Prescription Stimulant Misuse and Diversion

Prescription stimulant misuse and diversion is an increasing issue of public health and ethical concern, but not often addressed by clinicians. Individuals who abuse stimulants may achieve a “high” via parenteral routes and individuals also misuse psychostimulants to increase academic performance. Short-acting formulations of stimulants have a much greater risk for misuse and diversion compared to long-acting stimulants due to their pharmacokinetic profile and easy crushability. All clinicians involved the prescribing of stimulants need to be alert to the signs of abuse, diversion, and misuse.

• Methylphenidate does not have the same abuse risks as recreational stimulants (e.g. - cocaine) due to slower dissociation from the site of action, slower uptake into the striatum, and slower binding and dissociation with the dopamine transporter protein relative to cocaine.
  • However, this is also due to the fact that prescription stimulants are administered orally. If prescription stimulants are used parenterally (IV or snorted), this can cause similar levels of euphoria.
• Individuals with ADHD plus comorbid substance use disorder or conduct disorder are at greatest risk for misuse.^[1]
  • In certain cases, clinicians may choose to prescribe non-stimulants for ADHD, such as atomoxetine or guanfacine, which do not have abuse potential.

• Slate Star Codex: Adderall Risks: Much More Than You Wanted To Know

• Lakhan, S. E., & Kirchgessner, A. (2012). Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain and behavior, 2(5), 661-677.
• Rasmussen, N. (2008). America’s first amphetamine epidemic 1929–1971: a quantitative and qualitative retrospective with implications for the present. American journal of public health, 98(6), 974-985.
• Martinez-Raga, J., Ferreros, A., Knecht, C., de Alvaro, R., & Carabal, E. (2017). Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes. Therapeutic advances in drug safety, 8(3), 87-99.
• Chang, Z., Lichtenstein, P., Halldner, L., D'Onofrio, B., Serlachius, E., Fazel, S., ... & Larsson, H. (2014). Stimulant ADHD medication and risk for substance abuse. Journal of Child Psychology and Psychiatry, 55(8), 878-885.
• Prescription Stimulant Medication Misuse: Where Are We and Where Do We Go from Here?