Oftentimes, Attention-deficit/hyperactivity disorder (ADHD) is treated with prescription stimulants. While effective in the treatment of ADHD, stimulants carry a risk for misuse and require additional monitoring for safe prescribing practices. To ensure appropriate use of these medications, it is vital that healthcare providers implement comprehensive monitoring plans to promote both safe and effective prescribing practices. Available monitoring strategies utilized to reduce potential stimulant misuse include risk screenings, urine drug testing, Prescription Drug Monitoring Programs (PDMPs), and patient-provider agreements (PPAs). By utilizing all or a combination of these strategies, prescribers can reduce the risk associated with prescription stimulant use.
Screening for Substance Use in ADHD Treatment
Currently, there are no validated screening tools specifically designed to identify prescription stimulant misuse. However, various risk screenings are available to help clinicians assess the risk of substance misuse across age groups, including adolescents and adults. These tools, recommended by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP), assist in identifying individuals who may be at higher risk for misusing prescription stimulants (AAFP, 2019; Huang et al., 2020; Wolraich et al., 2019). For adolescents, universal screening for substance use is recommended by the AAP for those aged 12 to 17 in pediatric primary care settings (Wolraich et al., 2019). Screenings continue to be crucial throughout adulthood, with an emphasis on young adults (18 to 25 years), as they exhibit the highest rates of prescription stimulant misuse (AAFP, 2019; Huang et al., 2020). Clinicians should familiarize themselves with the range of screening and assessment tools. Utilizing said screening tools helps clinicians identify potential risks for substance use, thereby allowing for the development of personalized treatment plans. There are several validated tools available for substance use screening in adolescents and adults. For adolescents, commonly used tools include the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) and the CRAFFT® (Car, Relax, Alone, Forget, Friends, Trouble) screening tool. In adults, widely used screening tools include the Drug Abuse Screen Test (DAST-10), the Tobacco, Alcohol, Prescription Medication, and Other Substances (TAPS) tool, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and the Global Appraisal of Individual Needs Short-Screener (GAIN-SS). After a positive screening, a brief intervention should be provided, and then either treatment or a referral for treatment should be initiated if the patient is deemed moderate to high risk for substance use.
Click here for a summary of various screening tools for their validated age group and substances to screen.
Toxicology Testing in ADHD Treatment
In addition to the implementation of screening tools, toxicology testing is an important aspect of treatment plans when prescribing controlled substances, including stimulants for ADHD. Urine drug testing can be a useful tool to monitor adherence to prescribed medications and detect illicit substance use that may increase the risk of adverse effects or overdose (AAFP, 2019). The WVACC guidelines recommend urine drug screening/testing at the clinician’s discretion when adults are presenting with signs of misuse. Others recommend that a baseline urine drug test be performed when initiating stimulant treatment for ADHD, with follow-up tests at least annually or more often if concerns arise, such as early refill requests or missed appointments (Huang et al., 2020). For adolescents, although more evidence-based studies are needed, urine drug testing remains a tool that can help clinicians identify and reduce illicit substance use when the clinician deems it necessary. It is important for healthcare clinicians to be trained appropriately in interpreting testing results. False positives or negatives can occur with drug screenings, so confirmatory testing should be utilized to confirm results (Levy et al., 2014).
Read more about Urine Drug Screening and Testing here.
Prescription Drug Monitoring Programs (PDMP)
PDMPs are another vital resource available in nearly every state. For West Virginia, the Controlled Substance Automated Prescription Program (CSAPP) is utilized. This electronic database allows prescribers and dispensers to report and track controlled substance prescriptions. By accessing the PDMP with every prescription, clinicians can ensure that patients are not obtaining prescriptions for stimulants from multiple sources (prescribers and/or pharmacies), a practice that can lead to misuse or diversion. All clinicians or practitioners who prescribe or dispense scheduled medication shall register with the West Virginia Controlled Substance Monitoring Program (CSMP) and maintain online or other electronic access to the program database. Not only must they be registered, but they must also check the CSMP anytime a schedule II, opioid, or benzodiazepine is prescribed to a patient that is not terminally ill and at least yearly thereafter if therapy is continued. It is considered “best practice” to check the CSMP when a new prescription is provided or at least every 3 months.
Read more about Prescription Drug Monitoring Programs here.
Patient-Provider Agreements (PPA) for Prescription Stimulant Therapy
To implement additional diligent prescribing practices, a PPA is recommended when initiating treatment with prescription stimulants. This written agreement outlines the roles and responsibilities of the clinician and patient (or their caregiver) and serves as a safety measure to promote responsible medication use. It includes an understanding of the risks and benefits of stimulant medications, consent for urine drug testing, and the commitment to regular follow-up visits with the clinician. These agreements help ensure that patients and their families are fully informed about the risks and expectations associated with medication use. Additionally, PPA’s can establish clear guidance for the clinician to follow if misuse is suspected or if the benefits of continued stimulant use no longer outweigh the risks (Substance Abuse and Mental Health Administration, 2021; Huang et al., 2020).
Read more Patient Provider Agreements here.
Shared Decision Making with Initiating Therapy
The decision to initiate treatment with a controlled substance, such as a prescription stimulant, should always be a shared decision-making process. By utilizing risk screenings, drug testing, PDMPs, and PPA, healthcare providers can take a comprehensive approach to managing ADHD treatment while minimizing the potential harm. These strategies help clinicians make informed decisions, protect their patients, and foster a collaborative approach that focuses on the therapeutic benefits and the responsible use of medication.
To read more about risk reduction strategies, click here to go to the Risk Reduction Strategy section in the WVACC guidelines.
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Resources
References:
- American Academy of Family Physicians. (2019). Attention-deficit/hyperactivity disorder (ADHD) in adults. American Family Physician. Retrieved from https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit/treatment-and-management.html[1](https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit/treatment-and-management.html)
- Huang, R., Ridout, S. J., Harris, B., Ridout, K. K., & Raja, K. (2020). Pharmacist Medication Management of Adults with Attention Deficit: An Alternative Clinical Structure. The Permanente journal, 24, 19.122.
- Levy, S., Siqueira, L. M., Committee on Substance Abuse, Ammerman, S. D., Gonzalez, P. K., Ryan, S. A., Siqueira, L. M., & Smith, V. C. (2014). Testing for drugs of abuse in children and adolescents. Pediatrics, 133(6), e1798–e1807
- Substance Abuse and Mental Health Services Administration. (2021). Prescription stimulant misuse and prevention among youth and young adults. Retrieved from https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP21-06-01-003.pdf
- West Virginia University School of Pharmacy’s Rational Drug Therapy Program with Expert Panel. (2024). A West Virginia Guide to Evidence-Informed Evaluation, Diagnosis, and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) and Comborbid Concerns. https://wvadhd.org/
- Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTIONDEFICIT/HYPERACTIVE DISORDER. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528
