AUTHORITY AND STUDY OBJECTIVES

Adopted by the 2001 Session of the General Assembly, HJR 660 created a 10-member joint subcommittee to study the effects of attention deficit disorder and attention deficit hyperactivity disorder (ADHD) on student performance and to investigate the improper prescription and illegal use and diversion of Ritalin and OxyContin. The General Assembly assigned the HJR 660 joint subcommittee a number of responsibilities, specifically, to:

"(i) determine the number of students diagnosed as having ADD/ADHD in Virginia's public schools, and whether such children receive treatment;
(ii) ascertain whether such students also have dual exceptionalities or chronic and acute health problems, and the demand created by these conditions for certain school services;
(iii) determine the academic performance levels of such children;
(iv) identify other educational, social, and health factors that may compromise their academic performance and educational outcomes;
(v) identify school practices to manage, the methods used to treat, and the medications prescribed for and dispensed to ADD/ADHD students in the school setting for their disorder;
(vi) evaluate the special education programs and related services provided or which may be provided to meet the needs of such students;
(vii) assess the demand for and effectiveness of existing education programs and related services, including school health services, by ADD/ADHD students;
(viii) evaluate the effect of ADD/ADHD on grade retention, absenteeism, school suspension and expulsion, and disciplinary action taken by public schools;
(ix) and make appropriate recommendations that address identified problems and allow public schools to serve such children efficiently and effectively;
(x) determine the health conditions for which Ritalin and OxyContin are lawfully prescribed in Virginia;
(xi) ascertain the number of such prescriptions for the last five years to determine the rate of increase or decrease, and the cause of any increase in the number of such prescriptions;
(xii) determine if Ritalin and OxyContin have been diverted to the street drug trade, and, if so, assess the demand for Ritalin and OxyContin as street drugs in Virginia;
(xiii) establish whether the use of Ritalin or OxyContin for non-medical purposes is a problem among school-aged children and college students in the Commonwealth;
(xiv) consider and explore such other issues as the joint subcommittee may determine pertinent; and
(xv) recommend ways to correct problems associated with the over-prescription and the illegal use, possession, and distribution of Ritalin and OxyContin, as appropriate."

The joint subcommittee met three times in 2001 and was to submit its findings and recommendations to the Governor and the 2002 Session of the General Assembly.

ATTENTION DEFICIT HYPERACTIVITY DISORDER AND RITALIN USE

One of the most common mental disorders among children, Attention Deficit Hyperactivity Disorder (ADHD), affects an estimated three to five percent of all children in the United States. Other estimates place ADHD in two to 9.5 percent of school-age children worldwide. The condition typically presents in childhood, often between the ages of three and five, and may persist throughout adulthood. Today, specialists agree that Attention Deficit Hyperactivity Disorder is not a single condition but may be classified in subtypes reflecting the behaviors typically associated with the condition: inattentiveness, impulsivity, and hyperactivity. While these behaviors are certainly not necessarily indicative of ADHD, experts generally assess whether these behaviors are excessive, pervasive, and long-term. Distinguishable from ADHD are certain classroom behaviors that may be addressed through adjustments in instruction, recognition of learning style, or acknowledgement of individual student emotional or social needs.

The causes of ADHD remain under scientific investigation. Theories being explored today focus on brain development and processes as well as possible genetic influences. Recent brain imaging studies and other research indicate the involvement of specific brain areas that regulate attention; one theory focuses on genetic mutations-specifically, defects in those genes responsible for the regulation of the brain's use of the neurotransmitter dopamine.

Three medications--all classified as stimulants--have been used over the years to treat ADHD: Ritalin, Dexedrine or Dextrostat, and Cylert. Although considered safe when administered under medical supervision, the stimulant drugs can be addictive if misused by adolescents and adults. Used since the 1960s, Ritalin is found to assist 70 to 90 percent of children over age five for whom it is prescribed.

The National Institute of Mental Health has recognized concern regarding cases in which children who do not suffer from ADHD, but whose disruptive behavior prompted by other conditions or causes may be classified as impulsive or inattentive, are medicated unnecessarily. Expressing similar concerns are some physicians and educators who question describing ADHD as a disease or disability and who urge increased focus on the talents and skills of these children. Prompting much of this debate are escalating Ritalin prescriptions. Differing attitudes toward medications, insurance coverage, physician preferences, and other factors are generally viewed as contributing to the range of prescribing frequencies.

Abuse of Ritalin remains a national concern. While there is little hard data regarding specific Ritalin-related crimes, anecdotal information reveals incidences of abuse, theft, and diversion by dispensing school officials, sales among students, and threats against students on the medication to sell their pills. A September 2001 report of the U.S. General Accounting Office indicated that there are no data directly indicating either the degree of drug diversion or abuse in American public schools or the effect of state laws and regulations guiding schools in the administration of these medications. Concluding that the diversion of attention deficit disorder medications is not "a major problem at middle or high schools," the report noted that the development of non-stimulant medications and increased use of once-a-day attention deficit disorder medications may ameliorate the possibility of abuse or diversion in schools.

Dispensing of student medications during school hours also warranted committee consideration. The Code of Virginia does not prohibit student possession and administration of their own prescription medications at school. School board policies have typically governed possession and administration of student medications; this is not, however, clearly delineated in statute. School boards may prohibit student possession of their own prescription medications, and anecdotal evidence suggests that many do.

Virginia ranks in the highest quartile in the nation for Ritalin prescription; within the Commonwealth, higher concentrations are seen in Tidewater, Richmond, and Northern Virginia. In response to a Virginia Department of Education survey conducted in September 2001, 129 school divisions (95.5 percent response rate), indicated that 16,521 students--or 1.52 percent of the student population--received ADHD medication at school in 2000-2001. Of these students, 55 percent receive Ritalin; 45 percent are receiving other ADHD medication. These numbers are not indicative of the numbers of public school children with ADHD, as some children may not receiving medication or may be taking medication at home. The highest rates were noted in grades four and five; the lowest in kindergarten and in grade 12. Boys comprised 76 percent of students receiving ADHD medication at school; students with disabilities accounted for 59 percent of pupils receiving ADHD medication at school. The survey found no significant statistical differences among racial/ethnic groups receiving ADHD medication at school.

OXYCONTIN USE AND DIVERSION

In addition to exploring Ritalin abuse, the resolution also directs the joint subcommittee to examine the abuse and diversion of OxyContin in the Commonwealth. Abuse of OxyContin may be facilitated in part by its potency, effectiveness, and available dosages. According to the Virginia State Police, OxyContin diversion is primarily achieved through "doctor shopping" and physician over-prescribing. In addition, instances of importing from Mexico or Canada, forged or altered prescriptions, and travel to neighboring North Carolina or from West Virginia and Kentucky to Virginia to obtain prescriptions have been reported.

The Attorney General's Task Force on Prescription Drug Abuse is also examining the rising problem of abuse of OxyContin in Southwest Virginia. Comprised of doctors, health care consumers, a pain management specialist, pharmacists and pharmaceutical companies, rehabilitation experts, and state and local law-enforcement officials, the task force is expected to issue its report in fall 2001.

A plan released in May 2001 by Purdue Pharma, the manufacturer of OxyContin, and the DEA targets the dissemination of educational brochures to physicians and pharmacists; the distribution of tamper-resistant prescription pads; and support for a study of "best practices in state prescription monitoring programs" with the goal of developing a national model. In addition, Purdue Pharma is working with the Virginia Attorney General to co-sponsor continuing medical education regarding OxyContin abuse for physicians in southwest Virginia.

Increased diagnoses of anxiety, depression, and ADHD among college students may potentially bring more antidepressants and other medications to campuses, with greater opportunities for nonmedical use. While Ritalin and OxyContin abuse do not appear to be a problem at Virginia institutions of higher education, continued drug education and appropriate interventions are necessary to reduce high-risk behaviors. The Virginia State Police reported that while Ritalin and OxyContin abuse remain problematic among school- and college-aged students in Virginia, these drugs are more often diverted and abused by other age groups. Campus police at three Virginia universities have reported no campus arrests involving either of these drugs.

CONCLUSIONS AND RECOMMENDATIONS

The joint subcommittee makes the following recommendations:

Recommendation 1: That § 22.1-279.3:1 of the Code of Virginia be amended to require reporting of theft of student prescription medications from students during school hours, on school property, or at school-sponsored activities, or from school storage.

Recommendation 2: That reimbursement for pediatric specialists at pediatric medical centers through Medicaid and FAMIS be increased.

Recommendation 3: That the Joint Subcommittee endorse the efforts of the Attorney General's Task Force on Prescription Drug Abuse regarding the implementation of an appropriate prescription monitoring system for the Commonwealth.

Recommendation 4: That the Special Advisory Commission on Mandated Health Insurance Benefits examine and encourage continuing education of third party payers regarding adequate reimbursement for behavioral evaluations and ADHD and study the feasibility and appropriateness of expanding reimbursement for child evaluations to address an appropriate range of mental health services, including comprehensive assessment by clinical psychologists, without tying such reimbursement to a specific, final diagnosis.

Recommendation 5: That the Department of Health, in collaboration with the Departments of Education, Health Professions, and Mental Health, Mental Retardation, and Substance Abuse Services, with the assistance of researchers with public health and education expertise, conduct a statewide epidemiological study examining the prevalence of methylphenidate use and ADHD diagnoses in the Commonwealth; that such study incorporate, among other things, consideration of (i) contributing factors to any such prevalences; (it) any relevant nutritional and educational issues; and (iii) the identification of age-appropriate behaviors by education and health professionals; and that such study include the input of psychologists, physicians, and other health professionals.

Recommendation 6: That the governing bodies of the Commonwealth's public and private institutions of higher education support increased student prescription drug abuse prevention and education programs on their respective campuses.