Stimulants For ADHD Research Articles

7.6 Clinical Implications of ADHD and CNS Stimulants on Weight Gain and Growth

7.6 Clinical Implications of ADHD and CNS Stimulants on Weight Gain and Growth

The Impact of Under‐Diagnosing ADHD in Young Females

When I was in adult psychiatry residency, I was shocked by the frequency of which young adult female patients would request evaluation for potential ADHD. Many of these young women presented as well with mood and anxiety symptoms, and it was imperative to determine whether the predominant impairment was secondary to untreated ADHD or other psychiatric conditions. In full disclosure, I was unfortunately primed to be skeptical of these college‐aged students who were seeking a diagnosis of ADHD, and I naively felt that their presenting concerns of inattentiveness, difficulty with concentration, and reduced motivation was more likely attributed to untreated depression in this population rather than an undetected ADHD. After all, I wondered, how would ADHD have gone unnoticed for all of their childhood and only now manifest in young adulthood? Oddly enough, I encountered very few young adult males with signs concerning for untreated ADHD; if anything, I saw more males on stimulants for ADHD than women, despite encountering more young women reporting concerns for untreated ADHD.

Teens prescribed stimulants for ADHD not likely to have later drug misuse

Teens prescribed stimulants for ADHD not likely to have later drug misuse

Researchers find maternal use of ADHD stimulants safe during pregnancy

Researchers find maternal use of ADHD stimulants safe during pregnancy

Research: ADHD stimulants safe during pregnancy

A recent study has found that mothers who used stimulant medications for attention deficit hyperactivity disorder (ADHD) during pregnancy did not increase the risk of neurodevelopmental disorders in their children. The cohort study included health care utilization data from publicly insured and commercially insured pregnant individuals aged 12 to 55 years in the United States with enrollment from three months prior to pregnancy through one month after delivery, linked to children. Children were monitored from birth until outcome diagnosis, disenrollment, death or the end of the study.

Prescribed psychotropic medication patterns among treated Foster Care enrollees: a single institution study.

While several state-based studies have shown that children in foster care are more likely to be prescribed psychotropic medications and experience concomitant medication use both within and among medication class, these patterns have not been explored in the state of Nevada, which lacks state mandated oversight of psychotropic prescribing for foster care enrolled youth. Data from an electronic medical record system from a single institution were analyzed to examine the prevalence of psychotropic prescribing and concomitant medication use in children ages 2 to 19 who were enrolled and received psychotropic prescriptions between July 2019 to June 2022. Out of 569 distinct psychotropic medication treatment episodes within this cohort, the most frequent psychotropic classes prescribed were non-stimulant ADHD medications (alpha-agonists and atomoxetine, 31.5%), atypical antipsychotics (22.1%), antidepressants (20.6%), and stimulants (16.0%). The use of stimulants and non-stimulant ADHD medications decreased in older age groups while the use of antidepressants and antipsychotics increased in older age groups. During the three-year period studied, 24.0% of psychotropic medications prescriptions increased in dosage. Treatments were prescribed for only one month in 43.8% of youth. In children prescribed psychotropic medications, concomitant medication use for at least 60 days occurred in 28.0% of children who had any psychotropic medication prescribed. Within the cohort of 273 foster care enrolled subjects aged 2 to 19 years old who received psychotropic medication prescriptions, non-stimulant ADHD medications (both alpha-agonists and atomoxetine) and atypical antipsychotics were more commonly co-prescribed additional psychotropic medication compared to other co-prescribed medication categories. This study illustrates prescribing patterns in a community mental health clinic focused on judicious prescribing of psychotropic medications in foster care enrolled youth. Despite this, 41% of the youth treated in this clinic received at least one prescription for psychotropic medication, and of those, 27.8% were prescribed more than one psychotropic medication at the same time. More studies are necessary to understand the underlying causes of high prevalence of concomitant medication use and prescribing practices of psychotropic medications use in foster care involved pediatric populations.

Association between ADHD medication history and stimulant misuse in adolescents

Association between ADHD medication history and stimulant misuse in adolescents

ADHD and central nervous system stimulant prescribing has increased by almost 70% in five years

ADHD and central nervous system stimulant prescribing has increased by almost 70% in five years

ADHD and central nervous system stimulant prescribing nearly doubles in adults in three years

ADHD and central nervous system stimulant prescribing nearly doubles in adults in three years

New research sounds alarm about increased stimulant use among U.S. adults

The number of adults using central nervous system (CNS) stimulants grew by approximately 80% over a 5-year period, according to new findings published in BMJ Open in August 2021. The total number of amphetamine and methylphenidate prescriptions dispensed grew even faster, with an increase of roughly 96%, according to the study results. “My message is this: It's time to start paying attention,” said lead author Thomas J. Moore from the Center for Drug Safety and Effectiveness at Johns Hopkins University Bloomberg School of Public Health. “The opioid epidemic continued for years before the medical and public health community realized action was needed. We need more research to understand this major trend and why it is happening.” Trends in CNS stimulant use that Moore and the research team found included a younger population of adults, as well as adults with higher education degrees who were more likely to be unmarried. “We need to know what is driving this increase, and why so much use is in combination with antidepressants and antianxiety drugs,” said Moore. The study results found that stimulant users frequently reported taking medications for a variety of mental, neurological, and developmental conditions: 77.8% indicated they took medication for ADHD, 26.8% reported taking anxiety medication, 25.1% said they had taken drugs for depression, and 15.3% indicated drug therapy for other mental or neurological conditions. Andrew Peterson, PharmD, PhD, FCPP, executive director of the Substance Use Disorder Institute at the University of the Sciences in Philadelphia, was not surprised by the results of the BMJ Open study. The trend for youths being diagnosed and treated for conditions such as ADHD with stimulant medications has been increasing since the early 2000s, according to CDC. “Therefore, as the youths became adults, the carry-over for using stimulants to treat these conditions may be a strong factor contributing to the increase seen,” said Peterson. “A particularly vulnerable group are college students who may be misusing these agents to improve cognitive ability and academic achievement.” In the BMJ Open study, Moore and the researchers wrote that the growing use of these stimulants should renew interest in updating, characterizing, and managing the risks of this drug class. For example, the larger numbers of younger age groups using CNS stimulants raises the question of whether or when these prescribed stimulants for ADHD in childhood or adolescence should be discontinued as the child grows older. Peterson encourages pharmacists to help counsel patients—youths and parents, as well as adults—about the risks associated with stimulant misuse. He said research should focus on how pharmacists can use evidence-based strategies such as Screening, Brief Intervention and Referral to Treatment (SBIRT) in the community setting to identify individuals at risk for misusing stimulants. But before this, pharmacists and other health care providers need to feel confident addressing substance use disorders with their patients, which includes understanding the prevalence, incidence, and consequences of stimulant use and misuse. “This appears to be a great opportunity for researching the pharmacist's role in providing this education,” Peterson said. While CNS stimulant use was more frequent in the youngest age cohort, according to the study findings, the largest percentage increases occurred in adults aged 25 years and older. Examined by sex, the largest rise occurred among females, with a 72% jump in CNS stimulant use over the 5-year period. “We saw big differences by age, race, and sex,” said Moore. “The growth was largest in younger, white, and female patients, smallest in minorities and older patients. Increase was much larger in amphetamines versus methylphenidate.” Amphetamine product use increased by roughly 119% over the 5-year period. Growth in methylphenidate products was slower with an estimated 39% increase during that time frame. The findings come from the annual U.S. Medical Expenditure Panel Survey, the largest annual health care survey sponsored by the federal government. Researchers analyzed annual surveys from 2013 through 2018 and looked at a random sample of approximately 30,000 individuals and 325,000 prescriptions each year.

Personalized Remote Mobile Surveys of Adult ADHD Symptoms and Function: A Pilot Study of Usability and Utility for Pharmacology Monitoring

Objective: Validate the usability and treatment-sensitivity of a remote SMS-based ADHD monitoring method. Method: 206 adults taking stimulants for ADHD participated. Participants selected ADHD symptoms and functional impairments that they anticipated to be stimulant-sensitive, which were rated via mobile messages up to 20 times over 10 days. Results: A majority of participants found it only somewhat or not at all difficult to identify an ADHD symptom sensitive to presence of stimulant medication, and 79% responded to at least one survey message. As expected, a majority of participants endorsed it was “easy” to participate, and less burdensome than a paper diary. Surveys significantly discriminated between on and off medication states, both between days, and within the same day. Conclusion: Our findings suggest SMS-based monitoring of patient-selected ADHD-related challenges is both feasible and sensitive to stimulant treatment. This remote assay method may be a meaningful adjunct to in-visit treatment monitoring

40.2 STIMULANT MISUSE, DIVERSION, AND ABUSE IN COLLEGE STUDENTS

Substance abuse among college students has been the focus of considerable recent attention, given the high prevalence of use/abuse in this population, the nature of the drugs that are abused, the specific contextual issues that fuel abuse in this population, and the potentially dire outcomes of substance use in this population. It is hoped that better understanding of the types of substance abuse that most often occur in the college-age population, the specific contextual factors that support substance abuse in this population, and the various available methods of prevention and treatment of substance abuse that have been developed for college students will contribute to more informed approaches to managing this problem. This presentation will use data from the medical literature to examine patterns of stimulant misuse and diversion among college students, and gain understanding into factors that contribute to misuse and diversion, with the goal of improving care of transitional-age youth. Integrated into the presentation are case studies and audience polls with a period of discussion with a master clinician to enhance learning. We look at ways that stimulants are misused by college students including in combination with alcohol. We also take a look at what we know and do not know about how the shift to online classes during the COVID-19 pandemic has affected stimulant misuse. In 1 study, over half of college students prescribed stimulants for ADHD said they had been approached to sell, trade, or give away their medication. There are multiple factors impacting stimulant misuse, including social and biological factors, resulting in different patterns of misuse. Stimulants are a highly effective treatment for ADHD but carry the risk of misuse and diversion. There is evidence that in treating ADHD, different treatment trajectories can impact later substance use. By understanding the multiple factors involved in misuse, we can improve clinical care by enhancing screening for misuse and make informed choices in individualized treatment of ADHD.

A2As or stimulants: which is better for treatment of ADHD in young children?

The use of α2-adrenergic agonists (A2As), like guanfacine and clonidine, in preschool-aged children with ADHD has been on the rise, even though little data support safety and effectiveness for these medications in this patient population. A May 2021 study conducted by Harstad and colleagues and published in JAMA compared the use of A2As with stimulants in childhood ADHD. Similar to other studies, the research team found that both A2As and stimulants were associated with improvement in ADHD symptoms for most children between approximately 4 and 6 years in whom they were initiated, with clinical improvement in 66% and 78% of young children, respectively. The study highlights the potential role that A2As could play in treating young children with ADHD, said Elizabeth Harstad, MD, MPH, a physician at Boston Children's Hospital and an assistant professor of pediatrics at Harvard Medical School. According to the American Academy of Pediatrics (AAP) and the Society for Developmental and Behavioral Pediatrics (SDBP), firstline therapy for ADHD is behavioral intervention, followed by stimulant treatment with methylphenidate (Ritalin) at the lowest effective dose if behavioral interventions are not sufficient. In general, AAP recommends behavioral therapy first then medication treatment, if necessary. Amphetamine salts (Adderall) are FDA-approved for children as young as 3 years because they were grandfathered in, not because there is stronger evidence for their use compared with methylphenidate, said Michael Ellis, DO, a child and adolescent psychologist and clinical associate professor at Mercer College of Medicine in Georgia. He said methylphenidate has more efficacy and safety data to promote its use, even though it is approved for individuals 6 years and older. “In general, I find less irritability with methylphenidate and prefer the use of that medication first, especially for those with ADHD and autism spectrum disorder,” Ellis said. The NIH's Preschool ADHD Treatment study, a randomized, placebo-controlled study, found that children between the ages of 3 and 5.5 years who were treated with methylphenidate had a significant reduction in ADHD symptoms, but often experienced adverse effects like irritability and depressive symptoms, like crying and sadness. The retrospective, medical records study in JAMA examined 497 preschool-age children younger than 6 years with ADHD. They came from seven academic developmental behavioral pediatric programs located in diverse geographical locations across the United States. “We found that developmental behavioral pediatricians use A2As when initiating medication treatment and use stimulant medication about two-thirds of the time,” said Harstad. “Children who were younger, or had a coexisting autism or sleep disorder, were more likely to be initiated on A2As.” Since stimulants are associated with more adverse effects than A2As—like moodiness/irritability (50% vs. 29%, respectively), appetite suppression (38% vs. 7%, respectively), and sleep difficulties (21% vs. 11%, respectively)—some providers prefer to prescribe A2As for their patients. “But these are not as effective for focus [compared with stimulants], and there can be a good deal of somnolence or hypotension,” said Ellis. Daytime sleepiness was the only adverse effect that was more common when young children with ADHD took A2As versus stimulants (38% vs. 3%, respectively), according to the study. A limitation of the study is its retrospective nature, which resulted in the collection of non-randomized and non-controlled data regarding the level of improvement over time, severity of baseline ADHD symptoms, and severity of adverse effects, said Harstad. “Medication may have been influenced by confounding factors [such as coexisting conditions]. Therefore, it is clinically imperative to conduct a prospective clinical study to assess effectiveness,” said Harstad. Preschool-aged children are being diagnosed with ADHD at higher rates than ever before. According to a 2018 article published in the Journal of Clinical Child & Adolescent Psychology, preschool ADHD rates have risen from 1.0% in 2007 to 2.4% in 2016. Since delay in early detection can lead to expulsion from preschool, future underachievement in school, and undue family stress, it is important for parents to have their child evaluated early on. “Preschoolers especially with severe ADHD likely need treatment right away,” said Ellis. While there are benefits and risks to treatments with both A2As and stimulants, options should be assessed with a patient-centered approach to optimize individual needs. Future randomized, controlled studies are also needed to assess efficacy and safety with both medication classes to determine more conclusive results.

Intentional Discontinuation of Psychostimulants Used to Treat ADHD in Youth: A Review and Analysis

Objectives: This paper reviews the literature on intentional discontinuation of psychostimulants in ADHD to summarize what is known about clinical course of controlled discontinuation and guide practitioners who are considering stopping these medications for youth with ADHD.Methods: A systematic search was executed in Cochrane CENTRAL, EMBASE, Psychinfo, and MEDLINE databases to identify all articles that addressed the topic of deprescribing of psychotropic medications in children and adolescents. Keywords and search strings were developed using “PICO” framework, involving Population of interest (<18 y.o.), Intervention (“discontinuation,” “deprescribing,” and synonyms), Comparator (continuation of specific medications), and Outcomes. Ten reviewers conducted the initial screen via a single reviewer system. Articles that met a set of three inclusionary criteria were selected for full text review and identification as specific to discontinuation of stimulants in ADHD.Results: The literature review identified 35 articles specifically addressing intentional deprescribing, discontinuation, tapering, or withdrawal of stimulants for children and adolescents with ADHD. In addition to providing broad support for the efficacy of stimulants to treat ADHD and reduce negative outcomes, there is a distinct population of children and adolescents with ADHD who do not relapse or deteriorate when taken off medications for ADHD. The majority of articles addressed either the re-emergence of ADHD symptoms or side effects, both desired and adverse, following discontinuation of stimulants. While confirming the ability of stimulants to treat ADHD in youth, our results support periodic consideration of trials of stopping medications to determine continued need.Conclusions: This systematic review summarizes the literature on deprescribing stimulants for ADHD in children and adolescents. Further research is needed to determine the optimal duration of treatment, identify patients that may benefit from medication discontinuation, and inform evidence-based guidelines for discontinuation when appropriate. More research is needed to understand and define the subgroup of youth who may succeed with stimulant discontinuation.

Patient access to chronic medications during the Covid-19 pandemic: Evidence from a comprehensive dataset of US insurance claims.

Patient access and adherence to chronic medications is critical. In this work, we evaluate whether disruptions related to Covid-19 have affected new and existing patients’ access to pharmacological therapies without interruption. We do so by performing a retrospective analysis on a dataset of 9.4 billion US prescription drug claims from 252 million patients from May, 2019 through August, 2020 (about 93% of prescriptions dispensed within those months). Using fixed effect (conditional likelihood) linear models, we evaluate continuity of care, how many days of supply patients received, and the likelihood of discontinuing therapy for drugs from classes with significant population health impacts. Findings indicate that more prescriptions were filled in March 2020 than in any prior month, followed by a significant drop in monthly dispensing. Compared to the pre-Covid era, a patient’s likelihood of discontinuing some medications increased after the spread of Covid: norgestrel-ethinyl estradiol (hormonal contraceptive) discontinuation increased 0.62% (95% CI: 0.59% to 0.65%, p<0.001); dexmethylphenidate HCL (ADHD stimulant treatment) discontinuation increased 2.84% (95% CI: 2.79% to 2.89%, p<0.001); escitalopram oxalate (SSRI antidepressant) discontinuation increased 0.57% (95% CI: 0.561% to 0.578%, p<0.001); and haloperidol (antipsychotic) discontinuation increased 1.49% (95% CI: 1.41% to 1.57%, p<0.001). In contrast, the likelihood of discontinuing tacrolimus (immunosuppressant) decreased 0.15% (95% CI: 0.12% to 0.19%, p<0.001). The likelihood of discontinuing buprenorphine/naloxone (opioid addiction therapy) decreased 0.59% (95% CI: 0.55% to 0.62% decrease, p<0.001). We also observe a notable decline in new patients accessing these latter two therapies. Most US patients were able to access chronic medications during the early months of Covid-19, but still were more likely to discontinue their therapies than in previous months. Further, fewer than normal new patients started taking medications that may be vital to their care. Providers would do well to inquire about adherence and provide prompt, nonjudgmental, re-initiation of medications. From a policy perspective, opioid management programs seem to demonstrate a robust ability to manage existing patients in spite of disruption.

Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system

Objective We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them. Methods The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of “amphetamine and related compounds” or “methylphenidate” and specific product name containing XR, CD, ER, LA, and SR. Results A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent. Conclusion Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.

A novel digital health intervention to improve patient engagement to stimulants in adult ADHD in the primary care setting: Preliminary findings from an open label study

AimsWe piloted the effectiveness and acceptability of a novel text messaging-based (SMS) digital health intervention aimed at addressing the previously documented poor rate of patient engagement in stimulant treatment in the primary care setting. Methods117 adults ages 18–55 from primary care and psychiatric practices who were prescribed a stimulant medication for ADHD treatment received the SMS intervention. Comparators were age-, race-, and sex-matched patients from the same health care organization's electronic medical record who had been prescribed stimulant medications over a similar time period. Using documented prescription records, we determined whether patients had timely prescription refills. ResultsNinety-six percent (N = 112) of participants completed our a priori metric of patient engagement consisting of 37 days of the SMS program. Eighty-one percent of participants refilled their index prescriptions in a timely manner compared to only 36% of patients receiving treatment as usual (OR=7.54, 95% CI: 4.46, 12.77; p<0.001). We found no significant interaction between prescribing source (non-psychiatry vs. psychiatry) and intervention group (SMS vs. treatment as usual). ConclusionsThese data suggest that an ADHD-centric, digital health intervention using text messaging significantly improves patient engagement in stimulant treatment in adults with ADHD.

Effects of computerized cognitive training as add-on treatment to stimulants in ADHD: a pilot fMRI study.

The neurofunctional effects of Cognitive training (CT) are poorly understood. Our main objective was to assess fMRI brain activation patterns in children with ADHD who received CT as an add-on treatment to stimulant medication. We included twenty children with ADHD from a clinical trial of stimulant medication and CT (10 in medication + CT and 10 in medication + non-active training). Between-group differences were assessed in performance and in brain activation during 3 fMRI paradigms of working memory (N-back: 0-back, 1-back, 2-back, 3-back), sustained attention (Sustained Attention Task - SAT: 2s, 5s and 8s delays) and inhibitory control (Go/No-Go). We found significant group x time x condition interactions in working memory (WM) and sustained attention on brain activation. In N-back, decreases were observed in the BOLD signal change from baseline to endpoint with increasing WM load in the right insula, right putamen, left thalamus and left pallidum in the CT compared to the non-active group; in SAT - increases in the BOLD signal change from baseline to endpoint with increasing delays were observed in bilateral precuneus, right insula, bilateral associative visual cortex and angular gyrus, right middle temporal, precentral, postcentral, superior frontal and middle frontal gyri in the CT compared to the non-active group. CT in ADHD was associated with changes in activation in task-relevant parietal and striato-limbic regions of sustained attention and working memory. Changes in brain activity may precede behavioral performance modifications in working memory and sustained attention, but not in inhibitory control.

Trends in psychiatric disorders prevalence and prescription patterns of children in Alberta, Canada.

To describe the trends in the prevalence and incidence of children with psychiatric disorders, the types of medication prescribed, and the type of physician providing the prescriptions. This retrospective study linked six population-based administrative databases (2008-2015) in Alberta, Canada. The prevalence of paediatric psychiatric disorders increased from 12.6 per 100 population in 2008 to 15.0 per 100 population in 2015, while the incidence rate increased from 2.0 per 100 population to 2.2 per 100 population in the same period. The proportion of patients dispensed any psychiatric medication increased from 21.4% in 2008 to 28.2% in 2015. Over the same period, dispensations for antidepressants increased from 7.0% to 11.2% and stimulants to treat ADHD, from 11.9% to 15.9%. For antidepressants, general practitioners (GPs) wrote the highest proportion of prescriptions (44.3% in 2011-48.1% in 2015), while paediatricians wrote the lowest proportion (8.7% in 2011-11.0% in 2015) and the proportion by psychiatrists decreased from 33.4% in 2011 to 27.2% in 2015. For stimulants to treat ADHD, paediatricians were the most frequent prescribers (36.9% in 2011-39.3% in 2015) followed by GPs as the second most frequent (33.1% in 2011-33.5% in 2015), while psychiatrists were the least likely to prescribe stimulants for ADHD. The increasing trend of psychiatric diagnoses and medication prescriptions in the paediatric population is evident using population-based administrative databases. The lack of safety and adverse consequences of medication use in this cohort warrants additional monitoring data.

"The White Version of Cheating?" Ethical and Social Equity Concerns of Cognitive Enhancing Drug Users in Higher Education.

So-called cognitive enhancing drugs (CEDs) are relatively common in higher education, especially among students who are white, male, and attend highly selective institutions. Using qualitative data from a diverse sample of 32 students at an elite university, the present study aims to examine whether students perceive CED use to be advantageous, equitable, and fair. Participants were either medical or nonmedical users of CEDs-primarily ADHD stimulant medications such as Adderall. Data were first coded openly, then axially into themes, and finally arranged to respond to research aims around social and ethical concerns. Ethical perceptions and behavioral justifications varied by participants' personal use frequency, class standing, and perceived social norms surrounding CEDs. Among the salient themes to emerge was the belief that CED use is a lesser or more tenable form of cheating, that the vagueness and prevalence of ADHD justifies nonmedical use, and that above all, CEDs are advantageous. Some participants expressed concern about the advantageousness of CEDs when coupled with a perceived imbalance of their use among students from traditionally underrepresented backgrounds, with one calling it "the white version of cheating." Implications for cheating and drug use prevention are discussed, situating cognitive enhancement as an emerging ethical and social equity concern in higher education.