Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016

Evolution of methylphenidate prescriptions in the region of Occitanie, France, from 2013 to 2021

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a frequent neurodevelopmental disorder with a lasting functional impact. Our objective was to analyze methylphenidate prescription rates between 2013 and 2021 in Occitanie, to study their evolution over time, disparities within the same region, and factors that could influence them.

METHODS

Data were extracted via the national insurance health data system, the inter-regime consumption data mart of the Occitanie region. Prevalence and incidence data were reported based on population data from NISES within the same territories. Deprivation indices of municipalities and classification of territories according to rurality were used as analysis variables.

RESULTS

Between 2013 and 2021, the overall rate of methylphenidate prescription in Occitanie increased by 97.3% with territorial disparities. In 2019, the prescription prevalence across all age groups studied was 0.19%, and the incidence was 0.06%. The abandonment rate represents 22.32% across all ages. The decrease in deliveries in the second quarter of 2020 coincides with the COVID-19 pandemic.

CONCLUSION

Our data are consistent with the results observed at the national level, namely an increase in methylphenidate prescriptions of around 12% per year. Similar results are observed in countries using methylphenidate with initially low prescription rates. The level of prescription reached in Occitanie remains significantly lower than that of comparable Occidental countries, with significant territorial disparities.

Characterizing patients at higher cardiovascular risk for prescribed stimulants: Learning from health records data with predictive analytics and data mining techniques

OBJECTIVE

Given the significantly increased number of individuals prescribed stimulants in the past decade, there has been growing concern regarding the risk of cardiovascular events among adults on stimulant therapy. We aimed to quantify the added risk of cardiovascular events by prescription stimulant use and characterize patients who were adversely affected.

METHODS

Using electronic health records of adults with Attention-Deficit/Hyperactivity Disorder from TriNetX Research Network in 2010-2020, we developed and compared different machine learning models to predict one-year cardiovascular risk based on individual's prescription stimulant use, demographics, and comorbidities for four separate age groups. With the trained risk prediction models, we estimated added risk of cardiovascular events and utilized association rule mining (ARM) to identify clinical characteristics of patients adversely affected by prescription stimulant use.

RESULTS

The study cohort consisted of 219,965 adults, including 102,138 (46.4 %) persons on stimulant therapy. All prediction models achieved high areas under receiver operating characteristic curve of 0.77-0.84 in predicting one-year cardiovascular risk across all age groups. Of patients with 25 % highest added risks, ARM identified critical features in major categories including common risk factors of cardiovascular events, prior cardiovascular events, substance use disorders, and psychological disorders. A watch list of comorbidities was constructed and validated for each age group to show added risk of prescribing stimulants to patients with these conditions.

DISCUSSION AND CONCLUSION

We integrated predictive modeling and data mining to characterize patients adversely affected by prescription stimulant use. Future research is needed to externally validate identified features to guide safer stimulant prescribing.

Socioeconomic status and prescribing of ADHD medications: a study of ICB-level data in England

BACKGROUND

Little is known about the impact of healthcare structural changes and socioeconomic indices, such as deprivation, mental health needs, and inequalities, on attention-deficit hyperactivity disorder (ADHD) medication prescribing across different regions in England.

OBJECTIVE

The objective was to examine trends in ADHD medication prescribing and explore their association with socioeconomic factors.

METHODS

A population-level observational study was conducted using the English Prescribing Dataset (from April 2019 to March 2024) published by the NHS Business Services Authority and the OpenPrescribing platform (Bennett Institute for Applied Data Science, University of Oxford). The study examined trends in five licensed ADHD medications at national, regional and integrated care board (ICB) levels, using linear regression and a generalised additive model to explore the association between socioeconomic factors and prescription rates.

FINDINGS

The prescriptions increased significantly from 25.17 items per 1000 population in 2019/20 (pre-COVID-19) to 41.55 items in 2023/24 (post-COVID-19), with an average annual increase of 18% nationally. Methylphenidate remained the most prescribed medication, while lisdexamfetamine showed the highest growth rate (55% annually, 95% CI 40% to 71%, p<0.01). Significant regional variations were observed, with London experiencing the highest annual increase (28%), and the Northeast and Yorkshire the lowest (13%). Socioeconomic factors, including ethnicity and deprivation, were significantly associated with ADHD prescription rates (p<0.05).

CONCLUSIONS

Findings reveal a substantial increase in ADHD medication use in England following the COVID-19 pandemic, with significant variations at regional and ICB levels and complex socioeconomic influences.

CLINICAL IMPLICATIONS

Findings highlight the need to understand and address drivers of disparities in ADHD care while optimising management strategies across diverse populations.

Gamified Adaptive Approach Bias Modification in Individuals With Methamphetamine Use History From Communities in Sichuan: Pilot Randomized Controlled Trial

Background

Cognitive bias modification (CBM) programs have shown promise in treating psychiatric conditions, but they can be perceived as boring and repetitive. Incorporating gamified designs and adaptive algorithms in CBM training may address this issue and enhance engagement and effectiveness.

objectives

This study aims to gather preliminary data and assess the preliminary efficacy of an adaptive approach bias modification (A-ApBM) paradigm in reducing cue-induced craving in individuals with methamphetamine use history.

Methods

A randomized controlled trial with 3 arms was conducted. Individuals aged 18-60 years with methamphetamine dependence and at least 1 year of methamphetamine use were recruited from 12 community-based rehabilitation centers in Sichuan, China. Individuals with the inability to fluently operate a smartphone and the presence of mental health conditions other than methamphetamine use disorder were excluded. The A-ApBM group engaged in ApBM training using a smartphone app for 4 weeks. The A-ApBM used an adaptive algorithm to dynamically adjust the difficulty level based on individual performance. Cue-induced craving scores and relapses were assessed using a visual analogue scale at baseline, postintervention, and at week-16 follow-up.

Results

A total of 136 participants were recruited and randomized: 48 were randomized to the A-ApBM group, 48 were randomized to the static approach bias modification (S-ApBM) group, and 40 were randomized to the no-intervention control group. The A-ApBM group showed a significant reduction in cue-induced craving scores at postintervention compared with baseline (Cohen d=0.34; P<.01; 95% CI 0.03-0.54). The reduction remained significant at the week-16 follow-up (Cohen d=0.40; P=.01; 95% CI 0.18-0.57). No significant changes were observed in the S-ApBM and control groups.

Conclusions

The A-ApBM paradigm with gamified designs and dynamic difficulty adjustments may be an effective intervention for reducing cue-induced craving in individuals with methamphetamine use history. This approach improves engagement and personalization, potentially enhancing the effectiveness of CBM programs. Further research is needed to validate these findings and explore the application of A-ApBM in other psychiatric conditions.

Risk Factors for Adverse Cardiac Events in Individuals Prescribed Stimulants Across the Lifespan

INTRODUCTION

Prescription stimulants are an effective FDA approved treatment for attention deficit hyperactivity disorder (ADHD) however their safety has come under scrutiny. Multiple studies demonstrate safe use in pediatric populations, but prescriptions are increasing to adults and it is not evident which comorbidities might place people at risk of adverse outcomes. The aim of this study is to identify risk factors of adverse cardiovascular events for individuals exposed to stimulants across the lifespan.

METHODS

We conducted a case control study utilizing the TriNetX research network database. Individuals were included for study if they were younger than 90 years old and prescribed stimulants between January 1, 2010 and December 31, 2020. We utilized summary statistics, chi2, and multivariate logistic regression to identify risk factors for cardiovascular events.

RESULTS

Of the 987,762 individuals prescribed stimulants, 49,902 experienced an adverse cardiovascular event. Individuals with atherosclerotic heart disease had the highest odds of adverse events (aOR = 36.7, p < .001). Hypertension (aOR = 2.78 p < .001), cocaine use (aOR = 1.64 p < .001), and anxiety (aOR = 1.46 p < .001) were also strongly predictive of adverse outcomes, but risk varied by age.

CONCLUSIONS

Atherosclerotic heart disease and its antecedents pose the greatest risk for cardiovascular events for people prescribed stimulants. Mental health diagnoses are also independent predictors and age may be an effect modifier of these relationships. ADHD was not an independent risk factor for major adverse cardiovascular events when controlling for other biopsychosocial variables in adult populations. Additional research focused on predictive models and prospective studies may be warranted to better inform clinical decisions regarding stimulant prescriptions for the broad demographic of patients that may benefit from these medications.

Single-Cell RNA-Seq Uncovers Robust Glial Cell Transcriptional Changes in Methamphetamine-Administered Mice

Methamphetamine is a highly addictive stimulant known to cause neurotoxicity, cognitive deficits, and immune dysregulation in the brain. Despite significant research, the molecular mechanisms driving methamphetamine-induced neurotoxicity and glial cell dysfunction remain poorly understood. This study investigates how methamphetamine disrupts glial cell function and contributes to neurodevelopmental and neurodegenerative processes. Using single-cell RNA sequencing (scRNA-seq), we analyzed the transcriptomes of 4000 glial cell-associated genes from the cortical regions of mice chronically administered methamphetamine. Methamphetamine exposure altered the key pathways in astrocytes, including the circadian rhythm and cAMP signaling; in microglia, affecting autophagy, ubiquitin-mediated proteolysis, and mitophagy; and in oligodendrocytes, disrupting lysosomal function, cytoskeletal regulation, and protein processing. Notably, several transcription factors, such as Zbtb16, Hif3a, Foxo1, and Klf9, were significantly dysregulated in the glial cells. These findings reveal profound methamphetamine-induced changes in the glial transcriptomes, particularly in the cortical regions, highlighting potential molecular pathways and transcription factors as targets for therapeutic intervention. This study provides novel insights into the glial-mediated mechanisms of methamphetamine toxicity, contributing to our understanding of its effects on the central nervous system and laying the groundwork for future strategies to mitigate its neurotoxic consequences.

Association between exposure to antidepressants and stimulants and age at onset of mania or psychosis: A retrospective population-based cohort study

This study investigated the impact of prior antidepressant and stimulant exposure on the age at onset (AAO) of first episode mania (FEM) or psychosis (FEP). Patients with FEP and FEM born after 1985 in Olmsted County, Minnesota, were identified using the Rochester Epidemiology Project. Duration and peak dose of antidepressant and stimulant exposure were quantified by review of the electronic health record. Peak doses were converted to defined daily dose (DDD), and cumulative exposure was calculated as DDD multiplied by treatment duration. Linear models were used to assess relationships between AAO with any exposures, and cumulative antidepressant and stimulant exposures. A total of 190 FEM/FEP patients (mean AAO=20.8 ± 3.7 years) were included. There was no significant difference in AAO with vs. without exposure to antidepressants or stimulants. Cumulative antidepressant exposure correlated with a later AAO in overall sample (r = 0.28, p < 0.001), and in FEP (r = 0.33, p < 0.001). No significant correlation emerged between cumulative stimulant exposure and AAO. Multivariable modeling confirmed that cumulative antidepressant exposure (Estimate=2.42, 95 %CI=1.66-3.18, p < 0.001), but not cumulative stimulant exposure (Estimate=-0.04, 95 %CI=-1.10-1.02, p = 0.94), was associated with later AAO. Antidepressant and stimulant exposures were not associated with earlier AAO. However, cumulative antidepressant exposure was associated with later AAO. Limitations include retrospective design and relatively small sample size. Our findings may inform adolescent treatment recommendations when assessing risk for psychotropic-related adverse events. Further risk modeling investigations of antidepressants and stimulants with larger sample sizes are needed to explore the role of antidepressant and stimulant exposure in the trajectory leading to FEM/FEP.

Challenges and Opportunities with at-Home Blood Collection for HIV-1 Viral Load Monitoring among Sexual Minoritized Men who use Stimulants

Sexually minoritized men (SMM) with HIV who use stimulants experience difficulties achieving and maintaining an undetectable viral load (VL). Home-based VL monitoring could augment HIV care by supporting interim, early identification of detectable VL. We describe implementation challenges associated with a home-collection device for laboratory-based VL testing among SMM with HIV who use stimulants. From March-May 2022, cisgender SMM with HIV reporting moderate-to-severe stimulant use disorder and suboptimal (< 90%) past-month antiretroviral therapy (ART) adherence were recruited via a consent-to-contact participant registry. Eligible men completed teleconference-based informed consent and were mailed a HemaSpot-HD blood collection device (volume capacity 160 µL; lower limit of detection 839 copies/mL) with detailed instructions for home blood self-collection and return shipment. Implementation process measures included estimated blood volume and VL quantification. Among 24 participants, 21 (88%) returned specimens with a median duration of 23 days (range: 10-71 days) between sending devices to participants and receiving specimens. Of these, 13/21 (62%) included enough blood (≥ 40 µL) for confidence in detectable/undetectable results; 10/13 (77%) had detectable VL, with 4/10 (40%) were quantifiable at ≥ 839 copies/mL. The remaining 8/21 had low blood volume (< 40 µL), but 3/8 (38%) still had detectable VL, with 1/3 (33%) quantifiable at ≥ 839 copies/mL. Home blood collection of ≥ 40 µL using HemaSpot-HD was feasible among this high-priority population, with > 50% having a VL detected. However, interim VL monitoring using HemaSpot-HD among those experiencing difficulties with ART adherence may be strengthened by building rapport via teleconferencing and providing detailed instructions to achieve adequate sample volume.

Recreational Cannabis Legalization: No Contribution to Rising Prescription Stimulants in the USA

INTRODUCTION

There have been substantial increases in the use of Schedule II stimulants in the United States. Schedule II stimulants are the gold standard treatment for attention-deficit hyperactivity disorder (ADHD), but also carry the risk of addiction. Since the neurocognitive deficits seen in ADHD resemble those of chronic cannabis use, and the rise in stimulant use is incompletely understood, this study sought to determine if recreational cannabis (RC) legalization increased distribution rates of Schedule II stimulants.

METHODS

The distribution of amphetamine, lisdexamfetamine, and methylphenidate were extracted from the ARCOS database of the Drug Enforcement Administration. The three-year population-corrected slopes of distribution before and after RC sales were evaluated.

RESULTS

Total stimulant distribution rates were significantly higher in states with RC sales after (p=0.049), but not before (p=0.221), program implementation compared to states without RC. Significant effects of time (p<0.001) and RC sales status (p=0.045) were observed, while time x RC sales status interaction effects were not significant (p=0.406).

DISCUSSION

RC legalization did not contribute to a more pronounced rise in Schedule II stimulant distribution in states. Future studies could explore the impact of illicit cannabis use on stimulant rates and the impact of cannabis sales on distribution rates of non-stimulant ADHD pharmacotherapies and ADHD diagnoses.

Supporting treatment adherence for resilience and thriving (START): protocol for a mHealth randomized controlled trial

BACKGROUND

Although behavioral interventions show some promise for reducing stimulant use and achieving durable viral suppression in sexual minority men (SMM) with HIV, scalable mHealth applications are needed to optimize their reach and cost-effectiveness.

METHODS

Supporting Treatment Adherence for Resilience and Thriving (START) is a randomized controlled trial (RCT) testing the efficacy and cost-effectiveness of a mHealth application that integrates evidence-based positive affect regulation skills with self-monitoring of adherence and mood. The primary outcome is detectable HIV viral load (i.e., > 300 copies/mL) from self-collected dried blood spot (DBS) specimens at 6 months. Secondary outcomes include detectable DBS viral load at 12 months, self-reported stimulant use severity, anti-retroviral therapy (ART) adherence, and positive affect over 12 months. A national sample of up to 250 SMM with HIV who screen positive for stimulant use disorder and reporting suboptimal ART adherence is being recruited via social networking applications through April of 2024. After providing informed consent, participants complete a run-in period (i.e., waiting period) including two baseline assessments with self-report measures and a self-collected DBS sample. Those who complete the run-in period are randomized to either the START mHealth application or access to a website with referrals to HIV care and substance use disorder treatment resources. Participants provide DBS samples at baseline, 6, and 12 months to measure HIV viral load as well as complete self-report measures for secondary outcomes at quarterly follow-up assessments over 12 months.

DISCUSSION

To date, we have paid $117,500 to advertise START on social networking applications and reached 1,970 eligible participants ($59.77 per eligible participant). Although we identified this large national sample of potentially eligible SMM with HIV who screen positive for a stimulant use disorder and report suboptimal ART adherence, only one-in-four have enrolled in the RCT. The run-in period has proven to be crucial for maintaining scientific rigor and reproducibility of this RCT, such that only half of consented participants complete the required study enrollment activities and attended a randomization visit. Taken together, findings will guide adequate resource allocation to achieve randomization targets in future mHealth research SMM with HIV who use stimulants.

TRIAL REGISTRATION

This protocol was registered on clinicaltrials.gov (NCT05140876) on December 2, 2021.

Do prescription stimulants increase risk of Parkinson's disease among adults with attention-deficit hyperactivity disorder? A retrospective cohort study

BACKGROUND

Parkinson's disease (PD) is a common neurodegenerative disorder in older adults that is associated with neuroinflammation, oxidative stress, and characterized by loss of dopaminergic cells. Illicit stimulants increase oxidative stress and are associated with increased risk of PD. Prescription stimulants are similar in mechanism to illicit stimulants, yet their influence on PD is not well described. This study aims to determine if prescription stimulants influence risk of PD among older adults with attention-deficit and hyperactivity disorder (ADHD).

METHODS

We implemented a retrospective observational cohort design utilizing the TriNetX database which sources from the electronic health records of 57 healthcare organizations. Inclusion criteria were ADHD diagnosis and age ≥50. Those exposed to stimulants and the unexposed controls were matched based on demographics and known risk factors for PD. The outcome of interest was the incidence of PD over a 30-year follow-up period. We utilized TriNetX software for hazard ratio (HR) analysis.

RESULTS

Among the 59,471 individuals treated with prescription stimulants 131 of them developed PD, and there were 272 individuals who developed PD that were not prescribed stimulants. This analysis yielded a HR of 0.419 (HR = 0.419 [95% CI 0.34, 0.516], P = 0.0013).

CONCLUSION

Illicit stimulants are associated with increased risk of PD, but this study suggests prescribed stimulants may not impart that same risk. The reduced risk in this cohort may be due to protection from illicit substance use and oxidative stress, however additional study exploring the relationship between prescription stimulants and PD is warranted.

Switch to Lisdexamfetamine in the Treatment of Attention-Deficit Disorder at a Psychiatric Outpatient Clinic for School-Aged Children: A Danish Cohort Study

Objectives: This study aimed to examine switch from first-line methylphenidate (MPH) to lisdexamfetamine (LDX) in school-aged children with attention-deficit/hyperactivity disorder (ADHD). Methods: This is a retrospective observational study based on systematic review of patient records of all children (7-13 years) diagnosed with ADHD and referred to a Danish specialized outpatient clinic. The study included 394 children switching from MPH to LDX as either second-line or third-line treatment (atomoxetine [ATX] as second-line treatment) during the study period from April 1, 2013, to November 5, 2019. Results: One in five children switched from MPH to LDX at some point during the study period. The most frequent reasons for switching to LDX were adverse effects (AEs; 70.0% for MPH, 68.3% for ATX) and lack of efficiency (52.0% for MPH, 72.7% for ATX). Top five AEs of LDX were decreased appetite (62.4%), insomnia (28.7%), irritability/aggression (26.1%), weight decrease (21.1%), and mood swings (13.9%). MPH and LDX had similar AE profiles, yet most AEs were less frequent after switching to LDX. At the end of the study period, the majority were prescribed LDX as second-line rather than third-line treatment (86.1% in 2019). However, the likelihood of LDX as second-line treatment decreased with the number of psychiatric comorbidities, ADHD symptom severity as assessed by parents, and if AEs were a reason for MPH discontinuation. Among children observed for at least 1 year after initiation of LDX, 41.3% continued LDX treatment for a year or longer. LDX continuation was less likely if AEs were a reason for MPH discontinuation. Similarly to MPH and ATX, the most frequent reasons for LDX discontinuation were AEs (74.4%) and lack of efficiency (34.7%). Implications: The findings support LDX as an important option in the personalized treatment of children with ADHD and may support prescribers in the clinical decision-making on switching medication.

Stimulant Drugs and Stimulant Use Disorder

The authors aim to summarize several key points of stimulant drugs and stimulant use disorder, including their indications, short-term and long-term adverse effects, current treatment strategies, and association with opioid medications. The global prevalence of stimulant use has seen annual increase in the last decade. Multiple studies have shown that stimulant use and stimulant use disorder are associated with a range of individual and public health issues. Stimulant misuse has led to a significant increase of overdose deaths in the United States.

Clinical pharmacist intervention to ensure safe stimulant prescribing practices at a Veterans Affairs facility

Introduction

The Psychotropic Drug Safety Initiative (PDSI) is a national Veterans Affairs program that recommends obtaining cardiovascular vital signs semiannually and urine toxicology screening annually for veterans prescribed stimulants. The PDSI also recommends a risk review of concurrent central nervous system (CNS) depressants to ensure the benefits of coadministration with stimulants outweigh the risks. This project's purpose was to evaluate the occurrence of coprescriptions for CNS depressants and stimulants and encourage compliance with the PDSI recommendations to increase safe and appropriate management of veterans prescribed the combination. This study aimed to evaluate the occurrence of coprescriptions for CNS depressants and stimulants, evaluate compliance with stimulant monitoring recommendations, and measure the proportion of pharmacist recommendations implemented by the prescriber.

Methods

This quality improvement project identified veterans with an outpatient prescription for a stimulant and any coprescription(s) for benzodiazepines, sedative-hypnotics, and/or opioids. A pharmacy intervention note was generated to request a risk review, provide recommendations for de-escalation, and notify the stimulant prescriber of overdue monitoring parameters. Impact was measured 60 days after intervention. Descriptive statistics and a McNemar test were used to compare preintervention and postintervention data.

Results

From the 61 patients included, there were 67 unique prescriptions for benzodiazepines (49.3%), sedative-hypnotics (34.3%), and opioids (16.4%) in combination with a stimulant. Pharmacist intervention resulted in de-escalation of coprescribing for 9 patients (16.1%) and was associated with statistically significant improvement in compliance to stimulant monitoring recommendations.

Discussion

Clinical pharmacists can assist in ensuring safe and appropriate monitoring and management of veterans prescribed stimulants.

Is age of onset and duration of stimulant therapy for ADHD associated with cocaine, methamphetamine, and prescription stimulant misuse?

BACKGROUND

To assess whether age of onset and duration of stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) are associated with cocaine, methamphetamine, and prescription stimulant misuse during adolescence.

METHODS

Nationally representative samples of US 10th and 12th grade students (N = 150,395) from the Monitoring the Future study were surveyed via self-administered questionnaires from 16 annual surveys (2005-2020).

RESULTS

An estimated 8.2% of youth received stimulant therapy for ADHD during their lifetime (n = 10,937). More than one in 10 of all youth reported past-year prescription stimulant misuse (10.4%)-past-year cocaine (4.4%) and methamphetamine (2.0%) use were less prevalent. Youth who initiated early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years) did not have significantly increased adjusted odds of cocaine or methamphetamine use relative to population controls (ie, non-ADHD and unmedicated ADHD youth). Youth who initiated late stimulant therapy for ADHD (≥10 years old) and for short duration (<1 year) had significantly higher odds of past-year cocaine or prescription stimulant misuse in adolescence than those initiating early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years). Youth who initiated late stimulant therapy for ADHD (≥10 years) for short duration (<1 year) had significantly higher odds of past-year cocaine, methamphetamine, and prescription stimulant misuse versus population controls during adolescence. No differences in past-year cocaine, methamphetamine, and prescription stimulant misuse were found between individuals who only used non-stimulant therapy for ADHD relative to youth who initiated early stimulant therapy (≤9 years old) and for long duration (≥6 years).

CONCLUSIONS

An inverse relationship was found between years of stimulant therapy and illicit and prescription stimulant misuse. Adolescents with later initiation and/or shorter duration of stimulant treatment for ADHD should be monitored for potential illicit and prescription stimulant misuse.

Association Between Patient-Level Factors and Positive Treatment Response Among Individuals With a Psychostimulant Use Disorder: A Cross-Sectional Study

Objectives

The purpose of this study was to provide insights into which patient-level characteristics are associated with a positive treatment response among patients whose primary drug of choice was a psychostimulant with a particular emphasis on understanding the impact of age at first use and co-occurring psychiatric comorbidities.

Methods

We used a cross-sectional study design and the 2019 US Treatment Episode Data Set: Discharges (n = 167 802) to identify outpatient treatment episodes for which the primary drug of choice was a psychostimulant. We defined a positive treatment response as (1) a reduction in drug use between treatment admission and discharge or (2) no use at both admission and discharge. Multivariable logistic regression was conducted, overall and stratified by presence of psychiatric comorbidity, to identify demographic, clinical, and treatment-level factors associated with positive treatment response.

Results

Treatment episodes among patients 11 years and under at the time of first use had a 22% higher odds of having a positive response to treatment as compared to those treatment episodes in which the person was 30 years or older at the time of first use. The presence of psychiatric comorbidity resulted in substantial differences in direction and magnitude of the relationships between treatment response and covariates. Positive response to treatment was less likely for episodes among Non-Hispanic Black/African American persons, in detoxification settings, for unemployed individuals, or for individuals living in the South, but a positive response was more likely for episodes occurring in rehabilitation/residential settings.

Conclusions

Race/ethnicity, geographic region, treatment setting, and employment status were the strongest predictors of response to treatment. Treatment programs should maximize treatment of psychiatric conditions, intensify support for persons of color seeking treatment in detoxification settings, and increase efforts to find adequate employment for patients.

Single-nucleus transcriptome profiling of prefrontal cortex induced by chronic methamphetamine treatment

Background

Methamphetamine (METH) addiction causes a huge burden on society. The prefrontal cortex (PFC), associated with emotion and cognitive behaviours, is also involved in addiction neurocircuitry. Although bulk RNA sequencing has shown METH-induced gene alterations in the mouse PFC, the impact on different cell types remains unknown.

Aims

To clarify the effects of METH treatment on different cell types of the PFC and the potential pathways involved in METH-related disorders.

Methods

We performed single-nucleus RNA sequencing (snRNA-seq) to examine the transcriptomes of 20 465 nuclei isolated from the PFC of chronic METH-treated and control mice. Main cell types and differentially expressed genes (DEGs) were identified and confirmed by RNA fluorescence in situ hybridization(FISH).

Results

Six main cell types were identified depending on the single-cell nucleus sequencing; of particular interest were the mature oligodendrocytes in the PFC. The DEGs of mature oligodendrocytes were enriched in the myelin sheath, adenosine triphosphate (ATP) metabolic process, mitochondrial function and components, and so on. The messenger RNA levels of Aldoc and Atp5l (FISH) and the protein level of the mitochondrial membrane pore subunit TOM40 (immunofluorescence) decreased in the mature oligodendrocytes. Fast blue staining and transmission electron microscopy image indicated myelin damage, and the myelin thickness decreased in METH brains.

Conclusions

snRNA-seq reveals altered transcriptomes of different cell types in mouse PFC induced by chronic METH treatment, underscoring potential relationships with psychiatric disorders.

Medical Cannabis Legalization: No Contribution to Rising Stimulant Rates in the USA

INTRODUCTION

There has been a pronounced increase in the use of Schedule II stimulants to treat attention-deficit hyperactivity disorder (ADHD) in the United States over the last two decades. Interestingly, chronic medical cannabis (MC) use can present with cognitive impairments that resemble ADHD symptoms. This study aimed to determine if MC legalization increased prescription stimulant distribution.

METHODS

Information on the distribution of methylphenidate, amphetamine, and lisdexamfetamine for 2006 to 2021 was extracted from the Drug Enforcement Administration's comprehensive database and the three-year population-corrected slopes of stimulant distribution before and after MC program implementation were compared.

RESULTS

We found a significant main effect of time (p<0.001); however, contrary to the hypothesis, the sales status of states' MC, did not influence slopes of distribution (p=0.391). There was a significantly large interaction effect of time and MC sales status on slopes of distribution (p<0.001). Slopes of distribution rates of stimulants were significantly lower in states that proceeded to legalize MC prior to MC program implementation than those states that did not (p=0.022). After MC program implementation, however, the distribution rates of the Schedule II stimulants were not significantly different when comparing states with MC sales to those without (p=0.355).

DISCUSSION

These findings suggest that MC program legalization did not contribute to certain states having rapid increases in Schedule II stimulant distribution rates over time. Other factors, including the liberalization of the adult ADHD diagnostic criteria in the DSM-5 and the introduction of Binge Eating Disorder, also likely contributed to elevations in stimulant distribution.

Initiation Patterns and Transitions Among Adults Using Stimulant Drugs: Latent Transition Analysis

BACKGROUND

The fourth wave of the drug overdose epidemic in the United States includes increasing rates of stimulant-involved overdose. Recent studies of transitions leading to stimulant misuse have shown complex patterns that are not universally applicable because they have isolated individual populations or individual behaviors. A comprehensive analysis of transitions between behaviors and the associations with present-day problematic drug use has not been conducted.

OBJECTIVE

This study aims to determine whether adults from the general population who use stimulants initiate use through a heterogeneous combination of behaviors and quantify the association between these typologies with present-day problematic drug use.

METHODS

Individuals who have reported use of any stimulant in their lifetime were recruited from the 2021 Survey of Nonmedical Use of Prescription Drugs Program, a nationally representative web-based survey on drug use, to participate in a rapid follow-up survey about their past stimulant use. Individuals were asked which stimulants they used, the reasons for use, the routes of administration, and the sources of the stimulant. For each stimulant-related behavior, they were asked at what age, between 6 and 30 years, they initiated each behavior in a 6-year time window. A latent transition analysis was used to characterize heterogeneity in initiation typologies. Mutually exclusive pathways of initiation were identified manually by the researchers. The association of these pathways with present-day problematic drug use was calculated using logistic regression adjusted by the current age of the respondent.

RESULTS

From a total of 1329 participants, 740 (55.7%) reported lifetime prescription stimulant use and 1077 (81%) reported lifetime illicit stimulant use. Three typologies were identified. The first typology was characterized by illicit stimulant initiation to get high, usually via oral or snorting routes and acquisition from friends or family or a dealer (illicit experimentation). The second typology was characterized by low, but approximately equal probabilities of initiating 1-2 new behaviors in a time window, but no singular set of behaviors characterized the typology (conservative initiation). The third was characterized by a high probability of initiating many diverse combinations of behaviors (nondiscriminatory experimentation). The choice of drug initiated was not a strong differentiator. Categorization of pathways showed those who were only in an illicit experimentation status (reference) had the lowest odds of having severe present-day problematic drug use. Odds were higher for a conservative initiation-only status (odds ratio [OR] 1.84, 95% CI 1.14-2.94), which is higher still for those moving from illicit experimentation to conservative initiation (OR 3.50, 95% CI 2.13-5.74), and highest for a nondiscriminatory experimentation status (OR 5.45, 95% CI 3.39-8.77).

CONCLUSIONS

Initiation of stimulant-related use behaviors occurred across many time windows, indicating that multiple intervention opportunities are presented. Screening should be continued throughout adulthood to address unhealthy drug use before developing into full substance use disorders.

Regional Disparities in Prescription Methamphetamine and Amphetamine Distribution Across the United States

OBJECTIVE

The objectives of this report were to characterize the regional and state differences in prescription methamphetamine and amphetamine distribution in the US.

METHODS

Prescription methamphetamine and amphetamine distribution was obtained from the Drug Enforcement Administration for 2019.

RESULTS

Total per capita drug weight distribution of amphetamine was 4,000 times higher than methamphetamine. Regionally, total per capita drug weight for methamphetamine was highest in the West (32.2% of total distribution) and lowest in the Northeast (17.4%). The total per capita drug weight for amphetamine was highest in the South (37.0% of total distribution) and lowest in the Northeast (19.4%). Distribution of methamphetamine was 16.1% while amphetamine was 54.0% of its production quota.

CONCLUSION

Overall, prescription amphetamine distribution was common while prescription methamphetamine distribution was rare. The patterns observed in distribution are likely the result of stigmatization, differences in accessibility, and the efforts of initiatives such as the Montana Meth Project.

Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000 to 2021

OBJECTIVES

To investigate the characteristics and trends of out-of-hospital attention-deficit/hyperactivity disorder (ADHD) medication-related therapeutic errors among youth <20 years old reported to US poison centers.

METHODS

National Poison Data System data from 2000 through 2021 were analyzed. Population-based rates were calculated using US census data.

RESULTS

There were 124 383 ADHD medication-related therapeutic errors reported to US poison centers from 2000 through 2021, with the annual frequency increasing by 299.0% during that period. Two-thirds (66.6%) of the 87 691 first-ranked exposures involved children 6 to 12 years old, three-fourths (76.4%) were among males, and half (50.5%) involved amphetamines and related compounds. Most (79.7%) therapeutic errors were single-substance exposures. Although most (82.7%) individuals did not receive treatment in a health care facility (HCF), 2.3% were admitted to a HCF and 4.2% had a serious medical outcome. Children <6 years old were more likely to experience a serious medical outcome (odds ratio = 2.1; 95% confidence interval: 1.9-2.3) or be admitted to a HCF (odds ratio = 3.4; 95% confidence interval: 3.0-3.7) than 6 to 19-year-olds. The most common scenarios were "inadvertently taken or given medication twice" (53.9%), followed by "inadvertently taken or given someone else's medication" (13.4%), and "wrong medication taken or given" (12.9%).

CONCLUSIONS

The frequency of cases reported to poison centers of pediatric out-of-hospital therapeutic errors related to ADHD medications increased by almost 300% during the 22-year study period and is likely attributable to increased prescribing of these medications. Because therapeutic errors are preventable, more attention should be given to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems.

Prescribed stimulant medications: Trends in the last decade, pre and post COVID-19 response

Background

Recent studies indicate that COVID-19 has had a significant impact on access and continuity to opioid and benzodiazepine medications; little is known about its effect on access to and utilization of stimulant medications.

Objective

To investigate trends of dispensed stimulant medications in relation to the COVID-19 pandemic response.

Methods

Stimulant prescriptions dispensed during 2011-2021 were analyzed using the Massachusetts Prescription Drug Monitoring Program (PDMP), the state's data repository for all controlled substance medications dispensed to residents from retail pharmacies and out of state mail-order pharmacies. Statewide trends were estimated by age group, sex, and stimulant-naïve patients (individuals with no stimulant prescription in the prior one-year period).

Results

Overall, stimulant prescriptions increased 70% from 2011 to 2021. Wide differences by sex and age groups were found pre and post COVID response periods. Between 2019 and 2021, stimulant prescriptions for males 12-18 years old decreased 14.6% compared to 0.9% for females. Female stimulant-naïve patients ages 25-34 increased more than males between 2019 and 2021 (11.6% compared to <1%, respectively) and females ages 35-44 increased 4.1% while males decreased by 2.7%.

Conclusions

Administrators, clinicians, and policy makers should closely monitor stimulant prescribing trends, a critical step in improving access to and quality of care.

Identification of PROK2 gene polymorphisms as predictors of methamphetamine use disorder risk and indicators of craving scale in the Chinese Han population

Background: Methamphetamine use disorder (MUD) has become a global problem due to the highly addictive nature of methamphetamine. Earlier research have demonstrated that PROK2 functions as a compensatory and protective response against neurotoxic stress by stimulating astrocyte reactivity. The aim of our study was to evaluate the correlation between the PROK2 gene and both MUD risk susceptibility and craving scale in the Chinese Han population. Methods: A total of 5,282 participants (1,796 MUD patients and 3,486 controls) were recruited. Seven tag SNPs of the PROK2 gene were chosen and genotyped in the samples. Genetic association analyses were performed to capture the significant SNPs. To investigate the relationship between PROK2 levels and craving scores with the associated-SNP genotypes, we conducted a linear model. Results: SNP rs75433452 was significantly linked with MUD risk (p-value = 1.54 × 10^-8), with the A allele being positively correlated with an increased risk of MUD. Moreover, the average serum level of PROK2 decreased when more copies of the A allele were presented in both MUD patients (p-value = 4.57 × 10^-6) and controls (p-value = 1.13 × 10^-5). Furthermore, the genotypes of SNP rs75433452 were strongly correlated with the craving scores in MUD patients (p-value = 4.05 × 10^-4). Conclusion: Our study identified a significant association signal of the PROK2 gene with MUD risk susceptibility and methamphetamine craving scores in the Chinese Han population, providing potential valuable insights into the underlying mechanisms of METH dependence.

Trends in substance use disorder diagnoses among Veterans, 2009-2019

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data.

METHODS

We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD.

RESULTS

Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances.

DISCUSSION AND CONCLUSIONS

Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults.

SCIENTIFIC SIGNIFICANCE

These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.

Medical Expenditures Associated with Attention-Deficit/Hyperactivity Disorder Among Adults in the United States by Age, 2015-2019

BACKGROUND

Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures.

OBJECTIVE

To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population.

DESIGN

Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders.

PARTICIPANTS

Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776).

MAIN MEASURES

Overall and service specific direct ADHD-attributable medical expenditures.

KEY RESULTS

A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69-$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75-$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18-30), the incremental cost was $1856.66.

CONCLUSIONS

The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18-30). Future research is needed to understand the increasing trend in ADHD attributable cost.

Multivariate associations between dopamine receptor availability and risky investment decision-making across adulthood

Enhancing dopamine increases financial risk taking across adulthood but it is unclear whether baseline individual differences in dopamine function are related to risky financial decisions. Here, thirty-five healthy adults completed an incentive-compatible risky investment decision task and a PET scan at rest using [11C]FLB457 to assess dopamine D2-like receptor availability. Participants made choices between a safe asset (bond) and a risky asset (stock) with either an expected value less than the bond ("bad stock") or expected value greater than the bond ("good stock"). Five measures of behavior (choice inflexibility, risk seeking, suboptimal investment) and beliefs (absolute error, optimism) were computed and D2-like binding potential was extracted from four brain regions of interest (midbrain, amygdala, anterior cingulate, insula). We used canonical correlation analysis to evaluate multivariate associations between decision-making and dopamine function controlling for age. Decomposition of the first dimension (r = 0.76) revealed that the strongest associations were between measures of choice inflexibility, incorrect choice, optimism, amygdala binding potential, and age. Follow-up univariate analyses revealed that amygdala binding potential and age were both independently associated with choice inflexibility. The findings suggest that individual differences in dopamine function may be associated with financial risk taking in healthy adults.

Receipt of Prescription Psychostimulants and Stimulant-Involved Fatal Overdose: A Population-Based Case-Control Study

Background: Rates of psychostimulant use, misuse, and hospitalization have increased markedly over the past decade. The objective of this study was to estimate the association between receipt of a psychostimulant prescription in the past year and fatal, unintentional psychostimulant-involved overdose. Methods: We conducted a population-based case-control study using linked, state-level databases from the Rhode Island Department of Health. Cases were defined as Rhode Island residents who experienced a fatal, unintentional drug overdose involving a psychostimulant, and controls included non-psychostimulant involved fatal overdoses occurring between May 1, 2017 and May 31, 2020 The primary exposure of interest was receipt of a psychostimulant prescription within 12 months prior to death, ascertained through linkage to the state's prescription drug monitoring program. Conditional logistic regression was used to estimate unadjusted and adjusted odds ratios. Results: Of 894 eligible overdose fatalities, the majority were white/non-Hispanic (72%), mean age was 43 years, and most resided in Providence County (69%). A total of 39 (4%) involved a psychostimulant. After adjusting for year of death and matching by sex, age, and county of residence, cases had 4.1 (95% confidence interval: 1.6, 10.6) times the odds of receiving a prescription stimulant in the past year compared to controls. Conclusions: Our findings suggest that there is a strong, positive association between prescription psychostimulant receipt and psychostimulant-involved fatal overdose. In response to an evolving polysubstance use landscape, current harm reductions measures, including naloxone training, fentanyl test strip distribution, and overdose education, should be expanded to include patients who receive psychostimulant prescriptions.

Trends in amphetamine prescriptions given at discharge in emergency departments: A national analysis (2012-2019)

OBJECTIVES

In parallel with the opioid epidemic, there has been a resurgence in abuse, medical complications, and deaths related to amphetamines. The opioid epidemic began with increasing rates of prescription products that evolved overtime to include heroin and more recently, fentanyl analogues. Current trends in amphetamine prescriptions are less well described. We sought to determine if there has been a change in amphetamine prescriptions given at discharge in U.S. emergency departments (EDs) in recent years.

METHODS

We conducted a retrospective review of data provided by the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2019. We computed total number of visits that were given amphetamine prescriptions (amphetamine salts, methylphenidate derivatives, and dexmethylphenidate) at discharge for each year. We computed the total number and rate of visits (of all ED visits) that had both amphetamines and opioids prescribed at discharge over the years. We computed data normality using Shapiro Wilke's test and used descriptive statistics such as mean to describe the data distribution as applicable. We used spearman's rho (SR) or pearson's correlation (PC) as applicable to describe trends in data. All p-values were one-tailed and were reported at a 0.05 significance level. All analyses were conducted in IBM SPSS version 28.

RESULTS/FINDINGS

From 2012 to 2019, there were an estimated 817,895 ED visits where an amphetamine prescription was given at discharge, with an overall strong increase in rate over time (SR = 0.71, p = 0.02). At the beginning of the study period (2012) there were 83,503 (0.06%) visits and in 2019 there were 186,539 (0.12%) visits (123% absolute increase). On average, there were 102,237 (SD: 52,725) visits with discharge amphetamine prescriptions per year. There was a strong, linear increase in number of visits that involved a discharge amphetamine salt prescription (PC = 0.92, p = 0.001). In 2012, there were a total of 23,676 visits and in 2019, a total of 124,773 visits (427% increase). There was no trend in visits where both an amphetamine and opioid were prescribed (PC: 0.61, p = 0.06).

CONCLUSION

There have been increases in discharge prescriptions for amphetamines in the ED over time. This was largely driven by prescriptions for amphetamine salts. Future research initiatives should continue to monitor this trend and in prescriptions and associated abuse in the setting of rising amphetamine abuse.

Behavioral, Neurochemical and Developmental Effects of Chronic Oral Methylphenidate: A Review

The majority of animal studies on methylphenidate (MP) use intraperitoneal (IP) injections, subcutaneous (SC) injections, or the oral gavage route of administration. While all these methods allow for delivery of MP, it is the oral route that is clinically relevant. IP injections commonly deliver an immediate and maximum dose of MP due to their quick absorption. This quick-localized effect can give timely results but will only display a small window of the psychostimulant's effects on the animal model. On the opposite side of the spectrum, a SC injection does not accurately represent the pathophysiology of an oral exposure because the metabolic rate of the drug would be much slower. The oral-gavage method, while providing an oral route, possesses some adverse effects such as potential animal injury and can be stressful to the animal compared to voluntary drinking. It is thus important to allow the animal to have free consumption of MP, and drinking it to more accurately mirror human treatment. The use of a two-bottle drinking method allows for this. Rodents typically have a faster metabolism than humans, which means this needs to be considered when administering MP orally while reaching target pharmacokinetic levels in plasma. With this oral two-bottle approach, the pathophysiological effects of MP on development, behavior, neurochemistry and brain function can be studied. The present review summarizes these effects of oral MP which have important implications in medicine.

Unpacking Inequities in ADHD Diagnosis: Examining Individual-Level Race/Ethnicity and State-Level Online Information-Seeking Patterns

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, persistent, and costly mental health condition. The internet is an increasingly popular source for information related to ADHD. With a nationally representative sample (2018 NSCH), we aimed to separate individual- and state-level effects to examine inequities in ADHD diagnoses. We extracted state-level relative search volumes using "ADHD," "ADHD treatment," "ADHD medication," and "ADHD therapy" from Google Trends, and sociodemographic and clinical variables from the 2018 National Survey of Children's Health (N = 26,835). We examined state variation in ADHD-related information-seeking and applied multilevel modeling to examine associations among individual-level race/ethnicity, state-level information-seeking patterns, and ADHD diagnoses. Online information seeking related to ADHD varies by state and search term. Individual-level racial/ethnic background and state-level information-seeking patterns were associated with ADHD diagnoses; however, their cross-level interaction was not significant. This study adds to the strong body of evidence documenting geographical variation and diagnostic disparity in mental health and the growing literature on the impact of the digital divide on population health, indicating an urgent need for addressing inequities in mental health care. Increasing public interest in and access to empirically supported online information may increase access to care, especially among people of color.

Recreational marijuana laws and the misuse of prescription opioids: Evidence from National Survey on Drug Use and Health microdata

Several studies have concluded that legalizing medical marijuana can reduce deaths from opioid overdoses. Drawing on micro data from the National Survey on Drug Use and Health, a survey uniquely suited to assessing patterns of substance use, we examine the relationship between recreational marijuana laws (RMLs) and the misuse of prescription opioids. Using a standard difference-in-differences (DD) regression model, we find that RML adoption reduces the likelihood of frequently misusing prescription opioids such as OxyContin, Percocet, and Vicodin. However, using a two-stage procedure designed to account for staggered treatment and dynamic effects, the DD estimate of relationship between RML adoption and the likelihood of frequently misusing prescription opioids becomes positive. Although event study estimates suggest that RML adoption leads to a decrease in the frequency of prescription opioid abuse, this effect appears to dissipate after only 2 or 3 years.

Geographic variation and sociodemographic correlates of prescription psychotropic drug use among children and youth in Ontario, Canada: a population-based study

BACKGROUND

Population-based research examining geographic variability in psychotropic medication dispensing to children and youth and the sociodemographic correlates of such variation is lacking. Variation in psychotropic use could reflect disparities in access to non-pharmacologic interventions and identify potentially concerning use patterns.

METHODS

We conducted a population-based study of all Ontario residents aged 0 to 24 years who were dispensed a benzodiazepine, stimulant, antipsychotic or antidepressant between January 1, 2018, and December 31, 2018. We conducted small-area variation analyses and identified determinants of dispensing using negative binomial generalized estimating equation models.

RESULTS

The age- and sex-standardized rate of psychotropic dispensing to children and youth was 76.8 (range 41.7 to 144.4) prescriptions per 1000 population, with large variation in psychotropic dispensing across Ontario's census divisions. Males had higher antipsychotic [rate ratio (RR) 1.40; 95% confidence interval (CI) 1.36 to 1.44) and stimulant (RR 1.75; 95% CI 1.70 to 1.80) dispensing rates relative to females, with less use of benzodiazepines (RR 0.85; 95% CI 0.83 to 0.88) and antidepressants (RR 0.81; 95% CI 0.80 to 0.82). Lower antipsychotic dispensing was observed in the highest income neighbourhoods (RR 0.72; 95% CI 0.70 to 0.75) relative to the lowest. Benzodiazepine (RR 1.12; 95% CI 1.01 to 1.24) and stimulant (RR 1.11; 95% CI 1.01 to 1.23) dispensing increased with the density of mental health services in census divisions, whereas antipsychotic use decreased (RR 0.82; 95% CI 0.73 to 0.91). The regional density of child and adolescent psychiatrists and developmental pediatricians (RR 1.00; 95% CI 0.99 to 1.01) was not associated with psychotropic dispensing.

CONCLUSION

We found significant variation in psychotropic dispensing among young Ontarians. Targeted investment in regions with long wait times for publicly-funded non-pharmacological interventions and novel collaborative service models may minimize variability and promote best practices in using psychotropics among children and youth.

Selecting the appropriate hurdles and endpoints for pentilludin, a novel antiaddiction pharmacotherapeutic targeting the receptor type protein tyrosine phosphatase D

Substance use disorders provide challenges for development of effective medications. Use of abused substances is likely initiated, sustained and "quit" by complex brain and pharmacological mechanisms that have both genetic and environmental determinants. Medical utilities of prescribed stimulants and opioids provide complex challenges for prevention: how can we minimize their contribution to substance use disorders while retaining medical benefits for pain, restless leg syndrome, attention deficit hyperactivity disorder, narcolepsy and other indications. Data required to support assessments of reduced abuse liability and resulting regulatory scheduling differs from information required to support licensing of novel prophylactic or therapeutic anti-addiction medications, adding further complexity and challenges. I describe some of these challenges in the context of our current efforts to develop pentilludin as a novel anti-addiction therapeutic for a target that is strongly supported by human and mouse genetic and pharmacologic studies, the receptor type protein tyrosine phosphatase D (PTPRD).

Neurodevelopmental Disorders: Past, Present, and Future

Recent decades have seen a dramatic increase in neurodevelopmental disorders and the attention paid to them. Since their emergence in the not-so-distant past, some neurodevelopmental disorders have undergone considerable redefinition and, beginning in the 21st century, there has been a massive increase in research. In this paper, we briefly review the history of some of them, address some of the issues that characterize their current management and relationship with neurological pathologies, and share some insights for the future.

Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act

Background

This study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation.

Methods

National Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009-2013) and post-ACA (2015-2019) implementation. The sample (n = 44,622) included respondents 18-64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use.

Results

Ninety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA.

Conclusions

There was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.

Pronounced Declines in Meperidine in the US: Is the End Imminent?

Background: Once a widely used analgesic in the United States (US), meperidine offered an alternative opioid to other opioids as a pain reliever and was widely assumed to be safer with acute pancreatitis. However, within the last two decades meperidine, has gone from a frequently used drug to being used only when patients exhibit atypical reactions to opioids (e.g., morphine and hydromorphone), to being taken off the World Health Organization List of Essential Medications and receiving strong recommendations for overall avoidance. The aim of this study was to identify changes in meperidine distribution in the US, and regional disparities as reported to the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (DEA ARCOS) and Medicaid. Methods: Data related to meperidine distribution was obtained through ARCOS (2001−2021) and Medicaid public use files (2016−2021). Heat maps were used to visualize regional disparities in distribution by state. States outside a 95% confidence interval were statistically significant. Results: Meperidine distribution between 2001 and 2021 decreased by 97.4% (R = −0.97, p < 0.0001). There was a 34-fold state-level difference in meperidine distribution between Arkansas (16.8 mg/10 persons) and Connecticut (0.5 mg/10 persons) in 2020. Meperidine distribution in 2020 was elevated in Arkansas, Mississippi, and Alabama. In 2021, meperidine distribution was highest in Arkansas (16.7 mg/10 persons) and lowest in Connecticut (0.8 mg/10 persons). Total prescriptions of meperidine as reported by Medicaid decreased by 73.8% (R = −0.67, p = 0.045) between 2016 and 2021. Conclusion: We observed a decrease in the overall distribution of meperidine in the past two decades, with a similar recent decline in prescribing it to Medicaid enrollees. The shortage of some parenteral formulations is an important contributor to these declines, however, the most likely explanation for this global decline in use is related to an increased recognition of safety concerns related to important drug interactions and a neurotoxic metabolite. This data may reflect plans to phase out the use of this opioid, especially in the many situations where safer and more preferred opioids are available.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019

OBJECTIVE

To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019.

METHOD

This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD.

RESULTS

The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%.

CONCLUSION

There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Psychiatrists' Cognitive and Affective Biases and the Practice of Psychopharmacology: Why Do Psychiatrists Differ From One Another in How They View and Prescribe Certain Medication Classes?

Cognitive and affective biases impact clinical decision-making in general medicine. This article explores how such biases might specifically affect psychiatrists' attitudes and prescribing patterns regarding two medication classes (stimulants and benzodiazepines) and addresses related issues. To supplement personal observations, selective PubMed narrative literature searches were conducted using relevant title/abstract terms, followed by snowballing for additional pertinent titles. Acknowledging that there are many more types of biases, we describe and use clinical vignettes to illustrate 17 cognitive and affective biases that might influence clinicians' psychopharmacological practices. Factors possibly underlying these biases include temperamental differences and both preprofessional and professional socialization. Mitigating strategies can reduce the potentially detrimental impacts that biases may impose on clinical care. How extensively these biases appear, how they differ among psychiatrists and across classes of medication, and how they might be most effectively addressed to minimize harms deserve further systematic study.

Efficacy of psychotropic medications on suicide and self-injury: a meta-analysis of randomized controlled trials

Using psychotropic medications to treat and prevent self-injurious thoughts and behaviors (SITBs) has become increasingly popular, but conclusive evidence supporting the efficacy this approach remains elusive. To empirically examine whether psychotropic medications are efficacious treatments for SITBs, the present meta-analysis comprehensively summarizes all published randomized controlled trials (RCTs) that have reported the causal effects of psychotropic medications on suicide and self-injury. A total of 251 papers from 718 unique RCTs were included. A frequentist pairwise approach was adopted for meta-analyses. Potential effect modifiers were examined via met regressions and potential biases were evaluated through sensitivity analyses. On average, medications yielded an 8% reduction in SITB frequency and a reduction of 0.2 standard deviations in symptoms and severity. Findings were largely consistent across potential effect modifiers, and significant evidence of publication bias was not detected. Only one medication class (i.e., antipsychotics) and two specific medications (i.e., citalopram, ketamine) produced larger-than-average treatment effects. Psychostimulants and typical antipsychotics may produce iatrogenic effects. Less than 4% of included studies required individuals to exhibit SITBs, and nearly half of analyzed effects were drawn from studies that excluded individuals on the basis of SITB risk. Taken together, findings suggest that psychotropic medications produce small treatment effects on SITBs; however, these findings should be considered in light of the methodological constraints of the existing literature, including the lack of studies intentionally including individuals with SITBs. It is critical for future RCTs to prioritize including individuals with existing SITBs to further clarify treatment effects in self-injurious and suicidal populations. Additional research is needed to better understand the treatment mechanisms of psychotropic medications and identify the causal processes underlying SITBs.

Methamphetamine-associated pulmonary arterial hypertension

PURPOSE OF REVIEW

Methamphetamine use is increasing in popularity globally, and chronic users suffer from various drug toxicities, including the development of pulmonary arterial hypertension. Although it was previously thought to be a possible cause of pulmonary arterial hypertension, as of the sixth World Symposium on Pulmonary Hypertension, methamphetamine use is now recognized as a definite cause of pulmonary arterial hypertension. This review will discuss the history of methamphetamine use, the link between methamphetamine use and pulmonary arterial hypertension, and the clinical characteristics of patients with pulmonary hypertension from methamphetamine use.

RECENT FINDINGS

The mechanism by which methamphetamine abuse leads to pulmonary hypertension is unclear. However, recent studies have suggested that reduced expression of carboxylesterase 1 may be implicated due to maladaptation to the environmental injury of methamphetamine abuse. Based on the report of two recent cohort studies, patients with methamphetamine-associated pulmonary arterial hypertension have a worse functional class, less favorable hemodynamics, impaired health-related quality of life, increased health-care utilization, and attenuated survival, as compared to those with idiopathic pulmonary arterial hypertension.

SUMMARY

Future studies are needed to better understand the mechanism by which methamphetamine use leads to pulmonary arterial hypertension. Methamphetamine-associated pulmonary arterial hypertension likely represents a more advanced disease state than idiopathic pulmonary arterial hypertension, however, it is treated less aggressively in clinical practice.

Treatment with stimulants and the risk of COVID-19 complications in adults with ADHD

Adults with attention deficit hyperactivity disorder (ADHD) have shown higher infection rates and worse outcomes from COVID-19. Stimulant medications are prescribed as the first-line treatment for ADHD in adults and mitigate risk of negative ADHD-related health outcomes, but little is known about the association between stimulant medications and COVID-19 outcomes. The objective of this study was to assess the risks of severe COVID-19 outcomes among people with ADHD who were prescribed stimulant medications versus those who were not. This retrospective cohort study used electronic health records in the TriNetX research database. We assessed records of adults with ADHD diagnosed with COVID-19 between January 1, 2020 and June 30, 2021. The stimulant cohort consisted of 28,011 people with at least one stimulant prescription; the unmedicated cohort comprised 42,258 people without prescribed stimulants within 12 months prior to their COVID infection. Multiple logistic regression modeling was utilized to assess the presence of critical care services or death within 30 days after the onset of COVID diagnoses, controlling for patient demographics, and comorbid medical and mental health conditions. The stimulant cohort was less likely to utilize emergency department, hospital, and intensive care services than the unmedicated cohort, and had significantly lower 30-day mortality. Further research, including prospective studies, is needed to confirm and refine these findings.

Stimulant misuse among youth

Rates of stimulant use, including misuse of prescription stimulants and use of cocaine and methamphetamine, are rising rapidly among adolescents and young adults ("youth"). Stimulant misuse is associated with overdose, polysubstance use, substance use disorders, and other medical harms. Substance use is often initiated during adolescence and young adulthood, and interventions during these crucial years have the potential to impact the lifetime risk of stimulant use disorder and associated harms. In this narrative review, we review recent data on prescription and illicit stimulant use in youth. We describe the rising contribution of stimulants to polysubstance use involving opioids and other substances and to overdose, as well as ways to minimize harm. We also discuss prescription stimulant misuse, which is especially prevalent among youth relative to other age groups, and the limited evidence on potential pathways from prescription stimulant use to illicit stimulant use. Last, we assess potential strategies for the prevention and treatment of stimulant use disorder in youth.

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study

BACKGROUND

Stimulant prescriptions increased by 250% in the United States from 2006-2016 while diagnoses for ADHD minimally increased. There is insufficient data regarding who may be the recipients of these new stimulant prescriptions and safety of stimulants have come under scrutiny in some populations. We aim to describe trends in stimulant prescriptions across biopsychosocial patient level factors between 2010 and 2020.

METHODS

We applied a retrospective observational cohort design utilizing electronic health records from 52 healthcare organizations sourced from the TriNetX research network database in the United States. We assessed new stimulant prescriptions across biopsychosocial variables for recipients of prescriptions. We utilized linear regression to assess longitudinal trends of all participants and also conducted an age stratified logistic regression analysis.

FINDINGS

There was an increase in stimulants to people categorized as white (OR 1.24 CI 1.20-1.28), female (OR 1.28 CI 1.23-1.31), and to those with diagnosed anxiety disorders (OR 1.39 CI 1.35-1.44) as well as obesity (OR 1.34 CI 1.28-1.41). The average age of recipients increased throughout the study, and among people sixty-five and older, there was an increase in prescriptions to people with multiple cardiovascular risk factors.

INTERPRETATION

Prescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors) between 2010 and 2020. Similar trends in prescription medications were witnessed through the opioid epidemic and warrant attention given concerning trends with illicit stimulants. Additional research that investigates patient and provider motivation for stimulant prescriptions, as well as risk perception of stimulants, may be warranted.

FUNDING

This study was made possible by institutional resources at Penn State Hershey Medical Center.

Tolerance to Stimulant Medication for Attention Deficit Hyperactivity Disorder: Literature Review and Case Report

Recommended treatment for attention deficit hyperactivity disorder (ADHD) includes stimulant medication. While these medicines are effective for most ADHD patients, benefits may wear off, suggesting tolerance. This paper reviews the published literature on tolerance to stimulant medication treatment for ADHD. As there are relatively few studies published, pivotal studies and ADHD treatment guidelines were also reviewed. Research demonstrates physiological changes related to continued stimulant usage in neurons and certain brain regions, suggesting a mechanism for tolerance development. One clinical study showed that 24.7% of patients developed tolerance to stimulants in the time of days to weeks; another showed 2.7% developed tolerance over 10 years. Long term follow-up studies demonstrate that medication response may lessen over longer durations of treatment in a high percentage of patients. Strategies to manage tolerance include switching stimulant medicines, drug holidays, or clinical reassessment. Three cases illustrate challenges with treating patients who develop tolerance to stimulant medication. The paucity of research and lack of guidance to clinicians may contribute to significant under recognition of tolerance to stimulant medication. Further research is required to define clinical tolerance for stimulants in ADHD and to provide guidance on identifying and managing tolerance in clinical practice.

Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overprescriptions: Medicalization of Distractions

The use and misuse of prescription stimulants has escalated during the past decade, with concerns of being "the next epidemic." The diagnosis of attention-deficit/hyperactivity disorder and the use of prescription stimulants have rapidly increased in children and adults in the past decade. Amphetamine use more than doubled from 2006 to 2016. In 2018, among illicit substance users in the past year (53.2 million), more than 5 million 12 years or older had misused prescription stimulants. The most commonly reported motivations for misuse were to help with alertness and concentration, in approximately 60% of respondents. Most persons who misused prescription stimulants received the medication from a friend or relative, who got it through a health care provider. It is important to reexamine the pattern of prescription stimulant use after the loosening of Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for attention-deficit/hyperactivity disorder diagnosis. Caveats to the this report could be the understudied specific populations (such as medical students), the exclusion of the military and institutionalized populations from the study, and the variations among individual states in stimulant prescribing patterns.

Prediction of Carboxylesterase 1-mediated In Vivo Drug Interaction between Methylphenidate and Cannabinoids using Static and Physiologically Based Pharmacokinetic Models

The use of cannabis products has increased substantially. Cannabis products have been perceived and investigated as potential treatments for attention-deficit/hyperactivity disorder (ADHD). Accordingly, co-administration of cannabis products and methylphenidate (MPH), a first-line medication for ADHD, is possible. Oral MPH undergoes extensive presystemic metabolism by carboxylesterase 1 (CES1), a hepatic enzyme which can be inhibited by two prominent cannabinoids, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). This prompts further investigation into the likelihood of clinical interactions between MPH and these two cannabinoids through CES1 inhibition. In the present study, inhibition parameters were obtained from a human liver S9 system and then incorporated into static and physiologically-based pharmacokinetic (PBPK) models for prediction of potential clinical significance. The inhibition of MPH hydrolysis by THC and CBD was reversible, with estimated unbound inhibition constants (Ki,u) of 0.031 and 0.091 µM, respectively. The static model predicted a mild increase in MPH exposure by concurrent THC (34%) and CBD (94%) from smoking a cannabis cigarette and ingestion of prescriptive CBD, respectively. PBPK models suggested no significant interactions between single doses of MPH and CBD (2.5 - 10 mg/kg) when administered simultaneously, while a mild interaction (area under drug concentration-time curve increased by up to 55% and maximum concentration by up to 45%) is likely if multiple doses of CBD (10 mg/kg twice daily) are administered. In conclusion, the pharmacokinetic disposition of MPH can be potentially influenced by THC and CBD under certain clinical scenarios. Whether the magnitude of predicted interactions translates into clinically relevant outcomes requires verification in an appropriately designed clinical study. SIGNIFICANCE STATEMENT: This work demonstrated a potential mechanism of drug-drug interactions between methylphenidate (MPH) and two major cannabinoids (Δ9-tetrahydrocannabinol [THC] and cannabidiol [CBD]) not previously reported. We predicted a mild interaction between MPH and THC when the cannabinoid exposure occurred via cannabis smoking. Mild interactions between MPH and CBD were predicted with multiple oral administrations of CBD.

Abstinence following intermittent methylphenidate exposure dose-dependently modifies brain glucose metabolism in the rat brain

Methylphenidate (MP) is a psychostimulant chronically prescribed for the treatment of attention deficit hyperactivity disorder (ADHD). Additionally, MP users may take breaks from using the medication during "drug holidays," which may include short-term or long-term breaks from medication. The present study utilized fluorodeoxyglucose (FDG) positron emission tomography (PET) to analyze the effects of chronic oral MP use and abstinence on brain glucose metabolism (BGluM) in rats at two different doses: high dose (HD) and low dose (LD). The schedule of treatment was 3 weeks on-treatment and 1 week off-treatment for a period of 13 weeks, followed by an abstinence period of 4 total weeks. Results showed that chronic MP treatment using this schedule did not lead to significant changes in BGluM when comparing the control to HD MP groups. However, significant activation in BGluM was observed after periods of abstinence between control and HD MP rats in the following brain regions: the trigeminal nucleus, reticular nucleus, inferior olive, lemniscus, mesencephalic reticular formation, inferior colliculus, and several areas of the cerebellum. These brain regions and functional brain circuit play a role in facial sensory function, the auditory pathway, organizing connections between the thalamus and cortex, motor learning, auditory function, control over eye movement, auditory information integration, and both motor and cognitive functions. These results, when considered with previous studies, indicate that MP schedule of use may have differing effects on BGluM. BGluM following long-term MP use was dependent on MP dose and schedule of use in rats. This study was conducted in non-ADHD model rats with the aim to establish an understanding of the effects of MP itself, especially given the growing chronic off-label and prescribed use of MP. Further studies are needed for analysis of the drug's effects on an ADHD model.

Central serous chorioretinopathy associated with Adderall (dextroamphetamine-amphetamine) and topical steroid use

Purpose

To report a case of central serous chorioretinopathy (CSC) associated with Adderall (dextroamphetamine-amphetamine) and topical steroid use.

Observations

A 34-year-old man presented for evaluation of a “cloud” in his vision for three months. He was taking Adderall for attention deficit hyperactivity disorder and mometasone 0.1% topical cream for eczema. He was found to have subretinal fluid in the left eye consistent with CSC. The subretinal fluid persisted despite cessation of the steroid cream but resolved after cessation of the Adderall. The subretinal fluid returned when the patient restarted Adderall and again resolved after he stopped it for a second time.

Conclusions

Though we cannot prove causality, the course of events was suggestive of a direct relationship between Adderall use and CSC in this patient, with exogenous steroid as a possible modifying factor.