Prescription Stimulant Misuse Research Articles

Adverse Childhood Experiences and Prescription Stimulant Use in Adults: A Systematic Review.

Nonmedical prescription stimulant use (NPSU) is an ongoing public health crisis in the United States. There exists, however, a dearth of research investigating specific childhood risk factors that may contribute to this illicit use. Adverse childhood experiences (ACEs) may be a significant risk factor to address in the prevention and treatment of NPSU, as research has provided evidence for increased substance use, potentially including prescription stimulant misuse, among individuals who have experienced trauma. A systematic review of the literature was conducted to gather and synthesize research articles specifically examining the relationship between nonmedical prescription stimulant use in adults and the experience of adverse childhood experiences (ACEs). Four studies met all inclusion criteria and were included in the review. The results demonstrated that the nonmedical use of prescription stimulants in adults is significantly associated with ACEs, with a higher numerical count of ACEs associated with a greater likelihood of nonmedical prescription stimulant use. Gaps in the literature were identified, specifically noting a lack of information available regarding the relationship between ACEs and NPSU within gender- and racially diverse populations. The findings have implications for informing interventions related to ACEs and the misuse of prescription stimulant medication in adults.

Attention-Deficit Hyperactivity Disorder Stimulant Therapy and Prescription Drug Misuse During Transition to Young Adulthood.

Limited prospective data exist about the impact of stimulant therapy for attention-deficit hyperactivity disorder (ADHD) during adolescence on the risk for later prescription drug misuse (PDM; i.e., of benzodiazepines, opioids, and stimulants). National longitudinal multicohort panels (baseline cohort years 2005-2017) of U.S. 12th grade students (N=11,066; ages 17 and 18 years) from the Monitoring the Future study were surveyed via self-administered questionnaires and followed up biennially during young adulthood (ages 19-24). A multivariable analysis was used to assess whether adolescents' lifetime history of stimulant therapy for ADHD was associated with subsequent PDM. Overall, 9.9% of adolescents reported lifetime stimulant therapy for ADHD at ages 17 and 18. No significant differences were found in the adjusted odds of later incidence or prevalence of past-year PDM during young adulthood between adolescents with lifetime stimulant therapy and adolescents with no stimulant therapy. Over the 5-year follow-up, past-year PDM during young adulthood was most prevalent among adolescents who reported both stimulant therapy and prescription stimulant misuse (53.1%) and those who reported prescription stimulant misuse only (51.5%). Compared with adolescents in a control group without lifetime stimulant therapy or misuse, adolescents reporting prescription stimulant misuse had significantly higher adjusted odds of later incidence and prevalence of PDM during young adulthood. Adolescents' stimulant therapy for ADHD was not significantly associated with increased risk for later PDM during young adulthood. In contrast, adolescents' misuse of prescription stimulants strongly predicted later PDM. Monitoring adolescents for prescription stimulant misuse may help identify and mitigate the risk for future PDM.

Primary prevention of prescription stimulant misuse in first-year college students

Objective: Eight percent of college students report past year prescription stimulant misuse (nonmedical use of stimulants defined as taking stimulants in a manner other than prescribed). Despite this high prevalence rate, primary prevention efforts are lacking on college campuses. Participants and Methods: A prescription stimulant misuse primary prevention intervention targeting first-year college students was developed, refined, and pilot tested. Existing substance use treatment (motivational interviewing) and time management (cognitive behavioral therapy for adult ADHD) techniques were integrated into the novel brief prevention intervention. Focus groups provided feedback to help refine the prevention intervention. Following refinements, 484 first-year college students were randomly assigned to condition (327 treatment, 157 control) and followed for 3 months. Results: Participants rated the intervention as satisfactory. After controlling for time invariant covariates, condition significantly predicted prescription stimulant misuse. There was a lower rate of past 3-month prescription stimulant misuse reported in the intervention group (4.9%) compared to the control group (11.5%). Academic expectancies remained stable in the intervention group yet increased in the control condition over time. Time management skill ratings remained stable in both groups. Changes in academic expectancies, yet not time management skills, were a partial mediator of the prevention efficacy in prescription stimulant misuse at 3-month follow-up. Conclusions: These results provide preliminary support for the acceptability and efficacy of a brief primary prevention intervention for college student prescription stimulant misuse. Changes in positive prescription stimulant expectancies, yet not time management skills, appear to be potential targets for future preventive efforts.

Gender differences in the prevalence of stimulant misuse in the United States: 2015-2019.

The gender gap in prevalence of substance-use disorders has narrowed. However, gender differences in stimulant misuse have not been well-characterized in recent years. The aim of this study was to quantify gender differences in past-year stimulant misuse and stimulant-use disorder, separated by stimulant type (cocaine/crack, prescription stimulants, and methamphetamine). In an exploratory aim, we investigated whether gender differences were moderated by age or sexual orientation. We combined data from the National Survey on Drug Use and Health from 2015 to 2019 (unweighted N = 282,768) to test gender differences in the prevalence of past-year stimulant misuse. Results indicated that stimulant misuse was significantly more prevalent in men than women for all stimulant types for both past-year use and past-year use disorder. The magnitude of this sex difference was smallest for prescription stimulants, where men had 1.37 times higher odds of past-year misuse and no gender difference was observed in the prevalence of prescription stimulant-use disorder. The magnitude of gender differences also varied based on both age and sexual orientation. Illicit stimulant misuse continues to be more common in men than in women; however, gender differences are more modest for prescription stimulant misuse, suggesting a narrowing of this historical gender difference.

Risky doses of stimulants for ADHD yield minimal therapeutic benefit

Efforts to combat the risk of overdose and substance use disorder (SUD) associated with prescription stimulant misuse could receive a boost from new meta‐analytic findings that higher‐than‐recommended doses of the medications show little benefit in the treatment of attention deficit hyperactivity disorder (ADHD).

Cocaine or Methamphetamine Use During Young Adulthood Following Stimulant Use for Attention-Deficit/Hyperactivity Disorder During Adolescence

The prescribing of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) has increased in the US. Prescription stimulants are one of the most commonly misused controlled substances during adolescence. Despite a 10-fold increase in stimulant-related overdose deaths in the past decade, the transitions from prescription stimulants to illicit stimulants (eg, cocaine, methamphetamine) remain relatively unknown in longitudinal population-based studies. To determine the longitudinal transitions from adolescents' prescription stimulant exposure (ie, stimulant therapy for ADHD and prescription stimulant misuse [PSM]) to later cocaine and methamphetamine use during young adulthood. National longitudinal multicohort panels of US 12th grade public and private school students in the coterminous US were assessed annually (baseline cohort years 2005-2017 [between March and June]) and followed up across 3 waves over a 6-year period to 23 to 24 years of age (follow-up years 2011-2021 [between April and October]). History of self-reported stimulant therapy for ADHD at baseline. Incidence and prevalence of past-year use of cocaine and methamphetamine during young adulthood (19-24 years of age). Among 5034 students enrolled at baseline (2589 [52.0%] female), 470 (10.2% [95% CI, 9.4%-11.2%]) reported use of stimulant therapy for ADHD, 671 (14.6% [95% CI, 13.5%-15.6%]) reported PSM only, and 3459 (75.2% [95% CI, 73.9%-76.4%]) reported neither (and served as population controls). In controlled analyses, there were no statistically significant differences between adolescents who reported stimulant therapy for ADHD at baseline compared with population controls in the adjusted odds of transitioning to later cocaine or methamphetamine initiation or use during young adulthood (19-24 years of age). In contrast, PSM during adolescence in those not treated with stimulants for ADHD had significantly higher odds of transitioning to later cocaine or methamphetamine initiation and use during young adulthood compared with population controls (adjusted odds ratio, 2.64 [95% CI, 1.54-4.55]). In this multicohort study, adolescents' stimulant therapy for ADHD was not associated with increased risk of later cocaine and methamphetamine use during young adulthood. Adolescents' prescription stimulant misuse offered a signal for subsequent cocaine or methamphetamine use and warrants monitoring and screening.

Prescription Stimulant Misuse Among Nursing Students: A Systematic Review.

Nonmedical prescription stimulants are used to reduce symptoms of inattention, impulsivity, and hyperactivity in children and adults with attention-deficit hyperactivity/disorder. They are Schedule II controlled substances because of their high potential for dependence, and individuals who misuse them without a valid prescription are subject to criminal charges. Stimulant medications are also associated with common side effects (e.g., insomnia) as well as more serious but less common side effects (e.g., arrhythmias). Despite the potential health and legal consequences, misuse of prescription stimulants has become a public health crisis on college campuses in the United States. Neurocognitive enhancement is the primary reason that college students report misusing prescription stimulants, despite no enhancement of cognitive functioning when taken by healthy adults. Nursing students may be at risk for misuse because of their high levels of academic and clinical demands and because many start misusing in nursing school. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the databases PubMed, Science Direct, EBSCOhost, and Academic OneFile were systematically searched to investigate the (a) percentage of prescription stimulant misuse studies that have included nursing students, (b) prevalence of prescription stimulant misuse among nursing students, (c) motivations for prescription stimulant misuse among nursing students, and (d) demographic factors associated with increased use among nursing students. Results revealed that of the 197 studies conducted within the past decade (2010-2021), only 1.02% (two) included nursing students. Future studies must investigate the prevalence and nature of prescription stimulant misuse among nursing students.

Overcoming defensive responding in the estimation of prescription stimulant misuse

Overcoming defensive responding in the estimation of prescription stimulant misuse

Examining Symptoms of Stimulant Misuse and Community Support Among Members of a Recovery-Oriented Online Community

ABSTRACT Misuse of prescription and non-prescription stimulants and related overdose deaths represent a growing public health crisis that warrants immediate intervention. We examined 100 posts and their respective comments from a public, recovery-oriented Reddit community in January 2021 to explore content related to DSM-V stimulant use disorder symptoms, access and barriers to recovery, and peer support. Using inductive and deductive methods, a codebook was developed with the following primary themes: 1) DSM-V Symptoms and Risk Factors, 2) Stigma/Shame, 3) Seeking Advice or Information, 4) Supportive or Unsupportive Comments. In 37% of posts community members reported taking high doses and engaging in prolonged misuse of stimulants. Nearly half of posts in the sample (46%) were seeking advice for recovery, but 42% noted fear of withdrawal symptoms or a loss of productivity (18%) as barriers to abstinence or a reduction in use. Concerns related to stigma, shame, hiding use from others (30%), and comorbid mental health conditions (34%) were also noted. Social media content analysis allows for insight into information about lived experiences of individuals struggling with substance use disorders. Future online interventions should address recovery barriers related to stigma and shame as well as fears associated with the physical and psychological impact of quitting stimulant misuse.

Subtypes of prescription stimulant misuse among students: a nuanced story

ABSTRACT Research on stimulant misuse among students has been rising. These medicines are generally prescribed to treat ADHD, but they are also used by students to enhance their academic performance. To date, qualitative research on the topic is limited, specifically in understanding the process of misuse, i.e. the motivations embedded in a particular academic and social context driving students’ decision to use. The aim of this research was to develop subtypes by disentangling patterns in the process of stimulant misuse. We conducted a focus group (n = 5) and semi-structured interviews (n = 28) with Flemish university students who had misused stimulants during their academic career. We employed abductive analysis principles, in which we build on Conrad’s medicalization and enhancement theory and Cox and Klinger’s motivational model of alcohol use. Two dimensions were key in differentiating theoretically meaningful subtypes: (1) perception of academic need and (2) frequency of use. The normalization subtype indicates having concentration problems and structurally uses stimulants to deal with these problems; the rescue subtype is able to study without stimulants, but occasionally uses them to cope with academic demands and/or personal stressors; the experimental subtype does not have an academic need to use stimulants, but temporarily uses them out of curiosity; the performance subtype does not need the medication, but perceives it as a convenient tool to structurally facilitate academic life, e.g. to shorten the study process. Our study shows a nuanced story of students’ stimulant misuse and helps inform the development of tailored preventive measures.

NIDA study finds link between ADHD stimulant medication and stimulant misuse

Researchers at the University of Michigan have found a strong association between prevalence of prescription stimulant therapy for attention‐deficit/hyperactivity disorder (ADHD) and rates of prescription stimulant misuse according to a study published last week in JAMA Network Open. The study, funded by the National Institute on Drug Abuse (NIDA) and part of the Monitoring the Future database, highlights the need for schools to make sure students don't share their medication, according to NIDA.

Is age of onset and duration of stimulant therapy for ADHD associated with cocaine, methamphetamine, and prescription stimulant misuse?

To assess whether age of onset and duration of stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) are associated with cocaine, methamphetamine, and prescription stimulant misuse during adolescence. Nationally representative samples of US 10th and 12th grade students (N = 150,395) from the Monitoring the Future study were surveyed via self-administered questionnaires from 16 annual surveys (2005-2020). An estimated 8.2% of youth received stimulant therapy for ADHD during their lifetime (n = 10,937). More than one in 10 of all youth reported past-year prescription stimulant misuse (10.4%)-past-year cocaine (4.4%) and methamphetamine (2.0%) use were less prevalent. Youth who initiated early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years) did not have significantly increased adjusted odds of cocaine or methamphetamine use relative to population controls (ie, non-ADHD and unmedicated ADHD youth). Youth who initiated late stimulant therapy for ADHD (≥10 years old) and for short duration (<1 year) had significantly higher odds of past-year cocaine or prescription stimulant misuse in adolescence than those initiating early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years). Youth who initiated late stimulant therapy for ADHD (≥10 years) for short duration (<1 year) had significantly higher odds of past-year cocaine, methamphetamine, and prescription stimulant misuse versus population controls during adolescence. No differences in past-year cocaine, methamphetamine, and prescription stimulant misuse were found between individuals who only used non-stimulant therapy for ADHD relative to youth who initiated early stimulant therapy (≤9 years old) and for long duration (≥6 years). An inverse relationship was found between years of stimulant therapy and illicit and prescription stimulant misuse. Adolescents with later initiation and/or shorter duration of stimulant treatment for ADHD should be monitored for potential illicit and prescription stimulant misuse.

Sources for prescription stimulant misuse: A person-centered approach to understanding links to substance use and psychiatric impairment.

Prescription stimulant misuse (PSM) is most prevalent among college students and is associated with numerous negative academic and psychosocial outcomes. A large body of literature has identified predictors of PSM in this population, however few studies have utilized a person-centered approach to examine how the sources from which students procure prescription stimulants are associated with substance-related and psychiatric impairment. We used latent class analysis (LCA) to classify a geographically and racially/ethnically diverse sample of U.S. undergraduates (N = 538) who misused prescription stimulants into groups based on their endorsement of nine sources of medication. We selected a five-group classification from the LCA with classes of peer/dealer, given by friend, own prescription, lower multiple sources (i.e., relatively infrequent endorsement of multiple sources), and any source. Compared to the reference group (given by friend), the own prescription class was less likely to report marijuana use, simultaneous alcohol and marijuana use, alcohol or marijuana consequences, and nonoral routes of administration. On the other hand, the own prescription class was more likely to screen positive for anxiety, anger, and suicidality. Similarly, the lower multiple sources group was more likely to screen positive for depression, anxiety, anger, and suicidality. Prevention and intervention efforts focused on PSM may be tailored differently for students who are misusing their own medication and/or endorsing multiple sources. Specifically, these students may need broader assistance with comorbid psychiatric conditions, particularly suicidality, while students who obtain stimulants from peers or a dealer may benefit more from substance-focused interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trends in Diversion Sources for Prescription Stimulant Misuse in U.S. Adolescents

Trends in Diversion Sources for Prescription Stimulant Misuse in U.S. Adolescents

Specificity in genetic and environmental risk for prescription opioid misuse and heroin use.

Many studies aggregate prescription opioid misuse (POM) and heroin use into a single phenotype, but emerging evidence suggests that their genetic and environmental influences may be partially distinct. In total, 7164 individual twins (84.12% complete pairs; 59.81% female; mean age = 30.58 years) from the Australian Twin Registry reported their lifetime misuse of prescription opioids, stimulants, and sedatives, and lifetime use of heroin, cannabis, cocaine/crack, illicit stimulants, hallucinogens, inhalants, solvents, and dissociatives via telephone interview. Independent pathway models (IPMs) and common pathway models (CPMs) partitioned the variance of drug use phenotypes into general and drug-specific genetic (a), common environmental (c), and unique environmental factors (e). An IPM with one general a and one general e factor and a one-factor CPM provided comparable fit to the data. General factors accounted for 55% (a = 14%, e = 41%) and 79% (a = 64%, e = 15%) of the respective variation in POM and heroin use in the IPM, and 25% (a = 12%, c = 8%, e = 5%) and 80% (a = 38%, c = 27%, e = 15%) of the respective variation in POM and heroin use in the CPM. Across both models, POM emerged with substantial drug-specific genetic influence (26-39% of total phenotypic variance; 69-74% of genetic variance); heroin use did not (0% of total phenotypic variance; 0% of genetic variance in both models). Prescription sedative misuse also demonstrated significant drug-specific genetic variance. Genetic variation in POM, but not heroin use, is predominantly drug-specific. Misuse of prescription medications that reduce experiences of subjective distress may be partially influenced by sources of genetic variation separate from illicit drug use.

Type of medication therapy for ADHD and stimulant misuse during adolescence: a cross-sectional multi-cohort national study

Attention-deficit/hyperactivity disorder (ADHD) is associated with higher substance use rates. Stimulant and non-stimulant pharmacotherapy improve adolescent ADHD, but their associations with prescription stimulant misuse (PSM), cocaine, and methamphetamine use are unclear. Using 2005-2020 US Monitoring the Future data, we investigated relationships between ADHD pharmacotherapy history and PSM, cocaine, or methamphetamine use. Secondary students (13-19 years) provided data on pharmacotherapy history (N=199,560; 86.3% of total sample) between January 1, 2005 and May 31, 2020 in a cross-sectional multi-cohort study; weights assured a nationally representative sample. Participants were grouped by ADHD pharmacotherapy history: none (88.7%; principally non-ADHD controls); stimulant-only (5.8%); non-stimulant-only (3.3%); both stimulant and non-stimulant (2.1%). Outcomes were past-year PSM, cocaine, and methamphetamine use. Logistic regressions examined relationships between pharmacotherapy history and outcomes, controlling for sociodemographics, recent substance use, and stimulant treatment cessation. Past-year outcome rates were lowest in adolescents with no pharmacotherapy history: 4.7% for PSM [8310/174,561], 1.6% for cocaine [2858/174,688], and 0.7% for methamphetamine [1036/148,378]. A history of both stimulant and non-stimulant treatment was associated with the highest rates: 22.3% for PSM [940/4098], 10.4% for cocaine [450/4110], and 7.8% for methamphetamine [275/3427]. Adolescents who received monotherapy (stimulant- or non-stimulant-only) had intermediate rates, with no differences between monotherapy groups. While elevated PSM and illicit stimulant use rates are likely influenced by ADHD, our findings suggested adolescents with a history of both stimulant and non-stimulant pharmacotherapy are at highest risk for these stimulant outcomes. Adolescents receiving ADHD pharmacotherapy should be monitored for PSM and illicit stimulant use. National Institute on Drug Abuse/National Institutes of Health (USA) and Food and Drug Administration (USA).

Who Persists and Who Desists? A Prospective Study of Prescription Stimulant Misuse in College Graduates.

Prescription stimulant misuse (PSM) has been studied extensively in college populations, but few studies have examined how PSM changes after graduation. We used a longitudinal design to follow individuals at risk for PSM two years after college graduation to document PSM prevalence, motives, and predictors of PSM persistence. Participants from two small, private colleges completed online surveys focused on intrapersonal, interpersonal, and sociocultural predictors of PSM. Overall, PSM declined over time. Lack of premeditation, perceived peer norms, positive expectancies, media exposure, and other substance use were associated with continued PSM; however, only lack of premeditation, descriptive norms, and other substance use predicted PSM in a multivariate model. This preliminary study suggests dispositional and behavioral risk factors may help to explain why PSM persists after college. Interventions that enhance decision-making skills, correct misperceptions about peers' PSM, and reduce polysubstance use may be effective in curbing PSM in college graduates.

Prevalence and Correlates of Prescription Stimulant Misuse Among US College Students: Results From a National Survey.

Objective: There is a high prevalence of prescription stimulant misuse (PSM) among college students in the United States (US). Preventing and identifying PSM requires an understanding of risk factors and correlates, but large-scale surveys regarding this issue have been lacking. We present the largest multi-institution study to date on the correlates of PSM among US college students. Methods: We performed a secondary analysis of the 2017 American College Health Association–National College Health Assessment (ACHA-NCHA), an annual national survey on the demographics, health, and academic experiences of US college students. Logistic regression models examined associations between past-year PSM in 40,645 undergraduate college students and hypothesized risk factors. Results: PSM was reported in 8% of college students. PSM was associated with past-year diagnosis or treatment of depression (adjusted odds ratio = 1.16; 99% CI, 1.01–1.33), anorexia (AOR = 1.44; 99% CI, 1.02–2.03), attention-deficit/hyperactivity disorder (AOR = 1.66; 99% CI, 1.41–1.95), and substance use disorder/other addiction (AOR = 1.79; 99% CI, 1.30–2.46). The odds of PSM were 5.5 times higher for students who endorsed past-month use of “Legal drugs” and 8 times higher for students who endorsed past-month use of “Illegal drugs” than for those who did not. Other factors associated with PSM included academic difficulty, daytime sleepiness, fraternity or sorority involvement, White race, and cis-male gender. Conclusions: This study identifies many potential risk factors for PSM among US undergraduate college students. Targeted outreach, prevention, and clinical management are discussed. As the COVID-19 pandemic has exacerbated psychiatric distress, sleep difficulties, substance use, and attentional challenges among college students, this study may serve as a baseline for future studies examining the impact of COVID-19 on PSM among college students.

Perspectives on Deterrents from Students Who Have Discontinued Prescription Stimulant Misuse and Diversion Behaviors.

Although a growing number of studies have sought to understand what motivates the initiation of prescription stimulant misuse and diversion among college students, there has been a lack of studies focused on what motivates behavior cessation. We aimed to explore what motivates prescription stimulant misuse and diversion cessation, from the perspective of college students with a history of having initiated and then discontinued these behaviors. We conducted face-to-face interviews with students who had a history of misuse, diversion, or both, and who had intentionally, either for the short-term or long-term, ceased these behaviors. We audio-recorded, transcribed, and analyzed interviews inductively using a thematic analysis approach. Of the six themes we identified, four applied to both misuse and diversion, while two applied to diversion only. Engaging in related behavior change, seasonality of the behaviors, changes in personal needs, and negative and/or null experiences with the behaviors were themes for both misuse and diversion cessation. Themes that emerged solely for diversion cessation included: moral and legal concerns and not wanting to be perceived as a drug dealer. The information shared by students with first-hand misuse and diversion cessation experience has the potential to guide interventions designed to address prescription stimulant misuse on college campuses.

Stimulant use by athletes

Open AccessStimulant use by athletesThe role of sports psychiatryAndres R. Schneeberger, Jessica Thackaberry, Alexandra Sietsma, Charles Ashbrook, and Steve KohAndres R. SchneebergerAndres R. Schneeberger, M.D., Department of Psychiatry, University of California San Diego, 8950 Villa La Jolla Drive, Suite C101, La Jolla, CA 92037, USAaschneeberger@health.ucsd.eduhttps://orcid.org/0000-0001-8176-9126 Department of Psychiatry, University of California San Diego, CA, USA Search for more papers by this author, Jessica Thackaberryhttps://orcid.org/0000-0001-9535-1660 Department of Psychiatry, University of California San Diego, CA, USA Search for more papers by this author, Alexandra Sietsmahttps://orcid.org/0000-0003-4294-095X Department of Psychiatry, University of California San Diego, CA, USA Search for more papers by this author, Charles Ashbrook Department of Psychiatry, University of California San Diego, CA, USA Search for more papers by this author, and Steve Kohhttps://orcid.org/0000-0001-9846-3174 Department of Psychiatry, University of California San Diego, CA, USA Search for more papers by this authorPublished Online:October 12, 2022https://doi.org/10.1024/2674-0052/a000027PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreAmphetamine use in the United States of America (US) has more than doubled in the past 15 years and the consumption of methylphenidate increased by a third [1]. Between 2003 and 2011 the prevalence of ADHD diagnosed in children increased by 41% [2] and after the new and more inclusive DSM-5 criteria for adult ADHD [3], there have been increasing prescriptions for stimulants in adults. In 2016, according to the National Surveys on Drug Use and Health, 6.6% (approximately 16 million) of US adults used prescription stimulants, while estimates show that, in contrast, almost 5 million (2.1%) people misused prescription stimulants overall [4]. In this context, appropriate use of stimulants in athletes is controversial and confusing. While the National Collegiate Athletic Association (NCAA) bans the drug class of stimulants, it allows medical exceptions for ADHD [5]. Also, the World Anti-Doping Agency (WADA) and the International Olympic Committee (IOC) list stimulants as prohibited substances but allow Therapeutic Use Exemptions (TUE) [6].Stimulant medications have a proven and legitimate indication for the treatment of ADHD [7], while stimulants are commonly used in the treatment of ADHD, their use in elite sports is controversial [8]. Athletes taking stimulant medications are often subject to discrimination based on the suspicion that they are using the substance as a performance enhancer [9]. In the context of sports, the likelihood of performance enhancement is a reality that might have serious and dangerous consequences [10]. Athletes might find themselves under the influence of their greater environment and see the effect of such drugs as a desired effect without it being misuse or abuse of the substance. It is therefore paramount to discuss the tension between the therapeutic use of stimulants for e.g. ADHD, and the use of stimulants in and outside sports for performance enhancement in the context of sports psychiatry. The physiological effects of these substances are well known, at the same time good evidence for the effects in athletes in general is lacking. Using methylphenidate may increase core body temperature and heart rate while exercising without being perceived by the athlete [11]. Hence, two of the major health risks are stimulant-induced cardiovascular and heat incidents, which have caused numerous fatalities among athletes during demanding exercise [12].The ethical considerations regarding the use of stimulants in amateur and elite sports has to focus on fairness [13]. The discussion of fairness within competitive sports might seem irrelevant, considering that competition is the celebration of differences, which stem from a complex interplay between genetic predispositions and environmental factors. While we could argue that untreated health conditions might put athletes at a disadvantage in some disciplines, this might not necessarily hold true in the case of disorders treated with stimulants for other disciplines. Even if stimulants are discontinued before the competition, athletes show an improved exercise endurance with increases in several performance measures including strength, acceleration, anaerobic capacity, time to exhaustion, and maximum heart rate [14]. Hence, rather than focusing on the impact of stimulants on fairness in regards to the potential athletic outcome, the discussion should focus on the rules and regulation of the competition. This highlights the importance of TUE and the expertise of the health care provider who determines the exemption. Considering the lack of biomarkers or other physiologic measurements of ADHD, the interrater reliability of ADHD is subject to distortion [7]. Clinicians who are not used to treating athletes might misinterpret hyperactive athletic behaviors as a mental disorder. In contrast, in some disciplines ADHD might impact sport performance in a way that would simply disadvantage the participant if not being actively treated, i.e. archery or other sports that require focus and concentration. Without an open discourse about TUEs, the risk persists that athletes suffering from mental health disorders such as ADHD might not recevive adequate treatment, while other athletes that ask, are getting TUEs without meeting criteria for a diagnosis.Sports psychiatrists need not only focus on the use of stimulant medications within sports but also outside of sports. Increasing athletes’ awareness and responsible use of stimulants will not only influence the person but also have an impact on a wider level. We believe that sports have the potential to spearhead change. Studies have shown that physical exercise represents a promising alternative or supplementary treatment option for adults with ADHD. In a recent meta-analysis, Xie et al. [15] showed that physical activity interventions on ADHD symptoms in before-after studies had beneficial effects on attention (I2=51.1%, p=0.010) and hyperactivity (I2=66.3%, p<0.001). This result was confirmed for physical activity intervention for attention problems in two-group control studies (I2=85.4%, p<0.001). In combination with the pillars of state-of-the-art psychiatric treatment such as psychopharmacology for the treatment of co-morbid disorders, psychotherapy (i.e. cognitive behavioral therapy), social interventions and healthy lifestyle changes, it is not only an opportunity for sports psychiatry to embrace evidence-based change but also a responsibility. As mental health care workers we should support people’s effort to be physically active and to do sports in a healthy and balanced way.There is a need for action. Sports psychiatrists need to be involved in the continuing development of TUEs, national and international standards, and they should participate in TUE committees and TUE application [16, 17]. It should be the sport psychiatrists role, as an expert and well-informed medical professional to strive for the optimal use of TUEs and contribute to a legitimate use of stimulants by athletes who need it while rendering equity in sports.References1 Piper B, Ogden C, Simoyan O, Chung D, Caggiano J, Nichols S, et al. Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016. PLoS One. 2018;13(11):e0206100. First citation in articleGoogle Scholar2 Centers for Disease Control and Prevention (CDC). Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children - United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep. 2010;59(44):1439–43. First citation in articleGoogle Scholar3 Diagnostic and statistical manual of mental disorders. Arlington, VA: American Psychiatric Association; 2013. First citation in articleGoogle Scholar4 Compton W, Han B, Blanco C, Johnson K, Jones C. 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First citation in articleGoogle ScholarFiguresReferencesRelatedDetailsCited bySubstance use in elite and recreational sport A socio-cultural, medical, and regulatory field of tensionKatinka van de Ven, Bengt Kayser, Malte Christian Claussen, and Samuel Iff17 November 2022 | Sports Psychiatry, Vol. 1, No. 4 Special Issue: Psychiatric Issues of “Doping” in SportsVolume 1Issue 4November 2022ISSN: 2674-0052eISSN: 2674-0052 ReceivedAugust 26, 2022AcceptedOctober 1, 2022Published onlineOctober 12, 2022 InformationSports Psychiatry (2022), 1, pp. 135-136 https://doi.org/10.1024/2674-0052/a000027.© 2022The Author(s)LicensesDistributed as a Hogrefe OpenMind article under the license CC BY 4.0 ( https://creativecommons.org/licenses/by/4.0)PDF download