AD/HD Medication Abuse

1. AD/HD Medication Abuse Hannah Jayne Harris, M.A. and Ross Barr The School of Professional Psychology at Forest Institute

2. DSM-IV-TR Diagnostic Criteria • A. Either (1) or (2): • (1) Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: • (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • (b) often has difficulty sustaining attention in tasks or play activities • (c) often does not seem to listen when spoken to directly • (d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • (e) often has difficulty organizing tasks and activities • (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) • (h) is often easily distracted by extraneous stimuli • (i) is often forgetful in daily activities

3. DSM-IV-TR Diagnostic Criteria • (2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: • Hyperactivity • (a) often fidgets with hands or feet or squirms in seat • (b) often leaves seat in classroom or in other situations in which remaining seated is expected • (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) • (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" • (f) often talks excessively • Impulsivity • (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn • (i) often interrupts or intrudes on others (e.g., butts into conversations or games)

4. DSM-IV-TR Diagnostic Criteria • B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. • C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). • D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. • E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder).

5. State-Based Prevalence Data of AD/HD Diagnosis http://www.cdc.gov/ncbddd/adhd/prevalence.html

6. Comprehensive Treatment Approach • Multimodal Treatment Plan • Educational • Behavioral • Psychological • Medical

7. State-Based Prevalence Data of AD/HD Medication Treatment http://www.cdc.gov/ncbddd/adhd/medicated.html

8. AD/HD Medications • Amphetamine Stimulants • Adderall • Dexedrine • Vyvanse • Methylphenidate Stimulants • Focalin • Methylin • Ritalin • Concerta • Non-Stimulants • Strattera • Intuniv • Antidepressants • Wellbutrin

9. Why amphetamines and methylphenidate??? • Increase the activity of dopamine in the nucleus accumbens and the ventral tegmental area of the midbrain (Babcock & Byrne, 2000) • These areas are part of the reward pathway http://ibgwww.colorado.edu/cadd/a_drug/essays/essay4.htm

10. Mouse Party • Cocaine also blocks dopamine reuptake leading to increased excitation • http://learn.genetics.utah.edu/content/addiction/drugs/mouse.html

11. Some numbers… • In the United States, approximately 8% of children ages 4 – 17 have been diagnosed with AD/HD • In 2007, 66.3% of children age 4 – 17 diagnosed with AD/HD were receiving some form of medication as a part of their treatment • From 1998 – 2005, calls to the American Association of Poison Control Center’s National Poison Data System related to adolescent abuse of AD/HD medication rose 76% • (Setlik et al, 2009)

12. Monitoring the Future (www.monitoringthefuture.org) • Yearly assessment of the extent of drug use among high school students, college students and young adults • Asks about the use of amphetamines and methylphenidate in the year preceding the survey • 2003 Results: • 5.7% of college students reported non-medical use of methylphenidate compared to 2.5% of non-college students of the same age

13. McCabe, Knight, Teter & Wechsler, 2005 • 10,904 college students from 119 four-year colleges in the United States • 6.9% reported non-medical use of prescription stimulants in their lifetime • 4.1% in the last year • 2.1% in the last month

14. McCabe, Knight, Teter & Wechsler, 2005 • Groups more likely to report non-medical use of prescription stimulants • Men • Caucasian students • Fraternity and sorority members • Students with a B average or lower • Students at colleges in the Northeastern United States • Students at colleges with competitive or highly competitive admissions criteria

15. Jardin, Looby & Earleywine, 2011 • 43 undergraduate students • All with prescriptions for Ritalin or Adderall • GOAL: Determine characteristics of students with AD/HD who were likely to abuse their prescription medications

16. Jardin, Looby & Earleywine, 2011 • Findings: • 45% misused prescriptions • 27.9% altered route of administration • 62.8% took dose higher than recommended • 23.3% mixed medications with alcohol • 48.8% gave or sold medication • Misusers were significantly more likely to report lifetime use of nicotine, marijuana, cocaine, hallucinogens, and opiates

17. Upadhyaya, et. al., 2010 • Primary Motivation for misuse among nonmedical users aged 18-25 • 64.7% - performance enhancement • 23.7% - to stay awake • 40.9% - to be more productive • 2.9% - relaxation • 31.1% - recreational fun • 8.8% - for fun, kicks or excitement • 16.7% - to feel good or get high • 5.6% - to have a good time with friends

18. College students are able to justify their illegal use of AD/HD medications.

19. DeSantis & Hane, 2010 • In-depth interviews • 175 undergraduate students at a large Southeastern university • GOAL: Identify how students view ADHD stimulants and their illegal use • Discovered that there seemed to be a “popular, socially constructed storyline” created by students

20. Four Basic Arguments • Comparison and Contrast • All Things in Moderation • Self Medicating • Minimization Arguments DeSantis & Hane, 2010

21. “I’m doing it for the right reasons” • It comes from a medical establishment • There’s no high • There aren’t any internal or physical side effects Basic Arguments Comparison and Contrast All Things In Moderation Self Medicating Minimization Arguments DeSantis & Hane, 2010

22. Non-medical use was occasional and students felt little or no anxiety over it • Primarily use during periods of high academic stress • “I don’t use as much as…” Basic Arguments Comparison and Contrast All Things In Moderation Self Medicating Minimization Arguments DeSantis & Hane, 2010

23. Students claim to have AD/HD and believe that taking stimulants is morally and physiologically okay Basic Arguments Comparison and Contrast All Things In Moderation Self Medicating Minimization Arguments DeSantis & Hane, 2010

24. Minimizing severity of the non-medical use of stimulants • Harmless • Benign • Socially acceptable anti-fatigue aid • It’s just as safe as coffee Basic Arguments Comparison and Contrast All Things In Moderation Self Medicating Minimization Arguments DeSantis & Hane, 2010

25. What happens when you overdose? • High blood pressure • Irregular heart beat • Seizures • Twitching • Uncontrolled movements • Sweating • Dry mouth • Dry eyes • Vomiting • Death http://kidshealth.org/teen/drug_alcohol/drugs/ritalin.html#

26. Large Doses Over Long Periods of Time • Increased heart rate • Increased blood pressure • Tremors • Irregular Breathing • Changes in mood • Confusion • Paranoia • Hallucinations • Delusions http://kidshealth.org/teen/drug_alcohol/drugs/ritalin.html#

27. http://youtu.be/kW0gqTIY3mQ

28. So what should we do? • Attack • Address • Target • Educate • Dispel DeSantis & Hane, 2010

29. So what should we do? • Attack • Attack the illusion that the use of prescription medication is safe DeSantis & Hane, 2010

30. So what should we do? • Attack • Address • Address the erroneous belief that AD/HD stimulants have no harmful physical side effects DeSantis & Hane, 2010

31. So what should we do? • Attack • Address • Target • Target the misconception that illegally using or distributing a Schedule II amphetamine in moderation is safe. DeSantis & Hane, 2010

32. So what should we do? • Attack • Address • Target • Educate • Educate illegal users as to what AD/HD actually is. DeSantis & Hane, 2010

33. So what should we do? • Attack • Address • Target • Educate • Dispel • Dispel the belief that AD/HD medications are nothing more than a stiff cup of coffee or a can of coke. DeSantis & Hane, 2010

34. And finally… • “Appropriate diagnosis, treatment and therapeutic monitoring of college students who are receiving prescription psychostimulants is crucial, not only to improve clinical outcomes but also to help prevent the abuse of these medications within a population that is largely responsible for their own medication management.” (McCabe et al, 2005, p. 104)

35. Questions???

36. References Center for Disease Control and Prevention. (n.d.) Attention-deficit/hyperactivity disorder. Retrieved from http://www.cdc.gov/ncbddd/adhd/ Babcock, Q. & Byrne, T. (2000). Student perceptions of methylphenidate abuse at a public liberal arts college. Journal of American College Health, 49, 143-145. doi: 10.1080/07448480009596296 DeSantis, A.D. & Hane, A.C. (2010). “Adderall is definitely not a drug”: Justifications for the illegal use of ADHD stimulants. Substance Use & Misuse, 45, 31-46. doi: 10.3109/10826080902858334 Frauger, E., Pauly, V., Natali, F., Pradel, V., Reggio, P., Coudert, H., … Micallef, J. (2011). Patterns of methylphenidate use and assessment of its abuse and diversion in two French administrative areas using a proxy of deviant behavior determined from a reimbursement database. CNS Drugs, 25(5), 415-424. doi: 10.2165/11587640- 000000000-00000 Giardino, W.J., Pastor, R., Anacker, A.M.J., Spangler, E., Cote, D.M., Li, J., …Ryabinin, A.E. (2011). Dissection of corticotropin-releasing factor system involvement in locomotor sensitivity to methamphetamine. Genes, Brain and Behavior, 10, 78-89. doi: 10.1111/j.1601- 183X.2010.00641.x

37. References Jardin, B., Looby, A., & Earleywine, M. (2011). Characteristics of college students with attention- deficit/hyperactivity disorder symptoms who misuse their medications. Journal of American College Health, 59(5), 373-377. doi: 10.1080/07448481.2010.513073 Looby, A. & Earleywine, M. (2011). Expectation to receive methylphenidate enhances subjective arousal but not cognitive performance. Experimental and Clinical Psychopharmacology, 19(6), 433-444. doi: 10.1037/a0025252 McCabe, S.E., Knight, J.R., Teter, C.J. & Wechsler, H. (2005). Non-medical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction, 99, 96-106. doi: 10.1111/j.1360-0443.2004.00944.x National Institute on Drug Abuse. (2009). Stimulant ADHD medications: Methylphenidate and amphetamines. Retrieved from http://www.drugabuse.gov/publications/infofacts/stimulant-adhd-medications- methylphenidate-amphetamines National Resource Center on AD/HD. (2011). Managing Medication for Children and Adolescents with AD/HD. Retrieved from http://www.help4adhd.org/documents/WWK3.pdf

38. References Setlik, J., Bond, G.R., & Mona, H. (2009). Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics, 124, 875-880. doi: 10.1542/peds.2008-0931 Upadhyaya, H.P., Kroutil, L.A., Deas, D. Durell, T.M., Van Brunt, D.L. & Novak, S.P. (2010). Stimulant formulation and motivation for nonmedical use of prescription attention- deficit/hyperactivity disorder medications in college-aged population. The American Journal on Addictions, 19, 569-577. doi: 10.1111/j.1521-0391.2010.00078.x Williams, R.J., Goodale, L.A., Shay-Fiddler, M.A., Gloster, S.P., & Chang, S.Y. (2004). Methylphenidate and dextroamphetamine abuse in substance-abusing adolescents. The American Journal on Addictions, 13, 381-389. doi: 10.1080/10550490490483053