Attention deficit hyperactivity disorder (ADHD) is a complex, chronic neurodevelopmental condition that affects more than 6.1 million (9.4%) children and adolescents between the ages of 2 and 17 years.1 Among adults aged 18 to 44 years, prevalence rates are just over 4% with lifetime prevalence in this age group at 8%.2

Prescription stimulant medications – such as amphetamine, methylphenidate, and lisdexamfetamine –are commonly prescribed, along with behavioral therapy, as first-line treatment for ADHD.3 According to the 2016 National Survey of Children’s Health (NSCH), 62% of children (ages 2 to 17) diagnosed with ADHD were taking prescription medications.3

While clinical studies have established the effectiveness of prescription stimulant medications for ADHD in children and adults, these drugs also have the potential for misuse and abuse. Nonmedical use of stimulants has been growing in recent years. Of those 12 years and older, 1.6 million reported misuse of prescription stimulants in the year prior, according to the latest 2019 National Survey on Drug Use and Health (NSDUH).4

Herein, Psycom Pro takes a closer look at some of the factors involved with the misuse of prescription stimulants and what steps clinicians can take to mitigate risk when prescribing as part of an ADHD treatment plan.

Challenges with Defining Misuse of ADHD Stimulants: The Terminology Gap

The evolving nature and lack of consensus regarding the terminology used to define “misuse,” “abuse,” and “nonmedical use” of prescription medications complicate our understanding of the scope of the problem and interpretation of research and data. This terminology gap also leads to difficulties for clinicians making initial assessments and managing ongoing patient care related to substance use disorders (SUDs). In addition, policy and regulation around prescribed stimulants – coupled with public health messaging – is weak due to lack of a standardized classification of terminology.5

Editor’s Note on Terminology: For the puposes of this article, we use the term “misuse” as advocated in recent years by regulatory bodies to describe the nonmedical use of prescription drugs. The National Institute on Drug Abuse (NIDA) points out that the term “misuse” – that is, consumption outside prescribed parameters – should be used instead of “abuse” when talking about prescribed drugs due to negative associations with the word  “abuse.” When talking about illicit drugs, the term is simply “use.” NIDA also uses “misuse” and “nonmedical use” interchangeably as we do herein. SAMHSA differentiates the terms as well, utilizing “misuse” for prescription drugs and “abuse” for illicit drugs. Thus, in the DSM, what was previously called “substance abuse” is now called “substance use disorder.”

How to Ask Patients about Nonmedical Use of ADHD Medications

Psycom Pro spoke to Frances R. Levin, MD, a Kennedy-Leavy Professor of Psychiatry at Columbia University, about how behavioral and mental health clinicians can best proceed in this context. Specifically, when treating ADHD, if there is confirmed nonmedical use of prescribed medication, Dr. Levin suggests the following:

  • Ask the patient how and why they are using the medication in a nonprescribed fashion. For instance, are they using for recreational purposes or because the dose seems inadequate to manage ADHD symptoms?
  • Explore the context of the nonmedical use: Is it an ongoing problem or momentary/stress-related?
  • Ensure that the prescribed medication is helping the patient by utilizing structured assessments.

 Understanding the reasons for a patient’s nonmedical use of a prescribed drug can guide clinical decision-making on tweaking the treatment plan and help reduce future misuse.

Reasons Behind ADHD Stimulant Misuse in College Students and Adults

Broad misperceptions among consumers (including some patients) regarding the overall benefits of prescription stimulant medications as “smart drugs” – along with greater availability – have led to a rise in nonmedical use of stimulants in recent years. The prevalence of prescription stimulant misuse among college students, in particular, has continued to grow, reaching 17% in 2016.6 Primary rationales among college students for nonmedical use includes mental and academic performance enhancement.6  Yet, studies show again and again that people without ADHD do not benefit from nonmedical use of stimulant medications for working memory, scholastic achievement, or cognitive ability.6,7

Reasons for nonmedical use vary depending on age, access to substances, gender, and other factors but data shows that misuse is higher in the 18-to 25-year age group.8 According to NSDUH’s 2015 national survey, primary reasons for the misuse of prescription stimulants among adults 18 years or older was to:

  • increase alertness or stay awake (28.4%)
  • assist with focus (26.%)
  • aid studying (22.4%).

Less common reasons included experimentation (5.2 %), weight loss (4.3%), and other reasons.9 Since the COVID-19 pandemic began, institutions like CHADD and psychiatrists have seen an uptick in demand for ADHD diagnoses as potential ADHD symptoms may appear more pronounced to parents and caregivers.

According to Sidarth Wakhlu, MD, a distinguished professor of psychiatry at UT Southwestern Medical Center and an associate director of the Addiction Division in the Department of Psychiatry, approved ADHD medications have low abuse potential when used appropriately, and have documented benefits for those diagnosed with the disorder. “Nonmedical use of prescription stimulant medications is often with people who do not have ADHD,” he says, adding,  “There are challenges around screening and accurate diagnosis that can allow misuse to occur. Accurate assessments are crucial to avoid misuse in those without ADHD who are seeking medications.”

He also emphasized that “It’s important for pediatricians and family practitioners to refer patients to mental health professionals for accurate assessment and treatment of ADHD. And before prescribing, clinicians should get the full clinical picture for a comprehensive evaluation, including school and caregiver assessments, detailed patient history, and the existence of any comorbidities.”

ADHD Stimulant Misuse Complicated by Psychostimulants and Polysubstance Overdose

While substantial recent focus has been on opioid misuse and overdose in the United States, according to National Center for Health Statistics data from 2012-2019, there was a six-fold increase in overdose deaths involving psychostimulants (eg, cocaine, methamphetamine, prescription stimulants); notably, pointed out Dr. Levin, many of these overdoses had concomitant high potency opioids present as well.10

In recent years, overdose deaths attributed to polysubstance misuse (eg, opioids and stimulants) have been rising sharply as well.10 Stimulant overdose carries added danger as there are currently no overdose reversal medications available for stimulant overdose, unlike with opioid overdose where administration of naloxone has the potential to save lives.

A study by Wilens and colleagues found that misuse of prescription stimulant medications varies among children and adolescents with rates between 5% and 9% among high school and younger grades and rates of misuse among college students ranging from 5% to as high as 35%. The researchers also reported that diversion of prescribed stimulants ranged from 16% to 29% among individuals with legitimate stimulant prescriptions who were invited to exchange, sell or give away their medications for nonmedical use.11

 A NIDA Monitoring the Future survey revealed in 2017 that an estimated 6% of 12th graders reported nonmedical use of the prescription stimulant Adderall in the year prior.8 (See also, a research review of stimulant abuse among children and adolescents.)

Emergency room overdose data from 2016 to 2019 found suspected psychostimulant overdoses (cocaine, amphetamines, and other psychostimulants) rose in every age group.12 Specifically, the study by Roehler and colleagues found a:

  • 3% increase among 0- to 10-year-olds
  • 4% increase among 11- to 14-year-olds
  • 3% increase among 15- to 24-year-olds

These are concerning trends and should be weighed alongside the benefits of stimulant medications by clinicians as part of a balanced approach to ADHD treatment on an individualized basis.

Comorbid ADHD and Substance Use Disorder

Research indicates that there are intricate links between ADHD and SUD. Co-occurring ADHD and substance use disorders present added challenges for clinical practices regarding diagnosis (due to similarities in cognitive and behavioral manifestations of ADHD and SUD related to dopamine deficiencies), treatment, and even selection choice for prescription stimulant medications (eg, immediate release, long-acting, non-stimulant).13

 Misuse of prescription stimulants can also increase a person’s risks of broader substance misuse and harm. A 2021 published study by Vosburg et al found that misuse of oral prescription stimulants led to the use of other illicit – and non-oral – substances (eg, heroin, cocaine, methamphetamine).14

 According to the NSDUH 2018 National Survey, around 561,000 individuals 12 years and older were classified as having a prescription stimulant use disorder (a type of SUD according to the DSM-5) in the year prior.15 Data suggests about 23% of people with SUD have co-existing adult ADHD.15 For this reason, clinicians may be hesitant to prescribe stimulant medications such as methylphenidate (a commonly used medication for ADHD) to individuals with comorbid SUD and ADHD stemming from fear of potential misuse or diversion.16,17 Studies indicate that long-acting medications have a lower potential for misuse and diversion than immediate-release medications.17

 In addition, to reduce risks of nonmedical use and diversion, clinical assessments of patients with SUD should routinely include screening and assessment for ADHD.18 According to Dr. Levin, “Most addiction treatment programs do not assess for ADHD. Careful assessment is crucial. Addressing existing ADHD symptoms may improve addiction treatment retention and even enhance treatment success. Recognizing the existence of ADHD among patients with SUD should be an important part of addiction treatment.”

ADHD Treatment Risks and Mitigation Strategies: How to Proceed with Stimulant Prescribing

Prescription stimulants have proven to be effective in the treatment of ADHD and may reduce the prevalence of substance misuse.18 However, given the rise in misuse and diversion of these products, it’s imperative for clinicians to assess the significance and patterns of nonmedical use to lower risk and improve treatment outcomes for ADHD.

When prescribing stimulants, clinicians should develop strategies to quantify risk and implement mitigation measures at the outset to ensure positive treatment outcomes. Dr. Wakhlu recommends the following risk mitigation plan when prescribing ADHD stimulants:

  • Develop a comprehensive evaluation plan for ADHD diagnosis (use multiple sources of data such as parents, teachers, others for an accurate diagnosis) along with evidence-based screening tools.
  • Obtain a urine drug screen as part of your comprehensive evaluation.
  • Screen for misuse and substance use disorder (Screening and Assessment Tools Chart) for adolescents and adults.
  • When developing and implementing the individualized treatment plan, the benefits and risks of stimulant medications should be discussed with the patient (and any caregivers).
  • Monitor potential misuse throughout treatment (diagnostic urine drug screens, communication with patient).
  • Implement an early intervention plan such as this one from SAMHSA if misuse is suspected or discovered.

Dr. Levin suggests checking your state’s PDMP for concurrent prescription medication use (opioids, sedatives, other) as well. She notes that “It’s important to determine if there are other existing ailments that might increase risk with prescription stimulant use (eg, heart, anxiety, mental health disorders). In addition, provide tips on safeguarding medications, safe disposal, and not advertising to others that stimulant medications are being prescribed to avoid diversion.”

Dr. Wakhlu adds that it is not necessary to always stop treatment for ADHD with prescription stimulants if misuse is discovered. It’s more important to explore why misuse is occurring and address it.

He offers these additional suggestions:

  • Be sure to take an accurate history of SUD (what substances) and/or misuse at the initial visit, going back 5 years.
  • Set guidelines for the treatment plan (including patient agreements if deemed necessary) with the patient, including urine drug screens and what misuse of prescribed medications will mean for treatment.
  • Start slowly with medication doses and monitor more frequently if needed.
  • Engage in open dialogue with patients (and caregivers) that is non-judgmental (eg, consider tone, language, empathy) and encourage open-ended discussions regarding misuse.
  • If misuse is discovered during treatment, find out the cause (one time or ongoing). Adapt treatment strategy based on individual patient factors.
  • Refer patients with active SUD to an addiction treatment expert/clinic when needed. ADHD treatment can start or continue post SUD treatment based on individual cases.

Professional Takeaways

Overall, nonmedical use of prescription stimulants continues to be a problem across all patient age groups. There are also knowledge gaps regarding evidence-based best practice treatment options for patients with comorbid ADHD and SUD, complicating assessments and treatment of both disorders.

In light of this, it is imperative to increase public education regarding misconceptions of ADHD stimulants being “smart drugs” and the negative health consequences of nonmedical use of stimulants, and the risks associated with overdose as a prevention strategy. In addition, the development and use of standard terminology for misuse/nonmedical use/abuse are necessary to better understand the scope of the issue for future research, data collection, and clinical interventions.

Resources for Clinicians

 

References
Last Updated: May 7, 2021