Stimulant Prescribing in ADHD: Reassessing Risk-Benefit Evidence

Helene Alphonso, DO, previewed her session at the American Psychiatric Association meeting in which she critically examined the evidence base for stimulant prescribing in attention deficit hyperactivity disorder (ADHD) and its parallels to the opioid epidemic.¹

Alphonso described the first section, which she led, as a reassessment of the risk-benefit framework for stimulant prescribing, contrasting the population-based studies commonly featured at continuing medical education conferences with more recent randomized controlled trial data. She offered a methodological caution that she characterized as central to the session's thesis: "do not let the large N seduce you because population studies are not equal to randomized controlled trials." The second section, led by a child and adolescent psychiatrist, examined changes in the education system and their contribution to increased stimulant prescribing over the past 25 years, alongside proposed solutions for improving educational accessibility for all students.²

The third section, presented by a neuroscience researcher, reviewed the effects of stimulants on dopamine circuits and brain physiology, drawing on research linking stimulant mechanisms to addiction and Parkinson disease pathways. The fourth section, delivered by a women's health and perinatal psychiatrist, addressed stimulant use in pregnancy, reviewing population-based and animal studies in the absence of randomized controlled trial data for this population.

Alphonso noted that her lectures across the country on parallels between the opioid epidemic and rising stimulant prescribing had elicited strong responses, with some clinicians privately expressing that they "feel trapped and would rather prescribe nonstimulants for patients with ADHD." She argued that ADHD should be reconceptualized as a spectrum disorder and called for development of a validated screening instrument to identify patients at higher risk of adverse consequences from stimulant treatment.

Dr Alphonso is a psychiatrist at John Peter Smith Hospital in Fort Worth, Texas, and board-certified in both addiction medicine and lifestyle medicine.

References

1. Park TW, Baul TD, Morgan JR, et al. Trends in attention-deficit hyperactivity disorder diagnosis and pharmacotherapy among adults with opioid use disorder. Psychiatr Serv. 2024;75(3):214-220.

2. Li L, Coghill D, Sjölander A, et al. Increased prescribing of attention-deficit/hyperactivity disorder medication and real-world outcomes over time. JAMA Psychiatry. 2025;82(8):830-837.