Prescribed Stimulant Medication Research Articles

Exploring the Relationship Between the Misuse of Stimulant Medications and Academic Dishonesty Among a Sample of College Students.

The misuse of prescription stimulant medications (MPS) and academic dishonesty (AD) are both problematic behaviors among college students. Although both behaviors are linked to a student's desire to succeed academically, little research has been conducted to examine the relationship between these behaviors. The purpose of this study was to determine if students who engaged in past-year MPS committed acts of AD more frequently than those who do not engage in MPS. We collected our data from a sample of undergraduates (n = 974) between the ages of 18 and 25 enrolled at one of three universities in the US who completed an online questionnaire to assess AD and MPS. Results indicated that 18.2 % of the sample engaged in MPS in the past year and 65 % committed one or more acts of AD during the past year. An increased frequency of AD increased the odds of reporting MPS when controlling for known covariates (e.g., gender, stimulant prescription status, and energy drink consumption). In addition, higher rates of MPS were identified in students affiliated with a Greek organization, those with a current stimulant prescription, those who consume energy drinks, and those who misuse other prescriptions. Concerning specific AD-types, misusers reported copying off someone else's homework, having someone copy of their homework, and using the internet to commit acts of dishonesty more frequently than those who do not engage in MPS. This study adds to the MPS college student literature by highlighting the relationship between MPS and AD.

The role of sleep quality and quantity in moderating the effectiveness of medication in the treatment of children with ADHD

The current study examined: (1) whether long-acting stimulant medication is effective in improving performance on measures of memory, attention, and academic productivity; and (2) whether sleep impacts the relationship between medication and performance. Participants were 21 newly diagnosed, medication-naïve children (mean age=9.1years) with ADHD, who participated in a 4-week blinded placebo-controlled randomized trial of long-acting MPH. Participants underwent assessments of sleep (i.e., polysomnography) and of cognitive performance. Long-acting stimulant medication was found to be an effective treatment for enhancing alerting attention, executive attention, working memory, and academic productivity, but resulted in poorer sleep. Moreover, sleep duration was found to impact the treatment response to medication, in that longer sleep duration at baseline was related to improved executive attention. These results underscore the importance of evaluating and monitoring sleep when prescribing stimulant medication as a treatment for ADHD in children.

Neurocognitive enhancement or impairment? A systematic meta-analysis of prescription stimulant effects on processing speed, decision-making, planning, and cognitive perseveration.

Increasing numbers of adults, particularly college students, are misusing prescription stimulants primarily for cognitive/academic enhancement, so it is critical to explore whether empirical findings support neurocognitive benefits of prescription stimulants. Previous meta-analytic studies have supported small benefits from prescription stimulants for the cognitive domains of inhibitory control and memory; however, no meta-analytic studies have examined the effects on processing speed or the potential impairment on other domains of cognition, including planning, decision-making, and cognitive perseveration. Therefore, the present study conducted a meta-analysis of the available literature examining the effects of prescription stimulants on specific measures of processing speed, planning, decision-making, and cognitive perseveration among healthy adult populations. The meta-analysis results indicated a positive influence of prescription stimulant medication on processing speed accuracy, with an overall mean effect size of g = 0.282 (95% CI [0.077, 0.488]; n = 345). Neither improvements nor impairments were revealed for planning time, planning accuracy, advantageous decision-making, or cognitive perseveration; however, findings are limited by the small number of studies examining these outcomes. Findings support that prescription stimulant medication may indeed act as a neurocognitive enhancer for accuracy measures of processing speed without impeding other areas of cognition. Considering that adults are already engaging in illegal use of prescription stimulants for academic enhancement, as well as the potential for stimulant misuse to have serious side effects, the establishment of public policies informed by interdisciplinary research surrounding this issue, whether restrictive or liberal, is of critical importance. (PsycINFO Database Record

Non-Medical Prescription Stimulant Use in Graduate Students

Objective: The objective of this study was to examine graduate students’ non-medical use of prescription stimulant medication, and the relationship between non-medical use of prescription stimulants with academic self-efficacy, psychological factors (i.e., anxiety, depression, and stress), and internal restlessness. Method: The sample consisted of 807 graduate students from universities located in five geographic regions of the United States. Results: Past-year rates of self-reported non-medical use were determined to be 5.9%, with overall lifetime prevalence of 17.5%. Observed self-reported non-medical use of prescription stimulant medications was significantly correlated with self-reported levels of anxiety and stress, various aspects of internal restlessness, and perceived safety of the medications. Conclusion: Findings support graduate students’ motivations of non-medical prescription stimulant use to be both academic and social in nature. Effective prevention and education efforts are needed to help address the non-medical use of prescription stimulants by graduate students on university campuses.

Nonmedical Stimulant Use in College Students

The nonmedical use of stimulants (misuse) in the college setting remains of utmost public health and clinical concern. The objective of this study was to evaluate comprehensively the characteristics of college students who misused stimulants, attending to rates of attention-deficit/hyperactivity disorder (ADHD), other psychopathology, and substance use disorders. The data presented are from a cross-sectional study of college students who misused prescription stimulant medications (not including cocaine or methamphetamine) and controls (college students without stimulant misuse). Between May 2010 and May 2013, college students were assessed blindly for psychopathology and substance use disorder by way of Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P) and completion of self-report questionnaires. The analysis included 198 controls (mean ± SD age = 20.7 ± 2.6 years) and 100 stimulant misusers (20.7 ± 1.7 years). Misusers, when compared to controls, were more likely to endorse alcohol, drug, alcohol + drug, and any substance use disorder (all P values < .01). When a subset of stimulant misusers (n = 58) was examined, 67% had a full or subthreshold prescription stimulant use disorder. Misusers also had higher rates of conduct disorder (10% vs 3%; P = .02) and ADHD (including subthreshold cases; 27% vs 16%; P = .02) in addition to lower Global Assessment of Functioning score (P < .01). Higher rates of misuse of immediate-release—relative to extended-release—stimulants were reported. Our data suggest that, compared to controls, college students who misuse stimulant medications are more likely to have ADHD, conduct disorder, stimulant and other substance use disorder, and overall dysfunction.

Effects Of Attention-Deficit/Hyperactivity Disorder Medications On Resistance-Exercise-Induced Hypoalgesia, Perceived Exertion, Heart Rate, And Blood Lactate

PURPOSE:An increase in prescribed stimulant medication for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) has led to treatment misuse as a result of the ability of these medications to improve concentration and decrease fatigue. Although they provide cognitive benefits, the effects of stimulant treatment for ADHD during physical activity are fairly unknown. The primary goal of this study was to investigate the effects of ADHD medications on resistance exercise-induced pain perception, perceived exertion, heart rate, and blood lactate concentrations. METHODS:Thirty college-age students (10 no ADHD diagnosis, 10 ADHD diagnosis, and 10 ADHD diagnosis with medications) completed 2 sessions: 1) a maximal testing session and 2) an experimental session consisting of 3 consecutive dynamic resistance exercise circuits. Each circuit was comprised of 12 repetitions of 9 resistance exercises at 60% of 1-repetition maximum using a 1:1 work to rest ratio. Pain and blood lactate concentrations were measured pre- and post-exercise using a pressure algometer and lactate meter, respectively. Heart rate and perceived exertion were measured during the exercise bout. RESULTS:Participants displayed exercise-induced hypoalgesia ([INCREMENT]17.8% ± 5.2, p = 0.002) 1-min post-exercise, accompanied by an increase in blood lactate (12.47 ± 0.66mM, p = 0.000). Moreover, participants displayed significant elevations in heart rate (p = 0.000) and perceived exertion (p = 0.000) for the duration of the exercise bout. These findings for pain tolerance, lactate, heart rate, and perceived exertion were similar regardless of condition (no ADHD diagnosis vs. ADHD without medications vs. ADHD with medications). CONCLUSIONS:Dynamic resistance exercise produces increases in pain tolerance, perceived exertion, heart rate, and blood lactate. The effects of resistance exercise are not altered by ADHD diagnosis or psychostimulant medication use for ADHD. These findings are intriguing given the known ergogenic and analgesic effects of caffeine, a less potent stimulant.

Cosmetic Neurocognitive Enhancement and Healthcare Providers

I.INTRODUCTION 730 II. NEUROCOGNITIVE ENHANCEMENT IN HEALTH CARE ..... 732 III.REQUESTS 737 A. Neuromyths Facilitating Requests 737 B. Direct-to-Consumer Advertising as a Driver of Patient Requests 739 C. So What Is It That People Do (and Do Not) Want To Alter? 741 IV. RESPONSES: PROVIDER ISSUES 745 A. Models of Provider-Patient Interactions 746 B. Provider Attitudes About Enhancement 749 C. Availability of Enhancing Drugs (Off-Label Prescribing) 751 D. Currently Available Enhancing Drugs 753 1. Schedule II Drugs 753 2. Schedule IV Drugs 756 3. OTC Drugs 758 4. Other Considerations 761 V. RECOMMENDATIONS FOR PROVIDERS AND SYSTEMS ....... 763 VI. CONCLUSION 767

Misuse of prescription stimulant medication in a sample of college students: Examining differences between varsity athletes and non-athletes

BackgroundThe misuse of prescription stimulants (MPS) has been identified as an adverse health behavior among college students. Because stimulant medication is often taken to increase focus and decrease reaction time, these substances have the potential to enhance athletic performance. However, the role that athlete status (varsity athlete vs. non-athlete) has on MPS has rarely been examined in the college student population. ObjectivesTo examine whether there are differences in past-year MPS and MPS-related motivations between college varsity athletes and non-athletes. MethodsA sample of 682 (482 non-athletes; 200 athletes) college students between the ages of 18 and 25 completed a paper-based questionnaire to assess MPS, MPS-related motivations, and other potential MPS correlates (e.g., gender, energy drink consumption, tobacco use, heavy episodic drinking). Then, we conducted bivariate and multivariate analyses to examine potential correlates of MPS, including athlete status. Finally, we examined differences in MPS-related motivations between varsity athletes and non-athletes. ResultsOverall, 98 (13.9%; 16.6% non-athletes v. 7.5% varsity athletes) respondents reported past-year MPS and varsity athletes were significantly less likely (p<0.05) to do so. Past-year MPS was also significantly associated with energy drink consumption, tobacco use, and heavy episodic drinking in our sample. Concerning MPS-related motivations, athletes more often cited a need to enhance athletic performance as the impetus for their misuse. ConclusionsMPS was prevalent among the sample. Varsity athletes were significantly less likely to engage in past-year MPS and were motivated to do so for different reasons.

The Medical Ethics of Cognitive Neuroenhancement

Prescription stimulant medications have been sought for cognitive “neuroenhancement”, the practice of enhancing ostensibly normal cognitive function such as attention span, focus, and memory. This trend, particularly studied in college students, has driven a debate about many ethical aspects related to cognitive enhancement; however, the central role of physicians and the medical ethics of this practice have been minimally investigated. In this paper, a clinical case serves as the focal point to review the current state of prescription stimulant use for enhancement, beginning with the medical and legal problems related to the surreptitious, yet common, behaviors of diversion and malingering. In contrast, there may be a growing trend for individuals to seek prescription stimulants “openly” (without malingering or diversion) as a direct request from their physician, which leads to complex ethical questions. A model of clinical-ethical decision making (the “four-box model” from Jonsen et al.) is applied to analyze the factors that a physician must consider when deciding whether to engage in the open prescribing of a stimulant neuroenhancer to otherwise healthy, autonomous adults. Four domains are explored in depth: medical indications, quality of life/beneficence, patient preferences, and contextual factors. Relevant experiences from the medical disciplines involved in athletic enhancement and cosmetic enhancement are discussed. Although an overall ethical framework for neuroenhancement continues to evolve, from a perspective of medical ethics there are presently significant reasons to be wary of cognitive neuroenhancement with stimulant medications.

The diversion of stimulant medications among a convenience sample of college students with current prescriptions.

Diversion is defined as the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace. Persons with legal prescriptions often give away or sell their medications to others. The misuse of prescription stimulant medications continues to be a problem on college campuses and a need to understand how students are obtaining stimulant medications exists. The object of the study was to identify the prevalence, correlates, and motivations associated with diversion of prescription stimulants among current prescription holders. A large sample of undergraduates (n = 1,022) between the ages of 18 and 24 enrolled at a large public university in the southeastern United States completed an in class questionnaire. Among those respondents, we identified 151 current stimulant prescription holders and analyzed the prevalence, motivations, and correlates associated with lifetime and current diversion. Overall, 58.9% of current prescription holders had given away or sold their stimulant medication during their lifetime. Those with a history of nonmedical use of prescription stimulants were almost 5 times more likely to divert their medication during their lifetime. The majority of those engaging in lifetime and current diversion medication did so infrequently. The most common motivations reported for both lifetime and current diversion were "to make extra money" and to "help during a time of high academic stress." Students who reported a history of prescription misuse were also more likely to engage in current diversion. Diversion-related behaviors should be explored further and programs aimed at the reducing these behaviors should be considered.

Collegiate Misuse of Prescription Stimulants: Examining Differences in Self-Worth

Background: Prescription stimulant medication is commonly used to treat attention-deficit hyperactivity disorder (ADHD). However, stimulant medication misuse is a prevalent problem among the college population. There is limited research on psychological factors associated with collegiate nonmedical stimulant misuse. Objectives: To examine the association between college students’ self-worth and stimulant medication misuse. Methods: A quantitative study implemented during the 2013–2014 academic year in which we utilized a convenience sample of undergraduate students at a public university. College students (N = 3,038) completed an electronic survey packet including a stimulant use index and the Contingencies of Self-Worth Scale. We conducted descriptive discriminant analysis (DDA) to measure the associations between four groups: Nonusers, Appropriate Users, Nonprescribed Misusuers, and Prescribed Users. Results: Significant differences in contingencies of self-worth existed between the four groups of students. Specifically, external contingencies of self-worth, such as appearance and approval, were associated with stimulant medication misuse, whereas, internal contingencies of self-worth, such as God's love and virtue, were associated with nonuse and appropriate prescribed use. Conclusions/Importance: The findings of the current study suggested contingencies of self-worth partially explain prescription stimulant misuse among the collegiate population. Addressing self-worth may be helpful in the treatment of stimulant misuse with college students.

Amphetamine sensitization and cross-sensitization with acute restraint stress: impact of prenatal alcohol exposure in male and female rats.

Individuals with fetal alcohol spectrum disorder (FASD) are at increased risk for substance use disorders (SUD). In typically developing individuals, susceptibility to SUD is associated with alterations in dopamine and hypothalamic-pituitary-adrenal (HPA) systems, and their interactions. Prenatal alcohol exposure (PAE) alters dopamine and HPA systems, yet effects of PAE on dopamine-HPA interactions are unknown. Amphetamine-stress cross-sensitization paradigms were utilized to investigate sensitivity of dopamine and stress (HPA) systems, and their interactions following PAE. Adult Sprague-Dawley offspring from PAE, pair-fed, and ad libitum-fed control groups were assigned to amphetamine-(1-2 mg/kg) or saline-treated conditions, with injections every other day for 15 days. Fourteen days later, all animals received an amphetamine challenge (1 mg/kg) and 5 days later, hormones were measured under basal or acute stress conditions. Amphetamine sensitization (augmented locomotion, days 1-29) and cross-sensitization with acute restraint stress (increased stress hormones, day 34) were assessed. PAE rats exhibited a lower threshold for amphetamine sensitization compared to controls, suggesting enhanced sensitivity of dopaminergic systems to stimulant-induced changes. Cross-sensitization between amphetamine (dopamine) and stress (HPA hormone) systems was evident in PAE, but not in control rats. PAE males exhibited increased dopamine receptor expression (medial prefrontal cortex (mPFC)) compared to controls. PAE alters induction and expression of sensitization/cross-sensitization, as reflected in locomotor, neural, and endocrine changes, in a manner consistent with increased sensitivity of dopamine and stress systems. These results provide insight into possible mechanisms that could underlie increased prevalence of SUD, as well as the impact of widely prescribed stimulant medications among adolescents with FASD.

The effects of stimulant medications on children’s growth velocity

Objective: This study sought to determine whether relationships exist between stimulant medications and children’s growth velocity. Methods: The investigators conducted a retrospective review of 280 charts of pre-pubertal children with attention-deficit hyperactivity disorder (ADHD) who were prescribed stimulant medications for a minimum of 1 year. The children were patients in a university child development/ADHD clinic. Results: The average growth velocity across all genders and ages was 5.72 cm/year (females 5.53 cm/year,males 5.28 cm/year). The majority of the children had growth velocities in the 25-50th percentiles for age. Conclusion: This study did not find evidence of significant effect on growth velocity in children with ADHD treated with stimulant medications. Our results concur with the majority of other studies of growth in children taking stimulant medications for ADHD management. It supports our continued prescription of stimulant medications without concern for slowed or stunted growth in our patients with ADHD.

Predictors of and barriers to service use for children at risk of ADHD: longitudinal study.

Many children with, or at risk of, ADHD do not receive healthcare services for their difficulties. This longitudinal study investigates barriers to and predictors of specialist health service use. This is a 5-year follow-up study of children who participated in a cluster randomised controlled trial, which investigated school-level interventions (provision of books with evidence-based information and/or feedback of names of children) for children at risk of ADHD. 162 children who had high levels of ADHD symptoms at age 5 (baseline) were followed up at age 10 years. Using baseline data and follow-up information collected from parents and teachers, children who had and had not used specialist health services over the follow-up period were compared and predictors (symptom severity, comorbid problems, parental perception of burden, parental mental health, and socio-demographic factors) of specialist service use investigated. The most common parent-reported barrier reflected lack of information about who could help. Amongst children using specialist health services who met criteria for ADHD at follow-up, 36% had been prescribed stimulant medication. Specialist health service use was associated with each one-point increase in teacher-rated symptoms at baseline [inattention symptoms (adjusted OR = 1.40; 95% CI 1.12-1.76) and hyperactivity/impulsivity symptoms (adjusted OR = 1.23; 95% CI 1.05-1.44)]. Parental mental health problems were also independently associated with service use (for each one-point increase in symptoms, adjusted OR = 1.41; 95% CI 1.04-1.91). Severity of teacher-rated ADHD symptoms in early school years is a determinant of subsequent service use. Clinicians and teachers should be aware that parental mental health problems are independently associated with service use for children at risk of ADHD.

Pediatric Integrative Medicine Approaches to Attention Deficit Hyperactivity Disorder (ADHD).

Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder in children and is increasing in prevalence. There has also been a related increase in prescribing stimulant medication despite some controversy whether ADHD medication makes a lasting difference in school performance or achievement. Families who are apprehensive about side effects and with concerns for efficacy of medication pursue integrative medicine as an alternative or adjunct to pharmacologic and cognitive behavioral treatment approaches. Integrative medicine incorporates evidence-based medicine, both conventional and complementary and alternative therapies, to deliver personalized care to the patient, emphasizing diet, nutrients, gut health, and environmental influences as a means to decrease symptoms associated with chronic disorders. Pediatric integrative medicine practitioners are increasing in number throughout the United States because of improvement in patient health outcomes. However, limited funding and poor research design interfere with generalizable treatment approaches utilizing integrative medicine. The use of research designs originally intended for drugs and procedures are not suitable for many integrative medicine approaches. This article serves to highlight integrative medicine approaches in use today for children with ADHD, including dietary therapies, nutritional supplements, environmental hygiene, and neurofeedback.

Possible Medication-Resistant Deficits in Adult ADHD

Objective: The nature of ADHD, especially in adulthood, is not well-understood. Therefore, we explored subcomponents of attention in adult ADHD. Method: Twenty-three adults with ADHD were tested on neurocognitive and visual tracking performance both while on their regular prescription stimulant medication and while abstaining from the medication for 1 day. Pairwise comparisons to 46 two-for-one matched normal controls were made to detect medication-resistant effects of ADHD, and within-participant comparisons were made to detect medication-sensitive effects in patients. Results: Even when on medication, patients performed more poorly than controls on a spatial working memory task, and on visual tracking and simple reaction time tasks immediately following other attention-demanding tasks. Patients’ visual tracking performance degraded while off-medication in a manner consistent with reduced vigilance. Conclusion: There may be persistent cognitive impairments in adult ADHD despite medication. In addition, the benefit of stimulants seems reduced under cognitive fatigue.

Children diagnosed with attention deficit disorder and their hospitalisations: population data linkage study.

Examine the hospital admission risk in young children who are subsequently diagnosed with attention deficit hyperactivity disorder (ADHD). We conducted a population-based, record linkage study. Records of all non-Aboriginal children under 18 years who met the DSMIV/ICD10 criteria for ADHD and prescribed stimulant medication in Western Australia between 2003 and 2007 (n = 11,902) were linked to two other health data systems-the hospital morbidity data system and the midwives notification system (MNS). The non-ADHD reference population (n = 27,304) was randomly selected from the MNS. Compared with controls, children under 4 years who subsequently were diagnosed and treated for ADHD were 70% [odds ratio (OR) 1.70; 95% confidence intervals (CI) 1.62-1.77] more likely to be admitted to hospital under 4 years of age. There was an increased risk for injury or poison (OR 1.73; 95% CI 1.59-1.88), respiratory disease (OR 1.49; 95% CI 1.40-1.59), ear disease (OR 2.03; 95% CI 1.86-2.21), infectious diseases (OR 1.68; 95% CI 1.53-1.85) and neurological conditions (OR 2.03; 95% CI 1.68-2.44). Admissions under 4 years of age for head injuries, burns, poisons, all other injuries, diseases of the tonsils and adenoids, asthma and early infections were all more common amongst children subsequently diagnosed with and treated for ADHD. There is significant early hospital morbidity for children subsequently diagnosed with ADHD. Multiple aetiologies and causal pathways need to be considered where some of these may include early infections, inflammatory conditions, epilepsy and injuries. Future studies should look at which of these conditions may be on the causal pathway or likely early markers for ADHD.

Risk Factors by Gender for Children with ADHD

Investigators at University of Western Australia conducted a population-based, case-control study of maternal, pregnancy, and newborn risk factors by gender for children prescribed stimulant medication for treatment of ADHD.

Environmental Risk Factors by Gender Associated With Attention-Deficit/Hyperactivity Disorder

Early environmental risk factors associated with attention-deficit/hyperactivity disorder (ADHD) have been increasingly suggested. Our study investigates the maternal, pregnancy, and newborn risk factors by gender for children prescribed stimulant medication for treatment of ADHD in Western Australia. This is a population-based, record linkage case-control study. The records of all non-Aboriginal children and adolescents born in Western Australia and aged <25 years who were diagnosed with ADHD and prescribed stimulant medication (cases = 12,991) were linked to the Midwives Notification System (MNS) to obtain maternal, pregnancy, and birth information. The control population of 30,071 children was randomly selected from the MNS. Mothers of children with ADHD were significantly more likely to be younger, be single, have smoked in pregnancy, have labor induced, and experience threatened preterm labor, preeclampsia, urinary tract infection in pregnancy, or early term delivery irrespective of the gender of the child, compared with the control group. In the fully adjusted model, a novel finding was of a possible protective effect of oxytocin augmentation in girls. Low birth weight, postterm pregnancy, small for gestational age infant, fetal distress, and low Apgar scores were not identified as risk factors. Smoking in pregnancy, maternal urinary tract infection, being induced, and experiencing threatened preterm labor increase the risk of ADHD, with little gender difference, although oxytocin augmentation of labor appears protective for girls. Early term deliveries marginally increased the risk of ADHD. Studies designed to disentangle possible mechanisms, confounders, or moderators of these risk factors are warranted.

Frequency of Energy Drink Use Predicts Illicit Prescription Stimulant Use

ABSTRACT. Background: The purpose of this study was to examine energy drink (ED) usage patterns and to investigate the illicit use of prescription stimulants among college students. Methods: A sample of 267 undergraduate and graduate students (mean age of 22.48 among stimulant users) from a large midwestern university and its branch campus locations voluntarily participated in the study. Results: Among prescription stimulant users without a valid medical prescription, Mann-Whitney U tests and logistic regression analysis revealed that the frequency of ED use was a significant predictor of the illicit use of prescription stimulants. Moreover, frequency of ED consumption was a significant predictor of the illicit use of prescription stimulant medications, with the odds for using increasing by .06 with each additional day of ED use past 0 day (odds for use = 1.06, P =.008). Conclusions: Results indicate that the frequency of ED use is a significant predictor of the illicit use of prescription stimulants. All prescription stimulant users with or without a valid script also used EDs. This finding is important to practitioners because of the harmful interactions (eg, serotonin syndrome) that can occur when ED ingredients (eg, ginseng, yohimbine, evodamine, etc) are mixed with prescription stimulants.