August 27, 2009 — A sharp increase in calls to poison control centers suggests a rising problem with abuse and misuse of prescription stimulant medications among teens, according to results published online August 24 in Pediatrics.
In addition, sales data on these medications, prescribed for the treatment of attention deficit hyperactivity disorder (ADHD), suggest that the use and call-volume increase reflects availability, but that this increase disproportionately involves amphetamines.
Call-volume increases (76%) paralleled sales increases (80%), but the percentage of calls related to amphetamines rose faster than sales, and methylphenidate calls fell as sales rose, the researchers report.
"ADHD is a disease that needs to be appropriately treated," lead author Jennifer Setlik, MD, from the Cincinnati Children's Hospital Medical Center in Ohio, told Medscape Psychiatry. "However, we need to be aware of the increasing abuse of ADHD medications and [their] misuse...[teens] using their prescriptions or their friends' prescriptions to, for example, pull an all-nighter studying for a test."
"It is more common for teens to abuse alcohol and marijuana. But this is a medication that is now commonly prescribed to teenagers, so they have easy access to it," she added.
Majority Use Meds Appropriately
ADHD affects between 8% and 12% of children and 4% of adults worldwide. Recently, there has been a significant increase in the diagnosis of ADHD and the use of prescription stimulants, with mixed amphetamine salts and methylphenidate being the most frequently prescribed medications.
Recent reports have suggested that methylphenidate can elicit dependence and the potential for abuse. According to the National Survey on Drug Use and Health, 9% of adolescents aged 12 to 17 years used prescription drugs for nonmedical purposes in the past year, including 2% who admitted to nonmedical use of stimulant medication.
"Although the majority of individuals with ADHD use their medications appropriately, increased prescriptions will likely lead to increases in medical adverse effects associated with the use of medications and potentially greater use of these drugs for non-medical purposes," write the authors.
In this study, the investigators sought to better understand the trend for teen abuse of ADHD medication and how the usage has changed over time.
They queried the American Association of Poison Control Centers's National Poison Data System for the years 1998 to 2005 for all cases involving adolescents between 13 and 19 years of age for the reason of intentional abuse or intentional misuse of a prescription medication used for ADHD treatment. Stimulant medications were categorized as methylphenidate (including D-methylphenidate) or amphetamine and/or dextroamphetamine.
In addition, the investigators used teen and preteen ADHD medication sales data from IMS Health Inc's National Disease and Therapeutic Index database to compare poison center call trends with likely availability in the home.
Amphetamine Use Increased the Most
Results showed that calls related to adolescent abuse of prescription ADHD medication rose 76% (from 330 to 581 per year), which is faster than calls for victims of substance abuse in general (59%) and for teen substance abuse specifically (55%).
During the same time, prescriptions for ADHD medications written for 10- to19-year-olds rose 86% (from 4.2 million to 7.8 million), and those for 3- to 19-year-olds increased 80% (from 6.5 million to 11.8 million).
In addition, estimated prescriptions for teens and preteens increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both products together.
The increase in total calls related to teen ADHD abuse and the increase in ADHD prescriptions was not significantly different.
Reports of exposure to methylphenidate (as the percentage of teen ADHD medication abuse calls) fell from 78% to 30%, whereas methylphenidate as a percentage of ADHD prescriptions decreased from 66% to 56%. Plus, substance-related abuse calls per million adolescent prescriptions rose 140% (from 48 to 115), whereas those for methylphenidate decreased 55% (from 91 to 40.5).
Moderate effects, major effects, and deaths were significantly more frequent in amphetamine/dextroamphetamine reports at 45% vs 37% for methylphenidate reports (P < .001), and the severity between the 2 groups did not change over time (P = .804).
Finally, girls represented 40.1% of all victims, but only 19.4% of major effects or death.
"The sharp increase, out of proportion to other poison center calls and general poison center use, suggests a rising problem with abuse, teen abuse, and particularly teen ADHD stimulant medication abuse," the authors write."Although there are less than 1000 calls annually, and these numbers can be subject to bias, these data are broad, consistent, and representative."
"Our data do not suggest that abuse is kindled by availability, merely that it occurs and has grown," they add.
According to Dr. Setlik, clinicians should talk with parents to make them aware of where their children's medications are stored, how many pills there are, and how long they should last, and they should be concerned about who has access to these medications.
"Parents should also look for signs of abuse of ADHD medications, which include increased agitation and difficulty focusing, and should talk about the risks of using any medication improperly with their children," she said.
Reflection of Substance Abuse
Asked by Medscape Psychiatry to comment on the study, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, said the results highlight the fact that, in general, ADHD medications are well monitored.
"If there are over a million children now taking medication for their attention problems and there were only 581 calls to the poison control center, that tells me that the vast majority of families are doing a great job and staying on top of their children's medical problems and monitoring their medications appropriately," he said.
"The [investigators] report an increase in the number of abuse calls for the amphetamine salts," said Dr. Benson. "But I think a lot of this reflects our continued national concern with teenaged substance abuse problems.
"So instead of these being children where the medication was prescribed to them, I think it more likely reflects, unfortunately, a large population of teenagers who have substance abuse problems and are overdosing on these and a variety of other medicines."
Regarding the decrease in the abuse of methylphenidates, Dr. Benson said that the most marketed of these is "engineered in a way that you can't get a buzz or get high from when taking it."
He pointed out that a recent study reported that between 20% and 30% of individuals with a substance abuse diagnosis also have ADHD. "We've struggled with how to treat this population. Since some of these products are not abusable, they might be the best ones for treating this group of people."
"Nobody wants children to have overdose problems, but the numbers are tiny compared with the 11 million prescriptions for stimulant medication. Most doctors that are prescribing these medications are following these children closely," he added.
Educating children about their condition and the medicines that they are taking is one way clinicians can combat prescription abuse right from the start, said Dr. Benson.
"You don't hear about diabetic children or those with seizure disorder sharing their medications with other children. And the reason for that is because we approach those conditions in a very straightforward, educational way. Let the child know about the benefits and risks of their medication and get them really involved with their treatment process," he said.
The study authors and Dr. Benson have disclosed no relevant financial relationships.
Pediatrics. Published online August 24, 2009.
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