Tuesday, March 26, 2013

Misuse & Abuse of ADHD Meds among college students: Updated review of a growing concern [feedly]

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Misuse & Abuse of ADHD Meds among college students: Updated review of a growing concern

amphetamine-moleculeThe misuse and abuse of prescription medication is a growing concern. I remember speaking with colleagues 15–20 years ago as reports about the nonmedical use of stimulant medications used to treat ADHD (nonmedical use is defined as use by individuals without a prescription) were first appearing in the media. At the time, these were generally thought to be isolated incidents that were being over-dramatized in the press.

It has become clear, however, that this is not the case today and that the nonmedical use of ADHD meds, as well as misuse by individuals for whom medication is prescribed, is an important problem. Below is a brief overview and summary of research on these issues.

How common is nonmedical use of stimulant medications?

Between 2000 and 2011, the annual prevalence of nonmedical use of amphetamines — this includes drugs used to treat ADHD but is not limited to ADHD medications — declined from 6.5% to 3.5% among 8th graders, from 11.7% to 6.6% among 10th graders, and from 10.5% to 8.2% among 12th graders. Among college students, however, the rate increased from 6.6% to 9.3%. For non-college adults ages 19–28, the rate also increased — from 5.4% to 7.2%. This data is from the Monitoring the Future Study, an annual survey of alcohol and drug used conducted with a nationally representative sample. You can find an overview results from the 2011 survey online Here (opens PDF).

These data may underestimate nonmedical use of ADHD stimulants because the MTF survey does not inquire about all widely prescribed medications and individuals using medications not mentioned may inadvertently fail to mention nonmedical use.

How frequently do individuals engage in nonmedical use?

Published research on the frequency of nonmedical use has focused on college students. Results obtained from a nationally representative data base of college students indicated 32% of nonmedical users had used only once in the prior year, 45% used 2–10 times, and 19% used 11 or more times 15. In a study of adults in the general population, 30% of nonmedical users reported using only 1–2 times per year while 70% reported using 3 or more times.

Although most individuals who use nonmedically do so through oral routes of administration only, reports of crushing and snorting are not uncommon. In fact, this was reported by nearly 20% of nonmedical users in one recently published study of college students.

Where do those without prescriptions get medication?

The vast majority of nonmedical users among college students obtain medication from a friend with a prescription. And, results from several studies indicate that students with prescriptions are commonly approached by peers asking for their meds. Research with middle school and high school students makes clear that younger students are also approached for their meds, although at what appears to be a lower rate than for college students.

Feigning ADHD to obtain medication is also a growing concern. Studies with college students suggest that many who self-refer for an ADHD evaluation exaggerate their symptoms, perhaps to obtian stimulant medication. In a study of non-college adults, 20% of those who used nonmedically reported that they had 'faked' ADHD to obtain a prescription from a physician.

What are the characteristics of nonmedical users of ADHD medication?

Reports in the popular press sometimes imply that taking ADHD medication without a prescription has become almost 'normal' behavior for college students, part of a 'work hard, play hard' lifestyle. Research does not support this view, however.

Multiple studies conducted with college populations indicate that compared to their peers, nonmedical users:

- have higher rates of drug and alcohol use.
– perform less well academically.
– are more concerned about their ability to succeed academically.
– report significantly greater problems with attention.

Higher rates of substance use has also been found among nonmedical users of ADHD medication in the general adult population.

Thus, rather than being normative behavior, it appears that many individuals engaging in nonmedical use also misuse other substances and/or feel that attention problems are undermining their ability to be successful.

What are the main motivations for nonmedical use of ADHD medications?

Most research on the motives for nonmedical use has been conducted with college students. Among students, the primary motivation for most nonmedical users is to enhance academic performance, especially the ability to concentrate/focus while studying. However, other motives are also reported by a significant minority of individuals, including using to 'get high'.

Less is known about motives for use outside of college populations. In one study using a nationally representative sample of adults, 40% of nonmedical users indicated that their primary motive was to 'be more productive'. Another 13% reported that their primary motive was to 'feel good or get high'.

What are the consequences of nonmedical use of ADHD medication?

The vast majority of college students who engage in nonmedical use to enhance their academic performance believe that it is helpful. In one study, 70% rated the overall impact of nonmedical use as being either 'positive' or 'very positive' and only 5% rated the overall impact as 'negative' or 'very negative'.

This is striking because there is no data on whether nonmedical use actually improves academic performance. One recent review concluded that "…the cognitive effects of stimulants on healthy adults cannot yet be characterized definitively…"

Furthermore, most work on this issue is conducted in lab settings and examines the impact of stimulant medication on research measures of cognitive performance. Whether taking stimulants to pull an 'all nighter' improves exam performance the next day is unknown. In fact, a plausible hypothesis is that students who delay studying because they expect stimulants to help them cram the night before would perform worse than if they prepared using a more reasonable schedule.

Adverse consequences

Side effects — Although most students in the study mentioned above reported overall positive effects of nonmedical use, adverse events were also frequently reported. These included sleep difficulties (reported by 72%), irritability (62%), dizziness and lightheadedness (35%), headaches (33%), stomachaches (33%), and sadness (25%).

In addition, roughly 5% believed that nonmedical use had contributed to their using other prescription drugs and illicit substances. Approximately 10% reported occasional worries about obtaining stimulant medication and about becoming dependent on it. Over 10% believed that they needed stimulants to perform their best academically. This does not seem like a useful cognition to have.

Abuse and dependence — The abuse potential of stimulants when used by individuals without ADHD has been documented in multiple studies, although this is reduced in longer-acting formulations. Although information on how often nonmedical use of ADHD stimulants meets criteria for stimulant abuse or stimulant dependence is limited, data from the 2002 National Survey on Drug Use and Health showed that nearly 5% of individuals reporting past-year use of ADHD medications met screening criteria for these disorders.

Adverse reactions — Between 2005 and 2010 the number of emergency department visits resulting from the nonmedical use of stimulant drugs nearly tripled, from 5,212 to 15,585. The number of emergency department visits linked to adverse reactions to prescribed ADHD stimulants nearly doubled, from 5,085 visits to 9,181 visits.

Thirty-seven percent of all emergency department visits related to stimulant medication involved stimulant medications exclusively; the remainder involved use in combination with other drugs – frequently other pharmaceuticals — and alcohol.

What about the misuse and diversion of prescribed medication?

The misuse of stimulant medication by those with a prescription is also a concern.

Although most individuals use their prescribed stimulant medication appropriately, use in ways that deviate from those intended by the prescribing clinician is not uncommon. This generally takes the form of taking medication at higher doses or more frequently than prescribed, which has been reported by between 27% and 36% of college students across several studies. However, up to 25% of college students have reported using prescribed ADHD medication to get high and up to 30% have reported using in conjunction with alcohol and/or other drugs.

Similar to what has been found for nonmedical users, academic enhancement was the most frequently reported motive and most college students misusing for this purpose felt that it was helpful. Nonacademic reasons for misuse, e.g., to feel better or to lose weight, were reported as frequent reasons for misuse by relatively few students. Data on motives for misusing prescribed medication outside of college samples is limited.

As noted above, diversion of prescribed stimulant medication is a significant problem. In studies of college students, giving away or selling medication to peers has been reported by 26% in the previous 6 months, 35% in the previous 12 months, and 62% in their lifetime. Diversion of prescribed stimulants – generally to friends and relatives – was also reported by a significant minority of non-college adults.


Concerns about the nonmedical use of stimulant drugs used to treat ADHD are warranted, with nearly 10% of college students reporting this is a recent national survey; in some studies, the rates are far higher.

Although relatively infrequent use is most common, perhaps 20% of nonmedical users do so regularly and engage in intranasal routes of administration. Roughly 5% of nonmedical users may meet criteria for stimulant abuse or stimulant dependence and emergency department visits associated with nonmedical use are increasing.

In addition to nonmedical use, many individuals with prescriptions for ADHD medication occasionally misuse their medication by taking it in higher doses or with greater frequency than prescribed; some also use intranasally to 'get high' and/or in conjunction with other drugs or alcohol. As with nonmedical use, this is associated with higher rates of other substance use. Diverting medication to friends and family members is not uncommon and many are approached to do so, placing them at repeated risk for engaging in illegal behavior.

To address these issues, physicians should instruct patients about the abuse potential of their medication, the need to store it in a secure location, and obtain a commitment not to divert it. Children and adolescents may need coaching on how to respond if approached by peers seeking their medication.

Colleges should consider revising their conduct policies to address the misuse and diversion of ADHD medication, provide students with secure storage places, and educate students about the potential dangers associated with nonmedical use, especially when used with alcohol and other substances.

Pic courtesy of: BigStockPhoto

David Rabiner Attention Research Update– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

References — Information provided above is drawn from the following sources among others.

  • Arria AM, Garnier-Dykstra, KM, Caldeira, KM, et al.: Persistent nonmedical use of prescription stimulants among college students: Possible association with ADHD symptoms. J Atten Disord 2011, 15:347–356.
  • Dupont RL, Coleman JJ, Bucher RH, Wilford BB. (2008). Characteristics and motives of college students who engage in nonmedical use of methylphenidate. The American Journal on Addictions 2008, 17:167–171.
  • Garnier-Dykstra LM, Caldeira, KM, Vincent, KB, et al.: Nonmedical use of prescription stimulants during college: Four year trends in exposure opportunity, use, motives, and sources. J Am College Health 2012, 60:226–234. One of the few longitudinal studies of nonmedical use of stimulants.
  • Johnston LD, O-Malley PM, Bachman, JG, et al.: Monitoring the Future national survey results on drug use, 1975–2011: Volume II, College students and adults ages 19–50. Ann Arbor: Institute for Social Research, The University of Michigan. Includes recent national data on nonmedical use of stimulant medications.
  • McCabe SE, Teter, CJ. Drug use related problems among nonmedical users of prescription stimulants: a web-based survey of college students from a Midwestern university. Drug Alcohol Depen 2007, 91:69–76.
  • Novak SP, Kroutil LA, Williams RL, Van Brunt DL. The nonmedical use of prescription ADHD medications: Results from a national Internet panel. Substance Abuse Treatment, Prevention, and Policy 2007, 2:32.
  • Peterkin, AL, Crone CC, Sheridan MJ, Wise, TN (2010). Cognitive performance enhancement: Misuse or self-treatment? J Atten Disord 2010, 15:263–268.
  • Rabiner, DL, Anastopoulus AD, Costello EJ et al.: Motives and Perceived Consequences of Nonmedical ADHD Medication Use by College Students: Are students treating themselves for attention problems? J Atten Disord 2009a, 13:259–270. Careful examination of motives for nonmedical use and association of nonmedical use with attention problems.
  • Rabiner DL, Anastopoulus AD, Costello, EJ et al.: The misuse and diversion of prescribed ADHD medications by college students. J Atten Disord 2009, 13:144–153.
  • Sepulveda DR, Thomas LM, McCabe, SE, et al.: Misuse of prescribed stimulant medication for ADHD and associated patterns of substance use: Preliminary analysis among college students. Journal of Pharmacy Practice 2011, 24:551–560.
  • Sullivan, BK, May K, Galbally L. Symptom exaggeration by college adults in attention-deficit hyperactivity disorder and learning disorder assessments. Appl Neuropsychol 2007, 14:189–207.
  • Upadhyaya HP, Rose K, Wang W, Brady KT. Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults. J Child Adolesc Psychopharmacol 2005, 15:799–809.

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