Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial

Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased use of diversion prevention strategies with adolescents with ADHD. The study was a cluster-randomized trial in 7 pediatric primary care practices. Participants were pediatric PCPs (N = 76) at participating practices. Practices were randomized to a 1-h training in stimulant diversion prevention or treatment-as-usual. At baseline, 6 months, 12 months, and 18 months, PCPs rated how often they used four categories of strategies: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes, implementation climate, knowledge/skill, and resource constraints. Generalized Estimating Equations estimated differences in outcomes by condition. Mediation analyses tested if changes in knowledge/skill mediated training effects on strategy use. PCPs in the intervention condition reported significantly greater use of patient/family education strategies at all follow-up time points. There were no differences between conditions in medication management, assessment of mental health symptoms/functioning, or assessment of risky behaviors. At 6 months, PCPs in the intervention condition reported more positive attitudes toward diversion prevention, stronger implementation climate, greater knowledge/skill, and less resource constraints. Differences in knowledge/skill persisted at 12 months and 18 months. Brief training in stimulant diversion had substantial and enduring effects on PCPs' self-reported knowledge/skill and use of patient/family education strategies to prevent diversion. Training had modest effects on attitudes, implementation climate, and resource constraints and did not change use of strategies related to medication management and assessment of mental health symptoms/functioning and risky behaviors. Changes in knowledge/skill accounted for 49% of the total effect of training on use of patient/family education strategies. Trial registration This trial is registered on ClinicalTrials.gov (NCT03080259). Posted March 15, 2017.

Use of Stimulant Diversion Prevention Strategies in Pediatric Primary Care and Associations With Provider Characteristics

PURPOSE

Diversion of stimulant medications for ADHD is a prevalent problem. Pediatric primary care providers (PCPs) are well-positioned to reduce diversion risk among adolescents prescribed stimulants, but little is known about their use of prevention strategies. The objectives of this study were to describe the frequency with which pediatric PCPs use diversion prevention strategies and examine potential determinants (facilitators and barriers) of strategy use.

METHODS

Participants were pediatric PCPs (N = 76) participating in a randomized controlled trial of stimulant diversion prevention strategies. At baseline, before randomization, PCPs rated the frequency with which they used specific strategies in each of four categories: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes toward diversion prevention, subjective norms (i.e., implementation climate), and perceived behavioral control (i.e., knowledge/skill, resource constraints). Associations between determinants and strategy use were tested with correlational and regression analyses.

RESULTS

PCPs used strategies for assessing mental health symptoms/functioning most frequently and patient/family education strategies least frequently. Attitudes about the effectiveness of diversion prevention, implementation climate, knowledge/skill, and resource constraints were positively correlated with the use of at least one category of strategies. In regression analysis, PCP knowledge/skill was positively associated with patient/family education, medication management, and risk assessment strategies.

CONCLUSIONS

Findings suggest that improving knowledge and skill may increase the use of diversion prevention strategies by PCPs. Identifying provider-level determinants of strategy use informs implementation efforts in pediatric primary care and can facilitate efforts to prevent stimulant diversion among adolescents.

Achievement goal orientation and stimulant misuse in college students

Objective: The prevalence of stimulant medication misuse is rising in college students. Motivations to use stimulant medications differ from motivation to use other substances such as alcohol or cannabis. However, no previous research has examined the impact of achievement goal orientation on stimulant misuse in college students. Participants: 309 college students (mean age = 18.9; 117 males) without an ADHD diagnosis were invited to participate. Methods: Participants completed an online research questionnaire that assessed factors associated with stimulant medication misuse as well as achievement goal orientations (Learning and Performance Orientations). Results: Approximately 12% endorsed a history of stimulant misuse within the past year. More males (17.1%) than females (9.4%) reported stimulant misuse. Those with and without a history of stimulant misuse differed on Performance Orientation (misuse > no misuse) yet were comparable on Learning Orientation. Conclusions: Having a higher Performance Orientation independently predicted stimulant misuse.

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.

Risk/benefit perceptions underlying lower African American Students' illicit stimulant use

Researchers have documented lower illicit use of prescription stimulants (IUPS) in African American (AA) populations but have not provided empirically-based explanations for this finding. Four gender-balanced groups of AA and Caucasian male/female college students (n = 120/group, mean age of 19.23, SD = 1.30) reported any IUPS and rated their ADHD symptoms (using the Adult ADHD Self-Report Scale; ASRS). AA participants endorsed IUPS less frequently compared to Caucasian participants (9.2% vs. 21.3%; χ²(1) = 13.59, p < .001) and reported lower levels of ADHD symptoms (M = 4.65, SD = 4.17) compared to Caucasians (M = 5.84, SD = 4.22), F(1,473) = 9.83, p < .01. Second, AA participants perceived lower benefits for IUPS than Caucasian participants for targets of concentration (M = 2.29, SD = 1.22 vs. M = 1.79, SD = 1.04, F(1,473) = 23.57, p < .001), alertness (M = 2.29, SD = 1.24 vs. M = 1.92, SD = 0.93, F(1,473) = 18.04, p < .001), and help with studying (M = 2.53, SD = 1.25 vs. M = 1.90, SD = 1.05, F(1,473) = 35.69, p < .001). Third, AA participants perceived higher social risk (M = 2.63, SD = 1.11) than Caucasian participants (M = 3.03, SD = 0.91, F(1,476) = 18.44, p < .001). No significant differences were found for legal or health risks. Despite lower rates of IUPS in AA populations, prevention and treatment programs for AA students are still needed and may benefit from targeting the observed risk/benefit belief patterns.

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.

Social contextual risk factors for stimulant use among adolescent American Indians

OBJECTIVE

Stimulants are the most common and efficacious treatment for Attention-Deficit Hyperactivity Disorder (ADHD). We examined the relationship between stimulant misuse and social factors that could be malleable to prevention among American Indian (AI) adolescents.

METHOD

Participants were AI students (N=3498) sampled from 33 schools in 11 states. Participants completed the American Drug and Alcohol Survey. A multilevel analytic approach was used to evaluate the effects of participant-level (level 1) variables (i.e., gender, grade, peer, school, family, stimulant prescribed by doctor) on lifetime and current simulant use to 'get high.'

RESULTS

Nearly 7% of our sample had been prescribed stimulants and nearly 6% of the sample reported using stimulants to get high. Age [OR=1.22; 95% CI=1.09, 1.36, p<0.001], perception of peer substance use [OR=1.19; 95% CI=1.14, 1.23, p<0.001], parental monitoring [OR=0.96; 95% CI=0.92, 1.99, p=0.04], and stimulants prescribed by a doctor [OR=8.79, 95% CI=5.86, 13.18, p<0.001] were associated with ever using stimulants to get high. Perception of peer substance use, [b=0.09, SE=0.02, p<0.001, 95%CI [0.05, 0.13], and having stimulants prescribed by a doctor, [b=0.58, SE=0.21, p=0.006, 95%CI [0.17, 0.99], were associated with frequency of past month use to get high. There was also a significant quadratic effect for parental monitoring, suggesting that low and high levels were associated with increased stimulant use.

CONCLUSIONS

Our results suggest a need for prevention efforts to be directed to AI youth who are prescribed stimulants.

Exploring the Relationship Between the Misuse of Stimulant Medications and Academic Dishonesty Among a Sample of College Students

The misuse of prescription stimulant medications (MPS) and academic dishonesty (AD) are both problematic behaviors among college students. Although both behaviors are linked to a student's desire to succeed academically, little research has been conducted to examine the relationship between these behaviors. The purpose of this study was to determine if students who engaged in past-year MPS committed acts of AD more frequently than those who do not engage in MPS. We collected our data from a sample of undergraduates (n = 974) between the ages of 18 and 25 enrolled at one of three universities in the US who completed an online questionnaire to assess AD and MPS. Results indicated that 18.2 % of the sample engaged in MPS in the past year and 65 % committed one or more acts of AD during the past year. An increased frequency of AD increased the odds of reporting MPS when controlling for known covariates (e.g., gender, stimulant prescription status, and energy drink consumption). In addition, higher rates of MPS were identified in students affiliated with a Greek organization, those with a current stimulant prescription, those who consume energy drinks, and those who misuse other prescriptions. Concerning specific AD-types, misusers reported copying off someone else's homework, having someone copy of their homework, and using the internet to commit acts of dishonesty more frequently than those who do not engage in MPS. This study adds to the MPS college student literature by highlighting the relationship between MPS and AD.