Characteristics of college students with attention-deficit hyperactivity disorder symptoms who misuse their medications

Personal, Social and Cultural Predictors of Intention to Misuse Prescription Stimulants among Medical Students: A Test of the Theory of Triadic Influence

OBJECTIVE

The misuse of prescription stimulants among students has been identified as a public health problem. To date, most research has focused on individual-level determinants of stimulant misuse, making research on the socio-cultural context of students' misuse a priority. This study aims to test the applicability of the Theory of Triadic Influence, capturing three influence streams (personal, social and cultural) and three causational levels (ultimate, distal and proximal).

METHOD

A questionnaire on stimulant misuse was distributed among all bachelor's and master's students from the five Flemish medical faculties. In total, 3159 students participated (48.99% response rate). Data were analyzed using structural equation modeling.

RESULTS

Multiple personal (i.e., fear of failure, procrastination, self-perceived ADHD, sensation-seeking, academic stress, controllability), social (i.e., living situation, peer endorsement, social norm) and cultural (i.e., competitive study-environment, financial worries, positive and negative expectancies, attitude) factors were identified as risk factors of misuse intention. The strongest ultimate to distal pathway was found between self-perceived ADHD and positive expectancies, meaning that students who believed they have ADHD, although not diagnosed, were more likely to have positive expectancies about stimulants. Moreover, the strongest distal to proximal pathways were found between expectancies and attitudes toward stimulant misuse (i.e., more positive and fewer negative expectancies were associated with more favorable attitudes). Finally, attitudes were most strongly related to misuse intention.

CONCLUSIONS

The current study shows that the TTI is an important framework to understand the risk factors of stimulant misuse among medical students. This study offers a strong basis for prevention initiatives.

Pharmacological Neuroenhancement: Current Aspects of Categorization, Epidemiology, Pharmacology, Drug Development, Ethics, and Future Perspectives

Recent pharmacoepidemiologic studies suggest that pharmacological neuroenhancement (pNE) and mood enhancement are globally expanding phenomena with distinctly different regional characteristics. Sociocultural and regulatory aspects, as well as health policies, play a central role in addition to medical care and prescription practices. The users mainly display self-involved motivations related to cognitive enhancement, emotional stability, and adaptivity. Natural stimulants, as well as drugs, represent substance abuse groups. The latter comprise purines, methylxanthines, phenylethylamines, modafinil, nootropics, antidepressants but also benzodiazepines, β-adrenoceptor antagonists, and cannabis. Predominant pharmacodynamic target structures of these substances are the noradrenergic/dopaminergic and cholinergic receptor/transporter systems. Further targets comprise adenosine, serotonin, and glutamate receptors. Meta-analyses of randomized-controlled studies in healthy individuals show no or very limited verifiability of positive effects of pNE on attention, vigilance, learning, and memory. Only some members of the substance abuse groups, i.e., phenylethylamines and modafinil, display positive effects on attention and vigilance that are comparable to caffeinated drinks. However, the development of new antidementia drugs will increase the availability and the potential abuse of pNE. Social education, restrictive regulatory measures, and consistent medical prescription practices are essential to restrict the phenomenon of neuroenhancement with its social, medical, and ethical implications. This review provides a comprehensive overview of the highly dynamic field of pharmacological neuroenhancement and elaborates the dramatic challenges for the medical, sociocultural, and ethical fundaments of society.

Assessment of prescription stimulant misuse among college students using the MMPI-2-RF

Prescription stimulant misuse (PSM) is a growing concern on college campuses and more research is needed to validate clinical measures commonly used for the assessment of risk for PSM among college students. The present study examined correlations between scores on the Minnesota Multiphasic Personality Inventory-Second Edition-Restructured Form (MMPI-2-RF) and self- and peer-reported misuse of prescription stimulants and other drugs in a sample of 96 pairs (included within a total N = 212) of undergraduate students. Nearly half of the participants (48%) reported that they had been offered prescription stimulants and one quarter (26%) reported trying someone else's prescription stimulant medications, often to perform better academically. Scores on the MMPI-2-RF scales designed to measure general substance misuse (Substance Abuse [SUB]) and related behavioral or externalizing constructs (e.g., Antisocial Behavior [RC4], Behavioral/Externalizing Dysfunction [BXD], and Disconstraint-Revised [DISC-r]), were correlated positively with both self- and peer-reported prescription stimulant misuse (rs = 0.45-0.66), as well as with problematic use of other drugs (rs = 0.44-0.63). MMPI-2-RF scales designed to measure constructs in the domains of Emotional/Internalizing, Somatic/Cognitive, and Thought Dysfunction, as well as Interpersonal Functioning, had weaker correlations with misuse of prescription stimulants (rs < 0.24) and other drugs (rs < 0.29). These results provide support for the convergent validity of the MMPI-2-RF with regard to the assessment of prescription stimulant misuse and general drug misuse among college students.

Stimulant Diversion Risk Among College Students Treated for ADHD: Primary Care Provider Prevention Training

OBJECTIVE

To address increasing rates of stimulant misuse in college students, this study developed an evidence-based, brief clinical practice intervention for primary care providers (PCPs) to reduce stimulant medication diversion among young adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

College students (N-114; 18-25 years; 68% attending universities; 24% attending community college) treated for ADHD with a stimulant and their PCPs across six practices participated in this initial, uncontrolled study of pre- to post-intervention change. An educational workshop providing strategies aimed at reducing stimulant diversion was developed and delivered to providers and staff across all practices (50% pediatric; 50% family medicine). Patients and providers completed baseline and post intervention surveys.

RESULTS

Diversion was relatively infrequent, 16.7% at baseline and 14.9% post-intervention, respectively. Statistically significant decreases from baseline to post-intervention were found for three diversion risk factors: (1) number of times approached to divert, (2) intent to share, sell, or trade stimulants, and (3) disclosure of stimulant use. Providers and staff reported mostly high satisfaction with the training.

CONCLUSIONS

This study provides initial evidence for a PCP-delivered intervention to reduce stimulant diversion. Research is needed on the efficacy of targeting college students directly, working with pharmacies and student health centers, and preventing misuse among teenagers.

Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies

OBJECTIVE

To review all literature on the nonmedical use (NMU) and diversion of prescription stimulants to better understand the characteristics, risk factors, and outcomes of NMU and to review risk-reduction strategies.

METHOD

We systematically searched PubMed, PsycINFO, and SCOPUS from inception to May 2018 for studies containing empirical data about NMU and diversion of prescription stimulants. Additional references identified by the authors were also assessed for inclusion.

RESULTS

A total of 111 studies met inclusion criteria. NMU and diversion of stimulants are highly prevalent; self-reported rates among population samples range from 2.1% to 58.7% and from 0.7% to 80.0%, respectively. A variety of terms are used to describe NMU, and most studies have examined college students. Although most NMU is oral, non-oral NMU also occurs. The majority of NMU is associated with no, or minor, medical effects; however, adverse medical outcomes, including death, occur in some individuals, particularly when administered by non-oral routes. Although academic and occupational performance enhancement are the most commonly cited motivations, there is little evidence that academic performance is improved by NMU in individuals without attention-deficit/hyperactivity disorder.

CONCLUSION

NMU of stimulants is a significant public health problem, especially in college students, but variations in the terms used to describe NMU and inconsistencies in the available data limit a better understanding of this problem. Further research is needed to develop methods to detect NMU, identify individuals at greatest risk, study routes of administration, and devise educational and other interventions to help reduce occurrence of NMU. Colleges should consider including NMU in academic integrity policies.

Predictors of Prescription Stimulant Misuse in U.S. College Graduates

Background: Research has shown that prescription stimulant misuse (PSM) is prevalent among college students and that full-time college attendance is associated with PSM following graduation. Few studies, however, have examined predictors of PSM in college graduates. Objectives: We examined constructs from the Theory of Triadic Influence (TTI) to determine predictors of PSM in this population. Methods: We utilized Amazon's Mechanical Turk and snowball sampling in 2018-2019 to anonymously survey 219 adults in the United States (56% male, M_age = 32.5) with a college degree and history of college PSM. We assessed sensation seeking, ADHD symptoms, negative affect, social norms, workload, positive beliefs and perceived safety, other substance use, PSM motivations, and source(s) of prescription stimulants. Measures were administered online. Results: Over half (55%) of participants reported PSM after college; 36% used in the previous year. Ordinal logistic regressions for each domain of the TTI (i.e. intrapersonal, social/normative, cultural/attitudinal) showed that college graduates engaging in PSM in the previous year were younger and reported higher sensation seeking, more friends/coworkers who engaged in PSM, a heavier workload, and more positive beliefs about PSM. Chi-square analyses showed that college graduates engaging in PSM in the previous year also were more likely to use other substances (e.g. prescription opioids, tobacco/nicotine, cocaine) and to have misused stimulants in college to socialize or to get high. Conclusions: Preventive interventions could target college students and recent graduates who engage in PSM and who demonstrate the aforementioned risk factors, with the goal of curbing PSM and possibly other substance use.

Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes

While treatment of patients with attention-deficit hyperactivity disorder (ADHD) is based on a multimodal approach that combines medication with specific psychological interventions, pharmacotherapy alone is generally considered an essential and cost-effective element. This paper aims to comprehensively and critically review factors involved in prescribing and medication use in individuals diagnosed with ADHD, focusing on the difficulties facing patients with ADHD seeking treatment, as well as the safety and tolerability aspects of ADHD pharmacotherapies, with particular attention on the cardiovascular adverse events and the potential risk of misuse or diversion of ADHD medications. A comprehensive and systematic literature search of PubMed/MEDLINE database was conducted to identify studies published in peer-reviewed journals until 1 August 2016. Children, adolescents and adults often encounter significant difficulties in the process of accessing specialist assessment and treatment for ADHD as a consequence of disparities in service organization and available treatment provision. Despite the well-established efficacy and overall safety profile, ADHD medications are not exempt from adverse events. The cardiovascular safety of pharmacotherapies used for treating individuals with ADHD has raised particular concerns; however there is little evidence of serious cardiovascular adverse events, including no serious corrected QT (QTc) abnormalities associated with stimulants, atomoxetine or α2-adrenergic receptor agonists. Although the abuse of prescription stimulant drugs, particularly, short-acting stimulants is a prevalent and growing problem, nonmedical use of prescription stimulants within the clinical context is very limited. In addition, nonstimulant ADHD medications lack any reinforcing effects and consequently any abuse potential.

Management and Treatment of Attention-Deficit/Hyperactivity Disorder on College Campuses

Attention-deficit/hyperactivity disorder (ADHD) on college campuses is a serious and often underdiagnosed condition. The current investigation analyzed current best practice guidelines for the management of ADHD in a mid-sized university in the Midwestern United States. Best practices were identified through a review of current evidence-based literature on ADHD management. A data collection tool was developed and used to organize data and determine adherence with best practice guidelines. Investigators revealed that policy and procedures followed best practice guidelines. Development and implementation of ADHD protocols on college campuses allows nurse practitioners to confidently provide safe, quality care to patients diagnosed with ADHD.

Sensation seeking and cocaine dependence in adults with reported childhood ADHD

OBJECTIVE

To compare measures of sensation seeking in a clinical group of cocaine-dependent (CD) patients with and without a history of probable childhood ADHD and in non-cocaine-dependent (NCD) healthy volunteers.

METHOD

Patients (n = 75; 42 with and 33 without probable childhood ADHD) and comparisons (n = 84) were assessed with the Diagnostic Interview for Genetic Studies, the Wender Utah Rating Scale for childhood ADHD, and the Zuckerman Seeking Sensation Scale.

RESULTS

We found significantly higher prevalence rates of probable childhood ADHD in CD versus NCD (p < .001). The mean total scores of sensation seeking were significantly higher in CD versus NCD participants (p < .001) as well as in CD patients with versus those without a probable history of childhood ADHD (p < .001).

CONCLUSION

Our study sets the basis for longitudinal investigation assessing whether the persistence of high level of sensation seeking in adults with childhood ADHD contributes to the transition to cocaine dependence.

Pharmacological interventions for adolescents and adults with ADHD: stimulant and nonstimulant medications and misuse of prescription stimulants

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity that cause functional impairment. Recent research indicates that symptoms persist into adulthood in the majority of cases, with prevalence estimates of approximately 5% in the school age population and 2.5%–4% in the adult population. Although students with ADHD are at greater risk for academic underachievement and psychosocial problems, increasing numbers of students with ADHD are graduating from high school and pursuing higher education. Stimulant medications are considered the first line of pharmacotherapy for individuals with ADHD, including college students. Although preliminary evidence indicates that prescription stimulants are safe and effective for college students with ADHD when used as prescribed, very few controlled studies have been conducted concerning the efficacy of prescription stimulants with college students. In addition, misuse of prescription stimulants has become a serious problem on college campuses across the US and has been recently documented in other countries as well. The purpose of the present systematic review was to investigate the efficacy of prescription stimulants for adolescents and young adults with ADHD and the nonmedical use and misuse of prescription stimulants. Results revealed that both prostimulant and stimulant medications, including lisdexamfetamine dimesylate, methylphenidate, amphetamines, and mixed-amphetamine salts, are effective at reducing ADHD symptoms in adolescents and adults with ADHD. Findings also suggest that individuals with ADHD may have higher rates of stimulant misuse than individuals without the disorder, and characteristics such as sex, race, use of illicit drugs, and academic performance are associated with misuse of stimulant medications. Results also indicate that individuals both with and without ADHD are more likely to misuse short-acting agents than long-acting agents. These findings have implications for intervention, prevention, and future research.

Stress, Drugs, and Alcohol Use Among Health Care Professional Students

Objective:

To contrast the characteristics of pharmacy, medicine, and physician assistant (PA) students regarding the prevalence of drug, alcohol, and tobacco use and to identify risk factors associated with prescription stimulant use.

Participants:

Five hundred eighty nine students were recruited to complete a 50-item Web-based survey.

Main Outcome Measures:

Demographics, nonmedical prescription medication use, illicit drug and alcohol use, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR) psychiatric diagnoses, and perceived stress scale (PSS) scores.

Results:

Medicine and PA students reported greater nonmedical prescription stimulant use than pharmacy students (10.4% vs 14.0% vs 6.1%; P < .05). Medicine and PA students were more likely to report a history of an anxiety disorder (12.1% vs 18.6% vs 5.9%; P < .05), major depressive disorder (9.4% vs 8.1% vs 3.3%; P < .05), and attention-deficit hyperactivity disorder (ADHD; 4.0% vs 9.3% vs 0.7%; P < .001) than pharmacy students. PSS scores for all 3 groups (21.9-22.3) were roughly twice as high as the general adult population.

Conclusion:

Illicit drug and prescription stimulant use, psychiatric disorders, and elevated stress levels are prevalent among health care professional students. Health care professional programs may wish to use this information to better understand their student population which may lead to a reassessment of student resources and awareness/prevention programs.

Volunteerism and self-selection bias in human positron emission tomography neuroimaging research

Scientists have known for decades that persons who volunteer for behavioral research may be different from those who decline participation and that characteristics differentiating volunteers from non-volunteers may vary depending on the nature of the research. There is evidence that volunteer self-selection can impact representativeness of samples in studies involving physically or psychologically stressful procedures, such as electric shocks, sensory isolation, or drug effects. However, the degree to which self-selection influences sample characteristics in "stressful" studies involving positron emission tomography (PET) has not been evaluated. Since estimation of population parameters, robustness of findings, and validity of inferred relationships can all be impacted by volunteer bias, it is important to determine if self-selection may act as an unrecognized confound in such studies. In the present investigation, we obtained baseline data on 114 (56M, 58F) subjects who participated in a study involving completion of several self-report questionnaires and behavioral performance tasks. Participants were later given the opportunity to enroll in an [11C]raclopride PET study involving intravenous amphetamine (AMPH) administration. Demographic characteristics, personality traits, and task performance of subjects who consented to the latter study were compared with those who declined participation. Findings showed that the principal personality trait that distinguished the two groups was sensation-seeking; volunteers scored significantly higher on this dimension than non-volunteers. Males were more likely to volunteer than females. However, results of mediation analysis suggested that the relationship between gender and volunteer status was mediated by greater sensation-seeking traits in the males. Implications of these findings are discussed.

Illegal college ADHD stimulant distributors: characteristics and potential areas of intervention

This study identifies indicators of college students, with prescriptions to Attention Deficit Hyperactivity Disorder (ADHD) stimulants, who are most likely to distribute their medication to nonprescribed peers. 2,313 undergraduate students at a large Southeastern University were surveyed from 2009 to 2011. 5.2% (n = 120) were currently taking a prescribed ADHD stimulant. Analyses revealed that distributors are more likely to (1) take their medication less frequently; (2) misuse their stimulants for "off label" purposes; (3) be a member of a fraternity; (4) overestimate the percentages of users; and (5) belong to at-risk peer groups. The work concludes by discussing the study's implications, limitations and future research.

Environmental enrichment during development decreases intravenous self-administration of methylphenidate at low unit doses in rats

Despite the efficacy and widespread use of methylphenidate (MPH) as a treatment modality for attention deficit hyperactivity disorder, clinical and preclinical findings indicate that it has abuse potential. Environmental enrichment reduces susceptibility to cocaine and amphetamine self-administration and decreases impulsive behavior, but its effects on MPH self-administration are unknown. The present experiments sought to determine the influence of environmental enrichment on MPH self-administration. Male rats were raised in an enriched condition (EC) or isolated condition (IC). They were trained to self-administer MPH (0.3 mg/kg/infusion) and then exposed to varying doses of MPH on either a fixed-ratio (experiment 1) or a progressive-ratio (experiment 2) schedule of reinforcement. EC rats earned significantly fewer infusions of MPH at low doses (0.03 and 0.056 mg/kg/infusion) compared with IC rats under both schedules; however, no differences were observed at high unit doses (0.1-1.0 mg/kg/infusion). During saline substitution at the end of MPH self-administration, EC rats also responded less for saline compared with IC rats, indicative of more rapid extinction. As with other stimulant drugs with different mechanisms of action, environmental enrichment during development protects against self-administration of MPH at low unit doses but not at high unit doses.

The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care?

AIMS

To examine the literature pertaining to the diversion and misuse of pharmaceutical stimulants.

METHODS

Relevant literature was identified through comprehensive MEDLINE, EMBASE and PubMed searches.

RESULTS

The evidence to date suggests that the prevalence of diversion and misuse of pharmaceutical stimulants varies across adolescent and young adult student populations, but is higher than that among the general population, with the highest prevalence found among adults with attention deficit-hyperactive disorder (ADHD) and users of other illicit drugs. Concerns that these practices have become more prevalent as a result of increased prescribing are not supported by large-scale population surveys. Information on trends in misuse in countries where there have been recent increases in prescription and consumption rates, however, is limited. Little is known about the frequency and chronicity of misuse, or the extent of associated harms, particularly among those populations, i.e. adolescents, young adult student populations, those with ADHD and illicit drug users, where abuse may be more likely to occur.

CONCLUSIONS

Continued monitoring of the diversion and misuse of pharmaceutical stimulants is of major clinical importance. Despite recognition of the abuse liability of these medications, there is a paucity of data on the prevalence, patterns and harms of diversion and misuse among populations where problematic use and abuse may be most likely to occur (e.g. adolescents, young adults, illicit drug users). Comprehensive investigations of diversion and misuse among these populations should be a major research priority, as should the assessment of abuse and dependence criteria among those identified as regular users.