Diversion and Misuse of Stimulant ADHD Medications Uncommon in the Absence of Comorbid Disorders

Paula Moyer, MA

June 01, 2005

June 1, 2005 (Atlanta) — Although diversion and misuse of stimulant medications used to treat attention deficit/hyperactivity disorder (ADHD) can and does occur, most patients take their medications as directed and do not let other people use them, according to findings presented here at the 2005 American Psychiatric Association Annual Meeting.

While the issue of diversion and misuse of stimulant medications used to treat ADHD has been a concern, the findings should be reassuring, according to the investigators. Most patients do not abuse them, and the study showed that all diversion and misuse occurred with intermediate-acting formulations and that none occurred with extended-release formulations.

"The findings show that most patients with ADHD use their medications appropriately but that misuse and diversion are a reality," said principal investigator Timothy Wilens, MD. "As physicians, we need to educate patients, particularly college students to leave their medications in a safe place and even be discrete among roommates and other friends about their medications to avoid them being stolen and diverted."

Dr. Wilens is the director of Substance Abuse Services in the Pediatric and Adult Psychopharmacology Clinics at Massachusetts General Hospital in Boston and is also an associate professor of psychiatry at Harvard Medical School, Boston, Massachusetts.

To address the paucity of information regarding the extent of these problems, Dr. Wilens and colleagues recruited participants from a 10-year longitudinal study and administered a self-report questionnaire to 98 patients receiving medication for ADHD. The patients were grouped into several groups: ADHD patients with concomitant conduct disorder or substance abuse problems or those with both, the study group, and control group who only had ADHD. The study was funded by the National Institute on Drug Abuse.

The subjects were young adults who were an average of 20.8 years old, with 55 patients in the ADHD group and 43 in the control group. They responded to a structured psychiatric interview to confirm the ADHD diagnosis and a self-report questionnaire regarding medication use. Among these, 11% of the comorbid ADHD patients responded that they had sold their medications compared with none of the controls (P < .05). Regarding misuse, 22% of the comorbid subjects had misused their medications by using them too frequently vs 5% of the controls (P = .09). Most misuse was motivated by performance enhancement, according to the subjects' self-reports.

Among those who diverted medications, 83% had a substance abuse history, and 30% had comorbid conduct disorder. Among those who misused their medications, 75% had a substance abuse history, and 59% had comorbid conduct disorder.

The study underscores the need for common sense to be exercised by psychiatrists and patients alike, said Lenard Adler, MD, in a telephone interview seeking outside commentary. Dr. Alder is the director of the Adult ADHD Program at New York University Medical Center in New York, where he is also an associate professor of psychiatry and neurology.

"For adults with ADHD, we like for the treatment to be long acting, to get them through work, childcare, and domestic responsibilities, and the findings are another reason to use such formulations," Dr. Adler said. "It is important to notice that all of the diversion occurred with the shorter-acting formulations. It is also important to see that diversion and misuse can occur, but they are not all that common. It is important not to have an impulsive reaction."

Instead, as in all areas of medicine, physicians need to tailor therapy to patients' specific needs. For ADHD patients who have a history of substance abuse, for example, the treating psychiatrist may want to start treatment with a nonstimulant therapy. If the treatment is not adequate, the second choicewould be a long-acting stimulant coupled with rigorous monitoring. "Because the stimulants used to treat ADHD are controlled substances, there is built-in monitoring," Dr. Alder said. "However, we can watch such patients with extra care for warning signs such as early refills."

Dr. Alder agreed with Dr. Wilens that for young ADHD patients who are in dormitory or other shared-living arrangements, keeping medications in a secured place, such as a locked cabinet, would help ward off diversion.

2005 APA Annual Meeting: Abstract 9. Presented May 23, 2005.

Reviewed by Gary D. Vogin, MD

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