Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for the initiation of substance use and subsequent substance use disorders, including prescription stimulant misuse. While stimulant therapy effectively manages ADHD symptoms and reduces long-term negative consequences associated with untreated ADHD, ongoing controversies persist within clinical and public health domains. Concerns have been raised regarding the use of prescription stimulants based on the pharmacological similarities between prescription and illicit drugs like cocaine and methamphetamine, as well as studies demonstrating a higher prevalence of prescription stimulant misuse among older adolescents and young adults treated with stimulants. Consequently, recent research has focused on identifying patient characteristics or prescribing patterns linked to heightened risk of stimulant misuse.
In a recent study, researchers, including Timothy Wilens, MD, Chief of the Division of Child and Adolescent Psychiatry and the Co-Director of the Center for Addiction Medicine at Mass General Hospital, analyzed data from a multi-cohort national study in order to examine whether age at initiation of treatment and duration of prescription stimulant therapy for ADHD are factors that affect risk of use of cocaine and methamphetamine and prescription stimulant misuse during late adolescence.
In a nationally representative sample of US 10th and 12th grade students (N = 150,395) drawn from the Monitoring the Future study, students were surveyed via annual self-administered questionnaires (2005-2020). According to self-reported data, an estimated 8.2% of youth received stimulant therapy for ADHD at some point in their lifetime (n = 10,937). More than one in ten of all youth reported past-year prescription stimulant misuse (10.4%). Past-year cocaine use (4.4%) and methamphetamine use (2.0%) use were less common.
Youth who initiated stimulant therapy for ADHD at a younger age (9 years of age or younger) and who reported a longer duration of treatment (6 years or longer) did not have a greater likelihood of cocaine or methamphetamine use, compared to controls (youth without ADHD and youth with unmedicated ADHD). In contrast, youth who initiated stimulant therapy for ADHD at a later age (10 years of age or older) and who reported a shorter duration of treatment (less than 1 year) were more likely to report past-year cocaine use, methamphetamine use, or prescription stimulant misuse than population controls.
Just to put this in perspective, those initiating stimulant therapy for ADHD after 15 years of age and reporting shorter duration of stimulant therapy were 2 to 4 times more likely to report stimulant prescription misuse than those who initiated treatment before the age of 10 years and reported longer duration of stimulant treatment.
Clinical Implications
This study observed an inverse relationship between years of stimulant therapy and subsequent use of illicit drugs and prescription stimulant misuse. Earlier initiation of treatment and longer duration of stimulant therapy for ADHD were associated with lower risk for prescription stimulant misuse and/or cocaine use in late adolescence compared to later initiation and shorter duration of stimulant therapy for ADHD. This study contributes to a growing body of evidence indicating better outcomes in youth receiving earlier versus later initiation of ADHD stimulant therapy, a finding that suggests the existence of a sensitive developmental period. Some experts hypothesize that early identification and appropriate medication management may decrease core ADHD symptoms, such as impulsivity, and may promote adaptive behaviors that could reduce risk of substance use disorders in youth with ADHD.
Further research is needed to identify other factors associated with stimulant misuse and illicit drug use, specifically ADHD severity and adverse childhood experiences. The lack of an ADHD severity measure in this study represents an important limitation, as ADHD severity will influence age at treatment initiation, duration of treatment, and type of ADHD medication (stimulant or non-stimulant).
The findings of the present study reinforce the importance of prompt evaluation for ADHD in children exhibiting possible ADHD symptoms. While parents and clinicians may understandably want to avoid or delay using medications for the treatment of ADHD, this study indicates that delaying treatment may carry additional risks. In addition to the negative consequences of untreated ADHD on academic performance and psychosocial development, later initiation and shorter duration of treatment may be associated with increased vulnerability to illicit substance use and prescription stimulant misuse later on.
In addition, the research team recommends that adolescents with later initiation and/or shorter duration of stimulant treatment for ADHD should be monitored for potential illicit drug use and prescription stimulant misuse.
Other contributors to this research include Sean Esteban McCabe, Olivia Figueroa, Vita V. McCabe, Ty S. Schepis, John E. Schulenberg, Philip T. Veliz, and Kennedy S. Werner.
Funding Sources: This manuscript is a secondary analysis using datafrom the Monitoring the Future study. The developmentof this article was supported by a research award75F40121C00148 from the US Food and Drug Admin-istration (FDA) and research awards R01DA001411,R01DA016575, R01DA031160, R01DA036541,UH3DA050252 and R01DA043691 from the NationalInstitute on Drug Abuse (NIDA) and the NationalInstitutes of Health (NIH).[/su_accordion]
Read More
McCabe SE, Figueroa O, McCabe VV, Schepis TS, Schulenberg JE, Veliz PT, Werner KS, Wilens TE. Is age of onset and duration of stimulant therapy for ADHD associated with cocaine, methamphetamine, and prescription stimulant misuse? J Child Psychol Psychiatry. 2024 Jan; 65(1): 100-111.
