Misuse of Prescription Stimulant Medication Among College Students: Summary of the Research Literature and Clinical Recommendations

Accurate diagnosis of ADHD in patients with substance use disorders can be challenging given the symptom overlap between intoxication and withdrawal syndromes of substances and symptoms of ADHD. Evaluating for ADHD is an important part of a thorough assessment and can be completed in several ways. The gold standard is with a standardized diagnostic tool such as the Connors Adult ADHD Diagnostic Interview for DSM-IV (CAADID) [45], which can be time consuming for a clinician and would likely involve referral to a psychologist for completion. Other scales have been examined, and the Connors Adult ADHD Rating Scale (CAARS) has been found to closely agree with the CAADID when both are administered [45]. Other scales are available, including the Wender Utah Rating Scales (WURS) and the Adult ADHD Self-Report Scale (ASRS), and have been found to have adequate sensitivity and specificity [45]. In an international study, the ASRS, a relatively brief instrument, showed encouraging results with 84% sensitivity and 66% specificity in detecting ADHD upon entry into substance disorder treatment for treatment-seeking patients [46]. When diagnosing ADHD among adults, it is crucial not to rely only on self-reported symptoms. A thorough childhood history of ADHD symptom presentation should be collected from a parent or caregiver, and collateral concurrent report should be collected from someone who knows the patient well, such as an employer, close friend, significant other, or parent. Valid diagnosis, whether ADHD is present or not, is of utmost importance in this population as individuals with comorbid substance use disorders and ADHD tend to have worse outcomes overall [47]. It is also important to appreciate that inaccurately diagnosing ADHD in individuals misusing stimulants could potentially diminish the importance of the diagnosis [48].

If ADHD is found, there are medications available that have a lower abuse potential compared to stimulant medications. Atomoxetine is the only FDA-approved nonstimulant for ADHD; off-label or second-line treatments include antidepressants, such as bupropion, venlafaxine, or tricyclic antidepressants, for which the data is limited, and clonidine [34,49,50]. If these therapies are not effective and, after careful consideration of risks and benefits, it is determined that a trial with a stimulant is needed, longer-acting formulations appear to be less abused [34,44]. Education for both the patient and his or her family should be provided on abuse and diversion potential and appropriate use and misuse [34,43,51]. Pill counts [43], regular office visits [52], and random urine toxicology screens [34] with informed interpretation of the screens may be helpful in deterring misuse or diversion. While medications are the mainstay of treatment for ADHD, there are several psychosocial interventions available, including cognitive behavioral therapy, coaching, and behavioral modification therapies [34].

Other Comorbidities

Other psychiatric comorbidities also should be explored. Studies have found a relation between depression and misuse of stimulant medication in that there is an increased likelihood of depression and thoughts of suicide among those that misuse stimulant medication and vice versa [23,24,53]. The National Survey on Drug Use and Health in 2012 found that, of those that misused stimulants, nearly 20% had serious thoughts of suicide over the past year [54]. As noted earlier, stimulant medication can affect sleep and appetite. Among those that report misuse of stimulant medication for weight loss, these individuals are more likely to report other eating-disordered behaviors [55]. Sleep quality is worse and sleep disturbance greater in those that misuse stimulant medication [32]. Other traits and behaviors that have been described in individuals that misuse stimulant medications include impulsivity [56,57], sensation seeking [20], perfectionism [58], and poor time management skills or procrastination [59].