Nonmedical Use of Prescription Stimulants: A Clinical Unmet Need

In this video, Kevin Antshel, PhD, discusses the nonmedical use of prescription stimulants, including the problem of diversion, motivations involved, and adverse medical outcomes. Dr. Antshel is Professor of Psychology and Director, Clinical Psychology Program, Syracuse University, New York.

Read the transcript:

Hi, I’m Dr. Kevin Antshel, and I’m a Professor of Psychology and the Director of the Clinical Psychology doctorate program at Syracuse University. Today, I’m here to talk about the nonmedical use of prescription stimulants, a clinical unmet need.

Over the next time period, I’m going to be addressing five questions. The first question, how big of an issue and how pervasive is the nonmedical misuse and abuse of prescription ADHD stimulants?

Next question will be, what are the demographics or the population that is engaged in the nonmedical misuse and abuse, and are college students at particular risk?

The third question will be, is diversion of prescription stimulants associated with this problem, and if so, how prevalent is diversion?

The fourth question, how are prescription stimulants being misused and abused, and what are the motivations involved?

Our final question today will be, what are the adverse medical outcomes associated with the nonmedical misuse and abuse of stimulants?

Let’s go back. Our first question is, how big of an issue and how pervasive is the nonmedical misuse and abuse of prescription stimulants?

Even before getting into that specific answer, I’d like to make sure we’re all on the same page with our definitions. These are going to be four terms that you will hear in this presentation, and so I want to make sure we all have the same understanding.

First, diversion. Diversion of a prescription stimulant is the exchange, either selling or giving away, of a controlled medication such as a prescription stimulant.

Misuse is defined as intentional therapeutic use in an inappropriate way that excludes the definition of abuse. An example of misuse would be an individual who has a prescription for 20 milligrams a day, [and] decides to take 60 milligrams that particular day due to an exam or something coming up that they needed to stay awake to study for.

Abuse, on the other hand, is intentional nontherapeutic use of a drug to achieve a desired psychological or physiological effect—so, to get high, to induce euphoria, to be able to achieve something that they’re not able to achieve without the medication.

The term that we’re going to use most often today is nonmedical use. The nonmedical use of prescription stimulants captures both misuse and abuse. In other words, it’s a more inclusive umbrella term that is used to describe both misuse and abuse.

The FDA has taken note of the problem of prescription stimulant nonmedical use. In 2014, the FDA issued a statement that said the abuse and misuse of CNS stimulant drugs are a serious public health concern, and supports the effort by manufacturers to modify formulations to reduce this risk of abuse.

In 2019, the Federal Register commented that ADHD stimulants have a high potential for misuse and abuse, with associated morbidity and mortality, and between 10 to 30 percent of nonmedical users report at least sometimes using them intranasally.

Again, the FDA has been quite clear that this is a growing public health concern, and they are paying particular attention to the nonmedical use of prescription stimulants.

How prevalent is this? The first thing to note is that the prevalence rate increases almost linearly, from early adolescence, ages 12 or so, up until early adulthood, age 21 or 22.

Early adolescence, the annual rate of nonmedical use of stimulants is less than 1 percent, yet by the time we’re in the early 20s, age 21, 22, the annual rate of nonmedical use of stimulant medications is close to 10 percent.

It begins to tail off a little bit after age 21 or 22, but yet remains higher than it did in the adolescence, and the rates are in the five to seven percent of annual nonmedical use.

Just to give the scope of this problem, in the year 2018, an estimated 5.1 million individuals aged 12 and older misused or abused a prescription stimulant medication. Again, this is a common public health concern, and unfortunately increasing in prevalence if you look at the data compared to 10, even 20 years ago.

Question number two is, what are the demographics or the population that’s engaged in a nonmedical misuse and abuse of prescription stimulants, and are college students at particular risk?

The nonmedical use of ADHD stimulants has been reported in roughly 2.1 percent of Americans aged 12 and older, yet for those age 18 to 25, typically inclusive of the college years, the estimate goes up to 7.4 percent.

A recent paper talked about a higher rate in urban adolescents than we thought previous, and roughly eight percent of urban adolescents are thought to engage in nonmedical use.

College students are at particular risk, and are particular for having higher rates of nonmedical use, and so I’d like to take a little bit of a deeper dive into the college student population.

These are college students. This particular study sampled roughly 600 college students between the ages of 18 to 26, and everyone in this study reported nonmedical use. Of those who reported nonmedical use, under half of them reported an ADHD diagnosis, so 43 percent reported having an ADHD diagnosis and engaging in nonmedical use.

Of those who had an ADHD diagnosis, 59 percent had taken a prescription medication to treat ADHD, and probably most troubling of this is that, of those who had an ADHD diagnosis, 38 percent reported exaggerating or lying about their symptoms in order to obtain an ADHD prescription. For those of you who are familiar with the literature on malingering of ADHD, you will know that this is a clinical problem, especially in college students.

For those who had an ADHD diagnosis and a history of prescription stimulant treatment, 64 percent of that sample reported modifying their ADHD medication. The most common modification or altered route of administration was snorting; 42 percent chewed their medication, 40 percent dissolved, 28 [percent] and 27 [percent] smoked and injected, respectively.

The most common motivation for nonmedical use in these individuals with ADHD who had a prescription for a stimulant was to attempt to enhance performance at school. The key word there I want to hit on is attempt. Actually, if you look at the data, and the data are really quite convincing that the nonmedical use of stimulants for someone without ADHD is not going to help.

Again, here we’re talking about people who had an ADHD diagnosis, but even there, the most common motivation is attempted performance enhancement.

Less common include things such as to increase energy, that their regular dose wasn’t working, to improve their mood, elevate spirits, and to get high. Of this sample, 65 percent were asked to divert their medication, and of that, 65 percent actually diverted their medication.

These individuals who have ADHD and a history of nonmedical use are being approached quite often to divert their medication, and in turn, they often divert their medication.

This is also looking at the nonmedical use of prescription stimulants in Greek life. This, again, is a college sample, and it is specifically looking at individuals that are affiliated with a sorority or a fraternity. This was an online survey that captured three groups. Greek-affiliated college students, non-Greek–affiliated college students, and non-college students.

You’ll see the three major dependent variables that were measured in this study was the prevalence of lifetime nonmedical use, nonmedical use via nonoral routes, and in particular, snorting. You’ll see across all three parameters, the Greek-affiliated college students had higher prevalence of all three—higher prevalence of lifetime, higher prevalence of nonoral routes (almost half), and of those who had nonoral route, a high percentage engaged in snorting.

While all three groups were more likely to obtain the prescription from a doctor and/or their family and friends, the Greek-affiliated students were three times more likely to purchase from a drug dealer.

Depression and anxiety diagnoses were common in all groups, and for those of you that are keeping up with the college mental health literature, you know these are increasing in prevalence on our college campuses.

However, the Greek students that reported prescription nonmedical use were more likely to report histories of externalizing disorders such as ADHD, substance use disorder, oppositional defiant disorder, and conduct disorder, as well as higher rates of bipolar disorder and learning disabilities.

Taken as a whole, the college student literature suggests that nonmedical use of prescription stimulants is particularly common in college students, and is especially common in those affiliated with Greek organizations. Those affiliated with Greek organizations are especially common to engage in nonoral routes of administration.

Question three. Is diversion with prescription stimulants associated with this problem, and if so, how prevalent is it?

Prescription stimulant diversion is unfortunately a common problem. As a clinical child psychologist, I’m particularly concerned about the figure all the way to the left, that roughly a third of children between the ages of 10 to 17 who are prescribed a stimulant report selling, or giving, or trading away their prescription medications, their prescription stimulants. And so diversion is quite common, particularly and for teenagers.

As I’ve alluded to, 65 percent of college students who were prescribed a stimulant have actually diverted their medication, and 57 percent of college students who have misused or abused a prescription stimulant did not have ADHD. In other words, they’re gaining access to the stimulant most often from a friend who has an ADHD stimulant prescription.

And 16 percent of parents of children and adolescents who are prescribed ADHD prescription stimulants report a history of diverting their medication, typically to themselves, and so diversion of ADHD stimulants is a public health problem, and it for sure is the most common reason that the stimulants are available for nonmedical use.

As I’ve already alluded to, but I’ll highlight here, was some data that family and friends are the most common sources of the diverted prescription stimulants for those who engage in nonmedical use. This is a compilation of 10 studies, and these are all reporting on the prevalence of nonmedical user who reported that they obtained this from friends and families.

You’ll see [among] adolescents and college students, anywhere from 50 to upwards of 90 percent of the individuals who engage in nonmedical use reported they obtained the stimulant from a friend or a family member.

Three classes of individuals are at the greatest risk for diversion. The first class I think is going to make intuitive sense, just because of access. The first class that’s at risk is anyone who has a prescription stimulant medication. It’s hard to divert your own prescription stimulant medication if you don’t have a prescription.

The latter two I think are more interesting. I think also more important to consider is that students who have or do not have an ADHD diagnosis and/or treatment are more likely to divert if they have conduct problems, and so, histories of oppositional defiant disorder, histories of conduct disorder, increased the likelihood that someone will engage in diversion.

The final group are individuals who are nonmedical users of other prescription drugs or opioids or other prescription drugs. These individuals are also at the greatest risk for diverting ADHD stimulants.

Question four. How are prescription stimulants being misused and abused, and what are the motivations that are involved?

We’re going to take a little bit of a deeper dive into nonoral routes of administration. However, before getting to that, it’s important to know that oral administration or oral route of administration is the most common for nonmedical use.

Of those who report nonmedical use, nonoral routes of administration such as snorting, smoking, and injecting are estimated to be between anywhere between 14 to 27 percent of adolescents and adults respectively.

Snorting and injecting in turn have the greatest risks for major adverse outcomes, including mortality. In a large university survey, over half of the college students with ADHD prescribed stimulants reported being approached to divert their medication. As I’ve already alluded to, this is how it gets into the public sphere, is most often through diversion.

Other things that are important to know about these nonoral routes such as snorting or injecting is that the nonoral routes lead to faster onset of effects. What we know from the substance abuse literature is that, how quickly the effects are associated with use is a powerful index of the addiction potential of that substance.

Nonoral routes lead to quicker, and quicker usually leads to higher euphoria, a sense of feeling high, and these two in turn lead to desire to take the drug again, also known as craving.

Prescription stimulants and cocaine may exert similar rewarding and reinforcing properties through elevated levels of dopamine when they’re taken via the same route of administration.

I want to be clear here that an oral prescription for a stimulant when taken appropriately is not the same thing as cocaine. However, when you take a prescription stimulant and you grind it up and snort it, and you have the same route of administration as cocaine, that ground-up stimulant and cocaine exert similar rewarding and reinforcing properties.

The nonoral routes of administration are associated with a variety of adverse effects, including increased craving and increased potential for addiction.

What are the motivations for the nonmedical use of prescription stimulants? Let’s begin with any nonmedical use, and then we’ll get into nonoral nonmedical use. For adolescents and adults, the most commonly reported motivation for any type of nonmedical use is perceived performance enhancement, so, in the academic, the occupational setting.

As I’ve already alluded to yet, I want to take a moment to highlight again, the key word there is perceived. The person is in search of performance enhancement.

However, if you look at the data on how well the stimulant medications work in individuals who do not have ADHD, the data are really quite convincing that nonmedical use is not associated with performance enhancement, and any performance and enhancement that occurs is completely expectancy effects.

Rather, the nonmedical use in individuals who do not have ADHD is associated with lower academic functioning. There is drop in grade point average across time. Again, it’s important to highlight the word perceived.

Other common motivations include recreational use, getting high, enhancing the effects of alcohol, enhancing socialization, and also enhancing wakefulness.

For college students, the most common motivations for nonoral routes of administration are quite similar. The perceived performance enhancement, that continues to be the most common motivation for nonoral routes of administration, and again, the data are really quite clear that it is not associated with performance enhancement.

Other things that are also motivations for nonoral routes is for energy, to treat my ADHD better, improve mood, elevate spirit, get high, and as an appetite suppressant or for weight loss.

Our last question today is, what are the adverse medical outcomes associated with the nonmedical use and abuse of prescription stimulants? I’m going to focus here on poison control data in this slide, and this is from the 2019 National Poison Control.

This is looking at the rates of adverse outcomes. Here, we’re particularly focused on medical outcomes. We’re not looking at functional outcomes, like how they’re doing in their relationship and their work. Here, we’re looking at medical outcomes, so, the need for hospitalization, the need for a trip to the emergency department, all the way up to mortality.

As you look on the left here, and again, I want to highlight that these are data from the National Poison Control, and so these individuals contacted a poison control center.

You will see that the intravenous and the nasal routes of administration for stimulants are associated with a higher level of medical outcomes. Almost three medical outcomes for each of the 164 people who contacted poison control, who had IV-administered their prescription stimulant.

It drops down to 2.46 but it’s still high, you’ll see the oral administration, and then those who were not engaged in abuse but also had to call poison control center. Again, you’ll see that the nonoral routes are associated with a higher number of medical outcomes.

On the right, you’ll see a heat index, which is looking at the number or the degree of these outcomes. You’ll see in the columns go from the left to right, as you go across, it increases the severity of the effect. At the top are non-abuse, in the rows, and then intravenous, nasal, and oral routes of administration.

I hope it’s clear to you that if you go across, all the way to death, you’ll see that death is much more common in intravenous and nasal administrations, compared to non-abuse. Intravenous is associated with a higher risk for major complications compared to non-abuse, IV administrations, nasal, as well as oral routes of administration are associated with moderate.

What we know is that the nonoral routes of administration are associated with more significant effects as well as a higher mean number of medical outcomes.

Nonoral use is also associated with more severe clinical outcomes than oral administration, so the relative risk of death is substantially higher for nonoral administration. Intranasal is three times higher than oral administration, and IV administration is over seven times higher risk for death than oral administration.

There’s also a higher risk of significant medical outcomes. These are things like acute cardiac events, acute central nervous system events, neuropsychiatric events such as hallucinations, delusions, pulmonary complications, and as I’ve already alluded to, physical and psychological dependence.

It is also an increased risk for admission to a health care facility in those who snort prescription stimulants and inject prescription stimulants, compared to those that are engaged in nonmedical use but through an oral route of administration.

I’ve presented some information to you today about the public health concern, about this emerging issue that this is more common in college students, yet is also occurring with some frequency in adolescents and adults. The nonmedical use of prescription stimulants is a concern in and of itself, but is especially a concern when we engage in nonoral routes of administration.

Thank you for your attention.