As a guest expert during a radio interview, talking with children about attention deficit/hyperactivity disorder (ADHD), I heard things about the nonmedical use of prescription stimulants that surprised me. The first four teenagers calling in to the program admitted to either taking stimulant medications belonging to others, being the providers in such transactions, or knowing of others who had done so. Although as a clinician who specializes in treating adult ADHD I realized that nonmedical usage of these drugs occurs, this interview made me aware that it is not an infrequent event.
These young people confirmed for me the surveys which indicate that as many as 1 in 12 adolescents of high school and college age have used prescribed stimulants nonmedically.1,2 Most youth who use these drugs nonmedically do so only intermittently (often experimentally), and for brief periods of time. Later, however, I spoke with a group of adolescents in an outpatient 12-step substance-abuse treatment program who reported a high frequency of nonmedical use of these medicines based on their own personal drug use experiences. This confirmed a research survey demonstrating that 23% of adolescents referred for substance-abuse treatment reported having used nonprescribed stimulants (eg, methylphenidate and dextroamphetamine) non-medically, with 6% diagnosed as abusing these drugs to a significant extent.3
Intrigued by these encounters, I discussed this problem with a number of clinicians who prescribe stimulants for ADHD. Most of them were unaware of the size of the nonmedical use problem as they focused, understandably, on the profound therapeutic benefits of these medicines. At that point, I realized the important role physicians could play in helping to decrease this type of prescription misuse while continuing to focus on the benefits of these medicines.
This article is designed for clinicians who are actively involved in treating children and adults with ADHD. It is by no means designed to frighten away these physicians from appropriately treating this serious condition with these useful medications. Hundreds of studies show the great potential life impairment — educationally, socially, occupationally, and legally — resulting from not properly diagnosing and treating the disorder, as well as the safety of the appropriate use of stimulants for those who are accurately diagnosed.4,5
There are a number of things the clinician can do to aid in maximizing ADHD treatment benefits and prevention of patient misuse of stimulants (Sidebar 1). Even the most detailed attention to the potential for abuse, however, will not stop all patients from the misuse of their medications. By using these suggestions, the clinician can decrease the misuse, identify the problem of misuse when it occurs earlier, and intervene more effectively when that is appropriate.
Methods to Improve ADHD Treatment Benefits and Reduce Stimulant Misuse
- Make an accurate diagnosis of ADHD. This is important not only for appropriate treatment, but also to reduce misuse of prescribed medications.
- Describe the benefits of effective ADHD treatment to the patient and his or her caretakers.
- Choose the most appropriate medication for each patient and use the best prescribing methods. This includes the perspective that the potential for the nonmedical use of these medicines is one important factor to consider every time controlled substances are prescribed, including the stimulants used to treat ADHD.
- Educate patients, family members, and significant others about the problems of misuse of these medicines.
- Pay particular attention to those populations most likely to have misuse problems with stimulants. This is especially important for patients with substance use disorders.
Methods to Improve ADHD Treatment Benefits and Reduce Stimulant Misuse
Accurate Diagnosis of ADHD
Making a correct diagnosis of ADHD is important not only because it is good medicine but also because it may reduce diversion of prescribed stimulants. Patients with true ADHD benefit in the short-term and long-term from the appropriately prescribed and dosed drugs and are more likely to be adherent with their physicians' advice. In addition, they are less likely to have extra or untaken medication to supply to others and less willing to give up medications that are truly improving their lives.
For diagnosis, clinicians should use more than just rating scales or symptom checklists. Guidelines for making the diagnosis of ADHD are outside of the scope of this article, but they are well described elsewhere.6–9 Many patients presenting for evaluation today have access to information of the symptoms of ADHD from a variety of sources, including other patients, the Internet, and even substance abusers seeking access to prescribed stimulants. Those wishing to feign the disorder may report all the required symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.10 Therefore, symptom checklists, while useful, are not enough on their own to make the diagnosis.
Critical to accurate diagnosis is taking a detailed history from patients and significant others of not only symptoms but also life areas adversely affected by their ADHD, and the degree of impairment caused by these symptoms. The use of diagnostic questionnaires should be part of the diagnostic evaluation.8 If the diagnosis is still in doubt, psychological testing to rule out other psychiatric disorders or continuous performance tests can be used to augment the clinical history and improve diagnostic accuracy. Most important to remember is that the clinician needs to do more than simply make a checklist of symptoms diagnosis.
The clinician should inquire about coexistent medical and psychiatric disorders, and perform appropriate medical and laboratory evaluations.11,12 There also should be an inquiry regarding present and past history of any substance use disorder (SUD), recognizing that dishonesty, generously labeled denial, is a central feature of the substance abuse disorders. Failure to recognize co-existent SUD greatly increases the risk of misuse of prescribed controlled substances, including the stimulants used to treat ADHD.
A mistake commonly made by patients is to assume that simply because they can focus better after taking a stimulant, the diagnosis of ADHD is confirmed. While it is well known that ADHD has a strong genetic component,4,12 friends and even family members without ADHD may sometimes use someone else's prescribed stimulants and find that it helps them focus, think, and concentrate better.
The reality is that stimulants often help by increasing focused attention, at least initially, even for people without true ADHD. It is my experience that people without ADHD who use stimulant medicines often become tolerant to the positive effects, which can lead them to raise their dose, if they have access to the medicine. In clear contrast to this picture, in patients with ADHD, the dose of the prescribed stimulant usually remains the same over many years of ADHD treatment.
Common clinical wisdom suggests that if the patient has used stimulants nonmedically in the past, it is useful to note the effect of the medicines. That is, did it allow them just to focus better, or in addition did it make them feel up, high, or euphoric? If they felt the former without the latter, it is more likely that ADHD is the correct diagnosis. If they emphasize the feeling of being high, they are more likely to suffer from SUD.
Choosing and Prescribing Medication
Clinicians must be cautious to use the most appropriate medication for the patients but also not to let fear of non-medical use cloud their judgment. Once the appropriate diagnosis is made, the clinician should educate the patient about the role of the medication in treatment, including what to expect, the potential side effects, and the fact that the dose and timing of the medications must be individualized for each patient. Although some ADHD experts believe that the stimulants are the most appropriate first-line drugs,11,13 other choices are now available, including the nonstimulant atomoxetine, which is approved by the Food and Drug Administration (FDA) to treat ADHD. Other nonstimulant options, while not FDA approved for ADHD treatment, have been shown to be effective treatment for ADHD in some controlled clinical trials.14 These include antidepressants such as bupropion, desipramine, or venlafaxine.
All of these alternatives to the stimulants have little, if any, abuse potential. For this reason, they are not controlled substances. This may make them better first-line choices for patients with ADHD who have active alcohol or other drug use problems, in the same way that active SUD makes buspirone or a selective serotonin reuptake inhibitor [SSRI] the first-line choice to treat anxiety disorders in addiction-prone patients, instead of a benzodiazepine.
If practical, the clinician also may choose a long-acting formula of a medication, rather than immediate-release formulations. If stimulants are prescribed for ADHD, the longer-acting medications (eg, XR, LA, CD) may have less attraction and value for non-medical use than the immediate-release product.12 This may be one factor making long-acting preparations the better option, although for most patients with ADHD, the smoother and longer lasting coverage is the most important reason to make this choice.
When it comes to abuse, however, there is a caveat that relates to the experience with oxycodone, a longer-acting synthetic opiate that was initially thought to have a lower abuse potential. The problem that emerged was that simply crushing or chewing the tablet easily overcame the long-acting feature. Thus, although the long-acting feature reduces abuse in theory, some long-acting formulation stimulants are more abuse resistant than others. (For a more detailed discussion of these issues, see Dr. DuPont's article, page 253.)
Another important consideration is the fine-tuning of dosing of all medications, including prescription stimulants. If stimulants are prescribed, the dose should be carefully adjusted for the individual patient. Unlike with other medications, body weight is not the best way to estimate the most appropriate dose.12 Prescribing less than the optimum dose of a stimulant for ADHD can result in only partial improvement in symptoms, while prescribing more than the optimum dose may produce dysphoria or other unpleasant side effects. The result of either under- or over-dosing can mean that the medication is taken less frequently than prescribed or not at all, making it more likely that the patient will have extra medication for possible gift or sale to others. With appropriately dosed medication, the patient usually realizes the benefit and does not wish to lose efficacy by taking less than the prescribed dose.
Common clinical experience has shown that even if patients respond fully to the ADHD medications, they sometimes will discontinue the medication early in treatment with the explanation that they thought they could do well without the medicine. In many cases after that early discontinuation episode, patients with ADHD who have an appropriately fine-tuned dosing become believers in the value of the medication. After an unpleasant experience with self-directed discontinuation, my patients often have reported better adherence with their medication regimen.
For the proper treatment of ADHD, regularly scheduled follow-up visits are appropriate. For patients using prescription stimulants, follow-up visits are mandatory. A recent study by Gardner15 of children treated for ADHD showed few scheduled follow-up sessions. He recommends follow-up sessions occur at least every 3 to 6 months in patients stable on their treatment regimen. Patients taking stimulants should be checked for side effects, blood pressure, weight and height (if children), and sleep history. Patients also should be monitored for the effectiveness of the treatments.
Children and adolescents who sold their prescribed medicines have told me that they discontinued taking their medications due to side effects such as feeling jittery, wired, or nervous. Often, these side effects were due to excessive dosing, titrating dosing too rapidly, or an inappropriate choice of medication for that particular patient. Careful and repeated inquiry about side effects or problems with the way the medication makes patients feel are an important part of follow-up visits. Actions should be taken in response to the side effects. This can make the difference between adherence and treatment rejection. Failure to deal with side effects and concerns of patients or their family members can result in decreased patient adherence.
The clinician should work with the patient to set goals of treatment early and regularly follow up on progress in achieving them. Rating scales administered during follow-up visits can be useful to quantify improvement in patients' most troubling symptoms of ADHD. At least as important, however, is inquiry about improvement in life functions as a result of ongoing ADHD treatment. The principal goal of ADHD treatment is not simply to improve symptoms but, more important, to improve the major areas of functioning that have been most severely affected. My experience has been that significantly improved patients are more likely to be adherent patients.
Educating About Nonmedical Use of Stimulants
Part of the clinician's role is to educate patients, families, and even the general public about the need to diagnose and treat ADHD. In addition, physicians should provide information about the dangers from potential misuse of prescribed stimulant treatment medications. These include problems with giving or selling medications or taking someone else's medication. Such effects may include:
- Medical problems (eg, cardiovascular effects, insomnia);
- Psychiatric problems (eg, psychosis, precipitation or worsening of other disorders);
- Potential promotion of, or worsening of, substance abuse (SUD); and
- Legal problems.
A survey of young people treated with prescribed stimulants in Wisconsin revealed that 1 in 5 had been approached by other children to give or sell their medication.1 Many students mistakenly believe that because they were prescribed and take the medications, those medications cannot cause any trouble for anyone else. It is useful to remind these patients that they have been psychiatrically and medically evaluated before the medication was prescribed, and that they are being monitored routinely and carefully by their physicians.
Patients and families should be reminded that it is illegal to sell or even give away these medications to others, and that it is illegal for others to possess or use them without a prescription. Potential misuse by family members, including parents, should also be directly discussed. This means taking family history of SUD and reminding both patient and family that prescribed stimulants are controlled substances precisely because people prone to addiction can abuse them. It is unwise to take the medicines for reasons other than the reasons for which they were prescribed. It is also unwise and dangerous to take them in ways and at doses not compatible with the prescribing physician's recommendations. It is potentially risky for these medicines to be used by people other than the person for whom the medicine is prescribed. All too often, patients and family members have a casual attitude toward the prescribed medicine that invites nonmedical use. These are serious medicines used to treat a serious disorder. They are remarkably safe and effective when taken as prescribed but can be dangerous when used outside of medical guidelines.
It is useful to remind patients of these misuse issues on both initial and follow-up visits, while at the same time trying to avoid frightening appropriate patients from personally taking them.
Treating Patients with SUD
Patients with ADHD are more likely to have comorbid SUD than similar people without ADHD. Early concerns were that the appropriate medical use of stimulant medications in children with ADHD predisposed them to abuse drugs, especially stimulant drugs such as cocaine and methamphetamine, as they got older. Several recent studies have challenged this myth and confirmed that appropriate treatment of children with ADHD leads to a significant decrease in the likelihood of later development of SUD.15–17
There is, however, a substantial group of patients who are comorbid for SUD and ADHD. Treatment of this population must include particular concern for treating the underlying ADHD without aggravating or reactivating the SUD. In this regard, for patients with SUD as well as ADHD it is often wise to use a medication with lower abuse potential (eg, atomoxetine, bupropion, desipramine, venlafaxine).
Clinicians treating ADHD need to screen for current and past SUD not only in the patient but also in family members. At a minimum, it is desirable to ask the patient and any family members involved in the patient's care about use of alcohol and other drugs and about a history of addiction treatment. While nonmedical drug use is unlikely in pre-teen patients, the abuse of alcohol and other drugs is common in both adolescents and adults with ADHD. If there is doubt in the physician's mind about drug use, it is often valuable to order a drug test before prescribing stimulants for ADHD.
If a clinician makes the decision that a stimulant is the best drug to use for an ADHD patient with a history of comorbid SUD, he or she should use special care to reduce the potential for nonmedical us of these medicines. Patients with SUD should be in stable recovery and in an ongoing recovery program before they are prescribed any controlled substance, including a stimulant. It is helpful to discuss the risks of this approach by talking openly and directly with family members (with the patient present) about the risks involved. Including the patient's 12-step program sponsor in these discussions is helpful as well.18,19
As a general rule, it is not desirable to prescribe a controlled substance, including a stimulant to treat ADHD, to a patient with active SUD, due to the risk of starting the patient into a relapse of the SUD. There is ongoing research into whether some patients with comorbid SUD and ADHD, with careful follow-up monitoring, might benefit from stimulants.20 However, the existence of active SUD does not disqualify the patient with ADHD from treatment. In fact the opposite is the case; these patients deserve more attention and care because of their comorbid SUD.
In some cases, the existence of SUD may emerge during the treatment for ADHD. It is important for the physician to help the patient and the patient's family find and use an effective drug abuse treatment. Addicted patients do not need rejection; they need help to get clean and stay clean. The prescribing physician is in a good position to help promote the lifelong process of recovery.
Clinicians should further note that college is a high-risk environment for drug use in general and for the nonmedical use of prescribed stimulants in particular. Special caution is appropriate in prescribing for this population.
Research has shown that effective treatment of ADHD increased the length of sobriety in those with comorbid substance abuse and did not aggravate the SUD.19,20 However, it is my experience as an addictionist that in patients with a history of prior amphetamine or cocaine abuse, although the prescribed stimulants may help the ADHD, a small possibility does exist that the stimulant medication might adversely affect sobriety. The family and significant others can be an important support system fostering sobriety. They can make the patient and the physician aware of concerns that relapse may be imminent or even presently occurring.
Patients with a history of SUD are helped by having a written contract with their prescribing physicians that addresses issues that are in the best interest of continued sobriety (Dodson W, personal communication, 2004) (Sidebar 2, see page 224). In addition, when stimulants are prescribed, the physician should keep careful watch over refills, paying particular attention to lost prescriptions and early refill requests.
Treatment Contract Provisions for Patients With Comorbid ADHD and SUD
- Maintain ongoing active treatment of SUD.
- Attend 12- step meetings with active involvement of a sponsor.
- Undergo active observation by significant others along with input from them to the prescribing physician to monitor the patient's response to treatment and possible relapse to alcohol or drug use.
- Undergo required, unannounced urine drug screens by physician.
- If in psychotherapy, maintain ongoing collaboration between the prescribing physician and the psychotherapist.
ADHD = attention-deficit/hyperactivity disorder; SUD = substance use disorder.
Dodson W, personal communication, 2004.
Good medical practices can significantly reduce the possibility of diversion and misuse of the stimulants commonly prescribed to treat ADHD. While the problems of misuse and abuse are real, they should not become a barrier to appropriate use of these medicines, which are safe and effective for the large majority of ADHD patients using them. With appropriate care, physicians treating patients with ADHD can be confident that their treatments are safe, not only for the patients they treat but also for the communities in which they live.
- Musser CJ, Ahmann PA, Theye FW, et al. Stimulant use and the potential for abuse in Wisconsin as reported by school administrators and longitudinally followed children. J Dev Behav Pediatr. 1998;19(3):187–192. doi:10.1097/00004703-199806000-00006 [CrossRef]9648044
- Lou KG, Gendaszek AE. Illicit use of psychostimulants among college students: a preliminary study. Psychol Health Med. 2002; 7(3):283–387. doi:10.1080/13548500220139386 [CrossRef]
- Williams RJ, Goodale LA, Shay-Fiddler MA, Gloster SP, Chang SY. Methylphenidate and dextroamphetamine abuse in substance-abusing adolescents. Am J Addict. 2004;13(4): 381–389. doi:10.1080/10550490490483053 [CrossRef]15370936
- Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279(14):1100–1107. doi:10.1001/jama.279.14.1100 [CrossRef]9546570
- Biederman J, Spencer TJ. Pharmacology of adults with attention-deficit/hyperactivity disorder. Primary Psychiatry. 2004;11(7):57–62.
- Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics. 2000; 105(5):1158–1170. doi:10.1542/peds.105.5.1158 [CrossRef]10836893
- Farone SV, Biederman J, Spencer T, et al. Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry. 2000; 48(1):9–20. doi:10.1016/S0006-3223(00)00889-1 [CrossRef]
- Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004; 27(2):187–201. doi:10.1016/j.psc.2003.12.003 [CrossRef]15063992
- Spencer TJ, Adler L. Diagnostic approach to adult attention-deficit/hyperactivity disorder. Primary Psychiatry. 2004;11(7):49–53.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.
- Dodson WW. Practical Daily Techniques for Treating Adult ADHD. MedLearning Inc. [monograph]. April2004.
- Wilens TE, Dodson W. A clinical perspective of attention-deficit/hyperactivity disorder into adulthood. J Clin Psychiatry. 2004;65(10): 1301–1313 doi:10.4088/JCP.v65n1003 [CrossRef]15491232
- Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):85S–121S. doi:10.1097/00004583-199710001-00007 [CrossRef]9334567
- Gardner W, Kelleher KJ, Pajer K, Campo JV. Follow-up care of children identified with ADHD by primary care clinicians: a prospective cohort study. J Pediatr. 2004;145(6): 767–771. doi:10.1016/j.jpeds.2004.08.028 [CrossRef]15580198
- Biederman J. Pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) decreases the risk for substance abuse: findings from a longitudinal follow-up of youths with and without ADHD. J Clin Psychiatry. 2003;64Suppl 11:3–8.14529323
- Wilens TE. Attention-deficit/hyperactivity disorder and the substance use disorder: the nature of the relationship, who is at risk, and treatment issues. Primary Psychiatry. 2004; 11(7):63–69.
- Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. 2003;111(1): 179–185. doi:10.1542/peds.111.1.179 [CrossRef]12509574
- A summary of recent presentations on attention-deficit/hyperactivity disorder. Current ADHD insights. Veritas Institute. 2004.
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- Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult attention-deficit/hyperactivity disorder: a pilot study. J Clin Psychiatry. 1998;59(6):300–305. doi:10.4088/JCP.v59n0605 [CrossRef]9671342