Adderall abuse in Texas, 1998-2004

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.

Surveillance of diversion and nonmedical use of extended-release prescription amphetamine and oral methylphenidate in the United States

This article examines rates of nonmedical use and diversion of extended-release amphetamine and extended-release oral methylphenidate in the United States. Prescription dispensing data were sourced from retail pharmacies. Nonmedical use data were collected from the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System Drug Diversion Program and Poison Center Program. Drug diversion trends nearly overlapped for extended-release amphetamine and extended-release oral methylphenidate. Calls to poison centers were generally similar; however, calls regarding extended-release amphetamine trended slightly lower than those for extended-release oral methylphenidate. Data suggest similar diversion and poison center call rates for extended-release amphetamine and extended-release oral methylphenidate.

Adolescent synthetic cannabinoid exposures reported to Texas poison centers

OBJECTIVE

This study describes the pattern of adolescent synthetic cannabinoid exposures reported to a large statewide poison center system.

METHODS

Synthetic cannabinoid exposures among patients younger than 20 years reported to Texas poison centers during January 2010 to June 2011 were identified. The distribution of exposures by various demographic and clinical factors was determined.

RESULTS

For 305 adolescent exposures, the mean age was 16.7 years (range, 12-19 y). The exposure was by inhalation in 77.4% of the cases, and 72.1% involved males. The exposure site was the patient's own residence in 70.5% of the cases, and a health care facility was the caller site in 68.9%. The patient was already at or en route to a health care facility in 80.3% of the cases, and the medical outcome was serious in 61.0%. The most frequently reported adverse clinical effects were tachycardia (41.6%), drowsiness/lethargy (24.3%), agitation/irritability (16.4%), vomiting (13.1%), hallucinations/delusions (11.5%), nausea (8.5%), confusion (8.2%), hypertension (7.5%), chest pain (6.9%), and dizziness/vertigo (5.2%).

CONCLUSIONS

Adolescent synthetic cannabinoid exposures reported to Texas poison centers were more likely to involve inhalation. The adolescents were more likely to be male. The exposures more often occurred at the patient's own residence and managed at a health care facility with a serious outcome. This pattern of exposures was similar to that observed among adults.

Dextromethorphan abuse in Texas, 2000-2009

Dextromethorphan abuse is increasing in United States. Intentional misuse or abuse ingestions of dextromethorphan-containing products reported to Texas poison centers during 2000-2009 were identified and the distribution of ingestions by selected factors was determined. There were 3,421 total cases; Coricidin® (Schering-Plough Health Care Products, Inc., Memphis, TN) products were involved in 53.6% of cases. The number of cases increased during 2000-2002 and then declined during 2003-2005 before increasing again in 2006 and remaining relatively constant afterward. The majority of patients were male (60.4%) and between 13 and 19 years of age (69.0%). A potentially serious outcome was assigned in 46.2% of the cases and 83.1% were managed at a health care facility.

How addictive drugs disrupt presynaptic dopamine neurotransmission

The fundamental principle that unites addictive drugs appears to be that each enhances synaptic dopamine by means that dissociate it from normal behavioral control, so that they act to reinforce their own acquisition. This occurs via the modulation of synaptic mechanisms that can be involved in learning, including enhanced excitation or disinhibition of dopamine neuron activity, blockade of dopamine reuptake, and altering the state of the presynaptic terminal to enhance evoked over basal transmission. Amphetamines offer an exception to such modulation in that they combine multiple effects to produce nonexocytic stimulation-independent release of neurotransmitter via reverse transport independent from normal presynaptic function. Questions about the molecular actions of addictive drugs, prominently including the actions of alcohol and solvents, remain unresolved, but their ability to co-opt normal presynaptic functions helps to explain why treatment for addiction has been challenging.

A qualitative review of issues arising in the use of psycho-stimulant medications in patients with ADHD and co-morbid substance use disorders

OBJECTIVE

This review addresses the relationship between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs), with an emphasis on factors that determine the potential for psychostimulant abuse. Strategies for identification and treatment of patients with ADHD who are at risk for, or have, co-morbid SUD are also addressed.

RESEARCH DESIGN AND METHODS

The article was based on a qualitative review of current literature addressing co-morbid ADHD and SUD.

DISCUSSION

Adolescent and adult patients with ADHD are at increased risk for SUD, as well as a number of other psychiatric disorders. Psychostimulant agents like methylphenidate (MPH) and mixed amphetamine salts (MAS) are effective first-line pharmacotherapies for ADHD; however, they are Schedule II controlled substances with a potential for abuse. Evidence suggests that treatment of ADHD during childhood with stimulant agents may reduce the risk of developing SUD later on. Factors associated with the highest risk of SUD in patients with ADHD include co-morbid antisocial personality disorder, bipolar disorder, an eating disorder, severe ADHD and/or antisocial behavior symptoms, and dropping out of school. Treatment initiation during adolescence or young adulthood also has been linked to increased risk of polydrug use and non-medical stimulant use, a pattern of behavior consistent with a risk of SUD development. Treatment plans for patients with ADHD and co-morbid SUD should include behavioral interventions, careful monitoring, and when appropriate, pharmacotherapy. When oral formulations of psychostimulants are used at recommended doses and frequencies, they are unlikely to yield effects consistent with abuse potential in patients with ADHD. Long-acting stimulant formulations and non-stimulants, like atomoxetine or bupropion, have a lower potential for abuse, and provide several safe and effective treatment options for the development of a comprehensive management plan for patients with co-morbid ADHD and SUD.

CONCLUSIONS

The present review is neither exhaustive nor systematic. Moreover, the reviewed studies vary widely with regards to methodology and patient populations. In light of these limitations, several conclusions are still warranted. Patients with ADHD are at increased risk for SUD. Under certain conditions, psychostimulants may be a pharmacologic option in the treatment of patients with co-morbid ADHD and SUD. However, clinicians should be mindful of the risks and benefits of this treatment approach in a high-risk population and should also bear in mind the labeling guidelines when working with this co-morbidity.

Pediatric atomoxetine ingestions reported to Texas poison control centers, 2003-2005

Limited information exists on potentially adverse consequences following pediatric atomoxetine ingestions reported to poison control centers. Using pediatric atomoxetine ingestions reported to Texas poison control centers during 2003-2005, the proportion of cases involving serious outcomes (medical outcomes classified as moderate effects, major effects, death, or judged as potentially toxic exposures) was determined for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). Of 501 cases identified, 31 (6%) involved serious outcomes. Higher serious outcome rates were found with a maximum dose of >2.8 mg/kg or >200 mg or >4 tablets. Serious outcome rates were also higher if the exposure involved intentional self-harm or the patient was already at or en route to a health care facility when the poison control center was contacted or referred to a health care facility by the poison control center. The severity of the outcome associated with pediatric atomoxetine ingestions was dependent upon the dose and the circumstances of the ingestion (whether intentional self-harm was involved). The management of patients with serious outcomes was more likely to involve health care facilities. This information is useful for creating triage guidelines for the management of pediatric atomoxetine ingestions.