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Adult ADHD: Addressing a unique set of challenges
Attention-deficit/hyperactivity disorder (ADHD) in adults brings with it unique challenges, not the least of which are arriving at a proper diagnosis and ensuring that any psychostimulant drugs that you prescribe are not misused. A number of conditions such as anxiety, bipolar disorder, and substance abuse can mimic some of the symptoms of ADHD, and diagnostic criteria for the condition in adults changed with the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Furthermore, for many of the estimated 4.4% of adults who have ADHD,1 psychostimulants provide necessary and effective treatment, but misuse and diversion of these agents are real concerns. In fact, recent research reveals that these issues are more common than previously thought.2 Data suggest that the prevalence of misuse and diversion of ADHD medication is 5% to 10% among high school students and 5% to 35% among college students.2,3
This is not meant to indicate that adults diagnosed with ADHD should go untreated. In fact, adults with ADHD often struggle in their professional and family lives because they do not receive the treatment they need.
Rather, family physicians should take certain steps, first to diagnose ADHD correctly, and then to ascertain and maintain correct use of psychostimulants and other treatments among their adult patient populations. Read on for several practical strategies.
Criteria for adult Dx differ from those in children
ADHD, a common behavioral disorder that often, but not always, begins in childhood, is characterized by deficits in paying attention, difficulty controlling impulses, and marked hyperactivity. Diagnosis of ADHD is based on the DSM-5 criteria and supplemented with historical data and clinical observations.4 Using self-report measures may also aid in the diagnosis, and psychological testing may be required for some individuals when the clinical presentation is unclear.
With the DSM-5 changes (TABLE 14), the diagnosis of ADHD in adults (people ≥18 years) requires fewer symptoms than the diagnosis of ADHD in children; just 5 symptoms from either of the 2 categories of diagnostic criteria are sufficient now, whereas 6 symptoms were required previously and still are required to make the diagnosis in young people. People may present with the inattentive profile (5 or more symptoms of inattention), the hyperactive-impulsive profile (5 or more hyperactive-impulsive symptoms), or a combination of the 2 (5 or more symptoms of inattention plus 5 or more symptoms of hyperactivity-impulsivity for a total of 10 or more symptoms). While children are more likely to present with the combined type of ADHD, adults of any age are more likely to present with the inattentive type.4
In addition, patients must meet the diagnostic criteria for ADHD for at least 6 months, have had some of the symptoms prior to age 12, and the symptoms must cause significant impairment in 2 or more environments (eg, home, work, school). When the diagnosis is unclear, it is important to obtain collateral information from the family, school, or workplace. The requirement regarding symptomatology before age 12 indicates the need for a review of the patient’s educational history. Research reveals that many adults with ADHD struggled in school and were considered “underachievers” as students.5
Common complaints and characteristics. Previous studies have shown the following to be common complaints and characteristics of adult patients diagnosed with ADHD:5
- difficulty meeting time limits
- vocational struggles, such as frequent job changes or nonpromotion at work
- anger issues
- addiction
- relationship/social strain
- comprehension problems, and
- a family history of ADHD.
Common correlates include low socioeconomic status, driving violations, frequent injuries, legal problems, alcohol and/or tobacco use, and self-reported maladjustment.5 People treated for ADHD have a comorbid DSM diagnosis 81% of the time with the most likely diagnoses being substance abuse, depression, and anxiety.6
Adult-onset ADHD? Even though the DSM-5 criteria for an ADHD diagnosis in adulthood require that some ADHD symptoms were manifest prior to age 12, recent longitudinal research on ADHD in Brazil and the United Kingdom reveals that a large portion of people who meet the criteria for ADHD in adulthood did not meet the criteria as children. The researchers in these studies proposed that there may be a form of ADHD that manifests later in life, a so-called “adult-onset ADHD.”7 While this information is something for clinicians to consider, further research is needed to justify a paradigm shift in how ADHD is diagnosed.
Self-rating measures can offer clarification. Whether or not history-gathering leaves the diagnosis murky, self-rating measures can be valuable in rounding out the clinical picture and alerting clinicians to any inconsistencies in symptoms.8 Four common ADHD self-rating measures are provided in TABLE 2. As one example, the Adult ADHD Self-Report Scale (ASRS) Symptom Checklist is a valuable ADHD screening tool that is free of charge and takes only 5 to 10 minutes.8 Other self-report measures require a similar amount of time, but are not available on a complimentary basis.
Psychological testing. Some adults who seem to have symptoms of ADHD may require a referral for psychological testing. These may be patients who present with complicated cases or whose histories and/or findings do not consistently indicate an ADHD diagnosis. In such cases, psychological testing can fill in the holes and provide a more complete picture of the patient’s neurocognitive abilities and deficits.9,10
Psychostimulant treatment: Opt for longer-acting agents
The standard treatment for ADHD is a psychostimulant. One controlled trial, for example, of a mixed amphetamine salts compound (Adderall) found that the compound effectively treated ADHD symptoms (hyperactivity, impulsivity, inattention) in adults and was well tolerated.11 While far fewer studies have been performed in adult vs youth populations, those that have been conducted in adults indicate that psychostimulants are largely safe and efficacious. In fact, the study mentioned above found that 70% of patients with ADHD ages 18 and older reported improvement of symptoms while on a short-acting psychostimulant, as compared to 7% who reported improvement on placebo.11
Similarly, a meta-analysis of 1991 participants in 11 studies found significant improvement in patients who received medication vs placebo, with stimulant medications demonstrating greater efficacy than non-stimulant treatments for ADHD.12 In general, psychostimulant treatment for adults is similar to that for children; the only difference is that adults tend to be more forthcoming with information regarding how the treatment is working and what adjustments might be needed.
Longer-acting stimulants (ie, extended release) tend to be preferred by patients to short-acting ones because they typically provide adequate control of symptoms over a longer period of time and thus may be taken less frequently.13 Also, the potential for abuse of psychostimulant medication tends to be lower with the longer-acting, extended-release formulations.14 A shorter acting formulation may be preferred if a patient has a specific window of time when their ADHD symptoms impact them. For example, a patient may request a short-acting form of medication for afternoons if he or she has to attend many business meetings at that time of day. A relatively new category is the intermediate-acting psychostimulants. For more on specific psychostimulants, see Table 3.15
Adverse effects lead many to discontinue treatment
Regardless of the length of action of the psychostimulant, studies show that about 30% of adults (and, incidentally, 10% to 30% of children) discontinue treatment due to uncontrolled/unwanted symptoms or adverse effects.16 These include decreased appetite, headache, insomnia, abdominal pain, and irritable mood.17 If you are prescribing a psychostimulant for an adult with ADHD, it is important to tell the patient that if the effects become intolerable, adjustments can be made, such as tweaking dosages, switching to a different medication, or adding an adjunctive therapy such as cognitive behavioral therapy. Keep in mind, too, that if a medication is to be discontinued, tapering is suggested for most psychostimulants; patients should take a lower (eg, half) dose for about a week prior to complete discontinuation. People who have difficulties with a number of treatments for ADHD should be reevaluated in a year to see if circumstances have changed.5
Combatting misuse and diversion
Perhaps the most controversial issues surrounding the treatment of adults with ADHD are abuse and diversion of psychostimulants. Abuse generally refers to misuse of the drug by the person prescribed the agent, whereas diversion refers to use of the drug by people for whom the drug was not intended—with or without the prescribee’s knowledge.3 Although rare, chronic abuse of psychostimulants can lead to serious problems such as aggression, suicidal thoughts/behaviors, psychosis, and mania.5
While earlier studies tended to downplay the likelihood of diversion, recent research indicates that physicians should not underestimate the possibility. In fact, a previous article in this journal about student athletes with ADHD (http://bit.ly/2k1a6TL) indicated that psychostimulants have “great potential for misuse” and that recently there has been “a surge in nonprescription stimulant use among adolescents and young adults.”17 The authors of the article concluded, however, that while physicians should be aware of the potential for misuse, fear should not preclude treatment.17
A national multi-cohort study of 4572 US high school seniors who had used psychostimulants either medically or nonmedically indicated that while one in 6 high school seniors had been exposed to psychostimulants, about half were appropriately exposed through prescription use, while the other half was not. The researchers also reported that current nonmedical users of psychostimulants and those with a history of nonmedical use had a greater risk of substance use and abuse when compared to medical users of psychostimulants.18
Young men are at higher risk for diversion. In a nationwide survey of a sample of adults ages 18 to 49 years who had a prescription for psychostimulant medication in the past month, 17% admitted diverting their medication.
In another study, 483 students ages 17 to 19 years were followed for one year and interviewed frequently regarding their use of medications.20 The researchers reported that the lifetime prevalence of diversion of any medication in those students was around 36%. They also found that of those who diverted medication, 62% diverted ADHD medications at least once. These were most commonly diverted by sharing (34%) and selling (9%) the psychostimulants. Interview analysis revealed that those students who diverted were more likely to have used illicit drugs and to have had conduct problems. The authors advised “vigilance regarding…stimulant medications for young adults.”
Psychostimulant prescriptions do not cause substance abuse. Nevertheless, a salient point in the literature is that there is no causal relationship between psychostimulant prescriptions that are properly prescribed for people who have ADHD and substance abuse. One study that followed young people with ADHD for 8 years into adulthood revealed that psychostimulant treatment did not make adolescents or young adults any more or less likely to abuse drugs.21 The study also found that alcohol use was common in young adults whether they were diagnosed with ADHD or not. Nonetheless, family physicians should urge those taking psychostimulants to refrain from alcohol use or at least to drink in moderation.
The bottom line is that adults diagnosed with ADHD carry about the same risk of substance abuse as the general population if they are effectively treated for their presenting attention problems.22 If they are taking a psychostimulant, however, they have access to a controlled substance, unlike most of their cohorts. So it's important to teach patients with ADHD that for safety and legal reasons, they should not share or sell their stimulant medication to anyone.
Minimize the risk for abuse, diversion using these strategies
As with any drug regimen, it is important to monitor the patient’s response to treatment and minimize adverse effects and outcomes. When the drug is a psychostimulant for adults diagnosed with ADHD, it’s also important to minimize the risk for abuse and diversion. The following steps can help:
- Obtain a signed controlled substance agreement.23 This agreement between the physician and the patient usually outlines such specifics as frequency of office visits, circumstances surrounding medication refills, urine drug monitoring, and pill counts. (For more on the specifics of a controlled substance agreement, see "Key points of a controlled substance agreement.")
- Schedule frequent follow-up appointments with open communication about abuse and diversion.20,23 The age-old adage, “Start low, go slow,” applies to stimulant medications for ADHD. Medication dosage may vary and necessitate titration depending on the person’s weight and tolerance. At the onset of treatment, frequent office visits allow the physician to gauge treatment response and the patient’s commitment to therapy.
- Review your state’s prescription drug monitoring program.24 It is imperative that providers check their state’s medical board rules for prescribing controlled medications to ensure practice compliance. As diversion rates of controlled medications have risen in this country, most states have established monitoring systems through their pharmacy boards.24 Although the names of the programs vary, these prescription drug monitoring programs provide information on any medication prescribed. This allows the prescribing physician to ensure patient compliance and ascertain that no other controlled medications are being prescribed that could interfere with treatment. (For more information about state prescription drug monitoring programs, see https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm.)
- Perform random urine drug screenings (UDS).20,23 An important strategy for ensuring adherence to the treatment plan and the controlled substance contract is UDS. Explain to patients that this is a way of making sure they are taking the medication exactly as prescribed. If the UDS indicates that the patient has not been taking the medication, then the provider should intervene by either restricting or discontinuing the controlled substance to prevent or counteract potential diversion. Similarly, if a higher dose is requested by a patient, the provider can closely monitor the situation to determine whether the additional drug is actually being taken and whether the dose is optimal. (See JFP’s October 2016 “3 in 3” video on urine drug testing at: http://bit.ly/2iDnfgD.)
- Employ a team-based, multimodal approach.25 A referral to a mental health professional and multimodal treatment are often recommended in the literature as best practices.25 Behavioral therapies are a cornerstone of treatment in adults with ADHD and often serve as important adjuncts to pharmacotherapy. Also, a referral provides a second professional opinion about the patient’s motivations, adherence, and response to treatment.
Trained cognitive behavioral therapists (eg, psychologists, counselors) can be helpful with treatment for ADHD.23 Therapists can be useful in setting goals for the patient regarding adherence, organization, impulse control, and social skills training. Therapists may wish to involve the family in treatment, depending on the nature of the patient’s presenting issues.
SIDEBAR
Key points of a controlled substance agreementThe primary purpose of a controlled substance agreement is to provide clarity for the provider and the patient regarding the use of controlled medications. The document is meant to prevent potential problems and confusion down the road. There are generally 3 parts:
- a doctor/patient agreement
- information about medications
- patient consent to utilize controlled substances that the provider believes would be beneficial.
Patients are typically told of the potential value of controlled medications in helping them and are warned about the potential for problems should the medications be used in ways other than intended. While wording may differ, patients are generally asked to agree to variations of the following 10 guidelines:
- I will talk with my doctor before using more than the prescribed amount of the medicine or discontinuing its use.
- I will tell my doctor if new medications are prescribed by another provider.
- I will tell the doctor if I become pregnant, so that any necessary medication adjustments can be made.
- If I abuse this drug, I understand that the doctor may need to stop treatment.
- I will uphold the visit schedule to the office/clinic according to guidelines for controlled substances (eg, every 90 days).
- I will refrain from using illicit drugs including marijuana and excessive quantities of alcohol.
- I will refrain from sharing, trading, or selling controlled substances.
- I will submit to regular urine drug screens as requested by the doctor.
- I understand that a failed drug screen may mean discontinuation of treatment.
- I will be forthright and honest about how the treatment is going, adverse effects, and how I am taking the medication.
Adapted from: https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf.
Don’t tempt fate. As with any controlled medication, safe storage of psychostimulants is paramount. Patients should be urged to keep their medication in a locked box or cupboard that is accessible to only the adult for whom the drug is prescribed. Prior research cautions that open access to controlled substances can lead to larger issues with abuse and diversion, particularly when adolescents are in the home.26
Consider atomoxetine. Research has also demonstrated that the non-stimulant medication atomoxetine has some benefit in the treatment of ADHD.12 Unlike psychostimulants that act on the neurotransmitter dopamine, atomoxetine acts on the neurotransmitter norepinephrine. This different mechanism of action results in a lower potential for abuse and diversion.
CORRESPONDENCE
Scott A. Fields, PhD, 3200 MacCorkle Avenue Southeast, 5th Floor, Robert C. Byrd Clinical Teaching Center, Department of Family Medicine, Charleston, WV 25304; sfields@hsc.wvu.edu.
1. Kessler RC, Adler LA, 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;163:716-723.
2. Clemow DB, Walker DJ. The potential for misuse and abuse of medications in ADHD: a review. Postgrad Med. 2014;126:64-81.
3. Novak SP, Kroutil LA, Williams RL, et al. The nonmedical use of prescription ADHD medications: results from a national internet panel. Subst Abuse Treat Prev Policy. 2007;2:32.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association Press; 2013.
5. Kolar D, Keller A, Golfinopoulos M, et al. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4:389-403.
6. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162:1621-1627.
7. Faraone SV, Biederman J. Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry.
8. van de Glind G, van den Brink W, Koeter MWJ, et al. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend. 2013;132:587-596.
9. Gualtieri CT, Johnson LG. ADHD: Is objective diagnosis possible? Psychiatry. 2005;2:44-53.
10. Perrin AE, Jotwani VM. Addressing the unique issues of student athletes with ADHD. J Fam Pract. 2014;63:E1-E9.
11. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2001;58:775-782.
12. Mészáros A, Czobor P, Bálint S, et al. Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmacol. 2009;12:1137-1147.
13. Weiss M, Shingler T, Capone NM. Medication satisfaction among adults with ADHD: long term results from the Quality of Life, Effectiveness, Safety and Tolerability (Qu.S.T) study. New Orleans: Program and Abstracts of the 19th US Psychiatric and Mental Health Congress, Abstract 120, 2006.
14. Lopez FA, Leroux JR.
15. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90:456-464.
16. Spencer T, Biederman J, Wilens T. Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27:373-383.
17. Withrow LM, Hash PA, Holten KB. Managing ADHD in children: are you doing enough? J Fam Pract. 2011;60:E1-E3.
18. McCabe SE, West BT. Medical and nonmedical use of prescription stimulants: results from a national multicohort study. J Am Acad Child Adolesc Psychiatry. 2013;52:1272-1280.
19. Aldridge AP, Kroutil LA, Cowell AJ, et al. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. Pharmacoeconomics. 2011;29:621-635.
20. Garnier LM, Arria AM, Caldeira KM, et al. Sharing and selling of prescription medications in a college student sample. J Clin Psychiatry. 2010;71:262-269.
21. Molina BSG, Hinshaw SP, Arnold LE, et al. Adolescent substance use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52:250-263.
22. Brahmbhatt K, Hilty DM, Hah M, et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: a concise review. J Adolesc Health. 2016;59:135-143.
23. Post RE, Kurlansik SL. Diagnosis and management of attention-deficit/hyperactivity disorder in adults. Am Fam Physician. 2012;85:890-896.
24. Cepeda MS, Fife D, Berwaerts J, et al. Doctor shopping for medications used in the treatment of attention deficit hyperactivity disorder: shoppers often pay in cash and cross state lines. Am J Drug Alcohol Abuse. 2015;41:226-229.
25. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. 2010;304:875-880.
26. Ross-Durow PL, McCabe SE, Boyd CJ. Adolescents’ access to their own prescription medication in the home. J Adolesc Health. 2013;53:260-264.
Attention-deficit/hyperactivity disorder (ADHD) in adults brings with it unique challenges, not the least of which are arriving at a proper diagnosis and ensuring that any psychostimulant drugs that you prescribe are not misused. A number of conditions such as anxiety, bipolar disorder, and substance abuse can mimic some of the symptoms of ADHD, and diagnostic criteria for the condition in adults changed with the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Furthermore, for many of the estimated 4.4% of adults who have ADHD,1 psychostimulants provide necessary and effective treatment, but misuse and diversion of these agents are real concerns. In fact, recent research reveals that these issues are more common than previously thought.2 Data suggest that the prevalence of misuse and diversion of ADHD medication is 5% to 10% among high school students and 5% to 35% among college students.2,3
This is not meant to indicate that adults diagnosed with ADHD should go untreated. In fact, adults with ADHD often struggle in their professional and family lives because they do not receive the treatment they need.
Rather, family physicians should take certain steps, first to diagnose ADHD correctly, and then to ascertain and maintain correct use of psychostimulants and other treatments among their adult patient populations. Read on for several practical strategies.
Criteria for adult Dx differ from those in children
ADHD, a common behavioral disorder that often, but not always, begins in childhood, is characterized by deficits in paying attention, difficulty controlling impulses, and marked hyperactivity. Diagnosis of ADHD is based on the DSM-5 criteria and supplemented with historical data and clinical observations.4 Using self-report measures may also aid in the diagnosis, and psychological testing may be required for some individuals when the clinical presentation is unclear.
With the DSM-5 changes (TABLE 14), the diagnosis of ADHD in adults (people ≥18 years) requires fewer symptoms than the diagnosis of ADHD in children; just 5 symptoms from either of the 2 categories of diagnostic criteria are sufficient now, whereas 6 symptoms were required previously and still are required to make the diagnosis in young people. People may present with the inattentive profile (5 or more symptoms of inattention), the hyperactive-impulsive profile (5 or more hyperactive-impulsive symptoms), or a combination of the 2 (5 or more symptoms of inattention plus 5 or more symptoms of hyperactivity-impulsivity for a total of 10 or more symptoms). While children are more likely to present with the combined type of ADHD, adults of any age are more likely to present with the inattentive type.4
In addition, patients must meet the diagnostic criteria for ADHD for at least 6 months, have had some of the symptoms prior to age 12, and the symptoms must cause significant impairment in 2 or more environments (eg, home, work, school). When the diagnosis is unclear, it is important to obtain collateral information from the family, school, or workplace. The requirement regarding symptomatology before age 12 indicates the need for a review of the patient’s educational history. Research reveals that many adults with ADHD struggled in school and were considered “underachievers” as students.5
Common complaints and characteristics. Previous studies have shown the following to be common complaints and characteristics of adult patients diagnosed with ADHD:5
- difficulty meeting time limits
- vocational struggles, such as frequent job changes or nonpromotion at work
- anger issues
- addiction
- relationship/social strain
- comprehension problems, and
- a family history of ADHD.
Common correlates include low socioeconomic status, driving violations, frequent injuries, legal problems, alcohol and/or tobacco use, and self-reported maladjustment.5 People treated for ADHD have a comorbid DSM diagnosis 81% of the time with the most likely diagnoses being substance abuse, depression, and anxiety.6
Adult-onset ADHD? Even though the DSM-5 criteria for an ADHD diagnosis in adulthood require that some ADHD symptoms were manifest prior to age 12, recent longitudinal research on ADHD in Brazil and the United Kingdom reveals that a large portion of people who meet the criteria for ADHD in adulthood did not meet the criteria as children. The researchers in these studies proposed that there may be a form of ADHD that manifests later in life, a so-called “adult-onset ADHD.”7 While this information is something for clinicians to consider, further research is needed to justify a paradigm shift in how ADHD is diagnosed.
Self-rating measures can offer clarification. Whether or not history-gathering leaves the diagnosis murky, self-rating measures can be valuable in rounding out the clinical picture and alerting clinicians to any inconsistencies in symptoms.8 Four common ADHD self-rating measures are provided in TABLE 2. As one example, the Adult ADHD Self-Report Scale (ASRS) Symptom Checklist is a valuable ADHD screening tool that is free of charge and takes only 5 to 10 minutes.8 Other self-report measures require a similar amount of time, but are not available on a complimentary basis.
Psychological testing. Some adults who seem to have symptoms of ADHD may require a referral for psychological testing. These may be patients who present with complicated cases or whose histories and/or findings do not consistently indicate an ADHD diagnosis. In such cases, psychological testing can fill in the holes and provide a more complete picture of the patient’s neurocognitive abilities and deficits.9,10
Psychostimulant treatment: Opt for longer-acting agents
The standard treatment for ADHD is a psychostimulant. One controlled trial, for example, of a mixed amphetamine salts compound (Adderall) found that the compound effectively treated ADHD symptoms (hyperactivity, impulsivity, inattention) in adults and was well tolerated.11 While far fewer studies have been performed in adult vs youth populations, those that have been conducted in adults indicate that psychostimulants are largely safe and efficacious. In fact, the study mentioned above found that 70% of patients with ADHD ages 18 and older reported improvement of symptoms while on a short-acting psychostimulant, as compared to 7% who reported improvement on placebo.11
Similarly, a meta-analysis of 1991 participants in 11 studies found significant improvement in patients who received medication vs placebo, with stimulant medications demonstrating greater efficacy than non-stimulant treatments for ADHD.12 In general, psychostimulant treatment for adults is similar to that for children; the only difference is that adults tend to be more forthcoming with information regarding how the treatment is working and what adjustments might be needed.
Longer-acting stimulants (ie, extended release) tend to be preferred by patients to short-acting ones because they typically provide adequate control of symptoms over a longer period of time and thus may be taken less frequently.13 Also, the potential for abuse of psychostimulant medication tends to be lower with the longer-acting, extended-release formulations.14 A shorter acting formulation may be preferred if a patient has a specific window of time when their ADHD symptoms impact them. For example, a patient may request a short-acting form of medication for afternoons if he or she has to attend many business meetings at that time of day. A relatively new category is the intermediate-acting psychostimulants. For more on specific psychostimulants, see Table 3.15
Adverse effects lead many to discontinue treatment
Regardless of the length of action of the psychostimulant, studies show that about 30% of adults (and, incidentally, 10% to 30% of children) discontinue treatment due to uncontrolled/unwanted symptoms or adverse effects.16 These include decreased appetite, headache, insomnia, abdominal pain, and irritable mood.17 If you are prescribing a psychostimulant for an adult with ADHD, it is important to tell the patient that if the effects become intolerable, adjustments can be made, such as tweaking dosages, switching to a different medication, or adding an adjunctive therapy such as cognitive behavioral therapy. Keep in mind, too, that if a medication is to be discontinued, tapering is suggested for most psychostimulants; patients should take a lower (eg, half) dose for about a week prior to complete discontinuation. People who have difficulties with a number of treatments for ADHD should be reevaluated in a year to see if circumstances have changed.5
Combatting misuse and diversion
Perhaps the most controversial issues surrounding the treatment of adults with ADHD are abuse and diversion of psychostimulants. Abuse generally refers to misuse of the drug by the person prescribed the agent, whereas diversion refers to use of the drug by people for whom the drug was not intended—with or without the prescribee’s knowledge.3 Although rare, chronic abuse of psychostimulants can lead to serious problems such as aggression, suicidal thoughts/behaviors, psychosis, and mania.5
While earlier studies tended to downplay the likelihood of diversion, recent research indicates that physicians should not underestimate the possibility. In fact, a previous article in this journal about student athletes with ADHD (http://bit.ly/2k1a6TL) indicated that psychostimulants have “great potential for misuse” and that recently there has been “a surge in nonprescription stimulant use among adolescents and young adults.”17 The authors of the article concluded, however, that while physicians should be aware of the potential for misuse, fear should not preclude treatment.17
A national multi-cohort study of 4572 US high school seniors who had used psychostimulants either medically or nonmedically indicated that while one in 6 high school seniors had been exposed to psychostimulants, about half were appropriately exposed through prescription use, while the other half was not. The researchers also reported that current nonmedical users of psychostimulants and those with a history of nonmedical use had a greater risk of substance use and abuse when compared to medical users of psychostimulants.18
Young men are at higher risk for diversion. In a nationwide survey of a sample of adults ages 18 to 49 years who had a prescription for psychostimulant medication in the past month, 17% admitted diverting their medication.
In another study, 483 students ages 17 to 19 years were followed for one year and interviewed frequently regarding their use of medications.20 The researchers reported that the lifetime prevalence of diversion of any medication in those students was around 36%. They also found that of those who diverted medication, 62% diverted ADHD medications at least once. These were most commonly diverted by sharing (34%) and selling (9%) the psychostimulants. Interview analysis revealed that those students who diverted were more likely to have used illicit drugs and to have had conduct problems. The authors advised “vigilance regarding…stimulant medications for young adults.”
Psychostimulant prescriptions do not cause substance abuse. Nevertheless, a salient point in the literature is that there is no causal relationship between psychostimulant prescriptions that are properly prescribed for people who have ADHD and substance abuse. One study that followed young people with ADHD for 8 years into adulthood revealed that psychostimulant treatment did not make adolescents or young adults any more or less likely to abuse drugs.21 The study also found that alcohol use was common in young adults whether they were diagnosed with ADHD or not. Nonetheless, family physicians should urge those taking psychostimulants to refrain from alcohol use or at least to drink in moderation.
The bottom line is that adults diagnosed with ADHD carry about the same risk of substance abuse as the general population if they are effectively treated for their presenting attention problems.22 If they are taking a psychostimulant, however, they have access to a controlled substance, unlike most of their cohorts. So it's important to teach patients with ADHD that for safety and legal reasons, they should not share or sell their stimulant medication to anyone.
Minimize the risk for abuse, diversion using these strategies
As with any drug regimen, it is important to monitor the patient’s response to treatment and minimize adverse effects and outcomes. When the drug is a psychostimulant for adults diagnosed with ADHD, it’s also important to minimize the risk for abuse and diversion. The following steps can help:
- Obtain a signed controlled substance agreement.23 This agreement between the physician and the patient usually outlines such specifics as frequency of office visits, circumstances surrounding medication refills, urine drug monitoring, and pill counts. (For more on the specifics of a controlled substance agreement, see "Key points of a controlled substance agreement.")
- Schedule frequent follow-up appointments with open communication about abuse and diversion.20,23 The age-old adage, “Start low, go slow,” applies to stimulant medications for ADHD. Medication dosage may vary and necessitate titration depending on the person’s weight and tolerance. At the onset of treatment, frequent office visits allow the physician to gauge treatment response and the patient’s commitment to therapy.
- Review your state’s prescription drug monitoring program.24 It is imperative that providers check their state’s medical board rules for prescribing controlled medications to ensure practice compliance. As diversion rates of controlled medications have risen in this country, most states have established monitoring systems through their pharmacy boards.24 Although the names of the programs vary, these prescription drug monitoring programs provide information on any medication prescribed. This allows the prescribing physician to ensure patient compliance and ascertain that no other controlled medications are being prescribed that could interfere with treatment. (For more information about state prescription drug monitoring programs, see https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm.)
- Perform random urine drug screenings (UDS).20,23 An important strategy for ensuring adherence to the treatment plan and the controlled substance contract is UDS. Explain to patients that this is a way of making sure they are taking the medication exactly as prescribed. If the UDS indicates that the patient has not been taking the medication, then the provider should intervene by either restricting or discontinuing the controlled substance to prevent or counteract potential diversion. Similarly, if a higher dose is requested by a patient, the provider can closely monitor the situation to determine whether the additional drug is actually being taken and whether the dose is optimal. (See JFP’s October 2016 “3 in 3” video on urine drug testing at: http://bit.ly/2iDnfgD.)
- Employ a team-based, multimodal approach.25 A referral to a mental health professional and multimodal treatment are often recommended in the literature as best practices.25 Behavioral therapies are a cornerstone of treatment in adults with ADHD and often serve as important adjuncts to pharmacotherapy. Also, a referral provides a second professional opinion about the patient’s motivations, adherence, and response to treatment.
Trained cognitive behavioral therapists (eg, psychologists, counselors) can be helpful with treatment for ADHD.23 Therapists can be useful in setting goals for the patient regarding adherence, organization, impulse control, and social skills training. Therapists may wish to involve the family in treatment, depending on the nature of the patient’s presenting issues.
SIDEBAR
Key points of a controlled substance agreementThe primary purpose of a controlled substance agreement is to provide clarity for the provider and the patient regarding the use of controlled medications. The document is meant to prevent potential problems and confusion down the road. There are generally 3 parts:
- a doctor/patient agreement
- information about medications
- patient consent to utilize controlled substances that the provider believes would be beneficial.
Patients are typically told of the potential value of controlled medications in helping them and are warned about the potential for problems should the medications be used in ways other than intended. While wording may differ, patients are generally asked to agree to variations of the following 10 guidelines:
- I will talk with my doctor before using more than the prescribed amount of the medicine or discontinuing its use.
- I will tell my doctor if new medications are prescribed by another provider.
- I will tell the doctor if I become pregnant, so that any necessary medication adjustments can be made.
- If I abuse this drug, I understand that the doctor may need to stop treatment.
- I will uphold the visit schedule to the office/clinic according to guidelines for controlled substances (eg, every 90 days).
- I will refrain from using illicit drugs including marijuana and excessive quantities of alcohol.
- I will refrain from sharing, trading, or selling controlled substances.
- I will submit to regular urine drug screens as requested by the doctor.
- I understand that a failed drug screen may mean discontinuation of treatment.
- I will be forthright and honest about how the treatment is going, adverse effects, and how I am taking the medication.
Adapted from: https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf.
Don’t tempt fate. As with any controlled medication, safe storage of psychostimulants is paramount. Patients should be urged to keep their medication in a locked box or cupboard that is accessible to only the adult for whom the drug is prescribed. Prior research cautions that open access to controlled substances can lead to larger issues with abuse and diversion, particularly when adolescents are in the home.26
Consider atomoxetine. Research has also demonstrated that the non-stimulant medication atomoxetine has some benefit in the treatment of ADHD.12 Unlike psychostimulants that act on the neurotransmitter dopamine, atomoxetine acts on the neurotransmitter norepinephrine. This different mechanism of action results in a lower potential for abuse and diversion.
CORRESPONDENCE
Scott A. Fields, PhD, 3200 MacCorkle Avenue Southeast, 5th Floor, Robert C. Byrd Clinical Teaching Center, Department of Family Medicine, Charleston, WV 25304; sfields@hsc.wvu.edu.
Attention-deficit/hyperactivity disorder (ADHD) in adults brings with it unique challenges, not the least of which are arriving at a proper diagnosis and ensuring that any psychostimulant drugs that you prescribe are not misused. A number of conditions such as anxiety, bipolar disorder, and substance abuse can mimic some of the symptoms of ADHD, and diagnostic criteria for the condition in adults changed with the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Furthermore, for many of the estimated 4.4% of adults who have ADHD,1 psychostimulants provide necessary and effective treatment, but misuse and diversion of these agents are real concerns. In fact, recent research reveals that these issues are more common than previously thought.2 Data suggest that the prevalence of misuse and diversion of ADHD medication is 5% to 10% among high school students and 5% to 35% among college students.2,3
This is not meant to indicate that adults diagnosed with ADHD should go untreated. In fact, adults with ADHD often struggle in their professional and family lives because they do not receive the treatment they need.
Rather, family physicians should take certain steps, first to diagnose ADHD correctly, and then to ascertain and maintain correct use of psychostimulants and other treatments among their adult patient populations. Read on for several practical strategies.
Criteria for adult Dx differ from those in children
ADHD, a common behavioral disorder that often, but not always, begins in childhood, is characterized by deficits in paying attention, difficulty controlling impulses, and marked hyperactivity. Diagnosis of ADHD is based on the DSM-5 criteria and supplemented with historical data and clinical observations.4 Using self-report measures may also aid in the diagnosis, and psychological testing may be required for some individuals when the clinical presentation is unclear.
With the DSM-5 changes (TABLE 14), the diagnosis of ADHD in adults (people ≥18 years) requires fewer symptoms than the diagnosis of ADHD in children; just 5 symptoms from either of the 2 categories of diagnostic criteria are sufficient now, whereas 6 symptoms were required previously and still are required to make the diagnosis in young people. People may present with the inattentive profile (5 or more symptoms of inattention), the hyperactive-impulsive profile (5 or more hyperactive-impulsive symptoms), or a combination of the 2 (5 or more symptoms of inattention plus 5 or more symptoms of hyperactivity-impulsivity for a total of 10 or more symptoms). While children are more likely to present with the combined type of ADHD, adults of any age are more likely to present with the inattentive type.4
In addition, patients must meet the diagnostic criteria for ADHD for at least 6 months, have had some of the symptoms prior to age 12, and the symptoms must cause significant impairment in 2 or more environments (eg, home, work, school). When the diagnosis is unclear, it is important to obtain collateral information from the family, school, or workplace. The requirement regarding symptomatology before age 12 indicates the need for a review of the patient’s educational history. Research reveals that many adults with ADHD struggled in school and were considered “underachievers” as students.5
Common complaints and characteristics. Previous studies have shown the following to be common complaints and characteristics of adult patients diagnosed with ADHD:5
- difficulty meeting time limits
- vocational struggles, such as frequent job changes or nonpromotion at work
- anger issues
- addiction
- relationship/social strain
- comprehension problems, and
- a family history of ADHD.
Common correlates include low socioeconomic status, driving violations, frequent injuries, legal problems, alcohol and/or tobacco use, and self-reported maladjustment.5 People treated for ADHD have a comorbid DSM diagnosis 81% of the time with the most likely diagnoses being substance abuse, depression, and anxiety.6
Adult-onset ADHD? Even though the DSM-5 criteria for an ADHD diagnosis in adulthood require that some ADHD symptoms were manifest prior to age 12, recent longitudinal research on ADHD in Brazil and the United Kingdom reveals that a large portion of people who meet the criteria for ADHD in adulthood did not meet the criteria as children. The researchers in these studies proposed that there may be a form of ADHD that manifests later in life, a so-called “adult-onset ADHD.”7 While this information is something for clinicians to consider, further research is needed to justify a paradigm shift in how ADHD is diagnosed.
Self-rating measures can offer clarification. Whether or not history-gathering leaves the diagnosis murky, self-rating measures can be valuable in rounding out the clinical picture and alerting clinicians to any inconsistencies in symptoms.8 Four common ADHD self-rating measures are provided in TABLE 2. As one example, the Adult ADHD Self-Report Scale (ASRS) Symptom Checklist is a valuable ADHD screening tool that is free of charge and takes only 5 to 10 minutes.8 Other self-report measures require a similar amount of time, but are not available on a complimentary basis.
Psychological testing. Some adults who seem to have symptoms of ADHD may require a referral for psychological testing. These may be patients who present with complicated cases or whose histories and/or findings do not consistently indicate an ADHD diagnosis. In such cases, psychological testing can fill in the holes and provide a more complete picture of the patient’s neurocognitive abilities and deficits.9,10
Psychostimulant treatment: Opt for longer-acting agents
The standard treatment for ADHD is a psychostimulant. One controlled trial, for example, of a mixed amphetamine salts compound (Adderall) found that the compound effectively treated ADHD symptoms (hyperactivity, impulsivity, inattention) in adults and was well tolerated.11 While far fewer studies have been performed in adult vs youth populations, those that have been conducted in adults indicate that psychostimulants are largely safe and efficacious. In fact, the study mentioned above found that 70% of patients with ADHD ages 18 and older reported improvement of symptoms while on a short-acting psychostimulant, as compared to 7% who reported improvement on placebo.11
Similarly, a meta-analysis of 1991 participants in 11 studies found significant improvement in patients who received medication vs placebo, with stimulant medications demonstrating greater efficacy than non-stimulant treatments for ADHD.12 In general, psychostimulant treatment for adults is similar to that for children; the only difference is that adults tend to be more forthcoming with information regarding how the treatment is working and what adjustments might be needed.
Longer-acting stimulants (ie, extended release) tend to be preferred by patients to short-acting ones because they typically provide adequate control of symptoms over a longer period of time and thus may be taken less frequently.13 Also, the potential for abuse of psychostimulant medication tends to be lower with the longer-acting, extended-release formulations.14 A shorter acting formulation may be preferred if a patient has a specific window of time when their ADHD symptoms impact them. For example, a patient may request a short-acting form of medication for afternoons if he or she has to attend many business meetings at that time of day. A relatively new category is the intermediate-acting psychostimulants. For more on specific psychostimulants, see Table 3.15
Adverse effects lead many to discontinue treatment
Regardless of the length of action of the psychostimulant, studies show that about 30% of adults (and, incidentally, 10% to 30% of children) discontinue treatment due to uncontrolled/unwanted symptoms or adverse effects.16 These include decreased appetite, headache, insomnia, abdominal pain, and irritable mood.17 If you are prescribing a psychostimulant for an adult with ADHD, it is important to tell the patient that if the effects become intolerable, adjustments can be made, such as tweaking dosages, switching to a different medication, or adding an adjunctive therapy such as cognitive behavioral therapy. Keep in mind, too, that if a medication is to be discontinued, tapering is suggested for most psychostimulants; patients should take a lower (eg, half) dose for about a week prior to complete discontinuation. People who have difficulties with a number of treatments for ADHD should be reevaluated in a year to see if circumstances have changed.5
Combatting misuse and diversion
Perhaps the most controversial issues surrounding the treatment of adults with ADHD are abuse and diversion of psychostimulants. Abuse generally refers to misuse of the drug by the person prescribed the agent, whereas diversion refers to use of the drug by people for whom the drug was not intended—with or without the prescribee’s knowledge.3 Although rare, chronic abuse of psychostimulants can lead to serious problems such as aggression, suicidal thoughts/behaviors, psychosis, and mania.5
While earlier studies tended to downplay the likelihood of diversion, recent research indicates that physicians should not underestimate the possibility. In fact, a previous article in this journal about student athletes with ADHD (http://bit.ly/2k1a6TL) indicated that psychostimulants have “great potential for misuse” and that recently there has been “a surge in nonprescription stimulant use among adolescents and young adults.”17 The authors of the article concluded, however, that while physicians should be aware of the potential for misuse, fear should not preclude treatment.17
A national multi-cohort study of 4572 US high school seniors who had used psychostimulants either medically or nonmedically indicated that while one in 6 high school seniors had been exposed to psychostimulants, about half were appropriately exposed through prescription use, while the other half was not. The researchers also reported that current nonmedical users of psychostimulants and those with a history of nonmedical use had a greater risk of substance use and abuse when compared to medical users of psychostimulants.18
Young men are at higher risk for diversion. In a nationwide survey of a sample of adults ages 18 to 49 years who had a prescription for psychostimulant medication in the past month, 17% admitted diverting their medication.
In another study, 483 students ages 17 to 19 years were followed for one year and interviewed frequently regarding their use of medications.20 The researchers reported that the lifetime prevalence of diversion of any medication in those students was around 36%. They also found that of those who diverted medication, 62% diverted ADHD medications at least once. These were most commonly diverted by sharing (34%) and selling (9%) the psychostimulants. Interview analysis revealed that those students who diverted were more likely to have used illicit drugs and to have had conduct problems. The authors advised “vigilance regarding…stimulant medications for young adults.”
Psychostimulant prescriptions do not cause substance abuse. Nevertheless, a salient point in the literature is that there is no causal relationship between psychostimulant prescriptions that are properly prescribed for people who have ADHD and substance abuse. One study that followed young people with ADHD for 8 years into adulthood revealed that psychostimulant treatment did not make adolescents or young adults any more or less likely to abuse drugs.21 The study also found that alcohol use was common in young adults whether they were diagnosed with ADHD or not. Nonetheless, family physicians should urge those taking psychostimulants to refrain from alcohol use or at least to drink in moderation.
The bottom line is that adults diagnosed with ADHD carry about the same risk of substance abuse as the general population if they are effectively treated for their presenting attention problems.22 If they are taking a psychostimulant, however, they have access to a controlled substance, unlike most of their cohorts. So it's important to teach patients with ADHD that for safety and legal reasons, they should not share or sell their stimulant medication to anyone.
Minimize the risk for abuse, diversion using these strategies
As with any drug regimen, it is important to monitor the patient’s response to treatment and minimize adverse effects and outcomes. When the drug is a psychostimulant for adults diagnosed with ADHD, it’s also important to minimize the risk for abuse and diversion. The following steps can help:
- Obtain a signed controlled substance agreement.23 This agreement between the physician and the patient usually outlines such specifics as frequency of office visits, circumstances surrounding medication refills, urine drug monitoring, and pill counts. (For more on the specifics of a controlled substance agreement, see "Key points of a controlled substance agreement.")
- Schedule frequent follow-up appointments with open communication about abuse and diversion.20,23 The age-old adage, “Start low, go slow,” applies to stimulant medications for ADHD. Medication dosage may vary and necessitate titration depending on the person’s weight and tolerance. At the onset of treatment, frequent office visits allow the physician to gauge treatment response and the patient’s commitment to therapy.
- Review your state’s prescription drug monitoring program.24 It is imperative that providers check their state’s medical board rules for prescribing controlled medications to ensure practice compliance. As diversion rates of controlled medications have risen in this country, most states have established monitoring systems through their pharmacy boards.24 Although the names of the programs vary, these prescription drug monitoring programs provide information on any medication prescribed. This allows the prescribing physician to ensure patient compliance and ascertain that no other controlled medications are being prescribed that could interfere with treatment. (For more information about state prescription drug monitoring programs, see https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm.)
- Perform random urine drug screenings (UDS).20,23 An important strategy for ensuring adherence to the treatment plan and the controlled substance contract is UDS. Explain to patients that this is a way of making sure they are taking the medication exactly as prescribed. If the UDS indicates that the patient has not been taking the medication, then the provider should intervene by either restricting or discontinuing the controlled substance to prevent or counteract potential diversion. Similarly, if a higher dose is requested by a patient, the provider can closely monitor the situation to determine whether the additional drug is actually being taken and whether the dose is optimal. (See JFP’s October 2016 “3 in 3” video on urine drug testing at: http://bit.ly/2iDnfgD.)
- Employ a team-based, multimodal approach.25 A referral to a mental health professional and multimodal treatment are often recommended in the literature as best practices.25 Behavioral therapies are a cornerstone of treatment in adults with ADHD and often serve as important adjuncts to pharmacotherapy. Also, a referral provides a second professional opinion about the patient’s motivations, adherence, and response to treatment.
Trained cognitive behavioral therapists (eg, psychologists, counselors) can be helpful with treatment for ADHD.23 Therapists can be useful in setting goals for the patient regarding adherence, organization, impulse control, and social skills training. Therapists may wish to involve the family in treatment, depending on the nature of the patient’s presenting issues.
SIDEBAR
Key points of a controlled substance agreementThe primary purpose of a controlled substance agreement is to provide clarity for the provider and the patient regarding the use of controlled medications. The document is meant to prevent potential problems and confusion down the road. There are generally 3 parts:
- a doctor/patient agreement
- information about medications
- patient consent to utilize controlled substances that the provider believes would be beneficial.
Patients are typically told of the potential value of controlled medications in helping them and are warned about the potential for problems should the medications be used in ways other than intended. While wording may differ, patients are generally asked to agree to variations of the following 10 guidelines:
- I will talk with my doctor before using more than the prescribed amount of the medicine or discontinuing its use.
- I will tell my doctor if new medications are prescribed by another provider.
- I will tell the doctor if I become pregnant, so that any necessary medication adjustments can be made.
- If I abuse this drug, I understand that the doctor may need to stop treatment.
- I will uphold the visit schedule to the office/clinic according to guidelines for controlled substances (eg, every 90 days).
- I will refrain from using illicit drugs including marijuana and excessive quantities of alcohol.
- I will refrain from sharing, trading, or selling controlled substances.
- I will submit to regular urine drug screens as requested by the doctor.
- I understand that a failed drug screen may mean discontinuation of treatment.
- I will be forthright and honest about how the treatment is going, adverse effects, and how I am taking the medication.
Adapted from: https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf.
Don’t tempt fate. As with any controlled medication, safe storage of psychostimulants is paramount. Patients should be urged to keep their medication in a locked box or cupboard that is accessible to only the adult for whom the drug is prescribed. Prior research cautions that open access to controlled substances can lead to larger issues with abuse and diversion, particularly when adolescents are in the home.26
Consider atomoxetine. Research has also demonstrated that the non-stimulant medication atomoxetine has some benefit in the treatment of ADHD.12 Unlike psychostimulants that act on the neurotransmitter dopamine, atomoxetine acts on the neurotransmitter norepinephrine. This different mechanism of action results in a lower potential for abuse and diversion.
CORRESPONDENCE
Scott A. Fields, PhD, 3200 MacCorkle Avenue Southeast, 5th Floor, Robert C. Byrd Clinical Teaching Center, Department of Family Medicine, Charleston, WV 25304; sfields@hsc.wvu.edu.
1. Kessler RC, Adler LA, 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;163:716-723.
2. Clemow DB, Walker DJ. The potential for misuse and abuse of medications in ADHD: a review. Postgrad Med. 2014;126:64-81.
3. Novak SP, Kroutil LA, Williams RL, et al. The nonmedical use of prescription ADHD medications: results from a national internet panel. Subst Abuse Treat Prev Policy. 2007;2:32.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association Press; 2013.
5. Kolar D, Keller A, Golfinopoulos M, et al. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4:389-403.
6. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162:1621-1627.
7. Faraone SV, Biederman J. Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry.
8. van de Glind G, van den Brink W, Koeter MWJ, et al. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend. 2013;132:587-596.
9. Gualtieri CT, Johnson LG. ADHD: Is objective diagnosis possible? Psychiatry. 2005;2:44-53.
10. Perrin AE, Jotwani VM. Addressing the unique issues of student athletes with ADHD. J Fam Pract. 2014;63:E1-E9.
11. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2001;58:775-782.
12. Mészáros A, Czobor P, Bálint S, et al. Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmacol. 2009;12:1137-1147.
13. Weiss M, Shingler T, Capone NM. Medication satisfaction among adults with ADHD: long term results from the Quality of Life, Effectiveness, Safety and Tolerability (Qu.S.T) study. New Orleans: Program and Abstracts of the 19th US Psychiatric and Mental Health Congress, Abstract 120, 2006.
14. Lopez FA, Leroux JR.
15. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90:456-464.
16. Spencer T, Biederman J, Wilens T. Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27:373-383.
17. Withrow LM, Hash PA, Holten KB. Managing ADHD in children: are you doing enough? J Fam Pract. 2011;60:E1-E3.
18. McCabe SE, West BT. Medical and nonmedical use of prescription stimulants: results from a national multicohort study. J Am Acad Child Adolesc Psychiatry. 2013;52:1272-1280.
19. Aldridge AP, Kroutil LA, Cowell AJ, et al. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. Pharmacoeconomics. 2011;29:621-635.
20. Garnier LM, Arria AM, Caldeira KM, et al. Sharing and selling of prescription medications in a college student sample. J Clin Psychiatry. 2010;71:262-269.
21. Molina BSG, Hinshaw SP, Arnold LE, et al. Adolescent substance use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52:250-263.
22. Brahmbhatt K, Hilty DM, Hah M, et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: a concise review. J Adolesc Health. 2016;59:135-143.
23. Post RE, Kurlansik SL. Diagnosis and management of attention-deficit/hyperactivity disorder in adults. Am Fam Physician. 2012;85:890-896.
24. Cepeda MS, Fife D, Berwaerts J, et al. Doctor shopping for medications used in the treatment of attention deficit hyperactivity disorder: shoppers often pay in cash and cross state lines. Am J Drug Alcohol Abuse. 2015;41:226-229.
25. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. 2010;304:875-880.
26. Ross-Durow PL, McCabe SE, Boyd CJ. Adolescents’ access to their own prescription medication in the home. J Adolesc Health. 2013;53:260-264.
1. Kessler RC, Adler LA, 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;163:716-723.
2. Clemow DB, Walker DJ. The potential for misuse and abuse of medications in ADHD: a review. Postgrad Med. 2014;126:64-81.
3. Novak SP, Kroutil LA, Williams RL, et al. The nonmedical use of prescription ADHD medications: results from a national internet panel. Subst Abuse Treat Prev Policy. 2007;2:32.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association Press; 2013.
5. Kolar D, Keller A, Golfinopoulos M, et al. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4:389-403.
6. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162:1621-1627.
7. Faraone SV, Biederman J. Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry.
8. van de Glind G, van den Brink W, Koeter MWJ, et al. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend. 2013;132:587-596.
9. Gualtieri CT, Johnson LG. ADHD: Is objective diagnosis possible? Psychiatry. 2005;2:44-53.
10. Perrin AE, Jotwani VM. Addressing the unique issues of student athletes with ADHD. J Fam Pract. 2014;63:E1-E9.
11. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2001;58:775-782.
12. Mészáros A, Czobor P, Bálint S, et al. Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmacol. 2009;12:1137-1147.
13. Weiss M, Shingler T, Capone NM. Medication satisfaction among adults with ADHD: long term results from the Quality of Life, Effectiveness, Safety and Tolerability (Qu.S.T) study. New Orleans: Program and Abstracts of the 19th US Psychiatric and Mental Health Congress, Abstract 120, 2006.
14. Lopez FA, Leroux JR.
15. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90:456-464.
16. Spencer T, Biederman J, Wilens T. Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27:373-383.
17. Withrow LM, Hash PA, Holten KB. Managing ADHD in children: are you doing enough? J Fam Pract. 2011;60:E1-E3.
18. McCabe SE, West BT. Medical and nonmedical use of prescription stimulants: results from a national multicohort study. J Am Acad Child Adolesc Psychiatry. 2013;52:1272-1280.
19. Aldridge AP, Kroutil LA, Cowell AJ, et al. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. Pharmacoeconomics. 2011;29:621-635.
20. Garnier LM, Arria AM, Caldeira KM, et al. Sharing and selling of prescription medications in a college student sample. J Clin Psychiatry. 2010;71:262-269.
21. Molina BSG, Hinshaw SP, Arnold LE, et al. Adolescent substance use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52:250-263.
22. Brahmbhatt K, Hilty DM, Hah M, et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: a concise review. J Adolesc Health. 2016;59:135-143.
23. Post RE, Kurlansik SL. Diagnosis and management of attention-deficit/hyperactivity disorder in adults. Am Fam Physician. 2012;85:890-896.
24. Cepeda MS, Fife D, Berwaerts J, et al. Doctor shopping for medications used in the treatment of attention deficit hyperactivity disorder: shoppers often pay in cash and cross state lines. Am J Drug Alcohol Abuse. 2015;41:226-229.
25. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. 2010;304:875-880.
26. Ross-Durow PL, McCabe SE, Boyd CJ. Adolescents’ access to their own prescription medication in the home. J Adolesc Health. 2013;53:260-264.
PRACTICE RECOMMENDATIONS
› Be sure to take steps, which include utilization of a self-report measure—to correctly diagnose attention-deficit/hyperactivity disorder (ADHD) in adult patients before beginning treatment.
› Consider prescribing stimulant medications, such as the short-acting dextroamphetamine/amphetamine or the long-acting lisdexamfetamine, for adults with ADHD.
› Don't underestimate the problems of misuse and diversion among patients taking psychostimulant medications, particularly among younger men.
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
