similar trajectories toward targeting NM-stimulant use as a public health and safety concern (Express Scripts, 2014; Quintero, 2012).
Research on NM-stimulant use has accordingly surfaced as the salience of this social issue grows. The research literature confirms that competitive and demanding postsecondary contexts are associated with higher rates of NM-stimulant use (Arria et al., 2008; McCabe, Knight, Teter, & Wechsler, 2005; Peralta & Steele, 2010; Quintero, 2012; White, Becker-Blease, & Grace-Bishop, 2006; Wolff & Brand, 2013). This analysis of 36 semistructured interviews with NM-stimulant-using and nonusing undergraduate students at the University of Toronto (UoT) responds to the repeated calls for inquiry into the "motivations, dynamics, and contexts of the growing phenomenon of 'nonmedical prescription drug use'" (Fischer & Rehm, 2007, p. 1932; Haydon, Rehm, Fischer, Monga, & Adlaf, 2005). The analysis proceeds from drug normalization scholarship on changing drug trends and practices and explores how NM-stimulant-using university students and their nonusing peers make sense of such use. To date, no qualitative studies focus particularly on nonusing student evaluations of NM-stimulant use among their peers. According to the drug normalization framework, drug acceptability is an evaluative process arising from attitudes of both drug-using students and their nonusing counterparts, thus exploration of nonuser perspectives is essential for identifying the contours of drug acceptability repertoires and shifting use trends among students more generally (Aldridge, Measham, & Williams, 2011).
The next section briefly introduces the drug normalization framework which has been central to developing the study of drug acceptability and drug use trends. An overview of NM-stimulant use prevalence estimates among students and drug effects is then provided. Thematic analysis of interviews is used to identify the drug navigation practices and discourses informing NM-stimulant acceptability. To explain convergences in the attitudes of using and nonusing students toward NM-stimulant use as "nonrecreational" and oriented toward academic achievement, this article draws on literature on normative discourses of health, risk, and self-regulation that shape moral repertoires on drug use. The salience of achievement-oriented NM-stimulant use among nonusing students is here situated in social processes that position individuals as risk assessing, enterprising moral consumers (Race, 2009; Rose, 2007; Rose, O'Malley, & Valverde, 2006; Skeggs, 2004a, 2004b). To conclude, recommendations are made for future research, and implications for university policies are considered.
Drug Acceptability and Drug Normalization
Student navigation of drug acceptability is receiving increased attention as interest in understanding the patterns and effects of illicit drug use among conventional populations (1) builds. Drug acceptability refers to individual or group evaluations of which drugs are seen as un/acceptable to use, through which mode of ingestion, how often, and in which situations. Exploring shifts in how groups engage in and morally position certain kinds of drug use allows for insight into the material, symbolic, and discursive pressures driving such changes. The study of drug acceptability thus provides an important avenue for understanding the operation of social processes more broadly.
The drug normalization framework has been central to mapping the research territory of drug acceptability (Aldridge et al., 2011; Parker, 2005). Drug normalization studies suggest that widespread availability and acceptability of illicit drugs among university students, and of cannabis in particular, indicate that navigation of drug use has become an increasingly common aspect of undergraduate experience for both illicit drug users and nonusing peers (Aldridge et al., 2011; Duff et al., 2012; Measham & Shiner, 2009). One shortcoming of normalization research is that it typically focuses on how drug users characterize drug acceptability through a binary formulation of substance use as either "problematic" or "recreational." (2) An opportunity for conceptualizing drug acceptability along more nuanced lines of assessment is suggested by the academic achievement-oriented illicit substance use of students to facilitate alertness and studying (DeSantis & Hane, 2010; Vrecko, 2013; White et al., 2006; Wilens et al. 2008).
Undergraduate University Context of NM-Stimulant Use Acceptability
The stressors and demands of university life prove highly taxing for students. A survey of over 38,000 Canadian postsecondary students finds that "in the previous 2 weeks" more than half reported feeling exhausted and overwhelmed by all they had to do (College Health Association 2013). In the same period, one quarter of students reported feeling very lonely, very sad, and/or feeling overwhelming anxiety. At UoT specifically, a highly ranked research university, students report that large classes present intimidating environments which discourage student-faculty interaction (UoT, 2010). Financial and time constraints act as barriers to participation in cocurricular activities, which may otherwise facilitate student interaction and reduce anxiety (UoT, 2010). These extensive pressures have informed the emergence of substance-based practices to optimize alertness (e.g., energy drinks, NM-stimulant use) and to pursue leisure and pleasure (e.g., binge drinking, recreational drug use) among students (Adlaf, Demers, & Gliksman 2005; Schulenberg & Patrick, 2012; Trunzo et al., 2014; White & Rabiner, 2012).
Although stimulants commonly prescribed for ADHD may be used recreationally, the majority of students who report nonmedical use of these drugs state that they do so for academic purposes (Arria et al., 2008; Bavarian, Flay, & Smit, 2014). (3) Estimates of past-year NM-stimulant use range from 0% to 25% of college students in the U.S. (Bavarian et al., 2014; McCabe et al., 2005; Racine & Forlini, 2010; Sharp & Rosen, 2007), with one study finding a rate of 55% NM-stimulant use among a sample of fraternity members (DeSantis, Noar, & Webb, 2009). Canadian estimates for NM-stimulant use among postsecondary students are not available. However, a survey of students in Grades 7, 9, 10, and 12 in Atlantic Canada found that over 25% of those who were prescribed such medications had sold or given them away and that about 8% of students had engaged in past-year NM-stimulant use (Poulin, 2007). A more recent survey reports past-year use among youth ages 15-24 across Canada to be 2.4% (Canadian Centre on Substance Abuse, 2013).
Individuals who do not qualify for ADHD diagnosis have not exhibited significant effects of these medications on test performance in comparison to those taking a placebo--though individuals may believe these drugs improve performance (Ilieva, Boland, & Farah, 2013; Nonnann & Berger, 2008; Ruiz, Strain, & Langrod, 2007; Vrecko, 2013). As stated in a study that administered mixed-amphetamine salts (MAS) to young adults and compared their performance on a range of cognitive tests: "a standard clinical dose of a drug that is commonly used for cognitive enhancement did not enhance cognition ... If [MAS] does enhance cognition among healthy and adequately-rested young adults, the effects are likely to be small" (Ilieva et al., 2013, p. 504). Although NM-stimulant use may not translate into test perfonnance improvement, this does not mean that fatigued students are simply mistaken about drug effects. Stimulants have demonstrated effects of alertness and decreased fatigue, and so may allow for prolonged periods of studying (DeSantis & Hane, 2010; Ilieva et al., 2013; Nonnann & Berger, 2008; Ruiz et al., 2007). (4)
In February and March 2012, 58 semistructured interviews were conducted for a drug nonnalization research project with illicit drug-using undergraduate students and their nonusing peers at UoT. Students were recruited from a 1,300-person first-year social science elective course using e-mail announcements to the course list. Such class sizes are common for first- and second-year undergraduate courses at large, public, top-tier institutions in Canada such as the UoT. While social science students comprise the majority taking this course, it is also a popular elective for sciences, arts, and commerce students looking to fulfill degree breadth requirements. Sampling was aimed at capturing variation in experiences of navigating drug use, particularly cannabis as the most common drug of use (Adlaf et al., 2005). The semistructured interview guide was developed by the research team to explore young people's perceptions and experiences of drug use as well as the meanings that they ascribe to use of drugs, particularly cannabis. Drug acceptability was assessed through questions on whether and how often students themselves used drugs; how accessible drugs were to them; how they perceived drug use, and legal sanctions against drug use, to impact their lives and the lives of friends and family; and for drug users, how they managed the stigma of drug use.
Prior to proceeding with interviews, the interview process was discussed with participants and participants were given consent information sheets. Participants' questions or concerns were addressed before obtaining verbal or written consent, as preferred by the participant. Students were informed that their participation was entirely voluntary, that they could stop the interview at any time, and that they did not have to answer any questions they did not wish to answer. Interviews were tape-recorded and transcribed. Participants were provided a SCAN 20 honorarium. Ethical approval for this study was provided by the research ethics board at the UoT (#26892).
Although this study of drug nonnalization was not initially designed to investigate NM-stimulant use, as interviews progressed it became apparent that the subject of NM-stimulant use was being highlighted repeatedly by students. In turn, NM-stimulant use was later introduced into the semistructured interview guide as a probe to explore the salience and evaluation of this drug practice. This resulted in 36 interviews elaborating on issues of NM-stimulant use acceptability, which are the focus of this analysis. Participants ranged from 18 to 26 years of age and included 17 women, 18 men, and 1 gender diverse student. Within this subset of interviews, the majority of participants (81%; n = 29) identified as nonusers of prescription stimulants, as appears consistent with estimates of NM-stimulant use cited above. Of the 7 students who identified as engaging in NM-stimulant use, all reported use of cannabis. Three of these students also reported experimenting with illicit drugs (other than cannabis or NM-stimulant use). Of the 29 participants who did not engage in NM-stimulant use, 18 students identified as current cannabis users, 9 as nonusers of any illicit drug, and 2 as former cannabis users, that is, as having no intention to use cannabis in the future. Four of these 29 students reported having used other illicit drugs.
Thematic analysis of the interview data was guided by issues highlighted in the literature review of NM-stimulant use and drug nonnalization. Attention was directed to identifying decisions and valuations that students describe in their navigation of NM-stimulant use, and discourses that students draw upon to position assessments of NM-stimulant use. Results are grouped into three themes: (1) NM-stimulant use as a risky tool? (2) NM-stimulant use as "worth the risk," and (3) limited effectiveness of NM-stimulant use as a "study aid." (5) Taken together, these themes explore the broader question of how students situate the acceptability of NM-stimulant use in relation to the pursuit of success in a competitive university environment. All participant names are pseudonyms.
Theme I: NM-stimulant use as a risky tool? By pointing to the various risks that students refer to in their navigation of study drug use, the "NM-stimulant use as a risky tool?" theme identifies the forms that more acceptable NM-stimulant use takes, namely, nonrecreational, nonpatterned, and orally ingested. Two subthemes here illustrate student positioning of NM-stimulant use risks in relation to drug acceptability. In the more acceptable NM-stimulant use: neither patterned, nor recreational sub-theme, students position patterned or recreational usage as indicative of undesirable and potentially problematic substance use behavior, as they broadly associate such behavior with drug dependency. Whereas the more acceptable NM-stimulant use: neither patterned, nor recreational subtheme suggests a shared orientation to the evaluation of NM-stimulant risks and acceptability, student comparisons of NM-stimulant use to caffeine suggest more ambivalence in situating the riskiness of NM-stimulant use. While some students compare stimulant medications to caffeine in order to illustrate the relative similarity of both licit and illicit stimulants as tools to enhance studying in the university context, other students suggest that those comparisons are untenable due to the heightened health risks associated with NM-stimulant use. The question mark in the theme name "NM-stimulant use as a risky tool?" is intended to draw attention to the uncertainty communicated by students on the effects of NM-stimulant use. Although students are concerned about negative effects of such use, there was no clear sense of what these effects actually involve.
More acceptable NM-stimulant use: neither patterned, nor recreational. Chloe's reflections on NM-stimulant use among peers here captures what nonusing participants perceive as "more appropriate" use.
Chloe (NM-stimulant nonuser): I'm not totally against [NM-stimulant use] I guess, cuz if it helps you study--like they're only using it for study purposes, and they're using it for its real effects. They're not like: "I'm going out [to party], I'm going to take it." It's kinda like: "I'm studying, I need to focus, it's a big exam." And they don't take very big doses, so it's kind of just like an aid ... I've never used it ... I'd rather just study on my own. Cuz I don't know how it's going to affect me.
Interviewer: Do you think it gives people an unfair advantage or anything like that?
Chloe: I wouldn't say an unfair advantage ... They're people just using resources I guess. I mean, if someone didn't have a laptop versus someone who did have a laptop, like while studying, kind of with Internet, I just consider it something like that.
Chloe differentiates recreational NM-stimulant use from study-oriented use when she expresses disapproval of "going out" as a rationale to take stimulant medications. She assesses NM-stimulant acceptability according to its capacity to act as a study aid. This suggests an explicitly productivity-oriented form of use; one that Chloe sees as appropriately corresponding to clinically intended effects of enhanced "focus" or concentration (what she terms as the "real effects") of stimulant medications. These "real effects" are contrasted by Chloe's reference to "big doses" which would produce the recreationally sought effect of a euphoric stimulant high. These contrasts illustrate differences in acceptability assessments between recreational versus productivity-oriented NM-stimulant use. Chloe's description of stimulants as an optional resource to enhance studying capacity, like "a laptop," also positions NM-stimulant use as a potential tool for increasing productivity and facilitating academic achievement. Yet there is conflict evident in Chloe's description: she sees illicit access to stimulant medications as risky due to a lack of understanding of potential negative effects.
Pam also abruptly contrasts recreational with academic productivity-oriented NM-stimulant use. Unlike Chloe, Pam has engaged in NM-stimulant use.
Pam: My critical reading score went up 100 points from the first time I took [the exam], so [NM-stimulant use] definitely did something ... I just felt really aware ... I've only done it once. But a few of my friends have used it not for studying, but they crush it, they snort it, and I've never done that ... kids are really stupid sometimes.
Interviewer: What do you think about people using prescription drugs to study?
Pam: I don't really find it cheating to be honest ... it doesn't make you smarter, just shuts out noise. Kids are so overworked, overstressed, and haven't got enough sleep, that it's like, if you wanna do that, sure. I don't think it's that big a deal. Some kids would be like: "It's so unfair." But it's not increasing your intelligence. Just maybe a little extra focus.
Interviewer: So would you consider doing it again?
Pam: Honestly, no, cuz my grades are good enough without it ... Like if it's just readily there, I don't know if I would. It's not something that I'd want to make a pattern out of.
Pam expresses a stark evaluative opposition between recreational and academic NM-stimulant use, with the former being described as foolish. The "snorting" mode of ingestion is indicative of recreational use, "not for studying." Although above Pam characterizes achievement-oriented NM-stimulant use as understandable, given the pressures on time and performance in university, she is uninterested in ongoing use despite the availability of stimulant medication through her friends. This reluctance to use stimulants, despite availability, is similarly suggested by Karen (NM-stimulant user) who states that she would only engage in NM-stimulant use again if she found herself completely unprepared for an important test.
Like Pam, Nikolas found NM-stimulant use to "be very effective" for studying. Nikolas has in NM-stimulant use on multiple occasions and describes his use as being very restricted: "I use it the least as possible. I only use it if I have to. Like if I'm in a really tight situation. But every now and then, it's not bad ... If there's a pattern, that's too often." Patterned use is suggestive of a reliance on drugs in order to perform and so is taken to be indicative of problem drug use or addiction. Despite their aversion to "patterned use," participants communicated only a vague sense of where drug use may cross into the territory of "dependence."
Comparisons of NM-stimulant use to caffeine. In situating the riskiness of NM-stimulant use, some students compared such drugs to caffeine as a legal stimulant. For example, Cameron (NM-stimulant nonuser) states that:
I've never really considered [NM-stimulant use] ... Like I don't even drink coffee, so I don't believe that I need anything for my productivity.... If I was doing something at the last minute, I'd consider doing it. So I don't really care. And in the end, you're still doing the work, it's just that a drug is helping you do the work. I mean, people drink coffee, and people don't look at them differently for drinking coffee, so. Even though Adderall is obviously on a more extreme magnitude, it's still more or less the same concept to me.
Cameron discusses his ambivalence regarding NM-stimulant use in relation to stimulants as tools for productivity. His comparison to coffee suggests that academically-oriented stimulant use exists on a spectrum of acceptability, with unregulated stimulants such as caffeine being more acceptable and prescription medications as "more extreme." Yet these are all tied together by their role as tools for "helping you do the work."
Ethan (NM-stimulant nonuser) makes a similar comparison:
I don't see anything morally wrong with [NM-stimulant use]. It's probably not the best way to study, but if it works for them, I'm not one to judge ... [But] I don't want to be associated with drugs that could potentially be addictive. Or I don't want to be using things that are really going to alter my mind state. But I'm kind of a hypocrite, cuz I do drink an energy drink before each exam, just cuz I know the effects will help ... But I don't want to be in a position where I'd need to use [prescription stimulants],
Ethan's reflections highlight both the similarities between highly caffeinated drinks and NM-stimulant use and the differences between these as centered on concerns of dependency and addiction. For Ethan, NM-stimulant use is not in and of itself immoral. Rather, it is the threat that NM-stimulant use poses to self-control ("alter my mind state") and self-sufficiency ("potentially be addictive," "need to use") which underlies Ethan's aversions to such use.
Sam has engaged in NM-stimulant use, comparing it to "when you drink a lot of coffee, but without the jitteriness." Sam conveys ambivalence about occasional student NM-stimulant use but positions such use as "not a fantastic idea. It's not a good long-term thing at all." Unlike other participants' caffeine comparisons, Sam compares the potential harms of NM-stimulant use to high levels of consumption of caffeinated energy drinks. For Sam, both NM-stimulant use and high levels of energy drink use are risky as long-term study optimization strategies.
Countering the ambivalence toward achievement-oriented NM-stimulant use articulated by several participants, some students found that such use was unnecessary and could not be easily compared to caffeine. Billy (NM-stimulant nonuser) states that:
Ritalin in my mind is much harder than caffeine, which is extremely mild. Also, Ritalin, it's a prescription, obviously there's a reason for that. So if people are abusing prescription drugs as opposed to, say, coffee, that would be different for me.
Two acceptability orientations are evident in student comparisons of prescription stimulants to caffeine. Some students used caffeine comparisons to communicate ambivalence to productivity-oriented NM-stimulant use (though not to recreational or patterned use) while situating prescription stimulants as being similar, yet riskier tools than caffeine. Other students considered NM-stimulant use to be ill-advised due to the possibility of side effects or addiction, and so as not comparable to caffeine as a study aid.
Theme 2: NM-stimulant use as "worth the risk". The NM-stimulant use as "worth the risk" theme expands from the previous theme to explore the logic of how participants weigh the risks and advantages of NM-stimulant use, specifically in relation to the pursuit of scholastic success. For example, when asked if NM-stimulant use gives students any advantage, Nikolas (NM-stimulant user) states that:
Yeah. Huge advantage. Like for studying, being more focused, taking in information ... It does make you do better. It could be unfair, but at the same time ... somebody that does it a lot, they're going to be less healthy than lam ... It's just not worth the sacrifice for me. I don't feel "Oh that's unfair, and I feel bad about that." I know it's unfair, but I accept that.
Nikolas argues that any "unfairness" associated with regular NM-stimulant use is mitigated by the fact that users are making health sacrifices. For Nikolas, health acts as a currency that one can trade for success on an individualized basis. NM-stimulant use may be unfair, but because NM-stimulant users are in a sense "paying their dues" for success in the form of health sacrifices, this unfairness in turn becomes acceptable.
Robert (NM-stimulant nonuser), like Nicholas, expresses this tension between attaining success and maintaining health. Robert does not drink alcohol and avoids taking medication, aiming to be "substance free." When asked if he would consider NM-stimulant use, he responded with an ambivalence which contrasts with his resolve to be substance free:
Yeah, probably ... if it's for like future success, I mean, sure ... if it affects my memory or something, then I probably wouldn't. If it just like, shortens my life a little bit, then I probably wouldn't care that much. I'd rather be like, you know, successful, than a healthy hobo on the street kind of thing.
This conceptualization of exchanging health risks for future success is apparent throughout the interviews, and particularly in the generalized disapproval of either "patterned" productivity-oriented NM-stimulant use or recreational use.
As Robert's comment suggests, even for some students who do not use illicit drugs, NM-stimulant use was considered a possibility. Likewise, Tianna (NM-stimulant nonuser) rarely drinks alcohol and does not use illicit drugs, yet she feels that under certain circumstances, NM-stimulant use might prove acceptable:
I've been tempted before to use amphetamines, like Ritalin or something, close to exam time. But I've never done it ... the fear of damaging my brain is always in the back of my mind ... For me, personally, I just wouldn't, but for anyone, sure.... It's not that I'm actively considering it, but there are times when I'm studying and it's late at night, I'm tired, I need to cram in 100 more pages ... [NM-stimulant use] looks good! You know? It looks fantastic. Would I love to be hyper-productive? Absolutely! What's the crash like? You know what, when I'm tired, things like that don't matter as much.
Although less explicitly a statement of NM-stimulant use being "worth the risk" than is apparent in Nikolas' reflections, Tianna's comments nevertheless elicit that sense of tension between feeling driven to succeed and the health risks and sacrifices students associate with NM-stimulant use.
Michael (NM-stimulant nonuser) generally disapproves of NM-stimulant use. He suggests that proximity to NM-stimulant users and accessibility may compel students to consider such use:
I just feel like you're resorting to something, instead of time managing, or getting services from the [student] center. It's like instead you've just chosen to take a drug to mitigate all those other things that you could've adjusted. But easier said than done. Like, it's not an easy thing. Especially if you have access to it, and a group of friends who does it, and [they say] "Yeah it's safe, I'm ok, it just helps me really focus." I definitely feel like it's a very last resort for me.
NM-stimulant use exists as a potential resource, particularly as one of "last resort," for strained students. Maintaining self-sufficiency in academic work by avoiding risks to health that are "unnecessary" is central to evaluations of when NM-stimulant use is "worth the risk." If the effects of prescription stimulants are short-lived and controlled, that is, they do not result in addiction or (immediate) detrimental health effects, then use is seen as more acceptable. This attitude is also captured by student aversions to patterned usage, as shown in the "NM-stimulant use as a risky tool?" theme above, where patterned use suggests a risk of substance dependence, a "disease of the will" (Valverde, 1997) that fundamentally threatens one's capacity for self-control.
Theme 3: Limited effectiveness of NM-stimulant use as a "study aid". As illustrated above, participants generally positioned NM-stimulant use as being more acceptable when it is not patterned, and when it is used as a productivity tool for alertness that facilitates assignment completion or long hours of studying. Chloe's comments on such use being like a "laptop" capture this tool-based conception of NM-stimulant use, as do student comparisons of prescription stimulants to caffeine (though this tool may be seen as "too risky," particularly by nonusers). Despite the perception that nonmedical use of stimulants may facilitate academic achievement, several participants were hesitant to identify such use as "cheating." The final theme identifies an understanding among students that NM-stimulant use provides limited compensation for health risks because it is not seen as able to enhance one's intelligence. Instead, NM-stimulant use can provide compensation for fatigue or lack of time by potentially increasing alertness and thus prolonging engagement in work.
Ron (NM-stimulant nonuser) locates the pressures to engage in NM-stimulant use in the organization and costs of university. To Ron, NM-stimulant use is understandable given these pressures, but it only facilitates completing assignments, not "learning" from them:
I don't think [NM-stimulant use is] good for memory, you don't really learn anything, you're just finishing assignments ... I think that [NM-stimulant use] has a whole lot to do with the school system ... there's a personal fear of the length it takes to graduate, and also the what's going to happen after graduation ... The fact that it's expensive is really putting a toll on people, especially now that it's a recession.
This sense that "you don't really learn" when engaging in NM-stimulant use is echoed by Gary (NM-stimulant user):
Everything was just happening so fast [when I took Adderall], You're writing, you're stimulated, you're concentrated. It's not cheating, because cheating means there's a benefit. People that take Adderall ... don't get me wrong, they'll get good marks, and they'll think they're successful. But they're only putting themselves through a meat grinder. Whereas the person who comes here and really just absorbs everything. And that's the person who's gonna be brilliant at the end of his university career.
Thus, for Ron, and particularly for Gary, the benefits of increased alertness and concentration do not carry over to "really just absorbing]" the material, though this does assist in completing assignments and meeting the deadlines necessary to accrue educational credentials. This characterization positions academic NM-stimulant use as "not cheating" insofar as such use does not alter something seen as fundamental to fair evaluation and to individual character: intelligence or learning capacity. Pam's comments above also convey this understanding that NM-stimulant use does not "make you smarter."
A "compensatory" understanding of academically oriented NM-stimulant use acceptability is evident, such that changes in performance are not beyond what one would be capable of in rested, less stressful circumstances in the absence of NM-stimulant use. That is, if NM-stimulant use resulted in enhancements to what students perceive to be essential aspects of one's character, such as learning capacity or intelligence, this would suggest that NM-stimulant use could constitute "cheating" and so would be unacceptable. In contrast, enhancements to alertness or focus in the pursuit of academic achievement are not necessarily seen as unfair. This lack of fundamental concern with the unfairness of alertness optimization is partly captured by student comparisons to caffeine as an acceptable stimulant alertness aid. Rather than constituting "cheating," some participants propose NM-stimulant use be understood as a compensatory strategy for fatigued students, albeit a riskier one than caffeine use.
Discourses of Health and Risk in the University Context
In order to identify the evaluative metrics of drug acceptability circulating in the arena of student life, this article looks to the operation of discourses that converge in patterning drug-using and non-using student repertoires of what constitutes responsible or acceptable drug use practices, and what instead signals deviance, lack of moral standing, and vulnerability to addiction. Such discourses produce moral imperatives of health at the same time that they produce possible avenues for conduct, evaluation, and pressures as well as possibilities for self-cultivation (Race, 2009; Rose, 2007; Turner, 1992). Discourses of health and risk responsibilize individuals for social sources of pathology or disorder, situating them as accountable for their own life outcomes regardless of unequal access to social, symbolic, and material resources for normative self-making which also structure one's mode of living (Gusfield, 1996; Hannah-Moffat & O'Malley, 2007; Hunt, 2003; Skeggs, 2004a).
Participants draw upon these discourses of health and risk to articulate that students are responsible for their personal decisions about how they choose to pursue scholastic success. Exchanging health risks for success, as through NM-stimulant use, is understood as one such decision. Failure to avoid drug dependence or associated harms is suggestive of a lack of self-discipline or sufficient care in conducting one's consumption (Race, 2009; Valverde, 1997). Risk concerns are especially evident in student discussions of peer recreational NM-stimulant use, which are largely considered an illegitimate form use by participants. Concerns are also evident in students' vague descriptions of patterned use as potentially resulting in dependence. While dependence can occur with chronic stimulant usage, the students here do not articulate how much of a pattern results in vulnerability to dependence. This analysis contradicts recent findings that NM-stimulant users in university frame stimulant use as generally lacking harmful physical side effects in order to justify their use (see DeSantis & Hane, 2010). In contrast, the current study finds that concern with health harms figures prominently in delimiting the acceptability of forms and patterns of NM-stimulant use among both users and nonusers.
Respondents broadly hold in common an ethic of self-sufficiency for the evaluation of NM-stimulant use acceptability. This ethic operates as a moral compass for navigating NM-stimulant acceptability in relation to university pressures, even among nonusing students. This ethic involves practices of moderation, or self-regulation of substance intake to the aim of avoiding any prolonged negative effects on performance. For several participants, this meant that sporadic NM-stimulant use as a resource of "last resort" was acceptable but ill-advised due to the more extreme nature of NM-stimulant use in comparison to popularly available legal stimulants, such as caffeine products, and the potential for harm or addiction. For others, only medically prescribed stimulant use was acceptable since NM-stimulant use presented unwarranted health risks that ultimately threatened this self-sufficiency.
The ethic of self-sufficiency is informed by responsibilizing discourses of risk and health discussed above. These discourses lend themselves to an individualized sense of struggle for achievement among students. Although students repeatedly pointed to contextual pressures centered on workload management and maintaining scholastic performance as drivers of NM-stimulant use, their responses to these pressures were very matter-of-fact. Students approached these pressures as simply those of university life and saw little alternative but to bear the pressure as best one could. The social process of pharmaceuticalization, whereby "pharmaceutical products come to be put to work in the management of an increasingly wide array of problems and experiences" (Vrecko, 2015, p. 299), is evident in the way that both users and nonusers navigate the acceptability and administration of stimulant medications in pursuit of university education and in response to these contextual pressures.
When these contextual pressures coalesce, they make it difficult for students to meet demands for academic success and so act as push factors for students to consider unsanctioned resources such as NM-stimulant use. Financial pressures, particularly in the face of growing employment uncertainty postgraduation, also play a role in the sense of generalized strain experienced by students. In addition, familiarity with peer group NM-stimulant use acts as a contextual pull factor. No student suggested that peers pressure one another into NM-stimulant use. Rather, NM-stimulant use becomes more salient as a resource for personal use once peers confirm drug effects and provide potential avenues for access to medications. This social learning effect has been supported by quantitative research on student NM-stimulant use (Peralta & Steele, 2010; Schroeder & Ford, 2012). Yet as several participants above indicate, simply because students have engaged in NM-stimulant use previously does not mean they are interested in continuing such use, even if their experiences were positive ones.
While NM-stimulant use is understood as unable to alter one's intelligence, students may nevertheless perceive themselves to be performing more effectively during a test due to an enhanced sense of focus. Recent research reports lack of significant effects of clinical stimulant doses on student performance on a variety of cognitive tests among "adequately rested" students (Ilieva et al., 2013). In fact, this research suggests that academically oriented NM-stimulant use may slightly reduce performance (Ilieva et al., 2013; Normann & Berger, 2008). The findings of Ilieva, Boland, and Farah (2013) indicate that NM-stimulant use does not effectively operate as a "doping agent" for test scores. Interestingly, this is confirmed by participant responses above that suggest some students recognize NM-stimulant use as not impacting learning capacity.
The health sacrifices associated with NM-stimulant use appear to offset student concerns of unfair advantages. Students signal the existence of an exchange economy of achievement (afforded by extending time awake or concentration) and health risks, where one who engages in NM-stimulant use is seen as paying dues in the form of life years or eventual health compromises. Engaging in NM-stimulant use is thus positioned as an individual choice of risk assessment. Such an economy helps us to understand why students would be reluctant to call such use "cheating," which intimates a request for authoritative intervention and regulation to dispel unfair advantage. Rather, NM-stimulant use appears to be approached as a self-governing economy of advantages and built-in costs, and so one that does not compel students, users or nonusers, to call for university intervention into protecting the process of academic evaluation from the impacts of "unearned" advantages.
In sum, NM-stimulant use is evaluated as acceptable by the students here in terms of it being an exchange value-oriented productivity tool--one that must be negotiated in relation to the ethic of self-sufficiency which guides moral appraisals of NM-stimulant self-administration practices. Students are constantly in the process of navigating the health pressures of scholastic performance in terms of fatigue, stress, and lack of sleep. The patterning of student responses in how they evaluate NM-stimulant acceptability indicates that the ethic of self-sufficiency is geared toward the pursuit of two related goals among both NM-stimulant-using and nonusing students. First, self-sufficiency is conceived in terms of ableist conceptions of health, such that one is able to continue developing one's accrual of educational capital--a goal which students suggest cannot be effectively pursued in the case of patterned, dependent, or otherwise problematic NM-stimulant usage. Second, self-sufficiency is understood in terms of eventual employability, which may require short-term exchanges of health or engagement in "risky" behavior to accrue the necessary educational capital to ensure success (and avoid becoming what Robert derides as a "healthy hobo"). The ethic of self-sufficiency is thus a way of navigating the ongoing tensions between the accrual, exchange, and maintenance of health and educational capitals in a competitive university context.
Yet it is clear that students do not unilaterally take up the discourses of health and risk in pursuing academic success, nor do they do this in a way that corresponds to institutionally sanctioned directives. Discourses are productive of potential ways to navigate, evaluate, and discipline conduct. Evident in student descriptions of NM-stimulant acceptability is the creative mix-and-match manner with which they navigate the multiple and contradictory demands placed upon them in university. (6) Students recognize they must remain free of problematic substance use in order to pursue educational success. They also identify the pressures they face with regard to lack of sleep and the need for supplementing study habits with stimulants, legal or otherwise. Thus, some students are complying with directives for academic success (e.g., studying for long hours) but through the use of illicit tools that subvert university codes of conduct and through an experimental juggling of health risks for success "payoffs." The self-sufficiency ethic informs how students navigate these demands, providing a way to integrate contradictory directives and to guide their experimentations with illegal and legal stimulants. Given that academic success is seen as a primary determinant of future employment, it is little wonder that even students who do not use illicit drugs and who are averse to personal NM-stimulant use have come to consider it as a viable strategy, should they find themselves in difficult circumstances.
Implications for the Drug Normalization Framework
Drug normalization is a framework or "barometer of change" (Parker, 2005) intended to assess shifts in drug use trends. Drug normalization is characterized by several components including (a) changes in rates of illicit drug use, in drug accessibility, and in availability of drug knowledge among users and nonusers; (b) cultural accommodation of drug use, as for instance, is evident in the proliferation of favorable media depictions of illicit drugs; and (c) in acceptance of drug use as part of "ordinary" life, or drug acceptability, identified in the attitudes of both drug users and nonusers toward drug use (Aldridge et al., 2011; Duff et al., 2012; Hathaway, 2004).
Although the drug normalization framework has proven fruitful for expanding the scope of knowledge on drug acceptability, this framework was initially developed in the early 1990s, when productivity-oriented illicit substance use was not a prominent phenomenon. Thus, there are apparent limitations to applying the framework for investigation of NM-stimulant use. Like much research on conventional population drug use, drug normalization literature proceeds from a binary approach to understanding drug acceptability according to the categories of "problematic" or "recreational" use (Aldridge et al., 2011; Parker, 2005). Due to its largely nonrecreational character (Arria et al., 2008), student NM-stimulant use for studying is unlikely to be adequately described by these binary formulations on which the drug normalization framework has relied to characterize assessments of acceptability. This limitation arises because the normalization framework was developed from this "problematic versus recreational drug use" division as an operative analytic foundation. Recreational use was initially formulated as a way to push the research conversation beyond "pathological" or "deviant" drug use on which the majority of drug studies have focused, yet which characterizes but a small fraction of all illicit drug activities (Aldridge et al., 2011; Duff et al., 2012; Parker, 2005). This analytic move was an important development in sociological work on drug issues. However, the growing salience of productivity-oriented illicit substance use now requires normalization research to attempt to account for drug use that cannot be classified as neither recreational pleasure-/leisure-oriented use nor problematic due to compulsive or damaging use patterns.
As indicated by the phenomenon of student NM-stimulant use as a "study drug," examples of substance use are steadily emerging that do not conform to the "controlled pleasure" versus "pathology" evaluative principles initially posited by the drug normalization framework. (7) The interview analysis above suggests a conceptual compatibility that allows for extension of the normalization framework to consider illicit drug use that is oriented toward productivity and achievement. The interviews illustrate that student acceptability assessments of NM-stimulant use are indeed anchored in considerations of pathological or problematic use, which corresponds with the original formulation of the normalization framework. However, beyond their references to pathological use, student assessments of academically oriented NM-stimulant use are simultaneously anchored in considerations of recreational use as largely unacceptable in the context of a competitive university environment. So while "recreational" and "achievement-oriented" drug use evaluations are assessed by comparison with one another, both of these evaluations share a foundation for acceptability assessment in the form of "pathological" drug use. These student evaluations of NM-stimulant use thus suggest that a third type of substance use be conceptually integrated into the normalization framework's construct of acceptability assessment: productivity and achievement-oriented illicit drug use.
This article contributes a qualitative exploration of student navigation of NM-stimulant use acceptability. This analysis suggests that NM-stimulant use is not adequately captured by the formulations of "recreational versus problem" dichotomy of acceptability put forward by the drug normalization framework. Instead, the focus in student evaluations of NM-stimulant acceptability is not limited to the recreational use of drugs to "get high" versus "problematic use" typified by compulsive or patterned drug behavior but includes a separate set of highly conditional evaluative standards specific to the university context: the capacity for NM-stimulant use to temporarily enhance alertness for a period of time in order to facilitate academic success. It is the context of university pressures and goals of academic success that bring into view the parallel alignments between the repertoires of using and non-using students on NM-stimulant use acceptability.
Where might such an orientation be traced? Beyond their familiarity with caffeine as a stimulant tool to get through long days, students are also introduced to understandings of drug effects and self-administration practices through the widespread prescription of stimulant and antidepressant medications to peers, friends, and family (Quintero, 2012; Rose, 2007). Indeed, several participants cited friends or family being prescribed such medications. As stigma for mental health medication use decreases, and as people are expected to actively participate in the pursuit of mental and physical health through psychological or psychopharmaceutical therapies, the conversation regarding self-regulation also shifts from medical to more generalized discourses of well-being and achievement (Race, 2009; Rose, 2007). Situating student approaches to NM-stimulant use within the institutional pressures of the university and within wider social processes that converge to prompt specific approaches to drug acceptability can help us to understand why favorable attitudes to productivity-oriented NM-stimulant use are gaining traction even among students who declared themselves opposed to illicit drug use.
It is important not to assume that NM-stimulant acceptability evaluations or rates of use are uniform across students. Although beyond the scope of this article, future work should consider how racialized, gendered, and other axes of inequality differentiate acceptability evaluations and use patterns. For instance, recent reports on rates of adult ADHD prescription suggest that women have begun to outnumber men in receiving diagnoses--an inversion of the childhood diagnosis pattern (Express Scripts, 2014). Women also have been demonstrated to engage in NM-stimulant use for bodily modification and to face stigmas of use very different from those faced by men (Poole & Dell, 2005; Sharp & Rosen, 2007; Vecitis, 2011). It is unknown whether these gendered patterns transfer to NM-stimulant use in the university context.
This article is limited mainly to the perspectives of first-year social science students. All NM-stimulant users in this sample described their use as being infrequent, as is consistent with quantitative research which finds that most NM-stimulant use is sporadic among university students (Arria et al., 2008). Older students, those in different disciplines, and those who engage in more frequent NM-stimulant use may suggest different evaluations of acceptability. Further comparative work is essential to expanding understanding in this regard. The sensationalization of hazardous instances or risks of student NM-stimulant use by the media and academic researchers is likely to drive "an anxious demand for ... authoritarian techniques aimed at domesticating consumption" (Race, 2009, p. 79). In the face of what may be a brewing drug panic, it is important to advocate for proportionate policy responses to address harmful use practices; failure to do so will result in marginalization of visible drug users rather than effective reduction of harms, as the history of drug panics so clearly illustrates (Race, 2009; Young 2009). Given the generally sporadic nature of NM-stimulant use documented among university students (Arria et al., 2008), increasing the restrictiveness of prescribing practices looks to be positioned to disproportionately negatively affect those who require medication for treatment, rather than to deter those who are illicitly using such medications (Ruiz et al., 2007). In addition, given the lack of evidentiary support that NM-stimulant use operates as a "doping agent" to inflate test scores (Arria et al., 2008; Ilieva et al., 2013), punishment of study drug use as "cheating" does not appear to be a viable strategy to ensure academic integrity. Further, identifying NM-stimulant-using students requires invasive surveillance (e.g., searching of student belongings to confirm illicit possession of stimulant medications) and drug testing (e.g., urinalysis), and so encounters various legal barriers. It is doubtful that Canadian universities could justify such intrusive and costly measures, given the low level of harm currently posed by NM-stimulant use, in addition to the lack of evidence for effectiveness of "cognitive enhancement" practices.
Rather than the pursuit of punishment and surveillance, providing education on the potential harms and lack of effectiveness of "study drug" use may help to discourage students from turning to NM-stimulant use in moments of desperation. The results here suggest that universities, especially those with highly competitive environments, would do well to evaluate the roles that tuition structures, examination schedules, and grading practices play in contributing to the student "meat grinder" that compels consideration of NM-stimulant use as a compensatory strategy.
The author would like to thank Dr. Patricia G. Erickson, Dr. Adam I. Green, Dr. Philip Goodman, Dr. Ronit Dinovitzer, Dr. Monica Boyd, and Dr. Ann Mullen for their support throughout the writing of this article, and the anonymous reviewers for their thoughtful comments.
Project investigators include Dr. Andrew Hathaway (principal investigator), Dr. Geraint Osborne (coinvestigator), and Dr. Patricia Erickson (lead coinvestigator for the University of Toronto portion of this project).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by a Social Sciences and Humanities Research Council Grant.
(1.) Undergraduate students are here considered "conventional" insofar as that relative to marginalized drug users, university students face lower risk of criminal sanction for their drug use.
(2.) "Problematic" drug use generally refers to patterns of use characterized by dependency (physiological or psychological) and/or by socially detrimental effects such as crime and poor social functioning. "Recreational" drug use is characterized in drug normalization literature as the occasional leisure-oriented use of certain substances in a controlled way (Aldridge et al., 2011; Parker, 2005).
(3.) Common names for "psychostimulant" medications prescribed for attention-deficit hyperactivity disorder include ritalin, biphentin, and concerta (methylphenidate); adderall (mixed-amphetamine salts); and dexedrine (dextroamphetamine; Poulin, 2007).
(4.) Stimulant medications are usually taken orally, though pills may be crushed and snorted. Typical clinical doses have been demonstrated to be safe in individuals without cardiac issues (Graham et al., 2011; Kooij et al., 2010). Low or clinical doses result in some of the effects sought after by students: alertness and decreased fatigue. Larger doses, more common with recreational use, may result in euphoria and may be accompanied by side effects such as insomnia, anxiety, and irritability (Ruiz et al., 2007). Depending on severity, overdoses may induce severe agitation, cardiac issues, and may be lethal (Rosenfield et al., 2011). Prolonged use at doses that exceed clinical applications may result in behavioral dependence (Ruiz et al., 2007).
(5.) Theme 1 was identified in 20 of the 36 interviews, Theme 2 was identified in 13 interviews, and Theme 3 was identified in 11 interviews.
(6.) In the interviews, students are not simply expressing their views on stimulant acceptability but are also constituting themselves as enterprising subjects (Callero, 2003; Skeggs, 2005). Through their narrative positioning of what signifies "responsible consumption" of stimulants, students perform a disciplined, calculating self that appropriately self-regulates NM-stimulant use. By attributing a moral value of self-discipline to themselves, they may make a claim to the role expectation of "good student," whereas habitual or recreational NM-stimulant users are positioned as a foil for excessive or risky conduct that demands sanction.
(7.) Other research, though not addressing the drug normalization framework directly and usually limited to athletes or specific subcultures of drug use, is also engaging in the conceptual work of problematizing this dichotomy (Duff & Erickson, 2014; Monaghan, 2002; Pappa & Kennedy, 2013; Race, 2009; Vecitis, 2011).
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Kat Kolar is a PhD student at the Department of Sociology, University of Toronto, where she is completing the Collaborative Program in Addiction Studies.
Kat Kolar (1)
(1) Department of Sociology, University of Toronto, Toronto. Ontario, Canada
Received July 30, 2015. Accepted for publication October 6, 2015.
Kat Kolar, Department of Sociology, University of Toronto, 725 Spadina Avenue, Toronto, Ontario, Canada M5S 2J4. Email: firstname.lastname@example.org
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|Publication:||Contemporary Drug Problems|
|Date:||Dec 22, 2015|
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