OPINION
DOCTORS' Lounge
of testing and inconsistent punishment for
illicit drug use, and lack of recent studies
elucidating the problem all contribute to
the ubiquity of stimulant use among med-
ical students.
Primary studies of medical student
stimulant use are entirely cross-sectional
surveys. The general conclusion of litera-
ture review articles (Substance Use Among
Physicians and Medical Students - Catalina
I. Dumitrascu1*, Philip Z. Mannes2, Lena J.
Gamble3, Jeffrey A. Selzer4), is that there is
not enough data on the subject. Prevalence
of stimulant use among both international
and US medical students varies from 11-20
percent in surveys. In one of the more recent
(2013) US-based cross-sectional surveys,
the most common (62.5 percent) reason
for stimulant use among medical students
was, “to help me study” and 18 percent of
medical student users reported their meth-
od of ingestion as inhalation.
The popularity of stimulants on college
campuses is partly due to their being pre-
scribed on subjective criteria. If a person
wants a prescription, they only need to learn
the diagnostic criteria and present as symp-
tomatic to a prescribing physician. If you are
even nominally medically literate, it is easy
to do this. Some medical school classmates
of mine have described not needing to take
stimulants during their (demonstrably suc-
cessful) undergraduate careers but being
unwilling to take the risk of being distract-
ible or unproductive during medical school.
This rationale in isolation does not satisfy
the diagnostic criteria for the conditions for
which amphetamines are prescribed, chiefly
Attention Deficit Hyperactivity Disorder
and Attention Deficit Disorder.
Risks of stimulant use are beyond the
scope of this article but can be crudely
summarized as addiction and cardiovas-
cular stress. On a personal note, I would
add that classmates on stimulants become
irritable and lose qualities that make them
charismatic, creative and just plain fun to
be around. Idiosyncratic changes aside, why
would a medical student want to take an ad-
dictive substance with clear cardiovascular
health risks?
The advantages of stimulant use to a
medical student are concrete and manifold.
In addition to the initial physical buzz of
energy, the user gains focus on whatever
mundane task they are engaged in for the
predictable duration of their dose. My class-
mates in medical school took long-acting
pills to prepare for studying in the morning
and might take another short-acting pill in
the evening if they needed more study time.
It seemed that these students were unable
to continue studying without an extra dose.
Or at least it would have been so compara-
tively unproductive as to make it worthless
to study without stimulants. Socially, they
are often used as an alternative to cocaine
or other stimulants and act as legal, inex-
pensive and readily available surrogates for
street drugs. I have seen medical students
leave parties to procure stimulants because
they were unable to enjoy themselves with-
out them.
Loss of function can also help the stu-
dious stimulant-user as parasympathetic
suppression leads to decreased appetite and
GI motility. You don’t get hungry as often.
You don’t go to the bathroom as often. You
don’t spend as much time preparing food,
or going to get it, or daydreaming about it.
You can crank out eight hours in the library
without much corporeal distraction. There
is an understandable benefit to taking stim-
ulants, but another powerful motivator is
the danger of not taking them.
The risks of failing as a medical student
are huge. Student loan debt has skyrocket-
ed from an average of ~$70,000 (in today’s
dollars) in 1986 to $179,068 in 2016. The
number of unmatched US medical school
graduates, while not large (1,279), is not
drawn from the highest-scoring special-
ties alone. Therefore, students have reason
to abuse stimulants no matter how com-
petitive the specialty they chose to pursue.
Furthermore, student performance is based
on, well, just that. Performance is measured
by standardized test scores. Performance
isn’t measured by the obstacles overcome in
achieving it, or the personality traits devel-
oped through the process. Performance in
medical school is certainly not measured by
the medications used to help you achieve it.
As one would expect, there are strict
drug-use policies in place at medical
schools, but enforcement is nebulous
when it comes to pharmaceutical stimu-
lants. Medical schools may even encour-
age struggling students to be prescribed
stimulants as a remedy for failing grades.
Every medical student at the University of
Louisville submits to a urine drug screen
once per year as of 2018. The data from
those tests are not being studied and the
repercussions of failing are handled on a
subjective basis. The answer to whether the
lack of data represents a problem is as sub-
jective as policymakers would like it to be.
The risks of failing medical school are
dangerous to the students, their families,
the school, and the state. What are the risks
of allowing a generation of students to use
performance-enhancing stimulant medi-
cations? Are we encouraging stimulant use
by putting non-users at a disadvantage? Is
there a need for a drug-use detection and
enforcement policy in place in our nation’s
medical schools, despite the controversy at
what might be revealed? Is this a problem at
all if it means higher test scores and greater
professional attainment? What are the risks
to the hearts, minds, personalities and cre-
ativity of our future physicians? Why is an
NCAA athlete subject to more drug tests in a
few months than a medical student is during
the entire four years of medical school?
Neither the commonality of illicit stim-
ulant use nor the lack of data is good reason
to ignore this issue. As physicians we have
the sobering responsibility and training to
discover problems that our patients might
be unaware or in denial of. Can today’s
medical students depend on their physi-
cian-administrators to hold them account-
able for their own health and, by extension,
ensure better care of their future patients?
The answer to this problem will depend
on acknowledgment of the problem, cre-
ative data collection, and most crucially;
courageous leadership. For the sake of my
children whom I may one day be able to
support along their path through medical
school, I hope that change comes soon.
MARCH 2019
27