Joint Subcommittee to Investigate Illegal Use of Ritalin and OxyContin and to Study ADD and ADHD
August 28, 2001, Richmond
Attention Deficit Hyperactivity Disorder (ADHD)
One of the most common mental disorders among children, Attention Deficit Hyperactivity Disorder (ADHD) affects an estimated three to five percent of all children in the United States; other estimates place ADHD in two to 9.5 percent of school-age children worldwide. The condition typically begins in childhood, often between the ages of three and five, and may persist throughout adulthood. Today, specialists agree that ADHD is not a single condition but may be classified in subtypes reflecting the behaviors typically associated with the condition: inattentiveness, impulsivity, and hyperactivity. While these behaviors are certainly not necessarily indicative of ADHD, experts generally assess whether these behaviors are excessive, pervasive, and long-term. Distinguishable from ADHD are certain classroom behaviors that may be addressed through adjustments in instruction, recognition of learning style, or acknowledgement of individual student emotional or social needs.
The causes of ADHD remain under scientific investigation. Theories being explored today focus on brain development and processes as well as possible genetic influences. Recent brain imaging studies and other research indicate the involvement of specific brain areas that regulate attention; one theory focuses on genetic mutationsspecifically, defects in those genes responsible for the regulation of the brain's use of the neurotransmitter dopamine.
Controversy in Diagnosis and Treatment
Treatment options typically combine parental support and education, appropriate school placement, behavioral therapy, and pharmacology. Three medicationsall classified as stimulantshave been used over the years to treat ADHD: Ritalin, Dexedrine or Dextrostat, and Cylert. Although considered safe when administered under medical supervision, the stimulant drugs can be addictive if misused by adolescents and adults. Used since the 1960s, Ritalin is found to assist 70 to 90 percent of children over age five for whom it is prescribed.
Recent years have witnessed growing concern regarding cases in which children who do not suffer from ADHD, but whose disruptive behavior prompted by other conditions or causes may be classified as impulsive or inattentive, are medicated unnecessarily. Expressing additional concerns are some physicians and educators who question describing ADHD as a disease or disability and who urge increased focus on the talents and skills of these children.
Prompting much of this debate are escalating Ritalin prescriptions. One 1995 estimate reported that 10 to 12 percent of American boys between the ages of six and 14 have been diagnosed with ADHD and are receiving Ritalin. In Virginia, an estimated 20 percent of white male fifth graders received a stimulant medication from school officials; in North Carolina, another study indicated 10 percent of all children were taking these medications either at home or at school. According to the Drug Enforcement Administration (DEA), production of Ritalin increased 450 percent over a four-year period in the mid-1990s.
1999 Rankings: States
with Highest Use of Methylphenidate
Grams per 100K
Source: DEA Congressional Testimony, Statement by Terrance Woodworth, Deputy Director, Office of Diversion Control, Drug Enforcement Administration Before the Committee on Education and the Workforce: Subcommittee on Early Childhood, Youth and Families (May 16, 2000) <http://www.usdoj.gov/dea/pubs/cngrtest/ct051600.htm>
Ritalin use varies across the United States, with children in parts of the Northeast and Midwest three times as likely to be on the medication than children in the Southwest. Youngsters in Hawaii and New Mexico are prescribed Ritalin the least frequently. Differing attitudes toward medications, insurance coverage, physician preferences, and other factors are generally viewed as contributing to the range of prescribing frequencies.
Public school students diagnosed with ADHD may be eligible for special education under the Individuals with Disabilities Education Act (IDEA). Other accommodations may include providing a low-distraction work area, allowing space and mobility for the hyperactive student, preparing the student for daily shifts in activities, providing assignments and instructions in brief steps, offering alternative testing formats, and providing weekly course syllabi and lesson outlines.
Although the Commonwealth currently does not specifically track the numbers of public school students diagnosed with ADHD, Department of Education data for the 1998-1999 school year indicate that a total of 9,414 students were designated as "other health impaired," a categorization that embraces some children diagnosed with ADHD. It is important to note, however, that this figure includes children who have been diagnosed with a range of other impairments, and does not include those children with ADHD whose condition does not warrant special education services.
One of the top prescriptions stolen in the United States, Ritalin has been misused to experience a "euphoric" high, to counter the effects of alcohol, and to assist in studying. The drug may be prepared for injection or crushed and inhaled. The DEA includes methylphenidate among its listed "drugs of concern" and has reported that filler materials in Ritalin prompt serious complications when injected. Available in five, 10, and 20 milligram tablets as well as a timed-released formula, Ritalin has been reported to sell on a "street market" at three dollars to $15 per tablet, compared to the prescription cost of 25 to 50 cents per tablet. More recent data indicate street prices of five to six dollars per tablet. Because the medication targets dopamine neurotransmitters, it resembles the stimulant characteristics of cocaine. While there is little hard data regarding specific Ritalin-related crimes, anecdotal information reveals incidences of abuse, theft, and diversion by dispensing school officials, sales among students, and threats against students on the medication to sell their pills.
The superintendent of the Virginia State Police described the work of the Drug Diversion Unit (DDU), initially created with state and federal funds in 1987 as the Pharmaceutical Diversion Investigative Unit within the Virginia State Police. The unit's mission has been the statewide investigation of criminal diversion of drugs; the establishment of a database to assist in identifying the breadth of diversion activities; and the education of health care professionals, law enforcement personnel, and the public regarding illegal drugs. The State Police now fund the unit.
The diversion of Ritalin and OxyContin continue to be "a problem in Virginia." Diversion of Ritalin, however, is far less prevalent than diversion of OxyContin. Noting increased Ritalin production and numbers of ADHD diagnoses, the DDU received three complaints of Ritalin diversion in 1998, nine in 1999, and seven in 2000. To date, the DDU has received eight such complaints in 2001. Diversion is primarily accomplished by "doctor shopping" to obtain multiple prescriptions for subsequent use or sale to others, or by adult patients obtaining an ADHD diagnosis through deception.
In addition to exploring Ritalin abuse, the study resolution also directed the joint subcommittee to examine the abuse and diversion of OxyContin in the Commonwealth. Rural communitiesprimarily in Maine, Massachusetts, Kentucky, Ohio, Virginia, and West Virginiawere the first to witness marked abuse of OxyContin, a prescription pain reliever patented in 1996. Abuse of OxyContin may be facilitated in part by its potency, effectiveness, and available dosages.
A prescription pain reliever, oycodone hydrochloride is derived through an alkaloid found in opium. Typically prescribed to alleviate pain associated with injuries, cancer, arthritis, and other conditions, oxycodone products include not only OxyContin but also Percocet, Percodan, and Tylox. Oxycodone products act as a central nervous system depressant, yielding responses ranging from simple pain relief to respiratory depression and euphoria.
With increased emphasis on legitimate pain management within the medical profession, sales of painkillers rose to $1.8 billion in 2000, having tripled since 1996. Studies indicate a corresponding painkiller abuse over the same period. Although specific data is admittedly scarce, a 1999 estimate reported that four million Americans used painkillers in the last month for "nonmedical" purposes. The statistic divides first-time and repeated abusers in nearly equal portions. The Drug Enforcement Administration places oxycodone and similar drugs among those most frequently abused.
Deaths from OxyContin overdoses have been reported in the past three years across the country; Pike County, Kentucky, reported 19 such deaths in the year 2000 alone. Similarly, four fatal OxyContin overdoses have occurred in Pulaski, Virginia, since 1998, and five since May 2000 in southwestern West Virginia. In April 2001, Virginia officials were reported as attributing at least 28 deaths due to OxyContin abuse in the past two years.
A plan released in May 2001 by Purdue Pharma, the manufacturer of OxyContin, and the DEA targets the dissemination of educational brochures to physicians and pharmacists; the distribution of tamper-resistant prescription pads to Alabama, Maine, and Virginia doctors; and support for a study of "best practices in state prescription monitoring programs" with the goal of developing a national model. In addition, Purdue Pharma is working with the Virginia Attorney General to co-sponsor continuing medical education regarding OxyContin abuse for physicians in southwest Virginia.
Many of the 55 oxycodone-related deaths in Virginia are attributed to suicide, and the victims are most often middle-aged, white females. Victims also typically have alcohol or other drugs in their system, in addition to the oxycodone. Consistent with national trends, OxyContin abuse in Virginia is clustered in rural, mountain areas. However, while Southwest Virginia has witnessed much of the abuse, there is increasing evidence that the problem may be waning in that regionperhaps due to arrests and convictionsand escalating in Northern Virginia.
According to the Virginia State Police, OxyContin diversion is primarily achieved through "doctor shopping" and physician over-prescribing. In addition, instances of importing from Mexico or Canada, forged or altered prescriptions, and travel to neighboring North Carolina or from West Virginia and Kentucky to Virginia to obtain prescriptions have been reported. While Ritalin and OxyContin abuse remain problematic among school- and college-aged students in Virginia, these drugs are more often diverted and abused by other age groups. Campus police at Virginia Tech, Virginia Commonwealth University, and Radford University have reported no campus arrests involving either of these drugs. State Police statistics indicate that prescription drug arrests typically involve individuals between the ages of 31 and 40.
Like the Task Force on Prescription Drug Abuse, the State Police cited the value of a prescription drug-monitoring program. Already in effect in 17 states, these initiatives can protect patient privacy and ensure legitimate access to prescription medications while tracking physician, pharmacy, and patient information and providing information access to doctors as well as law enforcement personnel.
Also recommended was increasing the penalty for distribution of Schedule III and IV substances from misdemeanor to felony. While fraudulently obtaining these drugs is a felony, distribution remains a misdemeanor. Additional recommendations included requiring photo identification for obtaining Schedule II drugs (such as Ritalin or OxyContin); ensuring that any legislation addresses a class or schedule of drugs, rather than particular product names; and enhancing resources for the DDU, which currently employs only 16 agents statewide.
Recent developments include plans by Purdue Pharma to reformulate OxyContin in the next three years to eliminate its narcotic effects when crushed and abused; enhanced drug warnings by the Food and Drug Administration and Purdue Pharma; and a request by U.S. Senator John Warner of Virginia for Congressional inquiry into OxyContin abuse.
The Honorable Robert Tata, Chairman
Legislative Services contact: Kathleen G. Harris