(Part 4 of 5)
Timothy Wilens, MD, discusses strategies for limiting the misuse and diversion of prescription stimulants. Dr. Wilens is Chief, Division of Child and Adolescent Psychiatry, and Co-Director, Center for Addiction Medicine, at Harvard Medical School, Boston, Massachusetts.
Read the transcript:
While the stimulant medications can be amongst the most effective agents and treatments that we have for ADHD, reversing both short and longer‑term negative consequences of the disorder, they also have abuse liability.
They are either misused by individuals who don't have a prescription for ADHD medications, or people in whom they are prescribed and they misuse them by escalating the dose or taking them at other times, or they can be diverted. People with ADHD who have medication give them or sell them to other individuals. It is something that we need to think about.
What are some of the antidotes that we think that can help reduce the amount of misuse of the stimulants and ultimate diversion? Number one, to educate yourself about this, watch lectures, get a better understanding of stimulant misuse and some of the risks that are connected to stimulant misuse.
Educate your patients. Let them know that there are legal considerations for it. Think about this, if people are using, let's say, mixed amphetamine salts, and they're getting 20‑milligram tablets, and they have 30 of them, they're going to be at a level, if they get caught selling the medication, of a felony offense. It is not a trivial offense at that point.
Also, that there are ethical codes. Most of this is occurring in college settings and that each of the schools have codes about using medication nonmedically, which is that you're using such as a stimulant the way it's not supposed to be used or giving or selling your medication. There are strict codes about that.
Another thing is to appreciate that as prescribers and especially in light of e‑prescriptions, which allow us to electronically send stimulant prescriptions now, that we should right‑size the prescriptions.
In other words, whereas you may have been tempted because somebody's going away to school and you want to ensure that they had adequate supply, to give them 2 months' or 3 months' supply of their stimulant, we're now suggesting that you get 1 month's supply of the medication, only give 30.
What happens when you give 2 or 3 months' is you create a reservoir of the stimulant medication. Data from the University of Texas, Michigan, and Mass General working together shows that these reservoirs serve as the well from which medication gets diverted to individuals who don't have the disorder.
It's not just stimulants by the way. That's with opioids and benzodiazepines too. Give the right number of pills now and get refills. You can send those more directly to the pharmacies local to the college student.
Another thing is safe storage of the medication. Don't keep medicines in medicine cabinets. Probably the only thing you're going to remember from this series of interviews is that medication gets stolen from medicine cabinets. This is a word of advice to you too. That is, medicine should be kept elsewhere. Keep it in a chest of drawers. Keep it solidly somewhere else. Keep it in a safe. Medicine cabinets are where people look for controlled substances.
People will know exactly what you're taking, by the way, if you keep your prescriptions there. We recommend not keeping them in the bathroom, not in a closed area where somebody can go and rifle through drawers and stuff. Keep them somewhere else safe. Rehearse this with the kids that you're going to be sending to college, or trade school, or boarding school, whatever.
As a practitioner, you're going to monitor pill counts, early refills, when somebody seems to be going through their medicines too quickly. That's certainly a prompt for a conversation to make a decision.
Finally, doing some simple things such as any of these high‑risk groups, people with past histories of conduct or antisocial disorder, people with substance use disorders, kids that you're concerned about in certain boarding schools or certain very competitive colleges where you're hearing there's a lot of misuse of these medicines, I would think about using the extended‑release or nonstimulants.
You might want to try a nonstimulant. If you're using a stimulant, use extended‑release stimulants instead of the immediate‑release. Some data shows that up to 40 percent of immediate‑release stimulants are crushed and snorted and about 5 percent are shot intravenously. That's a problem.
Until we have abuse‑deterrent types of immediate‑release preparations of stimulants, we're obligated to try to use the extended‑release whenever possible. If we're giving immediate‑release, we do it with a lot of education.
Using these techniques and common‑sense approaches will help us in some ways police ourselves to help keep stimulant misuse and diversion to a minimum particularly in high‑risk areas such as college campuses.