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THE MISUSE AND ABUSE OF STIMULANT MEDICATION: WHAT DO WE KNOW?

by David Rabiner, Ph.D.
Duke University

(Note: Attention Research Update receives support from pharmaceutical companies who manufacture stimulant medication for treating ADHD.  I do not believe this has influenced the objectivity of the report below, but I want you to be aware of this relationship). 

A recent report from the National Institute on Drug Abuse (NIDA) notes that stimulant medications used to treat ADHD are valuable medicines.  Research shows that people with ADHD do not become addicted to stimulant medications when taken in the form prescribed and at appropriate treatment dosages.  It has also been shown that appropriate stimulant medication treatment is associated with a reduced risk for developing drug and alcohol problems.  For a complete review of this study, go to www.helpforadd.com/2003/march.htm

As the NIDA report notes, however, "because of its stimulant properties, in recent years there have been reports of abuse of methylphenidate by people for whom it is not a medication.  Some individuals abuse it for its stimulant effects: appetite suppression, wakefulness, increased focus/attentiveness, and euphoria.  When abused, the tablets are either taken orally or crushed and snorted.  Some abusers dissolve the tablets in water and inject the mixture."

How widespread is the misuse and abuse of stimulant medications?  Does this practice reflect a significant public health problem? Surprisingly, despite all the media attention about this important issue, the data available on this important issue is relatively sparse.  Below is a summary of what is currently known. 

* The Massachusetts Department of Public Health conducted an anonymous survey of 6000 students to learn about illicit drug use.  Thirteen percent of high school students and 4% percent of middle school students acknowledged the "illicit, unprescribed use" of stimulant medications.  Information about the frequency and consequences of such use was not available.

* In a survey of 161 students with ADHD attending a number of schools in central Wisconsin, 16% reported that they had been approached to sell, give, or trade their medication.  During school hours, 44% of children and 37% of schools reported that stimulants were stored unlocked.  Ten percent of schools permitted students to carry their own medication and many did not have written policies pertaining to prescription drugs.

* A second survey study was conducted in several middle and high schools in Wisconsin that involved 651 students, including 50 who reported taking medication to treat ADHD.  Of those taking medication, nearly one-third reported that they had been approached to give away or sell their meds including 10% who stated that this was a frequent occurrence.  Over 50% of students without ADHD reported that they had seen a peer with ADHD being asked to sell or give away their medication.

* Data from the 2001 National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that 2.2% of 12-17-year-olds and 3.4% of 18-25-year-olds reported the non-medical use of stimulant medication during the prior year.  These percentages were roughly comparable to those reporting the non-medical use of tranquilizers.

* In 2000, the National Institute on Drug Abuse (NIDA) reported on emerging trends in methylphenidate abuse in several metropolitan areas.  NIDA's report indicated that the annual prevalence of nonmedical abuse of methylphenidate by high school seniors peaked at 2.8% in 1997 and 1998 compared with .1% in 1992.  These figures dropped to 2.4% in 1999 and 2.2% in 2000.

* Data obtained from the American Association of Poison Control Centers between 1993 and 1999 was examined for cases of methylphenidate abuse in individuals between 10 and 19.  These involved cases where the abuse of methylphenidate was actually reported to a poison control center and the medical outcome was known.  Because only a small percentage of cases would be reported to poison control centers, this data is more useful for examining trends that emerge over time as opposed to the actual number of occurrences.

Intentional abuse was defined as an exposure resulting from the deliberate improper or incorrect use of methylphenidate where the subject was "likely attempting to gain a high, euphoric effect of some other psychotropic effect".  Examples of intentional abuse include "adolescents not prescribed methylphenidate who used it recreationally or an adolescent taking methylphenidate on a long-term basis who takes extra doses or snorts or injects it to get high".

Over the 7-year study period, there was a sevenfold increase in methylphenidate abuse cases in pre-teens and adolescents.  The total number reported was just over 1200.  Approximately 40% of reports were for 10-14-year-olds and about 66% were for 13-16-year olds. Males accounted for 59% of cases.  Oral administration was the predominant route of ingestion (86% of 10-14-year-olds and 74% of 13-16-year-olds, with nearly all remaining cases involving snorting.

It is important to note that most pre-teens and adolescents abusing methylphenidate were not prescribed the drug - i.e. about 85% of cases were individuals for whom methylphenidate had never been prescribed.  Thus, it was infrequent for a child who was prescribed medication to treat ADHD to abuse it.

Two-thirds of those abusing methylphenidate had no effect or experienced only minor toxicity.  In nearly all the remaining cases, the clinical toxicity was categorized as "moderate".  The most common symptoms when methylphenidate was abused in isolation (i.e. other substances were not ingested simultaneously) were tachycardia (i.e. elevated heart rate), agitation/irritability, and hypertension.

* There has been only a single published study of stimulant medication abuse among college students.  This involved 283 students from a small liberal arts college in Massachusetts.  Nearly 21% reported taking stimulant medication for "fun" and 65% reported knowing someone who had done so.  Sixteen percent reported that they had snorted stimulants and 59% reported knowing someone who had done so.  Nearly half knew students from whom they could purchase stimulant medication and 36% felt that the abuse of stimulant medication was a problem on their campus.  In contrast, less than 2% currently had a prescription for stimulant medication.
 

SUMMARY AND IMPLICATIONS
 

The available research on stimulant medication misuse and abuse suggests that this occurs frequently.  Rates of misuse and abuse seem to have risen dramatically in the last decade before declining slightly in recent years.  Given the levels of substance abuse among pre-teens and adolescents overall, this is perhaps not surprising although it certainly is concerning.

Although the data summarized above indicate that stimulant medication abuse has increased, there are a number of important questions on which little information is available.  For example, there is an important difference between a student who may misuse stimulants one time, or restrict this practice to "cramming for exams", and someone who regularly uses stimulants to "get high".  Available data do not allow this distinction to be made, however, and how frequently each type of misuse/abuse occurs is not known.  How frequently stimulant medication abuse leads to significant adverse outcomes for adolescents is also unknown.  These are questions that should be addressed in subsequent research.

For parents whose child currently takes medication, or for those who are considering this treatment option, it is important to place these data in the broader context of what is known about stimulant medications.  Abundant research indicates that when stimulants are taken as prescribed, and treatment is appropriately monitored, they are safe, effective for the vast majority of children and teens with ADHD, and do not increase the risk for developing substance abuse problems.  In fact, as noted above, research suggests that children with ADHD who are treated with stimulants are less likely to develop substance abuse problems than those who are not.

Some of the data reviewed above is consistent with this - i.e. recall that the vast majority of reports of methylphenidate abuse to poison control centers were for individuals who had never been prescribed medication.  In addition, although nearly 21% of college students reported having taken stimulant medication "for fun" less than 2% were currently being treated for stimulants.  Thus, it appears that stimulant medication abuse is a far bigger problem among those who are not prescribed stimulants than among those who are.

Overall, therefore, there is no evidence to indicate that appropriately prescribed medication is a risk factor for subsequent abuse.  Thus, it does not appear that parents should be unduly concerned about this possibility.  However, what parents, professionals, and educators should be concerned about is that many adolescents prescribed medication may be approached by others to sell or give it away.  This was not an infrequently reported occurrence in the studies reviewed above, and the fact that many adolescents are responsible for administering their own medication at school can increase the likelihood of this occurring.

Thus, adolescents who receive stimulant medication to treat ADHD may be at risk for becoming approached to engage in behavior that could get them in some serious trouble.  And, for a teen with ADHD who is impulsive to begin with, who has difficulty thinking through the consequences of their behavior, and who may have developed the type of conduct problems that often accompany ADHD, it is not difficult to imagine their engaging in such behavior.  Unfortunately, this could lead to some serious consequences.

Educating children and teens that peers may approach them to buy medication, and how they should respond should this occur, would seem to be very important.  In addition, it may be preferable to avoid having a child/teen take medication during the school day, particularly if medication is self-administered because of concerns about coordinating this with the school, as this would seem to increase the odds of being approached.  Fortunately, a number of effective long acting medications for treating ADHD are now available, and these can obviate the need for a mid-day dose for most individuals.


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