Editor’s note: The author’s identity has been withheld by the Editorial Board due to the sensitive nature of the article. Please see the end of the article for an afterword by the Editors-in-Chief. For any students struggling with addiction, please contact your school’s student health office or the SAMSHA National Helpline at 1-800-662-HELP.

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Monday mornings of my first semester of med school I’d reach into the smaller pocket of my backpack, grabbing around until I heard that pill-rattle sound.

Over time, it’d come to rival my coffee machine in its Pavlovian salivation production.

I’d one handedly open the child-safety-capped prescription bottle still in the backpack, and return with the bounty that would make this cardiophysiology lecture (and the biochem and labs after it) more palatable: a roughly 6 mg bolus of Focalin, which is time-release Ritalin (methylphenidate).

But down the hatch? No, no, no. This isn’t JV undergrad work, here. This is medical school, and you know what we happened to learn the week prior in anatomy? The veins draining my inner nose and mouth don’t go to the liver. They go to the heart, and then to my brain. Why waste perfectly good Ritalin on that ol’ hepatic stick in the mud when I could just let all those molecules go free straight to my systemic circulation?

“Skipping the first hepatic pass” sounded more like a Ray Charles love song than a route of administration to me that morning. So I chewed up the little beads from inside the capsule and let the mash sit in my mouth and diffuse into my lingual and facial veins like cream into my coffee. Well, cream into coffee plus some numbness — the lidocaine family shares a lot in common with stimulants, it turns out.

Diagnosing and Dosing

Was I prescribed this drug? Yes, I was. Three years ago I went to my primary care doc and told him how unfocused I felt. He set me up with the local neurologist.

The neurologist asked me some questions, asked me to do a number of tests, and then, presto! “ADHD” and 20 mg of Focalin it was. Why, you might be thinking, was I so excited to carry this diagnosis? Because I’d already tried self-medicating with a family member’s Ritalin in the past year, and knew it worked for me. I didn’t care for the jittery-high-like feeling I got if taken on an empty stomach, but I did enjoy the productivity.

You might also be wondering why I said “6 mg” rather than 20 mg, which I was prescribed. While I strongly advise everyone to take medications as they’re prescribed, it was too much for me. Twenty milligrams would keep me up for 20 hours. I could take it with food, sure, and over time I’d desensitize to the 20 and it’d be fine.

But I run this body, not my doc. And I chose to vary my route of administration.

Sometimes I’d just take a third of the capsule swallowed, and sometimes I’d chew it and let it sit in the space between my cheeks and lower teeth. This allowed fewer milligrams to be eaten alive by the one who shall remain nameless (starts with L, ends with IVER) before ever reaching my brain. I could more finely control my blood levels.

Feeling drowsy? Skip the liver. Feeling awake, or planning on going for a run this afternoon? Orally it’ll be. And while most folks end up chasing the effect or “high” and having to up their dose, I’m still below my prescribed 20 mg. (To be fair, while studying for boards, I was definitely taking all 20 mg, albeit split through the day.)

Too Much?

Sometimes, I’d overdo it. One day, a friend dropped a trial pack of Nuvigil in my palm.

“What’s this?”

“A narcolepsy drug.”

We looked it up, and sure enough, it’s pretty much just the “upper” (read: epinephrine and norepinephrine) part of the Ritalin-Adderall playbook, which act primarily by blocking dopamine reuptake, among overlap with other catecholamines.

When is Nuvigil perfect for? When I went to bed at 2 a.m. and got up at 5:30 a.m. to run through my notes again for my 8 a.m. exam. Nothing opens your eyes like a dollop of Nuvigil, Ritalin, and a fat cup of coffee, I always say.

Then again, short of organic psychosis, nothing makes you feel like you know exactly what the term “depersonalization” means like that tetrad, either — I’m including the lack of sleep here too, of course. A few times I felt like a total zombie if I didn’t get in a three-hour nap after lunch.

And by “total zombie,” I don’t mean to reference that cute portrait of a teenager who stayed up late talking on the phone. I mean removed from the world, as if my body was working and I could talk, but no one was home. I’d laugh, but feel no pleasure, nor any pain. When I did feel, it was a mix of mild nausea and anxiety, with lids that were as heavy as the packet of the exam I’d just taken.

So what happened next exam? In the shadow of the zombie, did I quit the Nuvigil? No. I often took some. Not because I’m a drug addict — it was, after all, at least a week or two between exams. I just tampered with the dosage, only took it on a handful of the roughest exam mornings, and got a tad more sleep.

People often consider psychological side effects of medications to be prohibitive to their use, as if their psyche was so unstable to begin with that any rocking of the boat will cause it to tip for good. Remembering the beatings I took in playing college sports, I’d remind myself that sometimes humans feel like crap, and that’s okay. I’d plan for that post-exam nap right when I knew I’d be tanking, norepinephrine and dopamine supplies having been successfully toasted through said exam, no doubt minor oxidative stress on nearby neurons in tow.

I was doing well enough in school, and was pretty sure I’d be screwed without this self-prescribed cocktail, as low-dose as it was. So if you’re wondering “why bother?” with all the potential crappy feelings around it, I’ll just repeat that old mantra: no pain, no gain. That’s not a new lesson to me (or you), and the fact that my transient, zombified feelings were perfectly predictable just reiterated that I knew just about exactly what I was doing.

Ethics and Future Use

Now that I’m done with the book learning and spend all my days in the clinic (which is a pretty naturally ADD place to be), I get the sleep I need for the most part. There are days here and there where it doesn’t happen, and I’m sure my stimulant use will go back up during some months in residency, but I have no regrets about it thus far.

I’m certainly lucky not to have “severe” ADHD, and lucky not to have an addictive chemistry, as I’m still below 20 mg, that magic number that so many folks have blown out of the water (40 and 60 mg doses are very common). I think it’s partly because of my chemistry, and also because I was able to vary my route of administration and was willing to trade for an Adderall here or there, thus varying the exact transporters I was targeting, never desensitizing any one system overtly. Plus I ate well (add some panic eating here or there), and I exercised.

Do I “regret” doing any of this? Of course not. I carried the ADHD diagnosis, and it was the only way for me to survive. That I’m aware of and/or celebratory of my success after carrying this diagnosis on my medical record shouldn’t dissuade you of its legitimacy. To those feeling mild disgust or curiosity about what I’ve written here, I’d ask you tell me what the downside was. The old naturalistic fallacy creeps into folks’ minds far too easily in many ways, and in this case as well. That I was generally following my doctors’ advice and finally able to focus for hours rather than minutes is nothing but a success of modern medicine. The prescription I was given worked just as it was supposed to, so while I’d encourage everyone on Ritalin to watch out for side effects that can be harmful, I’d also remind them not to listen to the ad nauseam fear-mongering.

While the least compelling arguments against the use of stimulants prescribed or unprescribed include a restatement of their legal status and overblown fears of addiction or health risks, the most compelling arguments I’ve heard regard the supposed unleveling of the playing field. That is, those who have it are at a distinct advantage over those who don’t, akin to a sports player using steroids.

But “relative weakness to other professional athletes” is not a disease. The inability to focus for longer than a puppy, is.

ADD medications are generally marketed to “unleash the potential of the student,” which is accurate. In my case, I could finally barrel through those lecture notes without stopping five times to look at some shiny thing in order to earn a slightly below average grade on an exam (I’d stop only 2 times, instead).

Indeed, there is evidence to suggest that high-functioning students do not benefit from stimulant use the way lower-functioning students do. Of course, “high” and “low” functioning takes on a whole new meaning when we’re now splicing up classes of some of the highest achieving students from their colleges, but this is part of the issue in saying “ADD versus ‘normal.’” It’s really “ADD versus your potential.” The ability to synthesize complex ideas in my head had never been the issue, even through college (i.e. my intellect on its own was plenty strong). My ability to utilize this abstract synthetic ability was the issue, thus the obvious utility of Focalin.

A Note On Those Who Believe They’re “In The Know”

Another common misunderstanding stems from what people perceive to be going on among their non-stimulant-using colleagues and also their stimulant-using colleagues. What one says to their uptight friend about their use is unlikely to be perfectly true regarding their actual use.

Further, there are plenty of friends who only open up about their diagnosis and use when in certain company. Do not mistake silence or even agreement for truth. Social stigma will halt the surfacing of truths that would otherwise be free.

One last perspective before I let this point go: medicine doesn’t have to be a zero-sum game. My relative increase in board scores (to around average) is very unlikely to hurt or affect you. It is somewhat likely to help me, but not if I’m a jerk in the hospital. This is where the whole “my gain = your detriment” assumption breaks down: if I do well clinically, leading to the best letters of recommendation, it says nothing about your letter of rec. Perhaps if we’re working well together, we’ll both be lifted into the realm of “exceptional students” in the eyes of our attendings. If you think your clinical success rides on my failure, I don’t have much to say that can reach you.

So, if you think the recently-reported 15% usage of stimulants in medical schools is low, as I do, and you find use in stimulants in your studying, perhaps you’ll join my way of thinking and dosing. While the study of medicine is about anything but moderation, I’d say “everything in moderation” can be your best friend when wondering how to approach your pharmacologic needs in your first and second year of medical school, be it caffeine, Red Bull, food or prescription drugs.

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Afterword

in-Training was founded as the agora, the intellectual center of the medical student community. We strive to be a forum that authentically represents the voice of medical students worldwide, enabling the free discussion of all topics relevant to medical education.

Today, we publish this article in the pure spirit of that mission: to represent all perspectives that constitute the collective medical student voice. In our mission, it is our duty to offer all medical students, and all voices, the opportunity to communicate and engage in discourse on the global stage.

Indeed, this author’s voice may be in the minority, but his or her first-hand perspective on this controversial topic is an invaluable contribution to a larger discussion.

We hope that this article begins a conversation on this evolving development in medical education, and we encourage you to contribute your perspective. Please submit any rebuttals to editorinchief@in-training.org.

In closing, we must note that the author’s views to do not necessarily reflect those of in-Training or its Editorial Board. The Editorial Board decided unanimously to redact the name and institution of the author to protect his or her identity in the discussion of a sensitive issue.

Ajay Major, MBA and Aleena Paul, MBA
Editors-in-Chief

Image source: Pills by Victor licensed under CC BY 2.0.