Use Of Stimulant Medication Research Articles

PGR - 3 Adapting Neuropsychological Evaluation for a Complex Pediatric Patient with Challenging Behaviors

Abstract Objective The detrimental impact of in utero substance use on developing fetuses manifests well into adolescence (Wu, Ju, & Lu, 2011; Minnes, Lang, & Singer, 2011). Likewise, the effects of early childhood neglect during critical developmental periods may be long lasting (de Bellis, et al., 2009; Hildyard & Wolfe, 2002). Factors such as these may require creative adaptation of assessment. This case illustrates the process of evaluating a child presenting with an unusual developmental history and extremely challenging behaviors and describes efforts to maintain engagement while eliciting valid data. Successful and unsuccessful interventions will be reviewed. Method Patient is a 12-year-old Caucasian male admitted to a state psychiatric hospital with a complex presentation of emotional, behavioral, and cognitive difficulties. Aggravating factors consist of likely in utero drug and alcohol exposure, early trauma, chronic neglect, and unusually small physical stature. Neuropsychological evaluation was completed over the course of five days. Testing sessions were brief, on a unit where no one was present, and were structured using both intermittent and scheduled reinforcement to maintain effort and engagement. Results Testing indicated significant and consistent weaknesses in executive functioning, learning, memory, and attention. Despite the use of stimulant medication, difficulty with vigilance, sustained attention, and impulsivity persisted. Diagnoses were Neurodevelopmental Disorder associated with prenatal substance exposure, Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Combined presentation, and Oppositional Defiant Disorder, Moderate. Conclusions Unconventional history warrants unconventional approach to assessment. Recommendations included not only approaches to improving his attention, but just as important, strategies to elicit his best performance in various settings.

Quantifying the Protective Effects of Stimulants on Functional Outcomes in Attention-Deficit/Hyperactivity Disorder: A Focus on Number Needed to Treat Statistic and Sex Effects

PurposeThe aim of the study was to help quantify the protective effects of stimulant treatment on important functional outcomes in attention-deficit/hyperactivity disorder (ADHD) using the number needed to treat (NNT) statistic and examine whether these effects are moderated by sex. MethodsSubjects were derived from three independent samples, two similarly designed case–control, 10-year prospective follow-up studies of boys and girls with and without ADHD grown up and a cross-sectional randomized clinical trial of lisdexamfetamine on driving performance and behavior. For all studies, subjects were evaluated with structured diagnostic interviews. To measure psychopharmacologic treatment in the follow-up studies, we collected information about each subject's stimulant medication use, age at onset, and age at termination of treatment. Subjects in the driving study underwent two driving simulation assessments (premedication and after 6 weeks of treatment on lisdexamfetamine or placebo). For each outcome, we ran a logistic regression model that included an interaction between sex and treatment status. Lifetime rates were used to calculate the NNT statistic. We also calculated adjusted NNT statistics that accounted for sex, age, socioeconomic status, and family intactness. ResultsThe NNTs were very low, ranging from 3 to 10. No interaction effects with sex were detected (all p > .05). The adjusted NNTs mostly remained the same with the exception of any substance use disorder, which increased after controlling for age. ConclusionsStimulants have strong protective effects on functional outcomes in youth with ADHD that are not moderated by sex. These results support the critical importance of early identification and treatment of children with ADHD of both sexes.

Studies examine nonmedical use and outcomes of ADHD medications in adults

Recent trends indicate a rise in nonmedical use of prescription stimulant medications in adult patients with attention deficit hyperactivity disorder (ADHD). The nonmedical use of these medications, whether oral or non‐oral, carries risk for serious adverse medical outcomes, according to new data addressing both of these issues, released this month.

Using Neurofeedback to Improve ADHD Symptoms in School-Aged Children

The diagnosis and treatment of the behaviors associated with attention-deficit/hyperactivity disorder (ADHD) predominantly involves pharmacological interventions. Many children experience significant negative side effects (e.g., appetite suppression, insomnia, headaches, stomachaches, irritability, and impaired height) from the initial and continued use of stimulant medication. Consequently, many parents are motivated to consider alternative treatments for ADHD such as neurofeedback. This paper presents an archival review of the improvements in auditory and visual attention and response control after 40 sessions of artifact-corrected neurofeedback for 51 children ages 6 to 17 with ADHD. Initially, the majority of these clients were identified as having severe to extreme auditory and visual attention impairments. The IVA-2 CPT was administered prior to treatment and after 20 and 40 treatment sessions were completed. After 20 sessions of neurofeedback significant improvements of both auditory and visual attention and response control were found with small to large size effects. The clients continued to improve after an additional 20 sessions, with medium to large size effects after 40 sessions. At completion of treatment the mean of eight of the nine attention and response control scores fell within the “normal” range.

Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016.

BackgroundStimulants are considered the first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD) in the US and they are used in other indications. Stimulants are also diverted for non-medical purposes. Ethnic and regional differences in ADHD diagnosis and in stimulant use have been identified in earlier research. The objectives of this report were to examine the pharmacoepidemiological pattern of these controlled substances over the past decade and to conduct a regional analysis.MethodsData (drug weights) reported to the US Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System for four stimulants (amphetamine, methylphenidate, lisdexamfetamine, and methamphetamine) were obtained from 2006 to 2016 for Unites States/Territories. Correlations between state level use (mg/person) and Hispanic population were completed.ResultsAmphetamine use increased 2.5 fold from 2006 to 2016 (7.9 to 20.0 tons). Methylphenidate use, at 16.5 tons in 2006, peaked in 2012 (19.4 tons) and subsequently showed a modest decline (18.6 tons in 2016). The consumption per municipality significantly increased 7.6% for amphetamine and 5.5% for lisdexamfetamine but decreased 2.7% for methylphenidate (all p < .0005) from 2015 to 2016. Pronounced regional differences were also observed. Lisdexamfetamine use in 2016 was over thirty-fold higher in the Southern US (43.8 mg/person) versus the Territories (1.4 mg/person). Amphetamine use was about one-third lower in the West (48.1 mg/person) relative to the Northeastern (75.4 mg/person, p < .05) or the Midwestern (69.9 mg/person, p ≤ .005) states. States with larger Hispanic populations had significantly lower methylphenidate (r(49) = -0.63), lisdexamfetamine (B, r(49) = -0.49), and amphetamine (r(49) = -0.43) use.ConclusionsTotal stimulant usage doubled in the last decade. There were dynamic changes but also regional disparities in the use of stimulant medications. Future research is needed to better understand the reasons for the sizable regional and ethnic variations in use of these controlled substances.

Impact of Central Nervous System Stimulant Medication Use on Growth in Pediatric Populations with Attention-Deficit/Hyperactivity Disorder: A Review.

Central nervous system stimulants are a commonly used first-line treatment option for attention-deficit/hyperactivity disorder (ADHD). Stimulants are generally well tolerated, with anorexia and insomnia the most common adverse effects. However, there are some concerns with long-term use of stimulants, such as potential growth delay. Historically, data regarding this long-term adverse effect have been conflicting. In this article, we review the newer data surrounding the effects of central nervous system stimulants on growth parameters in children with ADHD. We conducted a literature search of the PubMed database; only articles using ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, were included to ensure the most up-to-date review of literature. Nine articles were identified for relevance and quality and are discussed in this review, describing clinical observations of height and weight of adolescent or pediatric patients receiving stimulant medications for ADHD therapy. In summary, this review points toward potential associations between duration of treatment and higher doses of stimulants with decreased weight and body mass index. Furthermore, this review demonstrates that evidence is still conflicting regarding the relationship between stimulant use and significant height decreases. Future studies with higher quality of evidence are needed to observe this potential adverse effect of stimulants in children and adolescents.

Non-medical prescription stimulant use to improve academic performance among Australian university students: prevalence and correlates of use

BackgroundSome university students consume pharmaceutical stimulants without a medical prescription with the goal of improving their academic performance. The prevalence of this practice has been well documented in the US, but less so in other countries. The potential harms of using prescription stimulants require a better understanding of the prevalence of this practice within Australian universities.MethodsAn internet survey of 1136 Australian students was conducted in 2015 in three large Australian universities. Students were asked about their personal use of prescription stimulants, attitudes and experiences with prescription stimulants. They were also asked about their use of caffeine, energy drinks and illicit drugs to enhance their academic performance.ResultsLifetime self-reported use of stimulant medication to improve academic performance was 6.5, and 4.4% in the past year. Students were far more likely to report using coffee and energy drinks (41.4 and 23.6% respectively, lifetime use) than prescription stimulants to help them study and complete university assessments. Non-medical use of prescription stimulants was strongly associated with a history of illicit drug use.ConclusionThe prevalence of nonmedical prescription stimulant use to improve academic performance is low among university students in Australia, especially when compared with their use of coffee and energy drinks.

HEREDITARY ANGIOEDEMA PRECIPITATED BY CONSTIPATION SECONDARY TO STIMULANT MEDICATION USE

Introduction Hereditary angioedema (HAE) is an inherited condition manifesting as recurrent episodes of swelling that commonly affects the skin and gastrointestinal tract (1,8). Various triggers can be the precipitating factors in an acute episode of HAE, however, sometimes the culprit cannot be determined. Case Description We present a patient with a diagnosis of hereditary angioedema, concomitant ADHD, with recurrent gastrointestinal exacerbations. Within 3 years, he had nine presentations to the emergency room, four related to abdominal pain, and the remainder for swelling alone. All presentations with abdominal pain had documentation indicating patient had not had a bowel movement for several days. He had abdominal ultrasounds showing thickened bowel loops and small amount of ascites, indicating likely hereditary angioedema attack with gastrointestinal involvement. HAE attacks became more frequent following initiation of stimulant medication for ADHD. It is hypothesized that these frequent attacks were exacerbated by constipation secondary to stimulant medication use, and upon discontinuation of medication, he has not presented to the ER with further abdominal crisis. Discussion HAE may present as recurrent episodes of swelling in one or more body parts, but should also be suspected when there are recurrent bouts of abdominal pain with or without emesis. Constipation, a common presenting pediatric complaint, can lead to stress on the body and result in an HAE acute attack (3,7). We are presenting this case for health care providers to consider stimulant medication as a cause of constipation in patients with HAE presenting with abdominal crisis. Hereditary angioedema (HAE) is an inherited condition manifesting as recurrent episodes of swelling that commonly affects the skin and gastrointestinal tract (1,8). Various triggers can be the precipitating factors in an acute episode of HAE, however, sometimes the culprit cannot be determined. We present a patient with a diagnosis of hereditary angioedema, concomitant ADHD, with recurrent gastrointestinal exacerbations. Within 3 years, he had nine presentations to the emergency room, four related to abdominal pain, and the remainder for swelling alone. All presentations with abdominal pain had documentation indicating patient had not had a bowel movement for several days. He had abdominal ultrasounds showing thickened bowel loops and small amount of ascites, indicating likely hereditary angioedema attack with gastrointestinal involvement. HAE attacks became more frequent following initiation of stimulant medication for ADHD. It is hypothesized that these frequent attacks were exacerbated by constipation secondary to stimulant medication use, and upon discontinuation of medication, he has not presented to the ER with further abdominal crisis. HAE may present as recurrent episodes of swelling in one or more body parts, but should also be suspected when there are recurrent bouts of abdominal pain with or without emesis. Constipation, a common presenting pediatric complaint, can lead to stress on the body and result in an HAE acute attack (3,7). We are presenting this case for health care providers to consider stimulant medication as a cause of constipation in patients with HAE presenting with abdominal crisis.

ADHD in children and youth: Part 2—Treatment

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD,2) Establish a standard for ADHD care, and3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 2, which focuses on treatment, include: evidence and context for a range of clinical approaches, combining behavioural and pharmacological interventions to address impairment more effectively, the role of parent and teacher (or other caregiver) training, the use of stimulant and nonstimulant medications, with effects and risks, and dosing and monitoring protocols. Treatment recommendations are based on current guidelines, evidence from the literature, and expert consensus.

2.43 Recent Trends in Stimulant Medication Use Among Children in Finland

2.43 Recent Trends in Stimulant Medication Use Among Children in Finland

Nighttime media use in adolescents with ADHD: links to sleep problems and internalizing symptoms

ObjectiveThis study examined nighttime media use in relation to sleep problems and anxiety/depression symptoms in adolescents with attention-deficit/hyperactivity disorder (ADHD). MethodsParticipants were 81 adolescents (69% male) ages 13–17 with ADHD. Adolescents completed measures assessing pubertal development, nighttime media use, circadian preference, and daytime sleepiness. Both adolescents and parents completed measures of sleep duration, sleep problems, and internalizing symptoms. ResultsWhen summing across media uses (eg, social networking, playing video games, watching television), the average nighttime media use (after 9:00PM) was 5.31 h. Overall, 63% of adolescents reported obtaining less than 8 h of sleep on school nights, and this percentage rose to 77% for parent-reported sleep duration. Moreover, adolescents obtaining less sleep than recommended had more nighttime media use than those obtaining ≥8 h of nightly sleep. Controlling for age, sex, pubertal development, stimulant medication use, and ADHD symptom severity; nighttime media use was associated with shorter sleep duration and increased sleep problems across both adolescent and parent report. Media use was also associated with greater adolescent-reported anxiety and depression, and marginally associated with eveningness circadian preference and greater daytime sleepiness. In considering specific anxiety dimensions, media use was associated with greater adolescent-reported panic symptoms and parent-reported generalized anxiety disorder symptoms. ConclusionsOur findings suggest that nighttime media use may contribute to sleep problems and comorbid internalizing symptoms in adolescents with ADHD, although additional studies are needed to determine causality, potential bidirectional associations, and underlying mechanisms such as using media to (mis)manage negative emotions. Media use is important to assess and monitor and may be a significant intervention target when addressing sleep and internalizing problems, and possible underlying cognitive-emotional processes in adolescents with ADHD.

The Effect of Previous Methylphenidate Use on Incidence of Stress Fractures in Military Recruits: A Retrospective Cohort.

Previous research has detected an increased risk of stress fractures among subjects who reported previous use of methylphenidate. Conversely, stimulant medication use has been associated with traumatic fracture risk reduction, possibly because of the improved control of the underlying symptoms of attention deficit hyperactivity disorder (ADHD). The goal of this study was to investigate the effect of previous methylphenidate use on the incidence of traumatic and stress fractures among combat soldiers with previously treated and untreated ADHD. The retrospective cohort included 100,000 combat soldiers recruited to the Israeli Defense Forces from 2005 through 2015. Diagnosis of ADHD and previous exposure to methylphenidate were determined on the basis of self-reported recruitment questionnaires and medical records. Accordingly, the cohort was divided into 3 groups: subjects with ADHD who were previously treated with methylphenidate (n = 689), untreated subjects with ADHD reporting no medication use (n = 762), and controls having no ADHD diagnosis (n = 98,549). Logistic regressions were fitted to determine the odds ratios (ORs) of study subjects for stress and non-stress (traumatic) fractures. Multivariate analysis incorporated baseline characteristics, including age, sex, weight, duration of service, and diagnosis of anemia, at some point during the service. After adjustment for sex, anemia, weight, age, and duration of service, the risk of traumatic fractures was increased in both subjects with treated ADHD (OR, 1.03 [95% confidence interval (CI), 1.00 to 1.05]) and subjects with untreated ADHD (OR, 1.04 [95% CI, 1.02 to 1.07]) compared with controls. Subjects in the treated ADHD group were at a higher risk of stress fractures (OR, 1.04 [95% CI, 1.02 to 1.07]). Interestingly, a diagnosis of anemia was an independent predictor of stress fractures (OR, 1.05 [95% CI, 1.04 to 1.06]). Methylphenidate use is associated with an increased risk of stress fractures but a decreased risk of traumatic fractures in individuals diagnosed with ADHD. These and previous findings may serve as sufficient basis for screening for other risk factors and perhaps taking prevention measures in all those using stimulant medications, especially those planning to engage in strenuous physical activity. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stimulant Use Among Undergraduate Nursing Students.

Research reveals a decade-long increase in prescription drug misuse (PDM) of stimulant medication used to treat attention deficit hyperactivity disorder, and college students in particular are at the highest risk for these behaviors. However, PDM has not been specifically studied in undergraduate nursing students, and thus, this study fills a gap in our knowledge of PDM of stimulants. This descriptive study used a cross-sectional, convenience sample of undergraduate nursing students (N = 249) attending a large midwestern university. The purpose of this study was to examine the medical use, medical misuse, nonmedical use, and diversion of attention deficit hyperactivity disorder stimulant medications as well as to compare CRAFFT scores among these four groups of stimulant users. A 28-item, Web-based survey was sent via email to all registered undergraduate nursing students during the winter semester of 2017. Results showed that 10.4% of respondents used prescription stimulants nonmedically in the past 12 months, and over half (51.5%) of respondents screened positive on the CRAFFT, an indication of possible alcohol and drug misuse behaviors. In addition, there was a strong association between medical misuse and nonmedical use and positive CRAFFT scores. The high percentage of positive CRAFFT scores is a concern and indicates a pressing need for nursing faculty to evaluate and address substance use by nursing students.

Esports: Children, stimulants and video-gaming-induced inactivity.

Esports: Children, stimulants and video-gaming-induced inactivity.

Stimulant Use in the Management of Mild Traumatic Brain Injury: A Qualitative Literature Review

Objective: Mild traumatic brain injury (mTBI) often presents with cognitive complaints including difficulty with attention and concentration. As these symptoms resemble those of ADHD, stimulants may be a potential treatment for mTBI. This review evaluates the literature on the use of stimulants for the treatment of mTBI. Method: A systematic evaluation of the literature using six databases: Ovidmedline, Pubmed, psychINFO, CINAH, Embase, and Cochrane. Broad search terms were used and studies were included that evaluate the use of stimulant and stimulant-like medications in the mTBI population. Data extracted included stimulant type and dosing, symptoms targeted, outcomes, safety and tolerability, and if the study population had ADHD. Results: Nine studies were identified that met the inclusion criteria. Immediate release methylphenidate and amantadine were used for treatment. Methylphenidate had some impact on attention, fatigue, and depression. However, due to the limited number of studies and heterogeneity of study populations, symptoms targeted, and outcome measures used, meaningful conclusions regarding the effect of stimulants in mTBI could not be made. No study evaluated for the presence of ADHD within the study population, despite stimulants being the mainstay treatment for ADHD. Conclusion: PProspective studies on the use of stimulants in mTBI, that evaluate participants for a diagnosis of ADHD, are needed.

Risk of amphetamine use disorder and mortality among incident users of prescribed stimulant medications in the Veterans Administration.

Non-medical use of prescribed stimulant medications is a growing concern. This study's aims were to ascertain the demographics of stimulant medication users compared with non-users, examine temporal trends of stimulant medication use and estimate risk factors for development of amphetamine use disorder (AUD) and mortality among new users of stimulant medications. Cox proportional hazards regression in a retrospective cohort adjusted by baseline covariates. United States, national administrative database of the Veterans Affairs (VA) health-care system. Adult incident users of stimulant medications (n=78 829) from fiscal years (FY) 2001 to 2012. Primary outcomes were time-to-event: (1) occurrence of AUD diagnosis and (2) death. Baseline covariates included demographic information, Food and Drug Administration (FDA)-approved indications for stimulant use, substance use disorders (SUD) and depression. Stimulant users compared with non-users were younger, more likely to be non-Hispanic white and female. Incident stimulant medication users increased threefold from FY2001-FY2012 and eightfold among adults aged 18-44years. Nearly one in 10 incident users in FY2012 had a comorbid baseline SUD. Off-label use was common-nearly three of every five incident users in FY2012. Comorbid SUDs among incident stimulant medication users were risk factors for occurrence of AUD during follow-up, with adjusted hazard ratio (AHR) estimates ranging from 1.54 to 2.83 (Ps<0.05). Increased mortality risk was observed with occurrence of AUD during follow-up [AHR=1.55, 95% confidence interval (CI)=1.13-2.14, P=0.007], while on-label prescribing was protective against death (AHR=0.686, 95% CI=0.63-0.75, P<0.0001). In a US national cohort of adult incident stimulant medication users in the Veterans Affairs health-care system, measured from fiscal years 2001 to 2012, comorbid substance use disorders were common and were risk factors for development of an amphetamine use disorder (AUD). Increased mortality risk among incident users of stimulant medications was observed among both those who developed an AUD later and those whose use was defined as off-label.

Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners.

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder in children and adolescents. ADHD affects multiple aspects of an individual's life and functioning in family, social, and academic realms. Effective management of ADHD is necessary for children and adolescents and may include non-pharmacologic treatments, pharmacologic therapy including use of stimulant and non-stimulant medications, or a combination of the different treatment modalities. In general, medications used to treat ADHD are safe and effective. Medical practitioners can follow a step-wise approach in the selection and adjustment of pharmacologic agents to treat ADHD, while working closely with families, caregivers, and other medical and educational professionals to form appropriate treatment plans. This article reviews practical aspects of pharmacological treatment of ADHD in children and adolescents.

Association Between Methylphenidate and Amphetamine Use in Pregnancy and Risk of Congenital Malformations

Given the rapidly increasing use of stimulant medications during pregnancy and among women of reproductive age who may become pregnant inadvertently, there is a need to better understand their safety. To examine the risk of congenital malformations associated with intrauterine exposure to stimulants. Cohort study of the Medicaid-insured population in the United States nested in the 2000-2013 US Medicaid Analytic eXtract, with follow-up of safety signals detected in the Medicaid Analytic eXtract data using the Nordic Health registries (2003-2013) (Denmark, Finland, Iceland, Norway, and Sweden). A total of 1 813 894 publicly insured pregnancies in the United States and 2 560 069 singleton pregnancies in the 5 Nordic countries ending in live births were included. Relative risks were estimated accounting for underlying psychiatric disorders and other potential confounders. Relative risk estimates for the US and Nordic data were pooled using a fixed-effects meta-analytic approach. The study was conducted from July 1, 2015, to March 31, 2017. Methylphenidate and amphetamines dispensed during the first trimester. Major congenital malformations and subgroup of cardiac malformations. In the US data, of the 1 813 894 pregnancies evaluated, 35.0 per 1000 infants not exposed to stimulants were diagnosed as having congenital malformations, compared with 45.9 per 1000 infants for methylphenidate and 45.4 for amphetamines. For cardiac malformations, the risks were 12.7 (95% CI, 12.6-12.9), 18.8 (95% CI, 13.8-25.6), and 15.4 (95% CI, 12.5-19.0) per 1000 infants, respectively. The adjusted relative risks for methylphenidate were 1.11 (95% CI, 0.91-1.35) for any malformation and 1.28 (95% CI, 0.94-1.74) for cardiac malformations. No increased risks were observed for amphetamines: 1.05 (95% CI, 0.93-1.19) for any malformations and 0.96 (95% CI, 0.78-1.19) for cardiac malformations. Findings were confirmed in sensitivity analyses accounting for proxies of unmeasured confounders and increasing the specificity of the exposure and outcome definitions. Replication of the analyses for methylphenidate using the Nordic data including 2 560 069 pregnancies yielded a relative risk of 1.28 (95% CI, 0.83-1.97) for cardiac malformations, resulting in a pooled estimate of 1.28 (95% CI, 1.00-1.64). These findings suggest a small increase in the risk of cardiac malformations associated with intrauterine exposure to methylphenidate but not to amphetamines. This information is important when weighing the risks and benefits of alternative treatment strategies for attention-deficit/hyperactivity disorder in women of reproductive age and during early pregnancy.

The Use of Stimulant Medication to Treat Attention-Deficit/Hyperactivity Disorder in Elite Athletes: A Performance and Health Perspective.

The use of stimulants as a treatment for attention-deficit/hyperactivity disorder (ADHD) among elite athletes is a controversial area with some arguing that stimulant use should not be permitted because it offers an advantage to athletes (fair play perspective). Guided by an integrated model of athletic performance, we address common concerns raised about stimulant use in sports from our perspective, which we coined the "performance and health perspective," highlighting relevant research and pointing to gaps in empirical research that should be addressed before bans on use of stimulants for athletes with ADHD are considered. The current article posits that a stimulant ban for athletes with ADHD does not necessarily facilitate fair play, ensure safety, or align with existing policies of large governing bodies. Instead, we recommend that stimulant medication be allowed in high-level sport, following proper diagnosis by a trained professional and a cardiac assessment to confirm no underlying heart conditions. Athletes with ADHD approved to use stimulant medication should be monitored by a health care professional, physically reevaluated and reassessed for ADHD as clinically appropriate and as indicated by relevant sports governing bodies. This performance and health perspective is consistent with that of multiple sport governing bodies who offer therapeutic use.

Management of Sea Sickness in Susceptible Flight Crews.

Sea sickness may greatly impact the readiness of Service personnel deployed aboard naval vessels. Medications used in the treatment of sea sickness may have adverse effects, limiting their use as flight crew. Although the prevalence of sea sickness in flight crews remains unclear, individual susceptibility and high sea states are established risk factors. Literature review can guide optimized management strategies for this population. The first author conducted a PubMed search using the terms "sea sickness" "flight crew" "scopolamine," "hyoscine," and "cinnarizine," identifying 15 articles of 350 matches, which addressed potential impact to flight performance. Analysis also included two historic reports about motion sickness maintained within the U.K. Army Aviation Centre's aeromedical archives in Middle Wallop, Hampshire. Both authors reviewed aeromedical policy for the International Civil Aviation Organization, U.K. Civil Aviation Authority, U.S. Federal Aviation Authority, the National Aeronautics Space Administration, U.S. Army, U.S. Navy, and U.S. Air Force. Scopolamine, also known as hyoscine, has fewer operationally relevant side effects than cinnarizine or first-generation antihistamines. Although no aeromedical authorities endorse the unsupervised use of scopolamine, many will consider authorizing its temporary use following an initial assessment on the ground. Evidence supports the concomitant use of stimulant medication for augmenting antinausea effects and countering the potential sedative effects of scopolamine. Scopolamine should be considered as a first-line medication for flight crews at risk of sea sickness but such use must be guided by the appropriate aeromedical authority, ideally in conjunction with a ground trial to evaluate individual response. The limited evidence to support concurrent use of stimulants must be weighed against the challenges of maintaining accountability of controlled substances in the operational environment.