Wednesday, March 27, 2013

Misuse & Abuse of ADHD Meds among college students: Updated ...

amphetamine-moleculeThe mis?use and abuse of pre?scrip?tion med?ica?tion is a grow?ing con?cern. I remem?ber speak?ing with col?leagues 15?20 years ago as reports about the non?med?ical use of stim?u?lant med?ica?tions used to treat ADHD (non?med?ical use is defined as use by indi?vid?u?als with?out a pre?scrip?tion) were first appear?ing in the media. At the time, these were gen?er?ally thought to be iso?lated inci?dents that were being over-dramatized in the?press.

It has become clear, how?ever, that this is not the case today and that the non?med?ical use of ADHD meds, as well as mis?use by indi?vid?u?als for whom med?ica?tion is pre?scribed, is an impor?tant prob?lem. Below is a brief overview and sum?mary of research on these issues.

How com?mon is non?med?ical use of stim?u?lant medications?

Between 2000 and 2011, the annual preva?lence of non?med?ical use of amphet?a?mines ? this includes drugs used to treat ADHD but is not lim?ited to ADHD med?ica?tions ? 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 col?lege stu?dents, how?ever, 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 Mon?i?tor?ing the Future Study, an annual sur?vey of alco?hol and drug used con?ducted with a nation?ally rep?re?sen?ta?tive sam?ple. You can find an overview results from the 2011 sur?vey online Here?(opens PDF).

These data may under?es?ti?mate non?med?ical use of ADHD stim?u?lants because the MTF sur?vey does not inquire about all widely pre?scribed med?ica?tions and indi?vid?u?als using med?ica?tions not men?tioned may inad?ver?tently fail to men?tion non?med?ical?use.

How fre?quently do indi?vid?u?als engage in non?med?ical?use?

Pub?lished research on the fre?quency of non?med?ical use has focused on col?lege stu?dents. Results obtained from a nation?ally rep?re?sen?ta?tive data base of col?lege stu?dents indi?cated 32% of non?med?ical 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 gen?eral pop?u?la?tion, 30% of non?med?ical users reported using only 1?2 times per year while 70% reported using 3 or more?times.

Although most indi?vid?u?als who use non?med?ically do so through oral routes of admin?is?tra?tion only, reports of crush?ing and snort?ing are not uncom?mon. In fact, this was reported by nearly 20% of non?med?ical users in one recently pub?lished study of col?lege students.

Where do those with?out pre?scrip?tions get medication?

The vast major?ity of non?med?ical users among col?lege stu?dents obtain med?ica?tion from a friend with a pre?scrip?tion. And, results from sev?eral stud?ies indi?cate that stu?dents with pre?scrip?tions are com?monly approached by peers ask?ing for their meds. Research with mid?dle school and high school stu?dents makes clear that younger stu?dents are also approached for their meds, although at what appears to be a lower rate than for col?lege students.

Feign?ing ADHD to obtain med?ica?tion is also a grow?ing con?cern. Stud?ies with col?lege stu?dents sug?gest that many who self-refer for an ADHD eval?u?a?tion exag?ger?ate their symp?toms, per?haps to obt?ian stim?u?lant med?ica?tion. In a study of non-college adults, 20% of those who used non?med?ically reported that they had ?faked? ADHD to obtain a pre?scrip?tion from a physician.

What are the char?ac?ter?is?tics of non?med?ical users of ADHD medication?

Reports in the pop?u?lar press some?times imply that tak?ing ADHD med?ica?tion with?out a pre?scrip?tion has become almost ?nor?mal? behav?ior for col?lege stu?dents, part of a ?work hard, play hard? lifestyle. Research does not sup?port this view, however.

Mul?ti?ple stud?ies con?ducted with col?lege pop?u?la?tions indi?cate that com?pared to their peers, non?med?ical?users:

- have higher rates of drug and alco?hol use.
? per?form less well aca?d?e?m?i?cally.
? are more con?cerned about their abil?ity to suc?ceed aca?d?e?m?i?cally.
? report sig?nif?i?cantly greater prob?lems with attention.

Higher rates of sub?stance use has also been found among non?med?ical users of ADHD med?ica?tion in the gen?eral adult population.

Thus, rather than being nor?ma?tive behav?ior, it appears that many indi?vid?u?als engag?ing in non?med?ical use also mis?use other sub?stances and/or feel that atten?tion prob?lems are under?min?ing their abil?ity to be successful.

What are the main moti?va?tions for non?med?ical use of ADHD medications?

Most research on the motives for non?med?ical use has been con?ducted with col?lege stu?dents. Among stu?dents, the pri?mary moti?va?tion for most non?med?ical users is to enhance aca?d?e?mic per?for?mance, espe?cially the abil?ity to concentrate/focus while study?ing. How?ever, other motives are also reported by a sig?nif?i?cant minor?ity of indi?vid?u?als, includ?ing using to ?get?high?.

Less is known about motives for use out?side of col?lege pop?u?la?tions. In one study using a nation?ally rep?re?sen?ta?tive sam?ple of adults, 40% of non?med?ical users indi?cated that their pri?mary motive was to ?be more pro?duc?tive?. Another 13% reported that their pri?mary motive was to ?feel good or get?high?.

What are the con?se?quences of non?med?ical use of ADHD medication?

The vast major?ity of col?lege stu?dents who engage in non?med?ical use to enhance their aca?d?e?mic per?for?mance believe that it is help?ful. In one study, 70% rated the over?all impact of non?med?ical use as being either ?pos?i?tive? or ?very pos?i?tive? and only 5% rated the over?all impact as ?neg?a?tive? or ?very negative?.

This is strik?ing because there is no data on whether non?med?ical use actu?ally improves aca?d?e?mic per?for?mance. One recent review con?cluded that ??the cog?ni?tive effects of stim?u?lants on healthy adults can?not yet be char?ac?ter?ized definitively??

Fur?ther?more, most work on this issue is con?ducted in lab set?tings and exam?ines the impact of stim?u?lant med?ica?tion on research mea?sures of cog?ni?tive per?for?mance. Whether tak?ing stim?u?lants to pull an ?all nighter? improves exam per?for?mance the next day is unknown. In fact, a plau?si?ble hypoth?e?sis is that stu?dents who delay study?ing because they expect stim?u?lants to help them cram the night before would per?form worse than if they pre?pared using a more rea?son?able schedule.

Adverse con?se?quences

Side effects ? Although most stu?dents in the study men?tioned above reported over?all pos?i?tive effects of non?med?ical use, adverse events were also fre?quently reported. These included sleep dif?fi?cul?ties (reported by 72%), irri?tabil?ity (62%), dizzi?ness and light?head?ed?ness (35%), headaches (33%), stom?achaches (33%), and sad?ness?(25%).

In addi?tion, roughly 5% believed that non?med?ical use had con?tributed to their using other pre?scrip?tion drugs and illicit sub?stances. Approx?i?mately 10% reported occa?sional wor?ries about obtain?ing stim?u?lant med?ica?tion and about becom?ing depen?dent on it. Over 10% believed that they needed stim?u?lants to per?form their best aca?d?e?m?i?cally. This does not seem like a use?ful cog?ni?tion to?have.

Abuse and depen?dence ? The abuse poten?tial of stim?u?lants when used by indi?vid?u?als with?out ADHD has been doc?u?mented in mul?ti?ple stud?ies, although this is reduced in longer-acting for?mu?la?tions. Although infor?ma?tion on how often non?med?ical use of ADHD stim?u?lants meets cri?te?ria for stim?u?lant abuse or stim?u?lant depen?dence is lim?ited, data from the 2002 National Sur?vey on Drug Use and Health showed that nearly 5% of indi?vid?u?als report?ing past-year use of ADHD med?ica?tions met screen?ing cri?te?ria for these disorders.

Adverse reac?tions ? Between 2005 and 2010 the num?ber of emer?gency depart?ment vis?its result?ing from the non?med?ical use of stim?u?lant drugs nearly tripled, from 5,212 to 15,585. The num?ber of emer?gency depart?ment vis?its linked to adverse reac?tions to pre?scribed ADHD stim?u?lants nearly dou?bled, from 5,085 vis?its to 9,181 visits.

Thirty-seven per?cent of all emer?gency depart?ment vis?its related to stim?u?lant med?ica?tion involved stim?u?lant med?ica?tions exclu?sively; the remain?der involved use in com?bi?na?tion with other drugs ? fre?quently other phar?ma?ceu?ti?cals ? and alcohol.

What about the mis?use and diver?sion of pre?scribed medication?

The mis?use of stim?u?lant med?ica?tion by those with a pre?scrip?tion is also a concern.

Although most indi?vid?u?als use their pre?scribed stim?u?lant med?ica?tion appro?pri?ately, use in ways that devi?ate from those intended by the pre?scrib?ing clin?i?cian is not uncom?mon. This gen?er?ally takes the form of tak?ing med?ica?tion at higher doses or more fre?quently than pre?scribed, which has been reported by between 27% and 36% of col?lege stu?dents across sev?eral stud?ies. How?ever, up to 25% of col?lege stu?dents have reported using pre?scribed ADHD med?ica?tion to get high and up to 30% have reported using in con?junc?tion with alco?hol and/or other?drugs.

Sim?i?lar to what has been found for non?med?ical users, aca?d?e?mic enhance?ment was the most fre?quently reported motive and most col?lege stu?dents mis?us?ing for this pur?pose felt that it was help?ful. Nonaca?d?e?mic rea?sons for mis?use, e.g., to feel bet?ter or to lose weight, were reported as fre?quent rea?sons for mis?use by rel?a?tively few stu?dents. Data on motives for mis?us?ing pre?scribed med?ica?tion out?side of col?lege sam?ples is limited.

As noted above, diver?sion of pre?scribed stim?u?lant med?ica?tion is a sig?nif?i?cant prob?lem. In stud?ies of col?lege stu?dents, giv?ing away or sell?ing med?ica?tion to peers has been reported by 26% in the pre?vi?ous 6 months, 35% in the pre?vi?ous 12 months, and 62% in their life?time. Diver?sion of pre?scribed stim?u?lants ? gen?er?ally to friends and rel?a?tives ? was also reported by a sig?nif?i?cant minor?ity of non-college adults.


Con?cerns about the non?med?ical use of stim?u?lant drugs used to treat ADHD are war?ranted, with nearly 10% of col?lege stu?dents report?ing this is a recent national sur?vey; in some stud?ies, the rates are far higher.

Although rel?a?tively infre?quent use is most com?mon, per?haps 20% of non?med?ical users do so reg?u?larly and engage in intranasal routes of admin?is?tra?tion. Roughly 5% of non?med?ical users may meet cri?te?ria for stim?u?lant abuse or stim?u?lant depen?dence and emer?gency depart?ment vis?its asso?ci?ated with non?med?ical use are increasing.

In addi?tion to non?med?ical use, many indi?vid?u?als with pre?scrip?tions for ADHD med?ica?tion occa?sion?ally mis?use their med?ica?tion by tak?ing it in higher doses or with greater fre?quency than pre?scribed; some also use intranasally to ?get high? and/or in con?junc?tion with other drugs or alco?hol. As with non?med?ical use, this is asso?ci?ated with higher rates of other sub?stance use. Divert?ing med?ica?tion to friends and fam?ily mem?bers is not uncom?mon and many are approached to do so, plac?ing them at repeated risk for engag?ing in ille?gal behavior.

To address these issues, physi?cians should instruct patients about the abuse poten?tial of their med?ica?tion, the need to store it in a secure loca?tion, and obtain a com?mit?ment not to divert it. Chil?dren and ado?les?cents may need coach?ing on how to respond if approached by peers seek?ing their medication.

Col?leges should con?sider revis?ing their con?duct poli?cies to address the mis?use and diver?sion of ADHD med?ica?tion, pro?vide stu?dents with secure stor?age places, and edu?cate stu?dents about the poten?tial dan?gers asso?ci?ated with non?med?ical use, espe?cially when used with alco?hol and other substances.

Pic cour?tesy of: Big?Stock?Photo

David Rabiner Attention Research Update??Dr. David Rabiner?is a child clin?i?cal psy?chol?o?gist and Direc?tor of Under?grad?u?ate Stud?ies in the Depart?ment of Psy?chol?ogy and Neu?ro?science at Duke Uni?ver?sity.? His research focuses on var?i?ous issues related to ADHD, the impact of atten?tion prob?lems on aca?d?e?mic achieve?ment, and atten?tion train?ing.? He also pub?lishes?Atten?tion Research Update, a com?pli?men?tary online newslet?ter that helps par?ents, pro?fes?sion?als, and edu?ca?tors keep up with the lat?est research on?ADHD.

Ref?er?ences ? Infor?ma?tion pro?vided above is drawn from the fol?low?ing sources among others.

  • Arria AM, Garnier-Dykstra, KM, Caldeira, KM, et al.: Per?sis?tent non?med?ical use of pre?scrip?tion stim?u?lants among col?lege stu?dents: Pos?si?ble asso?ci?a?tion with ADHD symp?toms. J Atten Dis?ord 2011, 15:347?356.
  • Dupont RL, Cole?man JJ, Bucher RH, Wil?ford BB. (2008). Char?ac?ter?is?tics and motives of col?lege stu?dents who engage in non?med?ical use of methylphenidate. The Amer?i?can Jour?nal on Addic?tions 2008, 17:167?171.
  • Garnier-Dykstra LM, Caldeira, KM, Vin?cent, KB, et al.: Non?med?ical use of pre?scrip?tion stim?u?lants dur?ing col?lege: Four year trends in expo?sure oppor?tu?nity, use, motives, and sources. J Am Col?lege Health 2012, 60:226?234. One of the few lon?gi?tu?di?nal stud?ies of non?med?ical use of stimulants.
  • John?ston LD, O-Malley PM, Bach?man, JG, et al.: Mon?i?tor?ing the Future national sur?vey results on drug use, 1975?2011: Vol?ume II, Col?lege stu?dents and adults ages 19?50. Ann Arbor: Insti?tute for Social Research, The Uni?ver?sity of Michi?gan. Includes recent national data on non?med?ical use of stim?u?lant medications.
  • McCabe SE, Teter, CJ. Drug use related prob?lems among non?med?ical users of pre?scrip?tion stim?u?lants: a web-based sur?vey of col?lege stu?dents from a Mid?west?ern uni?ver?sity. Drug Alco?hol Depen 2007, 91:69?76.
  • Novak SP, Kroutil LA, Williams RL, Van Brunt DL. The non?med?ical use of pre?scrip?tion ADHD med?ica?tions: Results from a national Inter?net panel. Sub?stance Abuse Treat?ment, Pre?ven?tion, and Pol?icy 2007,?2:32.
  • Peterkin, AL, Crone CC, Sheri?dan MJ, Wise, TN (2010). Cog?ni?tive per?for?mance enhance?ment: Mis?use or self-treatment? J Atten Dis?ord 2010, 15:263?268.
  • Rabiner, DL, Anastopoulus AD, Costello EJ et al.: Motives and Per?ceived Con?se?quences of Non?med?ical ADHD Med?ica?tion Use by Col?lege Stu?dents: Are stu?dents treat?ing them?selves for atten?tion prob?lems? J Atten Dis?ord 2009a, 13:259?270. Care?ful exam?i?na?tion of motives for non?med?ical use and asso?ci?a?tion of non?med?ical use with atten?tion problems.
  • Rabiner DL, Anastopoulus AD, Costello, EJ et al.: The mis?use and diver?sion of pre?scribed ADHD med?ica?tions by col?lege stu?dents. J Atten Dis?ord 2009, 13:144?153.
  • Sepul?veda DR, Thomas LM, McCabe, SE, et al.: Mis?use of pre?scribed stim?u?lant med?ica?tion for ADHD and asso?ci?ated pat?terns of sub?stance use: Pre?lim?i?nary analy?sis among col?lege stu?dents. Jour?nal of Phar?macy Prac?tice 2011, 24:551?560.
  • Sul?li?van, BK, May K, Gal?bally L. Symp?tom exag?ger?a?tion by col?lege adults in attention-deficit hyper?ac?tiv?ity dis?or?der and learn?ing dis?or?der assess?ments. Appl Neu?ropsy?chol 2007, 14:189?207.
  • Upad?hyaya HP, Rose K, Wang W, Brady KT. Attention-deficit/hyperactivity dis?or?der, med?ica?tion treat?ment, and sub?stance use pat?terns among ado?les?cents and young adults. J Child Ado?lesc Psy?chophar?ma?col 2005, 15:799?809.


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