Journal of Adolescent Health
Volume 42, Issue 5 , Pages 458-465, May 2008

The Availability and Portrayal of Stimulants Over the Internet

  • Ty S. Schepis, Ph.D.

      Affiliations

    • Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
    • Corresponding Author InformationAddress correspondence to: Ty S. Schepis, Ph.D., Department of Psychiatry, Yale University School of Medicine, 34 Park Street, Room S-213, New Haven, CT 06519.
    • ,
  • Douglas B. Marlowe, J.D., Ph.D.

      Affiliations

    • Treatment Research Institute, Philadelphia, Pennsylvania
    • Center for Studies of Addiction, University of Pennsylvania, Philadelphia, Pennsylvania
    • ,
  • Robert F. Forman, Ph.D.

      Affiliations

    • Treatment Research Institute, Philadelphia, Pennsylvania
    • Center for Studies of Addiction, University of Pennsylvania, Philadelphia, Pennsylvania
    • Alkermes, Inc., Cambridge, Massachusetts

Received 21 August 2007; accepted 27 November 2007. published online 20 February 2008.

Article Outline

Abstract 

Purpose

To quantify the online availability and portrayal of amphetamine-class prescription stimulants with a focus on those medications commonly prescribed to and abused by adolescents.

Method

The Google™ search engine was used in searches to assess the frequency of web sites offering to sell controlled stimulants (retail sites) or web sites that directly linked to retail sites (portal sites). In addition separate searches were used to evaluate the portrayal of controlled prescription stimulants by the initial 20 web sites returned by Google. Retail and portal web site frequency was collected for each search. For searches measuring the portrayal of stimulants, web pages were categorized as pro-use, anti-misuse, neutral or other, based on set criteria.

Results

Sites offering to sell stimulants without a prescription were found for nearly all search terms. Across all searches, the Schedule III stimulants indicated for the treatment of obesity returned more sites offering to sell stimulants without a prescription than Schedule II stimulants indicated for the treatment of attention-deficit hyperactivity disorder (ADHD). Internet site portrayal of each stimulant varied; however sites that contained “methamphetamine” often included anti-misuse information.

Conclusions

The apparent availability of stimulants over the Internet without a prescription indicates the potential for a significant public health problem. The extent to which teens are obtaining these drugs via the Internet remains unclear, but clinicians must be aware of the potential for abuse, concomitant prescription use issues, illicit sources, and diversion of these medications, which can be highly addictive. Education of consumers and physicians as well as further governmental interventions are needed to limit the potential scope of this problem.

Keywords: Internet, CNS stimulants, Adolescent, Drugs of abuse, Drug source

 

See Editorial p. 432

Central nervous system (CNS) stimulants are medications indicated for the treatment of attention-deficit hyperactivity disorder (ADHD), sleep disorders, and obesity [1], [2]. CNS stimulants that are properly administered provide much needed relief to adolescents suffering from the effects of these disorders [3], [4]. However, despite their beneficial effects, many CNS stimulants carry a high risk of misuse because their acute effects, which may include euphoria, increased energy and alertness, and decreased boredom and fatigue [2]. The high potential for misuse is reflected in the fact that all stimulants are regulated under the Controlled Substances Act (CSA) [5]. Text reflecting this from the medication information inserts is included in Table 1.

Table 1. Food and Drug Administration stimulant medication warnings
Schedule II amphetamines carry the following Black Box Warning:
Amphetamines have a high potential for abuse. Administration of amphetamines for prolonged periods of time may lead to drug dependence. Particular attention should be paid to the possibility of subjects obtaining amphetamines for nontherapeutic use or distribution to others, and the drugs should be prescribed or dispensed sparingly.
Misuse of amphetamine may cause sudden death and serious cardiovascular adverse events.
In addition, Schedule II amphetamines, such as methylphenidate, carry the following statement:
Drug Dependence. Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism.
Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during drug withdrawal from abusive use since severe depression may occur. Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder that may require follow-up.
Schedule III amphetamines, such as phendimetrazine, carry the following statement:
Drug Dependence: Phendimetrazine tartrate is related chemically and pharmacologically to the amphetamines. Amphetamines and related stimulant drugs have been extensively abused, and the possibility of abuse of phendimetrazine tartrate should be kept in mind when evaluating the desirability of including a drug as proof of a weight reduction program. Abuse of amphetamines and related drugs may be associated with intense psychological dependence and severe social dysfunction. There are reports of patients who have increased the dosage to many times that recommended. Abrupt cessation following prolonged high dosage administration results in extreme fatigue and mental depression; changes are also noted on the sleep EEG. Manifestations of chronic intoxication with anorectic drugs include severe dermatoses, marked insomnia, irritability, hyperactivity, and personality changes. The most severe manifestation of chronic intoxications is psychosis, often clinically indistinguishable from schizophrenia.

Concerns about the use of controlled stimulants have been increasing and have been particularly focused on diversion and misuse of these medications by adolescents and young adults [6], [7]. The Monitoring the Future Studies [8] found that 8.6% of high school seniors and 6.7% of college students misused amphetamines in 2005, which were similar to previously established rates [9], [10], [11]. In addition many children, adolescents, and young adults have been exposed to stimulant medication either directly or indirectly, often through peers. Stimulants are regularly prescribed in these age groups, with large increases in the number of prescriptions over the past two decades [12], [13]. To illustrate, Thomas et al [13] found that adolescent stimulant use increased 208% from 1994 to 2002. Regular exposure to stimulants and their relative availability may make these medications appear safe and beneficial for all individuals, potentially resulting in misuse [14]. Indeed 40% of teens believe potentially addictive prescription medications are “much safer” than their illicit counterparts [15].

Prescription stimulants are available from a variety of sources, including friends, family [16], and Internet retailers [17], [18]. The 2005 National Survey on Drug Use and Health found that 7.2% of stimulant misusers obtained stimulants most recently via the Internet, with both adolescents and young adults endorsing the Internet as a stimulant source [17]. Purchases of medication from online sources has had unfortunate consequences beyond the risk of fostering addiction, including the dangerous substitution of antipsychotic agents for controlled sedatives or hypnotics that were ordered online [19]. Thus adolescents and young adults appear to be putting themselves at notable risk through ordering and consuming medication from Internet retailers.

The purpose of this study was to investigate aspects of the Internet related to controlled stimulant and methamphetamine use. One facet of this investigation was to establish which stimulants are offered over the Internet without a prescription and to quantify the frequency of web sites offering to sell controlled stimulants. The methods were adapted from earlier studies [20], [21] that examined whether controlled opioids were offered online. The stimulants examined here are on Schedule II or III of the CSA, and analyses were stratified by schedule to investigate potential differences in frequency of offers to sell. Schedule II stimulants tend to be used in the treatment of ADHD and are associated with stronger penalties, whereas Schedule III stimulants are primarily used in the short-term treatment of obesity and have lesser associated penalties. With significant coverage in the popular media in 2006 and 2007 on the misuse of Ritalin® and other stimulants for ADHD treatment among adolescents and young adults [22], [23], it might be expected that Schedule II stimulants would have a greater putative availability online.

This study was also designed to categorize the portrayal of stimulants and their use by the first 20 web sites returned by Google™ in searches. This was believed to be important because of evidence that Internet searches by adolescents and young adults for information on club drugs (including methamphetamine and prescription stimulants) may increase the likelihood of their use [24], [25]. Methamphetamine, a potent “street” stimulant, was included in all searches, and whether instructions for methamphetamine synthesis were available on web sites was recorded. Given that the chemicals required to synthesize methamphetamine have been purchased from online retailers [26], the presence of online instructions for its manufacture could be a public health risk.

To the best of our knowledge, this is the first study to systematically evaluate whether controlled stimulants are offered for sale online and, if so, which are available. For this study we had two main hypotheses. First, we expected that all searched stimulants except for methamphetamine would be offered online, with a greater frequency of offers of Schedule II stimulants. Because methamphetamine is almost always a “homemade” drug [27] that is distributed through networks similar to those for other illicit substances (e.g., marijuana), we did not expect to find it offered online. Second, we expected that the portrayals of the searched medications would be predominantly negative, particularly for methamphetamine.

Back to Article Outline

Methods 

The investigators conducted two examinations using the Google (www.Google.com) search engine: (1) the frequency of web sites offering to sell stimulants without a prescription, and (2) the portrayal of controlled stimulants by web sites. Because the primary goal was to obtain a broad picture of the web sites offering to sell controlled stimulants, the first investigation was given priority. Thus these searches used the first 100 links, which provided a broad sample from which to form conclusions. Also adolescents searching for stimulants to purchase over the Internet might need to explore more links to find stimulants offered for sale, and use of 100 links was expected to allow for this possibility. The searches examining the portrayal of stimulants captured only the first 20 links, which are ranked by Google based on an algorithm that includes the number and importance of web pages that link to the web page in question [28]. Previous research indicated that nearly 80% of individuals do not go beyond the first 20 links in searches [29], [30], so the portrayal searches were structured to account for that tendency.

Nine terms were used in Google searches including six DEA Schedule II preparations: Adderall®, amphetamine, Concerta®, methamphetamine (placed on Schedule II as Desoxyn®; Desoxyn was not included in the searches), methylphenidate, and Ritalin; and three Schedule III preparations: Bontril®, Didrex®, and phendimetrazine. Terms were chosen only if they were on Schedule II or III of the CSA [31] and were classified as CNS stimulants using either the Physician's Desk Reference [1] or the MD Consult web site (www.mdconsult.com). We concentrated on Schedule II or III stimulants because of the significant penalties (up to 20 years and 5 years, respectively) levied for offenses related to the illegal distribution of these substances [5]. In addition medications placed on Schedule II or III carry a high (II) or moderate (III) risk for abuse with a concomitant risk for physical and/or psychological dependence. These aspects were believed to increase the impact of online sales of these medications. The methods for the searches were adapted from earlier studies [20], [21] examining whether controlled opioids were offered online.

Web sites offering to sell controlled stimulants without a prescription: “no prescription” searches 

The purpose of this study was to examine the frequency of web sites that offered to sell the stimulants under investigation without a prescription or sites that directly connected to such web sites. Searches captured the first 100 links and occurred on a quarterly basis from January through June of 2006 as follows: no prescription Bontril, Didrex, and phendimetrazine (January and April); no prescription methamphetamine, amphetamine, and methylphenidate (February and May); and no prescription Adderall, Concerta, and Ritalin (March and June). The “no prescription” term was used to maximize the likelihood of returning web sites that offered to sell stimulants without a prescription. Generally this type of search would be conducted by an individual specifically seeking stimulants without a prescription from an online retailer.

Internet address (URL), the presence of retail or portal characteristics (described below), and any relevant comments about the site were captured in these searches. After data capture, a second rater coded the web sites independently; in cases of discrepancy, a consensus was achieved between raters after joint viewing of the site. Web sites could be coded as retail or portal web sites for quarterly 100-link searches. Retail web sites offered to directly sell a Schedule II or III controlled stimulant to consumers. In addition retail web sites explicitly stated that medication was sold without a prescription (e.g., “no prior prescription necessary”) or offered an online consultation. Such consultations (i.e., those not performed in person) are not a valid or legal basis for making a medical diagnosis and/or prescribing medications [32]. Finally, retail web sites could not claim to need the approval of the patient's treating physician or a valid prescription. Thus retail sites offered to sell controlled stimulants without a valid prescription, which is an illegal activity. Portal sites contained web site links that directly connected the consumer with retail web sites.

Portrayal of stimulants on the Internet: drug term–only searches 

This study investigated the portrayal of controlled stimulant use over the Internet. Nine stimulant names alone (i.e., without the “no prescription” prefix) were entered in the Google search engine on a monthly basis from January to July 2006. The drug name alone was used to provide information on the portrayal of the drug and its use, not to capture offers to sell the medication. Such searches were expected to be conducted by adolescents who were already using stimulants or by individuals interested in learning about stimulants. The information captured in these searches included Internet address (URL), portrayal of stimulants (described below), whether portal or retail characteristics were present, and whether instructions for methamphetamine synthesis were present. Co-rating and consensus occurred as described above for the “no prescription” searches.

Web sites could be placed in one of four portrayal categories: pro-use, anti-misuse, neutral, or other. Pro-use web sites emphasized the benefits and/or minimized the risks associated with stimulant use. An example of a pro-use portrayal would be, “Adderall® helped out a lot on my ACT exam” [33]. Sites with portal or retail characteristics were coded as pro-use. Anti-misuse web sites contained information on risks of nonmedical stimulant use or had information about addiction treatment. An anti-misuse statement could be, “Taking high doses of a stimulant may result in a dangerously high body temperature” [34]. If a site contained both pro-use and anti-misuse portrayals, the site was classified as pro-use. This decision was made because the pro-use portrayals were believed to be more damaging. Neutral web sites contained information about the medication but were neutral about use of the drug. Neutral sites included academic abstracts or unbiased news stories. Finally, web sites were classified as other if they were unrelated to stimulant use (e.g., “Amphetamine Reptile Records,” a record company) or were inoperative links.

Data analysis 

Analysis of each data set began by calculating the inter-rater agreement (κ) for the type of site ratings. For the both searches, frequencies and percentages of retail or portal web site appearance were calculated for each individual drug. One-way analysis of variance was used to analyze the differences in retail or portal site appearance between the Schedule II and III stimulants. For the drug term–only searches, frequencies and percentages of both portrayal rating were calculated for each search, with χ2 analyses used to evaluate the deviation from chance appearance of each portrayal rating. Finally, analysis of variance was used to compare drug terms for the incidence of portal or retail web sites.

Back to Article Outline

Results 

The κ (inter-rater agreement) values for the 6 months of data collection were between .81 and .96 for all searches, and all showed significant agreement between raters (p < .001).

“No prescription” searches 

The mean portal and retail frequencies and percentages for each “no prescription” drug term are summarized in Table 2. Analysis showed that the Schedule III controlled stimulants used to treat obesity (i.e., Bontril, Didrex, and phendimetrazine) were more likely than the Schedule II stimulants used to treat ADHD (i.e., Adderall, amphetamine, Concerta, methamphetamine, methylphenidate, and Ritalin) to return retail or portal sites in these searches: F(1, 16) = 4.512, p = .050. Because data for each medication were collected at only two time points, sufficient power did not exist to investigate differences between specific drugs. Also it was noted that the vast majority of retail sites used medically oriented images (e.g., individuals in laboratory coats) and written claims of legality for the sale of medications over the Internet. Because of the pilot nature of this investigation, a standardized content analysis was beyond the scope of this study.

Table 2. Mean portal and retail site number from the “no prescription” drug term searches (Study 1)
“No prescription” drug termSchedulePrimary indicationMean portal sites (per month)Mean retail sites (per month)
PhendimetrazineIIIObesity58.52
AdderallIIADHD50.5.5
AmphetamineIIADHD491.5
BontrilIIIObesity47.5.5
DidrexIIIObesity461
RitalinIIADHD410
MethamphetamineIIADHD390
MethylphenidateIIADHD33.5
ConcertaIIADHD310
All Schedule III Obesity50.67 (SD = 10.893)1.17
All Schedule II ADHD40.58 (SD = 9.179).42

ADHD = attention-deficit hyperactivity disorder.

Note: The mean number and percentage for each drug (for both portal and retail sites) are the same, as searches were conducted on 100 links.

Drug term–only searches 

Portrayal rating 

The online portrayal of each medication is summarized in Table 3. Each drug fell into one of three groups based on the most common portrayal of each medication (p < .001). The most common portrayal of Ritalin, amphetamine, and methamphetamine was negative or anti-misuse; the most common portrayal of methylphenidate, Adderall, and Concerta was neutral; and the most common portrayal of phendimetrazine, Bontril, and Didrex was pro-use (because of a high incidence of portal sites). Methamphetamine was significantly more likely to have anti-misuse portrayals than any other searched drug, but it did have eight incidences of pro-use web sites through the 7 months of data collection. Of those eight, seven were from a single web site, namely that for Erowid (www.erowid.com). Also Erowid was the only web site in this sample to contain detailed information on methamphetamine synthesis.

Table 3. Mean attitude rating from the drug term–only searches (Study 2)
Search termAnti-misusePro-useNeutralOtherχ2
Methamphetamine118(84.3%)8(5.7%)12(8.6%)2(1.4%)χ2 = 263.89
p < .001
Ritalin70(50.0%)21(15.0%)44(31.4%)5(3.6%)χ2 = 68.63
p < .001
Amphetamine66(47.1%)19(13.6%)33(23.6%)22(15.7%)χ2 = 39.71
p < .001
Didrex0(.0%)78(55.7%)26(18.6%)36(25.7%)χ2 = 32.63
p < .001
Bontril7(5.0%)73(52.1%)31(22.1%)28(20.0%)χ2 = 65.98
p < .001
Phendimetrazine2(1.4%)71(50.7%)46(32.9%)21(15.0%)χ2 = 77.20
p < .001
Adderall39(27.9%)28(20.0%)70(50.0%)3(2.1%)χ2 = 66.11
p < .001
Methylphenidate33(23.6%)26(18.6%)72(51.4%)9(6.4%)χ2 = 60.86
p < .001
Concerta22(15.7%)38(27.1%)63(45.0%)17(12.1%)χ2 = 36.74
p < .001

Note: Boldface values denote the most common type of site for each medication.

Incidence of portal and retail sites 

The mean frequency of retail or portal sites for the drug term–only searches is summarized in Table 4. Analysis revealed significant differences in the frequency of retail and portal site appearance between drug terms: F(1,6) = 210.633, p < .001. Each of the Schedule III drugs indicated for the treatment of obesity were significantly more likely to return retail and portal sites than any of the Schedule II ADHD medications. As seen in the “no prescription” searches, many retail sites in the drug name–only searches contained medical images and statements that their activities were allowed under U.S. law.

Table 4. Mean portal and retail site numbers from the drug term–only searches(Study 2)
Drug termScheduleMean portal and retail sites (per month)Percentage
DidrexIII11.14(SD=3.761)55.7%
BontrilIII10.43(SD=2.760)52.2%
PhendimetrazineIII9.86(SD=2.116)49.3%
MethylphenidateII2.71(SD=.756)13.6%
AdderallII2(SD=1.633)10%
AmphetamineII1.71(SD=.488)8.6%
RitalinII.86(SD=1.215)4.3%
ConcertaII.29(SD=.756)1.5%
MethamphetamineII0(SD=0)0%
All Schedule III 10.48(SD=2.857)52.4%
All Schedule II 1.26(SD=1.326)6.3%

Back to Article Outline

Discussion 

This study offers substantial evidence that multiple web sites offer to sell controlled stimulants without requiring a valid prescription. As predicted in the first hypothesis, eight of nine searched stimulants appeared to be offered online, with methamphetamine as the exception. Contrary to the prediction made in the first hypothesis, however, Schedule III stimulants indicated for the treatment of obesity were more likely to return retail or portal web sites than the Schedule II stimulants for ADHD treatment. In addition instructions for the manufacture of methamphetamine are posted online. Finally, the portrayal of these stimulants varied depending on type: the Schedule III stimulants were associated with pro-use portrayals, whereas methamphetamine (in particular) was associated with a negative portrayal. The presence of mainly neutral or pro-use portrayals for some medications was not expected, and it contradicts the prediction made in the second hypothesis. Although the predominately negative portrayals of Ritalin and amphetamines might dissuade adolescents from misuse, other studies have found that Internet searches actually increase the likelihood of experimentation with certain “club drugs” [24], [25]. These drugs, including methylenedioxymethamphetamine (MDMA; “Ecstasy”) and dextromethorphan, are also likely to have predominately negative portrayals by web sites. Thus negative information may not have the intended effect of discouraging adolescent stimulant misuse.

The apparent availability of controlled stimulants over the Internet is alarming for many reasons. First, the ease and anonymity of making purchases over the Internet could make it easier for adolescents and young adults to obtain these medications than similar drugs that are seen as comparatively unsafe, such as methamphetamine. In addition using the Internet could facilitate purchases when other sources (e.g., peers) are unavailable. Second, even if the medication was legitimately prescribed, obtaining it via the Internet has resulted in dangerous substitutions [19]. Finally, retail web sites (e.g., www.hateweight.com) appeared in the searches using the medication name only. This could lead to adolescents who simply searched for medication information to find stimulants offered online.

In this and a separate study [21], retail sites used legitimizing images (e.g., individuals in laboratory coats) and written claims of legality for their activities. These images and claims may convince naive consumers that Internet purchases of controlled stimulants are legal and safe, thereby increasing the risk. Adolescents may be more vulnerable to such claims, based on their developing reasoning skills. Interestingly, however, it did not appear that the web sites offering to sell controlled stimulants over the Internet were specifically targeting adolescents through their appearances or content; indeed most web sites returned in these searches targeting adolescents would be characterized as anti-misuse, according to the criteria of this study.

Given the concern voiced in the popular media about the misuse of stimulants for treating ADHD among youth and young adults, it is surprising that these medications appeared less likely to be offered online than stimulants indicated for the treatment of obesity. In the drug term–only searches, retail or portal sites composed 52.4% of web sites returned in searches of Schedule III stimulants, but only 7.6% in searches for ADHD stimulants. Perhaps the less severe penalties associated with the illegal sale of Schedule III medications [5] are a factor in their greater availability. Alternatively, more frequent offers of Schedule III stimulants could indicate that these stimulants are more likely to be solicited online than ADHD stimulants. Regardless, more than half of the web sites in the Schedule III stimulant searches, and one of every 13 in Schedule II stimulant searches, returned web sites connected to offers to sell stimulants without a prescription. This was observed in the drug term–only searches as well, where offers to sell medication were not specifically sought.

The first 20 returned web sites had a consistently negative portrayal of methamphetamine. Given the great popular concern about methamphetamine use, the high degree of anti-misuse portrayals is not surprising. Pro-use web pages did appear in these searches, although with a much smaller frequency. As mentioned above, the main pro-use web page for methamphetamine was Erowid (www.erowid.com). Erowid includes information on the chemistry, effects, and legal issues related to the use of a wide variety of legal and illegal psychoactive substances. The best description of Erowid may be to call it a “harm reduction” web site, if harm reduction is concerned with reducing the adverse consequences of drug use without reducing use itself [35]. Erowid is of particular concern because it contains instructions for methamphetamine use and synthesis. The vast majority of methamphetamine is manufactured in clandestine laboratories [27], unlike the other medications here, which are made commercially. Thus online instructions for methamphetamine manufacture are a notable public health risk that could promote the illicit manufacture of the drug.

Two limitations of the study were identified: (1) the exclusive use of Google in searches; and (2) the exclusion of “slang” or “street” names in searches. Google was chosen because of its dominance of the Internet search engine marketplace, but different search engines might have returned a different pattern of results. In fact an investigation of opioid availability online [20] found that Yahoo!™ (www.yahoo.com) is more likely to return retail or portal sites than Google; thus these results may be a conservative estimate of the phenomenon. Also, slang names for stimulants (e.g., “meth” or “ice” for methamphetamine, “Vitamin R” for Ritalin) were excluded from these searches. The inclusion of these terms might have increased the likelihood of finding retail sites or methamphetamine synthesis instructions. Future studies should investigate this further.

For future research directions, continued monitoring of this phenomenon is warranted, using search engines other than Google. Also attempts to buy controlled stimulants online, and evaluations of whether the obtained drugs are authentic or adulterated, should occur. Investigators from the US Government Accounting Office (GAO) obtained authentic controlled medications online, including OxyContin® and hydrocodone [36]. As controlled stimulants were not ordered, future investigations should include these medications.

Clinicians can help limit the impact of online medication availability in a number of ways. Although federal agencies are taking important steps to limit the availability of potentially addictive medications sold by illegitimate Internet vendors [37], [38], consumer education can limit the dangers posed by these potentially addictive medications being offered online. Physicians, mental health professionals, and those in allied fields are well placed to inform parents about the apparent online availability of stimulants and opioid analgesics [20], [21] and other stimulant-related issues, including diversion and misuse [39], [40]. Clinicians can suggest practical steps that parents can take to prevent Internet purchases and stimulant misuse. First, parents should be urged to carefully monitor the Internet activity of adolescents, whether through monitoring software, blocking certain searches, and/or keeping the computer in a common household area such as a family room. Second, parents should monitor their credit card statements for unfamiliar charges, as use of a parent's credit card may be the major way that adolescents gain access to stimulants offered online. Third, parents should keep and monitor their adolescent's stimulant medications, and, if an adolescent ceases stimulant use or changes stimulants, parents should be instructed to safely destroy the medication. Perhaps most importantly, parents need to communicate that prescription stimulants are as dangerous as illicit stimulants when the prescription is used in a nonmedical fashion.

In sum, this investigation has established that controlled stimulants are offered for sale over the Internet without prescription. These findings may signal a major public health risk that requires both further monitoring and measures to prevent individuals from obtaining controlled stimulants via the Internet. Clinicians can help to prevent online purchases by adolescents through parental education, both about this phenomenon and about practical steps that parents can take to prevent online purchases, misuse, and diversion of stimulant medications.

Back to Article Outline

Acknowledgments 

The authors thank Christen McDonald, B.S., for her work in co-rating the collected web sites and for her editorial comments. The authors also thank Anne E. Smith, Ph.D., Emily Harrison, Ph.D., and Nicholas Patapis, Psy.D., for their editorial comments on later versions of the manuscript. This work was supported in part by National Institutes of Health grant T32-DA007238.

Back to Article Outline

References 

  1. Medical Economics Company. Physicians' Desk Reference. 59th ed. Montvale, NJ: Medical Economics Company, Inc; 2005;
  2. Julien RM. A Primer of Drug Action: A Concise, Nontechnical Guide to the Actions, Uses and Side Effects of Psychoactive Drugs. 8th ed. New York: W.H. Freeman and Co; 1997;
  3. Biederman J, Faraone SV. Attention-deficit hyperactivity disorder. Lancet. 2005;366:237–248
  4. Keating GM, Raffin MJ. Modafinil: A review of its use in excessive sleepiness associated with obstructive sleep apnoea/hypopnoea syndrome and shift work sleep disorder. CNS Drugs. 2005;19:785–803
  5. 21 USC 801. Comprehensive Drug Abuse Prevention and Control Act. 1970.
  6. Compton WM, Volkow ND. Abuse of prescription drugs and the risk of addiction. Drug Alcohol Depend. 2006;83(Suppl 1):S4–S7
  7. Poulin C. From attention-deficit/hyperactivity disorder to medical stimulant use to the diversion of prescribed stimulants to non-medical stimulant use: Connecting the dots. Addiction. 2007;102:740–751
  8. Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the Future national survey results on drug use, 1975–2005. Volume I: Secondary school students. NIH Publication No. 06-5883. Bethesda, MD: National Institute on Drug Abuse; 2006;
  9. McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use and diversion of abusable prescription drugs. J Am Coll Health. 2006;54:269–278
  10. McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use and diversion of prescription stimulant medication. J Psychoactive Drugs. 2006;38:43–56
  11. Poulin C. Medical and nonmedical stimulant use among adolescents: From sanctioned to unsanctioned use. Can Med Assoc J. 2001;165:1039–1044
  12. Rushton JL, Whitmire JT. Pediatric stimulant and selective serotonin reuptake inhibitor prescription trends: 1992 to 1998. Arch Pediatr Adolesc Med. 2001;155:560–565
  13. Thomas CP, Conrad P, Casler R, et al. Trends in the use of psychotropic medications among adolescents, 1994 to 2001. Psychiat Serv. 2006;57:63–69
  14. Friedman RA. The changing face of teenage drug abuse—the trend toward prescription drugs. N Engl J Med. 2006;354:1448–1450
  15. Partnership for a Drug-Free America. The Partnership Attitude Tracking Study (PATS): Teens in grades 7 through 12, 2005. New York: 2006.
  16. McCabe SE, Boyd CJ. Sources of prescription drugs for illicit use. Addict Behav. 2005;30:1342–1350
  17. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194. Rockville, MD: 2006.
  18. Wilford BB, Smith DE, Bucher R. Prescription stimulant sales on the Internet. Pediatr Ann. 2006;35:575–578581–2, 585–6
  19. Food and Drug Administration. FDA alerts consumers to unsafe, misrepresented drugs purchased over the Internet. Department of Health and Human Services, Washington, DC: February 16, 2007.
  20. Forman RF, Woody GE, McLellan T, et al. The availability of web sites offering to sell opioid medications without prescriptions. Am J Psychiatry. 2006;163:1233–1238
  21. Forman RF, Block LG. The marketing of opioid medications without prescription over the Internet. J Public Policy Marketing. 2006;25:133–146
  22. Fife-Yeomans J. Stimulating debate—Ritalin prescription rates for children are raising alarm bells. Daily Telegraph, April 28, 2007.
  23. Vedantam S. Millions have misused ADHD stimulant drugs, study says. Washington Post, February 25, 2006.
  24. Boyer EW, Shannon M, Hibberd PL. The Internet and psychoactive substance use among innovative drug users. Pediatrics. 2005;115:302–305
  25. Brewer NT. The relation of Internet searching to club drug knowledge and attitudes. Psychol Health. 2003;18:387–401
  26. Millon P. Penthouse lab busted in methamphetamine crackdown. Associated Press Newswires, November 30, 2006.
  27. Romanelli F, Smith KM. Clinical effects and management of methamphetamine abuse. Pharmacotherapy. 2006;26:1148–1156
  28. Google. Our search: Google technology. 2007 [Online; cited 2007 February 7]; Available at: http://www.google.com/technology/Last accessed November 6, 2007.
  29. Jansen BJ, Spink A, Pedersen J. A temporal comparison of AltaVista Web searching. J Am Soc Inform Sci Technol. 2005;56:559–570
  30. Jansen BJ, Spink A, Saracevic T. Real life, real users, and real needs: A study and analysis of user queries on the web. Inform Process Manag. 2000;36:207–227
  31. 21 CFR § 1308. Schedules of Controlled Substances. 2001.
  32. Federal Register: April 27, 2001, Volume 66, Number 82.21181–22118.
  33. Erowid. Erowid Experience Vaults: Amphetamines (Adderall). 2007 [Online; cited 2007 February 12]; Available at: www.erowid.org/experiences/exp.php?ID=34319Last accessed July 25, 2007.
  34. National Institute of Drug Abuse. Research Report Series–Prescription Drugs: Abuse and Addiction. NIH Publication No. 05-4881. Rockville, MD: National Institutes of Health; 2005;
  35. Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev. 2006;25:611–624
  36. United States General Accounting Office. Internet pharmacies: Some pose safety risks for consumers (Report to the Chairman, Permanent Subcommittee on Investigations, Committee on Governmental Affairs, US Senate). (GAO Report No. 04-820) Washington DC: General Accounting Office; 2004;
  37. Hubbard WK. March 18 Washington, DC: U.S. House of Representatives hearing on Internet drug sales; 2004;
  38. Rannazzisi JT. DEA congressional testimony, written statement. Washington, DC, December 13, 2005.
  39. McCabe SE, Teter CJ, Boyd CJ. The use, misuse and diversion of prescription stimulants among middle and high school students. Substance Use Misuse. 2004;39:1095–1116
  40. McCabe SE, Teter CJ, Boyd CJ, et al. Prevalence and correlates of illicit methylphenidate use among 8th, 10th, and 12th grade students in the United States, 2001. J Adolesc Health. 2004;35:501–504

PII: S1054-139X(07)00641-6

doi:10.1016/j.jadohealth.2007.11.140

Refers to article:

  • Health Information on the Internet—A Double-Edged Sword?

    Nicola J. Gray
    Journal of Adolescent Health May 2008 (Vol. 42, Issue 5, Pages 432-433)

Journal of Adolescent Health
Volume 42, Issue 5 , Pages 458-465, May 2008

Article Tools