Report to Congressional Requesters

United States General Accounting Office

GAO

September 2001 ATTENTION

DISORDER DRUGS

Few Incidents of

Diversion or Abuse

Identified by Schools

GAO-01-1011
Page i GAO-01-1011 Attention Disorder Drugs

Letter 1

Results in Brief 2

Background 2

Few Incidents of Diversion or Abuse of Attention Disorder Drugs

Identified by Schools 6

Most Schools Dispense Attention Disorder Medications and Follow

Drug Security Procedures 10

Many States and Local School Districts Have Provisions for School

Administration of Medications 15

Conclusions 19

Agency Comments 20

Appendix I Objectives, Scope and Methodology 21

Appendix II Survey of Public School Principals – Diversion/Abuse

of Medication for Attention Disorders 26

Appendix III State Controls on Dispensing of Drugs in Public

Schools 33

Appendix IV Anecdotal Accounts of School-Based Diversion or

Abuse of Attention Disorder Medications 36

Appendix V Studies Related to Diversion or Abuse of

Methylphenidate by School-Aged Children 38

Appendix VI State Statutes, Regulations, and Mandatory Policies

Addressing the Administration of Medication to

Students 40

Contents
Page ii GAO-01-1011 Attention Disorder Drugs

Appendix VII GAO Contacts and Staff Acknowledgments 46

Tables

Table 1:Rise in Production Quota for Methylphenidate and

Amphetamine 5

Table 2:Measures Taken by School Officials as a Consequence of

Diversion or Abuse of Attention Disorder Drugs 9

Table 3: School Personnel Dispensing Attention Disorder

Medication 13

Table 4: Sample of Schools in Our Study 23

Figures

Figure 1: Brand Name Methylphenidate Pills 4

Figure 2: Percent of Middle and High Schools Identifying Diversion

or Abuse of Attention Disorder Drugs in the 2000–2001

School Year 7

Figure 3: Diversion or Abuse of Attention Disorder Drugs at Middle

and High Schools and by Community Type 8

Figure 4: Percent of Schools Where School Staff Administer

Medication by Middle and High Schools and by

Community Type 11

Figure 5: Number of Attention Disorder Pills Typically on Hand for

Dispensing at School 12

Figure 6: Storage of ADHD and Other Medications 14

Abbreviations

ADHD Attention Deficit Hyperactivity Disorder

CCD Common Core of Data

DEA Drug Enforcement Administration

FDA Food and Drug Administration
Page 1 GAO-01-1011 Attention Disorder Drugs

September 14, 2001

The Honorable F. James Sensenbrenner

Chairman

The Honorable Henry Hyde

Committee on the Judiciary

House of Representatives

Children diagnosed with attention deficit disorders are commonly treated

with stimulant medications, such as Ritalin or Adderall. These drugs are

controlled substances under federal law because of their high abuse

potential. Many of these stimulant drugs must be taken several times a day

to be effective, so that children need medication during the school day.

There is some concern that the increase in the use of these medications in

a school environment might provide additional opportunities for the

diversion or abuse of these drugs. There is no data on the extent to which

attention disorder drugs have been diverted or abused at school, or the

extent to which state laws or regulations guide local school officials in

safely administering these drugs. To clarify these issues, you asked us to

provide you with information and analysis on (1) the diversion and abuse

of attention deficit disorder drugs in public schools,1

 (2) the school

environment in which drugs are administered to students, and (3) the state

laws or regulations addressing the administration of prescription drugs in

schools.

To address the first two objectives, we surveyed principals from a

representative national sample of public middle schools and high schools.

Elementary schools were not included based on discussion with your staff.

For the third objective, we surveyed state Department of Education

officials (or their designees) in the 50 states and the District of Columbia.

Specific information on our objectives, scope, and methodology is

provided in appendix I, and copies of our survey instruments are

presented in appendixes II and III.

 1

 For this report, “diversion or abuse” includes any instances in which the drug was stolen,

illegally sold, given away, or traded; possessed or ingested without a prescription; or

otherwise involved outside of sanctioned uses.

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-01-1011 Attention Disorder Drugs

Middle and high school principals we surveyed reported little diversion or

abuse of attention disorder drugs. For the first 7 to 9 months of school

year 2000-2001, approximately 8 percent of principals in public middle and

high schools reported knowing of attention disorder drugs being diverted

or abused at their school. Most of those principals reported knowing of

only one incident. Approximately 89 percent of the principals reported

that at their school, the diversion or abuse of attention disorder drugs was

less of a problem than other illicit drugs (excluding problems with alcohol

and marijuana). We were unable to draw any statistical conclusions about

associations between the reporting of incidents and other school

characteristics, such as if it was a middle or high school, due to the low

number of incidents overall.

Most of the principals reported that school officials administer attention

disorder medications, with about 2 percent of the school’s students on

average being administered attention disorder drugs on a typical day.

Medications are administered by nurses in about 60 percent of the schools,

and by non-health professionals, such as secretaries in most of the

remaining schools. Medications are kept locked in almost all (96 percent)

of the schools according to the principals, and students are observed while

taking their medications. We could not draw any statistical conclusions

relating incidents to who administers the medications, the number of

children on attention disorder medications, variations in storage, or

medication transportation due to the low number of incidents overall.

Thirty-seven states and the District of Columbia have either statutes,

regulations, and/or mandatory policies addressing the administration of

medication to students, based on our survey of state Department of

Education officials. State provisions include, for example, that schools

obtain written parental authorization to administer medication, ensure

that the medication is securely stored, and require prescription medication

to be stored in the original pharmacy container. Almost 90 percent of

principals reported their school received state and/or local guidance

regarding the administration of medications.

Attention deficit disorders are among the most commonly diagnosed

childhood behavioral disorders. Although there are a number of disorder

subtypes, as a group these disorders are referred to as Attention Deficit

Hyperactivity Disorder (ADHD). Symptoms include hyperactivity,

impulsiveness, and inattention. The American Psychiatric Association’s

Results in Brief

Background
Page 3 GAO-01-1011 Attention Disorder Drugs

diagnostic manual2 provides criteria for identifying ADHD; however, there

is no agreed upon test to confirm an attention disorder. Estimates of the

prevalence of the disorder vary widely. A recent international review of 19

epidemiological studies conducted in various countries since 1980 on the

prevalence of ADHD in school-age children reported ranges of 2 percent to

18 percent. The review found that the ADHD prevalence rate varies

depending on the diagnostic criteria, the children included in the sample,

and how the data were collected. Researchers conducting the review

concluded with a “best” estimate of between 5 and 10 percent of children

and adolescents having some form of this disorder.3

Although controversial, stimulants are the most common treatment for

attention disorder symptoms and are the only drugs that are approved by

the Food and Drug Administration (FDA) for this purpose.

Methylphenidate is the most widely used stimulant, but amphetamines

have been increasingly prescribed. Antidepressants, including buproprion

and velafaxine, are not approved by the FDA for the treatment of ADHD;

however, they are sometimes prescribed by physicians for ADHD if

stimulant medications are ineffective or inappropriate for a particular

patient.

ADHD drugs come in generic forms, but are often referred to by their

brand names. Methylphenidate brand names include Ritalin (see fig. 1),

Concerta, Methylin and Metadate. Brand name amphetamines include

Adderall, Dexedrine, and Dextrostat. Both types of stimulants are available

in quick acting, but short duration (2 to 6 hours) tablets. Recently,

sustained or extended release tablets lasting 8 to 12 hours have become

available, and a once-a-day skin patch is under development. Longer acting

drugs may reduce the need for some children to take their medications at

school. Several companies are testing nonstimulant drugs for ADHD

treatment that do not have the potential for abuse or physical dependency

associated with stimulant drugs.4

 2

 Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4th edition, 2000.

Diagnosis consists of a combination of symptoms, such as “often does not seem to listen

when spoken to directly,” or “often fidgets with hands or feet or squirms in seat.”

3

 Larry Scahill, MSN, PhD and Mary Schwab-Stone, MD, Epidemiology of ADHD in SchoolAge Children, Child and Adolescent Psychiatric Clinics of North America, Vol. 9(3), (July

2000).

4

 Nonstimulant drugs under development and their manufacturers include Atomoxetine

(Lilly), GW 320659 (GlaxoSmith Kline), Perceptin (Gilatech).
Page 4 GAO-01-1011 Attention Disorder Drugs

Figure 1: Brand Name Methylphenidate Pills

Source: Internet.

Methylphenidate and amphetamines are classified under the federal

Controlled Substances Act as Schedule II drugs—those with a high

potential for abuse and severe psychological or physical dependence if

abused.5

 A 1995 Drug Enforcement Administration (DEA) review of

methylphenidate concluded that based on studies of laboratory animals

and humans, methylphenidate was similar in pharmacological effects to

cocaine and amphetamines.6

 The DEA establishes annual production

quotas for Schedule II drugs by analyzing data on past sales, inventories,

market trends, and anticipated need.7

The production quotas for methylphenidate and amphetamines have risen

considerably since 1990. (See table 1.) A number of factors have

contributed to the increase in the quotas, according to researchers.8

 Key

 5 See 21 U.S.C. 812(b)(2); 21 C.F.R. 1308.12(d)(1), (4).

6

 Drug Enforcement Administration, Drug and Chemical Evaluation Section,

Methylphenidate Review Document (Revised October 1995).

7 Controlled Substance Quotas (GAO/GGD-95-52R, Jan. 18, 1995).

8

 Daniel J. Safer, Departments of Psychiatry and Pediatrics, John Hopkins University

School of Medicine, and Julie Magno Zito, Department of Pharmacy Practice and Science,

University of Maryland School of Pharmacy. “Pharmacoepidemiology of Methylphenidate

and Other Stimulants for the Treatment of Attention Deficit Hyperactivity Disorder” in

Ritalin, Theory and Practice, 2nd Edition. M.A. Liebert Publishers, 2000.
Page 5 GAO-01-1011 Attention Disorder Drugs

factors include (1) the number of people diagnosed as having ADHD has

grown with an expansion in the criteria used to diagnose ADHD; (2) longer

periods of treatment for the disorder; (3) more girls are receiving

medication than in prior years; and (4) a greater public acceptance of

psychopharmacologic treatment of youth. According to data obtained by

DEA, about 80 percent of the prescriptions for amphetamines and

methylphenidate were to treat children with ADHD.

Table 1:Rise in Production Quota for Methylphenidate and Amphetamine

1990 DEA production

quota in kilograms

2000 DEA production

quota in kilograms

Methylphenidate (percent

increase)

1,768 14,957

(746)

Amphetamine (percent

increase)

 417 9,007

(2060)

Source: DEA.

Along with the increase in the use of stimulant medications have come

concerns that these drugs may be being diverted from their prescribed use,

or otherwise abused. School settings are perceived as particularly

vulnerable for abuse because schools store attention disorder drugs for

students needing medication while at school. DEA interviews in 1997 with

schools officials in three states indicated that schools might leave

medications in unsecured locations, such as teachers’ desks, making theft

possible. A number of anecdotal news accounts of students abusing these

drugs at school have heightened concerns. (See app. IV.) However, no

studies are available to document the degree to which these medications

are diverted at school. There is some evidence from a small number of

studies and national data that abuse of these drugs does occur. (See app.

V.) For example, the University of Michigan has surveyed a national

sample of public and private 8th, 10th, and 12th grade students since 1991.

Of 12th graders surveyed in 2000, 2 percent reported using Ritalin without

a prescription in the past year. The University of Michigan survey does not

specify where drug use occurred.
Page 6 GAO-01-1011 Attention Disorder Drugs

Based on our survey, an estimated 8 percent9 of principals in public middle

schools and high schools in the United States reported at least one

incident of diversion or abuse of attention disorder drugs during the

current 2000-2001 school year. (See fig. 2.) Most of those principals

reported knowing of only one incident at their school.10 An additional 3

percent of school principals reported at least one possible incident, but

were uncertain of the drugs involved.

 9

 The results presented here are estimates based on a random sample of middle and high

school principals. This sample is only one of a large number of possible samples that could

have been drawn. Since each sample could have produced different estimates, we present

the estimate with a confidence interval (an upper and lower bound). Unless noted, the 95-

percent confidence interval for survey estimates is within +/-10 percent. This means that

for the principal survey percentages presented in this report, we are 95-percent confident

that the results we would have obtained if we had contacted all middle and high school

principals (rather than a sample) are within +/- 10 or fewer percentage points of our results.

10 The 95-percent confidence interval for incidents per school is within +/-16 percent.

Few Incidents of

Diversion or Abuse

of Attention Disorder

Drugs Identified

by Schools
Page 7 GAO-01-1011 Attention Disorder Drugs

Figure 2: Percent of Middle and High Schools Identifying Diversion or Abuse of

Attention Disorder Drugs in the 2000–2001 School Year

Source: GAO survey.

Of the 8 percent reporting an incident of diversion or abuse in the current

school year, only methylphenidate was involved at 73 percent of the

schools, and only amphetamines were involved at 20 percent of the

schools.11 In the remaining cases, the specific drug could not be

determined or both drugs were involved. Using the U.S. Department of

Education designations for community, we classified schools as being

located in central cities, urban communities, or small towns.12 We

compared incident rates by school and community type. (See fig. 3.) Due

to the low number of incidents overall, we were unable to draw any

 11 The 95-percent confidence interval for the type of drug involved in the incident is within

+/- 16 percent.

12 Central city communities include central cities of Metropolitan Statistical Areas or

central cities in Consolidated Metropolitan Statistical Areas; urban communities include

those located on the urban fringe of large- or mid-sized cities or large towns; small towns

include small towns and rural areas. (See Scope and Methodology in app. I.)

89%

3%

8%

No incident

Possible incident

Incident

5%

1%

1%

0.3%

1

2

3 to 5

6 or more

Percent of all

Middle and

High Schools

Incidents

per school
Page 8 GAO-01-1011 Attention Disorder Drugs

statistical conclusions about possible association between these factors

and the incidence rate.

Figure 3: Diversion or Abuse of Attention Disorder Drugs at Middle and High

Schools and by Community Type

Source: GAO survey.

Principals reporting any incident at their school were asked to briefly

describe the incident for which they had the most information. A content

analysis of the 51 incidents described by our sample respondents showed

that in 38 cases the student gave or sold pills to other students. For

example, “Student brought Adderall to school and attempted to sell it to

other students.” A second type of incident (4 cases) involved pills being

stolen from other students or the school. The remaining incident

descriptions were varied, such as “In all (6) cases, a pill was found

outside the entrance to the main building. We aren’t sure if it is a

student taking the medication at school or bringing it from home and

dropping it outside.”

The students involved in the estimated 8 percent of schools with reported

diversion or abuse incidents were most often expelled or suspended from

school as a consequence of the incident, according to principals. Other

measures taken by schools in response to the incident are shown in table

2. An estimated 42 percent of the principals that were aware of an incident

did not call police regarding the drug diversion or abuse incident.

All Schools Middle

Schools

High

Schools

Central City

Schools

Urban

Schools

Small Town

Schools

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

11

6

11

5

13

6

15

6

11

4

15

5

100%

Confidence interval: displays the upper and lower bounds of the

95% confidence interval for each estimate.
Page 9 GAO-01-1011 Attention Disorder Drugs

Consequently, measures of attention disorder diversion or abuse based on

official police records may underreport actual occurrences.

Table 2:Measures Taken by School Officials as a Consequence of Diversion or

Abuse of Attention Disorder Drugs

Measure taken Percent of schoolsa

Student was expelled or suspended 78

Police were called 58

Student was counseled 54

Other measures were takenb41

School policies or procedures were changed 0

No measures were taken 0

a

The 95-percent confidence interval for percent of schools taking specific measures is within +/-16

percent.

b

Other measures included discussions with parents, transfer to an alternative school, or involving

youth services.

Source: GAO survey.

Most principals did not perceive the diversion or abuse of prescribed

attention disorder drugs to be a major problem at their school. An

estimated 89 percent reported that it was less of a problem than other

illicit drug use, excluding alcohol and marijuana. In general, illicit drug use

(excluding alcohol and marijuana) was reported to be not a problem at all

or a minor problem by approximately 78 percent of the principals. In

addition, the most frequent comments voluntarily written by principals

were comments regarding the lack of an ADHD medication abuse problem

at their school. For example, one principal stated that “I feel comfortable

in stating that there is ‘NO DIVERSION’ of medication that is

administered through the office/clinic.” We compared incident rates by

the principal’s assessment of the problem, but were unable to draw any

statistical conclusions about a possible association due to the low number

of incidents overall.
Page 10 GAO-01-1011 Attention Disorder Drugs

Most school officials reported that attention disorder medications are

administered to students during the school day, most often by a nurse.

However, only a small fraction (less than 2 percent13) of a school’s

students were reported to receive these drugs. Most schools reported that

drugs were stored in locked cabinets or rooms, and that students are

observed when they take their medications.

Nationally, an estimated 90 percent of schools have school staff

administering attention disorder medication to some students on a typical

day, according to principals we surveyed. Schools that do not typically

administer these drugs may have policies that prohibit dispensing

medication, or do not have students currently requiring attention disorder

medication during school hours. As shown in figure 4 estimates,

statistically more middle school officials (96 percent) administered ADHD

medications than did high school officials (83 percent). However, incident

estimates by community type were not statistically different.

 13 The estimated fraction of students that receive these drugs is 1.7 percent and is

surrounded by a 95-percent confidence interval extending from 1.5 percent to 1.9 percent.

Most Schools

Dispense Attention

Disorder Medications

and Follow Drug

Security Procedures

Medication Administration
Page 11 GAO-01-1011 Attention Disorder Drugs

Figure 4: Percent of Schools Where School Staff Administer Medication by Middle

and High Schools and by Community Type

Source: GAO survey.

While 90 percent of principals in our study population reported that their

schools administer attention disorder medications, a relatively small

fraction of students attending these schools were administered attention

disorder medications while at school. An estimated 1.1 percent14 of

students (in schools where drugs are administered) were dispensed

methylphenidate and an estimated 0.5 percent15 of students were

administered amphetamines, for an overall rate of almost 2 percent.

A DEA drug diversion official expressed concern during recent

congressional testimony16 with the volume of methylphenidate on hand at

school for student daytime dosing. Our survey found that 6 percent of

schools stored 600 pills or more, while over half of the schools stored 100

pills or less. (See fig. 5.)

 14 The 95-percent confidence interval for this estimate extends from 1.0 to 1.3 percent.

15 The 95-percent confidence interval for this estimate extends from 0.47 to 0.59 percent.

16 Terrance Woodworth, Deputy Director, Office of Diversion Control, DEA, before the

House Committee on Education and the Workforce, Subcommittee on Early Childhood,

Youth and Families (May 15, 2000).

All Schools Middle

Schools

High

Schools

Central City

Schools

Urban

Schools

Small Town

Schools

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

92

87

98

93 87

77

93

84

94

86

94

84

Confidence interval: displays the upper and lower bounds of the

95% confidence interval for each estimate.
Page 12 GAO-01-1011 Attention Disorder Drugs

Figure 5: Number of Attention Disorder Pills Typically on Hand for Dispensing at

School

Source: GAO survey.

At schools that dispense attention disorder medications, the personnel

approved to administer medications varied among schools. Nurses were

reported to most often carry out that task, and second to nurses,

nonhealthcare professionals, such as secretaries, most often dispense

medications. (See table 3.) Lack of a nurse or other trained healthcare

professional was noted as a concern by several principals. Of the 107

optional comments written by principals in our survey, 13 comments were

about the need for nurses to administer medication to students. For

example, one wrote, “School districts should be forced to provide fulltime nursing services so that only medically-trained personnel can

distribute medication.”

15%

15%

6%

6%

5%

36%

17%

600 or more

Unknown

400 to 599

200 to 399

100 to 199 50 to 99

Less than 50
Page 13 GAO-01-1011 Attention Disorder Drugs

Table 3: School Personnel Dispensing Attention Disorder Medication

Personnel

Percent approved to

administer attention

disorder medicationa

 Percent most often

administering attention

disorder medicationsb

Nurse 75 59

Other healthcare professional 13 7

Principal 32 2

Teacher 12 2

Other nonhealthcare

professional 51 28

Students self-administer 6 1

a

The column total does not equal 100 percent because more than one person can be approved to

dispense medication.

b

The column total does not equal 100 percent because of rounding.

For nonhealthcare professionals administering attention disorder

medications, all but 5 percent of school officials reported some kind of

training was provided to prepare staff for their duties. Principals reported

multiple forms of training for staff. Training was provided by written

instruction at 41 percent of schools, by healthcare professionals in about

49 percent of the schools, by oral instruction at 49 percent of schools, and

9 percent were provided video instruction.

Most school principals reported that ADHD medications are kept in locked

spaces. Approximately 72 percent of the schools that dispense attention

disorder medications store the drugs in a locked cabinet and a locked

office or room. Examples of this type of storage are shown for schools “A”

and “B” in figure 6. An additional 24 percent of schools kept medications

in either a locked cabinet or a locked office or room. Some school

principals noted that during nonschool hours medication security was

tighter, such as locking the room in which medication was stored in

addition to a locked cabinet, or using a vault. Of those reporting that

medications were kept locked, the average number of people with access

was three people, and at most schools (93 percent) fewer than six persons

have access to the medications. Because most schools secure attention

disorder medications in locked storage, and the low overall rate of

diversion or abuse, we were unable to draw statistical conclusions about

any possible association between number of incidents, medication

security, or security and school type.

Medication Security
Page 14 GAO-01-1011 Attention Disorder Drugs

Figure 6: Storage of ADHD and Other Medications

Source: GAO.

Medication in cabinet at school A Cabinet and door locks at school A

Medication in cabinet at

school B

Cabinet and door locks school B
Page 15 GAO-01-1011 Attention Disorder Drugs

Almost all (96 percent) of the school principals in schools that administer

medications reported that students are observed when they are

administered medication to assure that it is taken.

Of the 90 percent of schools that administer attention disorder

medications, about 48 percent have parents only transporting student

medications from home to school. Another 34 percent of schools allow

either parents or students to transport medications and 12 percent had

students transporting their own medications. Among those schools that

have students transporting their own medications, several principals

commented that controls were in place to assure that none of the

medication was diverted from home to school. For example, one principal

reported that the medication bottle must be taped closed with the number

of pills inside indicated on the bottle and accompanied by a note signed by

the parent. We compared incident rates by how the medications were

transported to school, but were unable to draw any statistical conclusions

due to the low number of incidents overall and the distribution of

responses.

Many states in the United States have statutes, regulations, and/or

mandatory policies regarding the administration of medication at schools.

At the local level, most of the principals in our survey of middle and high

schools reported having school district provisions regarding the

administration of medication.

From our survey of state education officials (see app. III), we determined

that 37 states and the District of Columbia have statutes, regulations,

and/or mandatory policies addressing medication administration at

schools, as shown in appendix VI.17 The remaining 13 states do not, as

discussed in the following sections.

Of the 37 states with applicable provisions, 29 require or authorize schools

to adopt medication administration policies; in most of these states,

schools issuing policies for the administration of medication must

incorporate minimum statewide requirements. The other eight states and

 17 Two states, Oregon and Ohio, did not respond to the survey, and we researched these

states’ statutes and regulations as reported in the Lexis and Westlaw databases.

Many States and Local

School Districts Have

Provisions for School

Administration of

Medications

Many States Have

Established Requirements

for the Administration of

Medication
Page 16 GAO-01-1011 Attention Disorder Drugs

the District of Columbia do not expressly delegate authority to local

schools, but provide for the regulation of medication administration in

schools based on statewide or districtwide requirements.

We analyzed provisions in the 37 states and the District of Columbia based

on five common statewide requirements for administering medication at

schools: (1) whether schools must obtain authorization from the student’s

parent or guardian to administer medication, (2) whether schools must

obtain written orders or instructions from the student’s physician or other

licensed medication prescriber to administer medication, (3) whether

schools must receive and store prescription medication in an original

container with proper pharmaceutical labeling, (4) whether schools must

provide storage for medication that is secure and inaccessible except to

authorized school personnel, and (5) whether schools must document the

administration of medication to the student in a medication log.

Although these five categories represent the more common statewide

requirements, they do not represent the full array of state requirements

that regulate the administration of medication in schools. For example,

Maine and New Jersey have minimum state requirements for school

medication administration policies, but not in one of the five categories

reflected in appendix VI. Maine requires that all unlicensed personnel

receive training before administering medication, while New Jersey

prohibits anyone other than a doctor, nurse, or parent from administering

medication in a non-emergency situation.18 Other states limit the amount of

medication that schools may store; require parents or guardians to deliver

medications to schools; establish procedures for returning and/or

destroying any unused medications; and establish safeguards specific to

self-administration of medications by students.

From our review, we found that 28 states and the District of Columbia

require that schools obtain authorization from the student’s parent or

guardian before administering medication. Virtually all of these

jurisdictions specifically require written authorization. In addition, 19

states and the District of Columbia require that schools obtain orders or

instructions from the student’s physician or other licensed medication

prescriber before administering medication. In most of these jurisdictions,

the requirement for a medication order is met if the prescriber provides

specific instructions for administration (e.g., the name, route, and dosage

of the medication and the frequency and time of the administration).

 18 See 20-A Me. Rev. Stat. Ann., sec. 254, subsec. 5; N.J. Admin. Code 6A:16-2.3(b)(1).
Page 17 GAO-01-1011 Attention Disorder Drugs

However, in two states, Utah and Washington, schools must also obtain a

written statement from the prescriber that administering medication at

school is medically necessary or advisable.19 Finally, 22 states and the

District of Columbia require schools to obtain prescription medication in

an original container with proper pharmaceutical labeling.20

Eighteen states specify the manner in which schools must store

medication to ensure its security.21 These states vary in terms of the level

of security required. States such as Indiana, Iowa, and Oklahoma simply

require a secure or inaccessible location to store medication.22 However,

most states specify locked storage for medication and a few impose more

stringent security measures. For example, Massachusetts requires schools

to store prescription medications in a securely locked cabinet, which is

substantially constructed and anchored to a solid surface, with access to

keys restricted.23

Sixteen states require schools to document the administration of

medication to the student in a medication log or other like-named record.24

Documentation requirements vary between these states. Although some of

the states do not specify the content or format of the medication log, many

 19 See Utah Code Ann. 53A-11-601(1)(b)(ii); Rev. Code. Wash. 28A.210.260.

20 In appendix VI, we express the requirement in these 22 states and the District of

Columbia as a requirement for a “pharmacy container.” However, not all states, nor the

District, use this terminology. Some require schools to obtain medication that is properly

labeled and/or in its original container. In the case of prescription medications, we

interpreted such laws as essentially requiring a pharmacy container.

21 Some states (e.g., Oregon, Utah, Wisconsin, and Wyoming) require schools adopting

medication administration policies to address the safe storage of medication, but do not

specify any minimum requirements that the schools’ policies must incorporate. See Or.

Admin. Rules, 581-021-0037(4)(a); Utah Code Ann. 53A-11-601(1)(a)(ii); Rev. Code. Wash.

28A.210.260(1); Wyo. Admin. Code, Educ., ch. 6, sec. 17(a)(i)(F). We did not regard these

states as imposing secured storage requirements, in contrast with the 18 states that do

specify minimum requirements that schools must observe in storing medication.

22 See 511 Ind. Admin. Code 7-21-8(a)(4); 281 Iowa Admin. Code 41.12(11)(h); 70 Okla. Stat.

Ann. 1-116.2(D).

23 See 105 Code of Mass. Reg. 210.008(C), (D).

24 Colorado, the District of Columbia, New Mexico, and Wisconsin require “record keeping”

or “documentation,” but do not specifically state that schools must maintain records of

administering medication to students. See Colo. Dept. of Reg. Agencies, ch. XIII, sec. 7.5;

D.C. Code 31-2434(a)(4); 6 N.M. Admin. Code 4.2.3.1.11.3.2 (e); Wis. Stat. 118.29(4). Absent

such specificity, we did not treat these jurisdictions as requiring medication logs, in

contrast with the 16 states discussed above.
Page 18 GAO-01-1011 Attention Disorder Drugs

require, at a minimum, that the log reflect the date, time, and dosage of the

medication given to the student, and the name or signature of the person

administering the medication. A few states impose additional

documentation requirements. For example, along with other states,

Connecticut requires schools to document any skipped dose and the

reason for it; Maryland requires scheduled pill counts for controlled

substances and reconciliation against the medication log; and

Massachusetts requires schools to document the return of any unused

medication to the student’s parents.25

From our survey responses, we found that 13 states do not have applicable

statutes, regulations, or mandatory policies addressing the administration

of medication in schools, as reflected in appendix VI. Although 5 of the 13

states (Idaho, Kansas, Missouri, Montana, and New York) identified

provisions in their survey responses, the cited provisions cover areas that

are not directly within the scope of our inquiry and are not included in

appendix VI. For example, Missouri and New York have statutes

addressing when a student with asthmatic conditions may carry and use a

prescribed inhaler at school.26 Thus, appendix VI does not include every

provision cited by a survey respondent, only those provisions relevant to

our work.

Finally, during our survey, 22 states and the District of Columbia reported

that they have policy guidelines addressing the administration of

medication in schools.27 The policies in these jurisdictions are

discretionary and do not create legal requirements for administering

medication in schools, as do the statutes, regulations, and mandatory

policies reflected in appendix VI. Nevertheless, the discretionary policies

often contain detailed recommendations to assist schools adopting

medication administration policies. The discretionary policies cover the

same broad range of medication administration procedures reflected in

the various state statutes, regulations, and mandatory policies. Only seven

 25 See Regs., Conn. State Agencies 10-212a-6(a)(1)(K); 105 Code of Mass. Reg. 210.008(G).

Maryland’s requirements appear in a mandatory policy jointly issued by state

administrative agencies.

26 See Mo. Rev. Stat. 167.627; N.Y. Cons. Law Serv., Educ., sec. 916.

27 The states are Alabama, Arkansas, California, Delaware, Florida, Illinois, Iowa, Kentucky,

Louisiana, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New

York, North Dakota, South Dakota, Vermont, Virginia, Washington, and Wisconsin.
Page 19 GAO-01-1011 Attention Disorder Drugs

states have no applicable statutes, regulations, or policies (discretionary

or mandatory) addressing the administration of medication in schools.28

Lack of a state policy on the administration of medication does not

prevent schools in a state from developing their own provisions, and most

have. According to responses in our survey of school principals, 90

percent of schools have received district regulations or policies regarding

the administration of prescription medications. For example, South

Carolina officials reported that the state has no statutes, regulations, or

policies in this area; however, the Charleston County School District

medication administration policy mirrors many of the policies developed

by other states. For example, the Charleston district requires that written

medication requests be completed by the prescribing physician and

parent, that medication be delivered by the parent in its original container,

that medication be kept locked at the school, and be administered by a

nurse or designated staff.

An estimated 17 percent of school principals reported that their school

policy had recently changed regarding the administration of prescription

drugs to students. Of the 17 percent reporting a policy change in the last 2

years, 29 percent29 reported that the change was due to problems with the

handling of medications at the principal’s school or at a neighboring

school.

We do not believe that the diversion or abuse of attention disorder

medications is a major problem at middle or high schools. Based on our

findings, few middle or high school principals are aware of ADHD

medication diversion or abuse, and most do not believe this is a major

problem. Furthermore, states and localities appear to be cognizant of the

potential for problems and many have established policies and procedures

to minimize risks. Finally, the development of nonstimulants for attention

disorders and increasing use of once-a-day stimulant medications may

reduce the potential for diversion or abuse at school by reducing the need

for the medications to be administered during school hours.

 28 The states are Alaska, Georgia, Idaho, Kansas, Mississippi, Montana, and South Carolina.

29 The 95-percent confidence interval for this estimate extends from 19 to 41percent.

Many School Districts

Have Established Local

Procedures

Conclusions
Page 20 GAO-01-1011 Attention Disorder Drugs

Agency comments were not requested for this report because no federal

agency or federal policies were reviewed. We did discuss our findings with

the Drug Enforcement Administration’s Office of Diversion Control prior

to the completion of our report and have incorporated changes where

necessary.

We will send copies of this report to the Ranking Member, House

Committee on the Judiciary; the Chairman, Senate Committee on the

Judiciary; the Ranking Member, Senate Committee on the Judiciary; the

Administrator, Drug Enforcement Administration; and other interested

parties. Copies of this report will be available on GAO’s homepage at

http://gao.gov.

The major contributors to this report are acknowledged in appendix VII. If

you or your staffs have any questions about this report, please contact me

at (202) 512-8777 or Darryl W. Dutton at (213) 830-1000.

Paul L. Jones

Director, Justice Issues

Agency Comments
Appendix I: Objectives, Scope and

Methodology

Page 21 GAO-01-1011 Attention Disorder Drugs

Our objectives in this review were to (1) determine the prevalence of

diversion and abuse of attention disorder drugs in public schools, 2)

describe the school environment in which drugs are administered to

students, and (3) obtain information on state laws and regulations

regarding the administration of prescription drugs in schools.

We conducted our review between February and June 2001 in accordance

with generally accepted government auditing standards.

To attain our objectives, we surveyed a statistically representative random

sample of public school principals. We focused our attention on middle

schools and high schools, which we defined as schools containing grades 6

or higher. Specifically, we asked these principals a series of questions

about any incidents of diversion and abuse of attention disorder drugs at

their school since the beginning of the 2000-2001 school year. We also

asked a number of questions covering school policies and practices on the

administration and storage of these types of attention disorder drugs.

The study population for the survey of public school principals consisted

of all public schools in the 2000-2001 school year that have at least one

grade between 6th and 12th (inclusive), more than 1 teacher, and a total of

at least 10 students.1

 The sample was drawn from a list of all public

schools in the United States compiled by The Common Core of Data

(CCD) for the 1998-99 school year. The CCD is the U.S. Department of

Education’s primary database on public elementary and secondary

education in the United States. We used the 1998-99 CCD file to produce a

list of schools representing our study population. From this list of 35,522

schools, we drew a random sample of 1,033 schools to represent the study

population in the 50 states and the District of Columbia.

Of the 1,033 surveys we mailed out, 735 completed surveys were returned,

a response rate of 71 percent. See appendix II for a copy of our survey

instrument.

 1

 Schools with a high grade of 6th and a low grade of 3rd or less are excluded from our

study population. We did not include elementary schools based on discussion with our

requestor.

Appendix I: Objectives, Scope and

Methodology

Objectives

Survey Scope and

Methodology

Study Population
Appendix I: Objectives, Scope and

Methodology

Page 22 GAO-01-1011 Attention Disorder Drugs

The sample design for this study is a single-stage stratified sample of

schools in the study population. The strata were defined in terms of type

of school (middle school, high school, etc.) and community type2

 (city,

urban, or small community). Since type of school was not available on the

sample frame, we developed criteria based on the highest and lowest

grade level reported for the school. The first six strata consist of schools

for which an unambiguous assignment to middle school or high school can

be made. An additional three strata consist of upper grade schools that

have grade levels that overlap between the middle school and high school

definitions. The following rules are used to assign middle, high, or

high/middle school type:

High school – Schools on the CCD having their high grade and their low

grade between 9th and 12th grade, inclusive.

Middle school – Schools on the CCD having their high grade between 6th

and 9th, inclusive. In addition the low grade for the school must be 8th or

below (but not less than 4th grade).

High/middle – Schools with at least one grade that is greater than or equal

to 6th grade, no grades less than 4th grade, and not meeting the above

definitions for high school or middle school.

Finally, we sampled another six residual strata that are composed of

schools that would meet either the “middle school” or the “high/middle

school” definition, except for the presence of some grades less than the

4th grade.

The strata definitions, population sizes, and sample sizes are summarized

below.

 2 “City” is defined as a central city of Consolidated Metropolitan Statistical Area (CMSA) or

as a central city of a Metropolitan Statistical Area (MSA). “Urban” refers to Urban Fringe

(an incorporated place, Census Designated Place, or nonplace territory within a CMSA or

MSA of a city and defined as urban by the Census Bureau) or to a large town (an

incorporated place or Census Designated Place with a population greater than or equal to

25,000 and located outside a CMSA or MSA). A “small community” is an incorporated place

or Census Designated Place with a population less than 25,000 and greater than 2,500

located outside a CMSA or MSA, or any incorporated place, Census Designated Place, or

nonplace territory designated as rural by the Census Bureau.

Sample Design
Appendix I: Objectives, Scope and

Methodology

Page 23 GAO-01-1011 Attention Disorder Drugs

Table 4: Sample of Schools in Our Study

Stratum Definition Population Sample Respondents

1 Middle school, city community 3,220 148 100

2 Middle school, urban community 5,953 148 111

3 Middle school, small community 5,553 148 117

4 High school, city community 2,118 148 108

5 High school, urban community 4,236 148 109

6 High school, small community 5,251 148 101

7 High/middle school, city community 238 8 4

8 High/middle school, urban community 729 12 9

9 High/middle school, small community 2,517 33 25

10 Middle school with <=3rd grade, city community 1,042 24 10

11 Middle school with <=3rd grade, urban

community

1,009 13 6

12 Middle school with <=3rd grade, small

community

2,582 34 23

13 High/middle school with <=3rd grade, city

community

98 5 4

14 High/middle school with <=3rd grade, urban

community

155 5 2

15 High/middle school with <=3rd grade, small

community

821 11 6

Total 35,522 1,033 735

Estimates produced in this report are for schools in our study population

that could be classified as either a middle school or a high school for the

2000-2001 school year. Although the sample was stratified according to

1998-99 grade levels at the school, estimates are produced for type of

school (middle and high school) as determined from the responding

school’s grade composition for the 2000-2001 school year. The survey

responses provide each school’s lowest and highest grade for the 2000-

2001 school year, and these data were used to classify the responding

schools as a middle school or as a high school according to the definition

shown below. Of the 735 surveys returned, 596 could be classified as either

a middle school or as a high school. Data from schools that could not

unambiguously be classified as middle or as a high school are not included

in our estimates of middle or high school characteristics.

High school – Responding schools having their high grade and their low

grade between 9th and 12th grade, inclusive, for the 2000-2001 school year.

Middle school – Responding schools having their high grade between 6th

and 9th, inclusive, for the 2000-2001 school year. In addition, the low grade

for the school must be 8th or below (but not less than 4th grade).

Estimates
Appendix I: Objectives, Scope and

Methodology

Page 24 GAO-01-1011 Attention Disorder Drugs

These definitions are consistent with those used in the definition of the

survey’s sampling strata, except that the low and high grade is based on

2000-2001 school year data instead of on the 1998-99 CCD data.

Because we surveyed a sample of public school principals, our results are

estimates of all participants’ characteristics and thus are subject to

sampling errors that are associated with samples of this size and type. Our

confidence in the precision of the results from this sample is expressed in

95-percent confidence intervals. The 95-percent confidence intervals are

expected to include the actual results for 95 percent of the samples of this

type. We calculated confidence intervals for our study results using

methods that are appropriate for a stratified, probability sample. For the

percentages presented in this report, we are 95-percent confident that the

results we would have obtained if we had studied the entire study

population are within +/- 10 or fewer percentage points of our results,

unless otherwise noted. For example, a nurse administers medications at

an estimated 59 percent of the middle and high schools. The 95-percent

confidence interval for this estimate would be no wider than +/- 10

percent, or from 49 percent to 69 percent. For estimates other than

percentages (including estimates of ratios), 95-percent confidence

intervals are +/- 10 percent or less of the value of the estimate, unless

otherwise noted.

In addition to these sampling errors, the practical difficulties in conducting

surveys of this type may introduce other types of errors, commonly

referred to as nonsampling errors. For example, questions may be

misinterpreted or the respondents’ answers may differ from those of

people who did not respond. We took several steps in an attempt to reduce

such errors. For example, we developed our survey questions with the aid

of a survey specialist. We discussed the questionnaire with officials at the

American Association of School Administrators and the National

Association of Secondary School Principals. We held discussions or

pretested the questionnaire with 10 public school principals. All initial

sample nonrespondents were sent at least one follow-up questionnaire

mailing. All data were double keyed during data entry, and GAO staff

verified a sample of the resulting data. Computer analyses were performed

to identify inconsistencies and other indications of errors, and a second

independent analyst reviewed all computer programs.

To obtain information on state laws and regulations regarding the

administration of prescription drugs in schools, we conducted a brief

survey of state department of education officials (or persons designated by

Sampling Error

Nonsampling Error

Other Data Scope and

Methodology
Appendix I: Objectives, Scope and

Methodology

Page 25 GAO-01-1011 Attention Disorder Drugs

officials) in the 50 states and the District of Columbia. The survey

requested information on all state statutes, regulations, or other written

policies regarding the administration of prescription drugs to students in

public schools. As was the case with the survey of public school

principals, the questionnaire sent to the state education officials was

developed with the aid of a survey specialist, was reviewed by an attorney,

and was pretested. See appendix III for a copy of this survey instrument.

We received survey responses from 48 states and the District of Columbia,

and we verified the accuracy of the survey information by researching the

states’ statutes and regulations. Likewise, we researched the statutes and

regulations of the two states that did not respond (Ohio and Oregon). We

focused on five types of medication administration requirements that

appeared in many states as the basis for analyzing the various state laws.

As background, we searched Lexis-Nexis and Proquest databases for

anecdotal evidence of diversion and abuse of attention disorder

medications in schools. Using only the information provided in the

resulting pool of articles, specific incidents described in each article were

identified, matched for duplication where evidence allowed, and

summarized. We did not verify the reliability or validity of the reports.
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 26 GAO-01-1011 Attention Disorder Drugs

Appendix II: Survey of Public School

Principals – Diversion/Abuse of Medication

for Attention Disorders
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 27 GAO-01-1011 Attention Disorder Drugs
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 28 GAO-01-1011 Attention Disorder Drugs
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 29 GAO-01-1011 Attention Disorder Drugs
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 30 GAO-01-1011 Attention Disorder Drugs
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 31 GAO-01-1011 Attention Disorder Drugs
Appendix II: Survey of Public School Principals –

Diversion/Abuse of Medication for Attention Disorders

Page 32 GAO-01-1011 Attention Disorder Drugs
Appendix III: State Controls on Dispensing of Drugs in

Public Schools

Page 33 GAO-01-1011 Attention Disorder Drugs

Appendix III: State Controls on Dispensing of

Drugs in Public Schools
Appendix III: State Controls on Dispensing of Drugs in

Public Schools

Page 34 GAO-01-1011 Attention Disorder Drugs
Appendix III: State Controls on Dispensing of Drugs in

Public Schools

Page 35 GAO-01-1011 Attention Disorder Drugs
Appendix IV: Anecdotal

Accounts of School-Based

Diversion or Abuse of Attention

Disorder Medications

Page 36 GAO-01-1011 Attention Disorder Drugs

We reviewed the anecdotal1 accounts of school-based diversion or abuse

of attention disorder medications to provide an indication of the public

perception of diversion and abuse of attention disorder medications at

schools. We searched two major on-line databases for the period January

1996 to February 2001 for anecdotal accounts. The databases include

articles from over 30,000 sources, including every major U.S. newspaper,

magazines, and other published sources. Because of the nature of news

coverage, no conclusions can be drawn from these accounts. We did not

verify the reliability or validity of the identified incidences.

While school-based attention disorder medication diversion or abuse was

identified, the extent of problems was somewhat overstated by repeated

descriptions of incidents. Most of the articles identified in our review of 5

years of news accounts focused on concerns about the over-prescription

of Ritalin. Excluding these articles, about 250 articles mentioned one or

more incidences of school-based abuse of attention disorder medications.

Closer examination of these accounts indicated that many of the same

incidents were repeated in different articles. Using only information about

the incidents provided in the news accounts, about 130 of the incidents

within the 5-year period appeared to be unique incidents. For example, an

abuse incident at an Illinois middle school was mentioned in over 10

different articles. A sample of the accounts:

“Administrators at xx Middle School had heard about Ritalin Abuse for almost three years,

Principal X said. But they did not know of abuse within the school until a teacher spotted

two students passing something in a restroom last month. Since then, 15 students have

been suspended.” Cincinnati Post (Cincinnati, OH) May 8, 2000.

“Fifteen students at xx Middle School are suspected of abusing the prescription drug

Ritalin. According to details of the investigation of this incident, students gave away the

tablets or sold them for 50 cents to $1.” Daily Herald (IL) May 8, 2000.

“Now comes word that the drug used to control the disorder – Ritalin – is being used

recreationally by people who certainly don’t need it.... At xx Middle School, 15 students

were suspended recently for this.” The Deseret News (Salt Lake City, UT) May 6, 2000.

While most of the incidents identified involved students caught selling or

stealing the medications at school, about 20 anecdotal incidents involved

 1

 We define news accounts as “ancecdotal” because such accounts are not presented along

with evidence that allows the accuracy of the reports to be verified, nor is there any pretext

that news accounts coverage is comprehensive or otherwise systematically presented.

Appendix IV: Anecdotal Accounts of SchoolBased Diversion or Abuse of Attention

Disorder Medications
Appendix IV: Anecdotal

Accounts of School-Based

Diversion or Abuse of Attention

Disorder Medications

Page 37 GAO-01-1011 Attention Disorder Drugs

theft or abuse by a teacher, principal, nurse, or other school personnel.

For example, in one anecdotal incident, a principal was arrested on

charges that he stole Ritalin pills from the school medicine cabinet.

Anecdotal incidents were reported in 37 out of 50 states.
Appendix V: Studies Related to Diversion or

Abuse of Methylphenidate by School-Aged

Children

Page 38 GAO-01-1011 Attention Disorder Drugs

Study Findings Measure of abuse Study population

Monitoring the Future

National Institute on

Drug Abuse

University of

Michigan

Ritalin Abuse 12th Grade

 2000

Annual Use 2.2%

Students are asked if they have used any

of a wide range of drugs, including alcohol

and tobacco. Only students who answered

“yes” to the use of amphetamines are then

asked to specify the type of amphetamine

used, with Dexedrine and Ritalin as two of

the amphetamine type choices.a

Since 1991, a representative

national sample of public

and private school 8th, 10th,

and 12th graders have been

surveyed annually, a sample

of about 50,000 students

overall in 420 public and

private schools.

Indiana Prevention

Resource Center

Ritalin Abuse 12th Grade

1999 2000

Lifetime Use 7.4% 7.4%

Annual Use 4.3% 4.8%

Monthly Use 1.5% 1.9%

Students are asked about their lifetime,

annual, monthly, and daily use of specific

drugs, including their nonprescribed use of

Ritalin and of amphetamines, which are

described in the survey as “uppers.”

Since 1991, 6th through 12th

graders in Indiana have

been surveyed on their use

of amphetamines, and since

1998 on their nonprescribed

use of Ritalin.

Massachusetts

Department of Public

Health

Ritalin Abuse

7th

–12th Grade

 1999

Lifetime Use 9.7%

Monthly Use 3.3%

Students are asked about use of Ritalin

without a prescription in their lifetime and

within the last 30 days.

Every 3 years since 1984,

the state has surveyed 6th

through 12th graders. The

1999-2000 survey of

approximately 7,000

students was the first to

include questions specifically

about Ritalin.

National Household

Survey on Drug

Abuse

Nonmedical Use Of Any

Psychotherapeutic

12 to 17 Years Old

 1999

Lifetime Use 10.9 %

Monthly Use 2.9 %

Interviewees are asked about their use

and frequency of use of various licit and

illicit drugs. Nonmedical use of any

psychotherapeutic includes any

prescription-type pain reliever, tranquilizer,

stimulant, or sedative.

Since 1971, random

samples of households

throughout the United States

have been interviewed at

their place of residence. In

1999, 66,706 persons

including 12 to 17 year olds

were interviewed.

Drug Abuse Warning

Network (DAWN)

Substance Abuse

and Mental Health

Services

Administration

Drug Treatment Episodes

Methylphenidate (Ritalin)

1999

 0.27%b

Within each facility participating in DAWN,

a designated reporter, usually a member

of the emergency department or medical

records staff, is responsible for identifying

drug-related episodes and recording and

submitting data on each case.

Since 1988, data on

emergency department drug

related visits has been

collected from a

representative sample of

U.S. acute care hospitals,

including 21 oversampled

metropolitan areas. The

1999 sample consisted of

592 hospitals.

Arrestee Drug Abuse

Monitoring

National Institute of

Justice

Juvenile Amphetamine Use

% Tested Positive

(Range at different cities)

1999

Male 0 to 16%

Female 0 to 18%

Arrestees are asked about taking specific

drugs, including amphetamines “like

Ritalin,” on a lifetime, annual, monthly, and

48-hour basis. A general question is asked

to include other drugs not specifically

mentioned.

More than 2,500 juvenile

male detainees in 9 sites

and more than 400 juvenile

female detainees in 6 sites

are administered urine tests

and interviewed in detail

about their drug taking,

purchases and other drugrelated questions.

Note: Some of these surveys also ask about amphetamines; however, those results are not reported

here because they do not distinguish between amphetamines acquired through diversion from ADHD

prescriptions and those illegally manufactured.

Appendix V: Studies Related to Diversion or

Abuse of Methylphenidate by School-Aged

Children
Appendix V: Studies Related to Diversion or

Abuse of Methylphenidate by School-Aged

Children

Page 39 GAO-01-1011 Attention Disorder Drugs

a This method of questioning may underestimate the use of ADHD drug use because students may

not know that these drugs are amphetamines.

b

 Out of 554,932 occurrences of emergency department drug treatments, methylphenidate was

mentioned 1,478 times. Methylphenidate is not in the top 15 most frequently mentioned drugs for 6 to

17 year olds.

Sources: Monitoring the Future - http://www.monitoringthe future.org/

Indiana Prevention Resource Center - http://www.drugs.indiana.edu/

Massachusetts Department of Public Health - http://www.state.ma.us/dph/pubstats.htm

National Household Survey on Drug Abuse - http://www.samhsa.gov/oas/p0000016.htm

Drug Abuse Warning Network (DAWN) - http://www.icpsr.umich.edu/SAMHDA/dawn.html

National Institute of Justice’s Arrestee Drug Abuse Monitoring (ADAM) – http://www.adam-nji.net
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 40 GAO-01-1011 Attention Disorder Drugs

Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 41 GAO-01-1011 Attention Disorder Drugs
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 42 GAO-01-1011 Attention Disorder Drugs
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 43 GAO-01-1011 Attention Disorder Drugs
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 44 GAO-01-1011 Attention Disorder Drugs
Appendix VI: State Statutes, Regulations, and

Mandatory Policies Addressing the

Administration of Medication to Students

Page 45 GAO-01-1011 Attention Disorder Drugs

a

The California respondent told us that the implementing regulations are being drafted.

b

The respondent for the District of Columbia told us that currently there are no implementing rules or

regulations.

c

The regulation requires either a pharmacy label or the physician’s prescription. See 511 Ind. Admin.

Code 7-21-8(a)(3). In addition, although the regulation does not require schools to obtain a

physician’s written orders, an Indiana statute provides immunity from liability to school employees

who administer prescription medication in compliance with the parent’s or guardian’s written

permission and the practitioner’s written orders. See Ind. Code 34-30-14-2.

d

The Maine statute also requires the state commissioner of education to adopt rules for medication

administration in schools, including training requirements for unlicensed personnel. The Maine

respondent told us that the rules have been proposed but not yet enacted.

e

The regulation requires either the physician’s instructions or a pharmacy label. Oregon Admin. Rules,

581-021-0037(1)(c).

f

The Pennsylvania respondent told us that currently there are no implementing guidelines in effect.

g

The pharmacy-container requirement is specific to self-administered medications. Code of Rhode

Island Rules 14-000-011, sec. 18.9.1.1.

h

The South Dakota respondent told us that the state board of education has not promulgated rules

under the statute, but that the state department of health has issued discretionary guidelines

addressing medication administration in schools.
Appendix VII: GAO Contacts and Staff

Acknowledgments

Page 46 GAO-01-1011 Attention Disorder Drugs

Paul Jones, (202) 512-8777

Darryl W. Dutton, (213) 830-1000

William Bates, Christine Davis, Jennifer Joseph, Stuart Kaufman, Monica

Kelly, Lawrence Kinch, Lori Levitt, Mark Ramage, Anne Rhodes-Kline, and

Lisa Wallace.

Appendix VII: GAO Contacts and Staff

Acknowledgments

GAO Contacts

Acknowledgments

(440004)
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