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Prescription Stimulant Use and Misuse
Psychostimulants, including amphetamine-type stimulants and methylphenidate, are most often prescribed to treat attention-deficit/hyperactivity disorder (ADHD). In recent years, the number of adults receiving new prescriptions for these medications has increased.
In a recent article published in JAMA Psychiatry, Beth Han, Wilson Compton, and colleagues described changes in the use and misuse of prescription stimulants by adults in the United States and development of psychostimulant use disorder (PSUD). They analyzed data from the 2019-2022 IQVIA Total Patient Tracker and National Prescription Audit New to Brand databases. These databases track 93 percent of outpatient prescriptions dispensed by U.S. retail pharmacies. They also examined data from more than 83,000 community-dwelling adults aged 18 to 64 years who participated in the 2021-2022 National Surveys on Drug Use and Health (NSDUH).
First, Some definitions
Stimulant misuse indicates one or more of the following is present: using the drug without having a prescription of one’s own, using the drug in greater amounts than prescribed, using the drug more often than prescribed, using the drug longer than prescribed, and/or using the drug in some other way a doctor did not direct.
Psychostimulant use disorder (PSUD) is prescription stimulant use that leads to clinically significant impairment or distress as measured by Diagnostic and Statistical Manual of Mental Disorders, 5th edition, criteria. For a diagnosis of PSUD, at least two of 11 specific criteria must be present within a 12-month period. Examples of these criteria include unsuccessful efforts to cut down or control use, craving or a strong urge to use, continued use despite social problems related to use, and recurrent use in physically hazardous situations.
Age and gender patterns of psychostimulant use
From 2019 to 2022, the number of prescriptions for psychostimulants increased for all sex and age subgroups. Women aged 35 to 64 years received the most prescriptions and were also the group with the largest increase in prescriptions, from 1.2 million in the first quarter of 2019 to 1.7 million in the last quarter of 2022. For 35-to-64-year-old men, prescription numbers increased from about 800,000 to almost 1.1 million during the same time frame.
Patterns of prescriber specialty
Han and colleagues analyzed prescribing patterns for four different specialty groups. Each group increased the number of prescriptions written for stimulants between 2019 and 2022. Nurse practitioners and physician assistants had the most dramatic increase with the number of prescriptions more than doubling (from 2.1 million to 4.4 million). This compares with increases of 26.5 percent by internal medicine and osteopathic medicine physicians, 16.2 percent by general and family practice physicians, and 10.3 percent by psychiatrists. By the end of 2022, the number of prescriptions written by the nurse practitioner/physician assistant group surpassed that of the next largest prescribing group (psychiatrists) by about 50 percent.
Misuse and PSUD
The researchers found that of the more than 83,000 adults participating in the 2021-2022 NSDUH, 7.5 percent reported prescription stimulant use in the previous year. Most (80.9 percent) said they only used their own prescribed stimulants. About 25 percent of those prescribed psychostimulants reported misuse, and about 9 percent fulfilled criteria for PSUD. Although PSUD was more common in those reporting misuse (20.4 percent), about 5 percent of those who did not report misuse fulfilled criteria for PSUD.
Most individuals with PSUD (64 percent) had mild PSUD (2-3 symptoms). The others were about equally divided between those with moderate PSUD (4-5 symptoms) and those with severe PSUD (6 or more symptoms).
Both misuse and PSUD were more than twice as common in people prescribed amphetamine-type stimulants than in those prescribed methylphenidate.
Reflections
The results described in this paper are concerning. As mentioned earlier, psychostimulants are usually prescribed for individuals with symptoms suggestive of ADHD. A diagnosis of ADHD should involve a thorough psychiatric evaluation and consideration of other diagnoses associated with ADHD-like symptoms. When a diagnosis of ADHD is made in adults and psychostimulants prescribed, careful follow-up is required, which should include screening for both misuse and PSUD.
The 10-26 percent increase in psychostimulant prescriptions during the three years of the study by various clinician groups may reflect increased awareness of adult ADHD and/or patient requests. The dramatic 110 percent increase in prescriptions by nurse practitioners and physician assistants is remarkable, and some of this increase may reflect major increases in the number of these practitioners prescribing these agents.
Han and colleagues conclude that their results “may highlight the need for evidence-based clinical practice guidelines and clinician training programs for adult ADHD and prescription stimulant treatment, use of clinical tools (e.g., PDMPs [prescription drug monitoring programs]), and screening for and treating PSUD among adults prescribed stimulants regardless of misuse status and the reasons for prescription stimulant use.” We agree completely. Also, PSUD is more common in those individuals who use or misuse other substances such as sedatives, heroin, or opiates. Therefore, it is important to screen for use of other substances.
Individuals with ADHD often benefit from treatment with stimulants. However, with casual diagnostic efforts and less meticulous follow-up, many individuals may be harmed.
CREDIT: https://www.psychologytoday.com/us/blog/demystifying-psychiatry/202507/prescription-stimulant-use-and-misuse
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