Treatment Landscape for the Management of ADHD - Episode 13
Transcript: Theresa Cerulli, MD: I want to home in on something you just said about substance abuse and ADHD [attention-deficit/hyperactivity disorder]. What does that mean for a prescriber who's initiating, potentially, a stimulant medication? What are your thoughts? What's the feedback on that, Tim, regarding the safety of stimulants?
Timothy E. Wilens, MD: We know there is a percentage of individuals who misuse and divert their stimulants. Typically, the diverted samples are to college students. But we know of some take-home messages that can really help us out. Number 1, we know there is a difference regarding immediate-release stimulants, and misuse and diversion. The extended-release stimulants are better than immediate-release stimulants. And that's something we can do right away to help reduce the amount of misuse and diversion out there.
Another thing we know is that we need better stimulants. We need short-acting stimulants that can't be ground up and snorted and things like that.
Another thing practitioners can do is educate the person sitting across from you, who may be an adolescent or young adult, and say, “Look, it's not OK to sell your medicine. It's not OK to give it away. That has ethical and legal connotations if you do it. And by the way, when you store it, don't put it in a medicine cabinet. That's where people look for drugs. Put it in a chest of drawers. Keep it safely stored away.”
And finally, the other thing that data help us, as prescribers, understand is we don't need to be sending kids to school with 270 or 360 pills. We don't need these huge reservoirs, because that's where a lot of the diversion is occurring.
Now with e-prescribing, you can prescribe much easier. So I think there are some things you can do to help mitigate some of the abuse liability concerns we have with stimulants and still treat individuals who are in this age group with the most effective agents we have available.
Theresa Cerulli, MD: I strongly agree with what you're saying. My experience with patient care is that safety starts before you even write that first prescription for a controlled substance. It's all about the relationship and the collaborative discussion at the beginning. It's really a verbal contract between the patient and prescriber, isn't it? They're trusting that I'm going to do what I need to do to safely monitor their prescriptions. And that includes things like checking blood pressure and heart rate, and making sure I'm seeing them in follow-up appointments. And in kids, checking height and weight. It also means that they're part of that equation. The patient needs to be responsible about agreeing to attend their follow-up appointments, and agreeing to potentially having random toxicology screens done. They need to agree that they are to be responsible with where they store that medication. And if it happens to disappear, as in it is stolen, lost, etc, it will not be filled early, for their safety. It's an agreement we have before the first prescription is even written.
There are those logistics around managing the stimulant medications. And then, also, thinking about mechanism of action, delivery system, and trying to match what's the best fit for that patient. Some of the medications are going to feel differently to an individual. Vyvanse had those likeability studies done. It was given to a drug abuse population, and they were asked how much they liked that drug. It didn't score very well. I think part of that is because it is a longer-acting preparation, as you've discussed, Tim. The longer-acting preparations tend to be diverted less. So those are some things to think about when you're choosing a therapy, before, again, you even write that first stimulant prescription
Transcript Edited for Clarity