Over The Limit?

Linleigh Hawk starts the day at 5:30 a.m. by downing her first cup of coffee. She then stops at Starbucks for a grande vanilla skim latte on the way to Winston Churchill High School in Potomac, Md., where she's a senior. At 3 p.m., it's time for a jumbo iced tea to power her through hip-hop dance rehearsals and yearbook meetings. Homework, which often keeps her up past 1 a.m., requires more coffee. "I've got so much to do," she says. "I've got to have the caffeine." The java-fired schedule has paid off, says Hawk: She's been accepted by 15 of her 16 college choices, including first pick Wake Forest.

Hawk may sound like an anomaly, but she isn't. Overworked and sleep- deprived Americans young and old so crave a buzz these days that even alcoholic drinks come loaded with caffeine, and doctors are getting worried. In the past three years alone, the number of 18-to-24-year-olds who drink coffee daily has doubled, from 16 percent to 31 percent-and some of them go on to pop prescription stimulants such as Adderall or Ritalin for late-night study sessions. Energy drinks like Red Bull and Cocaine, with several times the buzz of a can of Coke, have mushroomed into a $3.5 billion-a-year industry.

"I can't go out and keep up with these 20-year-olds without it," says Jeremy Freer, a 29-year-old music teacher from Virginia Beach, Va., of his Saturday-night beverage of choice: vodka with Red Bull. (Partyers can opt instead for the new double espresso-double caffeinated Van Gogh vodka or a Bud Extra, a caffeinated beer.)

Wired. Health experts understand all too well why Americans gotta get wired. People of all ages are chronically sleep deprived, from teens who catch the bus before sunrise to working mothers who report they spend less than six hours a night in bed, according to a poll released in March by the National Sleep Foundation. But we may be pushing the limits of self-medication. Poison control centers and emergency room doctors report increasing numbers of people suffering from the rapid heartbeat and nausea of a caffeine overdose-like the 14-year-old boy who earlier this year showed up at a Minneapolis emergency room in respiratory distress after washing down caffeine pills with energy drinks so he could play video games all night. Instead, he spent the night in the pediatric intensive care unit, intubated, until the caffeine exited his system. They're also seeing more teens and young adults in distress after having bought or "borrowed" stimulant drugs from friends.

And, in the extreme, there are tragedies like that of James Stone, a 19-year-old from Wallingford, Conn., who died last November of cardiac arrest after taking nearly two dozen caffeine pills. His parents say he had been putting in long hours on a job search.

Doctors are particularly troubled to see youngsters forming the caffeine habit, even as toddlers. Children's consumption of soft drinks has doubled in the past 35 years, with sodas supplanting milk. A 2003 study of Columbus, Ohio, middle schoolers found some taking in 800 milligrams of caffeine a day-more than twice the recommended maximum for adults of 300 milligrams. "Their body weight is low," says Wahida Karmally, director of nutrition for the Irving Center for Clinical Research at Columbia University Medical Center. "They can't tolerate as much caffeine as adults."

Since scientists have never studied how caffeine affects growing bodies and brains, children who go through the day guzzling soda after iced tea after energy drink are serving as tiny guinea pigs. "This is something that nobody is looking at carefully," says Nora Volkow, a psychiatrist who directs the National Institute on Drug Abuse. "We really have no idea how it affects development long term."

The appeal to kids of high-octane energy drinks has some officials concerned enough to act. Just last week, the Food and Drug Administration announced it had sent a warning letter to the maufacturer of Cocaine Energy Drink, Redux Beverages LLC of Las Vegas, for marketing the beverage "as an alternative to an illicit street drug." Until last week, the manufacturer's website boasted "Cocaine-instant rush." Hyping the performance enhancements caffeine offers at the time you're introducing the drug to children "is a terrible message. It has implications for drug use in the future," says Roland Griffiths, a professor of behavioral biology at Johns Hopkins University Medical Center who has studied caffeine's effects for more than 30 years.

And last month, Doherty High School in Colorado Springs, Colo., banned a drink called Spike Shooter. Two students were taken to the hospital complaining of nausea, vomiting, and heart palpitations after drinking an 8-ounce can, which packs 300 mg of caffeine-the same as almost four Red Bulls.

For adults, and in reasonable doses-the equivalent of three 8-ounce cups of coffee, six Excedrin Migraine, or a half-dozen 12-ounce colas a day-caffeine has much to recommend it. As the world's most popular habit-forming drug, it fights fatigue, brightens mood, and eases pain while it's forestalling sleep. Test subjects dosed with the amount found in a cup of coffee come out ahead on problem-solving tasks. And by triggering the release of adrenaline to help muscles work harder and longer, caffeine so clearly enhances athletic performance that until 2004 it was considered a controlled substance by the International Olympic Committee. Supercaffeinated energy drinks like Redline RTD are marketed to bodybuilders.

Elixir of life. The latest findings on coffee suggest that it even staves off disease. Caffeine reduces the risk of Parkinson's disease, for example, by blocking receptors for adenosine, a neurotransmitter that plays a role in motor function. It is now being tested as a Parkinson's treatment. Caffeine also heads off migraines by contracting blood vessels in the brain.

And probably because coffee, like blueberries and broccoli, contains potent antioxidants, it appears to reduce the risk of colon cancer, gallstones, and liver cancer, among other illnesses. In 2005, Harvard researchers found that drinking six cups of coffee or more daily cut the risk of getting type 2 diabetes by half in men and 30 percent in women. One study of 80,000 women showed that those who drank more than two or three cups of coffee daily reduced their risk of suicide over 10 years by a third.

Alas, that glorious rush of energy isn't entirely benign. Numerous studies have found no link between caffeine and cardiovascular disease. But it can cause anxiety, jitters, and heart palpitations, particularly in people who are sensitive to it. It also can cause stomach pain and gastrointestinal reflux, may make it harder for a woman to get pregnant, and may increase the risk of miscarriage or a low-birth-weight baby. Doctors advise pregnant women to give up caffeine, or keep consumption down to a cup or two of coffee daily.

Sleeplessness, not surprisingly, is a notorious side effect of caffeine. In recent years, as the number of people taking prescription sleeping pills has soared, more than a few doctors have wondered if people should reconsider their use of caffeine before downing an Ambien or Lunesta. According to Medco Health Solutions of Franklin Lakes, N.J., use of such medications by adults ages 20 to 44 increased 114 percent from 2000 to 2005.

In kids, lack of sleep is both a worrisome cause and effect of the caffeine craze. Wilkie Wilson, a professor of pharmacology at Duke University Medical Center and coauthor of Buzzed, a guide to commonly used drugs, says he's stunned by how little sleep kids get these days. Teenagers, he says, need at least nine hours of sleep a night; grade schoolers, 10 to 12 hours. Very few get close to that much-either, as in Linleigh Hawk's case, because they're actively fighting sleep, or because they're so jazzed fom caffeine that they can't settle down at bedtime. The downside: "I'm exhausted. I can't remember simple things," Hawk says. But she gets the work done.

Indeed, lack of sleep interferes with concentration, says William Kohler, medical director of the Florida Sleep Institute in Spring Hill. It also can make kids fidgety. Since inattention and restlessness are signs of attention deficit hyperactivity disorder as well, sleep researchers increasingly believe that some kids diagnosed with ADHD are actually sleep deprived.

The caffeine itself makes kids fidgety, too, of course. Just ask Maya Thompson, a Sacramento, Calif., mother. "It's like two totally different extremes," she says of how much more aggressive her son Jordan, 12, becomes with even a sip of a caffeinated drink. Jordan, for his part, says that lots of kids in his sixth-grade class pull Monster or Rock Star energy drinks out of their backpacks and drink them before PE class. "Oh my gosh!" says Maya, 30. "I'm shocked by that-that is crazy!"

The young adult crowd who favor caffeine with their alcohol appear to be putting themselves at some risk, too. The stimulant does mitigate the effects of alcohol by improving response time, according to Mark Fillmore, a psychologist at the University of Kentucky who has been testing the combination on student volunteers. But it fails to reduce the number of errors that a person under the influence makes. "Caffeine seems to restore the speed of your behavior but not the accuracy," Fillmore says.

Until the advent of caffeine pills and highly caffeinated energy drinks, caffeine overdoses were exceedingly rare, because people became anxious, shaky, and nauseated before they could imbibe enough. Now, people are sometimes shocked to find out how few servings equal too much. "I'm a strong, 47-year-old man, and I tell you what, that stuff put me on my knees," says Scott Silliman, a construction worker from Citrus Heights, Calif., who recently grabbed two cans of Redline RTD energy drink at 7-Eleven when he picked up lunch for the crew.

Silliman pounded down the drinks, then ate a burrito. Twenty minutes later, "I was sweating, I was shaking, I was freezing cold. I never felt anything like that in my life." Silliman thought he was having a heart attack. Actually, he had drunk 500 mg of caffeine in a few minutes, the equivalent of five cups of coffee. "The government should put some kind of regulations on this, or at least warning labels."

Consumer watchdog groups think so, too. The government puts caffeine in its category of "generally recognized as safe" and so doesn't require food and drink manufacturers to list caffeine content. For more than a decade, the American Medical Association and the Center for Science in the Public Interest have been lobbying the Food and Drug Administration to require caffeine content labels, as well as the words "not appropriate for children." Meantime, soft drink manufacturers, seeing growing concern in Congress and among local politicians about children's access to energy drinks, announced in February that they'll now list caffeine content on drinks. The Coca-Cola Co. has already relabeled Full Throttle energy drink (141 mg per 16 ounces) and its new Enviga sparkling green tea (100 mg in 12 ounces); classic Coke will reveal its 34 milligrams in May. PepsiCo will have caffeine content on Pepsi and other drinks this summer.

Even as they're upping their dosage of caffeine, many high schoolers and college students are seeking a stronger boost than it can give. Prescription stimulants such as Ritalin, Concerta, and Adderall, widely prescribed to treat the inattention of ADHD, have become a source of alertness and energy for studying, and for late-night parties. About 3 percent of college students say they've used prescription stimulants illegally, according to a March 2007 study by the National Center on Addiction and Substance Abuse at Columbia University. Thnumber is small compared with students' use of alcohol, marijuana, and tobacco, but stimulant abuse is increasing faster, almost doubling between 1993 and 2005, according to Susan Foster, vice president and director of policy research and analysis.

The drugs are "universal performance enhancers," says Lawrence Diller, a pediatrician in Walnut Creek, Calif., and author of The Last Normal Child. He thinks doctors, including himself, overprescribe drugs for mild ADHD. About 1.5 million adults and 2.5 million children-some 10 percent of all 10-year-old boys-now have prescriptions.

That means just about everybody under age 20 knows someone with a potential source of Adderall or Ritalin. (Most nonmedical users prefer Adderall to the slower-acting Ritalin.) On college campuses, prices rise as exams approach, from $7 to $15 for a 10-mg pill.

Marshall Dines, 23, a senior at the University of Michigan, even had strangers E-mailing him to sell them medicine after he joined a Facebook group about Adderall. (He refused and later left the group.)

Prescription stimulants can be big trouble when used to excess; that's been apparent since World War II, when both Axis and Allies gave troops amphetamines like Dexedrine to keep them alert on the front lines and many soldiers came home addicted (Adolf Hitler was reportedly a fan). More recently, stimulants have been popular with truck drivers and dieters. In 1971, the federal government added amphetamines (Adderall and other brands) and methylphenidates (Ritalin, Concerta, and other brands) to its Schedule II list of controlled substances-drugs with legitimate medical uses that also have a high potential for abuse. Stimulants account for just 1 percent of drug-related emergency room visits. But the number of people showing up with symptoms like confusion and convulsions after nonmedical use rose 33 percent from 2004 to 2005, according to a Substance Abuse and Mental Health Services Administration survey. Visits due to Ritalin and other methylphenidates more than doubled.

All stimulant medications work by increasing the amount of dopamine in the brain, a neurotransmitter that's a major player in the pleasure response to food, say, or sex. Cocaine and methamphetamine, a powerful (and illegal) cousin of the amphetamine in Adderall, create sharp upward spikes in dopamine, causing an intensely pleasurable rush. The equally quick crash, and the memory of the euphoric high, are powerful spurs to addiction. Prescription amphetamines raise dopamine levels slowly and lose their effect gradually. Thus, they're less likely to prompt a high and crash and be addictive.

But the reality is that people can become addicted to prescription stimulants, and repeated overuse can lead to hostility, paranoia, confusion, hallucinations, psychotic episodes, depression, and seizures. "There's an optimal level of dopamine in your brain," says NIDA's Volkow, who studies how drugs of abuse remodel the brain. Go beyond that level, and the brain, in effect, gets stuck.

These days, the impetus on campus is often less the urge for a high than the desire to get more done. "I saw no point in sleeping," says Derek Simeone, now 22, who was prescribed stimulant medication while in high school-and took it more often as a freshman at Syracuse University. "Adderall allows me to do more with my life in a certain amount of time." Beyond studying, the medication helped him stay up and play video games, party, and hang out. He finally cut back after a week without sleep left him hot, pale, and sweaty, and he eventually gave up Adderall altogether. Now a programmer in New Jersey, Simeone relies on coffee.

Heart risks. Stimulant drugs also increase the chance of heart attacks and strokes, a risk that's well documented in abuse of drugs like cocaine and methamphetamine. In February 2006, after studies revealed 25 cases of fatal strokes or heart attacks in childre and adults taking stimulant medication for ADHD, the FDA ordered manufacturers to put warnings on all prescription stimulants, including Ritalin, Adderall, and Concerta. Those complications are rare. But Steven Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic, thinks the agency should go further, particularly since so many people are taking stimulants to treat only mild symptoms of ADHD.

"Can it possibly be that 10 percent of all the sixth-grade boys in America have a disease that requires amphetamines?" Nissen asks. "I'm unwilling to accept that that's an appropriate use of a psychotropic agent, particularly one that has well-known cardiovascular risks." He also worries about the rapidly increasing use of ADHD drugs by adults. "Ten percent of them are over age 55," Nissen says. "That's a potential disaster."

The popularity of stimulants on campus has not escaped the notice of university health officials. Although they are far more concerned about the dangers of binge drinking-a much more widespread problem-schools are becoming considerably more cautious about handing out stimulant medications. Two years ago, Indiana University initiated a screening process for students claiming to need stimulants that includes standardized tests, evaluation of a student's records as far back as elementary school, and a survey sent to parents, according to Hugh Jessop, director of the IU Health Center. Of the 283 students who scheduled appointments to get medication at Indiana in the past couple years, only 47 completed the process. The University of Wisconsin no longer even fills prescriptions from family doctors back home.

The lure of prescription stimulants may well fade, as it has in decades past, when the ugly effects of abuse and addiction become clear. (Hippies in the late 1960s graffitied the walls of San Francisco's Haight-Ashbury district with "Speed kills," a testament to the fact that overuse was no summer of love.) But the $4 minivacation from the stresses of daily life appears to be a destination with real staying power. "Coffee culture" has become so much a part of American culture that 36-year-old Starbucks, once considered a gourmet's treat, now boasts 9,401 stores nationwide and has focused growth on economically struggling neighborhoods far from the yuppified precincts of its early success.

Even McDonald's hawks a premium blend; Dunkin' Donuts sells lattes. "It's like a miniature splurge," says Tracy Allen, vice president for Zoka Coffee Roaster and Tea Co. in Seattle, which markets a barista-brewed cup of organic Ethiopian Yirgacheffe as if it were a fine wine. "The coffee shop is the 21st-century version of the 1950s malt shop," says Joseph DeRupo, director of communications for the National Coffee Association. "It's where kids go to meet friends and socialize."

What's next? Richard Holschen, a police officer in Kaktovik, Alaska, couldn't tote around coffee in the subzero temperatures above the Arctic Circle, so he invented caffeinated SpazzStick lip balm. "I needed to stay awake if I was on duty three days straight," Holschen, 34, says. "Caffeine and lip balm were a logical conclusion for me." Internet sales have been brisk, he says.

Robert Bohannon's phone started ringing off the hook in January, when the Durham, N.C.-based inventor announced that he'd perfected a recipe for caffeinated doughnuts and bagels. "I feel completely overwhelmed," he says. He hasn't yet produced the pastry on a commercial scale but plans to license his invention this year.


By Nancy Shute, with Justin Ewers, Alison Go, David LaGesse and Adam Voiland
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