Medication management
Psychostimulant therapy for ADHD has 3 essential stages: initiation/titration, maintenance, and termination.
With initiation and titration, determining the optimal dose requires twice monthly follow-up visits. With each visit, assess symptom control, review adverse effects, and record BP, pulse, height, and weight. The optimal dose is one at which target outcomes are achieved with minimal adverse effects. Long-acting agents are preferred to enhance compliance, ensure dosing consistency, and reduce abuse potential. If the desired outcome is not being achieved at the highest feasible dose, an alternative psychostimulant may be tried. If a desired response is still not achieved, reevaluate the diagnosis or consider the possibility of comorbid conditions or that the patient has stopped taking the medication.
During the maintenance stage, it is prudent to have monthly contact with the student athlete before writing refill prescription for a Schedule II medication.
Determining when to terminate treatment is a highly individualized decision that entails ongoing analysis of risks vs benefit.9,12,16,26,29 A student athlete’s diagnosis of ADHD might have been based on a positive response to medication in lieu of a comprehensive evaluation, which is regrettable. Response to medication cannot be used to confirm or refute a diagnosis of ADHD because psychostimulant medication will improve behavior in conditions other than ADHD, including learning disability and depression.22
Misuse of psychostimulants among athletes. Some athletes will use a psychostimulant primarily as an appetite suppressant for weight control. However, perceived ergogenic effects are what make psychostimulants especially problematic,16 and are the main reason they are banned from competitive sports. Potential performance enhancements include improved concentration and attention to tasks, increased aggression, decreased pain perception, and euphoria.
A 2006 NCAA study of substance abuse habits of college student athletes (reflecting 2005-2006 data) demonstrated the following findings concerning ergogenic use of psychostimulants:30
• Psychostimulant use has continually increased since 1997 among all student athletes.
• Psychostimulant use has increased across all divisions, with highest use in Division III.
• Psychostimulant use increased in all men’s sports except basketball, football, and swimming.
• Psychostimulant use increased in all women’s sports except tennis, gymnastics, soccer, and volleyball.
• Respondents who used stimulants said they did so to get more energy or to treat ADHD.
• Respondents who didn’t use stimulants said they were concerned about the effect on health, side effects, and going against personal beliefs.30 (The latter issue regarding why student athletes do or do not use specific substances is a focus of the 2012-2013 NCAA National Study of Substance Use Habits of College Student-Athletes, currently underway.)
The rise in the nonprescription use of Adderall among National Football League (NFL) players has become a hot topic. Regarded by the league as a game-day performance enhancer, it has been banned since 2006. Muddying the waters on the true prevalence of Adderall use is the NFL’s policy of silence on identifying the specific performance-enhancing drug that triggered suspension. Only the player, if he so chooses, can disclose the substance in question. It has become convenient for players to name Adderall as the culprit, as it lacks the stigma attached to anabolic steroids and human growth hormone. Whether the drug is being used for ergogenic purposes or as an easy alibi, or both, remains unclear.31
Competition restrictions and therapeutic-use exemption
At the college level and beyond, psychostimulant use is highly regulated in competitive sports. Primary care providers can be supportive by being mindful of existing restrictions when making treatment decisions, and by keeping detailed documentation as stipulated in NCAA policy that became effective on August 1, 2009.30
The policy requires student athletes with ADHD who take psychostimulant medication to provide “evidence that the student athlete has undergone clinical assessment to diagnose the disorder, is being monitored routinely with use of psychostimulant medication and has a current prescription on file.” If the diagnosis of ADHD was made in childhood, policy requires the student athlete to provide their institution with a copy of the comprehensive assessment, including history of treatment. If such documents are not available, then a comprehensive assessment, must be performed to establish the diagnosis.
At minimum, documentation must include a description of the evaluation process and assessment tool(s) used; a statement of the diagnosis; a history of ADHD treatment, both previous and ongoing; a statement that a nonbanned alternative ADHD medication has been considered, if a psychostimulant is currently prescribed; and a statement reflecting evidence of ongoing follow-up/medication monitoring.
If a psychostimulant medication is prescribed, NCAA regulations require that a TUE be included in the documentation. The NCAA asks only that the prescribing physician consider nonstimulants first; they do not require an initial trial of a nonstimulant medication.2,9,16 Per NCAA regulation the student athlete must undergo, at minimum, an annual clinical evaluation by the team physician. The NCAA Committee on Safeguards and Medical Aspects of Sports has issued a new mandatory reporting form that contains criteria, including any known history of substance abuse, to help differentiate legitimate use worthy of medical exemption from use that is abusive.32