by Randy A. Sansone, MD; and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician in practice (government service) at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.
This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked. In this edition of Psychiatry 2007, we summarize several recent articles on the potential risks of prescription psychostimulants.
Psychostimulants are unquestionably effective in the treatment of attention-deficit hyperactivity disorder (ADHD). While effective, there has been continuing concern about the risk of psychostimulant prescription misuse/abuse. The empirical literature generally indicates that rather than heightening the risk for substance use disorders in individuals with ADHD, these medications appear to lower the risk.
However, the potential risk of psychostimulant abuse remains.
According to Scheffler and colleagues,[1] the global use of psychostimulant medications for ADHD increased threefold between the years 1993 and 2003, with global expenditures during this time increasing ninefold. Surprisingly, in the United States, Canada, and Australia, there were higher-than-predicted prescription rates of psychostimulants. In Australia, Calver and colleagues[2] explored the epidemiological patterns of psychostimulant prescriptions and found that children from lower socioeconomic status were more likely to be prescribed drugs for ADHD, in contrast to adults of upper socioeconomic status who were more likely to receive ADHD prescriptions than their disadvantaged counterparts.
Clearly, the prescription of psychostimulants for ADHD is increasing. Are we clinicians sufficiently aware of the risks and patterns of illicit psychostimulant use? Several recent studies highlight these risks and patterns using data from very different types of samples. In the first study, Forrester[3] examined telephone calls that were received by several poison control centers in Texas between 1998 and 2004. Of those calls relating to dextroamphetamine (Adderall), 60 percent were from male patients, 69 percent of the callers were adolescents, and 12 percent related to queries involving misuse or abuse of the drug.
In another study of adolescents, Boyd and colleagues[4] explored prescription diversion among 1,086 secondary students in Michigan. Among those students prescribed psychostimulant medications (n=62), 14 percent had been approached by peers to sell, trade, or give away their prescriptions. Among the entire sample, only two percent reported the illicit use of their own prescribed psychostimulants.
Beyond adolescence, psychostimulant misuse/abuse is well known among college students. In a recent study by White and colleagues,[5] investigators queried through classroom and internet surveys undergraduate and graduate students about substance usage. Among the 1,025 respondents, 16 percent acknowledged misusing or abusing psychostimulant medications. The psychostimulant of preference was methylphenidate (Ritalin). While the majority orally ingested the psychostimulant (60%), 40 percent reported intranasal administration. Common reasons for the abuse of psychostimulants by participants in this study were improving attention, recreational purposes, reducing hyperactivity, and academic enhancement.
In a study of Canadian university students,[6] researchers compared 50 students with methylphenidate (Ritalin) misuse/abuse to 50 control students. The samples were matched for age, sex, and ethnic background. In comparison with control participants, those with methylphenidate (Ritalin) misuse/abuse were more likely to have used both prescription and non-prescription stimulants during their lifetimes. The most common explanation for methylphenidate (Ritalin) misuse/abuse was recreational purposes (70%), whereas 30 percent reported the use of this psychostimulant exclusively for academic enhancement. As expected, recreational users were more likely to report the intranasal administration of methylphenidate (Ritalin). Of those who identified their drug source, most obtained psychostimulants from an acquaintance who had a prescription.
What do these findings indicate? While psychostimulants are clearly useful and necessary medications in the treatment of ADHD, there are continuing risks of misuse and abuse among both adolescents and young adults. Some individuals may abuse their own prescription medications. Indeed, the empirical literature indicates that there are significantly higher rates of substance dependence and antisocial personality disorders (up to 30%) among those with ADHD compared with controls,[7] that the preceding relationship may be mediated by childhood conduct disorder,[8] and that the presence of hyperactivity in childhood predicts for criminal offenses in adolescence.[9] In addition, a substantial number of misusers/abusers appear to obtain their psychostimulants from individuals with legitimate prescriptions. Whether the preceding interaction involves the exchange of money or is simply related to acquaintanceship remains unknown. However, psychiatrists and primary care physicians need to remain alert to the abuse potential of psychostimulant drugs, either through patient misuse or through the “donation” of a prescription to a friend.
References
1. Scheffler RM, Hinshaw SP, Modrek S, et al. The global market for ADHD medications. Health Aff 2007;26:450–7.
2. Calver J, Preen D, Bulsara M, et al. Stimulant prescribing for the treatment of ADHD in Western Australia: Socioeconomic and remoteness differences. Med J Aust 2007;186:124–7.
3. Forrester MB. Adderall abuse in Texas, 1998-2004. J Toxicol Environ Health A 2007;70:658–64.
4. Boyd CJ, McCabe SE, Cranford JA, et al. Prescription drug abuse and diversion among adolescents in a southeast Michigan school district. Arch Pediatr Adolesc Med 2007;161:276–81.
5. White BP, Becker-Blease KA, Grace-Bishop K. Stimulant medication use, misuse, and abuse in an undergraduate and graduate student sample. J Am Coll Health 2006;54:261–8.
6. Barrett SP, Darredeau C, Bordy LE, et al. Characteristics of methylphenidate misuse in a university student sample. Can J Psychiatry 2005;50:457–61.
7. Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: A controlled 10-year follow-up study. Psychol Med 2006;36:167–79.
8. Lahey BB, Loeber R, Burke JD, et al. Predicting future antisocial personality disorder in males from a clinical assessment in childhood. J Consult Clin Psychol 2005;73:389–99.
9. Sourander A, Elonheimo H, Niemela S, et al. Childhood predictors of male criminality: A prospective population-based follow-up study from age 8 to late adolescence. J Am Acad Child Adolesc Psychiatry 2006;45:578–86.
