By Pamela K. Gonzalez, MD MS, FAAP, Diplomate ABAM, pediatrician and addiction medicine specialist at Abound Health LLC, adjunct assistant professor at the University of Minnesota and a member of AAP’s Committee on Substance Abuse.
While tobacco, alcohol and marijuana remain the most used and abused substances among adolescents, non-medical use (NMU) of prescription medications remains a serious problem. Reports on NMU, often dubbed “prescription drug abuse,” frequently focus on opioids. This may be due in part to relative greater overall use prevalence and overdose burden.
However, NMU of prescription psychostimulants by adolescents is quite prevalent, especially among US college students. The lay press often refer to these medications as ”study drugs”; a characterization that may minimize potential negative consequences, and miss the nuances of individual motivations for use, and the associated risks.
Before discussing prescription stimulant NMU, it is important to clarify some definitions. NMU may lead to, but is not the same as substance abuse or addiction. NMU generally involves taking a medication for which one does not have a prescription and/or taking one’s prescribed medication in a way other than prescribed (e.g., extra doses, increasing dose on one’s own, etc.) Many can suffer negative consequences from NMU, while their symptoms and behavior may be sub-threshold for a formal substance use disorder diagnosis.
According to Monitoring the Future, prescription amphetamine NMU has trended up since 2009, to current 12 percent by 12th graders. Use is more prevalent among college students, as illustrated by the College Life Study, where nearly two-thirds endorse being offered prescription stimulants by year 4, and just below one-third endorse trying them at least once. Almost 75 percent report the drug they used came from a student with a legal prescription. Other sources suggest that at least 1 in 7 youth receiving prescription stimulants for ADHD endorse diverting their medication.
Why are college kids taking these? A majority endorses academic pressure, needing a competitive edge, and enhanced focus provided by NMU. In fact, prescription stimulant NMU correlates with lower GPA, more class skipping, excessive alcohol use and other drug use, and more complaints of emotional distress and depressed mood. Non-medical users also endorse lower perceived harmfulness.
What is the harm? Common complaints include appetite suppression and sleep disruption. Potentially deadly complications can include hyperthermia, arrhythmia, MI, or stroke. Non-medical users frequently combine with alcohol or other drugs, contributing to drug interactions, unintended overdosage, and development of abuse or addiction. At its psychiatric extremes, some may experience psychotic symptoms (e.g., hallucinations, paranoid delusion) or become acutely suicidal, either during acute dysphoria of intoxication or post-intoxication “crash” when acute depression may ensue. Long-term effects of stimulant NMU remain unknown.
What can pediatricians do? First, ensure the accuracy of an ADHD diagnosis. Shockingly, only about one-quarter of physicians use all recommended components for establishing ADHD diagnosis. Develop a mental health provider network with which you feel comfortable collaborating and referring. This network ideally includes providers with expertise in youth substance abuse. If you are unsure of the ADHD diagnosis or management, refer to an appropriate specialist in your mental health network and/or utilize the Minnesota Collaborative Psychiatric Consultation Service.
Second, advise patients and caregivers against using prescription stimulants as academic enhancers, and educate them about the realities and pitfalls. In patients with established ADHD who are prescribed psychostimulants, reinforce the importance of never sharing or otherwise diverting medication.
Finally, screen for substance use problems at every adolescent encounter, including ADHD follow-up visits, according to the AAP recommended Screening, Brief Intervention and Referral to Treatment framework. Motivational Interviewing is an excellent approach to delivering such brief interventions.