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McGuier EA, Kolko DJ, Pedersen SL, Kipp HL, Joseph HM, Lindstrom RA, Bauer DJ, Subramaniam GA, Molina BSG. Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2022; 23:1299-1307. [PMID: 35951253 PMCID: PMC9489672 DOI: 10.1007/s11121-022-01411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased use of diversion prevention strategies with adolescents with ADHD. The study was a cluster-randomized trial in 7 pediatric primary care practices. Participants were pediatric PCPs (N = 76) at participating practices. Practices were randomized to a 1-h training in stimulant diversion prevention or treatment-as-usual. At baseline, 6 months, 12 months, and 18 months, PCPs rated how often they used four categories of strategies: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes, implementation climate, knowledge/skill, and resource constraints. Generalized Estimating Equations estimated differences in outcomes by condition. Mediation analyses tested if changes in knowledge/skill mediated training effects on strategy use. PCPs in the intervention condition reported significantly greater use of patient/family education strategies at all follow-up time points. There were no differences between conditions in medication management, assessment of mental health symptoms/functioning, or assessment of risky behaviors. At 6 months, PCPs in the intervention condition reported more positive attitudes toward diversion prevention, stronger implementation climate, greater knowledge/skill, and less resource constraints. Differences in knowledge/skill persisted at 12 months and 18 months. Brief training in stimulant diversion had substantial and enduring effects on PCPs' self-reported knowledge/skill and use of patient/family education strategies to prevent diversion. Training had modest effects on attitudes, implementation climate, and resource constraints and did not change use of strategies related to medication management and assessment of mental health symptoms/functioning and risky behaviors. Changes in knowledge/skill accounted for 49% of the total effect of training on use of patient/family education strategies. Trial registration This trial is registered on ClinicalTrials.gov (NCT03080259). Posted March 15, 2017.
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Affiliation(s)
- Elizabeth A McGuier
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA.
| | - David J Kolko
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA
| | - Sarah L Pedersen
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA
| | - Heidi L Kipp
- Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heather M Joseph
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA
| | - Rachel A Lindstrom
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA
| | - Daniel J Bauer
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | | | - Brooke S G Molina
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, 15213 PA, USA
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Taubin D, Wilson JC, Wilens TE. ADHD and Substance Use Disorders in Young People: Considerations for Evaluation, Diagnosis, and Pharmacotherapy. Child Adolesc Psychiatr Clin N Am 2022; 31:515-530. [PMID: 35697399 DOI: 10.1016/j.chc.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Co-occurring ADHD and substance use disorder (SUD) is a common clinical presentation associated with significant impairment requiring careful evaluation, diagnosis, and treatment. Treatment with medication, along with cognitive behavioral therapy, is generally regarded as effective in addressing symptoms and impairments associated with both disorders. Options for pharmacotherapy include stimulant and nonstimulant therapies administered with careful monitoring of dosage and compliance to optimize efficacy. In high-risk groups such as college students and/or those with SUD, prescribers should address risks of stimulant misuse and diversion through patient and family education, medication monitoring, and other risk-reducing practices.
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Affiliation(s)
- Daria Taubin
- Pediatric Psychopharmacology Program, Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Warren Building 628B, 55 Fruit Street, Boston, MA 02114, USA
| | - Julia C Wilson
- Pediatric Psychopharmacology Program, Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Warren Building 628B, 55 Fruit Street, Boston, MA 02114, USA
| | - Timothy E Wilens
- Division of Child and Adolescent Psychiatry, Child Psychiatry Service, Massachusetts General Hospital, 55 Fruit Street, YAW 6A, Boston, MA 02114, USA; Center for Addiction Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA.
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Roldan KD, Garcia J, Valencia B, Ayala JA, Garcia C, McMullen J, Bavarian N. Upstream Approaches to Addressing Prescription Stimulant Misuse and Diversion: Exploring Perspectives of College Students Who Misuse and Divert. JOURNAL OF DRUG ISSUES 2022. [DOI: 10.1177/00220426221090176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We interviewed college students who engage in prescription stimulant misuse and diversion to better understand perspectives on prevention and intervention strategies. Methods Trained student researchers at one southern California university completed 32 face-to-face interviews with students who had a history of misuse and/or diversion. Participants provided insights on programs, policies, and practices that have the potential to deter behavior. Data were analyzed inductively via thematic analysis. Results Students were often misinformed or unaware of existing programs, policies and practices. Additionally, some students felt their behaviors would not be detected, whereas other students felt the fear of being detected would lead them to change their behaviors. Harm reduction and treatment-based approaches to address misuse were also recommended. Conclusions Our findings emphasize the importance of better educating students about, and enforcing, existing policies. In addition, the need to better inform students of existing campus programs is warranted.
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Francis AR, Weyandt LL, Anastopoulos AD, DuPaul GJ, Shepard E. Outcomes and Predictors of Stimulant Misuse in College Students with and Without ADHD. J Atten Disord 2022; 26:779-793. [PMID: 34189993 DOI: 10.1177/10870547211027650] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In recent years, rates of prescription stimulant misuse have increased among young adults ages 18 to 25 along with increases in dispensing rates of these medications. Preliminary studies suggest that college students with Attention-Deficit Hyperactivity Disorder (ADHD) may be more likely to misuse their stimulant medication than their non-ADHD peers. Research is needed to further explore possible rates, correlates, and outcomes of prescription stimulant misuse among college students with and without ADHD. Data regarding study strategies, psychological functioning, stimulant misuse, and GPA were collected from students from universities within the US (N = 144), showing significantly higher rates of misuse among college students with ADHD. With depression and anxiety entered into the predictive model, inattentive symptoms were the only significant predictor of misuse in the full sample. The present findings have implications for academic interventions aimed at supporting the success of college students with and without ADHD and inform academic outcomes of prescription stimulant misuse.
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Characterizing prescription stimulant nonmedical use (NMU) among adults recruited from Reddit. Addict Behav Rep 2021; 14:100376. [PMID: 34938836 PMCID: PMC8664867 DOI: 10.1016/j.abrep.2021.100376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Adults reporting past 5-year non-oral prescription stimulant NMU were studied. Non-oral NMU preferences were snorting (59%) injecting (4%) or smoking (1%). Polysubstance use was reported by 79.1% of the sample. Route of administration and motivation for prescription stimulant NMU were related. Prescription stimulant oral and intranasal NMU was to enhance performance. Prescription stimulant intravenous and smoking NMU was to get high.
Objective Increased prescription stimulant nonmedical use (NMU) is part of a growing polysubstance use landscape. The purpose of the present study was to characterize prescription stimulant NMU among adults reporting past 5-year non-oral prescription stimulant NMU. Methods Adults who reported non-oral prescription stimulant NMU within the last 5 years were recruited by banner ads placed on the Reddit website between February and September 2019. Types of prescription stimulants used, routes of administration, preferred routes of administration, motivations for prescription stimulant NMU, concurrent substances used simultaneously during prescription stimulant NMU, illicit substances used and factors impacting prescription stimulant NMU were queried. Results Respondents (n = 225) were male (86.2%), non-Hispanic (92.4%), white (78.2%), between 18 and 24 (48.0%) or 25–34 (43.1%) years with some amount of college education (81.3%). Most reported lifetime intranasal (93.8%) or oral use (85.2%). Prescription stimulants were diverted: 64.5% reported the prescription stimulants were given to them by a family or a friend and 10.5% reported that they had stolen these medications from a family or friend. Preferred route of administration was oral use (70.2%). Motivations to use were stratified by route of administration: intranasal (55.6%) or oral (63.0%) use was primarily endorsed as an attempt to enhance performance at work or at school; use by injection (57.1%) or smoking (62.5%) was primarily endorsed to get high. Most of the sample reported concurrent drug use (79.1%) including tobacco (57.3%), marijuana (52.0%), caffeine (47.6%) or alcohol (41.8%), among others. When excluding licit substances, 30.7% reported using 1 illicit substance concurrently with prescription stimulants and 25.3% reported using 2 or more illicit substances concurrently with prescription stimulants. Whether participants would undertake prescription stimulant NMU was determined by their work/school schedules or the location of the NMU (48.9%) whereas the route of administration employed was primarily influenced by the desired feeling or effect (56.9%). Conclusions Adults reporting lifetime non-oral prescription stimulant NMU engage in substantial risky behaviors that in addition to alternate routes of administration include polysubstance use, diversion and concurrent substance use.
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McGuier EA, Kolko DJ, Joseph HM, Kipp HL, Lindstrom RA, Pedersen SL, Subramaniam GA, Molina BSG. Use of Stimulant Diversion Prevention Strategies in Pediatric Primary Care and Associations With Provider Characteristics. J Adolesc Health 2021; 68:808-815. [PMID: 33446402 PMCID: PMC8012236 DOI: 10.1016/j.jadohealth.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/23/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Diversion of stimulant medications for ADHD is a prevalent problem. Pediatric primary care providers (PCPs) are well-positioned to reduce diversion risk among adolescents prescribed stimulants, but little is known about their use of prevention strategies. The objectives of this study were to describe the frequency with which pediatric PCPs use diversion prevention strategies and examine potential determinants (facilitators and barriers) of strategy use. METHODS Participants were pediatric PCPs (N = 76) participating in a randomized controlled trial of stimulant diversion prevention strategies. At baseline, before randomization, PCPs rated the frequency with which they used specific strategies in each of four categories: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes toward diversion prevention, subjective norms (i.e., implementation climate), and perceived behavioral control (i.e., knowledge/skill, resource constraints). Associations between determinants and strategy use were tested with correlational and regression analyses. RESULTS PCPs used strategies for assessing mental health symptoms/functioning most frequently and patient/family education strategies least frequently. Attitudes about the effectiveness of diversion prevention, implementation climate, knowledge/skill, and resource constraints were positively correlated with the use of at least one category of strategies. In regression analysis, PCP knowledge/skill was positively associated with patient/family education, medication management, and risk assessment strategies. CONCLUSIONS Findings suggest that improving knowledge and skill may increase the use of diversion prevention strategies by PCPs. Identifying provider-level determinants of strategy use informs implementation efforts in pediatric primary care and can facilitate efforts to prevent stimulant diversion among adolescents.
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Affiliation(s)
- Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Heather M Joseph
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Heidi L Kipp
- Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel A Lindstrom
- Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah L Pedersen
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Brooke S G Molina
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Colaneri N, Keim SA, Adesman A. Physician Training and Qualification to Educate Patients on Attention-Deficit/Hyperactivity Disorder Stimulant Diversion and Misuse. J Child Adolesc Psychopharmacol 2018; 28:554-561. [PMID: 30124331 DOI: 10.1089/cap.2017.0066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The increased number of adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) in recent years has raised concerns regarding diversion and misuse of prescription stimulant medications. As prescribers of these medications, physicians must be prepared to educate patients on these issues. This is the first study to evaluate physician training and qualification to educate adolescent patients on stimulant diversion and misuse. METHODS A questionnaire was developed and mailed to a national sample of child and adolescent psychiatrists (CAPs), child neurologists (CNs), and developmental-behavioral pediatricians (DBPs) in the United States. In addition to descriptive statistics, multivariable regressions (log-binomial and ordinal logistic) were performed to identify differences between subspecialists. RESULTS The final sample consisted of 826 physicians who currently prescribe stimulants. Only 48% of physicians reported receiving formal training on prescription drug diversion (PDD) in medical school, residency, and/or fellowship. Twenty five percent and 48% of physicians felt inadequately qualified to educate patients on the health and legal consequences, respectively, of stimulant misuse and diversion. CAPs were more likely to have received formal training and felt better qualified to educate patients than CNs and DBPs. Physicians who received formal training were 2.4 times more likely to feel adequately qualified to educate patients on these issues. Only 58% of physicians correctly answered a legal question relating to stimulant diversion. CONCLUSIONS Most physicians have not received formal training on PDD and many feel inadequately qualified to educate patients on the health and legal consequences of stimulant misuse and diversion. Increased training is needed so physicians can effectively educate patients with ADHD.
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Affiliation(s)
- Natalie Colaneri
- 1 Division of Developmental and Behavioral Pediatrics, Cohen Children's Medical Center , New Hyde Park, New York
| | - Sarah A Keim
- 2 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio.,3 Department of Pediatrics, Ohio State University College of Medicine , Columbus, Ohio.,4 Department of Epidemiology, Ohio State University College of Public Health , Columbus, Ohio
| | - Andrew Adesman
- 1 Division of Developmental and Behavioral Pediatrics, Cohen Children's Medical Center , New Hyde Park, New York.,5 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead, New York
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Colaneri N, Keim S, Adesman A. Physician practices to prevent ADHD stimulant diversion and misuse. J Subst Abuse Treat 2017; 74:26-34. [DOI: 10.1016/j.jsat.2016.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 11/28/2016] [Accepted: 12/16/2016] [Indexed: 11/15/2022]
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