Stimulants are first-line treatment for ADHD and generally considered safe and effective when properly prescribed. However, use of these medications without a prescription is widespread, particularly among college students and young professionals. In this article, we review the scope of nonprescribed stimulant use, discuss the potential dangers, and what to do if you run across it in your clinical practice. 

How common is nonprescription use?

Age is the demographic factor most closely associated with nonprescription stimulant use. Such use is most common among young adults, particularly on college campuses, where half of students describe stimulants as “easy to get” (Weyandt L et al, J Affect Disord 2009:13(3):284–296).

We don’t have high-quality data on how widespread the issue is across different settings, but the 2023 National Survey of Drug Use and Health found that 3.1% of adults age 18 to 25 and 1.2% of adults age 26 and older reported misusing stimulant medication (www.tinyurl.com/26pw5ah2). 

Other factors associated with nonprescription stimulant use include:

• White ethnicity
• Male sex
• Membership in a fraternity or sorority
• Poor academic standing
• Poor executive or neuropsychological functioning
• Comorbid substance use disorder 
• Poorly treated ADHD

(Source: Wilens T and Kaminski T, Pediat Clin N 2019;66(6):1109–1120)

What are stimulants used for?

Cognitive enhancement

The most common reason for nonprescription stimulant use is to enhance cognitive performance; users are seeking to improve focus, alertness, and productivity. The rationale is straightforward: Stimulants improve cognition in ADHD, so they must also help those without ADHD.

The research, however, doesn’t quite bear this out. For example, a meta-analysis looking at stimulant effects in eight cognitive domains for participants without ADHD found that methylphenidate was associated with only slight improvement in three domains, modafinil had slight improvement in one domain, and amphetamines showed no improvements at all (Roberts CA et al, Eur Neuropsychopharmacol 2020;38:40–62). Another study in college students found that amphetamines produced only slight cognitive improvement in those without ADHD, but it had a large effect on subjective drug experience and positive states of activated emotion—in other words, students believed that the drug was much more effective than it was (Weyandt L et al, Pharmacy 2018;6(3):58).

Interestingly, there are suggestions that a person’s belief about stimulants might provide more benefit than stimulants themselves. In one study, healthy college students engaged in cognitive testing after taking low-dose mixed amphetamine salts or placebo. Participants were unable to differentiate between the medication and placebo but performed better if they believed they were receiving active medication (Cropsey KL et al, Drug Alcohol Depend 2017;178:302–309). 

Weight loss

Loss of appetite is a common side effect with these medications, so they are commonly taken without a prescription by those trying to lose weight. Studies show that people who use stimulants for weight loss are more likely to have other eating disorder symptomatology as well, such as use of laxatives, diet pills, or diuretics; purging; and higher-than-usual concerns about body image. One survey of 707 college students found that 4.4% of them reported using stimulants without a prescription to lose weight, with more than half of participants receiving the medication from a friend (Jeffers AJ and Benotsch EG, Eat Behav 2014;15(3):414–418). 

Recreation

Stimulants are frequently taken without a prescription recreationally, usually in groups or at parties. Prescription stimulant users might enjoy a “high” with feelings of euphoria or increased energy. For those who drink alcohol, the energizing effects of stimulants may reduce subjective feelings of intoxication, allowing them to drink more or stay up later into the night (Egan KL et al, Drug Alcohol Depend 2013;131(1–2):71–77).

What are the risks?

Prescription stimulants are Schedule II drugs, defined as having “a high potential for abuse, with use potentially leading to severe psychological or physical dependence” (www.tinyurl.com/ydj7r3mz). 

Stimulant use disorder

Nonprescription stimulant use can lead to the development of a stimulant use disorder (StimUD), although the prevalence of the disorder is unclear. Physiologic adverse effects range from mild—insomnia, irritability, tremors, and anorexia—to severe, including tachycardia, hypertension, and potentially fatal arrhythmias. Stimulants can cause psychiatric symptoms as well, particularly mania and psychosis (Moran LV et al, Am J Psychiatry 2024;181(10):901–909). 

Seizures

Those using stimulants for weight loss can be particularly at risk of seizures, especially if they are engaging in other behaviors that could lead to electrolyte abnormalities with subsequent lowering of the seizure threshold, such as diet restriction, using laxatives, and purging.

Drug-drug interactions

People who use stimulants recreationally may be more prone to combine stimulants with other drugs, putting them at risk of synergistic adverse effects. For example, combining stimulants with alcohol can lead to increased levels of alcohol intake with less awareness of intoxication. Combinations with other illicit psychostimulants, such as cocaine and methamphetamine, could compound the risk of acute cardiovascular events (eg, cardiac ischemia, stroke).

What to do about nonprescription use?

Establish a diagnosis

Guidelines recommend that an ADHD diagnosis be established before a stimulant prescription is written (Faltinsen E et al, BMJ Evid Based Med 2019;24(3):99–102). As with any psychiatric disorder, diagnosis should be based on a detailed interview. For ADHD, gathering a developmental history that includes school performance is particularly important in establishing a firm diagnosis. If you are treating a child or adolescent, try to obtain collateral from caretakers and teachers.

Clinicians should not solely rely on manualized screening tools, though these can be useful to build up a fuller diagnostic picture. 

Scales for young people include: 

• Conners’ Rating Scales (www.tinyurl.com/5d677buh) 
• The Strengths and Difficulties Questionnaire (www.tinyurl.com/­2m7ybwr3) 

Scales for adults include: 

• The Revised Adult ADHD Self Report Screening Scale (Ustun B et al, JAMA Psychiatry 2017;74(5):520–526)
• The Copeland Symptom List (www.tinyurl.com/yv46ardj)
• The Wender-Utah Rating Scale (www.tinyurl.com/wcpu4zx6)

For more on making an ADHD diagnosis, see our interview with Dr. Alyson Harrison in the January 2017 issue of The Carlat Psychiatry Report.

Look out for red flags

While you should exercise special care any time you are prescribing controlled substances, there are a few red flags that should make you particularly wary when it comes to stimulants:

• Patients requesting stimulants specifically, rather than ADHD symptom relief
• Patients unwilling to trial nonstimulant treatments 
• Repeated requests for early refills
• Requests for ever-escalating doses
• Rapid weight loss
• Comorbid substance use disorders 
• Unexpected negative urine drug screens 

As always, check your state’s prescription monitoring program to see if your patient is “doctor shopping.” 

Treat addiction

If you suspect stimulant misuse, ask your patient about it. Make sure they understand the risks and establish whether they meet criteria for StimUD. If they do, you should recommend that they receive proper StimUD treatment. There are no FDA-approved medications for this indication, though there are off-label options with evidence behind them, including topiramate, mirtazapine, bupropion, and the combination of bupropion and injectable naltrexone. Prescribing a stimulant medication as a treatment for StimUD is generally not recommended. Behavioral interventions and psychotherapy have the most evidence, including cognitive behavioral therapy and contingency management. For more on how to diagnose and treat StimUD, see CATR May/June 2021 and the accompanying articles in this issue.

Carlat Verdict

Stimulant medications are commonly taken without a prescription, especially among young people, for cognitive performance, weight loss, and recreation. Not only do stimulants have questionable benefits for those without a formal ADHD diagnosis, but they can have dangerous adverse effects. Restrict stimulant prescriptions to patients with an established ADHD diagnosis and provide addiction treatment for patients who meet criteria for StimUD.