The most frequently used medicines in the treatment of attention-deficit/hyperactivity disorder (ADHD) are prescription stimulants listed in Schedule II of the Controlled Substances Act. The increasing use of medicines to treat psychiatric indications, including ADHD, has re-ignited long-smoldering controversies over the use of medicines versus the use of drug-free approaches to mental and behavioral problems ranging from psychotherapy and education to willpower and greater social tolerance of deviant behavior.
During the past decade, there has been a significant increase in the use of prescription medicines for an increasing number of indications. Participating fully in this trend has been the use of medicines to treat psychiatric disorders and the widespread use of narcotic analgesics to treat outpatients for the first time in a century. These developments have sparked a wide range of controversies, including concerns about increases in the costs of healthcare, errors in prescribing, and adverse reactions to the medicines. Concerns about prescription drug abuse have made the problem a high priority of the 2004 National Drug Control Strategy1 and the central issue of a major new policy statement by the Center for Substance Abuse Treatment.2
Although we refer to some of the more global concerns about prescription drug abuse in this issue of Psychiatric Annals, our focus is primarily on the nonmedical use of prescription stimulants. Nonmedical use of a prescribed medicine is use by someone who does not have a prescription for the medicine, or use of the prescribed medicine by someone who does have a prescription in a manner that is not directed or approved by the prescribing physician. Although the problem of non-medical use often is referred to in the broader ADHD literature, there has been a paucity of evidence about the trends, character, consequences and possible solutions to the problem. It is that deficiency that we address here. Our principal conclusion is that the careful study of the problem of nonmedical use of prescription stimulants offers hope for an innovative approach to preventing the nonmedical use of a wide range of controlled substances through the development of abuse-resistant formulations.
In This Issue
Our articles begin appropriately with “The Science of Stimulant Abuse,” a focus on the biology of stimulant abuse in the broader context of the new understanding of the biology of addiction. Dr. Larry Greenhill summarizes this knowledge as it relates to the prescription stimulants and offers us new data showing that not all stimulants and stimulant formulations are equal pharmacologically in terms of their potential for nonmedical use.
Dr. Harry Croft, a clinician with deep experience in the treatment of both ADHD and drug abuse, sensitively explores “Physician Handling of Prescription Stimulants.” This area of prevention is often overlooked. As Dr. Croft emphasizes, prescribing physicians have many useful roles to play in the prevention of nonmedical use of these medicines.
Students of the nonmedical use of prescription stimulants have concluded that college campuses are Ground Zero. In “Nonmedical Use of Prescription Stimulants Among Students,” Drs. Eric Wish and Amelia Arria review the data on stimulant misuse on a large college campus and in the wider community. These data underline two fundamental points: first, that there is wide variability in the rates of abuse among the various prescription stimulants and formulations used to treat ADHD and, second, that most non-medical use of prescription stimulants on campus is for the purposes of studying rather than partying.
The newest and least understood source of controlled substances, for both licit and illicit purposes, is the Internet. This is true for prescription stimulants, as discussed in “Prescription Stimulant Sales on the Internet,” by Bonnie B. Wilford, Dr. David E. Smith, and Dr. Richard Bucher. They document the large, evolving and as yet poorly understood potential of the Internet to bypass our carefully constructed closed drug distribution system, which dates from 1970 and is over-seen jointly by the Food and Drug Administration and the Drug Enforcement Administration.
“Abuse-resistant Drug Delivery” is the topic of my article with Peter B. Bensinger. We highlight the finding that one of the stimulant formulations widely prescribed to treat ADHD appears to have significantly lower abuse potential than the others. We also point out that the reason for this reduced abuse potential — a relatively abuse-resistant drug delivery system — may have wide applicability to other controlled substances.
The federal government has assumed a leadership role in the prevention of prescription drug abuse, making it one of the nation's highest priorities for drug abuse prevention. Dr. H. Westley Clark, in his role as director of the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, is a key player in this effort. For our issue, he has teamed with Dr. Anton C. Bizzell to explain “A Federal Perspective on the Abuse of Prescription Stimulants.”
The issue closes with Dr. Kathy A. Gallardo's valuable perspective of residents and fellows on the non-medical use of prescription stimulants. Young psychiatrists have grown up in the era when ADHD has been widely treated. This experience gives them a unique perspective on the problems of the nonmedical use of stimulants and the possible solutions to these problems.
Our goal with this issue of Psychiatric Annals is to increase understanding among clinicians about both the problems with and the solutions to nonmedical use of prescription stimulants. We encourage, not discourage, the treatment of ADHD with both medications and nonmedication therapies. By significantly reducing the nonmedical use of the stimulant medicines for ADHD, we expect that this important area of medical practice will be protected for the benefit of ADHD patients. The lessons learned here can have broad positive applications to other medical treatments with controlled substances.