Although concerns about the misuse of stimulant medications used to
treat ADHD have become widespread, data regarding the magnitude of this
problem is relatively limited.
In a
prior issue of
Attention Research Update I summarized information available at the
time, which included the following study findings:
- The Massachusetts Department of Public Health conducted an
anonymous survey of 6000 students and reported that 13% of high
school students and 4% percent of middle school students acknowledged
the "illicit, unprescribed use" of stimulant medications.
- In a survey of 161 students with ADHD attending a number of
schools in central Wisconsin, 16% reported that they had been
approached to sell, give, or trade their medication.
- A survey of 651 students - including 50 with prescriptions for
ADHD medication - revealed that nearly one-third of those with
prescriptions had been approached to give away or sell their
meds. Over 50% of students without ADHD reported that they had
seen a peer with ADHD being asked to sell or give away their medication.
- Data from the 2001 National Household Survey on Drug Abuse
conducted by the Substance Abuse and Mental Health Services
Administration (SAMHSA) indicates that 2.2% of 12-17-year-olds and 3.4%
of 18-25-year-olds reported the non-medical use of stimulant medication
during the prior year.
- In 2000, the National Institute on Drug Abuse (NIDA) reported
that the annual prevalence of nonmedical abuse of methylphenidate by
high school seniors peaked at 2.8% in 1997 and 1998 compared with .1%
in 1992. These figures dropped to 2.4% in 1999 and 2.2% in 2000.
Limitations of
Prior Studies
Findings summarized above indicate that nonmedical use of stimulant
medications is not uncommon. However, because nonmedical use is
defined as reporting the "...use of any prescription-type stimulant,
even once, without a doctor's prescription", individuals misusing
stimulant medications a single time are not distinguished from those
whose misuse is a more serious problem.
In addition,data on the non-prescribed use of stimulant medications
provides no information on the misuse by individuals with ADHD for whom
the medications have been prescribed. Thus, although data
summarized above indicate that students with prescriptions are
approached to sell or give away their stimulant medication on a
disturbingly frequent basis, they do not tell us whether those with
prescriptions misuse their own medication. Such misuse could
include taking medication more often than prescribed, taking higher
doses than prescribed, or intranasal administration (i.e., snorting) in
an attempt to induce a high.
Recent Studies
In contrast to prior studies on this topic, a recent study attempted to
differentiate between one time/infrequent nonmedical use and nonmedical
use that was more problematic. The study will be published in the
upcoming issue of the journal Drug and Alcohol Dependence (Kroutil, L.,
et al., (2006). Nonmedical use of prescription stimulants in the United
States. Alcohol and Drug Dependence).
The authors used data from the 2002 National Survey on Drug Use and
Health, an annual survey of the US civilian population aged 12 or older
to estimate the rate of nonmedical use of stimulant medications.
Because the sample size wass large (over 50,000) and representative of
the general US population, reliable estimates of nonmedical use for the
entire population could be made.
As in prior studies, nonmedical use was defined as using any
prescription-type stimulant even once without a doctor's prescription
or for the experience or feeling it caused. The latter type of misuse -
taking only for the "experience or feeling it caused" could apply to
individuals with prescriptions who deviated from their prescribed
use. However, the data was not broken out in a way that permitted
an examination of this important issue.
Results
Results indicated that an estimated 7.3 million persons aged 12 or
older had misused at least one ADHD stimulant, in addition to other
stimulant medications, at least once in their lifetimes; this
represented 2.6% of persons aged 12-17 years and 5.9% of persons aged
18-25 years. The corresponding perentages for use during the
prior 12 months were 1.7% and 2.0% respectively.
Of these 7.3 million, 2.9 million had misused ADHD stimulants
exclusively. During the prior 12 months, .9% of 12-17-year-olds
and 1.3% of 18-25-year-olds had engaged in the nonmedical use of ADHD
stimulants exclusively.
Misuse of ADHD stimulants most frequently involved short acting
Ritalin/methylphendiate and Dexedrine. However, nonmedical use of
other stimulants, including longer-acting formulations were also
reported. Nonmedical use of longer acting formulations such as
Concerta, however, was far less frequent.
Serious forms of
Nonmedical Use
The authors estimated the percentage of nonmedical users of ADHD
stimulants whose misuse was more serious, i.e., those who met criteria
for stimulant dependence or stimulant abuse.
Individuals identified as stimulant dependent demonstrate at least 3 of
the following symptoms:
* Tolerance - requiring higher doses to attain the same effect;
* Withdrawal - experience of withdrawal symptoms when deprived of
stimulants;
* Using stimulants more often than intended;
* Desiring to stop/cut back but being unable to;
* Considerable time spent obtaining stimulants or recovering from their
effect;
* Important activities given up or neglected because of stimulant use;
* Continued use despite knowledge of problems caused or aggravated by
stimulant use;
Stimulant abuse represents a somewhat less severe form of nonmedical
stimulant use and is diagnosed in individuals who while not stimulant
dependent, show at least 1 of the following 4 symptoms:
* recurrent failure to meet important responsibilities due to stimulant
use;
* recurrent use of stimulants in situations where it is likely to be
dangerous;
* recurrent legal problems arising from use;
* continued use despite recurrent problems aggravated by use;
Among individuals ages 12-17 who engaged in any nonmedical use of
stimulant medications during the prior year, including ADHD stimulants,
2.2% met criteria for stimulant dependence and an additional 3.5% met
criteria for stimulant abuse. For those ages 18-25, the
corresponding figures were 3.1% and 3.5% respectively.
According to the authors, this translates into about 75,000 persons
ages 12-25 who qualified for DSM-IV diagoses of stimulant dependence or
stimulant abuse in the prior 12 months. This represents about
.06% of the total population in this age range.
Among those who had misused ADHD stimulants exclusively, the estimated
number of dependence and abuse cases was 24,000; this represents about
.02% of the population in this age group.
What about
misuse by those with
prescriptions?
The results summarized above suggest that about 2% of persons ages
12-25 each year engage in the nonmedical use of ADHD stimulants at
least once during a given year. In addition, among those who
misuse ADHD stimulants exclusively, nearly 25,000 meet criteria for
stimulant dependence or abuse during the year.
Although these concerning figures highlight that ADHD stimulants are
often diverted for nonmedical purposes, they provide no information on
the misuse of ADHD medications by those for whom they are
prescribed. For parents concerned about using stimulant
medications for their child, as well as for physicians who prescribe
these medications, this is an extremely important issue.
Unfortunately, data on the misuse of ADHD stimulants among prescribed
users is extremely limited. One of the few studies I have seen on
this topic was presented at the 2005 annual meeting of the American
Psychiatric Association by Dr. Timothy Wilens, the director of
Substance Abuse Services in the Pediatric and Adult Psychopharmacology
Clinics at Massachusetts General Hospital in Boston.
Participants were 98 individuals receiving medication for ADHD who were
part of a 10-year longitudinal study. Over half the participants
were diagnosed with a comorbid behavior disorder and/or substance use
disorder while the remainder had ADHD alone. Participants'
average age was just over 20 years.
These individuals were asked about selling their ADHD medication.
They were also asked about their own misuse, i.e., using them more
often then prescribed.
Eleven percent of those with comorbid difficulties reported having sold
their ADHD medication. Individuals with ADHD alone never reported this.
Regarding misuse, 22% of the comorbid subjects had misused their
medications by using them too frequently vs. 5% of participants with
ADHD alone. Information on the frequency of misuse, or the
consequence of misuse, was not available.
Summary and
Implications
Results from these studies highlight the need to be concerned about the
nonmedical use of stimulant medications used to treat ADHD.
Nonmedical use by individuals without a prescription is not an isolated
phenomena, and thousands of individuals between 12 and 25 report
symptoms that rise to the level of dependence or abuse.
Although this is concerning, it is important to recognize that the
percentage of the population for whom nonmedical use of ADHD stimulants
rises to this level is quite small. Thus, an estimated 75,000
cases would represent about .06% of the US population in the 12-25 age
range.
It is also important to recognize that these figures do not pertain to
the misuse of ADHD stimulants by those for whom such medications are
prescribed. As noted above, data on the misuse of ADHD
medications by those with prescriptions is limited. However, it
appears that such misuse is more likely in individuals who have
behavior disorders in addition to ADHD and/or who also have a substance
use disorder. How often individuals misuse their medication, and what
the consequences of this misuse may be, however, is not known. Clearly,
additional research on this issue is needed.
The authors of the large survey study summarized above conclude their
report by stating:
"The concerns about diversion of prescription stimulants should not be
construed as recommendations against the use of these medications to
treat ADHD or other disorders under appropriate medical supervision...
Several recent studies have indicated no increased risk for substance
experimentation or disorders among youth who were treated with
stimulants for ADHD, or reduced risk relative to persons whose ADHD was
not treated pharmacologically."
Thus, many ADHD experts and physcians would likely agree that the
misuse and abuse of these medications by some should not be construed
as an argument against their legitimate use in individuals with
ADHD.
These data do highlight the need to be vigilant about the potential
misuse of ADHD stimulant medications, however, and for parents,
professionals, and educators to recognize that many adolescents
prescribed such medication may be approached by others who wish to use
it for nonmedical purposes. Educating children and teens that
peers may approach them to buy medication, and how they should respond
should this occur, would thus seem to be very important.
In addition, data from the smaller study of misuse by those prescribed
ADHD medication suggest that misuse is more likely to occur in those
with comorbid behavior disorders and/or substance use disorders.
Therefore, extra caution needs to be exercised when treating such youth
with stimulant medications, and physicians may want to start treatment
with a nonstimulant therapy. If stimulant medications are required, a
long-acting stimulant coupled with rigorous monitoring would seem like
the safest course.
These data also underscore the ongoing need for research into the
development of nonmedical treatments for ADHD that can be as effective
in managing core symptoms as stimulant medications. I try to
include summaries of solid research on such treatments in Attention
Research Update whenever I come across such work, and will continue to
do so.