Attention-Deficit/Hyperactivity Disorder Newsletter Series 1, Issue 1, 2007

METHYLPHENIDATE USE AND ABUSE: EXTENT, PATTERNS, AND PREVENTION

Stephen Soreff, MD
Boston University

Patricia Bazemore, MD
University of Massachusetts Medical School

Methylphenidate (MPH) is both widely prescribed and widely misused and abused. The history of MPH and attention-deficit/hyperactivity disorder (ADHD) has been marked by controversy, but the reality of MPH abuse and misuse is not controversial. What makes this drug’s misuse pattern unusual is that it includes not only misuse by people who obtain the drug through means other than legitimate prescription but also scheduling and dosing alterations by patients with valid prescriptions. This newsletter reviews the evolution of the ADHD diagnosis and the rise of MPH treatment; surveys current abuse, misuse, and diversion activity; and recommends effective misuse prevention strategies.

The second half of the 20th century witnessed a growing interest in an entity that was first called minimal brain dysfunction (MBD) in the 1950s and 1960s. With the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM) II in 1968, MBD became known as hyperkinetic reaction of childhood or adolescence. The term ADHD first appeared in DSM-III, which was published in 1980.¹ Within approximately 20 years, the prevalence of ADHD was estimated to be 2-18% of school-aged children, a group that numbers more than 4 million.² The ADHD diagnosis has now been extended to include adults as well as children.

In 1937, amphetamine was first reported to be an effective treatment for hyperactivity.³ MPH, marketed as Ritalin by Ciba Pharmaceutical (Summit, NJ), replaced amphetamine as the leading treatment for hyperactivity in children following a landmark randomized controlled study by Eisenberg in 1963.⁴ The Centers for Disease Control and Prevention (CDC) report that 2.5 million patients diagnosed with ADHD were taking medication in 2005.² Most of these individuals received stimulants, and 90% of those taking stimulants received MPH.⁵ By 1995, physicians were annually writing 6 million prescriptions for MPH.¹ In 2003, MPH became the most widely prescribed of all Schedule II stimulants in the United States. Schedule II drugs are considered to have a high potential for addiction and include such drugs as amphetamine and cocaine.

The growing acceptance of the ADHD diagnosis in children and adults has increased the use, and subsequent abuse, of MPH.⁶ In one study of college students diagnosed with ADHD who were taking medication for the disorder, more than half of them reported that others have approached them to sell or give away their drugs.⁵ In this way, students with prescribed stimulants can become the suppliers for MPH abusers.⁷

Some of the basic pharmacologic properties of MPH set the stage for abuse. Martin studied the reinforcing effects of MPH on children with ADHD who were taking the medication as prescribed. They reported a sense of confidence, satiety, increased attention, and enhanced concentration as effects of MPH.⁸ Diller, a pediatrician who has devoted his career to the treatment of ADHD, notes that MPH not only normalizes deficits but also induces euphoria.⁹

Given the benefits and improved mood, people taking MPH tend to find it useful all the time. Families report that children in the early grades become worse than baseline in their concentration and behavior when the effects of the medication wear off. As the student matures and enters high school and, particularly, college, his or her personal time and academic time become more intertwined, and students may want to take MPH during most of their waking hours. In addition to the abuse pattern already described, some students may hoard their medications so they will have them on hand and use them to feel good, complete papers, study for exams, or party all night.

MPH is among the most frequently abused drugs on campuses at both the high school and college levels. Teter analyzed a 2003 anonymous questionnaire study that involved more than 21,000 undergraduate students at the University of Michigan.¹⁰ Results showed that more than 8.1% of the sample reported illicit use of prescription stimulant drugs in their lifetime, and 5.4% reported such use in the past year. Top motivators for illicit stimulant use included (1) to improve concentration, (2) to increase alertness, (3) to get high, and (4) to counteract the effects of other drugs (including alcohol). Historically, people have used stimulants for weight loss.

In 2003, Kollins reported that MPH was usually taken as a means to obtain indirect gratification rather than for direct pleasurable impact.¹¹ Indirect gratifications obtained through use of MPH include high grades, socializing with resultant contacts, and completed projects. In the 2003 analysis of drug use on US campuses prepared by Johnston, MPH was second only to marijuana as a drug of abuse.¹² One might think that today’s students turn to the Internet to obtain MPH, but this is not common because of the ready availability of MPH on campuses.

MPH abuse prevention strategies are important to curtail the abuse and misuse patterns described above. Also, some individuals taking MPH as prescribed have experienced psychosis and mood-congruent psychotic symptoms.¹³ MPH has also been shown to increase users’ sexual desire and promote behaviors that put an individual at a higher risk of transmission of sexually transmitted diseases.¹⁴

Physicians who prescribe MPH must follow clearly established diagnostic criteria for ADHD.¹⁵ Caution must be used to ensure that MPH is only offered to patients who legitimately need such a prescription. If a college student presents to student health services and claims to have ADHD, sometimes the first and only step in establishing that diagnosis is for the student to fill out a questionnaire in which the diagnostic answers can readily be anticipated. The student may have an entirely different problem or may be trying to obtain MPH for sale or recreational use. For example, a student with depression might seek MPH rather than an antidepressant medication and therapy because of faulty insight or self-diagnosis. Or, as a Time Magazine senior editor once demonstrated, an MPH prescription can be obtained by simply telephoning a psychiatrist.¹⁶

Patients who are taking appropriately prescribed MPH should be warned of the problems involved with sharing or selling their medications.¹⁷ An MPH prescription requires a monthly visit for refills, which provides an opportunity for additional practitioner oversight. Also, health educational programs directed at adolescents and young adults should inform students of the dangers of MPH abuse.

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