Patterns of psychostimulant prescribing to children with ADHD in Western Australia: variations in age, gender, medication type and dose prescribed

Psychopharmacological prescribing practices in pregnancy for women with severe mental illness: A multicentre study

There is little known about real world psychopharmacological prescribing practices in managing pregnant women with severe mental illness (SMI). This study utilised a sample of 535 women with a SMI across two hospitals in Australia. This included women with psychotic disorders, bipolar disorder and a range of non-psychotic disorders. The majority of women with a SMI in pregnancy were prescribed psychotropic medication as part of their management. Furthermore, more than one class of agent was prescribed for 31% of women with psychotic disorders and 30% of women with bipolar disorder. Differences between sites were identified in prescribing practices across the mental disorders. This included the variation in rates of use of multiple agents and pattern of use across pregnancy. This study also identified that women with a SMI had elevated rates of gestational hypertension, gestational diabetes mellitus, smoking and obesity in pregnancy and neonates admitted following delivery compared with the Australian average. These findings suggest that studies that examine associated risks for severe mental disorders or their treatments on pregnancy and infant outcomes should take into account the prescribing practices including the likelihood of exposure to polypharmacy and a range of potential confounding co-morbidities and exposures. The discrepancies in reported findings for pregnancy and infant outcomes following use of antipsychotic and mood stabiliser agents such as lithium may be at least partially accounted for by the complexity of multiple exposures that includes use of multiple psychopharmacological agents, co-exposures such as smoking and co-morbid conditions such as obesity.

Patterns and profiles of methylphenidate use both in children and adults

AIM

The aim of the present study was to characterize patterns of use of methylphenidate (MPH), a prescription stimulant medication recommended in the treatment of attention deficit hyperactivity disorder (ADHD) and of narcolepsy, in France, both in children and adults, over a 3-year period.

METHODS

Using the French General Health Insurance database, limited to two areas covering approximately 4 million individuals, we made up a cohort of incident MPH users between July 2010 and June 2013. Splitting them into distinct age groups (18-24, 25-49 and ≥50 years of age for adults and <6, 6-11 and 12-17 years of age for children), we established the characteristics of these populations at MPH initiation and during follow-up according to the duration of treatment, quantities dispensed and coprescription with central nervous system (CNS) drugs.

RESULTS

We included a cohort of 3534 incident users, involving 30 238 dispensings of MPH, leading to an annual rate of 29 incident users per 100 000 in 2013. Children (66% of new users) were characterized by long-term use of MPH with few comedications. The group of 25-49-year-old patients were dispensed MPH more frequently than other groups, had the highest mean dose and were more often coprescribed other CNS drugs. The ≥50 year-old group was more often coprescribed antidepressants and antiparkinsonian drugs.

CONCLUSIONS

Our pharmacoepidemiological study involving incident MPH users with a large number of characteristics showed different patterns of MPH use among children and adults. The results from the 25-49-year-old group suggested that MPH might be being used for medical conditions other than ADHD or narcolepsy in adults, and that it might be subject to misuse and/or abuse.

ADHD in children and young people: prevalence, care pathways, and service provision

Attention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups-younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services.

Identifying cross-cultural variations in psychostimulant use for attention deficit hyperactivity disorder using linked data

BACKGROUND

To validate the association between country-of-birth and disparities in the stimulant use for ADHD among individuals in Western Australia.

METHODS

Using linked data, a population-based retrospective cohort of individuals admitted to hospital before age 25 years was followed through to identify having stimulants for ADHD in 2003-2007. Multivariate logistic and linear regressions were used to characterise associations between stimulants and country-of-birth, geographical remoteness and socioeconomic status.

RESULTS

Of 679,645 individuals, 14,122 (2.1%) had a record of having stimulants for ADHD. Of these, 205 (1.5%) were born in Africa, Asia, Middle-East or South America, while 13,664 (96.8%) were born in Australia/New Zealand, Europe or North America. Individuals with traditionally non-Anglophonic backgrounds were around one-half as likely to have stimulants as individuals with Anglophonic backgrounds (OR = 0.53, 95% CI 0.46-0.61, p < 0.001). Non-Anglophones were an average of 2.7 years older than Anglophones at onset of having stimulants. Individuals from remote and disadvantaged backgrounds had stimulants at younger ages than individuals living in metropolitan areas and with least disadvantage.

CONCLUSIONS

The results highlight the importance of identifying factors underlying cultural differences in stimulant treatment for ADHD. Improving awareness of cultural variations may foster trust and rapport between patients and clinicians, and so better facilitate the appropriate and effective treatment of ADHD for each patient.

Psychotropic medicine prescriptions in Italian youths: a multiregional study

The aim of the study was to evaluate the trend of paediatric psychotropic drug prescriptions in Italy. Data sources were regional, outpatient prescription databases. Seven Italian regions, covering 50 % of the Italian population, provided data from 2006 to 2011. Prevalence and incidence of prescriptions by age and gender were evaluated for psychotropic, antidepressant, antipsychotic, and attention-deficit/hyperactivity disorders (ADHD) medications. The hospital admission rate for psychiatric conditions was calculated, also at the local health unit (LHU) level. The presence of trends in prescription prevalence and incidence during the 6 year period was assessed. Finally, the correlation between prevalence, prescription, hospital admission rates, latitude, longitude, and average annual income at the LHU level was also investigated. In 2011, 8834 youths received at least one psychotropic drug prescription, with a prevalence of 1.76 ‰ (95 % CI 1.72-1.80). The incidence of new psychotropic drug users was 1.03 ‰ (1.00-1.06). The prevalence of antidepressants was 1.02 ‰ (0.99-1.04), while that of antipsychotics was 0.70 ‰ (0.68-0.72), and that of ADHD medications 0.19 ‰ (0.18-0.21). The psychotropic drug prevalence increased with increasing age. Males were more exposed to psychotropic drugs than females (AUC0-17 male/female = 1.23). Antipsychotics were the most prescribed psychotropic drugs in males, while antidepressants were in females. Between-region prevalence ranged from 1.56 to 2.17 ‰. The overall prevalence of psychotropic drug from 2006 to 2011 was stable (χ(t)2 ≤ 0.001, p = 0.97). No correlation was found between prevalence and the variables investigated. Psychotropic drug prescription was very limited and stable. No geographical patterns were found.

Psychostimulant prescribing trends in a paediatric population in Ireland: a national cohort study

Background

Psychotropic paediatric prescribing trends are increasing internationally. The aim of this study is to examine the prevalence and secular trends in psychotropic prescribing in Irish children and adolescents between 2002 and 2011.

Methods

Data was obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive Primary Care Reimbursement Services (HSE-PCRS). Prescribing rates per 1000 eligible population and associated 95 % confidence intervals (CIs) were calculated across years (2002–2011), age groups (0–4, 5–11, 12–15 years) and gender. Rates of concomitant prescriptions for psycholeptics and antidepressants were also examined. The total expenditure costs were calculated and expressed as a percentage of the cost of all prescriptions for this age group (≤15 years).

Results

In 2002, 3.77/1000 GMS population (95 % CI: 3.53–4.01) received at least one psychostimulant prescription and this rate increased to 8.63/1000 GMS population (95 % CI: 8.34–8.92) in 2011. Methylphenidate was the most frequently prescribed psychostimulant. For both males and females the prevalence of medication use was highest among the 12–15 year old group. On average, a psycholeptic medication was prescribed to 8 % of all psychostimulant users and an antidepressant was concomitantly prescribed on average to 2 %. Total expenditure rose from €89,254 in 2002 to €1,532,016 in 2011.

Conclusions

The rate and cost of psychostimulant prescribing among GMS children and adolescents in Ireland increased significantly between 2002 and 2011. Further research is necessary to assess the safety, efficacy and economic impact of concomitant psychotropic prescribing in this population.

Psychostimulant prescription for ADHD in new South Wales: a longitudinal perspective

OBJECTIVE

There is a need for Australian studies of ADHD that utilize the individual child as the unit of analysis because they provide a more accurate picture of national patterns (in new prescriptions, start age, and duration). The aim of this study was to build toward a national picture of patterns in psychostimulant use for ADHD by undertaking a retrospective analysis of archival data on prescriptions within New South Wales (NSW), Australia's most populated state.

METHOD

A person-based data set was used to assess (a) rate of new prescriptions by age group, (b) demographic characteristics (age of start, male:female ratio), (c) duration of use, and (d) comparisons across the two decades.

RESULTS

Five findings were observed: (a) The prevalence of psychostimulant use was 1.24% in 2010, (b) there was significant variability in the rate of new prescriptions by age group after 2003, (c) start age declined over the 1990 to 2000 period, but began to increase from 2000 to 2010, (d) the male:female ratio declined, and (e) the duration of psychostimulant use declined consistently.

CONCLUSION

Results suggest disconnect between persistence across the life span and actual treatment patterns. A decline in medication treatment for more than 1 year and the growing proportion of discontinuous treatment suggests a need for strategies to assist families with the transition onto and off medications.

Longitudinal trends in the dispensing of psychotropic medications in Australia from 2009-2012: focus on children, adolescents and prescriber specialty

OBJECTIVE

Longitudinal trends in the dispensing of antidepressant, antipsychotic and ADHD medications from 2009-2012 were examined according to age and gender of patient and prescriber speciality. Of particular interest were changing trends in the prescription of psychotropic medications to children, adolescents and young adults.

METHOD

Dispensing data for government-subsidised antidepressant, antipsychotic and ADHD medications were obtained from the database maintained by the Department of Human Services. Results were expressed in terms of number of prescriptions dispensed.

RESULTS

Over the four- year study period, the dispensing of antidepressants, antipsychotics and ADHD medications showed overall increases of 16.1%, 22.7% and 26.1% respectively. The most rapid percentage increases in antidepressant and antipsychotic dispensing occurred in children aged 10-14 (35.5% and 49.1% respectively), while ADHD medication dispensing rose most rapidly in those aged 20-24 (70.9%). Dispensing to males was more common during childhood for all investigated classes while two-thirds of adult antidepressant prescribing was to female patients. The most commonly prescribed antidepressants varied by age and were as follows: fluoxetine (3-19 year olds), desvenlafaxine (20-24 years) and venlafaxine (>25 years). Risperidone was the most common antipsychotic dispensed to children under 15, quetiapine to adolescents and young adults (15-24 years), and olanzapine to adults. Methylphenidate was the most common ADHD medication in those aged under 25, and dexamphetamine the most common in adults. Most antidepressants and antipsychotics were prescribed by GPs (89.9% and 70.6% respectively), while the majority of ADHD medications were prescribed by paediatricians (59.1%).

CONCLUSIONS

Dispensing of psychotropic medications increased markedly from 2009 to 2012, with notable age-specific trends. General adherence to treatment guidelines is apparent, yet concerns exist regarding rapid increases in serotonin noradrenaline reuptake inhibitor (SNRI) antidepressant prescribing, the likely overmedication of persons with mild psychological distress, and the increasing use of powerful psychotropic medications in younger populations despite uncertain risk-benefit profiles.

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications.

METHOD

In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics.

RESULTS

Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model.

CONCLUSIONS

Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision.

Burden of psychiatric disorders in the pediatric population

In order to estimate the burden of mental disorders in a representative Italian pediatric population, an epidemiological study was performed using three administrative databases: a drug prescription, a hospital discharge form, and an outpatient ambulatory visit database. The population target was 1,616,268 children and adolescents under 18 years living in the Lombardy Region, Italy. A youth was defined as a case if during 2008 he/she received at least one psychotropic drug prescription or was hospitalized for a psychiatric disorder (International Classification of Disease codes 290-319), or attended a child neuropsychiatric outpatient unit for a visit and/or a psychological intervention or rehabilitation at least once. Epileptic children were excluded. In all, 63,550 youths (39.3 per 1000; 95%CI 39.1-39.7‰) were identified as users of health care resources for a putative mental disorder. The prevalence was higher in boys than in girls (47.0‰ versus 31.3‰) and the highest value was recorded in children 8 years old (60.2‰). A total of 59,987 youths (37.1‰) attended a child and adolescent neuropsychiatry service at least once, 3605 (2.2‰) were admitted to hospital, and 2761 (1.7‰) received at least one psychotropic drug prescription, 57% of which did not attend a child neuropsychiatry service. In all, 14,741 youths (23.1% of users) had a disorder that required a high intensity of care (e.g. recurrent prescriptions for drugs and/or ambulatory care). The proportion of youths who received care for mental disorders in the Lombardy Region seems lower than in other countries. However, the fact that many children were prescribed psychotropic drugs without the supervision of a child psychiatrist is a reason for concern.

Long-term effects of chronic oral Ritalin administration on cognitive and neural development in adolescent wistar kyoto rats

The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) often results in chronic treatment with psychostimulants such as methylphenidate (MPH, Ritalin^®). With increases in misdiagnosis of ADHD, children may be inappropriately exposed to chronic psychostimulant treatment during development. The aim of this study was to assess the effect of chronic Ritalin treatment on cognitive and neural development in misdiagnosed “normal” (Wistar Kyoto, WKY) rats and in Spontaneously Hypertensive Rats (SHR), a model of ADHD. Adolescent male animals were treated for four weeks with oral Ritalin^® (2 × 2 mg/kg/day) or distilled water (dH₂O). The effect of chronic treatment on delayed reinforcement tasks (DRT) and tyrosine hydroxylase immunoreactivity (TH-ir) in the prefrontal cortex was assessed. Two weeks following chronic treatment, WKY rats previously exposed to MPH chose the delayed reinforcer significantly less than the dH₂O treated controls in both the DRT and extinction task. MPH treatment did not significantly alter cognitive performance in the SHR. TH-ir in the infralimbic cortex was significantly altered by age and behavioural experience in WKY and SHR, however this effect was not evident in WKY rats treated with MPH. These results suggest that chronic treatment with MPH throughout adolescence in “normal” WKY rats increased impulsive choice and altered catecholamine development when compared to vehicle controls.

Prevalence, determinants and spectrum of attention-deficit hyperactivity disorder (ADHD) medication of children and adolescents in Germany: results of the German Health Interview and Examination Survey (KiGGS)

OBJECTIVE

To investigate the prevalence, determinants and spectrum of attention-deficit hyperactivity disorder (ADHD) medication and its associations with socioeconomic status (SES), health-related behaviour and living conditions.

DESIGN

Observational cross-sectional study.

SETTING

Germany.

PARTICIPANTS

Representative population-based sample of non-institutionalised youth aged between 0 and 17 years (n=17 450) and examined between 2003 and 2006.

MAIN OUTCOME MEASURE

Prevalence and spectrum of ADHD medication (Anatomical Therapeutic Chemical (ATC) code N04BA) measured by standardised computer-assisted personal interview (CAPI) on drug use.

RESULTS

The overall prevalence of ADHD medication (stimulants including atomoxetine) was 0.9% (95% CI 0.7% to 1.1%). Boys used these drugs (1.5%, 1.2% to 1.8%) five times more than girls 0.3% (0.2% to 0.5%). The highest prevalence rates were for boys aged 6-10 years (2.3%, 1.7% to 3.1%S) and 11-13 (2.7%, 2.0% to 3.7%). Boys from families with no immigration background used ADHD medication almost 6 times as frequently as boys with an immigration background (1.7% vs 0.3%). Multivariate analysis (binary logistic regression) showed boys (OR 5.16, 95% CI 3.15 to 8.47), 11-year-olds to 13-year-olds (2.24, 1.28 to 3.49), children in large cities (2.18, 1.13 to 4.22), children with no immigration background (3.06, 1.34 to 6.99), and children with only a good (vs excellent) parent-rated health status (1.91, 1.18 to 3.08) being more likely to be using ADHD medication. A visit to the doctor in the last month or last quarter was associated with a higher probability for ADHD medication (3.18, 1.29 to 7.95 and 3.59, 1.45 to 8.90, respectively).

CONCLUSIONS

Results show prevalence rates of ADHD medication use for the German child and adolescent population that are considerably lower than published prevalence rates from the USA, but comparable with those of western European and Scandinavian countries. Lower use rates in rural versus urban regions may point to differential healthcare access. The inverse association of ADHD medication use with immigration status suggests potentially restricted access to healthcare services for immigrants or may reflect culture-specific differences in attitudes towards symptoms of ADHD.

Pharmacologic treatment of attention-deficit/hyperactivity disorder in children: incidence, prevalence, and treatment patterns in the Netherlands

BACKGROUND

The prevalence of attention-deficit/hyperactivity disorder (ADHD) and the associated use of stimulant medications may have increased in the Netherlands in recent years, but there is a lack of data to confirm this trend. This retrospective analysis examined the incidence, prevalence, and treatment pattern of ADHD among children from a large sample representation of the general population of the Netherlands and represents the first such analysis in a large cohort of European children.

OBJECTIVE

The aim of this study was to estimate the incidence and prevalence of children receiving initial pharmacotherapy for ADHD between 2000 and 2007 in the Netherlands and to describe treatment patterns (including persistence and adherence to ADHD medications) in this pediatric population.

METHODS

Prescription and hospitalization data from the PHARMO medical record linkage system database in the Netherlands (2003 to 2006) were analyzed for patients with newly prescribed ADHD medication who were aged 6 to 17 years and received follow-up for at least 12 months after treatment initiation with methylphenidate, dexamphetamine, atomoxetine, or combination therapy. The yearly incidence and prevalence of children receiving ADHD pharmacotherapy were estimated for the period 2000 to 2007. Demographic characteristics and baseline medication data at treatment initiation were collected along with data on hospitalizations and psychotropic treatments in the year before initiation of ADHD treatment.

RESULTS

Of the 4909 patients in the study cohort, 82% were male and 46% were between 6 and 9 years of age. The yearly incidence of children receiving ADHD medication--extrapolated from the PHARMO database to the Netherlands population--increased from 30 per 10,000 in the year 2000 to 75 per 10,000 in the year 2007. Prevalence rates showed a similar trend, increasing from 110 per 10,000 in 2000 to 210 per 10,000 in 2007. Prevalence and incidence rates both were consistently higher among boys than girls, although the greatest increases over time were observed in female patients. Analysis of treatment patterns revealed that most children (98%) initiated treatment with methylphenidate. Of those, 89% received an immediate-release formulation, although increased use of long-acting amphetamine and atomoxetine was apparent over the study period. Persistence and adherence rates varied according to the medications used and the prescribing physician. Antipsychotic agents and melatonin were the most commonly used therapeutics in the year before ADHD treatment initiation (6% and 4% of patients, respectively).

CONCLUSIONS

The incidence and prevalence of children treated for ADHD increased from 2000 to 2007. Most children (98%) initiated treatment with immediate-release methylphenidate.

Less discontinuation of ADHD drug use since the availability of long-acting ADHD medication in children, adolescents and adults under the age of 45 years in the Netherlands

Treatment options for ADHD in the Netherlands have increased with the introduction of the extended-release formulations of methylphenidate (MPH ER, Concerta^®) in 2003 and atomoxetine (ATX, Strattera^®) in 2005, but data on the effect on drug usage patterns are scarce. The objective of the present study was to describe changes in the patterns of ADHD medication use and determinants thereof among children, adolescents and adults (<45 years) starting ADHD medication since the introduction of MPH ER and ATX. Data were obtained from Dutch community pharmacies as collected by the Foundation for Pharmaceutical Statistics, covering 97% of all dispenses for prescription medicines to outpatients in the Netherlands. Usage patterns (continuation, discontinuation, switching and addition) of ADHD drugs were evaluated at 3, 6 and 12 months after initiation for three separate time cohorts (patients starting ADHD medication in Jan-Dec 2002, Jan 2003–June 2004, respectively July 2004–Dec 2005). It was found that between 2002 and 2006, most ADHD drug users were initiated on methylphenidate IR. Discontinuation of any ADHD drug treatment decreased over time partly in favour of switching and addition. Discontinuation at 3 months decreased from around 33% to around 25%, at 6 months from less than 50% to almost 35%, and at 12 months from just fewer than 60% to less than 45%. Discontinuation was higher among females and in adults >18 years. After the introduction of MPH ER and ATX (time cohort III), 16.5% of the incident ADHD drug users switched their medication and almost 9% added an ADHD drug to the prior ADHD drug. In conclusion, discontinuation of incident ADHD drug use is high after 3, 6 and 12 months. During the study period, the incidence of discontinuation decreased because of the availability of extended-release methylphenidate and atomoxetine.

The changing prevalence of attention-deficit/hyperactivity disorder and methylphenidate prescriptions: a study of data from a random sample of insurees of the AOK Health Insurance Company in the German State of Hesse, 2000-2007

BACKGROUND

The goal of this study is to assess changes in the prevalence of attention-deficit/hyperactivity disorder (ADHD) and methylphenidate prescriptions over the period 2000 to 2007 on the basis of data from a German statutory health insurance carrier.

METHODS

In a cross-sectional study, we analyzed data from a random sample of insurees of the AOK health insurance company in the German state of Hesse for the years 2000 to 2007. Per calender year, 50,000 to 63,000 children and adolescents were retrospectively observed with respect to the documentation of ADHD diagnosis (ICD-10 diagnosis F90) and the prescribing of methylphenidate (ATC: N06BA04).

RESULTS

In 2007, the overall prevalence of ADHD in all age groups (0-18 years) was 2.21% (95% CI: 2.09-2.34). This figure was 45% greater than the corresponding figure for the year 2000. The prevalence increased by a larger amount among girls aged 6 to 18 years than among boys in the same age group (+69% vs. +53%). In 2007, 1.06% (95% CI: 0.98-1.16) of the children/adolescents received at least one prescription for methylphenidate; this was a 96% increase over the prescription rate for 2000. A comparison of the two years 2000 and 2007 reveals a clear prevalence shift towards the older age groups, as well as an 82% increase in the average number of daily doses per recipient. Outpatient departments of child and adolescent psychiatry initiated more treatments in 2007 than in 2000.

CONCLUSION

The 1% prevalence of methylphenidate use among children and adolescents that was found in this study is the same as that reported in other European countries, such as Switzerland, the Netherlands, and Norway. A drawback of our study is its limitation to a single insurance carrier in a single region. Nonetheless, data of this type are useful for monitoring. The findings suggest further issues worth studying, e.g., off-label use or the indications for treatment in older age groups.

Potential adverse effects of amphetamine treatment on brain and behavior: a review

Amphetamine stimulants have been used medically since early in the twentieth century, but they have a high abuse potential and can be neurotoxic. Although they have long been used effectively to treat attention deficit hyperactivity disorder (ADHD) in children and adolescents, amphetamines are now being prescribed increasingly as maintenance therapy for ADHD and narcolepsy in adults, considerably extending the period of potential exposure. Effects of prolonged stimulant treatment have not been fully explored, and understanding such effects is a research priority. Because the pharmacokinetics of amphetamines differ between children and adults, reevaluation of the potential for adverse effects of chronic treatment of adults is essential. Despite information on the effects of stimulants in laboratory animals, profound species differences in susceptibility to stimulant-induced neurotoxicity underscore the need for systematic studies of prolonged human exposure. Early amphetamine treatment has been linked to slowing in height and weight growth in some children. Because the number of prescriptions for amphetamines has increased several fold over the past decade, an amphetamine-containing formulation is the most commonly prescribed stimulant in North America, and it is noteworthy that amphetamines are also the most abused prescription medications. Although early treatment does not increase risk for substance abuse, few studies have tracked the compliance and usage profiles of individuals who began amphetamine treatment as adults. Overall, there is concern about risk for slowed growth in young patients who are dosed continuously, and for substance abuse in patients first medicated in late adolescence or adulthood. Although most adult patients also use amphetamines effectively and safely, occasional case reports indicate that prescription use can produce marked psychological adverse events, including stimulant-induced psychosis. Assessments of central toxicity and adverse psychological effects during late adulthood and senescence of adults who receive prolonged courses of amphetamine treatment are warranted. Finally, identification of the biological factors that confer risk and those that offer protection is also needed to better specify the parameters of safe, long-term, therapeutic administration of amphetamines to adults.

'Kiddie drugs' and controlled pleasure: recreational use of dexamphetamine in a social network of young Australians

BACKGROUND

This article explores the recreational use of diverted dexamphetamine, a pharmaceutical stimulant, amongst a social network of young adults (aged 18-31 years) in Perth, Western Australia (WA). Prior epidemiological research indicates that there are high levels of dexamphetamine prescription, and use of diverted dexamphetamine, in this jurisdiction. Little research exists on the social contexts of diverted dexamphetamine use in Australia or overseas.

METHODS

Ethnographic fieldwork was conducted over 18 months amongst a network of approximately 60 young adults who regularly used psychostimulants. Data collection involved participant observation conducted in natural settings including nightclubs and private parties. In-depth interviews were also conducted with 25 key contacts which explored drug use histories and themes emerging from fieldwork.

RESULTS

The use of diverted dexamphetamine, or 'dexies', was prevalent amongst the social network and integrated into local drug practices. The paper explores the ways in which dexamphetamine use is rationalised, negotiated and represented in the context of the use of alcohol and other psychostimulants such as methamphetamine and ecstasy. Two key aspects are emphasised. First, dexamphetamine use is seen as insignificant by network members and is positioned as 'safer' in relation to the use of other drugs by virtue of its pharmaceutical status. Second, dexamphetamine plays an instrumental role in facilitating the pursuit of 'controlled pleasure' via the heavy consumption of alcohol and other drugs.

CONCLUSION

The findings of the paper have implications for harm reduction policy. In particular, dexamphetamine use facilitates heavy drinking and polydrug use amongst young adults, which may increase the harms associated with such use. Further, current interventions targeting young psychostimulant users, which emphasise their adulterated and illegal nature, may inadvertently contribute to the cultural construction of dexamphetamine as a relatively 'safe' drug.

Características das prescrições no transtorno de déficit de atenção/hiperatividade

OBJETIVO: O trabalho busca conhecer, no atual momento, a realidade das prescrições para o transtorno de déficit de atenção/hiperatividade. MÉTODO: Revisão não sistemática dos descritores "transtorno de falta de atenção/ hiperatividade" e "prescrição de medicamentos" e seus similares em inglês. Foram utilizados os seguintes limitadores: publicações de 10 anos até novembro de 2008, idiomas inglês, francês, espanhol e português, nas bases de dados do Medline, SciELO, Lilacs, áreas especializadas e Cochrane. Não foram utilizados os artigos referentes ao uso ilícito e aspectos clínicos em geral. RESULTADOS: Foram tratados 8 itens: sistema de prescrições, características socioculturais, os sistemas de saúde que influenciam as prescrições, tempo de uso das medicações, aumento das prescrições, aspectos em comum, dosagens e prescrição em idades abaixo de 5 anos. CONCLUSÕES: Alguns aspectos são preocupantes, como a baixa adesão aos tratamentos medicamentosos, doses médias de metilfenidato relativamente baixas e aumento das prescrições de psicoestimulantes para crianças de até 3 anos. Características sociais e o sistema de saúde utilizado pelo afetado também geram grandes variações na prática clínica. Uma questão interessante é a evidência de que o sistema brasileiro de prescrições não é o mais restritivo.

Food additives and hyperactivity

Evidence supports a trial period of eliminating colourings and preservatives from the diet