INTRODUCTION
The diagnosis of attention-deficit/hyperactivity disorder (ADHD) increased significantly among US adolescents over the past two decades,1 potentially increasing the availability for diversion or misuse of prescription stimulants among this population.2 Currently, no research assesses recent trends in diversion sources for nonmedical prescription stimulant misuse (PSM) among US adolescents. Accordingly, analyses estimated trends in past-year diversion sources for nonmedical PSM among a national sample of adolescents between 2009–2021.
METHODS
This study uses nationally representative cross-sectional data from the 2009–2021 Monitoring the Future (MTF) survey.3,4 Surveys were self-administered by students during normal class periods (protocols were modified between 2019–2021 but did not influence the representativeness of the sample).4,5 The sample size for 2020 was smaller because data collection stopped in March of 2020 due to school closures. The average response rate between 2009–2021 was 80.6%. The University of Michigan’s IRB approved this study. Data were analyzed in December of 2022.
Ten items were used to assess diversion sources for nonmedical PSM, asking respondents: “Where did you get the amphetamines or other stimulant drugs you used without a doctor’s orders during the past year?” Three additional measures were used to assess past-year nonmedical stimulant misuse, current and previous medical use of prescription stimulants, and difficulty of getting prescription stimulants.
Descriptive statistics were used to estimate prevalence rates and 95% confidence intervals (CIs). Binary regression models estimated unadjusted linear trends for diversion sources of PSM. Analyses reported unadjusted odds ratios (ORs) and 95% CIs. Analyses were conducted in Stata 17.0 (StataCorp, LLC) and used the public-use weights provided by MTF.
RESULTS
Table 1 shows past-year nonmedical PSM decreased significantly from 5.94% (95% CI=5.28–6.67) in 2009–11 to 1.53% (95% CI=1.04–2.24) in 2020–21 (linear trend, OR=0.855 [95% CI=0.823,0.889]), while current and previous medical stimulant use to treat ADHD did not change. Regarding diversion sources (see Table 1), the results show three significant changes. First, an estimated 56.72% (95% CI=50.63–62.62) of individuals who reported past-year misuse were given stimulants for free by a friend in 2009–11; this dropped to 39.25% (95% CI=22.38–59.14) in 2020–21 (linear trend, OR=0.836 [95% CI=0.763,0.916]). Second, an estimated 17.75% (95% CI=13.47–23.03) of individuals who reported past-year misuse got these stimulants from their own leftover prescription in 2009–11; this increased to 41.08% (95% CI=24.63–61.30) in 2020–21. Finally, an estimated 19.46% (95% CI=18.38–20.57) of 12th graders indicated it would “probably be impossible” to get stimulants during 2009–11 compared to 28.56% (95% CI=24.78–32.66) during 2020–21.
Table 1.
Past-year Stimulant Misuse and Medical Use and Sources for Stimulant Misuse
| Measures | 2009–2011 n=6818 |
2012–2013 n=4270 |
2014–2015 n=4085 |
2016–2017 n=4006 |
2018–2019 n=4301 |
2020–2021 n=1977 |
Linear trend OR (95% CI) |
|---|---|---|---|---|---|---|---|
| Stimulant use | |||||||
| Past-year stimulant misusea | 5.94% (5.28%–6.67%) | 5.55% (4.84%–6.36%) | 5.48% (4.72%–6.36%) | 5.08% (4.36%–5.91%) | 3.42% (2.89%–4.04%) | 1.53% (1.04%–2.24%) | 0.855 (0.823,0.889) |
| Current medical stimulant useb | 2.86% (2.42%–3.38%) | 4.13% (3.46%–4.93%) | 3.39% (2.81%–4.08%) | 3.48% (2.86%–4.22%) | 3.59% (2.99%–4.32%) | 3.23% (2.38%–4.38%) | 1.02 (0.974,1.07) |
| Previous medical stimulant useb | 4.72% (4.16%–5.35%) | 4.68% (3.97%–5.51%) | 5.77% (4.89%–6.78%) | 4.86% (4.10%-5.74%) | 4.74% (4.02%–5.59%) | 4.57% (3.54%–5.87%) | 1.00 (0.960,1.04) |
| Sources for stimulant misuse | |||||||
| Bought on the internet | 4.68% (2.80%–7.72%) | 8.60% (4.81%–14.90%) | 2.79% (1.25%–6.07%) | 8.36% (4.26%–15.73%) | 5.97% (3.03%–11.40%) | 2.03% (0.27%–13.34%) | 1.02 (0.860,1.23) |
| Took from a friend | 4.99% (3.09%–7.96%) | 2.95% (1.47%–5.84%) | 6.26% (3.40%–11.24%) | 3.14% (1.39%–6.97%) | 5.82% (2.70%–12.12%) | 10.38% (3.20%–28.88%) | 1.06 (0.865,1.30) |
| Took from a relative | 9.40% (6.61%–13.19%) | 5.35% (2.95%–9.50%) | 6.84% (4.04%–11.35%) | 8.98% (5.40%–14.56%) | 10.57% (6.13%–17.63%) | 13.26% (4.84%–30.49%) | 1.04 (0.893,1.23) |
| Given for free by a friend | 56.72% (50.63%–62.62%) | 55.49% (48.29%–62.47%) | 53.78% (45.76%–61.61%) | 41.10% (33.19%–49.50%) | 39.24% (30.61%–48.61%) | 39.25% (22.38%–59.14%) | 0.836 (0.763,0.916) |
| Given for free by a relative | 9.98% (7.02%–13.99%) | 7.54% (4.60%–12.12%) | 9.32% (5.52%–15.33%) | 11.55% (7.17%–18.08%) | 17.83% (11.74%–26.15%) | 13.22% (5.14%–29.99%) | 1.14 (0.995,1.32) |
| Bought from a friend | 45.97% (40.02%–52.04%) | 38.18% (31.66%–45.14%) | 41.32% (33.86%–49.21%) | 41.56% (33.71%–49.87%) | 36.98% (28.34%–46.54%) | 28.02% (14.57%–47.05%) | 0.920 (0.840,1.01) |
| Bought from a relative | 2.75% (1.34%–5.55%) | 1.33% (0.39%–4.34%) | 3.85% (1.94%–7.50%) | 3.90% (1.49%–9.77%) | 5.56% (2.53%–11.74%) | 2.03% (0.27%–13.34%) | 1.18 (0.926,1.51) |
| From a prescription I had | 17.75%** (13.47%–23.03%) | 9.29%** (6.03%–14.04%) | 13.49%** (8.90%–19.94%) | 15.72%** (10.12%–23.61%) | 18.40%* (12.58%–26.11%) | 41.08% (24.63%–61.30%) | 1.08 (0.946,1.23) |
| Bought from a drug dealer/stranger | 21.75% (17.18%–27.13%) | 17.77% (12.90%–23.98%) | 14.88% (10.24%–21.11%) | 11.58% (7.02%–18.52%) | 23.92% (17.24%–32.18%) | 16.17% (6.73%–34.01%) | 0.935 (0.830,1.05) |
| Other | 13.78% (10.22%–18.35%) | 12.30% (8.36%–17.73%) | 12.57% (7.64%–19.99%) | 8.85% (5.18%–14.72%) | 20.77% (13.81%–30.03%) | 12.51% (5.04%–27.82%) | 1.03 (0.900,1.18) |
| Difficulty of getting stimulants c | |||||||
| Probably impossible | 19.46%*** (18.38%–20.57%) | 22.17%** (20.73%–23.69%) | 23.15%** (21.68%–24.69%) | 25.50% (23.94%–27.13%) | 25.52% (23.98%–27.12%) | 28.56% (24.78%–32.66%) | 1.09 (1.07,1.12) |
Notes: The estimates assessing past-year nonmedical stimulant use and sources for nonmedical use came from Form 1 of the Monitoring the Future (MTF) survey (2009–2021; n = 27,684); Estimates assessing difficulty to get amphetamines came from Form 2 of the MTF (2009–2021; n = 27,656); Estimates assessing current and previous medical use of stimulants to treat attention-deficit/hyperactivity disorder (ADHD) come from Form 5 of the MTF (2009–2021; n = 27,567). Only overall sample sizes are proved for Form 1, sample sizes for Form 2 and 5 can be provided upon request.
The questions were assessed with the following item: “Amphetamines and other stimulant drugs are sometimes prescribed by doctors for people who have trouble paying attention, are hyperactive, have ADHD, or have trouble staying awake. They are sometimes called uppers, ups, pep pills, and include drugs like Adderall and Ritalin. Drugstores are not supposed to sell them without a prescription from a doctor. They do NOT include any nonprescription drugs, such as over-the-counter diet pills or stay-awake pills. On how many occasions (if any) have you taken amphetamines or other prescription stimulant drugs on your own—that is, without a doctor telling you to take them...”. Seven response options were provided and ranged from “0 occasions” to “40 or more occasions”.
The questions were assessed with the following item: “Have you ever taken any stimulant-type prescription drugs under a doctor’s supervision for ADHD? [Do not count drugs that are not stimulant-type, like Strattera, Wellbutrin, Provigil, Tenex, Intuniv, or Catapres]”. Response options included “No”, “Yes, in the past, but not now”, and “Yes, I take them now”.
The questions were assessed with the following item “How difficult do you think it would be for you to get each of the following types of drugs, if you wanted some – Amphetamines (uppers, speed, Adderall, Ritalin, etc.).” Response categories included “Probably impossible”, “Very difficult”, “Fairly difficult”, “Fairly easy”, “Very easy”.
Boldface indicates statistical significance
p<0.05
p<0.01
p<0.001
Differences with the 2020–21 cohort (treated as the reference group) were assessed using binary logistic regression.
OR, odds ratio; CI, confidence interval; ADHD, attention-deficit/hyperactivity disorder.
DISCUSSION
Between 2009–2021, the modal diversion source for nonmedical PSM changed from peers to an individual’s own leftover medications. This study also found that while the percentage of 12th graders with current and previous medical use of prescription stimulants to treat ADHD did not change during this time period, the percentage indicating past-year PSM dropped substantially over the past decade among adolescents and should be interpreted as an important reduction in this type of drug misuse. However, PSM among adolescents and young adults remains more prevalent than prescription opioid or benzodiazepine misuse, suggesting that continued monitoring is needed for PSM and diversion within this population.4,6,7
Changes in the modal diversion source, along with the decline in PSM and other drug use, could be a consequence of COVID-related school closures and limited social interaction with peers during 2020–2021.4,8,9 Adolescents who previously obtained prescription stimulants from peers had fewer such opportunities during the pandemic, and therefore may not have engaged in PSM, resulting in those adolescents who engaged in PSM from their own leftover prescriptions to make up a larger proportion of PSM diversion sources. This is further evidenced by the significant increase in students who reported it was probably impossible to obtain stimulants during COVID-19–this could have been further exacerbated by prescribing disruptions in stimulant therapy for ADHD during this period.10
LIMITATIONS
Limitations include using cross-sectional data. Sample sizes were smaller for both 2020 and 2021 due to data collection protocols being interrupted (school closures in 2020) and fewer adolescents engaging in PSM.
CONCLUSIONS
While the results should be interpreted with these limitations in mind, this data provides needed information on prescription stimulant use, misuse and diversion sources during a period where social life for adolescents was seriously disrupted.
ACKNOWLEDGEMENTS
The authors would like to thank Caroline J. Huang, PhD; Zimri S. Yaseen, MD; and Jana McAninch, MD, MPH, MS, of the US Food and Drug Administration (FDA) for their valuable comments and suggestions during the development and progression of this paper. The authors would also like to thank Kathryn Lundquist, ABA, of the University of Michigan, Center for the Study of Drugs, Alcohol, Smoking and Health, for her assistance with proofreading and formatting the manuscript. Additionally, the authors thank the respondents, school personnel, and research staff for their participation in the study. No one received compensation for their contribution to this study.
The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), or FDA.
The development of this study was supported in part by research grants from NIDA, NIH (R01DA001411, R01DA016575, and R01DA031160); and a research award from the FDA (75F40121C00148). The NIDA, NIH, and FDA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Financial Disclosures
Dr PT Veliz has no conflict of interest or financial disclosures.
Dr TE Wilens is or has been a consultant for 3D Therapeutics. Dr Wilens has published the book Straight Talk About Psychiatric Medications for Kids (Guilford Press) and co-edited books ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). Dr Wilens is co-owner of a copyrighted diagnostic questionnaire: Before School Functioning Questionnaire (BSFQ). Dr Wilens has a licensing agreement with Ironshore (BSFQ). Dr Wilens serves as a clinical consultant to the US Minor/Major League Baseball, Gavin House, and Bay Cove Human Services.
Dr Wilens does not have any additional conflicts of interest or financial disclosures.
Dr TS Schepis has no conflict of interest or financial disclosures.
Dr VV McCabe has no conflict of interest or financial disclosures.
Dr SE McCabe has no conflict of interest or financial disclosures.
This study contains the results of secondary analysis of the USA Monitoring the Future (MTF) surveys. The authors followed university and MTF protocol regarding access to and analysis of the data for this study. Data is not available without written consent from MTF and interested researchers can apply for MTF panel data access through the US National Addiction & HIV Data Archive Program (NAHDAP) at the University of Michigan. More information may be found here: https://www.icpsr.umich.edu/web/NAHDAP/studies/37072
CREDIT AUTHOR STATEMENT
Drs Phil T. Veliz and Sean Esteban McCabe had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final manuscript version, accept responsibility for its contents, and approved submission to the American Journal of Preventive Medicine.
Phil T. Veliz: Conceptualization, Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing, Supervision. Sean Esteban McCabe: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Funding acquisition. Timothy E. Wilens: Writing - Review & Editing. Ty S. Schepis: Writing - Review & Editing. Vita V. McCabe: Writing - Review & Editing.
This paper contains original material, not submitted, in press, or published elsewhere, and will not be submitted to any other journal while under consideration by American Journal of Preventive Medicine.
Contributor Information
Phil T. Veliz, University of Michigan, Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109 USA.
Timothy E. Wilens, Harvard University, Department of Psychiatry, School of Medicine, Boston, Massachusetts.
Ty S. Schepis, Texas State University, Department of Psychology, San Marcos, Texas.
Vita V. McCabe, University of Michigan, Department of Psychiatry, Medical School, Ann Arbor, Michigan.
Sean Esteban McCabe, University of Michigan, Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, Ann Arbor, Michigan.
REFERENCES
- 1.Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-year trends in diagnosed Attention-Deficit/Hyperactivity Disorder among US children and adolescents, 1997–2016. JAMA Netw Open. 2018;1(4):e181471. 10.1001/jamanetworkopen.2018.1471. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students (2005–2020). JAMA Netw Open. In press. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Johnston LD, Miech RA, O’Malley PM, et al. Monitoring the Future national survey results on drug use 1975–2021: overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, the University of Michigan; 2022. https://monitoringthefuture.org/wp-content/uploads/2022/08/mtf-overview2021.pdf. Accessed June 20, 2022. [Google Scholar]
- 4.Miech RA, Johnston LD, Patrick ME, et al. Monitoring the Future national survey results on drug use, 1975–2022: secondary school students. Ann Arbor: Institute for Social Research, the University of Michigan; 2023. https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf. Accessed February 27, 2023. [Google Scholar]
- 5.Miech RA, Couper MP, Heeringa SG, Patrick ME. The impact of survey mode on US national estimates of adolescent drug prevalence: results from a randomized controlled study. Addiction. 2021;116(5):1144–1151. 10.1111/add.15249. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.McCabe SE, West BT, Teter CJ, Boyd CJ. Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: connecting the dots. Addict Behav. 2014;39(7):1176–1182. 10.1016/j.addbeh.2014.03.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Schulenberg JE, Patrick ME, Johnston LD, et al. Monitoring the Future national survey results on drug use, 1975–2020: Volume II, college students and adults ages 19–60. Ann Arbor: Institute for Social Research, the University of Michigan; 2021. https://monitoringthefuture.org/wp-content/uploads/2022/08/mtf-vol2_2020.pdf. Accessed February 27, 2023. [Google Scholar]
- 8.Layman HM, Thorisdottir IE, Halldorsdottir T, et al. Substance use among youth during the COVID-19 pandemic: a systematic review. Curr Psychiatry Rep. 2022;24(6):307–324. 10.1007/s11920-022-01338-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Patrick ME, Schulenberg JE, Miech RA, et al. Monitoring the Future Panel Study annual report: national data on substance use among adults ages 19 to 60, 1976–2021. Ann Arbor: Institute for Social Research, the University of Michigan; 2022. https://monitoringthefuture.org/wp-content/uploads/2022/09/mtfpanelreport2022.pdf. Accessed June 14, 2022 [Google Scholar]
- 10.McGrath J ADHD and Covid-19: current roadblocks and future opportunities. Ir J Psychol Med. 2020;37(3):204–211. 10.1017/ipm.2020.53. [DOI] [PMC free article] [PubMed] [Google Scholar]