Director of Training and Education in Child and Adolescent Psychiatry, Mount Sinai St. Luke’s Hospital, New York, NY
Dr. Gaveras has disclosed that she has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
Prescription medication abuse is the among the biggest health issues facing the United States, but prescription medications have an important place in responsible medical treatment. Psychostimulants are among the most commonly prescribed of all medications for children and adolescents (Zuvekas S et al, Am J Psychiatry 2012;169(2):160–166). Widespread abuse of these drugs may be due, in part, to their being the treatment of choice for ADHD, which affects approximately 6% to 8% in children and 4% to 5% of adults (Polanczyk, G et al, Am J Psychiatry 2007;164(6):942-8).
FDA-approved stimulant treatment for ADHD includes methylphenidate (Ritalin), dextroamphetamine (Dexedrine), mixed salts of amphetamines (Adderall) and lisdexamfetamine (Vyvanse). Stimulants, in general, act to increase availability of dopamine and serve as a false substrate to the dopamine transporter, increasing dopaminergic transmission. This dopamine activity is related to the abuse potential that has led to the classification of these medications as Schedule II by the FDA. All stimulants carry a warning from the FDA regarding this risk of abuse and dependence. Most experts agree that children who are treated with stimulant medication for ADHD have neither a greater nor lesser risk for later substance abuse (Biederman J et al, Am J Psychiatry 2008;165(5):597–603).
Increasingly, older adolescents and college students are seeking stimulants, particularly amphetamines but also methylphenidate, for academic performance enhancement. There is actually not much empirical evidence that these medications are effective as neuroenhancers (Normann C et al, Eur Arch Psychiatry Clin Neurosci 2008;258(Suppl 5):110–114), although they can enhance one’s productivity. On college campuses, students report non-medical use of these substances both for academic and recreational reasons and often in combination with alcohol (Low K et al, Psychology, Health & Medicine 2002;7(3):283–287).
Literature has shown that people with and without ADHD can misuse stimulants, which they obtain from both legal sources and from diverted prescriptions (Wilens T et al, J Am Acad Child Adolesc Psychiatry 2008;47(1):21–31). There have been numerous reports of children being asked by their peers to sell or otherwise share their medication: the 2012 Monitoring the Future study reported 7.6% of 12th graders had abused Adderall in the past year, and most of these teenagers had obtained the drugs for free from a friend or relative (Johnston LD et al. Monitoring the Future national survey results on drug use, 1975-2011. Volume II: College students and adults ages 19-50. Ann Arbor: Institute for Social Research, The University of Michigan; 2012). One study noted that 16% to 29% of students with stimulant prescriptions were asked to share or sell those medications (Wilens T et al, J Am Acad Child Adolesc Psychiatry 2008;47(1):21–31).
Certain college and graduate student populations may be at higher risk for developing a stimulant abuse problem, including pharmacy and medical school students (Tuttle J et al, Acad Psychiatry 2010;34(3):220–223). Individuals report that stimulants increase their ability to organize and complete work, which, by extension, leads to better academic achievement. That said, stimulants do not appear to improve any cognitive measures directly, in those with or without ADHD (Lakhan S et al, Brain and Behavior 2012;2(5):661–677).
It can be a challenge to identify someone with a stimulant abuse problem. Public health efforts for sensitive screening tools have been met with varied success. Ideally, such a tool would be short, specific, and easy to administer. A number of screening tools exist: the Drug Abuse Screening Test (DAST) (widely available online); the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (available at http://bit.ly/YSHh8B), and others. One tool that has shown some promise is a single question: “At any time in the past year, have you used an illegal drug or used a prescription medication for nonmedical reasons?” This single question has been shown to be 100% sensitive and 73.5% specific for detection of a drug use disorder (Smith PC et al, Arch Int Med 2010;170(13):1155–1160), and can be a valuable addition to any clinical evaluation.
It is important to be familiar with the signs and symptoms of someone who is abusing stimulants. Stimulants have strong cardiovascular effects, which can include heart palpitations and arrhythmias, occasionally resulting in heart failure. They can raise body temperature and cause seizures. Stimulants have also been related to previously unreported psychotic and manic symptoms, as well as aggression depression, and exacerbation of pre-existing psychiatric symptoms. Any erratic behavior or significant changes in mental status should be followed up immediately, since mania and psychosis are risk factors for harm to self and others. Other signs of abuse can include visual disturbance and tics.
What does one do with a patient who has been abusing prescription stimulants? That is a difficult decision, of course, and depends very much on the nature of the relationship between patient and physician. If you are treating a patient with a stimulant for ADHD, and learn that medication is being abused or diverted, the rupture in the therapeutic relationship must be addressed and repaired. “Lost” prescriptions must be dealt with in a clear fashion with no wiggle room. In my practice, I will replace the first lost prescription, but no others. If you are working with patients with substance abuse problems, stimulant abuse can be brought into the treatment plan and worked on in the context of their other addictive behaviors. Referral to an addiction specialist is another option. Similarly, a clear and consistent policy regarding urine drug screening is important; I make this clear from the start of treatment with all patients to avoid any misunderstanding or suspicion.
A variety of efforts are being made to prevent stimulant abuse. Many states, for instance, offer prescription drug monitoring programs (see TCPR, June 2012). In New York, the Internet System for Tracking Over-Prescribing (I-STOP) Act, passed in June 2012, would require that, effective in January 2015, prescribers consult the state database prior to prescribing any Schedule II, III, or IV medications to patients. While some have complained about the time burden involved with consulting a database for every prescription, this is a helpful way for doctors to identify “doctor shopping” and provide real-time information regarding medications dispensed by the pharmacy. Some colleges are recognizing the need for interventions as well. Duke University, for example, added a new policy in 2012 in which “the unauthorized use of prescription medication to enhance academic performance has been added to the definition of Cheating” (Duke University Student Handbook Student Policies on Academic Dishonesty/Cheating).
If you truly believe stimulants are indicated for your patient, these warnings should not deter you. Stimulants’ effects can be seen quickly, so dosages can be adjusted readily, thereby avoiding the urgency to give a prescription immediately or the need to give a large supply. As one would predict, extended-release formulations of medications seem to have a lower incidence of abuse, according to a recent review (Wilens T et al, J Am Acad Child Adolesc Psychiatry 2008;47(1):21–31). In addition to the extended release formulations, the osmotic controlled-release oral delivery system (OROS, available in methylphenidate form as Concerta) does not appear to cause a “high” sought by those using it for non-medical uses. Since 2008, lisdexamfetamine (Vyvanse) has been available for prescribing. This is a prodrug of dextromethamphetamine; it requires conversion to the active version of the stimulant in the GI tract so it doesn’t provide a high when smoked or snorted. Its onset of action is longer and the peak effects if slower than amphetamine and mixed-amphetamine salts.
You may also choose to prescribe a non-stimulant medication for ADHD. Atomoxetine (Strattera) is approved as monotherapy for ADHD in children and adults, although its onset of action is more gradual than with stimulants. Other options include buproprion (Wellbutrin), whose effect on dopamine makes it a somewhat effective and well-tolerated (Wilens T et al, Biol Psychiatry 2005;57(7):793–801) and the alpha-2 agonists guanfacine (Tenex) and clonidine (Catapres), which are less likely to be abused but are regarded as second-line agents for ADHD.
It is also important to note the nonpharmacologic treatments that are being researched for those with ADHD. Among other options, mindfulness has been targeted as a possible addition to treatment (Zylowska L et al, J Attention Disord 2008;11(6):737–746). Other dietary and behavioral treatments such as free fatty acids, neurofeedback, and cognitive training have been considered as well. A recent metaanalysis of these treatments showed very slight efficacy for free fatty acids but not for other nonpharmacological interventions (Sonuga-Barke EJS et al, Am J Psychiatry 2013:170(3);275–289). Stimulants will likely remain the mainstay of ADHD treatment but other options may be useful for the small but significant portion of the population that abuses stimulants.
TCPR’s Verdict: Stimulant medications have important and established therapeutic purposes for all age groups. There has been focus on the abuse potential of these medications especially in adolescence and early adulthood. A practitioner should be educated as to the signs and symptoms of misuse or abuse in order to prevent possible life threatening consequences. It is also important to know alternate effective treatments for those who are taking these medications for a therapeutic purpose in order to minimize abuse risk.