Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Stigma Related to the Non-Medical Use and Diversion of Prescription Stimulant Drugs: Should We Care

BACKGROUND

Non-medical use (NMU) and diversion of prescription stimulants are prevalent on college campuses. Diversion represents a primary source of acquisition for NMU among young adults. This study examined relationships between stigmatizing beliefs related to NMU and diversion of stimulant medications and engagement in these behaviors, as well as how such perceptions are associated with indicators of psychological distress among those who engage in these behaviors.

METHODS

Young adults (N = 384) were recruited from a large US university to participate in this cross-sectional electronic survey-based study. Relationships between stigma variables and NMU and diversion were assessed. Among those who engage in NMU and diversion, we tested relationships between stigma variables and indicators of psychological distress, using validated instruments.

RESULTS

Perceived social and personal stigmatic beliefs did not significantly predict NMU. However, perceived social and personal stigma of diversion significantly reduced diversion likelihood. For NMU, associations were found between stigma variables and indicators of psychological distress. Markedly, we found that as stigmatic perceptions of NMU increased, so did depressive, anxiolytic, and suicidal symptomatology among those who engage in NMU.

CONCLUSIONS

Stigmatization does not deter NMU; however, stigmatization is positively associated with psychological harm among those who engage in NMU. Interventions should be developed to reduce stigmatization in order to improve psychological health among those who engage in NMU. Stigmatic perceptions of diversion were not predictive of psychological harm, though they are negatively associated with diversion behavior.

Are cognitive aspects of defense a core feature of anxiety and depression?

Anxiety and depression are highly prevalent behavior disorders, particularly in women. Recent preclinical work using animal models has been suboptimal in predicting the efficacy of drugs targeted at these conditions, suggesting a potential discrepancy between such models and the human disorders. Notably female animals tend to be equal to, or less responsive than, males in these tasks. A number of analyses suggest that mammalian defense patterns are complex: In addition to relatively discrete and immediate fight, flight, and freezing responses, a risk assessment pattern may occur in response to threat stimuli or situations with ambiguous elements. This pattern combines defensiveness with a number of cognition-linked behaviors such as sensory attention and orientation, approach, contact, and investigation of the potential threat. Studies measuring elements of this pattern suggest that female rats, and perhaps female mice, show higher levels than equivalent males. Higher female involvement may also occur in tasks involving learning/generalization/extinction of defensiveness to conditioned stimuli. Such findings are consonant with recent analyses of "female survival strategies" based on differential adaptiveness of cognitive components of defensiveness in females, due to the necessity of female care of offspring until they are independent. These data suggest the value of additional behavioral and functional analyses of cognitive aspects of defensive behavior; contributing to both an understanding of their underlying mechanisms, and providing more sensitive measures of drug responsivity for use with animal models.

Malingering and Stimulant Medications Abuse, Misuse and Diversion

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that interferes with multiple aspects of daily functioning. Malingering or feigning of symptoms can be a major challenge during ADHD assessment. Stimulant medication abuse, misuse and diversion may constitute another challenge during management. A literature search of the past 15 years on the topic continued to suggest that there are several reasons for malingering and faking ADHD symptoms. Some of the reasons include the intent to obtain prescriptions for stimulant medications for performance enhancement, to gain access to additional school services and accommodations, to use recreationally and to sell as a street drug. In some countries, patients may receive additional tax or student loan benefits. Several researchers suggested that self-report rating measures are easily simulated by patients without ADHD. They concluded that no questionnaire has proved sufficiently robust against false positives. Some clinical factors that may suggest malingering during the ADHD assessment are highlighted and some available tests to detect malingering are discussed.

Associations of prescription stimulant misuse with subsequent methamphetamine use among a U.S. cohort of HIV-vulnerable sexual and gender minorities who have sex with men

INTRODUCTION

Prescription stimulants and methamphetamine have similarities in chemical structure and impact on biological functioning. However, there is limited literature on prescription stimulant misuse among sexual and gender minorities as well as how prescription misuse may impact later methamphetamine use.

METHODS

We used data collected from a HIV prevention cohort to describe (e.g., frequencies, percentages) prescription stimulant use/misuse and methamphetamine use at baseline and 12-month follow-up (n = 4857). We then used multivariable logistic regression models to determine the impact of baseline prescription stimulant misuse and methamphetamine use on 12-month prescription stimulant misuse and methamphetamine use.

RESULTS

At baseline, 10.2 % of participants misused prescription stimulants and 12 % of participants used methamphetamine in the past 3 months, while at 12-month follow-up 11.6 % of participants misused prescription stimulants and 11.2 % of participants used methamphetamine in the past 3 months. Multivariable regression analyses indicated that participants who misused prescription stimulants (in the absence of methamphetamine) at baseline had 2.51 (95 % CI: 1.44-3.59, ref. no stimulant or methamphetamine use) times the odds of using methamphetamine at 12-month follow-up.

DISCUSSION

Findings suggest that prescription stimulant use is a risk factor for continued meth use. Therefore, earlier and targeted public health interventions could reduce methamphetamine use by disrupting the progression from prescription stimulant misuse to methamphetamine use through early screening and interventions for prescription stimulant misuse.

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.

Differences in eating disorder symptoms and affect regulation for residential eating disorder patients with problematic substance use

PURPOSE

The aim of the current study was to investigate differences in treatment outcomes for residential eating disorder (ED) treatment patients diagnosed with comorbid substance use disorders (SUDs), particularly differences in ED pathology and affect dysregulation.

METHOD

Secondary data analysis was conducted on data from a previous study of 140 patients at a residential ED facility. SUD was diagnosed by a staff psychiatrist upon admission, and SUD diagnosis was extracted from electronic health records for the current study. Self-report measures of eating pathology and affect dysregulation from pre-treatment and post-treatment assessments were analyzed.

RESULTS

20.1% of the sample (n = 29) were diagnosed with a substance use disorder at the start of treatment. Contrary to hypotheses, those with comorbid SUD did not significantly differ in eating pathology severity, depression symptoms, emotion dysregulation, or psychological acceptance at baseline. Also contrary to hypotheses, individuals with comorbid SUD and ED evidenced slightly larger improvements in certain areas of eating pathology and affect dysregulation throughout treatment than those with ED diagnosis only.

CONCLUSIONS

These findings suggest that residential ED treatment is an appropriate treatment choice for individuals with comorbid SUD. The observed improvements in affect dysregulation combined with a period of forced abstinence from maladaptive affect regulation behaviors may explain these positive results, though more research is needed to test the mechanisms of action of residential treatment for this population.

LEVEL OF EVIDENCE

IV, multiple time series analysis.

Predicting eating disorders from Internet activity

OBJECTIVE

Eating disorders (EDs) compromise the health and functioning of affected individuals, but it can often take them several years to acknowledge their illness and seek treatment. Early identification of individuals with EDs is a public health priority, and innovative approaches are needed for such identification and ultimate linkage with evidence-based interventions. This study examined whether Internet activity data can predict ED risk/diagnostic status, potentially informing timely interventions.

METHOD

Participants were 936 women who completed a clinically validated online survey for EDs, and 231 of them (24.7%) contributed their Internet browsing history. A machine learning algorithm used key attributes from participants' Internet activity histories to predict their ED status: clinical/subclinical ED, high risk for an ED, or no ED.

RESULTS

The algorithm reached an accuracy of 52.6% in predicting ED risk/diagnostic status, compared to random decision accuracy of 38.1%, a relative improvement of 38%. The most predictive Internet search history variables were the following: use of keywords related to ED symptoms and websites promoting ED content, participant age, median browsing events per day, and fraction of daily activity at noon.

DISCUSSION

ED risk or clinical status can be predicted via machine learning with moderate accuracy using Internet activity variables. This model, if replicated in larger samples where it demonstrates stronger predictive value, could identify populations where further assessment is merited. Future iterations could also inform tailored digital interventions, timed to be provided when target online behaviors occur, thereby potentially improving the well-being of many individuals who may otherwise remain undetected.

Disordered eating is associated with non-medical use of prescription stimulants among college students

BACKGROUND

Disordered eating behaviors are associated with non-medical use of prescription stimulants for weight and appetite-related purposes. Yet, estimates of the prevalence and types of disordered eating associated with non-medical use vary. Additionally, little is known about the association between medical use of prescription stimulants and disordered eating.

METHOD

Data were collected from 87,296 college students at 127 institutions that participated in the Healthy Minds Study. We assessed the relationship between disordered eating, medical and nonmedical prescription stimulant use using multivariable logistic regression models adjusted for demographic characteristics, lifestyle and behavioral factors, and psychiatric comorbidity.

RESULTS

Non-medical use of prescription stimulants (NMUPS) was reported by 2.8 % n = 2435 of the sample. One-third of students using prescription stimulants non-medically reported two or more disordered eating attitudes and behaviors. Disordered eating was a significant predictor of non-medical, but not medical use of prescription stimulants. A dose-response relationship was identified between disordered eating and non-medical use, where risk for non-medical use increased with the number of disordered eating attitudes and behaviors reported.

CONCLUSIONS

The risk for NMUPS increases with disordered eating symptomatology. There is a need to assess for NMUPS among college students presenting with disordered eating.

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.

Attention Deficit Hyperactivity Disorder in Athletes

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in difficulties with sustaining attention in tasks and/or hyperactivity/impulsivity. Prevalence rates vary and difficulties in objectively diagnosing ADHD may lead to overdiagnosis or underdiagnosis. Assessment should include a comprehensive evaluation, including history, physical, psychological evaluation, and questionnaires for ADHD. Stimulant medications are effective for treatment, but their use, side effects, and potential for misuse and abuse are a concern, particularly in athletes. Athletes and physicians also need to be aware of the governing body's drug policy for the sport.

Prescription drug misuse in adolescents and young adults: an emerging issue as a health problem

INTRODUCTION

In recent years, prescription drug misuse has become a common issue among adolescents and young adults in many countries, with, for example, a lifetime prevalence of 12% among individuals aged 12-17 in 2017 in United States.

PURPOSE OF REVIEW

To summarize recently published studies about prescription drug misuse among adolescent and young adults.

RECENT FINDINGS

Prescription drug misuse has many definitions, one being any medication taken in a way other than prescribed, whether related to dosage or manner of usage. Among adolescents, it has a relationship with illicit drug use, decline in academic performance, future delinquency, and mental problems. Individual predisposing factors include identity crisis and role confusion, and there are also environmental influences. Preventive approaches include the use of monitoring systems. Management involves initial assessment and treatment, which largely focuses on behavioural interventions.

SUMMARY

Further understanding of risk and protective factors, co-occurring issues, and treatment can help prevent and reduce the prevalence of prescription drug misuse. Collaboration among government, clinicians, and patients is urged to combat this growing issue.

Exploring weight control as motivation for illicit stimulant use

OBJECTIVE

Research has highlighted a growing trend among young, adult women to initiate drug use for weight loss. With known suppressive effects on appetite, illicit stimulants (i.e., cocaine, amphetamine, methamphetamine, and ecstasy) may be particularly attractive to college women, who are at elevated risk for increased body dissatisfaction and experimenting with extreme weight loss techniques. The current study examines the association between risk factors and symptomatology of eating disorders and illicit stimulant use (ISU).

METHODS

A preliminary study was conducted on a nonclinical sample of 131 drug-using, college women (16- to 24-years old). Participants reported internalization of the thin ideal, body dissatisfaction, disordered eating behavior, and current drug use as well as corresponding weight-related motivation.

RESULTS

There were 15.3% of women who reported drug use for weight-control purposes. Results showed women who reported drug use for weight control predominantly used illicit stimulants (70%), such as cocaine, amphetamine, methamphetamine, and ecstasy. Moreover, the odds of ISU were increased among women who engaged in laxative misuse.

CONCLUSIONS

These results suggest that a desire for weight control may be associated with ISU among college women. Women engaging in more extreme weight loss behaviors are at high risk for initiating and maintaining ISU for weight-related reasons.

Eating Disorders Impact on Vigilance and Decision Making of a Community Sample of Treatment Naive Attention-Deficit/Hyperactivity Disorder Young Adults

Although impulsivity is suggested as a possible link to explain the association of Attention-Deficit/Hyperactivity Disorder (ADHD) with an Eating Disorder (ED), there is little research on how clinical and cognitive/neuropsychological functioning might change when this comorbidity occurs. ADHD individuals are at a higher of developing ED and also obesity. Some research has described the impact of ADHD in clinical treatment-seeking samples of ED patients. Consequently, we investigated how ED impacted on clinical and cognitive variables of a community sample of treatment-naive ADHD individuals. Ninety college students arranged in three groups (ADHD+ED, ADHD only and Controls) were analyzed using semi-structured interviews for ADHD (K-SADS), the Iowa Gambling Task, the Conner's Continuous Performance Test, Digit and Visual span, as well as rating scales for anxiety (STAI), depression (BDI) and impulsivity (BIS-11), and binge eating (BES). We found that ADHD+ED individuals significantly differed from both groups, presenting with a higher body mass index; more hyperactivity-impulsivity symptoms; higher binge eating scores; more omission errors on the Continuous Performance Test; disadvantageous choices on the Iowa Gambling Task. Also, we demonstrated through a moderation/mediation analysis that a greater level of binge eating mediated the increases in body mass index on our sample. There were no significant paths to explain binge-eating severity through changes on any of the neuropsychological tests used. The presence of an ED in normal weight in a community sample of ADHD individuals is associated with higher body mass index and a worse cognitive functioning.

Attention-Deficit Hyperactivity Disorder: Clinical Considerations for Women

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by hyperactivity, impulsivity, and/or inattention. Women with ADHD represent a particularly vulnerable group, given their increased risk for psychosocial and parenting difficulties. Women's health care clinicians should expect to encounter women with diagnosed and undiagnosed ADHD that may or may not be treated. Pharmacologic intervention, namely, prescription stimulants, is an important consideration for pregnant and breastfeeding women with ADHD, especially because the US Food and Drug Administration has determined that there is not enough information to confirm either harm or lack of harm to the developing fetus following exposure to these drugs. Due to the increase in use of prescription stimulants without a prescription, clinicians are also likely to encounter women misusing stimulants for a variety of reasons. This article provides an overview of ADHD diagnosis, outlines effective treatment options, and offers insight into the importance for clinicians to consider prescription stimulant misuse. Guidance concerning treatment of ADHD during pregnancy and lactation is reviewed.

Topiramate via NMDA, AMPA/kainate, GABAA and Alpha2 receptors and by modulation of CREB/BDNF and Akt/GSK3 signaling pathway exerts neuroprotective effects against methylphenidate-induced neurotoxicity in rats

Chronic abuse of methylphenidate (MPH) often causes neuronal cell death. Topiramate (TPM) carries neuroprotective effects, but its exact mechanism of action remains unclear. In the present study, the role of various doses of TPM and its possible mechanisms, receptors and signaling pathways involved against MPH-induced hippocampal neurodegeneration were evaluated in vivo. Thus, domoic acid (DOM) was used as AMPA/kainate receptor agonist, bicuculline (BIC) as GABA_A receptor antagonist, ketamine (KET) as NMDA receptor antagonist, yohimbine (YOH) as α₂ adrenergic receptor antagonist and haloperidol (HAL) was used as dopamine D₂ receptor antagonist. Open field test (OFT) was used to investigate the disturbances in motor activity. Hippocampal neurodegenerative parameters were evaluated. Protein expressions of CREB/BDNF and Akt/GSK3 signaling pathways were also evaluated. Cresyl violet staining was performed to show and confirm the changes in the shape of the cells. TPM (70 and 100 mg/kg) reduced MPH-induced rise in lipid peroxidation, oxidized form of glutathione (GSSG), IL-1β and TNF-α levels, Bax expression and motor activity disturbances. In addition, TPM treatment increased Bcl-2 expression, the level of reduced form of glutathione (GSH) and the levels and activities of superoxide dismutase, glutathione peroxidase and glutathione reductase enzymes. TPM also inhibited MPH-induced hippocampal degeneration. Pretreatment of animals with DOM, BIC, KET and YOH inhibited TPM-induced neuroprotection and increased oxidative stress, neuroinflammation, neuroapoptosis and neurodegeneration while reducing CREB, BDNF and Akt protein expressions. Also pretreatment with DOM, BIC, KET and YOH inhibited TPM-induced decreases in GSK3. It can be concluded that the mentioned receptors by modulation of CREB/BDNF and Akt/GSK3 pathways, are involved in neuroprotection of TPM against MPH-induced neurodegeneration.

Attention-deficit/hyperactivity disorder and eating disorders across the lifespan: A systematic review of the literature

Attention-deficit/hyperactivity disorder (ADHD) and eating disorders are common and concerning mental health disorders. There is both empirical and theoretical support for an association between ADHD and eating disorders or disordered eating. This systematic review aims to summarize the extant literature on the comorbidity of ADHD and eating disorders across the lifespan, including the influences of sex, age, eating disorder diagnosis, and potential mediators. A total of 37 peer-reviewed studies on diagnosed ADHD and eating disturbances were identified through key research databases. Twenty-six studies supported a strong empirical association between ADHD and eating disorders or disordered eating. The systematic review findings suggest that children with ADHD are at risk for disordered eating, while adolescents, emerging adults, and adults are at risk for both eating disorders and disordered eating. Methodological considerations, future research, and clinical implications are discussed.

Nonmedical prescription stimulant use for suppressing appetite and controlling body weight is uniquely associated with more severe eating disorder symptomatology

OBJECTIVE

Nonmedical prescription stimulant use (NPS; i.e., use without a prescription or in ways other than prescribed) to suppress appetite or control weight appears to be associated with eating disorder (ED) symptomatology among college students. However, it remains unknown if this relationship is motive-specific and uniquely related to ED symptomatology. This research examined whether engaging in NPS specifically for appetite/weight-related purposes is associated with ED symptomatology and a unique indicator of more severe symptomatology.

METHOD

A nonclinical sample of college students (N = 668; 79% female) reported eating disorder symptoms via the Eating Pathology Symptoms Inventory and Eating Disorder Examination-Questionnaire, and lifetime history of NPS and corresponding motives.

RESULTS

Binge eating, body dissatisfaction, negative attitudes towards obesity, restricting, purging, and cognitive restraint were reported more frequently by students who endorsed NPS for weight/appetite-related purposes than by those who used for other purposes or denied lifetime NPS. Additionally, NPS for appetite/weight-related purposes was uniquely associated with ED symptomatology after adjusting for gender, lifetime NPS, and past-month binge eating and purging.

DISCUSSION

Engaging in NPS for appetite/weight-related purposes is a unique indicator of ED symptomatology, highlighting the need to query for this behavior among individuals with an ED. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:813-816).