Beware of Stimulant Misuse for Clinical Reasons
Excerpted from an article in www.massmed.org written by Laurie Raymond, M.D. of Harvard Medical School
In the last 20 years, an increasing number of children, adolescents, and adults have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Multiple studies have shown prescription stimulants (both short- and longer-acting amphethamines and methylphenidate) to be the most efficacious treatment of ADHD.
A parallel rise in illicit use of these medications in all age groups has become a major public health concern. A recent systematic review of the literature from 1995 to 2006 found that the rates of non-prescribed stimulant use ranged from 5 to 9 percent in grade school and high school-age children and from 5 to 35 percent in college-age individuals. In addition, students with stimulant prescriptions who are asked/pressured to give, sell, or trade their medications have lifetime rates of diversion ranging from 16 to 29 percent.
Most recently, the Centers for Disease Control and Prevention's 2009 National Youth Risk Behavior Survey revealed that 20.2 percent of high school students had taken prescription drugs (including Oxycontin, Percocet, Vicodin, Adderall, Ritalin, or Xanax) without a doctor's prescription one or more times in their life.
Studies have shown that adults with ADHD who are prescribed stimulants as children have no increase in substance use or abuse patterns. However, adolescents and adults who start stimulant treatment for ADHD are found to engage in more polydrug abuse and nonmedical use of stimulants than those without ADHD. Furthermore, adolescents with undiagnosed ADHD have a rate of substance abuse patterns that is three to four times greater than those treated with stimulants, suggesting the possibility that they are self-medicating their ADHD symptoms.
In the face of these trends, clinicians are increasingly being asked to strike a balance between accurately diagnosing ADHD and monitoring their patients' potential misuse of prescribed stimulants, particularly if the patient started on stimulants as an adolescent or adult. Standardized assessment screening tools as well as thorough neuropsychiatric evaluation of patients are recommended for accurate diagnosis of ADHD at all ages. Another recommended practice is to educate patients who are prescribed stimulants for ADHD about the risks of abuse and dependence.
Clinicians should carefully monitor patient response to prescribed stimulants with rating scales. They should also assess any requests for increased dosages or prescriptions to rule out personal misuse or diversion to others.
For patients at risk of substance abuse and dependence, other ADHD-treatment strategies are recommended, such as non stimulant medications (e.g., bupropion or atomoxetine) or non-medication strategies, such as cognitive-behavioral therapy, coaching in organization and time management, , biofeedback, relaxation techniques, and psychotherapy
In Massachusetts, the Department of Public Health Bureau of Substance Abuse Services published a "Clinician Guide to Prevent Misuse of Opioid Analgesics and Stimulant Medications." This guide was adopted by the Massachusetts Board of Registration in Medicine in 2004 and is a useful resource for assessment tools, rating scales, and other web-based sources of information.
Due to the considerable risk for abuse and dependence associated with the short-term euphoric effects of stimulants (usually experienced when taken at higher-than-therapeutic doses, particularly in the immediate- rather than extended-release form), stimulants have been classified by the Drug Enforcement Administration as Class II controlled substances. As such, prescriptions are limited to a 30-day supply, and clinicians are required to continuously assess any patient with a stimulant prescription.
Serious legal penalties can result when patients divert their prescribed medication to others or non-patients use others' prescription stimulants. Stimulants carry a black box warning regarding their potential for abuse and dependence as well as for the risk of sudden death and adverse cardiovascular events associated with their misuse.
Multiple papers recommend that college-based health services educate their students with ADHD about the risks of personal misuse and/or diversion of prescribed stimulants. Particularly at exam times, health services clinicians should be "on the alert" for stimulant misuse in students who present with unexplained anxiety, irritability, excitability, confusion, depression, violence, as well as physical signs of tachycardia and/or increased blood pressure.
A recent study explored the difference in attitudes/beliefs between college-age illicit users of stimulants (both ADHD prescription holders and non-prescription holders) and non-illicit users. Illicit users had less concern with the ethics of misuse, greater perception of misuse as socially acceptable, and less perceived control over their behavior without the stimulant aid than non-illicit users. In addition, non-prescription holders among the illicit users had less concern about the health risks of illicit use, felt more dependent on stimulant medications, and were more likely to diagnose themselves as having ADHD.
In this same study, the two most predominant motives for illicit use (defined as excessive use as a prescription holder or any use without a prescription) were to improve concentration (28.8 percent) and to increase alertness or stay awake (23.4 percent). Frequency of other motives was much lower: to become high (6.3 percent); to control appetite (4.2 percent); to lose weight (3.6 percent); to enhance exercise (2.6 percent); to counteract effects of other drugs (2.1percent), and to experiment or enhance short-term memory (1.2 percent).
While college students who misuse stimulants may believe that the drugs increase their academic performance, at least one study has shown that methylphenidate, in particular, has its greatest benefit at lowest doses and that increased doses actually decrease academic performance. A separate study showed a negative relationship between illicit stimulant use and academic performance.