Despite the proven efficacy and safety of medications for ADHD, abuse is a growing concern.
SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
TABLE 1. Commonly prescribed FDA-approved medications for ADHD
TABLE 2. Assessment and characteristics
ADHD is a neurodevelopmental disorder characterized by inappropriate levels of inattention and/or hyperactivity-impulsivity and occurs in approximately 3% to 10% of children and adolescents and 2.5% of adults.1 Research indicates that increasing numbers of high school students with ADHD are going to college. Treatment options include both non-pharmacological (eg, behavioral support therapies, coaching, cognitive-behavior therapy, neurofeedback) and pharmacological approaches.
A plethora of studies attest to the effectiveness of prescription stimulants for ADHD symptoms in children and adults with the disorder, and more recent studies report that stimulants often lead to improvements in self-regulation, planning, and organizational skills (ie, executive functions).2 Commonly prescribed stimulants for ADHD include methylphenidate, mixed amphetamine salts, and the prostimulant lisdexamfetamine (see Table 1). Double-blind placebo-controlled studies support the efficacy and safety of these medications in children, adolescents, and adults when taken as prescribed and appropriately monitored.
The use of prescription stimulants to treat ADHD symptoms first began in 1937 when psychiatrist Charles Bradley administered benzedrine sulfate to children with behavior problems at the Emma Pendelton Bradley Home in Providence, Rhode Island. The practice of prescribing stimulants (methylphenidate) for the treatment of hyperactive and inattentive behavior became more commonplace in the 1950s and widely accepted in the 1980s, corresponding with the specification of attention deficit disorder in DSM-III.
Although prescription stimulants are often highly effective in reducing ADHD symptoms in children, adolescents, and adults, the misuse (ie, non-medical) of prescription stimulants among adolescents, college students, and adults has become problematic in recent years. Estimates of prescription stimulant misuse vary among studies but meta-analyses report between 5% to 35% of college students in the US report misusing prescription stimulants and varying rates have been reported among military personnel, lawyers, medical, dental, and nursing students.3,4
A recent population study conducted by the US National Association of Drug Abuse reported 16.0 million used prescription stimulants in the past year, 5.0 million misused prescription stimulants, and 0.4 million had prescription stimulant use disorders.5 International studies have found similar prevalence, underscoring that prescription stimulant misuse is present across cultures (eg, Germany, Iceland, Switzerland, UK).
The primary reason adults report taking prescription stimulants without a valid prescription is to enhance cognition functioning and improve performance. A secondary reason reported by college students and other adults is for recreational purposes (eg, experimentation, intoxication, poly use of substances). Less commonly reported reasons include social conformity and weight loss. The primary motivating factor for misuse among middle and high school students, in contrast to adults, appears to be social and recreational.
A number of studies have identified characteristics of individuals who are more likely to misuse prescription stimulants and include nicotine use and use of illicit drugs (eg, marijuana, cocaine, hallucinogens, opiates), heavy alcohol consumption, lower grade point average, sorority and fraternity membership, poor study skills, and poor class attendance.
Psychological factors are also implicated in misuse of prescription stimulants as higher rates have been found among young adults who report greater psychological distress and anxiety, executive function deficits, higher rates of sensation seeking, and symptoms associated with ADHD including difficulty concentrating, impulsivity, and internal restlessness.6,7
Students with ADHD in middle school, high school, and college have reported being pressured by others to share, trade, or sell their medication. The most common source of prescription stimulants for those who misuse is friends and family members followed by physicians and illegal sources.8,9 Students who are more likely to divert their medication are those who use other alcohol and other illicit substances.
These findings have direct implications for psychiatrists and other prescribers of stimulants. Specifically, when prescribing, it is important to emphasize to patients the illegality of sharing, selling, or distributing medication. It is also critical that patients understand the importance of safe storage of their stimulant medication to decrease the likelihood of theft and of being pressured into sharing their medication. With patients at risk for poly substance use, toxicology screens may be prudent. Furthermore, when prescribing, stimulant medications that have less potential for abuse via snorting or injection should be considered, including nonstimulants (Straterra) and lisdexamfetamine dimesylate (Vyvanse). Lisdexamfetamine is a prostimulant, requiring enzymatic bioconversion to dextroamphetamine, for optimal potency and effects.
It is also likely that a segment of individuals who are misusing prescription stimulants have undiagnosed ADHD and are self-medicating. Findings suggest that those who report difficulties with attention, executive functions, and internal restlessness are more likely to misuse prescription stimulants. Equally important to recognize is that patients who seek an ADHD diagnosis for themselves or for their children may be malingering in order to receive a prescription. Indeed, research shows that adults are highly successful at feigning ADHD when coached about symptoms.10
These scenarios emphasize the importance of obtaining a thorough childhood history, impairment information, and informant data (parents, teachers, significant others) when evaluating patients for ADHD and not rely only on self-report. Differential diagnosis is also crucial because adults who report higher levels of anxiety, substance use, and psychological distress are at greater risk for misusing prescription stimulants (Table 2). Moreover, consider learning factors when treating adolescents and young adults suspected of malingering-stimulant misuse is associated with lower grade point averages, poor class attendance, and poor study habits. Referrals for learning disability and/or neuropsychological evaluations, tutoring, time management, and study strategies may be necessary.
Are prescription stimulants “smart drugs”?
Individuals with ADHD who take prescription stimulants often report improvements in ability to focus, sustained attention, self-regulation, and executive function performance. Individuals without ADHD who take prescription stimulants do so primarily to enhance their cognitive functioning. However, contrary to expectations and beliefs that prescription stimulants will lead to neurocognitive enhancement and improved academic performance, there is no evidence that stimulants have robust cognitive effects in healthy individuals. Stimulant misuse is negatively, rather than positively correlated with academic functioning in college students. Furthermore, meta-analytic studies do not support significant effects of amphetamine on episodic memory, working memory, inhibitory control, creativity, intelligence, reading comprehension, or scholastic achievement in healthy adults.11 In fact, while stimulants may improve alertness and attention in adults without ADHD, findings indicate that amphetamine and methylphenidate impair performance on tasks of response inhibition, working memory, and cognitive flexibility.12
While taking prescription stimulants, healthy adults report improved mood and perceived neurocognitive enhancement, and these effects are likely fueling the increased misuse of these medications. The clinical implication of this research is that placebo effects probaby contribute to the perception of prescription stimulants as “smart drugs” among healthy adults.
What remains unknown, however, is the extent to which prescription stimulants may enhance or impair performance on “real world” measures such as exams, assignments, and presentations. In the meantime, students and other adults are likely to continue to seek prescriptions for stimulants or to obtain them from friends, family members, and illegal means. Given the increased misuse of these medications, psychiatrists need to keep in mind the importance of thorough ADHD evaluations, the possibility of patient malingering, and education of patients and their families regarding the proper storage and illegality of selling or sharing stimulant medications. Lastly, it is imperative that psychiatrists and other mental health professionals do their part to dispel the myth that stimulant medications are “smart drugs” for healthy adults.
Molly is a 19-year-old college student who was struggling in her major; her current GPA was 2.0. Her class attendance was variable. She complained to friends that she had difficulty focusing during lectures, daydreamed frequently, and had poor organizational skills. She withdrew from 3 courses and failed a physics course twice. Molly was concerned of not performing well on upcoming midterms and felt exceedingly “stressed out.”
Molly’s roommate suggested that she try Adderall and shared her prescription medication. Molly reported that Adderall “made an amazing difference” in her ability to stay awake and study. She continued to obtain Adderall from friends and other students on campus for several weeks but became concerned when she learned that purchasing and taking stimulants without a prescription was illegal and students who do so can be prosecuted and face university sanctions.
Molly subsequently sought an evaluation to determine whether she had ADHD. She presented with complaints of internal restlessness, difficulty focusing, poor organizational skills, distractibility, lack of follow through, and “impatience.” She reported that her symptoms began in elementary school and that she was frequently reprimanded for talking excessively and being off task. In elementary school her grades were “OK” (Bs and Cs); her father helped her study every night at the kitchen table and without his help she would have had to repeat 4th grade.
She had been evaluated in 4th grade to determine if she had a learning disability and the results were negative. Her teacher told her parents that she was “hyperactive” and needed medication. Her parents were opposed to medication and “did not believe in ADHD.” Molly reported that in middle school and high school she had been a mess and extremely disorganized. She graduated with a 2.2 GPA.
Now in college, she had difficulty focusing in lectures, often “spacing out,” and secretly recorded lectures so that she could review them prior to exams. In addition to poor academic functioning she reported that her symptoms resulted in impairments in her occupational and social functioning (eg, speeding tickets, spending money impulsively).
Developmental history indicated that her mother smoked cigarettes throughout her pregnancy and her medical history was significant for being accident-prone (broken elbow at age 3, stitches required on the forehead at age 6, broken ankle at age 10). Further evaluation revealed intellectual functioning and memory skills within the average range. Her performance on executive function, impulsivity, and vigilance tasks was in the clinical range as were her ratings on self-report instruments for childhood and current ADHD related symptoms. The informant’s ratings were also within the clinical range for attention problems, hyperactivity, impulsivity, and executive functions. Psychologically the student reported significant somatic symptoms. Molly’s symptoms were not consistent with MDD, anxiety, or other psychiatric disorders.
Developmental, academic, social, and medical histories in conjunction with clinical interview findings, behavior observations, and testing results supported a diagnosis of ADHD.
This case demonstrates that some individuals who misuse prescription stimulants are “self-medicating” and an ADHD diagnosis may be warranted. Treatment recommendations included a prescription for Adderall XR 20 mg daily with education regarding safekeeping and prohibition against sharing or selling the medication. Molly was also referred to the academic skills center at her university for academic support, tutoring, study skills, and time management. She was seen monthly for routine follow up and responded well to 20 mg of sustained release Adderall with minimal adverse effects. At 6-months follow up, she reported a significant improvement in her academic and social functioning, and she continued taking the medication as prescribed.
Dr Weyandt is Professor, Department of Psychology, University of Rhode Island, George and Anne Ryan Institute for Neuroscience; Ms Bjorn is an undergraduate, Department of Psychology, University of Rhode Island, Kingston, RI.
The authors report no conflicts of interest concerning the subject matter of this article.
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