Attention Disorder Drugs: Few Incidents of Diversion or Abuse	 
Identified By Schools (14-SEP-01, GAO-01-1011). 		 
								 
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.	 
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, approximately eight percent of  
principals in public middle and high schools reported knowing of 
attention disorder drugs being 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 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. Thirty-seven states and 
the District of Columbia have either statutes, regulations, or	 
mandatory policies addressing the administration of medication to
students. 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.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-1011					        
    ACCNO:   A01772						        
    TITLE:   Attention Disorder Drugs: Few Incidents of Diversion or  
             Abuse Identified By Schools                                      
     DATE:   09/14/2001 
  SUBJECT:   Drugs						 
	     Food and drug law					 
	     Public schools					 
	     Elementary schools 				 
	     Secondary schools					 
	     Students						 
	     Controlled substances				 

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GAO-01-1011
     
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 manual 2 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 percent 9 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 95percent 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 schools a

Student was expelled or suspended 78 Police were called 58 Student was
counseled 54 Other measures were taken b 41 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 percent 13 ) 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 percent 14 of
students (in schools where drugs are administered) were dispensed
methylphenidate and an estimated 0.5 percent 15 of students were
administered amphetamines, for an overall rate of almost 2 percent.

A DEA drug diversion official expressed concern during recent congressional
testimony 16 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 medication a

Percent most often administering attention

disorder medications b

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 percent 29 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 type 2 (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 20002001 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 anecdotal 1 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 7 th -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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To Report Fraud, Waste, and Abuse in Federal Programs
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