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Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use a
Kristin A. Cutler PhD a
Department of Sociology, Washington State University, Pullman, Washington Accepted author version posted online: 05 Jun 2014.Published online: 16 Sep 2014.
To cite this article: Kristin A. Cutler PhD (2014) Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use, Journal of American College Health, 62:7, 478-486, DOI: 10.1080/07448481.2014.929578 To link to this article: http://dx.doi.org/10.1080/07448481.2014.929578
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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 7
Major Article
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Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use Kristin A. Cutler, PhD
Abstract. Objective: National college health data indicate that prescription stimulants are the most widely misused prescription drugs among college students, with 9% admitting to nonmedical use within the past year.1 Although motivations for the nonmedical use of these drugs have been explored, scant attention has been paid to justifications for nonmedical use. This article fills that gap by expounding upon the justifications students incite to defend their nonmedical use of these drugs. Participants: Seventy-six college students from a large, public northwestern university. Methods: Semistructured interviews were conducted during the 2010–2011 academic year. Results: Inductive analysis uncovered social learning theories of crime/deviance, more specifically, Sykes and Matza’s neutralization theory2 as helping to inform justifications for nonmedical stimulant use. This theory was modified to better encompass the justifications that students employed. Conclusion: Justifications for use must become a more central part of the conversation surrounding nonmedical stimulant use among the college population.
NCHA data find that 9% of college students admit to the nonmedical use of these drugs within the past year.1 Furthermore, it has been found that almost two-thirds of college seniors have been offered prescription stimulants for nonmedical use during the course of their college careers and that upwards of 30% admit to using them at least once.6,7 Research produced in this area in the fields of medicine, psychology, and sociology has predominantly focused on the epidemiology of nonmedical prescription stimulant use. Less attention has been paid to motivations (ie, incentives and drives) for misuse and abuse, with little to no attention being paid to justifications (ie, rationalizations or neutralizations for use) for misuse and abuse. Those studies that have examined motivations surrounding nonmedical stimulant use have identified better focus, a quicker and cheaper high, and experimentation as typical reasons underlying misuse and abuse.8–23 When it comes to justifications for use, safety has been the only well-documented justification. With this justification, students argue that prescription stimulants, as opposed to illicit stimulants (ie, cocaine and methamphetamine), are “safer” options for experimentation and getting high because they have been approved by the Food and Drug Administration (FDA) and are “pure,” having known chemical compositions and predictable side effects. Additionally, they argue that the physical effects of these drugs are harder to detect and that they are overall easier to conceal.3,5–8,20 Beyond the lack of research addressing motivations and justifications for nonmedical stimulant use, there has been a disconnect in the literature when it comes to explaining the mechanisms or processes whereby college students come to incite various motivations and justifications for use. The few studies that have used theory to better inform motivations for nonmedical stimulant use have primarily focused
Keywords: college students, community health, justifications, prescription drugs, prescription stimulants
T
he most recent National College Health Assessment (NCHA) data suggest that 16% of undergraduate college students admit to using a prescription drug that was not prescribed to them in the last 12 months.1 Of these drugs, prescription stimulants (eg, Adderall, Ritalin, Concerta, and Vyvanse) are some of the most widely misused and abused among college students.3–5 In fact, the nonmedical use of these drugs (ie, use without a prescription or in ways that a doctor would not prescribe) come in second to marijuana as the most common form of illicit drug use.6,7
Dr Cutler is with the Department of Sociology at Washington State University in Pullman, Washington. Copyright Ó 2014 Taylor & Francis Group, LLC 478
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Students’ Justification of Nonmedical Prescription Stimulant Use
on academic strain (eg, juggling a full credit load, the extra stress that comes with midterm and finals weeks, finding balance being a student-athlete).6–23 Although this is an important contribution to our knowledge, survey research points to other factors outside of academic strain that influence motivations and justifications for use. Thus, it is imperative that these factors be explored and better contextualized using theories outside of strain. Although motivations and justifications are interrelated processes, motivations for nonmedical stimulant use have taken greater precedence within the literature. This is partially a result of the fact that motivations are more easily ascertainable through survey research (ie, quantitative methods). How college students go about justifying why it is acceptable to be engaged in such behavior, on the other hand, is a more complex process. A process that is arguably best discerned through the use of inductive, qualitative methods whereby individuals are able to self-reflect and share their personal experiences with using these drugs. Justifications for use are also arguably just as, if not more, important to focus on than motivations for use, given that they help individuals resolve any guilt, shame, or stigma associated with their deviant use of prescription drugs. Given these weaknesses in the current research, the purpose of this article is twofold. First, by using qualitative methods it will provide a more in-depth look into the justifications that college students employ (beyond just safety) to minimize their deviant identities when it comes to the nonmedical use of prescription stimulants. Second, this article will better explain and contextualize these findings on justifications using criminological theory, more specifically, Sykes and Matza’s neutralization theory.2 METHODS Protection of Participants Ethical approval for this project was obtained from the university’s Institutional Review Board (IRB). A certificate of confidentiality was obtained through the National Institutes of Health. With this certificate, the researchers cannot be forced to disclose, even by court subpoena, information that may identify participants, in any federal, state, civil, criminal, administrative, or legislative proceeding. Participants signed a consent form before the interview process began and were made aware that the project had been approved by the institution’s IRB. Additionally, participants were made aware that their identities would be protected by the use of pseudonyms and that the consent forms (the only documentation that had identifying information on it) would be safely stored and then destroyed after the appropriate amount of time had passed
Analytic Strategy Inductive analysis was employed in this study because it allows the details of qualitative data to uncover important VOL 62, OCTOBER 2014
patterns, themes, and interrelationships. This type of strategy, therefore, focuses on theory development and asserts that theory may be generated from incoming data, or that existing theories may be elaborated upon or modified depending upon the data.24–26 In addition to allowing for theory development and modification, inductive analysis recognizes that the participants under study have their own perspectives and interpretations of their own and other actors’ actions and behaviors.24–26 Given this approach, indepth, semistructured interviews were employed given that they are one of the best methods for eliciting information on newly emerging areas of study and can provide more clarification and context than do other methods, especially survey research. With respect to this study more specifically, interviews allowed for a better understanding of how college students interpret, understand, and justify their nonmedical use of prescription stimulants.
Sampling Procedure College students from a large, public university located in the northwestern United States constituted the sampling frame for this study. Purposive sampling techniques were employed whereby participants had to meet certain criteria for inclusion in the study. Participants had to be 18 years of age, enrolled at the institution that the sample was drawn from, and had to self-identify as someone who had engaged in nonmedical prescription drug use within the past year. Nonmedical prescription drug users (as opposed to nonusers) were the main targets given the interest in better pinpointing and understanding motivations and justifications use. Recruitment of participants took place through flyers posted in high-foot-traffic areas on and off campus, including the student union, the student recreation center, and the student health center. Announcements were also made in a variety of lower-level introductory classes where a crosssection of the student population is represented. Snowball sampling was also utilized whereby existing study participants voluntarily informed friends and acquaintances about the study. A total of 76 students (46 male, 30 female), ranging in age from 18 to 26 (average age being 21), and in class standing from freshman to graduate students took part in the study. Of these 76 participants, the majority are white and from middle and middle-upper class backgrounds (see Table 1 for participant and institutional demographics). These participants, though similar in race/ethnicity, age, and socioeconomic standing, were diverse when it came to drug use backgrounds (eg, some were self-pronounced drug addicts, whereas others were first-time, novice users).
Interview Guide The interview guide was constructed based upon the most current drug abuse literature, student focus groups, and extensive pretesting of various working versions of the 479
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TABLE 1. Participant Demographics Versus School Demographics
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Characteristic Race % White % Nonwhite Gender % Male % Female Class standing % Senior % Junior % Sophomore % Freshman % Graduate student Greek affiliation % Greek % Non-Greek Athlete % Athlete % Nonathlete Living arrangements % On-campus % Off-campus Other demographics Age (mean) GPA (mean)
Study participants
2010–2011 school demographics
99.3 0.7
69.9 30.1
60.5 39.5
49.0 51.0
42.1 19.7 22.4 13.2 2.6
22.0 19.0 16.0 27.0 15.0
40.8 59.2
18.0 92.0
7.9 92.1
2.3 97.7
30.3 69.7
36.0 64.0
21 3.0
23 3.3
guide. Given its extensive use within the existing literature, the following definition of nonmedical prescription drug use was used: past-year use of one or more prescription drugs without a prescription from a doctor, use that does not follow a doctor’s instructions, or use simply for the experience or feelings that the drug can cause. Central nervous system stimulants are classified as Schedule II drugs (ie, providing positive medical benefits but also considerable abuse potential) and were defined as those drugs most often used to treat attention deficit disorder, narcolepsy, obesity, and depression. Some of the most prescribed drugs in this category include Adderall, Ritalin, Concerta, and Vyvanse.4,5 The guide covered several topics, including (1) initiation into use and shifting patterns of use, (2) knowledge concerning the intended utility of these drugs, (3) access/opportunities for use, (4) diversion of these drugs, (5) poly-drug use, and (6) motivations for use. Given the flexible nature of this research design, this guide was used to generate discussion on the topics listed; nevertheless, the topics were not necessarily addressed in any particular order, and the respondents were allowed to guide the conversations and bring up new areas of interest. In some cases, not all of the topics were addressed given that some did not apply to a specific individual’s behavior. Data reliability and validity were established by making sure that the inclusion criteria 480
for the study were clearly explicated. It was known from the start that participants taking part in the study had participated in nonmedical prescription drug use within the past year. Additionally, over the course of the interviewing process, interview responses became quite repetitious and by interview 76, saturation had been achieved. Interviews were conducted during the fall of 2010 through the spring of 2011. All participants were interviewed in a private setting by the lead investigator and were compensated $25 for their time and participation in the study. Given the sensitivity of the topic, only the lead investigator conducted the interviews. Throughout the interview process, checks for validity were made by repeatedly summarizing back to participants their statements regarding their experiences using prescription stimulants. Participants were also asked if they could be recontacted if any questions or points of clarification came up during the transcription process. Interviews lasted anywhere from 30 to 60 minutes and were digitally recorded. Interviews were transcribed verbatim by the lead investigator and 2 trained research assistants using a qualitative data program called HyperTranscribe (ResearchWare, Inc., Randolph, Massachusetts). The transcribed data were then imported into a qualitative data management program called HyperResearch (ResearchWare, Inc., Randolph, Massachusetts). This program allows qualitative researchers to organize and code their data more efficiently and effectively than doing it manually. Initial themes were generated based upon the questions in the interview guide; however, other unexpected themes were also uncovered—one of which was justifications for use. After interviews were coded, comparisons were made across various sociodemographics (ie, age, gender, class standing, Greek affiliation, athletic affiliation).
Theoretical Rationale Throughout the interview and coding processes, social learning theories of crime/deviance were uncovered as helping to inform motivations and justifications underlying students’ nonmedical use of prescription stimulants. When explaining justifications for use more specifically, one must take a closer look at Sykes and Matza’s neutralization theory.2 This theory is intricately linked to the social learning tradition of criminology, which focuses on how significant others (ie, friends and family) impact the learning process and ultimately one’s decision to define deviance as desirable.27 When it comes to explaining drug use more specifically, social learning theories emphasize the importance of learned motives and techniques of acquiring and appropriately using drugs.28,29 Part of this learning process also encompasses learning to employ certain justifications for why engaging in drug use is desirable.2,27,30 These justifications or “techniques of neutralization,” as Sykes and Matza call them, allow individuals to neutralize and temporarily suspend their commitment to social values, providing them with the freedom to engage in deviant acts and avoid damage to their self-concept. Accordingly, it is not that deviant JOURNAL OF AMERICAN COLLEGE HEALTH
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Students’ Justification of Nonmedical Prescription Stimulant Use
behavior is “right,” it is that it is “all right” under certain circumstances.31 The original techniques of neutralization put forth by Sykes and Matza include passing the blame to others (denial of responsibility) and/or defining others as equally more corrupt or deviant (condemnation of the condemners), insisting that no one was hurt (denial of injury), insisting that the victim deserved what they got (denial of the victim), and insisting that the rules are not as important to remaining loyal to others (appeal to higher loyalties). Sometime later, Coleman added 4 more techniques to the list that were more common to the culture of white-collar crimes. These include denying that the behavior is inappropriate (denial of necessity of the law), claiming that economic survival is at stake (defense of necessity), claiming that “everybody else is doing it” and not penalized for doing it, and claiming that the benefit of engaging in the deviant behavior is deserved or owed (claim of entitlement).32–34 When applying these techniques of neutralization to shoplifting, Cromwell and Thurman added the “justification by comparison” neutralization and “postponement.” When employing the “justification by comparison,” individuals argue that if they were not engaged in X deviant behavior that they would be doing something worse, whereas with “postponement” individuals simply put the deviant event or incident out of their mind.32 Although neutralization theory has been applied to a variety of deviant behaviors, including the misuse and abuse of alcohol and illicit drugs, it has yet to be applied to individuals’ nonmedical use of prescription drugs. This research found that some of the same techniques of neutralization used for the misuse and abuse use of alcohol and illicit drugs (such as denial of injury, the claim that everybody else is doing it, and condemnation of the condemners) apply to the nonmedical use of prescription stimulants; however, the way in which these techniques are put into action were found to be different. In this study, students consistently combined various techniques to form more holistic neutralization categories (refer to Results below). Given these differences, and as inductive analysis dictates, the theory was modified as to best underscore how students went about explaining away their nonmedical use of prescription stimulants.
employed to justify why it was acceptable to be engaged in the nonmedical use of these drugs. These justifications or “techniques of neutralization” are categorized differently than past research, given that students often combined techniques to form more holistic neutralization categories. These techniques of neutralization have been categorized as follows: (1) The Safety Factor (which includes denial of injury, denial that the behavior is inappropriate, and the claim that everybody else is doing it), (2) Others as More Deviant (justification by comparison and denial of injury—this this includes claiming responsible use as opposed to irresponsible, “deviant” use), and (3) Authoritative Enabling (which includes condemnation of the condemner, denial of responsibility, denial that the behavior is inappropriate, and justification by comparison).
RESULTS Eight-eight percent of study participants admitted to engaging in the nonmedical use of prescription stimulants. Two overarching motivations for nonmedical were cited and include (1) “betterment purposes,” which primarily meant helping with study/focus in the academic arena or aiding with performance enhancement when it came to athletic events, workout performance or weight loss, and (2) party/social purposes, which included enhancing one’s party experience by extending and/or enhancing the effects of alcohol and other drugs and/or by allowing those that are more introverted to become more “social.” Attached to these end goals came specific vocabularies that students
Corresponding to this normalization and safety argument, students compared taking prescription stimulants to consuming candy or energy drinks. These types of comparisons made the nonmedical use of stimulants seem even more commonplace and harmless. Hunter states, “It’s [taking prescription stimulants] talked about, it’s common, it’s almost like popping Tic-Tacs or Tylenol.” Lexie reiterates this sense of safety and normalization when she states, “I think since it’s so prevalent now that people aren’t scared to take it all anymore. Maybe their first time they’re a little hesitant but . . . it’s just like candy around here. It’s like eating skittles [laughs].” In addition to the candy metaphor, students were also quick to point out that using these drugs
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The Safety Factor The data from this study indicate widespread use and acceptance of prescription stimulants by various types of college students (ie, those who refrain from drug use to those who regularly engage in drug uses), which led to an overall sense of safety and normalization (“everybody else is doing it” and denial that the behavior is inappropriate) among users. In point of fact, when participants were asked to check off what prescription drugs that they had used for nonmedical purposes many students forgot to mention Adderall and other attention-deficit/hyperactivity disorder (ADHD) medications all together because they simply do not view these drugs as “drugs.” Juan attests to this when he states, “Yeah, I don’t even see it [Adderall] as a drug anymore. It’s just like I have to get my work done, it’s not like I’m going out trying to score drugs and do drugs or anything.” Evan admits to not even knowing that Adderall was a prescription drug when he initially tried it. He states, When I first took it [Adderall] during summer, I didn’t realize it was a prescription drug. I figured that you could get it at a gas station . . . I thought everyone has tried this because it just helps you with studying and I really thought of it as something like one of those pill packets you can get at the gas station. You know those packaged pills that are on the counter? No one knows what they do. I figured it was something like that.
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is really no different than drinking a lot of coffee or consuming a couple of energy drinks. Some students even touted prescription stimulants as being “better,” given that they last longer, are more effective, and do not lead to the same kind of intense crash that other caffeinated products do. Brianna and Gavin both speak to this point:
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Students are very nonchalant and very open about using it [Adderall]. It’s talked about like it’s a RedBull or a Five Hour Energy. I mean you take those for the same purpose you’re using Adderall. Obviously Adderall is stronger but it’s also a lot more effective. (Brianna)
In addition to legitimizing use by pointing out that “nothing bad ever happens,” others point to the fact that they are uneducated on the adverse effects of these drugs (ie, denial of responsibility). For example, when asked about whether or not he worries about the potential dangers associated with the nonmedical use of prescription stimulants, Gavin states, “My parents were always like, ‘don’t drink, don’t smoke, don’t do drugs’ but they were never like ‘don’t go into the medicine cabinet.’” Others responded to this question accordingly:
I mean you can get an Adderall for less than a five hour energy and it’s gonna be twice as good, it’s gonna last longer. It’s cheaper than a latte or whatever and it’s just better. I mean why wouldn’t you do it? (Gavin)
I don’t know the long terms effects of that [Adderall] yet. Maybe I’ll figure that out down the line. Outside of losing sleep which does suck . . . I don’t know what to look for or what to fear . . . I want to know more about the effects of Adderall ’cause maybe then it will be more fearful for me to take. (Owen)
Those using prescription stimulants for social motivations made similar arguments by comparing their use of Adderall and alcohol to mixing alcohol with energy drinks such as Red Bull and Monster or drinking alcohol infused beverages such as FourLoko or Sparks. For example, Cole states,
I guess we don’t really know if there are any really bad side effects. I mean with any prescribed medication if you are not prescribed it there are side effects or dangers. But I guess since it’s [Adderall] such a common things for students to have and to use people really don’t even consider the dangers of it. Maybe if the dangers were more out there people would think twice. (Erika)
I guess there are other things out there that work like Adderall but maybe not as good . . . I mean there’s other ways of doing it [extending the effects of alcohol] rather than just popping a pill but . . . cocaine is more spendy and also a bit more dangerous and energy drinks are just not as effective. (Cole)
When asked if he was at all worried about the potential risks associated with people drinking different concoctions of alcohol and stimulants, Ian replied, “People drink FourLoko, Jager Bombs, Rum and Coke. I mean people have mixed caffeine and alcohol for years and nothing really bad has happened.” When asked about mixing Adderall and alcohol, he replied, “Yeah that’s basically the same thing, mixing a stimulant with alcohol. People around here do that too.” Another piece of this “safety” neutralization is when students point out that “nothing ever bad happens” with this particular class of drugs (ie, denial of injury). As Kimberly states, “I have never heard of anything going wrong with it [Adderall] or seen anything go wrong with it. It’s something that is happening without any really bad consequences.” Evan and Aaron make and similar arguments: Everything I ever heard about Adderall from my friends were good things. I have never seen an ad or a presentation or anything describing the negatives. (Evan) They have those scared straight stories of people who do meth and say that you are addicted that first time. With Adderall people are like “oh, a doctor made it, a doctor is prescribing it and they probably took all of the bad stuff out of it so, I’ll be alright.” (Aaron) 482
Students were also quick to point to people who were legitimately prescribed these drugs (ie, the main points of access) who do not suffer from any terrible side effects. By way of comparison, students argued being no different than these individuals (ie, justification by comparison) and, therefore, concluded that they too would not suffer from any of these side effects. For example, Jasmin states, “I sometimes question whether or not I could actually be prescribed it [Adderall]. ’Cause I mean when I do take it I bust everything out just like that. Am I that different than the person next to me who is prescribed it?” Chase goes on to make an even more pronounced point: “If little kids are prescribed these drugs, what are they gonna do to someone who’s an adult? Especially college kids at the high point of their lives.” Along with being unaware and/or unconcerned with the possible health consequences of taking Adderall and other prescription stimulants, many students also questioned what would actually happen if they got caught with prescription drugs that were not their own. Most doubted that anything too bad would result and felt that law enforcement had more important things to worry about. As Brooke points out, I don’t think people fear the legal ramifications of prescription drugs at all. It’s such a petty offense that I doubt that anyone would prosecute it. Maybe if you had like a huge Adderall ring or something you would get into trouble but I just don’t feel like a one or two pill exchange is anything to write home about.
Graeme makes a similar point when he states, “Everybody hears about people getting MIPS [minor in JOURNAL OF AMERICAN COLLEGE HEALTH
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possession of alcohol] every weekend, or getting busted for marijuana, who cares about some person arrested for possession and use of Adderall? I mean you don’t hear about that at all . . . the police around here don’t care about that.”
Others as More Deviant Beyond claiming safety, those who engage in the nonmedical use of prescription stimulants for strictly “betterment purposes” (ie, study/focus and/or performance enhancement) liked to minimize their deviance by pointing out that others were using these drugs in more reckless and deviant ways (ie, justification by comparison), therefore making their own use more responsible and less injurious (ie, denial of injury). Here are some of those comparisons: If they’re just doing it [Adderall] to party and wasting their lives away then I feel like that’s negative. How is that helping yourself to be better? But, I think if you’re using Adderall to study people are more apt to help you find it ’cause they’ve been in your position and they know how you feel. (Kimberly) Other than that one time that I tried it at a party I’ve never taken it to just do it socially. I would never go to a party just to take a bunch of Adderall and drink. People do mix it with alcohol and other drugs but that’s just not smart. When I was using it regularly [for study/focus purposes] I never thought I would use it enough to become addicted to it. I wasn’t feigning for it like some people do. (Dustin) The thing with Adderall and Concerta is that I can say with confidence in my usage it’s not addictive but I can definitely see people getting reliant on it. I have friends that can’t study for a test if they’re not on Adderall. If they’re gonna be up coffee is not gonna work, they are gonna have to take Adderall to stay up late. You can’t stay up late without Adderall in their opinion which is bad. (Ethan).
Authoritative Enabling As well as invoking safety and responsible use (denial of injury and denial that the behavior is inappropriate), students also justified their nonmedical use of prescription stimulants by referencing their parents’ ambivalence when finding out that they had tried these drugs for study/focus purposes (ie, denial of responsibility). Students took this ambivalence as a sign that the continued use of these drugs for such purposes was acceptable. In those cases where parents were unaware of their child’s use of these drugs, students justified use by claiming that their parents would deem their behavior acceptable as long as these drugs were helping them to perform better in the classroom and helping them to reach their academic goals (ie, denial that the behavior is inappropriate). For example, Eli states, “I really don’t think that they would be upset because it’s not like I recreationally use it. And it’s not like I absolutely need it to get good grades. I’ve just taken it a few times to help with VOL 62, OCTOBER 2014
studying and focus.” Others reacted similarly, when asked about parental reactions to use: I actually did tell my mom that I used it and I didn’t know how she would take it, but she like was like “well, do you actually think that you have ADD?” And I was like “no”, and she pretty much said don’t abuse it, and I told her it was for good grades, and I’m actually surprised she didn’t flip out about me using it. (Mark). I told my Mom I used it [Adderall] once and she told me that if I felt I needed it that she would set me up an appointment to get it prescribed. But that was the last time we really talked about it. But she didn’t have a negative response to me doing it. (Molli).
In addition to referencing parents’ lack of reaction or assumed lack of reaction to the use of stimulants for academic purposes, some participants felt that they legitimately suffered from ADHD, which would arguably make their parents less concerned with their “illegitimate-legitimate” use of these drugs (ie, denial of injury, denial that the behavior is inappropriate). Graeme speaks to this point: I wouldn’t feel bad about telling my mom about that just because I feel like I do have some sort of learning disability . . . I don’t think my Mom would get mad at me for taking it [Adderall] to get my work done. She knows that I struggle sometimes so I think she would be like pretty okay with it.
The few students who cited completely adverse parental reactions to their use of prescription stimulants happened to have parents who worked in the health care industry. For example, Olivia states, My Mom is a nurse so she would be upset. She told me before that she would be very upset if I did that [Adderall]. She told me that college kids were doing it and warned me of the bad things that could happen if I took it . . . She is really against people abusing prescription drugs . . . she would not be happy with me at all.
Ethan shares similar sentiments to Olivia. He states, My mom actually works for [name of hospital] and is familiar with prescription drugs and I’m sure there would be a shit storm about it. Like “this, this, and this could happen to you.” And I think there’s a stigma with it as well . . . It’s not the honorable way to go through your studies . . . they’d [his parents] be like “you’re not strong enough to do it yourself?”
Besides trying to claim that their parents would be on board with their nonmedical use of prescription stimulants for study/focus purposes, students also liked to shift the focus and the blame onto health care practitioners (ie, condemnation of the condemner and others as more deviant). They were quick to point out that doctors are irresponsible and willing to prescribe and/or refill prescriptions without much care or afterthought. Students also questioned doctors’ abilities to correctly diagnose ADHD and thought 483
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that faking the symptoms for this condition would be easy. Jocelyn states, “It’s gotta be easy to fake. I know so many people who have prescriptions that don’t have ADD.” Caleb and Gavin reiterate these points:
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Adderall is over prescribed for sure. I mean if you wanted to you could go in and say I don’t study worth a damn in class and the teacher sounds like the teacher off of Charlie Brown and the doctor is gonna write you up easy. (Caleb). Anyone can say that they have ADHD. There are only a few things that my friends said that they had to do . . . being fidgety and spacing out in front of the doctor . . . and saying that it is hard to concentrate in class and get your work done. It’s pretty easy to fake that stuff. Then it’s like “oh, let me give you this magic pill and all will be better.” (Gavin).
In those cases where students actually admitted to faking symptoms of ADHD, they did not find the process of obtaining a prescription for these drugs to be overly difficult. For example, Hunter states, “It wasn’t really hard to get diagnosed. I basically asked my doctor ‘please!’ It felt like it wasn’t any effort at all. I told him that I have a hard time reading and paying attention . . . and he was like ‘okay I’ll write you a prescription.’” Jason, like Hunter, attests to the ease of obtaining an Adderall prescription. He states, I was taking cognitive psych and there was a whole chapter in there on attention . . . I knew that when a doctor will diagnose you with ADD they kind of got to take your word on it . . . So I told my friend, “dude, if you went in there saying that you were suffering and couldn’t focus in school, they’d probably diagnose you with something” . . . So, he went in there and he did it . . . They gave him ninety days worth of Adderall and told him to take three a day. Three a day, (laughs) there’s no way he could take that much.
In addition to health care professionals being easily deceived into prescribing prescription stimulants, other students, like Jason, accused them of being heavy handed when prescribing to those who legitimately needed these drugs. For example, Damon, a legitimate ADHD sufferer, states, “I have a three month supply of Adderall and don’t like the way it makes me feel so what am I gonna do with it? And when people are calling and calling and calling you, you are finally like fuck here you go.” Along similar lines, Christopher, who also has a legitimate prescription for Adderall, states, “Really no one’s body can handle taking Adderall everyday . . . Everybody pretty much has to take days off.” The times where students did mention access becoming a problem was during the busiest times in the semester, primarily during midterms and finals. During these times, students who had legitimate prescriptions cited the difficulty that they faced when refilling their prescriptions. For example, Samantha states, “The only time that I have had a problem getting Adderall was this last week [dead week], like [name of town] ran dry of stimulants . . . My friend went in to get his actual prescription at [the health center] and they 484
were like ‘sorry come back later.’” Owen also speaks to ease of access and how this will eventually become problematic. He states, “I think more people are starting to realize that it [Adderall] helps a lot, just like a cheat sheet would for a final or something. Pretty soon everyone is gonna get it and it’s gonna be hard to obtain.”
COMMENT Conclusion When it comes to the nonmedical use of prescription stimulants, or any prescription drug, it is not only important to uncover motivations for use but also the vocabularies that individuals utilize to defend why it is appropriate or justified for them to engage in such behavior. It is these justifications or “techniques of neutralization” that help individuals defuse any shame, guilt, and/or stigma associated with their “deviant” behavior. And the more individuals are able to define behavior as good or at least justified, rather than negative or unjustified, the more likely they are to engage in it. The techniques of neutralization employed by participants in this study did not fit neatly into the categories originally put forth my Sykes and Matza, but rather reflected multiple techniques used at once to form more holistic neutralization categories. The first category combined denial of injury, denial that the behavior is inappropriate, and the claim that everybody else is doing it to form the “safety” neutralization category. Here students justified their nonmedical use of prescription stimulants by referencing the fact that these drugs are FDA approved, doctor prescribed, and used by many (including children) to claim safety. Furthermore, students made comparisons between prescription stimulants and everyday stimulants such as coffee and energy drinks to support this safety claim. In fact, some students went as far as to say that using prescription stimulants was more effective and just as safe as using these everyday stimulants. The second neutralization category, Others as More Deviant, consisted of students combining the justification by comparison neutralization with denial of injury. Here students compared their nonmedical use of prescription stimulants to other’s more reckless, “deviant” use while at the same time pointing out their responsible use of these drugs (denial of injury). Finally, students combined condemnation of the condemner, denial of responsibility, the denial that the behavior is inappropriate, and justification by comparison to form the Authoritative Enabling justification category. Here authority figures (primarily parents and doctors) were said to either explicitly or implicitly give consent for the nonmedical use of these drugs. It was inferred that if anyone was to blame for their behavior, it was these individuals, especially doctors who were in reality the “deviant” ones (condemnation of the condemner and justification by comparison), given their irresponsible diagnostic and prescribing practices. JOURNAL OF AMERICAN COLLEGE HEALTH
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Students’ Justification of Nonmedical Prescription Stimulant Use
This learned set of justifications can be directly linked to how students have been socialized to view prescription drugs. In many cases, students admitted to having experienced some of this socialization within the home where parents or other family members would happily give away their leftovers to “help” them or another family member or friend with a particular medical condition. This led to the belief that using someone else’s prescription (for legitimate purposes anyway) was completely acceptable. The few cases where students admitted to their parents having a problem with their nonmedical use of prescriptions occurred when these parents were employed in the medical field. It can be argued that these parents (and their children) are more educated than the average parents on the potential dangers associated with the misuse of these drugs and are more aware that the nonmedical use of prescription drugs, especially prescription stimulants, are becoming more and more popular on college campuses. The ease at which doctors and other health care professionals prescribed and/or were possibly duped into prescribing certain drugs, in this case prescription stimulants, was also viewed by students as an indicator of safety. They argued that those working in the health care industry have taken an oath to protect patients from unnecessary harm and, therefore, would not do anything to knowingly put a patient in harm’s way. In line with these safety justifications, many students also made mention of how they had been taught about the health and legal consequences of engaging in illicit drug use but had never been educated on these issues when it came to prescription drugs—unless, again, their parents happened to work in the medical field. With this justification, students were essentially “denying responsibility” and “condemning the condemners” by taking the spotlight off their own ignorance, and placing it onto a generalized other who should be educating them on the negative effects associated with these drugs. This lack of education or ignorance made it easier for them to disregard any of the possible negatives that could come with using and diverting these drugs. It is, therefore, the job of educators, health care practitioners, parents, counselors, and administrators to start changing the way that prescription drugs have been socially constructed and to start educating young people about the dangers associated with these drugs. If the “normalization” and “safety” neutralizations associated with nonmedical prescription drug use do not change, young people are essentially being given permission to continue to engage in nonmedical prescription drug use, especially with respect to prescription stimulants, which they will continue to regard as “A okay.” When it comes to health care professionals more specifically, it is important for future research to incorporate their voices into the discussion. These individuals represent a major point of access and possess important insights into how students navigate and negotiate their way through the health care system to obtain prescription drug. Furthermore, research must also take a closer look at health care practitioners’ prescribing practices and how these practices help or hinder the nonmedical use of prescription stimulants VOL 62, OCTOBER 2014
as well as other prescription drugs. The results of this study support the contention that a main reason the problem exits in the first place comes down to access. More specifically, it points to possible misconduct on the part of doctors when it comes to both diagnosing and prescribing drugs as well as irresponsible patients who doctor shop, fake symptoms, and refill their prescriptions before needed as helping to perpetuate the problem.
Limitations This study is unique in that it is one of the first to provide detailed insights into the ways in which college students go about justifying their nonmedical use of prescription stimulants (and other prescription drugs) and contextualizes these findings using an adaptation of Sykes and Matza’s neutralization theory.2 Nevertheless, there are limitations to how these findings can be used. First and foremost, the fact that the sample was small, drawn from students at 1 university, and is lacking in racial diversity limits how these findings can be applied to other college students and populations engaged in similar behavior. Additionally, given that faceto-face interviews were conducted, it is possible that social desirability (ie, the tendency for participants to answer questions in a favorable manner) impacted the results of this study. More specifically, it is possible that participants either held back information as to not appear too deviant or fabricated stories in order to appear more deviant. Despite these limitations, this research provides an important launching point for better identifying how we can best go about changing the way that young people (and society in general) have been socialized to view prescription drugs— especially prescription stimulants—and, therefore, the justifications that they employ to defend their deviant use of these drugs.
FUNDING No funding was used to support this research and/or the preparation of the manuscript.
CONFLICT OF INTEREST DISCLOSURE The author has no conflicts of interest to report. The author confirms that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the institution where the research took place.
NOTE For comments and further information, address correspondence to Kristin A. Cutler, Department of Sociology, Washington State University, PO Box 644020, Pullman, WA 99164-4020, USA (e-mail: [email protected]). 485
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Cutler REFERENCES 1. American College Health Association. National College Health Assessment II: Undergraduate Group Executive Summary. Hanover, MD: American College Health Association; 2013. Available at: http://www.acha-ncha.org. Accessed November 20, 2013. 2. Sykes G, Matza D. Techniques of neutralization: a theory of delinquency. Am Sociol Rev. 1957;22:664–673. 3. Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: national findings. Available at: http://www.oas.samhsa. gov/nsduh/2k8nsduh/2k8Results.pdf. Accessed October 9, 2009. 4. National Institute of Drug Abuse. Selected prescription drugs with potential for abuse. Available at: http://www. drugabuse.gov.Published2008. Accessed September 1, 2009. 5. Volkow ND. Scientific research on prescription drug abuse, before the Subcommittee on Crime and Drugs, Committee on the Judiciary and the Caucus on International Narcotics Control, United States Senate. Available at: http://www.nida.nih. gov/Testimony/3-12-08Testimony.html.Published2008. Accessed October 9, 2009. 6. Lakhan SE, Kirchgessner A. Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2012;2:661–667. 7. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use, 1975–2003, Volume II: College Students and Adults Ages 19–45. Bethesda, MD: National Institute on Drug Abuse; 2004. NIH publication no. 04-5508. 8. Gramier-Dykstra LM, Caldeira KM, Vincent KB, O’Grady KE, Arria AM. Nonmedical use of prescription stimulants during college: four-year trends in exposure opportunity, use, motives, and sources. J Am Coll Health. 2012;60:226–234. 9. Arria AM, Calderia KM, O’Grady KE, Vincent KB, Johnson EP, Wish ED. Nonmedical use of prescription stimulants among college students: associations with attention-deficit-hyperactivity disorder and polydrug use. Pharmacotherapy. 2008; 28:156–169. 10. Arria AM, O’Grady KE, Caldeira KM, Vincent KB, Wish ED. Nonmedical use of prescription stimulants and analgesics: associations with social and academic behaviors among college students. J Drug Issues. 2008;38:1045–1060. 11. DeSantis AD, Webb EM, Noar SM. Illicit use of prescription ADHD medications on college campus: a multimethodological approach. J Am Coll Health. 2008; 57:315–323. 12. DuPont RL, Coleman JJ, Bucher RH, Wilford BB. Characteristics and motives of college students who engage in nonmedical use of methylphenidate. Am J Addict. 2008;17:167–171. 13. Ford JA, Schroeder RD. Academic strain and non-medical use of prescription stimulants among college students. Deviant Behav. 2009;30:26–53. 14. Ford JA. Nonmedical prescription drug use among college students: a comparison between athletes and nonathletes. J Am Coll Health. 2008;57:211–219. 15. Judson R, Langdon SW. Illicit use of prescription stimulants among college students: prescription status, motives, theory of planned behaviour, knowledge and self-diagnostic tendencies. Psychol Health Med. 2009;14:97–104. 16. Lord S, Brevard J, Budman S. Connecting to young adults: an online social network survey of beliefs and attitudes associated
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with prescription opioid misuse among college students. Subst Use Misuse. 2011;46:66–76. 17. Low KG, Gendaszek AE. Illicit use of psychostimulants among college students: a preliminary study. Psychol Health Med. 2002;7:283–287. 18. McCabe SE, Boyd C, Teter C. Medical use, and diversion of abusable prescription drugs. J Am Coll Health. 2006;54: 269–278. 19. McCabe SE, Cranford JA, Boyd CJ, Teter CJ. Motives, diversion and routes of administration associated with nonmedical use of prescription drugs. Addict Behav. 2007;32:562–575. 20. Rabiner DL, Anastopoulos AD, Costello EJ, Hoyle RH, McCabe SE, Swartzwelder HS. Motives and perceived consequences of nonmedical ADHD medication use by college students. J Attent Disord. 2008;20:1–12. 21. Rigg KK, Ibanez GE. Motivations for non-medical prescription drug use: a mixed methods analysis. J Subst Abuse Treat. 2010;39:236–247. 22. Teter CJ, McCabe SE, Cranford JA, Boyd CJ, Guthrie SK. Prevalence and motives for illicit use of prescription stimulants in an undergraduate sample. J Am Coll Health. 2005;53:253–262. 23. Quintero G, Peterson J, Young B. An exploratory study of the socio-cultural factors contributing to prescription drug misuse among college students. J Drug Issues. 2006;43:903–932. 24. Strauss A, Corbin J. Grounded theory methodology. In: Denzin NK, Lincoln YS, eds. Strategies of Qualitative Inquiry. Thousand Oaks, CA: Sage Publications; 1998:158–179. 25. Babbie E. The Practice of Social Research. 7th ed. New York, NY: Wadsworth Publishing Company; 1995. 26. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. New Brunswick, NJ: Aldine Transaction Publishers; 2007. 27. Sutherland EH. Principals of Criminology. 4th ed. Philadelphia, PA: Lippincott; 1947. 28. Akers L. Deviant Behavior: A Social Learning Approach. New York, NY: Wadsworth; 1977. 29. Becker HS. Becoming a marihuana user. Am J Sociol. 1952;59:235–242. 30. Scott MB, Lyman SM. Accounts of deviance and social order. In: Douglas J, ed. Deviance and Respectability: The Social Construction of Moral Meanings. New York, NY: Basic; 1970:89–120. 31. Akers RL. Social Learning and Social Structure: A General Theory of Crime and Deviance. New Brunswick, NJ: Transaction Publishers; 2009. 32. Coleman JW. The Criminal Elite: The Sociology of White Collar Crime. New York, NY: St. Martin’s Press; 1994. 33. Cromwell P, Thurman Q. The devil made me do it: use of neutralizations by shoplifters. Deviant Behav. 2003;24:535–550. 34. Gauthier DM. Professional lapses: Occupational deviance and neutralization techniques in veterinary medical practice. Deviant Behav. 2001;22:467–490.
Received: 5 July 2013 Revised: 11 May 2014 Accepted: 22 May 2014
JOURNAL OF AMERICAN COLLEGE HEALTH
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use a
Kristin A. Cutler PhD a
Department of Sociology, Washington State University, Pullman, Washington Accepted author version posted online: 05 Jun 2014.Published online: 16 Sep 2014.
To cite this article: Kristin A. Cutler PhD (2014) Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use, Journal of American College Health, 62:7, 478-486, DOI: 10.1080/07448481.2014.929578 To link to this article: http://dx.doi.org/10.1080/07448481.2014.929578
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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 7
Major Article
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Prescription Stimulants Are “A Okay”: Applying Neutralization Theory to College Students’ Nonmedical Prescription Stimulant Use Kristin A. Cutler, PhD
Abstract. Objective: National college health data indicate that prescription stimulants are the most widely misused prescription drugs among college students, with 9% admitting to nonmedical use within the past year.1 Although motivations for the nonmedical use of these drugs have been explored, scant attention has been paid to justifications for nonmedical use. This article fills that gap by expounding upon the justifications students incite to defend their nonmedical use of these drugs. Participants: Seventy-six college students from a large, public northwestern university. Methods: Semistructured interviews were conducted during the 2010–2011 academic year. Results: Inductive analysis uncovered social learning theories of crime/deviance, more specifically, Sykes and Matza’s neutralization theory2 as helping to inform justifications for nonmedical stimulant use. This theory was modified to better encompass the justifications that students employed. Conclusion: Justifications for use must become a more central part of the conversation surrounding nonmedical stimulant use among the college population.
NCHA data find that 9% of college students admit to the nonmedical use of these drugs within the past year.1 Furthermore, it has been found that almost two-thirds of college seniors have been offered prescription stimulants for nonmedical use during the course of their college careers and that upwards of 30% admit to using them at least once.6,7 Research produced in this area in the fields of medicine, psychology, and sociology has predominantly focused on the epidemiology of nonmedical prescription stimulant use. Less attention has been paid to motivations (ie, incentives and drives) for misuse and abuse, with little to no attention being paid to justifications (ie, rationalizations or neutralizations for use) for misuse and abuse. Those studies that have examined motivations surrounding nonmedical stimulant use have identified better focus, a quicker and cheaper high, and experimentation as typical reasons underlying misuse and abuse.8–23 When it comes to justifications for use, safety has been the only well-documented justification. With this justification, students argue that prescription stimulants, as opposed to illicit stimulants (ie, cocaine and methamphetamine), are “safer” options for experimentation and getting high because they have been approved by the Food and Drug Administration (FDA) and are “pure,” having known chemical compositions and predictable side effects. Additionally, they argue that the physical effects of these drugs are harder to detect and that they are overall easier to conceal.3,5–8,20 Beyond the lack of research addressing motivations and justifications for nonmedical stimulant use, there has been a disconnect in the literature when it comes to explaining the mechanisms or processes whereby college students come to incite various motivations and justifications for use. The few studies that have used theory to better inform motivations for nonmedical stimulant use have primarily focused
Keywords: college students, community health, justifications, prescription drugs, prescription stimulants
T
he most recent National College Health Assessment (NCHA) data suggest that 16% of undergraduate college students admit to using a prescription drug that was not prescribed to them in the last 12 months.1 Of these drugs, prescription stimulants (eg, Adderall, Ritalin, Concerta, and Vyvanse) are some of the most widely misused and abused among college students.3–5 In fact, the nonmedical use of these drugs (ie, use without a prescription or in ways that a doctor would not prescribe) come in second to marijuana as the most common form of illicit drug use.6,7
Dr Cutler is with the Department of Sociology at Washington State University in Pullman, Washington. Copyright Ó 2014 Taylor & Francis Group, LLC 478
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Students’ Justification of Nonmedical Prescription Stimulant Use
on academic strain (eg, juggling a full credit load, the extra stress that comes with midterm and finals weeks, finding balance being a student-athlete).6–23 Although this is an important contribution to our knowledge, survey research points to other factors outside of academic strain that influence motivations and justifications for use. Thus, it is imperative that these factors be explored and better contextualized using theories outside of strain. Although motivations and justifications are interrelated processes, motivations for nonmedical stimulant use have taken greater precedence within the literature. This is partially a result of the fact that motivations are more easily ascertainable through survey research (ie, quantitative methods). How college students go about justifying why it is acceptable to be engaged in such behavior, on the other hand, is a more complex process. A process that is arguably best discerned through the use of inductive, qualitative methods whereby individuals are able to self-reflect and share their personal experiences with using these drugs. Justifications for use are also arguably just as, if not more, important to focus on than motivations for use, given that they help individuals resolve any guilt, shame, or stigma associated with their deviant use of prescription drugs. Given these weaknesses in the current research, the purpose of this article is twofold. First, by using qualitative methods it will provide a more in-depth look into the justifications that college students employ (beyond just safety) to minimize their deviant identities when it comes to the nonmedical use of prescription stimulants. Second, this article will better explain and contextualize these findings on justifications using criminological theory, more specifically, Sykes and Matza’s neutralization theory.2 METHODS Protection of Participants Ethical approval for this project was obtained from the university’s Institutional Review Board (IRB). A certificate of confidentiality was obtained through the National Institutes of Health. With this certificate, the researchers cannot be forced to disclose, even by court subpoena, information that may identify participants, in any federal, state, civil, criminal, administrative, or legislative proceeding. Participants signed a consent form before the interview process began and were made aware that the project had been approved by the institution’s IRB. Additionally, participants were made aware that their identities would be protected by the use of pseudonyms and that the consent forms (the only documentation that had identifying information on it) would be safely stored and then destroyed after the appropriate amount of time had passed
Analytic Strategy Inductive analysis was employed in this study because it allows the details of qualitative data to uncover important VOL 62, OCTOBER 2014
patterns, themes, and interrelationships. This type of strategy, therefore, focuses on theory development and asserts that theory may be generated from incoming data, or that existing theories may be elaborated upon or modified depending upon the data.24–26 In addition to allowing for theory development and modification, inductive analysis recognizes that the participants under study have their own perspectives and interpretations of their own and other actors’ actions and behaviors.24–26 Given this approach, indepth, semistructured interviews were employed given that they are one of the best methods for eliciting information on newly emerging areas of study and can provide more clarification and context than do other methods, especially survey research. With respect to this study more specifically, interviews allowed for a better understanding of how college students interpret, understand, and justify their nonmedical use of prescription stimulants.
Sampling Procedure College students from a large, public university located in the northwestern United States constituted the sampling frame for this study. Purposive sampling techniques were employed whereby participants had to meet certain criteria for inclusion in the study. Participants had to be 18 years of age, enrolled at the institution that the sample was drawn from, and had to self-identify as someone who had engaged in nonmedical prescription drug use within the past year. Nonmedical prescription drug users (as opposed to nonusers) were the main targets given the interest in better pinpointing and understanding motivations and justifications use. Recruitment of participants took place through flyers posted in high-foot-traffic areas on and off campus, including the student union, the student recreation center, and the student health center. Announcements were also made in a variety of lower-level introductory classes where a crosssection of the student population is represented. Snowball sampling was also utilized whereby existing study participants voluntarily informed friends and acquaintances about the study. A total of 76 students (46 male, 30 female), ranging in age from 18 to 26 (average age being 21), and in class standing from freshman to graduate students took part in the study. Of these 76 participants, the majority are white and from middle and middle-upper class backgrounds (see Table 1 for participant and institutional demographics). These participants, though similar in race/ethnicity, age, and socioeconomic standing, were diverse when it came to drug use backgrounds (eg, some were self-pronounced drug addicts, whereas others were first-time, novice users).
Interview Guide The interview guide was constructed based upon the most current drug abuse literature, student focus groups, and extensive pretesting of various working versions of the 479
Cutler
TABLE 1. Participant Demographics Versus School Demographics
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Characteristic Race % White % Nonwhite Gender % Male % Female Class standing % Senior % Junior % Sophomore % Freshman % Graduate student Greek affiliation % Greek % Non-Greek Athlete % Athlete % Nonathlete Living arrangements % On-campus % Off-campus Other demographics Age (mean) GPA (mean)
Study participants
2010–2011 school demographics
99.3 0.7
69.9 30.1
60.5 39.5
49.0 51.0
42.1 19.7 22.4 13.2 2.6
22.0 19.0 16.0 27.0 15.0
40.8 59.2
18.0 92.0
7.9 92.1
2.3 97.7
30.3 69.7
36.0 64.0
21 3.0
23 3.3
guide. Given its extensive use within the existing literature, the following definition of nonmedical prescription drug use was used: past-year use of one or more prescription drugs without a prescription from a doctor, use that does not follow a doctor’s instructions, or use simply for the experience or feelings that the drug can cause. Central nervous system stimulants are classified as Schedule II drugs (ie, providing positive medical benefits but also considerable abuse potential) and were defined as those drugs most often used to treat attention deficit disorder, narcolepsy, obesity, and depression. Some of the most prescribed drugs in this category include Adderall, Ritalin, Concerta, and Vyvanse.4,5 The guide covered several topics, including (1) initiation into use and shifting patterns of use, (2) knowledge concerning the intended utility of these drugs, (3) access/opportunities for use, (4) diversion of these drugs, (5) poly-drug use, and (6) motivations for use. Given the flexible nature of this research design, this guide was used to generate discussion on the topics listed; nevertheless, the topics were not necessarily addressed in any particular order, and the respondents were allowed to guide the conversations and bring up new areas of interest. In some cases, not all of the topics were addressed given that some did not apply to a specific individual’s behavior. Data reliability and validity were established by making sure that the inclusion criteria 480
for the study were clearly explicated. It was known from the start that participants taking part in the study had participated in nonmedical prescription drug use within the past year. Additionally, over the course of the interviewing process, interview responses became quite repetitious and by interview 76, saturation had been achieved. Interviews were conducted during the fall of 2010 through the spring of 2011. All participants were interviewed in a private setting by the lead investigator and were compensated $25 for their time and participation in the study. Given the sensitivity of the topic, only the lead investigator conducted the interviews. Throughout the interview process, checks for validity were made by repeatedly summarizing back to participants their statements regarding their experiences using prescription stimulants. Participants were also asked if they could be recontacted if any questions or points of clarification came up during the transcription process. Interviews lasted anywhere from 30 to 60 minutes and were digitally recorded. Interviews were transcribed verbatim by the lead investigator and 2 trained research assistants using a qualitative data program called HyperTranscribe (ResearchWare, Inc., Randolph, Massachusetts). The transcribed data were then imported into a qualitative data management program called HyperResearch (ResearchWare, Inc., Randolph, Massachusetts). This program allows qualitative researchers to organize and code their data more efficiently and effectively than doing it manually. Initial themes were generated based upon the questions in the interview guide; however, other unexpected themes were also uncovered—one of which was justifications for use. After interviews were coded, comparisons were made across various sociodemographics (ie, age, gender, class standing, Greek affiliation, athletic affiliation).
Theoretical Rationale Throughout the interview and coding processes, social learning theories of crime/deviance were uncovered as helping to inform motivations and justifications underlying students’ nonmedical use of prescription stimulants. When explaining justifications for use more specifically, one must take a closer look at Sykes and Matza’s neutralization theory.2 This theory is intricately linked to the social learning tradition of criminology, which focuses on how significant others (ie, friends and family) impact the learning process and ultimately one’s decision to define deviance as desirable.27 When it comes to explaining drug use more specifically, social learning theories emphasize the importance of learned motives and techniques of acquiring and appropriately using drugs.28,29 Part of this learning process also encompasses learning to employ certain justifications for why engaging in drug use is desirable.2,27,30 These justifications or “techniques of neutralization,” as Sykes and Matza call them, allow individuals to neutralize and temporarily suspend their commitment to social values, providing them with the freedom to engage in deviant acts and avoid damage to their self-concept. Accordingly, it is not that deviant JOURNAL OF AMERICAN COLLEGE HEALTH
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behavior is “right,” it is that it is “all right” under certain circumstances.31 The original techniques of neutralization put forth by Sykes and Matza include passing the blame to others (denial of responsibility) and/or defining others as equally more corrupt or deviant (condemnation of the condemners), insisting that no one was hurt (denial of injury), insisting that the victim deserved what they got (denial of the victim), and insisting that the rules are not as important to remaining loyal to others (appeal to higher loyalties). Sometime later, Coleman added 4 more techniques to the list that were more common to the culture of white-collar crimes. These include denying that the behavior is inappropriate (denial of necessity of the law), claiming that economic survival is at stake (defense of necessity), claiming that “everybody else is doing it” and not penalized for doing it, and claiming that the benefit of engaging in the deviant behavior is deserved or owed (claim of entitlement).32–34 When applying these techniques of neutralization to shoplifting, Cromwell and Thurman added the “justification by comparison” neutralization and “postponement.” When employing the “justification by comparison,” individuals argue that if they were not engaged in X deviant behavior that they would be doing something worse, whereas with “postponement” individuals simply put the deviant event or incident out of their mind.32 Although neutralization theory has been applied to a variety of deviant behaviors, including the misuse and abuse of alcohol and illicit drugs, it has yet to be applied to individuals’ nonmedical use of prescription drugs. This research found that some of the same techniques of neutralization used for the misuse and abuse use of alcohol and illicit drugs (such as denial of injury, the claim that everybody else is doing it, and condemnation of the condemners) apply to the nonmedical use of prescription stimulants; however, the way in which these techniques are put into action were found to be different. In this study, students consistently combined various techniques to form more holistic neutralization categories (refer to Results below). Given these differences, and as inductive analysis dictates, the theory was modified as to best underscore how students went about explaining away their nonmedical use of prescription stimulants.
employed to justify why it was acceptable to be engaged in the nonmedical use of these drugs. These justifications or “techniques of neutralization” are categorized differently than past research, given that students often combined techniques to form more holistic neutralization categories. These techniques of neutralization have been categorized as follows: (1) The Safety Factor (which includes denial of injury, denial that the behavior is inappropriate, and the claim that everybody else is doing it), (2) Others as More Deviant (justification by comparison and denial of injury—this this includes claiming responsible use as opposed to irresponsible, “deviant” use), and (3) Authoritative Enabling (which includes condemnation of the condemner, denial of responsibility, denial that the behavior is inappropriate, and justification by comparison).
RESULTS Eight-eight percent of study participants admitted to engaging in the nonmedical use of prescription stimulants. Two overarching motivations for nonmedical were cited and include (1) “betterment purposes,” which primarily meant helping with study/focus in the academic arena or aiding with performance enhancement when it came to athletic events, workout performance or weight loss, and (2) party/social purposes, which included enhancing one’s party experience by extending and/or enhancing the effects of alcohol and other drugs and/or by allowing those that are more introverted to become more “social.” Attached to these end goals came specific vocabularies that students
Corresponding to this normalization and safety argument, students compared taking prescription stimulants to consuming candy or energy drinks. These types of comparisons made the nonmedical use of stimulants seem even more commonplace and harmless. Hunter states, “It’s [taking prescription stimulants] talked about, it’s common, it’s almost like popping Tic-Tacs or Tylenol.” Lexie reiterates this sense of safety and normalization when she states, “I think since it’s so prevalent now that people aren’t scared to take it all anymore. Maybe their first time they’re a little hesitant but . . . it’s just like candy around here. It’s like eating skittles [laughs].” In addition to the candy metaphor, students were also quick to point out that using these drugs
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The Safety Factor The data from this study indicate widespread use and acceptance of prescription stimulants by various types of college students (ie, those who refrain from drug use to those who regularly engage in drug uses), which led to an overall sense of safety and normalization (“everybody else is doing it” and denial that the behavior is inappropriate) among users. In point of fact, when participants were asked to check off what prescription drugs that they had used for nonmedical purposes many students forgot to mention Adderall and other attention-deficit/hyperactivity disorder (ADHD) medications all together because they simply do not view these drugs as “drugs.” Juan attests to this when he states, “Yeah, I don’t even see it [Adderall] as a drug anymore. It’s just like I have to get my work done, it’s not like I’m going out trying to score drugs and do drugs or anything.” Evan admits to not even knowing that Adderall was a prescription drug when he initially tried it. He states, When I first took it [Adderall] during summer, I didn’t realize it was a prescription drug. I figured that you could get it at a gas station . . . I thought everyone has tried this because it just helps you with studying and I really thought of it as something like one of those pill packets you can get at the gas station. You know those packaged pills that are on the counter? No one knows what they do. I figured it was something like that.
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is really no different than drinking a lot of coffee or consuming a couple of energy drinks. Some students even touted prescription stimulants as being “better,” given that they last longer, are more effective, and do not lead to the same kind of intense crash that other caffeinated products do. Brianna and Gavin both speak to this point:
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Students are very nonchalant and very open about using it [Adderall]. It’s talked about like it’s a RedBull or a Five Hour Energy. I mean you take those for the same purpose you’re using Adderall. Obviously Adderall is stronger but it’s also a lot more effective. (Brianna)
In addition to legitimizing use by pointing out that “nothing bad ever happens,” others point to the fact that they are uneducated on the adverse effects of these drugs (ie, denial of responsibility). For example, when asked about whether or not he worries about the potential dangers associated with the nonmedical use of prescription stimulants, Gavin states, “My parents were always like, ‘don’t drink, don’t smoke, don’t do drugs’ but they were never like ‘don’t go into the medicine cabinet.’” Others responded to this question accordingly:
I mean you can get an Adderall for less than a five hour energy and it’s gonna be twice as good, it’s gonna last longer. It’s cheaper than a latte or whatever and it’s just better. I mean why wouldn’t you do it? (Gavin)
I don’t know the long terms effects of that [Adderall] yet. Maybe I’ll figure that out down the line. Outside of losing sleep which does suck . . . I don’t know what to look for or what to fear . . . I want to know more about the effects of Adderall ’cause maybe then it will be more fearful for me to take. (Owen)
Those using prescription stimulants for social motivations made similar arguments by comparing their use of Adderall and alcohol to mixing alcohol with energy drinks such as Red Bull and Monster or drinking alcohol infused beverages such as FourLoko or Sparks. For example, Cole states,
I guess we don’t really know if there are any really bad side effects. I mean with any prescribed medication if you are not prescribed it there are side effects or dangers. But I guess since it’s [Adderall] such a common things for students to have and to use people really don’t even consider the dangers of it. Maybe if the dangers were more out there people would think twice. (Erika)
I guess there are other things out there that work like Adderall but maybe not as good . . . I mean there’s other ways of doing it [extending the effects of alcohol] rather than just popping a pill but . . . cocaine is more spendy and also a bit more dangerous and energy drinks are just not as effective. (Cole)
When asked if he was at all worried about the potential risks associated with people drinking different concoctions of alcohol and stimulants, Ian replied, “People drink FourLoko, Jager Bombs, Rum and Coke. I mean people have mixed caffeine and alcohol for years and nothing really bad has happened.” When asked about mixing Adderall and alcohol, he replied, “Yeah that’s basically the same thing, mixing a stimulant with alcohol. People around here do that too.” Another piece of this “safety” neutralization is when students point out that “nothing ever bad happens” with this particular class of drugs (ie, denial of injury). As Kimberly states, “I have never heard of anything going wrong with it [Adderall] or seen anything go wrong with it. It’s something that is happening without any really bad consequences.” Evan and Aaron make and similar arguments: Everything I ever heard about Adderall from my friends were good things. I have never seen an ad or a presentation or anything describing the negatives. (Evan) They have those scared straight stories of people who do meth and say that you are addicted that first time. With Adderall people are like “oh, a doctor made it, a doctor is prescribing it and they probably took all of the bad stuff out of it so, I’ll be alright.” (Aaron) 482
Students were also quick to point to people who were legitimately prescribed these drugs (ie, the main points of access) who do not suffer from any terrible side effects. By way of comparison, students argued being no different than these individuals (ie, justification by comparison) and, therefore, concluded that they too would not suffer from any of these side effects. For example, Jasmin states, “I sometimes question whether or not I could actually be prescribed it [Adderall]. ’Cause I mean when I do take it I bust everything out just like that. Am I that different than the person next to me who is prescribed it?” Chase goes on to make an even more pronounced point: “If little kids are prescribed these drugs, what are they gonna do to someone who’s an adult? Especially college kids at the high point of their lives.” Along with being unaware and/or unconcerned with the possible health consequences of taking Adderall and other prescription stimulants, many students also questioned what would actually happen if they got caught with prescription drugs that were not their own. Most doubted that anything too bad would result and felt that law enforcement had more important things to worry about. As Brooke points out, I don’t think people fear the legal ramifications of prescription drugs at all. It’s such a petty offense that I doubt that anyone would prosecute it. Maybe if you had like a huge Adderall ring or something you would get into trouble but I just don’t feel like a one or two pill exchange is anything to write home about.
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possession of alcohol] every weekend, or getting busted for marijuana, who cares about some person arrested for possession and use of Adderall? I mean you don’t hear about that at all . . . the police around here don’t care about that.”
Others as More Deviant Beyond claiming safety, those who engage in the nonmedical use of prescription stimulants for strictly “betterment purposes” (ie, study/focus and/or performance enhancement) liked to minimize their deviance by pointing out that others were using these drugs in more reckless and deviant ways (ie, justification by comparison), therefore making their own use more responsible and less injurious (ie, denial of injury). Here are some of those comparisons: If they’re just doing it [Adderall] to party and wasting their lives away then I feel like that’s negative. How is that helping yourself to be better? But, I think if you’re using Adderall to study people are more apt to help you find it ’cause they’ve been in your position and they know how you feel. (Kimberly) Other than that one time that I tried it at a party I’ve never taken it to just do it socially. I would never go to a party just to take a bunch of Adderall and drink. People do mix it with alcohol and other drugs but that’s just not smart. When I was using it regularly [for study/focus purposes] I never thought I would use it enough to become addicted to it. I wasn’t feigning for it like some people do. (Dustin) The thing with Adderall and Concerta is that I can say with confidence in my usage it’s not addictive but I can definitely see people getting reliant on it. I have friends that can’t study for a test if they’re not on Adderall. If they’re gonna be up coffee is not gonna work, they are gonna have to take Adderall to stay up late. You can’t stay up late without Adderall in their opinion which is bad. (Ethan).
Authoritative Enabling As well as invoking safety and responsible use (denial of injury and denial that the behavior is inappropriate), students also justified their nonmedical use of prescription stimulants by referencing their parents’ ambivalence when finding out that they had tried these drugs for study/focus purposes (ie, denial of responsibility). Students took this ambivalence as a sign that the continued use of these drugs for such purposes was acceptable. In those cases where parents were unaware of their child’s use of these drugs, students justified use by claiming that their parents would deem their behavior acceptable as long as these drugs were helping them to perform better in the classroom and helping them to reach their academic goals (ie, denial that the behavior is inappropriate). For example, Eli states, “I really don’t think that they would be upset because it’s not like I recreationally use it. And it’s not like I absolutely need it to get good grades. I’ve just taken it a few times to help with VOL 62, OCTOBER 2014
studying and focus.” Others reacted similarly, when asked about parental reactions to use: I actually did tell my mom that I used it and I didn’t know how she would take it, but she like was like “well, do you actually think that you have ADD?” And I was like “no”, and she pretty much said don’t abuse it, and I told her it was for good grades, and I’m actually surprised she didn’t flip out about me using it. (Mark). I told my Mom I used it [Adderall] once and she told me that if I felt I needed it that she would set me up an appointment to get it prescribed. But that was the last time we really talked about it. But she didn’t have a negative response to me doing it. (Molli).
In addition to referencing parents’ lack of reaction or assumed lack of reaction to the use of stimulants for academic purposes, some participants felt that they legitimately suffered from ADHD, which would arguably make their parents less concerned with their “illegitimate-legitimate” use of these drugs (ie, denial of injury, denial that the behavior is inappropriate). Graeme speaks to this point: I wouldn’t feel bad about telling my mom about that just because I feel like I do have some sort of learning disability . . . I don’t think my Mom would get mad at me for taking it [Adderall] to get my work done. She knows that I struggle sometimes so I think she would be like pretty okay with it.
The few students who cited completely adverse parental reactions to their use of prescription stimulants happened to have parents who worked in the health care industry. For example, Olivia states, My Mom is a nurse so she would be upset. She told me before that she would be very upset if I did that [Adderall]. She told me that college kids were doing it and warned me of the bad things that could happen if I took it . . . She is really against people abusing prescription drugs . . . she would not be happy with me at all.
Ethan shares similar sentiments to Olivia. He states, My mom actually works for [name of hospital] and is familiar with prescription drugs and I’m sure there would be a shit storm about it. Like “this, this, and this could happen to you.” And I think there’s a stigma with it as well . . . It’s not the honorable way to go through your studies . . . they’d [his parents] be like “you’re not strong enough to do it yourself?”
Besides trying to claim that their parents would be on board with their nonmedical use of prescription stimulants for study/focus purposes, students also liked to shift the focus and the blame onto health care practitioners (ie, condemnation of the condemner and others as more deviant). They were quick to point out that doctors are irresponsible and willing to prescribe and/or refill prescriptions without much care or afterthought. Students also questioned doctors’ abilities to correctly diagnose ADHD and thought 483
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that faking the symptoms for this condition would be easy. Jocelyn states, “It’s gotta be easy to fake. I know so many people who have prescriptions that don’t have ADD.” Caleb and Gavin reiterate these points:
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Adderall is over prescribed for sure. I mean if you wanted to you could go in and say I don’t study worth a damn in class and the teacher sounds like the teacher off of Charlie Brown and the doctor is gonna write you up easy. (Caleb). Anyone can say that they have ADHD. There are only a few things that my friends said that they had to do . . . being fidgety and spacing out in front of the doctor . . . and saying that it is hard to concentrate in class and get your work done. It’s pretty easy to fake that stuff. Then it’s like “oh, let me give you this magic pill and all will be better.” (Gavin).
In those cases where students actually admitted to faking symptoms of ADHD, they did not find the process of obtaining a prescription for these drugs to be overly difficult. For example, Hunter states, “It wasn’t really hard to get diagnosed. I basically asked my doctor ‘please!’ It felt like it wasn’t any effort at all. I told him that I have a hard time reading and paying attention . . . and he was like ‘okay I’ll write you a prescription.’” Jason, like Hunter, attests to the ease of obtaining an Adderall prescription. He states, I was taking cognitive psych and there was a whole chapter in there on attention . . . I knew that when a doctor will diagnose you with ADD they kind of got to take your word on it . . . So I told my friend, “dude, if you went in there saying that you were suffering and couldn’t focus in school, they’d probably diagnose you with something” . . . So, he went in there and he did it . . . They gave him ninety days worth of Adderall and told him to take three a day. Three a day, (laughs) there’s no way he could take that much.
In addition to health care professionals being easily deceived into prescribing prescription stimulants, other students, like Jason, accused them of being heavy handed when prescribing to those who legitimately needed these drugs. For example, Damon, a legitimate ADHD sufferer, states, “I have a three month supply of Adderall and don’t like the way it makes me feel so what am I gonna do with it? And when people are calling and calling and calling you, you are finally like fuck here you go.” Along similar lines, Christopher, who also has a legitimate prescription for Adderall, states, “Really no one’s body can handle taking Adderall everyday . . . Everybody pretty much has to take days off.” The times where students did mention access becoming a problem was during the busiest times in the semester, primarily during midterms and finals. During these times, students who had legitimate prescriptions cited the difficulty that they faced when refilling their prescriptions. For example, Samantha states, “The only time that I have had a problem getting Adderall was this last week [dead week], like [name of town] ran dry of stimulants . . . My friend went in to get his actual prescription at [the health center] and they 484
were like ‘sorry come back later.’” Owen also speaks to ease of access and how this will eventually become problematic. He states, “I think more people are starting to realize that it [Adderall] helps a lot, just like a cheat sheet would for a final or something. Pretty soon everyone is gonna get it and it’s gonna be hard to obtain.”
COMMENT Conclusion When it comes to the nonmedical use of prescription stimulants, or any prescription drug, it is not only important to uncover motivations for use but also the vocabularies that individuals utilize to defend why it is appropriate or justified for them to engage in such behavior. It is these justifications or “techniques of neutralization” that help individuals defuse any shame, guilt, and/or stigma associated with their “deviant” behavior. And the more individuals are able to define behavior as good or at least justified, rather than negative or unjustified, the more likely they are to engage in it. The techniques of neutralization employed by participants in this study did not fit neatly into the categories originally put forth my Sykes and Matza, but rather reflected multiple techniques used at once to form more holistic neutralization categories. The first category combined denial of injury, denial that the behavior is inappropriate, and the claim that everybody else is doing it to form the “safety” neutralization category. Here students justified their nonmedical use of prescription stimulants by referencing the fact that these drugs are FDA approved, doctor prescribed, and used by many (including children) to claim safety. Furthermore, students made comparisons between prescription stimulants and everyday stimulants such as coffee and energy drinks to support this safety claim. In fact, some students went as far as to say that using prescription stimulants was more effective and just as safe as using these everyday stimulants. The second neutralization category, Others as More Deviant, consisted of students combining the justification by comparison neutralization with denial of injury. Here students compared their nonmedical use of prescription stimulants to other’s more reckless, “deviant” use while at the same time pointing out their responsible use of these drugs (denial of injury). Finally, students combined condemnation of the condemner, denial of responsibility, the denial that the behavior is inappropriate, and justification by comparison to form the Authoritative Enabling justification category. Here authority figures (primarily parents and doctors) were said to either explicitly or implicitly give consent for the nonmedical use of these drugs. It was inferred that if anyone was to blame for their behavior, it was these individuals, especially doctors who were in reality the “deviant” ones (condemnation of the condemner and justification by comparison), given their irresponsible diagnostic and prescribing practices. JOURNAL OF AMERICAN COLLEGE HEALTH
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This learned set of justifications can be directly linked to how students have been socialized to view prescription drugs. In many cases, students admitted to having experienced some of this socialization within the home where parents or other family members would happily give away their leftovers to “help” them or another family member or friend with a particular medical condition. This led to the belief that using someone else’s prescription (for legitimate purposes anyway) was completely acceptable. The few cases where students admitted to their parents having a problem with their nonmedical use of prescriptions occurred when these parents were employed in the medical field. It can be argued that these parents (and their children) are more educated than the average parents on the potential dangers associated with the misuse of these drugs and are more aware that the nonmedical use of prescription drugs, especially prescription stimulants, are becoming more and more popular on college campuses. The ease at which doctors and other health care professionals prescribed and/or were possibly duped into prescribing certain drugs, in this case prescription stimulants, was also viewed by students as an indicator of safety. They argued that those working in the health care industry have taken an oath to protect patients from unnecessary harm and, therefore, would not do anything to knowingly put a patient in harm’s way. In line with these safety justifications, many students also made mention of how they had been taught about the health and legal consequences of engaging in illicit drug use but had never been educated on these issues when it came to prescription drugs—unless, again, their parents happened to work in the medical field. With this justification, students were essentially “denying responsibility” and “condemning the condemners” by taking the spotlight off their own ignorance, and placing it onto a generalized other who should be educating them on the negative effects associated with these drugs. This lack of education or ignorance made it easier for them to disregard any of the possible negatives that could come with using and diverting these drugs. It is, therefore, the job of educators, health care practitioners, parents, counselors, and administrators to start changing the way that prescription drugs have been socially constructed and to start educating young people about the dangers associated with these drugs. If the “normalization” and “safety” neutralizations associated with nonmedical prescription drug use do not change, young people are essentially being given permission to continue to engage in nonmedical prescription drug use, especially with respect to prescription stimulants, which they will continue to regard as “A okay.” When it comes to health care professionals more specifically, it is important for future research to incorporate their voices into the discussion. These individuals represent a major point of access and possess important insights into how students navigate and negotiate their way through the health care system to obtain prescription drug. Furthermore, research must also take a closer look at health care practitioners’ prescribing practices and how these practices help or hinder the nonmedical use of prescription stimulants VOL 62, OCTOBER 2014
as well as other prescription drugs. The results of this study support the contention that a main reason the problem exits in the first place comes down to access. More specifically, it points to possible misconduct on the part of doctors when it comes to both diagnosing and prescribing drugs as well as irresponsible patients who doctor shop, fake symptoms, and refill their prescriptions before needed as helping to perpetuate the problem.
Limitations This study is unique in that it is one of the first to provide detailed insights into the ways in which college students go about justifying their nonmedical use of prescription stimulants (and other prescription drugs) and contextualizes these findings using an adaptation of Sykes and Matza’s neutralization theory.2 Nevertheless, there are limitations to how these findings can be used. First and foremost, the fact that the sample was small, drawn from students at 1 university, and is lacking in racial diversity limits how these findings can be applied to other college students and populations engaged in similar behavior. Additionally, given that faceto-face interviews were conducted, it is possible that social desirability (ie, the tendency for participants to answer questions in a favorable manner) impacted the results of this study. More specifically, it is possible that participants either held back information as to not appear too deviant or fabricated stories in order to appear more deviant. Despite these limitations, this research provides an important launching point for better identifying how we can best go about changing the way that young people (and society in general) have been socialized to view prescription drugs— especially prescription stimulants—and, therefore, the justifications that they employ to defend their deviant use of these drugs.
FUNDING No funding was used to support this research and/or the preparation of the manuscript.
CONFLICT OF INTEREST DISCLOSURE The author has no conflicts of interest to report. The author confirms that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the institution where the research took place.
NOTE For comments and further information, address correspondence to Kristin A. Cutler, Department of Sociology, Washington State University, PO Box 644020, Pullman, WA 99164-4020, USA (e-mail: [email protected]). 485
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Received: 5 July 2013 Revised: 11 May 2014 Accepted: 22 May 2014
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