Research PaperExamining social supply among nonmedical prescription stimulant users in the San Francisco Bay Area
Introduction
In the US, prescription stimulants are used to treat a variety of conditions including attention deficit hyperactivity disorder (ADHD) and narcolepsy. Some commonly prescribed stimulants include amphetamines (e.g. Adderall, Dexedrine, Vyvanse) and methylphenidate (e.g. Ritalin, Concerta). According to the 2015 National Survey on Drug Use and Health (NSDUH), during the past year an estimated 17.2 million people aged 12 or older used prescription stimulants. Furthermore, an estimated 5.3 million people aged 12 or older misused prescription stimulants in the past year (Hughes et al., 2016), with 1.7 million current misusers (Center for Behavioral Health Statistics and Quality, 2016). Prescription stimulant “misuse” (what we call “nonmedical”) is defined as use in any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. The reported primary reasons for the misuse of stimulants in the 2015 NSDUH were to be alert or to stay awake (26.8%) and to help concentrate (26.5 percent), followed by to help study (22.5%) (Hughes et al., 2016).
The dramatic increases in stimulant prescriptions over the last two decades have led to greater availability and increased risk for diversion and nonmedical use (McCabe, West, Teter, & Boyd, 2014). Misuse and diversion of prescription stimulants is a prevalent and growing phenomenon, particularly among college students (Flory, Payne & Benson, 2014). Hartung et al. (2013) study of stimulant medication use in college undergraduates at four public universities located in the Southeast, Rocky Mountain, and Midwest regions of the U.S. found that 81 percent of stimulant misusers without prescriptions got medications from friends, while 45 percent bought them. DeSantis, Anthony, and Cohen (2013) surveyed 2313 undergrads at a large Southeastern university to study illicit college ADHD stimulant distributors. They found that among students with stimulant prescriptions, 52.5 percent had given pills away, while 39.2 percent had sold them. Vrecko (2015) conducted semi-structured interviews with 38 students who used prescription stimulants as a means of improving academic performance on an American university campus.
The most common way that informants reported obtaining Adderall for non-medical use involved receiving pills from someone known personally to them, well enough to be described as a friend. More than three-quarters of individuals reported such transactions, in which a recipient would typically be given a small supply of pills without expectation of a monetary payment or other financial exchange (299).
Coomber and Turnbull (2007), Coomber and Moyle (2013) and Coomber, Moyle, and South (2016) concept of social supply addresses this phenomenon and raises the question: When friends supply or facilitate supplies of drugs to their friends, is this really dealing? Further, if dealing and supplying are distinct kinds of social transactions, should diverse types of criminal justice approaches be applied? Social supply extends our understanding of drug dealing as a complex social activity. Our own and other investigators' study findings indicate that many drug “suppliers” do not fit into the traditional image of “dealers” in drug markets (Blum, 1972; Dorn, Murji, & South, 1992; Coomber & Turnbull, 2007; Jacinto, Duterte, Sales, & Murphy, 2008; Coomber & Moyle, 2013). These suppliers typically do not identify themselves as “dealers,” but instead understand their drug distribution as sharing with people they know. These types of suppliers are in fact engaging in the types of drug distribution activities that fit our understandings of social supply. Yet, in the U.S., the concept of social supply has not yet penetrated academic or public discourse. In the United Kingdom, the concept of social supply has entered the political arena and triggered discussions concerning policy reform to change criminal sentencing to proportionately address various levels of drug supplying (Coomber & Moyle, 2013).
Coomber, Moyle, and South argue that while drug scholars in the UK have to some extent accepted the general process of the normalisation of drug use, “this process has not, thus far, been widely examined in relation to drug supply or drug markets” (2016: 261). Further, Parker, Aldridge, and Measham (1998) and later South (2004) and Coomber (2004) argue that the normalisation of drug use is also conducive to a relative normalisation of drug supplying. Murphy, Reinarman, and Waldorf (1990) utilised Matza’s (1964) conceptualisation of drift to explain pathways into cocaine distribution as committed users taking “short steps down a familiar path” rather than a long leap down an unknown road. Using illegal drugs regularly is the first step of the journey toward needing to access drugs and to acquire them safely, while trying to obtain the best possible quality and price, thus moving other trusted users into social supply roles.
In the U.S., with the notable exception of the increasing acceptance of medical and to a lesser extent recreational cannabis use, the go-to response to illegal drug use continues to be criminalisation and punishment. To this end federal drug legislation places drugs in different “schedules” of the Controlled Substances Act (CSA) based on medicinal value, harmfulness, and potential for addiction and abuse. For example, LSD and heroin are classified as Schedule I. Prescription stimulants, cocaine, and certain prescription narcotics (i.e. Fentanyl, oxycodone, and morphine) are included in Schedule II. Examples of Schedule III drugs include combination narcotic products (Vicodin, Tylenol with Codeine), anabolic steroids, and ketamine. Schedule IV drugs include benzodiazepines and other prescription sedatives, and Schedule V includes certain cough preparations. Within these schedules, penalties for “trafficking” are generally quantity-related or based on prior offenses. For example, cocaine trafficking can result in five years to life in prison depending on the quantity seized and whether or not it is a first offense. Trafficking prescription stimulants is punishable by no more than 20–30 years, depending on prior offense history. However, in the latter case, the law does not specify quantity considerations, and rather clusters “any amount of other Schedule I and II substances” (i.e. other than cocaine, fentanyl, heroin, LSD, methamphetamine, and PCP) into a generalised category. (For more information on drug scheduling and penalties, see: Chapman et al., 2015; Drug Enforcement Administration, “Federal Trafficking Penalties” and Title 21 United States Code (USC) Controlled Substances Act).
These laws to some extent apply different penalties for distinct types of drugs and specific quantities, but they do not differentiate types of dealing. For one, there is great ambiguity in defining “trafficking” regarding the “other” Schedule I and II drugs for which no quantity-based parameters exist, including prescription stimulants. Secondly, legislation does not specifically distinguish between “dealing” (selling drugs for a monetary profit) and “social supply” (sharing drugs to gain or promote social benefits). Essentially, a college student who gives a friend a few free Adderall pills to help improve school performance could conceivably receive the same penalty as a first-time offender who sold four hundred grams of cocaine. The language of the law creates a confounding dilemma for applying penalties to social suppliers of prescription drugs. To further complicate the matter, individual states have different statutes regarding prescription drug trafficking and diversion, and often include “possession with intent to sell” within the parameters of “trafficking” even if no money is exchanged (National Alliance for Model State Drug Laws, 2009). Given the ambiguity in the language of U.S. law and state to state variances in statutes, it would make sense for the U.S. to follow the international trend towards proportionality in sentencing as a way of working toward a more fair and balanced approach to convictions and sentencing guidelines.
Some of the various mechanisms of prescription drug diversion (e.g. stealing from medicine cabinets, trading with friends with legitimate prescriptions) have been examined in our own and others’ research (Chapman et al., 2015, Inciardi et al., 2009; Mui, Sales, & Murphy, 2013; Wood, 2015). Other studies have considered the prevalence of prescription stimulant diversion and nonmedical use in specific populations (Flory et al., 2014, Garnier et al., 2010; McCabe, Teter, & Boyd, 2004, McCabe, Teter, & Boyd, 2006; McCall et al., 2016; Sembower, Ertischek, Buchholtz, Dasgupta, & Schnoll, 2013). However, the magnitude of diversion on a national level is virtually impossible to quantify. In 2017, the data collection that specifically targets arrests for prescription drug trafficking is minimal, and often focuses on opiates rather than stimulants (Drug Enforcement Administration, 2016, McCall et al., 2016). At the same time, the prevalence of nonmedical use of prescription stimulant (NMUPS) remains a growing phenomenon (Center for Behavioral Health Statistics and Quality, 2016, Flory et al., 2014, Garnier et al., 2010; Kaloyanides, McCabe, Cranford, & Teter, 2007; Lakhan & Kirchgessner, 2012; McCabe et al., 2004, McCabe et al., 2006; Sembower et al., 2013, Sepúlveda et al., 2011; Sussman, Pentz, Spruijt-Metz, & Miller, 2006; Teter et al., 2006).
The lack of specified arrest data and the increasing prevalence of nonmedical use reflects the normalisation of NMUPS in the U.S., which differs from normalisation of marijuana and other drugs. Motivations for stimulant use can be understood as emanating from values in “conventional culture” that privilege successful school and work performance and illness intervention (Pedersen, Sanberg, & Copes, 2015). This may elucidate the criminal justice focus on prescription opiate trafficking rather than on prescription stimulants. The sociocultural context in the U.S. encompasses all the above: Protestant work ethic, health movements, and the emphasis on self-care. Included in this description of 21st century western “conventional culture” is the widespread medicalisation of attention deficit and hyperactivity disorders (ADD/ADHD) and the concept of “pharmaceuticalisation.” Medicalisation can be summarised as the use of medical interventions to treat a problem, usually an illness or disorder, as an instrument in the management of society (Bell & Figbert, 2012; Conrad, 2005 Zola, 1972). “Pharmaceuticalisation” describes “the process by which social, behavioral, or bodily conditions are treated, or deemed to need treatment/intervention, with pharmaceuticals by doctors, patients or both” (Abraham, 2010a: 290). It occurs both for conditions previously outside the jurisdiction of medicine and for established medical conditions already in the medical domain (Abraham, 2010b). “Evidence indicates that prescribing medicines has become a dominant, if not the dominant, form of health care in western societies and its role in middle-income countries is growing rapidly” (Busfield, 2010: 935). It combines “the biological effect of a chemical on human tissue, the willingness of consumers to adopt the technology as a ‘solution’ to a problem in their lives, and the corporate interests of drug companies” (Fox & Ward, 2008: 865). In the case of ADD/ADHD, medicalisation and “pharmaecuticalisation” are evident with growing numbers of people receiving diagnoses and prescriptions for stimulants (Olfson, Gameroff, Marcus, & Jensen, 2003; Thomas, Conrad, Casler, & Goodman, 2006; Toh, 2006). In fact, an estimated two million more U.S. children (ages 4–17) were diagnosed with ADHD in 2011 compared to 2003, and more than two-thirds of those with a current diagnosis were taking medication for treatment (Visser et al., 2014). Increases in the numbers of diagnoses creates a surge of prescription stimulants available for diversion to nonmedical users’ social networks.
Further research should help create guidelines that define different roles in the social supply of drugs, such as “brokers,” “advocates,” and “social profiteers.” Drug scholars have examined the role of social supply in distributing legal drugs (Coomber and Turnbull, 2007, Etter, 2006; Harrison, Fulkerson, & Park, 2000), illicit drugs (Coomber and Turnbull, 2007, Johnson, 2003; Hughes, Ritter, Cowdery, & Sindicich, 2014; Nyabadza, Njagarah, & Smith, 2013), and prescription drugs (Daniulaitye, Falck, & Carlson, 2014). The diversion of prescription stimulants within social networks in the U.S. has yet to be examined through the conceptual lens of social supply. The market for prescription stimulants is unique since many suppliers divert legitimate prescriptions to friends and associates. It is complex because the normalisation of nonmedical prescription stimulant use among specific user networks is facilitated by its “fit” with the US conventional values of acceptance of pharmaceuticals as appropriate responses to an ever-increasing list of conditions and prescription stimulants’ perceived facility for improvement of work and school performance.
For this article, we rely on participants' narratives concerning prescription stimulant acquisition practices and how they understand these interactions, purchases, and exchanges of prescription stimulants in their social networks. Coomber et al. (2016) argue that as specific kinds of drug use (in this case prescription stimulants) become normalised within “micro sites” of consumption, so do supplier roles. We discuss supplier roles and the differences in the transactions that take place in casual and formal prescription stimulant markets as well as the motivations for prescription stimulant diversion, including reciprocity, advocacy, brokering, and perceptions of doctors as “dealers.”
Section snippets
Methods
We conducted in-depth interviews with 150 nonmedical prescription stimulant users who were 18 or older and had used prescription stimulants nonmedically at least six times in the 12 months prior to the interview. We define nonmedical use as the use of prescription stimulants, prescribed or not, to get high, for the experience(s) they cause, to modify the effects of other drugs or alcohol, or if not prescribed for ADHD, to enhance school/work performance.
We used several strategies to identify,
Results
We completed 150 interviews, 95 (63.3%) men and 55 (36.7%) women. Participants ranged in age from 18 to 65 years old with a median age of 30. Ninety-five (63.3%) of the interviewees were white. Of those, 17 identified as Latino. Twenty-nine (19.3%) were African-American and 13 (8.7%) were Asian. Nine (7%) were of mixed ethnicity, of which one identified as Latino. One (0.7%) interviewee was East African, one (0.7%) was Pacific Islander, one (0.7%) was “human,” and one (0.7%) refused to answer.
Reciprocity and social profit
In our study sample, as with other types of drug users (Coomber et al., 2016, Ford and Ong, 2014, Werse and Bernard, 2016) we found that prescription stimulant diversion was driven by expectations of social profit and reciprocity. Gouldner (1960) defines reciprocity as “a pattern of mutually contingent exchange of gratifications.” Within social groups, people who either have legitimate stimulant prescriptions or have access to people with prescription stimulants share their supply with friends,
The advocate stance
Some drug suppliers are motivated to take an “advocate stance” by sharing drugs that could have positive impacts on the physical and mental well-being of people they know (Coomber & Moyle, 2013). We found that these ideas motivated many of our participants’ friends to share prescription stimulants with them, usually to enhance participants’ work or school performance or to help them to self-medicate for mental health issues, highly socially desirable outcomes that normalise prescription
Brokers and the social supply buffer
Werb et al. (2011) suggest that gun violence and high homicide rates within drug markets may be attributed to prohibition policies and disruption of drug markets by law enforcement, which can actually increase violence. For some drug users, social supply networks helped to shield “the user” from the risks of taking part in larger drug markets (e.g. arrest, exposure to other drugs, physical harm). Some prescription stimulant users acted as “brokers” between people within their social networks
Doctor “DEALERS”
The medicalisation and pharmaceuticalisation of attention deficit and hyperactivity disorder has resulted in a marked increase in the number of patients seeking and obtaining prescriptions for stimulants, fueling the trend of suppliers diverting legitimately prescribed stimulants to friends or people they know. While doctors are not direct participants in social supply, they are sources of legitimate prescriptions for stimulants which then get diverted down the social supply chain. Many
Discussion
The prescription stimulant market has many legal and ethical grey areas, particularly in a prescription-driven society. Americans belong to a “pill-based” culture where school and work success is considered socially positive (Busfield, 2010: 935; Hughes et al., 2016, Olfson et al., 2003, Pedersen et al., 2015, Thomas et al., 2006, Toh, 2006). Millions of American children receive prescriptions for stimulants and the numbers continue to increase (McCabe et al., 2014; CBHSQ, 2015; Olfson et al.,
Conflicts of interest
The authors of this publication declare no conflicts of interest.
Acknowledgements
We would like to thank all of the study participants for their time and candor, without whom this research project would not be possible. We also want to thank the National Institute on Drug Abuse (R01DA033594) and Moira O’Brien (Program Officer) for their support.
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