Opioid epidemic: What it looks like, what it means, & what to do

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What do you know about opioid abuse and addiction? Take our quiz to see how your knowledge compares to other students’, and find answers to questions like these:

  • Is it risky to take prescription pain meds?
  • Who’s at risk for addiction?
  • How rare is opioid abuse among college students?
  • Does opioid overdose reversal always work?

The US is experiencing a brutal opioid epidemic. In 2015, 33,000 Americans died from overdoses involving prescription painkillers, heroin, and synthetic opioids, according to the National Institutes of Health. Many opioid overdoses can be reversed with timely medical treatment, however—someday, you may be in a position to save a life. This brief guide shows you how.

The illicit use of heroin and prescription painkillers is rare among college students. Yet this epidemic is affecting demographics that were previously considered relatively immune to drug crises. “My freshman year of college, my older sister went to rehab for heroin addiction. People from all ethnicities and social classes are struggling with opioid addiction,” says a third-year undergraduate at Saint Louis University, Missouri.

In this article, “opioid” covers heroin, prescription painkillers, and synthetic opioids sold on the street. For info on getting help with abuse and addiction, see Get help or find out more.

What to do if someone may have overdosed: Call 911 immediately

  • Act quickly: Most deaths occur one to three hours after the overdose, so you have a window for intervention.
  • Get medical help: When people survive an overdose, it is because professional help was available. You do not need to be sure the person has overdosed on opioids (or any other substance) before calling 911. Calling 911 usually ensures quicker medical help than taking the victim to the hospital yourself.
  • Tell the 911 dispatcher: Let them know if the person’s breathing has slowed or stopped and if they are unresponsive. Give the dispatcher the exact location.
  • Be aware of Good Samaritan laws: In most states, people who seek help with a suspected overdose are immune from drug-related criminal charges under Good Samaritan laws (also known as 911 Immunity Laws). Your college may have similar policies (sometimes called medical amnesty). For information about your state, see Get help or find out more.

What does an opioid overdose look like?

Upset cartoon man

» The signs of opioid overdose include:

  • Small pupils
  • Droopy arms and legs, and the inability to stand or walk
  • Itching
  • Slurred speech
  • Shallow and uneven breathing
  • Being unresponsive
  • Loss of consciousness

» As the window for intervening narrows, signs include:

  • Pale face
  • Blue lips
  • Gurgling chest sounds

Could I be at risk for opioid abuse?

Opioid addiction is difficult to treat. Avoiding illicit drug use is the safest strategy. Here’s how to look out for yourself:

  • If you are using a prescription opioid medication that was not prescribed to you, seek help.
  • If you are using an opioid medication prescribed to you, be self-aware about your reasons: Opioid medications are prescribed for long-term pain associated with various medical issues or for short-term pain control after surgery or an injury. If you are using opioids for other reasons—e.g., to get high or buzzed—seek help.
  • If you are using opioids for pain relief, and your pain is becoming more difficult to control, discuss that with your physician immediately.
  • If you have a family history of drug abuse/addiction and need medication for short-term pain, consider asking your physician for a pain medication other than opioids. Having a family history of drug abuse/addiction puts you at a higher risk for abuse/addiction.
  • If you are abusing opioids or may be addicted, you will need support with your recovery. See Get help or find out more (below).

Where can I get help with opioid abuse or addiction?

  • Ask your physician or other health care provider for a referral to an addiction specialist.
  • If you have health insurance, check the insurance company website for addiction specialists covered by your plan.
  • Ask at your student health center, counseling center, place of worship, or community center about addiction assistance.
  • Call your local hospital for help finding medical professionals with addiction expertise.
  • Look at community directories or online for a specialist in your area: Make sure the person is licensed or certified in mental or behavioral health, or is a licensed counselor in social work or professional counseling.
  • Try Narcotics Anonymous for local, free, anonymous support groups.
  • Many detox centers offer free initial consultations.
  • For more key info and resources, see Get help or find out more (below).

What are the options for accessing reversal treatment?

Many opioid overdoses can be reversed with treatment. The opioid reversal medications naloxone and naltrexone can be delivered via a nasal spray, by injection, or intravenously. These reversal drugs (or antidotes) are also known by various brand names (e.g., Narcan®).

Naloxone treatment can be accessed in several ways:

  • At hospital emergency rooms
  • Via police departments and paramedics (ambulance responders), after calling 911
  • Via some fire departments
  • In most states, via some trained laypeople (not medical professionals) who may have a history of opioid abuse or family members who are abusing opioids
  • Some states allow pharmacies to dispense naloxone to people meeting certain criteria without a physician’s direct involvement (this is often reported as over-the-counter availability, although that term is technically incorrect)

What exactly does “unresponsive” mean?

Here’s what being unresponsive looks like, according to the Harm Reduction Coalition:

  • Not answering to their name
  • Not responding to information they may not want to hear (e.g., “I’m going to call 911”)
  • Not responding to physical stimulation (e.g., rubbing your knuckles into their sternum, the place in the middle of their chest where the ribs meet, or pinching their earlobes)
  • If the person wakes up but their breathing seems shallow or their chest feels tight, call 911 anyway

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Ask a pharmacologist: Can I take something to boost my brain?

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Assignments accumulating? Exams coming up? Halfway through this semester, you may be wondering how you’ll make it all happen. As a pharmacologist on a large campus, I routinely talk to students about how they grapple with this, and hear their conversations about strategies for success. Maybe your oversize coffee goes everywhere you go. Perhaps your friend bought some funky herbal product that claims to help with mental performance. Maybe your roommate hit up their ADHD classmate for a dose of Ritalin.

It’s possible that certain products may help you stay alert, think straight, and meet a deadline. Trying these substances may or may not work out as planned. Sometimes students tell me that they wanted to be more alert and took something that instead gave them a tremor, dry mouth, and insomnia. What went wrong? Did they waste their money? Could they have harmed their health? Good questions. If you consider using anything—even large amounts of caffeine—you need to know how that substance may affect you and how to manage or minimize the risks.

Using substances to enhance your focus or brainpower:

No drug makes you smarter
No medication, treatment, herbal product, street drug, or other substance has been shown to improve intelligence or enhance cognition in people with healthy brains.

ADHD medications don’t provide an intellectual advantage
Drugs prescribed for students with attention or learning issues help level the playing field, addressing the factors that could hold those students back. They may temporarily improve alertness. They do not boost intelligence or grades.

Energy drinks are no more effective than coffee
Energy and related products derive their “oomph” from the added caffeine (and, in many products, lots of added sugar).

Most herbal supplements offer little or no benefit
These products are not regulated and may be misleadingly labeled. The “natural” claim is often dubious, and products labeled this way can be risky. As a rule, I see the “non-drug” label that is required by law (a statement that the product has not been evaluated by the FDA and is not intended to treat a disease) as an admission that the product carries little, if any, benefit.

If you choose to use: Four things you need to know

1  Using any substance means accepting some risk

All drug use carries some risk. This is true whether the substance is legal or illegal, whether it is prescribed or available over-the-counter, and whether it is socially acceptable or socially stigmatized. When medical providers recommend a course of treatment, they consider your state of health and balance the possible risks of the drug against its possible benefits. If you self-medicate, you may not be aware of those risks or adequately factor them in.

Drugs are classified (“scheduled”) by the government according to how accepted they are for medical use and how liable they are to being abused. This scheduling is based on historical problems with drugs; it can be changed depending on new evidence. Scheduling does not fully inform users about the risks of a substance.

For example, acetaminophen (the active ingredient in Tylenol and some other over-the-counter pain relief medications) is unscheduled and “low-risk,” yet it kills hundreds of people every year, owing to liver failure.

Why drugs are classified differently:

  • Some drugs have no accepted medical use and high abuse potential (e.g., heroin, LSD, ecstasy, and “bath salts,” a synthetic stimulant).
  • Some drugs have accepted medical uses and low abuse potential (e.g., cough syrups that contain codeine).
  • Some drugs have accepted medical uses and high abuse potential (e.g., buprenorphine, an analgesic).

2  It’s on you to know exactly what the substance is and whether it can potentially generate the effect you want
Ever known someone to take a drug and then wonder why it did the opposite of what they desired, or it produced icky side effects? Maybe they took the wrong dose or were given the wrong drug. Maybe this was not the right drug for that user’s individual biology (even though it seemed to work for their friend). Or maybe the drug wasn’t even designed to improve alertness—which would be like taking Valium for pain (Valium has no pain-relieving properties). Even well-intentioned friends are unlikely to be reliable sources of info.

1.  What exactly is this drug or substance? “The risks are greater if you don’t know what exactly this is, who made it, did they make it well, and so on,” says Steve Lux, a former senior health educator at Northern Illinois University. Don’t count on your friends for the correct information. People without relevant professional qualifications tend to be vague about brand names versus generic names, drug classifications, and what drugs actually do. As a pharmacologist on campus, I hear students saying “narcotic” when they mean “sedative,” or “Tylenol” for any over-the-counter pain treatment.

2.  What is the active ingredient in this drug or substance? Some people misuse “fixed dose” products; these are combination drugs containing one or more medications. The chances are that one of the two is a drug you don’t want or need. It’s important to read all drug labels carefully, check the active ingredients, and make sure you’re not doubling up. For example, it’s possible to accidentally overdose on acetaminophen by using Nyquil for its sleep-inducing properties. It’s the diphenhydramine that makes people drowsy, but that comes with a sizable dose of acetaminophen, which can harm the liver.

3.  What effect could this drug or substance have on me? A drug may be right for a specific problem, but wrong for you. “Do not rely on what your friends or acquaintances are saying. Everybody is different and has different reactions; these are very hard to predict,” says Lux. Even health care providers make mistakes, in spite of their many years of training.

How your body and mind respond to a substance is largely determined by your genes. Being sick, or using any other substances, can also change the way a drug works for you (or doesn’t). For example, a sleep aid may be masked by the use of other substances, such as caffeine or stimulants, and actually make you restless. This is why some drugs are available only by prescription; in untrained hands, the risks may multiply.

3  It’s on you to be careful about dosing

It is not true that if a little bit of a drug is good, more must be better. That’s a dangerous approach to any medication.

1.  The dose makes the poison For example, 20 micrograms of fentanyl, a potent analgesic, can relieve pain. But as little as 2 milligrams of the same drug (an amount equal to two grains of sugar!) can be fatal, especially for someone who may be trying it for the first time and has no tolerance. When there isn’t much wiggle room between a therapeutic and a toxic dose, there’s a high risk of overdosing. Other examples include blood-thinning drugs, such as warfarin (also used as rat poison), and heart rhythm medications.

2.  Appropriate dosing depends on several factors The right dose of any substance also depends on your health, age, and genetics. The same dose of the same substance may be ineffective, therapeutic, or toxic to different people.

3.  Even the right dose can have side effects Even appropriate doses of prescribed medications can have negative effects. Talking with your medical provider about how you’re feeling on a drug is important; that’s how you and your provider monitor whether or not it’s the right treatment and dose for you.

4  It’s on you to anticipate any negative effects on your functioning and figure out how to manage and minimize those

Using drugs or substances can affect how you feel and function in the next few days. “There is no free lunch. You can steal from Peter to pay Paul only so far,” says Steve Lux, a former health educator at Northern Illinois University. “Using stimulants might help you stay up and get the paper done, but you’ll be depleted the next day.”

You can anticipate those effects. “If you’re going to burn through the nights during your exams, make sure that for one to two weeks beforehand, you are getting good sleep, eating well, and taking care of yourself,” Lux says.

Note: No amount of rest or self-care can mitigate the side effects of drugs.

Considering using any of these?

What they do, how they work, and what you need to know

  • Main takeaway Caffeine in the form of coffee, tea, soda, an over-the-counter tablet, a brewed yerba mate drink, or an energy drink is safe and effective for millions of people, and its use is usually socially acceptable. High doses of caffeinated products can have side effects.
  • Effectiveness Caffeine can enhance focus, increase stamina, and decrease the effort required to do physical work.
  • How this works Caffeine promotes release of stimulatory substances such as norepinephrine to increase energy and well-being, and it blocks a compound in the body that signals the need for sleep.
  • Possible side effects Headache, tremor, insomnia, nausea, tooth enamel erosion due to drink acidity, increased pulse and blood pressure in some people, and gastric distress; these effects depend on dose and individual tolerance, and can sometimes be controlled.
  • Need to know
    • Caffeine-containing products are relatively safe; there is mixed evidence on whether users can become dependent.
    • Although roughly 30 percent of students are reported to use energy drinks, they offer no performance benefits over and above coffee (American Journal on Addictions, 2016).
    • Consumption of several cups (coffee or yerba mate) or cans (energy drinks) of caffeinated beverages within a few hours may cause temporary side effects in some people (e.g., mild tremors, headaches, rapid heartbeat, irritability), which may discourage repeated misuse (Critical Care and Resuscitation, 2010).
    • Your own limits may be different from other people’s. Caffeinated products differ in volume, ingredients, and potency, and their effects depend partly on users’ body types. Use your judgment.
    • Additional ingredients, such as taurine and ginseng, are typically in quantities too small to provide any benefit (Nutrition Reviews, 2014). The caffeine and sugar (if included) are responsible for any perceived effects (Physician and Sportsmedicine, 2010).

Student perspectives
“Constant caffeine provides dramatic highs and lows of spiked energy. This makes a normal routine hard, as well as not feeling awake without it. It makes the day drag on longer and your body work harder because of the different demand in energy levels.”
—Fourth-year undergraduate, University of Wisconsin–Stout

“I don’t really think of drinking yerba mate as ‘using substances,’ but I suppose that’s exactly what it is. I drink yerba mate as an alternative to coffee when I need a pick-me-up.”
—Second-year undergraduate, University of Victoria, Alberta

“Everyone needs coffee or an energy drink sometimes. They aren’t healthy, but one every so often isn’t going to hurt. I suppose you could just get more sleep.”
—Third-year undergraduate, The College of New Jersey

  • Main takeaway Provigil and similar drugs used to increase wakefulness are specifically formulated for people with narcolepsy, a rare sleep disorder, or for people with shift-work sleep disorder. The side effects are relatively minimal, but obtaining these drugs without a prescription is risky.
  • Effectiveness For people without sleep disorders, these drugs seem safe; any toxic effects are transient and mild (Clinical Toxicology, 2009).
  • How they work These medications increase the activity of neurotransmitters (dopamine, serotonin, and norepinephrine) in the brain, which are stimulatory and reduce daytime sleepiness.
  • Possible side effects Headache, dizziness, anxiety, dry mouth, insomnia, nausea, diarrhea, multiple known drug-drug interactions.
  • Need to know
    • There are no real risks associated with use other than obtaining these drugs without a prescription through diversion (the illegal distribution of a prescription drug); this carries the risk of arrest, legal penalties, and college disciplinary sanctions.
    • Online purchases are not monitored by US government agencies; buyers cannot be sure the drug contains the active ingredient they seek at the correct strength, or that other unwanted or dangerous substances (“adulterants”) are not included.

Student perspectives
“I used modafinil because I work full time and go to school full time. Sometimes I have to be up for 18–24 hours and need its effects to help me last through the day.” —Undergraduate, Lord Fairfax Community College, Virginia

“I have a valid prescription for modafinil, and have never been asked to share or sell them.” —Second-year undergraduate, University of Victoria, Alberta

    • Main takeaway Nicotine is available in cigarettes (traditional tobacco and some e-cigarettes), cigars, and nicotine gum. Nicotine is the most addictive substance known and has serious (often lethal) side effects.
    • Effectiveness Nicotine can enhance focus and alertness. The dosing and the duration of this effect vary from person to person.
    • How this works Nicotine releases stimulatory neurotransmitters, such as norepinephrine. Paradoxically, at very high doses nicotine has a sedative-like effect (this dose varies, and depends on individuals’ tolerance).
    • Possible side effects Insomnia, nausea, gastric distress, craving and addiction to nicotine in an otherwise non-addicted person, increased irritability, anxiety, and a burning sensation in the mouth.
    • Need to know
      • Age restrictions apply to people seeking to purchase tobacco and/or nicotine gum in some states.
      • Tobacco (smoking and chewable) contains nicotine; this damages the DNA in our cells, and may lead to the growth of new cancerous tumors in the mouth and lungs, and activate or accelerate cancers that are already present or dormant.
      • Smoking nicotine is becoming less socially acceptable. Nicotine users may face higher health insurance premiums. Some employers will not hire smokers.

    Student perspectives
    “Positive effects: felt calmer. Negative: became addicted and needed more and more to feel the effects.” —Second-year undergraduate, Utah State University

    “I tried smoking nicotine, but didn’t do it long because I noticed it stressed me out more.” —Fourth-year undergraduate, University of West Georgia

    • Main takeaway Compounds that are sold to consumers as “smart drugs” (e.g., piracetam, aniracetam, oxiracetam) may do nothing more than generate expensive urine.
    • Effectiveness Studies confirm that these drugs offer little to zero cognitive enhancement. The FDA has declared them “unsafe” (FDA Warning Letters, 2010). False expectations about these medications may arise from misunderstandings of studies involving patients with mild cognitive decline or the early stages of dementia (e.g., Alzheimer’s disease) who experienced slight, temporary cognitive improvements. People with advanced dementia and those with normal cognition showed no benefit from these drugs (Current Pharmaceutical Design, 2002).
    • How they work These medications resemble GABA, a neurotransmitter in the brain, and stimulate fast transmission of nerve signals; they also increase oxygen and blood flow to the brain. Perhaps counterintuitively, this does not produce a meaningful effect (other than a whopping headache).
    • Possible side effects Headache, anxiety, insomnia, agitation, nervousness, hyperkinesia (involuntary jerking movements)
    • Need to know
      • These medications have not been approved by the FDA for legitimate medical uses.
      • Piracetam (previously sold online) cannot legally be sold as a dietary supplement in the US.
      • The FDA monitors the websites of vendors who sell these products and make false claims.
      • Studies have shown no cognitive benefit to the general population of using other prescription drugs designed to treat Alzheimer’s, which also have significant side effects.

    Student perspectives
    “I have taken a ‘nootropic’ in an attempt to help supplement my prescription medication for ADHD. Unfortunately, I found that nootropics actually made the ADHD more [severe] and I discontinued usage.” —Second-year graduate student, Southern Alberta Institute of Technology

    “It helps me with word availability and gives me crazy dreams.” —Fourth-year undergraduate, University of California, Los Angeles

    “I found out this helped some of my fellow students (I had a lot of respect for their knowledge) so I figured I would give it a whirl. I did not like it. I’ll stick with my mediocre knowledge and drug-free lifestyle.” —Second-year undergraduate, St. Lawrence College, Canada

  • Main takeaway Prescription medications, such as Ritalin, Adderall, and Concerta, are used to treat people diagnosed with ADHD. In people without ADHD, they act as direct stimulants, increasing wakefulness. They do not boost intellect or grades, and can have unpredictable side effects.
  • Effectiveness In people with ADHD, these medications correct neurological imbalances that diminish concentration and increase distractibility, potentially improving focus and helping people complete a task (Frontiers in Neuroscience, 2013). For those who do not have ADHD, they are simply stimulants and may actually increase distractibility.
  • How they work Certain neurotransmitters that send stimulatory signals are normally taken up into the cells; these drugs block that process, allowing more stimulatory effects.
  • Possible side effects Increased distractibility, increased pulse and blood pressure, headache, insomnia, and high risk for misuses and/or dependence.
  • Need to know
    • ADHD medications do not boost intellect; using them when ADHD is not present is associated with lower grades (Addiction, 2005).
    • Used without medical supervision, ADHD medication can have unpredictable side effects and may be more risky in combination with high doses of caffeine or other drugs (such as alcohol).
    • Obtaining these drugs without a prescription through diversion (the illegal distribution of a prescription drug) carries the risk of arrest, legal penalties, and college disciplinary sanctions.

Student perspectives
“I once took Adderall to study for the MCAT. I felt very stressed out [with] five courses, all the extracurricular activities, and studying for such a demanding exam. After the test, I stopped taking the drug. I also got a horrible score on the exam.”
—Fourth-year undergraduate, University of California, San Diego

“Adderall gave me laser-like focus and a kind of calm euphoria or feeling that things would work out. It seriously messed with my sleep, though.”
—Third-year undergraduate, Ridgewater College, Minnesota

Who’s using what in college?

Caffeine use is common among students, and sizable minorities of students have used energy drinks and other high-dose caffeinated substances, surveys show. The vast majority of students have not used prescription “study drugs” that were not prescribed for them.

GraphMost students are not misusing stimulants
In a national, anonymous survey of more than 80,000 college students, 88 percent said that in the past 12 months they had not used a prescription drug that wasn’t prescribed to them (National College Health Assessment, Spring 2016). Of the minority who had chosen to use medications that weren’t prescribed for them, stimulants were the most common (7 percent had used).

In a recent survey by SH101, here’s what students reported about their lifetime use of substances that they hoped would improve their alertness or performance:

Why some students wouldn’t use again
In each substance category in the chart below, around one in three students who had used this type of substance said they would not use it again. Most students who did not intend to use again cited concerns about how the substance(s) might affect their general well-being. Some said their use was a one-off event (e.g., to help them complete a single assignment). Some did not care for the side effects. Some were concerned about possible long-term consequences: “[Adderall] definitely increased my ability to focus, but I turned away from it because it was obviously habit forming,” said a third-year student at Ridgewater College, Minnesota.

Source: SH101 survey, October 2016, 1,000+ respondents (not representative of students nationally)

What are the legal, professional, and academic implications of misusing prescription drugs?

Open pill bottleAnyone who illegally accesses, uses, or distributes prescription drugs is violating federal law, and likely state law and your school’s code of conduct. Unauthorized possession of scheduled, non-narcotic substances (such as stimulant medications) is at minimum a misdemeanor. Possession of scheduled narcotics (such as methadone or Percocet) is more serious. You may be subject to federal and state charges and penalties, and/or college sanctions. A criminal record may limit your future employment prospects, damage your reputation, and threaten your college career and scholarships. Colleges can enact sanctions against students for crimes committed on and off campus; these can include academic probation, fines, rescinding scholarships, or expulsion.

“Doctor shopping” This means visiting multiple physicians with the goal of obtaining several prescriptions for the same or similar medications, and/or using more than one pharmacy to fill these prescriptions.

  • The laws vary by state, but you will likely be red flagged by the Drug Enforcement Administration.
  • If this happens, your name will be entered into a database and shared with all physicians and pharmacies, preventing you from obtaining and filling more than one prescription for certain medications.
  • You may end up reliant on one source for prescribing and dispensing drugs.
  • Your access to drugs you need when you need them may be reduced long-term; for example, when a “doctor shopper” is injured in a car accident, it may be harder for them to get prescribed pain relief medications.

Falsifying symptoms Pretending you have certain symptoms can get you barred from seeing some physicians.

Tampering with prescription forms Doing this with the intention to get drugs is a felony, punishable by fines and jail. It would likely result in fewer physicians and pharmacies being willing to help you in a time of real need.

Use of prescription substances without a prescription Legal penalties are based on the type of substance, when, and how you were caught (for example, whether you were possessing the drug or using it), and how much of the substance you obtained. Possession is often charged as a misdemeanor. Having large amounts of a substance implies that you intend to distribute it, resulting in heavier charges and penalties.

Giving away or selling your medication This is called “drug diversion,” and it’s a felony. Giving a drug away is considered the same as selling it for cash. People caught selling (or buying) diverted drugs may face fines or jail, and have to attend mandatory treatment for drug abuse, as these penalties vary by state.

Student perspective
“I had a friend actually go to prison for this. Even though it was a misdemeanor, he had to do six months.”
—Fourth-year student, Ashford University (online)

“Many of my (mostly guy) friends have asked me for some Ritalin, but once they discovered I was unwilling to partake in that illegal activity, they stopped asking.”
—Third-year undergraduate, Gonzaga University, Washington

Ernesto Dominguez

Third-year undergraduate, Concordia University, Oregon

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Article sources

Steve Lux, MS, former senior health educator, Northern Illinois University.

Advokat, C., & Scheithauer, M. (2013). Attention-deficit hyperactivity disorder (ADHD) stimulant medications as cognitive enhancers. Frontiers in Neuroscience, 7, 82. doi:10.3389/fnins.2013.00082

American College Health Association. (2016). National College Health Assessment Undergraduate Student Reference Group. Retrieved from https://www.acha-ncha.org/docs/NCHA-II%20SPRING%202016%20UNDERGRADUATE%20REFERENCE%20GROUP%20EXECUTIVE%20SUMMARY.pdf

Duchan, E., Patel, N. D., & Feucht, C. (2010). Energy drinks: A review of use and safety for athletes. Physician and Sportsmedicine, 38(2), 171–179. doi:10.3810/psm.2010.06.1796

Ernest, D., Chia, M., & Corallo, C. E. (2010). Profound hypokalaemia due to Nurofen Plus and Red Bull misuse. Critical Care and Resuscitation, 12(2), 109–110. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20513219

Food and Drug Administration. (2010). Warning Letters—Unlimited Nutrition. Retrieved from www.fda.gov

Gualtieri, F., Manetti, D., Romanelli, M. N., & Ghelardini, C. (2002). Design and study of piracetam-like nootropics, controversial members of the problematic class of cognition-enhancing drugs. Current Pharmaceutical Design, 8(2), 125–138.  Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11812254

Housman, J. M., Williams, R. D., Jr., & Woolsey, C. L. (2016). Impact of alcohol and alcohol mixed with energy drinks on non-medical prescription stimulant use in a nationally representative sample of 12th-grade students. American Journal on Addictions, 25(5), 378–384. doi:10.1111/ajad.12390

McCabe, S. E., Knight, J. R., Teter, C. J., & Wechsler, H. (2005). Non-medical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction, 100(1), 96–106. doi:10.1111/j.1360-0443.2005.00944.x

Mora-Rodriguez, R., & Pallares, J. G. (2014). Performance outcomes and unwanted side effects associated with energy drinks. Nutrition Reviews, 72, Suppl 1, 108–120. doi:10.1111/nure.12132

Spiller, H. A., Borys, D., Griffith, J. R., Klein-Schwartz, W., et al. (2009). Toxicity from modafinil ingestion. Clinical Toxicology, 47(2), 15–156. doi:10.1080/15563650802175595

Student Health 101 surveys, October and November 2016.