OBJECTIVE: We sought to better understand the trend for prescription attention-deficit/hyperactivity disorder (ADHD) medication abuse by teenagers.
METHODS: We queried the American Association of Poison Control Center's National Poison Data System for the years of 1998–2005 for all cases involving people aged 13 to 19 years, for which the reason was intentional abuse or intentional misuse and the substance was a prescription medication used for ADHD treatment. For trend comparison, we sought data on the total number of exposures. In addition, we used teen and preteen ADHD medication sales data from IMS Health's National Disease and Therapeutic Index database to compare poison center call trends with likely availability.
RESULTS: Calls related to teenaged victims of prescription ADHD medication abuse rose 76%, which is faster than calls for victims of substance abuse generally and teen substance abuse. The annual rate of total and teen exposures was unchanged. Over the 8 years, estimated prescriptions for teenagers and preteenagers increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both together. Reports of exposure to methylphenidate fell from 78% to 30%, whereas methylphenidate as a percentage of ADHD prescriptions decreased from 66% to 56%. Substance-related abuse calls per million adolescent prescriptions rose 140%.
CONCLUSIONS: The sharp increase, out of proportion to other poison center calls, suggests a rising problem with teen ADHD stimulant medication abuse. Case severity increased over time. Sales data of ADHD medications suggest that the use and call-volume increase reflects availability, but the increase disproportionately involves amphetamines.
Comments
Adolescent abuse of ADHD medications: a sad truth
We are grateful to Dr. Setlik and colleagues for an interesting article--it speaks volumes to the reality of our nation’s drug problem.[1]
We have considered the abuse potential and trends of use of ADHD drugs, especially among the youth who may deem their experimentation with these medications as ‘safe’ because they are prescribed by health providers. We have reported that use of these medications occur among college students and is promoted due to purported performance-enhancing effects on studying and/or test taking.[2] What can and what cannot be done by ingesting someone else’s psychostimulants is folklore and not evidence-based medicine. Many students appear on campus with new (or college-age onset) ADD or ADHD diagnoses seeking treatment. Others already have access to these prescriptions from childhood or have previously established sharing practices.
It could be argued that due to a better general understanding and acceptance of ADHD diagnoses, psychostimulant medications are widely- available, leading to increased risk of misuse and abuse. These drugs are snorted or injected in an attempt to reap positive psychostimulant effects and are also ingested in order to control weight or appetite and enhance energy.
Although abuse of other substances was not explicitly noted in this instance, early onset substance abuse is a risk factor among those with ADHD diagnoses.[3] Alcohol, marijuana, or benzodiazepines may be used in conjunction with ADHD medications to combat the undesirable effects (e.g., restless sleep, anxiety, irritability) or extend the pleasurable effects.[4] These potentially dangerous mixtures may have spurred many of the incidents noted in Setlik’s report. Assessing drug use behavior and overall mental health among patients before providing a prescription may be pivotal in preventing these types of toxic occurrences. Further, better communication and education of parents and adolescents of the risks of taking any medication, including candid discussion of misuse and diversion, may be a helpful start in combating abuse.
In this ever-challenging field, we also suggest taking great care to evaluate adolescent and adult onset “learning problems” and eliminating substance use as a possible cause. Many patients with active substance abuse problems will not self-report and are prescribed psychostimulants that they may ultimately divert, use to party, or abuse. The physician should continue to assess the nature and extent of the illness and whether stimulants are suitable in each instance, or if it would best suit the patient to explore non-stimulant medication options or nonpharmacological alternatives such as behavior management therapy.[5]
References:
1) Setlik J, Bond SR, Ho M. Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics 2009. Available at: www.pediatrics.org/cgi/doi/10.1542/peds.2008-0931
2) Svetlov SI, Kobeissy FH, Gold MS. Performance enhancing, non- prescription use of Ritalin: a comparison with amphetamines and cocaine. J Ad Dis 2007; 26(4)
3) Gray L, Park JJ, Msall ME. Children and adolescents with ADHD: Risk and protective factors for substance abuse and addictions. In Miller N and Gold MS Ed. Addictions in Medicine: Principles and Practice. Wiley- Blackwell 2010 In press.
4) Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA 1998; 279(14):1100-7.
5) Ninivaggi FJ. Attention-deficit/hyperactivity disorder in children and adolescents: rethinking diagnosis and treatment implications for complicated cases. Conn Med 1999; 63(9):515-21.
Conflict of Interest:
None declared