Prescription Stimulant Misuse Alarmingly Common

Stimulants, primarily amphetamines and methylphenidate, are increasingly prescribed to treat attention-deficit/hyperactivity disorder (ADHD) in adults — raising concerns about potential misuse and abuse.

New research confirms this concern, showing that one quarter of US adults who are prescribed stimulants misuse them, with nearly 1 in 10 meeting the criteria for prescription stimulant use disorder (PSUD).

The prevalence of misuse may be even higher, investigators noted, because some adults may not report misuse due to social stigma.

“Prescription stimulants have well-documented benefits for those with ADHD, and they can be life-changing and lifesaving. At the same time, our study highlights the growing need to ensure patients who are prescribed stimulants also receive effective screening for substance use disorder,” Wilson M. Compton, MD, MPE, deputy director of the National Institute on Drug Abuse, Bethesda, Maryland, and corresponding author of the study, told Medscape Medical News.

The study was published online on March 19 in JAMA Psychiatry.

Stimulant Prescriptions Increasing

The diagnosis of ADHD and the use of prescription stimulants have rapidly increased in children and adults in the past decade.

One study showed a 58% increase in dispensed prescription stimulants from 2012 to 2022, with the greatest increase occurring in adults aged 31-40 years and 71-80 years.

“As the rate of stimulant prescriptions increase in the US, there has been an urgent need to understand how rising usage may be linked to misuse and substance use disorder that can interfere with a person’s well-being,” Compton said.

To address this need, Compton and colleagues quantified prescription stimulant use, misuse, and PSUD among US adults aged 18-64 years.

They analyzed data on dispensed prescription stimulants from 2019 to 2022 using two pharmaceutical databases that capture 93% of outpatient prescriptions dispensed in US retail pharmacies (including mail-order prescriptions).

Among a nationally representative sample of 83,762 adults who participated in the 2021-2022 National Surveys on Drug Use and Health, 25% reported misuse of prescription stimulants — defined in the survey as endorsing any of the following statements: Past-year use without a prescription of my own, in greater amounts than prescribed, more often than prescribed, longer than prescribed, or in some other way a doctor did not direct me to use.

Further, 9% of those surveyed had PSUD, according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria. About two thirds (64%) of those cases were mild. Among those with PSUD, 73% solely used their own prescribed stimulants, 87% used amphetamines, 43% stated that they did not misuse the drugs.

“The findings suggest an overlooked risk of stimulant use disorder even for those who deny misuse and have their own prescriptions, especially when involving amphetamines,” Compton said.

The prevalence of prescription stimulant misuse was 3.1 times higher and the prevalence of PSUD was 2.2 times higher in those using prescription amphetamines than among those using methylphenidate.

The prevalence of stimulant misuse varied by demographic group, with lower rates among women aged 35-64 years (14%) than other sex- and age-specific subgroups, which ranged from 22% for men aged 35-64 years to 37% for women aged 18-25 years.

The data also confirm increases in stimulant prescriptions dispensed among all sex- and age-specific subgroups, with the largest increase among women aged 35-64 years — rising from 1.2 million in the first quarter of 2019 to 1.7 million in the fourth quarter of 2022.

Misusers Become Abusers

While concerns over misuse and PSUD have typically focused on individuals who take prescription stimulants without clinical supervision, “these new data suggest that even those who think they are using their stimulant medications as directed may be at risk of substance use disorder,” Compton said.

“Our findings emphasize the need for broader screening and more thorough clinical guidance to help improve clinician management of stimulant prescribing practices. It’s also critical to continue to refine diagnostic tools for ADHD and evaluate interventions aimed at reducing misuse and managing prescription stimulant use disorder more effectively,” Compton added.

It’s important to note that this study defines prescription stimulant use as “using one’s own prescription as directed by a physician or misuse,” said Stephen V. Faraone, PhD, distinguished professor, Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, New York, who commented on the findings for Medscape Medical News.

“Among those who used the medication as prescribed, only 5% had PSUD, which is not very high and in the absence of a control group, I would conclude is negligible,” Faraone said.

“Among those who were misusing prescription stimulants, the rate of PSUD was 20.4%. That is high but is not surprising because the group is defined as having already misused stimulants,” Faraone added. “It does tell us that misusers become abusers. That is not surprising, but it is an important public health message.” 

This study was sponsored by the National Institute on Drug Abuse of the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention. Compton and Faraone had no relevant disclosures.