Attention Disorder Drugs: Few Incidents of Diversion or Abuse Identified By Schools
Published: 2001-09-14T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Children diagnosed with attention deficit disorders are often treated with stimulant medications, such as Ritalin or Adderall. These drugs are controlled substances under federal law because of their high potential for abuse. Many of these stimulant drugs must be taken several times a day to be effective, so children need medication during the school day. Concern has arisen that the increasing use of these medications in school might provide additional opportunities for drug abuse. No data exists 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. Middle and high school principals reported little diversion or abuse of attention disorder drugs. For the first seven to nine months of school year 2000-2001, about eight percent of principals in public middle and high schools reported that attention disorder drugs had been diverted or abused at their school. Most of the principals reported that school officials administer attention disorder medications, with about two percent of the school's students on average being administered attention disorder drugs on a typical day. Medications are given 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. Thirty-seven states and the District of Columbia have either statutes, regulations, or mandatory policies addressing the administration of medication to students. State provisions require schools to obtain written parental authorization to administer medication, ensure that the medication is securely stored, and store prescription medication in the original pharmacy container.

section_title: Letter
paragraphs: 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, (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.
subsections: section_title: Background
paragraphs: 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 diagnostic manual 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.
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.
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. 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. The DEA establishes annual production quotas for Schedule II drugs by analyzing data on past sales, inventories, market trends, and anticipated need.
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. Key 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.
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.
section_title: Few Incidents of Diversion or Abuse of Attention Disorder Drugs Identified by Schools
paragraphs: Based on our survey, an estimated 8 percent 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. An additional 3 percent of school principals reported at least one possible incident, but were uncertain of the drugs involved.
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. 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. 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 statistical conclusions about possible association between these factors and the incidence rate.
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.
Consequently, measures of attention disorder diversion or abuse based on official police records may underreport actual occurrences.
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.
section_title: Most Schools Dispense Attention Disorder Medications and Follow Drug Security Procedures
paragraphs: 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 percent) 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.
subsections: section_title: Medication Administration
paragraphs: 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.
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 percent of students (in schools where drugs are administered) were dispensed methylphenidate and an estimated 0.5 percent of students were administered amphetamines, for an overall rate of almost 2 percent.
A DEA drug diversion official expressed concern during recent congressional testimony 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.)
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 full- time nursing services so that only medically-trained personnel can distribute medication.”
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.
section_title: Medication Security
paragraphs: 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.
Cabinet and door locks school B 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.
section_title: Many States and Local School Districts Have Provisions for School Administration of Medications
paragraphs: 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.
subsections: section_title: Many States Have Established Requirements for the Administration of Medication
paragraphs: 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. 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 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. 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).
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. Finally, 22 states and the District of Columbia require schools to obtain prescription medication in an original container with proper pharmaceutical labeling.
Eighteen states specify the manner in which schools must store medication to ensure its security. 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. 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.
Sixteen states require schools to document the administration of medication to the student in a medication log or other like-named record.Documentation requirements vary between these states. Although some of the states do not specify the content or format of the medication log, many 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.
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. 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. 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 states have no applicable statutes, regulations, or policies (discretionary or mandatory) addressing the administration of medication in schools.
section_title: Many School Districts Have Established Local Procedures
paragraphs: 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 percent reported that the change was due to problems with the handling of medications at the principal’s school or at a neighboring school.
section_title: Conclusions
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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.
section_title: Appendix I: Objectives, Scope and Methodology
subsections: section_title: Objectives
paragraphs: 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.
section_title: Survey Scope and Methodology
paragraphs: 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.
section_title: Study Population
paragraphs: 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. 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.
section_title: Sample Design
paragraphs: 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 type (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.
section_title: Estimates
paragraphs: 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).
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.
section_title: Sampling Error
paragraphs: 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.
section_title: Nonsampling Error
paragraphs: 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.
section_title: Other Data Scope and Methodology
paragraphs: 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 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.
section_title: Appendix II: Survey of Public School Principals – Diversion/Abuse of Medication for Attention Disorders
section_title: Appendix III: State Controls on Dispensing of Drugs in Public Schools
section_title: Appendix IV: Anecdotal Accounts of School- Based Diversion or Abuse of Attention Disorder Medications
paragraphs: We reviewed the anecdotal 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. “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 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.
section_title: Appendix V: Studies Related to Diversion or Abuse of Methylphenidate by School-Aged Children
subsections: section_title: Findings Ritalin Abuse 12th Grade
paragraphs: Measure of abuse 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.
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.”
Study population 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. 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.
Students are asked about use of Ritalin without a prescription in their lifetime and within the last 30 days.
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.
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. 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 Treatment Episodes Methylphenidate   (Ritalin)
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.
Juvenile Amphetamine Use % Tested Positive (Range at different cities)
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.
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. 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 drug- related questions.
section_title: Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students
paragraphs: Appendix VI: State Statutes, Regulations, and Mandatory Policies Addressing the Administration of Medication to Students The California respondent told us that the implementing regulations are being drafted.
The respondent for the District of Columbia told us that currently there are no implementing rules or regulations.
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.
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.
The regulation requires either the physician’s instructions or a pharmacy label. Oregon Admin. Rules, 581-021-0037(1)(c).
The Pennsylvania respondent told us that currently there are no implementing guidelines in effect.
The pharmacy-container requirement is specific to self-administered medications. Code of Rhode Island Rules 14-000-011, sec. 18.9.1.1.
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.
section_title: Appendix VII: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: William Bates, Christine Davis, Jennifer Joseph, Stuart Kaufman, Monica Kelly, Lawrence Kinch, Lori Levitt, Mark Ramage, Anne Rhodes-Kline, and Lisa Wallace.