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Strategies for Managing the Risks Associated With ADHD Medications

J. Sloan Manning, MD

Department of Family Medicine, University of North Carolina, Chapel Hill, and the Mood Disorders Clinic, Moses Cone Family Practice Center, Greensboro, North Carolina

ADHD may go unrecognized in college students and older adults because their symptoms do not meet the criteria for childhood ADHD, their symptoms are obscured by a comorbid psychiatric disorder, or they think their symptoms are part of their personality.1 Although onset begins in childhood, ADHD often persists into adulthood,1 affecting up to 4.4% of US adults.2 As a neurodevelopmental disorder that affects executive functioning, ADHD and its resulting impairments can hinder college students from reaching their full potential.

Diagnosing and treating ADHD in this population is critical, but some clinicians may be hesitant to prescribe agents for this disorder because illicit use of prescription medications (especially stimulant drugs for ADHD) has risen during the past decade among college students.3 To address this barrier and get students with ADHD the necessary treatment, clinicians can use strategies to make an accurate diagnosis, assess comorbidities, prescribe treatment, and monitor results to limit the risk of harm for these young adults.

Making an Accurate Diagnosis

Because some college students may try to falsely obtain a prescription for ADHD, clinicians should confirm a diagnosis using current diagnostic criteria and measurement-based rating scales.

AV 1. Patient Diagnosis with ASRS Screener (02:35)

The DSM-IV-TR criteria4 for ADHD require impairing symptoms of inattention and hyperactivity or impulsivity to be present prior to age 7 years (or 12 years in the DSM-5).5 During the patient interview, clinicians may find it helpful to annotate a hard copy of the diagnostic criteria, which can then be scanned into the electronic health record. This allows for checking off symptoms, documenting when symptoms began, and noting impairments, which must be present in at least 2 settings (eg, work, home, school).

Measurement-based rating scales are also helpful for screening adults, and the self-report scales are easy to administer in clinical practice.

  • The ASRS Screener has 6 questions, and a score of 4 or more suggests the need for further investigation (AV 1).
  • The 18-question Adult ADHD Self-Report Scale, which includes the ASRS Screener, gathers more in-depth information on the frequency of symptoms and suggests areas for interview regarding impairment and clinical focus. This assessment can also be annotated during the clinical interview and then scanned into the electronic record as evidence of the presence and pervasiveness of the illness and the level of functional impairment.
  • The CAARS, another tool for assessing, diagnosing, and monitoring treatment of ADHD in adults, is available in self-report and observer formats with both long and short versions.
  • Another useful, but not required, diagnostic tool is neuropsychological testing, which can be used to confirm clinical impressions.

AV 2. Adults With ADHD and Other DSM-IV Disorders (00:36)

Data from Kessler et al2
Abbreviations are defined before the References

Assessing Comorbid Conditions

In addition to screening patients for ADHD, clinicians should screen for other psychiatric disorders that are common in patients with ADHD. Depression, anxiety, bipolar disorder, and substance use disorders must be diagnosed or ruled out before treatment decisions can be made (AV 2).2 Marijuana use, binge drinking, and other illicit drug use are common in students who will misuse stimulants.3 The following tools can assist clinicians in assessing and diagnosing common comorbid conditions:

Students diagnosed with ADHD who admit past nonmedical use of prescriptions or who have a comorbid SUD will require appropriate prescription medications and regular monitoring to limit the risk of stimulant diversion and misuse.

Prescribing Appropriate Medications

ADHD treatment includes stimulant and nonstimulant medications, sometimes combined with psychosocial treatment. Stimulants like methylphenidate and amphetamine compounds are the most effective treatments, with response rates ranging from 70% to 80%.6 Long-acting stimulants are sometimes recommended because they may result in better patient adherence and longer-lasting symptom improvement than short-acting stimulants.6 Long-acting stimulant formulations (eg, OROS methylphenidate) can reduce opportunities for misuse, as may a prodrug (eg, lisdexamfetamine).

The nonstimulant atomoxetine is also effective in treating ADHD and, because of the lessened risk for abuse, may be a good treatment option for students with ADHD and a history of SUD. Antidepressants such as bupropion have shown efficacy for adult ADHD symptoms, although they are not FDA-approved to treat this disorder.7 Clinicians can also limit the quantity of prescription refills, which requires more face-to-face patient visits and allows monitoring for misuse or diversion.

Clinicians may recommend nonpharmacologic therapy, especially for patients with comorbid anxiety, depression, or risk for SUD. Young adults with ADHD may have difficulty acquiring new skills that cognitive-behavioral therapy could help them learn. Areas like coping skills, problem solving, organization strategies, and distraction management would benefit students with ADHD trying to manage the added responsibilities of college.

Treatment expectations. Clinicians should discuss what to expect from treatment and help patients set individual goals. Patients could identify 3 positive results they would like to attain from treatment, such as improving grades or completing projects. In addition to symptom reduction, treatment efficacy can be measured by progress toward achieving these goals.

AV 3. Patient Education on ADHD Medications (02:15)

Patient and parent education. Students who are given a stimulant prescription must be told that they can expect to be asked by their peers to share or sell their medication (AV 3). In a survey,3 over 50% of undergraduates who were prescribed stimulants for ADHD reported that they had been approached to share, trade, or sell their medication. Students need to know that diversion is illegal and will be reported to authorities. An office policy statement on refills and a controlled substance contract, signed by the patient and reviewed with the clinician or office personnel, will reinforce the seriousness of diversion and clarify the patient’s responsibility.

Clinicians should recommend that students keep their diagnosis and treatment confidential and keep their medication secure. Although this may be a challenge for some students depending on their living arrangements, it can limit the opportunities for peers to request or steal medication. Diverted stimulants that are misused by unevaluated individuals can result in serious consequences, including cardiac events and seizures, and side effects, such as irritability, reduced appetite, and insomnia,8 which would not be monitored by a clinician. An open discussion about the abuse potential of stimulants can help students recognize the severity of misuse.

More

Clinicians should also educate and involve the student’s parents, if possible. Parents of children with ADHD still have a role in their college students’ lives, but they may become tolerant of substance abuse, believing that it is a normal part of the college experience. Instead, clinicians must inform these parents that diverting or misusing medication can have serious consequences, and they must be alert for signs of both in their student.

Providing Regular Monitoring

College students being treated for ADHD require regular, face-to-face monitoring. Clinicians should measure treatment efficacy by using the ASRS or CAARS to assess the reduction of symptoms and by inquiring about the patient’s progress toward achieving his or her individual goals.

Monitoring should also focus on reducing treatment-related safety and tolerability issues. Cardiac history is an important part of both prescreening and follow-up, and clinicians should monitor exercise-induced syncope or dyspnea, weight, heart rate, and blood pressure at each visit. Occasional rescreening for depression, anxiety, and SUD is also appropriate, along with random urine drug screens to monitor marijuana and alcohol use. Clinicians should watch for these signs and symptoms of stimulant abuse:

  • Anxiety/panic attacks or states
  • Anorexia/weight loss
  • Increased pulse and blood pressure
  • Depression/mood changes
  • Paranoia/psychosis
  • Aggression
  • Tremors
  • Seizures
  • Worsening academic performance
  • Legal problems
  • Drug-seeking behaviors (such as early refill requests or lost or stolen prescriptions)

Students who exhibit these signs need to be reminded about adherence to the office protocol and, if abuse is suspected, a treatment contract and a change to another prescription or therapy may be required.

Conclusion

College students with ADHD need accurate diagnosis and treatment to manage their symptoms and reach their goals. Using DSM criteria and rating scales, such as the ASRS or CAARS, can help clinicians screen for and diagnose ADHD in college-aged patients. Other assessment tools can gauge common comorbid conditions, including mood and anxiety disorders and SUDs. Clinicians can reduce nonmedical stimulant use by prescribing appropriate treatments, by educating patients on the medical and legal ramifications of diverting and misusing medication, and by monitoring for signs of misuse at regular, face-to-face visits.

Clinical Points

  • Use rating scales to screen for ADHD and comorbid conditions
  • Consider nonpharmacologic therapies and prescriptions that are less likely to be abused, such as a nonstimulant or long-acting stimulants
  • Provide education to patients and their parents about the dangers and repercussions of diverting or misusing prescription stimulants
  • Regularly monitor ADHD symptoms, treatment side effects, and signs of medication or substance abuse

Drug Names

amphetamine/dextroamphetamine (Adderall, Adderall XR, and others), atomoxetine (Strattera), bupropion (Wellbutrin, Aplenzin, and others), lisdexamfetamine (Vyvanse), methylphenidate (Concerta, Ritalin, and others), OROS methylphenidate (Focalin XR, Concerta, and others)

Abbreviations

ADHD = attention-deficit/hyperactivity disorder; ASRS = Adult ADHD Self-Report Scale; AUDIT = Alcohol Use Disorders Interview Test; CAARS = Conners Adult ADHD Rating Scales; CIDI = Composite International Diagnostic Interview; DAST = Drug Abuse Screening Test; DSM = Diagnostic and Statistical Manual of Mental Disorders; FDA = US Food and Drug Administration; GAD = generalized anxiety disorder; MDQ = Mood Disorder Questionnaire; OROS = osmotically released controlled delivery system; PHQ = Patient Health Questionnaire; QIDS-SR = Quick Inventory of Depressive Symptomatology–Self-Report; SUD = substance use disorder; UDS = urine drug screen

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References

  1. Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr. 2008;13(11):977–984. PubMed
  2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–723. PubMed
  3. McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use, and diversion of abusable prescription drugs. J Am Coll Health. 2006;54(5):269–278. PubMed
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
  5. American Psychiatric Association. Attention deficit/hyperactivity disorder fact sheet. http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/DSM-5-ADHD-Fact-Sheet.pdf. Published 2013. Accessed April 15, 2013.
  6. Kolar D, Keller A, Golfinopoulos M, et al. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4(1):107–121. PubMed
  7. Maneeton N, Maneeton B, Srisurapanont M, et al. Bupropion for adults with attention-deficit hyperactivity disorder: meta-analysis of randomized, placebo-controlled trials. Psychiatry Clin Neurosci. 2011;65(7):611–617. PubMed
  8. Rabiner DL, Anastopoulos AD, Costello EJ, et al. Motives and perceived consequences of nonmedical ADHD medication use by college students: are students treating themselves for attention problems? J Atten Disord. 2009;13(3):259–270. PubMed
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