Nonmedical Stimulant Use in College Students: Association With Attention-Deficit/Hyperactivity Disorder and Other Disorders

Extended-Release Mixed Amphetamine Salts for Comorbid Adult Attention-Deficit/Hyperactivity Disorder and Cannabis Use Disorder: A Pilot, Randomized Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To determine if treatment of co-occurring adult ADHD and Cannabis Use Disorder (CUD) with extended-release mixed amphetamine salts (MAS-ER) would be effective at improving ADHD symptoms and promoting abstinence.

METHOD

A 12-week randomized, double-blind, two-arm pilot feasibility trial of adults with comorbid ADHD and CUD (n = 28) comparing MAS-ER (80 mg) to placebo. Main outcomes: ADHD: ≥30% symptom reduction, measured by the Adult ADHD Investigator Symptom Rating Scale (AISRS). CUD: Abstinence during last 2 observed weeks of maintenance phase.

RESULTS

Overall, medication was well-tolerated. There was no significant difference in ADHD symptom reduction (MAS-ER: 83.3%; placebo: 71.4%; p = .65) or cannabis abstinence (MAS-ER: 15.4%; placebo: 0%; p = .27). MAS-ER group showed a significant decrease in weekly cannabis use days over time compared to placebo (p < .0001).

CONCLUSIONS

MAS-ER was generally well-tolerated. The small sample size precluded a determination of MAS-ER's superiority reducing ADHD symptoms or promoting abstinence. Notably, MAS-ER significantly reduced weekly days of use over time.

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

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

Who Persists and Who Desists? A Prospective Study of Prescription Stimulant Misuse in College Graduates

Prescription stimulant misuse (PSM) has been studied extensively in college populations, but few studies have examined how PSM changes after graduation. We used a longitudinal design to follow individuals at risk for PSM two years after college graduation to document PSM prevalence, motives, and predictors of PSM persistence. Participants from two small, private colleges completed online surveys focused on intrapersonal, interpersonal, and sociocultural predictors of PSM. Overall, PSM declined over time. Lack of premeditation, perceived peer norms, positive expectancies, media exposure, and other substance use were associated with continued PSM; however, only lack of premeditation, descriptive norms, and other substance use predicted PSM in a multivariate model. This preliminary study suggests dispositional and behavioral risk factors may help to explain why PSM persists after college. Interventions that enhance decision-making skills, correct misperceptions about peers' PSM, and reduce polysubstance use may be effective in curbing PSM in college graduates.

Could psychostimulant drug use among university students be related to ADHD symptoms? A preliminary study

We aimed to explore if psychostimulant use among student could be linked to attention deficit-hyperactivity disorder (ADHD) symptoms using a self-administered questionnaire sent by email to French students in 2021. Participants were asked about their psychostimulant use and the presence of ADHD symptoms using the Wender Utah Rating Scale and the Adult Self-Report Scale. Among the 4431 respondents, the prevalence of psychostimulant use was concerning and significantly associated with ADHD symptoms. This association could be related to undiagnosed ADHD or to psychobehavioral impairments induced by psychostimulant use underlining the need of ADHD screening and targeted prevention measures.

Adult Attention-Deficit/Hyperactivity Disorder: a Narrative Review of Biological Mechanisms, Treatments, and Outcomes

PURPOSE OF REVIEW

Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous and complex neurodevelopmental disorder related to disruptions in various neuronal structures and pathways, dopamine (DA) transporter, and receptor genes, resulting in cognitive and regulation deficits. This article reviews recent research on the biological mechanisms and markers, clinical manifestations, treatments, and outcomes of adult ADHD as well as current controversies within the field.

RECENT FINDINGS

New research identifies white matter disruptions in multiple cortical pathways in adults with ADHD. New treatments for ADHD in adults such as viloxazine ER have shown preliminary effectiveness in addition to research showing transcranial direct current stimulation can be an effective treatment for adults with ADHD. Although questions exist about the effectiveness of current assessments of and treatments for adult ADHD, recent findings represent a step towards improving the quality of life and outcomes for individuals experiencing this life-long, chronic health condition.

ADHD and Substance Use Disorders in Young People: Considerations for Evaluation, Diagnosis, and Pharmacotherapy

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.

Predicting college student prescription stimulant misuse: An analysis from ecological momentary assessment

Prescription stimulant misuse (PSM) is common in young adult college students, at over 10% in the past year, and it is associated with other substance use and risk behaviors. Research focused on the real-time drivers of PSM is absent, impeding prevention and intervention. This research aimed to fill that gap by examining the relationships between affect, global stress, or academic stress and PSM via ecological momentary assessment (EMA); we also investigated baseline predictors of PSM frequency during the 21-day EMA period. Forty-one full-time college students (mean age: 20.5, 66% female) who endorsed current PSM (≥ 6 past-year episodes) participated. Participants were asked to complete EMA questions in response to 3 daily investigator-initiated prompts and after every PSM episode. Assessments were selected based on affect regulation (e.g., positive affect [PA], negative affect [NA]) and drug instrumentalization (e.g., academic stress and/or demands) theories of substance use. Mixed-effects linear models examined EMA data, and negative binomial regression analyses examined baseline predictors of PSM episode frequency. PA was higher on PSM days and increased post-PSM, whereas NA was unrelated to PSM. Although global and academic stress were largely unrelated to PSM, when the motive endorsed for PSM was "to study," pre-PSM ratings of academic demand and stress were significantly higher. Finally, a history of recreational motives (e.g., to get high) or higher levels of attention-deficit/hyperactivity disorder symptoms predicted a greater number of PSM episodes over the EMA period. The results offered mixed support for both affect regulation and instrumentalization as applied to PSM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

ADHD stimulant medication misuse and considerations for current prescribing practice: a literature review

BACKGROUND

Stimulant medications have been prescribed to effectively treat childhood Attention Deficit Hyperactivity Disorder (ADHD) since the 1960's, with improved outcomes observed in the three core symptom domains. Over the course of these decades researchers and clinicians have debated the issue of negative outcomes with regard to later development of substance use disorders (SUD) for these children.

AIMS

To chronicle the development of medical and scientific opinion on the subject of SUD outcomes in ADHD and to appraise most recently published research in this sphere.

METHODS

A systematic search of the literature was conducted over 4 databases. Removal of duplicates, application of exclusion criteria and inclusion of publications identified through manual and citation-based search yielded 9 papers.

RESULTS

Prescriptions for stimulant medications are increasing worldwide and in tandem the prevalence of stimulant misuse. Much research focuses on non-medical stimulant misuse as a study aid; however, they are also used as recreational drugs with action on dopaminergic neurotransmitter pathways implicated in addiction disorders. Considering the risks and benefits of stimulant prescribing on later SUD development research in recent decades has produced inconsistent results. Current research supports the hypothesis of improved SUD outcomes for young people treated early and intensely, with poorer outcomes for those with less robust treatment histories.

CONCLUSIONS

Consideration of the impact that variable treatment trajectories may have on the risk of later SUD development is recommended, with further research potentially leading to the development of different management pathways based on an individual's multivariate treatment profile.

Feigning ADHD and stimulant misuse among Dutch university students

The increasing number of university students seeking diagnosis of attention-deficit/hyperactivity disorder (ADHD), and findings of an increased stimulant misuse among university students, has raised concerns regarding the credibility of the symptoms of those students. However, most of our current knowledge refers to university students in North America and less is known about this issue on European campuses. The present survey aimed to collect opinions on feigning ADHD and to estimate the prevalence of stimulant misuse among 1071 university students in the Netherlands. The majority of students expressed liberal attitudes towards feigning ADHD. Also, a substantial number of respondents considered feigning ADHD themselves or know someone who feigns ADHD. Furthermore, 68% of students assumed benefits of taking stimulants without prescription and 16% have indeed already taken stimulants without prescription. Feigning ADHD and misuse of prescription medication are prevalent issues among Dutch students. The results underline the need for a careful diagnostic evaluation of individuals for ADHD. Furthermore, efforts are required in order to prevent stimulant drug trafficking and misuse among university students.

Changes in Brain Structure, Function, and Network Properties in Patients With First-Episode Schizophrenia Treated With Antipsychotics

Purpose: Comprehensive and longitudinal brain analysis is of great significance for understanding the pathological changes of antipsychotic drug treatment in patients with schizophrenia. This study aimed to investigate the changes of structure, function, and network properties in patients with first-episode schizophrenia (FES) after antipsychotic therapy and their relationship with clinical symptoms. Materials and Methods: A total of 30 patients diagnosed with FES and 30 healthy subjects matched for sex and age were enrolled in our study. Patients at baseline were labeled as antipsychotic-naive first-episode schizophrenia (AN-FES), and patients after antipsychotic treatment were labeled as antipsychotic treatment first-episode schizophrenia (AT-FES). The severity of illness was measured by using the PANSS and CGI score. Structural and functional MRI data were also performed. Differences in GMV, ALFF, and ReHo between the FES group and healthy control group were tested using a voxel-wise two-sample t-test, and the comparison of AN-FES group and AT-FES group was evaluated by paired-sample t-test. Results: After the 1-year follow-up, the FES patients showed increased GMV in the right cerebellum, right inferior temporal gyrus, left middle frontal gyrus, parahippocampal gyrus, bilateral inferior parietal lobule, and reduced GMV in the left occipital lobe, gyrus rectus, right orbital frontal cortex. The patients also showed increased ALFF in the medial superior frontal gyrus and right precentral gyrus. For network properties, the patients showed reduced characteristic path length and increased global efficiency. The GMV of the right inferior parietal lobule was negatively correlated with the clinical symptoms. Conclusions: Our study showed that the antipsychotic treatment contributed to the structural alteration and functional improvement, and the GMV alteration may be associated with the improvement of clinical symptoms.

Psychosocial functioning among college students who misuse stimulants versus other drugs

The misuse of prescription stimulants (e.g., Ritalin, Adderall) is a large and growing problem on college campuses. Emerging research examines not only the demographic predictors of stimulant misuse but also the potentially role that stimulant misuse plays in a college student's overall functioning and mental health. To better understand the experiences specifically linked with stimulant misuse rather than substance use more broadly, we tested whether psychosocial functioning differed across four groups of college students: those who do not misuse stimulants or other hard drugs; those who misuse both stimulants and other hard drugs; those who misuse stimulants but not other hard drugs; and those who misuse other hard drugs but not stimulants (N = 1534; 40.3% male; 33.9% ethnic minority). Those who misused stimulants reported higher levels of impulsivity, as well as substance use consequences, than those who did not use any hard drugs. However, these differences were exacerbated among those who misused stimulants and other hard drugs. Taken together, these findings suggest that stimulant misuse typically occurs in a broader pattern of substance use, and that stimulant misusers generally fall along a continuum of substance use severity in terms of psychosocial functioning.

Impulsiveness as a moderator of amphetamine treatment response for cocaine use disorder among ADHD patients

BACKGROUND

Amphetamines are a first-line treatment for ADHD and have shown promise for the treatment of cocaine use disorder (CUD), both alone and with comorbid ADHD. Impulsiveness is a key aspect of both ADHD and substance use disorders. We sought to understand the role of baseline impulsiveness in the treatment of comorbid CUD and ADHD.

METHODS

In a post hoc analysis (N = 76) of a 14-week, double-blind, randomized, placebo-controlled trial of mixed amphetamine salts-extended release (MAS-ER) for comorbid ADHD and CUD, we examined the relationship between treatment response and participants' baseline Barratt Impulsiveness Scale (BIS-11) score by comparing those with scores below versus above the median. In the original trial, participants received daily 60 mg MAS-ER, 80 mg MAS-ER, or placebo, in conjunction with cognitive behavioral therapy.

RESULTS

The odds of a cocaine-abstinent week over time were significantly greater in the high BIS group compared to the low BIS group, both when missing data was treated as missing (p = .0155; OR = 1.23, 95% CI: 1.13, 1.35 versus OR = 1.04, 95% CI: 0.95, 1.15) and when missing data was treated as cocaine-positive (p = .003; OR = 1.15, 95% CI: 1.06, 1.24 versus OR = 0.96, 95% CI: 0.88, 1.05).

CONCLUSIONS

The results show an association between higher within-group trait impulsiveness, as measured by the BIS-11, and response to MAS-ER for CUD in a cohort with comorbid ADHD. This result further demonstrates that impulsiveness is an important factor when considering treatment options for patients with CUD and that higher baseline impulsiveness may predict response to treatment with psychostimulants for CUD.

Disentangling the Social Context of Nonmedical Use of Prescription Stimulants in College Students

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the social context of nonmedical use of prescription stimulants (NMUPS) among college students who endorsed NMUPS with co-occurring substance use disorders (SUD) compared with those without co-occurring SUDs.

METHODS

Presented here are new analyses based on data previously collected from college students aged 18 to 28 years derived from the Boston metropolitan area who endorsed NMUPS (N = 100) at least once in their lifetime. Differences between those with lifetime history of SUD (N = 46) and without a history of SUD (N = 54) on the Massachusetts General Hospital ADHD Medication Misuse and Diversion Assessment were analyzed using the Student t test, the Pearson χ² test, and the Wilcoxon rank-sum test.

RESULTS

College students who endorsed NMUPS with co-occurring SUD were more likely than those without SUD to have bought or traded stimulants, bought or traded in their car, used at parties with drugs/alcohol, or used intranasally (all P < .05). Intranasal administration was common (38% of all students endorsing NMUPS) and was associated with misuse at a party and simultaneous use with cocaine (P = .04), marijuana (P < .001), and alcohol (P < .001), compared with only oral use.

DISCUSSION AND CONCLUSIONS

Notable characteristics were identified among individuals who engaged in NMUPS in the type, amount, cost, and ascertainment of stimulants.

SCIENTIFIC SIGNIFICANCE

The concurrence of SUD and/or intranasal administration appear to represent a more severe phenotype of NMUPS that should be considered in the implementation of future prevention and intervention protocols on college campuses. (Am J Addict 2020;29:476-484).

Prescription Drug Misuse: Taking a Lifespan Perspective

Prescription drug misuse (PDM), or medication use without a prescription or in ways not intended by the prescriber, is a notable public health concern, especially in the United States. Accumulating research has characterized PDM prevalence and processes, but age-based or lifespan changes in PDM are understudied. Given age-based differences in the medical or developmental concerns that often underlie PDM, it is likely that PDM varies by age. This review summarizes the literature on PDM across the lifespan, examining lifespan changes in prevalence, sources, motives and correlates for opioid, stimulant, and tranquilizer/sedative (or benzodiazepine) PDM. In all, prevalence rates, sources and motives vary considerably by age group, with fewer age-based differences in correlates or risk factors. PDM prevalence rates tend to decline with aging, with greater use of physician sources and greater endorsement of self-treatment motives in older groups. Recreational motives (such as to get high) tend to peak in young adulthood, with greater use of peer sources or purchases to obtain medication for PDM in younger groups. PDM co-occurs with other substance use and psychopathology, including suicidality, across age groups. The evidence for lifespan variation in PDM is strongest for opioid PDM, with a need for more research on tranquilizer/sedative and stimulant PDM. The current literature is limited by the few studies of lifespan changes in PDM within a single sample, a lack of longitudinal research, little research addressing PDM in the context of polysubstance use, and little research on minority groups, such as sexual and gender minorities.

Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies

OBJECTIVE

To review all literature on the nonmedical use (NMU) and diversion of prescription stimulants to better understand the characteristics, risk factors, and outcomes of NMU and to review risk-reduction strategies.

METHOD

We systematically searched PubMed, PsycINFO, and SCOPUS from inception to May 2018 for studies containing empirical data about NMU and diversion of prescription stimulants. Additional references identified by the authors were also assessed for inclusion.

RESULTS

A total of 111 studies met inclusion criteria. NMU and diversion of stimulants are highly prevalent; self-reported rates among population samples range from 2.1% to 58.7% and from 0.7% to 80.0%, respectively. A variety of terms are used to describe NMU, and most studies have examined college students. Although most NMU is oral, non-oral NMU also occurs. The majority of NMU is associated with no, or minor, medical effects; however, adverse medical outcomes, including death, occur in some individuals, particularly when administered by non-oral routes. Although academic and occupational performance enhancement are the most commonly cited motivations, there is little evidence that academic performance is improved by NMU in individuals without attention-deficit/hyperactivity disorder.

CONCLUSION

NMU of stimulants is a significant public health problem, especially in college students, but variations in the terms used to describe NMU and inconsistencies in the available data limit a better understanding of this problem. Further research is needed to develop methods to detect NMU, identify individuals at greatest risk, study routes of administration, and devise educational and other interventions to help reduce occurrence of NMU. Colleges should consider including NMU in academic integrity policies.

The Role of Past and Current Medical Use on Nonmedical Use of Prescription Drugs among College Students: Exploring Same-Drug and Cross-Drug Class Associations

Background: Understanding the role that medical use of prescription drugs plays in nonmedical use of prescription drugs can inform prevention efforts. In order to understand fully the potential risk that medical use of prescription drugs conveys for nonmedical use of prescription drugs, the current study explored (a) the simultaneous associations between the medical use of several classes of prescription drugs with current nonmedical use of the same and other prescription drug classes, and (b) whether the associations depended upon past or current medical use. Methods: Data came from a cross-sectional survey of 1686 college students, which assessed past and current medical use and current nonmedical use of stimulants, sedatives/anxiolytics, and opioid analgesics. Results: Logistic regression analyses revealed that both past and current medical use of sedatives/anxiolytics and opioid analgesics predicted the current nonmedical use of the same drug class, whereas past medical use of stimulants predicted the current nonmedical use of stimulants. In addition, current medical use of stimulants predicted current nonmedical use of sedatives/anxiolytics and past medical use of sedatives/anxiolytics predicted current nonmedical use of opioid analgesics. Conclusions: This study provides a broader examination than past research of simultaneous same-drug class and cross-drug class associations between medical and nonmedical prescription drug use, as well as the role of past and current medical use in these associations. Overall, the results suggest that efforts to prevent nonmedical use of a prescription drug class should move beyond targeting only those who have or who are using the same drug class medically.

Prescription Stimulants: From Cognitive Enhancement to Misuse

The nonmedical use of prescription stimulants has become increasingly pervasive among transitional age youth (TAY), aged 16 years to 26 years. Although therapeutically administered stimulants are regarded as safe and effective in TAY with attention-deficit/hyperactivity syndrome (ADHD), stimulant misuse is of concern due to prevalence, behavioral health and substance use correlates, and negative short-term and long-term outcomes. Although academic motivations primarily drive misuse, it is unclear whether prescription ADHD stimulants enhance cognition. Providers are advised to exercise precautions when prescribing ADHD medications, enhance surveillance for misuse, and screen those with misuse for ADHD and other psychopathology, executive dysfunction, and substance use disorders.

Age-specific risk of substance use disorders associated with controlled medication use and misuse subtypes in the United States

OBJECTIVE

To examine the age-specific risk of past-year substance use disorders (SUDs) associated with use and misuse of prescription opioids, stimulants, sedatives and tranquilizers.

METHODS

The authors analyzed nationally representative data from 114,043 U.S. individuals aged 12 and older in the 2015-2016 National Survey on Drug Use and Health. For each controlled medication class, logistic regression was used to model any past-year SUD as a function of use pattern: no use or misuse, use without misuse, prescription drug misuse (PDM). Among individuals reporting PDM, logistic regression was used to model any past-year SUD as a function of PDM subtype (misuse of someone else's medication only, misuse of one's own medication only, and misuse of one's own and someone else's medication). Analyses were stratified by age group.

RESULTS

Controlled medication use was associated with higher odds of any past-year SUD compared to no use in many age groups and medication classes. Compared to non-use, PDM was associated with higher odds of any past-year SUD across virtually all age groups and medication classes. Compared to misuse of one's own medication only, misuse of both someone else's and one's own medication was associated with higher odds of any past-year SUD for many age groups and medication classes among individuals reporting PDM.

CONCLUSIONS

Clinicians should screen all controlled medication users for PDM and SUDs. Age-specific screening may be required due to heterogeneity in the prevalence and risks of use and misuse of different medications. Determination of PDM subtype can guide interventions to prevent SUDs.

Attention-Deficit/Hyperactivity Disorder and Transitional Aged Youth

PURPOSE OF REVIEW

Extensive research has been conducted on attention-deficit/hyperactivity disorder (ADHD) in children and adults; however, less is known about ADHD during the transition from childhood to adulthood. Transitional aged youth (TAY) with ADHD represents a particularly vulnerable population as their newfound independence and responsibility often coincides with the development of comorbid disorders. The purpose of this review is to provide an update on the evaluation, diagnosis, and treatment of TAY-ADHD.

RECENT FINDINGS

Recent studies discovering ADHD symptoms emerging in TAY call the classification of ADHD as a disorder necessarily developing in childhood into question. TAY-ADHD are also shown to be vulnerable to academic and social impairments, increased risky behavior, and comorbid psychiatric disorders. Due to the risk of stimulant diversion in TAY, providers are advised to take precaution when prescribing medication to this population. Recent studies demonstrating the efficacy of psychotherapy in conjunction with non-stimulant or extended release stimulant medication provide a feasible alternative. This review highlights research on the course and evaluation of ADHD, impairments and comorbidities specific to TAY, and treatments tailored to address the unique challenges associated with TAY-ADHD.

Risk of amphetamine use disorder and mortality among incident users of prescribed stimulant medications in the Veterans Administration

BACKGROUND AND AIMS

Non-medical use of prescribed stimulant medications is a growing concern. This study's aims were to ascertain the demographics of stimulant medication users compared with non-users, examine temporal trends of stimulant medication use and estimate risk factors for development of amphetamine use disorder (AUD) and mortality among new users of stimulant medications.

DESIGN

Cox proportional hazards regression in a retrospective cohort adjusted by baseline covariates.

SETTING

United States, national administrative database of the Veterans Affairs (VA) health-care system.

PARTICIPANTS

Adult incident users of stimulant medications (n = 78 829) from fiscal years (FY) 2001 to 2012.

MEASUREMENTS

Primary outcomes were time-to-event: (1) occurrence of AUD diagnosis and (2) death. Baseline covariates included demographic information, Food and Drug Administration (FDA)-approved indications for stimulant use, substance use disorders (SUD) and depression.

FINDINGS

Stimulant users compared with non-users were younger, more likely to be non-Hispanic white and female. Incident stimulant medication users increased threefold from FY2001-FY2012 and eightfold among adults aged 18-44 years. Nearly one in 10 incident users in FY2012 had a comorbid baseline SUD. Off-label use was common-nearly three of every five incident users in FY2012. Comorbid SUDs among incident stimulant medication users were risk factors for occurrence of AUD during follow-up, with adjusted hazard ratio (AHR) estimates ranging from 1.54 to 2.83 (Ps < 0.05). Increased mortality risk was observed with occurrence of AUD during follow-up [AHR = 1.55, 95% confidence interval (CI) = 1.13-2.14, P = 0.007], while on-label prescribing was protective against death (AHR = 0.686, 95% CI = 0.63-0.75, P < 0.0001).

CONCLUSIONS

In a US national cohort of adult incident stimulant medication users in the Veterans Affairs health-care system, measured from fiscal years 2001 to 2012, comorbid substance use disorders were common and were risk factors for development of an amphetamine use disorder (AUD). Increased mortality risk among incident users of stimulant medications was observed among both those who developed an AUD later and those whose use was defined as off-label.

Neuropsychological functioning in college students who misuse prescription stimulants

BACKGROUND AND OBJECTIVES

Relatively little is known about the neuropsychological profiles of college students who misuse prescription stimulant medications.

METHODS

Data presented are from college students aged 18-28 years who misused prescription stimulants prescribed for attention-deficit/hyperactivity disorder and controls (no prescription stimulant misuse). Students were assessed neuropsychologically using the self-report Behavioral Rating Inventory of Executive Functioning (BRIEF-A), the Cambridge Automated Neuropsychological Test and Battery (CANTAB), and other tests of cognitive functioning. The analyses included 198 controls (age 20.7 ± 2.6 years) and 100 prescription stimulant misusers (age 20.7 ± 1.7 years).

RESULTS

On the BRIEF-A, misusers were more likely than controls to endorse greater dysfunction on 8 of 12 measures including Inhibition, Self Monitor, Initiation, Working Memory, and Plan/Organize, when adjusting for race and sex (all p's < .05). Similarly, when dichotomizing the BRIEF-A as abnormal (T score ≥ 65), misusers had more abnormalities on five of nine subscales, as well as all major indices (p's < .05). Misusers also performed worse on several subtests of the CANTAB and standardized cognitive battery (p's < .05). A proxy of prescription stimulant misuse frequency was positively correlated with greater executive dysfunction on the BRIEF-A.

DISCUSSION AND CONCLUSIONS

These data demonstrate elevated risk for neuropsychological dysfunction among students who misuse prescription stimulants compared to non-misusing peers. The presence of ADHD contributed significantly to these cognitive findings. Students who misuse prescription stimulants should be screened for neuropsychological dysfunction.

SCIENTIFIC SIGNIFICANCE

These data may better elucidate the neuropsychological profile of college-aged prescription stimulant misusers. (Am J Addict 2017;26:379-387).

Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes

While treatment of patients with attention-deficit hyperactivity disorder (ADHD) is based on a multimodal approach that combines medication with specific psychological interventions, pharmacotherapy alone is generally considered an essential and cost-effective element. This paper aims to comprehensively and critically review factors involved in prescribing and medication use in individuals diagnosed with ADHD, focusing on the difficulties facing patients with ADHD seeking treatment, as well as the safety and tolerability aspects of ADHD pharmacotherapies, with particular attention on the cardiovascular adverse events and the potential risk of misuse or diversion of ADHD medications. A comprehensive and systematic literature search of PubMed/MEDLINE database was conducted to identify studies published in peer-reviewed journals until 1 August 2016. Children, adolescents and adults often encounter significant difficulties in the process of accessing specialist assessment and treatment for ADHD as a consequence of disparities in service organization and available treatment provision. Despite the well-established efficacy and overall safety profile, ADHD medications are not exempt from adverse events. The cardiovascular safety of pharmacotherapies used for treating individuals with ADHD has raised particular concerns; however there is little evidence of serious cardiovascular adverse events, including no serious corrected QT (QTc) abnormalities associated with stimulants, atomoxetine or α2-adrenergic receptor agonists. Although the abuse of prescription stimulant drugs, particularly, short-acting stimulants is a prevalent and growing problem, nonmedical use of prescription stimulants within the clinical context is very limited. In addition, nonstimulant ADHD medications lack any reinforcing effects and consequently any abuse potential.