The increasing use of prescription stimulants to treat attention-deficit/hyperactivity disorder (ADHD) has led to mounting concern surrounding the use of controlled pharmacotherapies, including the challenge of reducing the nonmedical use of these medicines. Current psychiatric residents and fellows have a unique perspective on this issue as a result of its prominence in the field throughout our educational experience and by virtue of direct exposure as part of the generation in which ADHD diagnoses increased significantly.1,2 Many residents have used prescription stimulants themselves, and even more have observed their use by family and friends, and more recently, their patients. We have seen the benefits that often result from these treatments and we have also seen examples of their nonmedical use.
So why is nonmedical use of prescription stimulants of concern? Our current understanding about the abuse potential of methylphenidate, amphetamine, dextroamphetamine, and pemoline is that, when used orally at standard prescribed doses, the abuse liability is minimal. Only when taken intranasally or injected intravenously in its crushed form, or used in excess of the standard dose for extended periods of time, is there a problem.
This is only partly true. One problem relates to unintended use of prescription stimulant medication. In patients with ADHD, the core symptoms being treated are developmentally inappropriate levels of inattention, impulsivity and hyperactivity, which stimulants help mitigate.3–5 People intent on nonmedical use of central nervous system stimulants seek to capitalize on the psychoactive effects as well but often hope to exploit this class of medications for its side effects, including decreased need for sleep, appetite suppression, improved alertness and concentration, and augmentation of the effects of alcohol or other drugs. In truth, most of us wish for these effects at some point, especially those related to enhanced performance.
In school, I occasionally heard about peers using methylphenidate or amphetamines to facilitate late-night study sessions, then again to help them wake up after a long night of cramming. These were not people with known ADHD diagnoses, and yet they seemed to have easy access to prescription stimulants. I remember experiencing feelings of curiosity about what beneficial effects I might attain from their use, as well as some envy regarding their seemingly ready availability to others. However, a combination of stoicism and fear of reproach prevailed, and I did not pursue the temptation.
During internship, there were occasional jokes of how beneficial it might be to get through the long hours of call days, but it seemed that stimulant use was less acceptable. I somewhat suspected that nonmedical use was occurring, but people were less likely to admit to the use.
Now, among residents and fellows when the topic has come up, a small number in any given group admit to having tried prescription stimulants, primarily amphetamines or methylphenidate, in the context of curiosity about what their patients are taking, and they report only oral use of standard doses. This is not to imply that increased misuse occurs among physicians; that is not my sense. These are simply the experiences I have to draw from.
The appeal of having more energy, being more alert and more productive, losing weight, and for some even escaping reality periodically is undeniable for many of us. This is especially true in a society that appears to value hard-driving, sharp-thinking, thin people who “know how to party!” However, in the attempt to realize some of the desired qualities associated with nonmedical use, higher and higher doses of stimulant may be required as differential tolerance develops to the effects, placing individuals at risk of dependence. Other problems include the various medical, psychosocial, and psychiatric sequelae that emerge with abuse and dependence of stimulants.
So what is the scope of the problem? While tracking stimulant abuse has proved difficult, it does not appear to be as widespread as abuse of other drugs,6 although there is some evidence for increased abuse within particular subgroups.7 Some researchers agree that nonmedical abuse of prescription stimulants is increasing,8–10 although there appears to be a differential based on chemical formulation. Data suggest methylphenidate abuse is decreasing and amphetamine abuse is increasing.11 However, more recent data show a decreasing trend in the abuse of stimulants overall.6 The greatest incidence of prescription stimulant abuse appears to be among adolescents and young adults, although it is increasingly found in pre-adolescents and older adults.
Who are the people who seek out prescription stimulants for nonmedical use? In my short clinical experience, I've seen the college high-achiever who is driven to perfection, the medical school student who wants to do better, the athlete hoping to enhance performance, the college freshman wanting to lose weight, the “free-spirit” high school student who just likes the way it makes her feel, the law student who felt it was the only way he could tackle the volume of case law studies required, and the drug addict who will use it in lieu of cocaine or methamphetamine when necessary. Thus far, I've seen more purposeful use than recreational use, and most use in college students.
Finally, how is prescription stimulant medication obtained for non-medical use? It comes largely from peers for a fee or by barter, often by stealing from family members, and increasingly by feigning ADHD symptoms in overburdened clinics.12 One of the most readily available sources of prescription stimulants is the Internet. After choosing from the myriad sites advertising your desired stimulant, you need only register by filling in some basic information, and then you are prompted through the process. This may or may not require a “medical consultation,” depending on the source of drug. The consultation entails simply filling out a form or questionnaire, with the most pertinent questions being about past medical history, especially cardiac risk factors and possibly a cursory query about substance abuse history. There is no physical exam; you need only affirm you are in good health or have had a recent physical exam. Of course, there is a fee for this, and the costs of medications are generally two to four times the cost of those at your local pharmacy.
How do we deal with these problems? The most proximal strategy for physicians is increased diagnostic accuracy of disorders. This should result in less diversion of stimulant medication, since empiric evidence suggests that patients with bona fide ADHD are less likely to part with their stimulants because of recognized benefit. Additionally, alternate methods of regulating provision of medication may be considered.
However, in requiring increased stringency for medication dispensing, we run the risk of jeopardizing care to those individuals not abusing their prescription due to logistical constraints imposed. This is especially a concern in a system already overburdened because of a shortage of adult and child psychiatrists. In addition, nonspecialists, who now provide the bulk of psychiatric care, may be reluctant to continue to prescribe stimulants if prescribing this class of medication becomes more burdensome through an increase in documentation and oversight.
Given the relative ease of obtaining prescription stimulants for misuse, what can be done to control nonmedical use of this class of drugs? At minimum, physicians must be aware of specific risk factors for nonmedical use when deciding on a particular pharmacotherapy to treat ADHD. Just as we make thoughtful decisions about other classes of medications, often prescribing an alternate drug for a patient because of side effects, tolerability, and cost or dosing schedules, it is important to be mindful of individual needs, risk factors and past medical history in deciding on a therapeutic regimen to treat ADHD in each patient. For patients in which there is a concern for drug abuse, this may mean choosing a less easily abused methylphenidate formulation13–15 over other forms or amphetamines, or even moving to nonstimulant medications with even less abuse potential.
Now that I am in the position to write prescriptions, and frequently do so for this class of medications, I find myself wondering about other ways physicians might increase appropriate prescribing practices while discouraging misappropriation of medication by our patients. A critical intervention is to strive for accurate diagnoses. This can be difficult in the absence of objective diagnostic tests but is fundamental to the task. At minimum, we should be administering validated screening tests to patients and obtaining school and family corroboration where applicable.
Once the diagnosis has been made and the decision is to treat with stimulants, the physician must educate patients and families. Informed consent of patients should include discussing patient and family responsibilities with regard to medications, including assisting in ways to monitor and dispense stimulants when prescribed. We must allow adequate time, over several sessions if needed to educate patients and family members about the risks and benefits of this class of medicines. This should include making patients aware of the legal ramifications of selling or giving away any of one's personal supply, keeping in mind that physicians are not officers of law enforcement and do not want to become so. Recommendations for school and home administration must be discussed in the context of the patient's developmental level, family constraints and risk of abuse. And then medication efficacy and adherence must be closely monitored.
Next, as physicians our level of awareness must be heightened with regard to the prevalence of nonmedical use of prescription medications in general. There is no specialty or subspecialty of medicine in which substance abuse or medicine misuse is not encountered. Because of this, it is incumbent on us to recognize adverse effects of medications and to remain abreast of the latest clinical data in the substance abuse field, even if you hear yourself saying, “I don't treat substance abusers,” because you do. At the very least, we would do well to include stimulant misuse when screening patients for risk factors and practice broadening our differential diagnoses of patients presenting with psychosis, excess weight loss, anxiety, and depression, for example, especially when dealing with adolescents and young adults.
Unfortunately, general methods for detecting stimulants have limited clinical utility and are fraught with problems in interpreting the results. The standard urine toxicology screen often is not standardized to include the same component assays, requiring clinicians to investigate what is actually being tested in their respective laboratories. It may or may not include testing for stimulants, and if so, often only amphetamine is assayed, and not methylphenidate unless specifically requested. Specialized testing can be requested, but this requires knowledge of what you are looking for in advance and can be expensive when not part of a general screen. In addition, these assays generally are qualitative and not quantitative, requiring a threshold level of drug or metabolite for detection. This is a problem in patients who may be using stimulants legitimately but in whom you suspect nonmedical abuse. Again, quantitative analysis can often be requested, but the absence of standardized nomograms to plot therapeutic versus toxic levels makes interpretation difficult.
Stimulants are recognized for their short action and for not staying in the body for more than a day or two, a generally sought-after quality, especially in pediatric patients. However, because of this the usefulness of urine screening is limited, and futile in patients who have not just used stimulants. Finally, there is the problem of cross-reactivity in the urine toxicology screens, in which many other medications, herbal products, and even foods “look like” stimulants due to shared chemical moieties. This last problem is decreasing due to improved specificity of assays, but remains a significant issue, especially in light of increasing sophistication of people who are intent on “beating” a urine test and ready availability of this information on the internet.
Effective interventions to minimize nonmedical use of stimulants in the future should be based on the results of the past 2 decades of prevention research which clearly demonstrate programs and strategies that work as well as those programs that were shown ineffective and a waste of precious time, money and energy. Emerging models should draw not only from the substance abuse prevention field but also from related fields of psychological theory, social learning and even marketing, whereby principles of consumer behavior can be applied to assist in deterrence of medication diversion. Finally, appropriate safeguards will need to be enacted and enforced in the case of internet prescription medication sales.
Future work in this area should include expanded research into the epidemiology of nonmedical use of stimulants, focused prevention strategies, and improved detection methods. In addition, further neuropharmacologic studies will be critical to refine our understanding of the pharmacodynamics of involved brain systems and application of drug discovery technology may hasten development of compounds with limited abuse liability. Finally, as the neural substrates underlying ADHD and reward circuitry become better defined, especially in the context of the developing brain, alternative therapies may emerge.
In conclusion, while the benefits of stimulants in appropriately diagnosed individuals with ADHD are clear, the nonmedical use of stimulant medication is a complex issue of which we must be cognizant. Thankfully, the majority of our ADHD patients take their medication with good results and without evidence of abuse. For those who do not, we might consider it an opportunity to begin a dialogue to understand the reasons for misuse.
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