Adult ADHD: Addressing a unique set of challenges

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Applied Evidence

Adult ADHD: Addressing a unique set of challenges

J Fam Pract. 2017 February;66(2):68-74

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References

1. Kessler RC, Adler LA, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716-723.

2. Clemow DB, Walker DJ. The potential for misuse and abuse of medications in ADHD: a review. Postgrad Med. 2014;126:64-81.

3. Novak SP, Kroutil LA, Williams RL, et al. The nonmedical use of prescription ADHD medications: results from a national internet panel. Subst Abuse Treat Prev Policy. 2007;2:32.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5^th ed. Washington, DC: American Psychiatric Association Press; 2013.

5. Kolar D, Keller A, Golfinopoulos M, et al. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4:389-403.

6. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162:1621-1627.

7. Faraone SV, Biederman J. Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry. 2016;73:655-656.

8. van de Glind G, van den Brink W, Koeter MWJ, et al. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend. 2013;132:587-596.

9. Gualtieri CT, Johnson LG. ADHD: Is objective diagnosis possible? Psychiatry. 2005;2:44-53.

10. Perrin AE, Jotwani VM. Addressing the unique issues of student athletes with ADHD. J Fam Pract. 2014;63:E1-E9.

11. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2001;58:775-782.

12. Mészáros A, Czobor P, Bálint S, et al. Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmacol. 2009;12:1137-1147.

13. Weiss M, Shingler T, Capone NM. Medication satisfaction among adults with ADHD: long term results from the Quality of Life, Effectiveness, Safety and Tolerability (Qu.S.T) study. New Orleans: Program and Abstracts of the 19th US Psychiatric and Mental Health Congress, Abstract 120, 2006.

14. Lopez FA, Leroux JR. Long-acting stimulants for treatment of attention-deficit/hyperactivity disorder: a focus on extended-release formulations and the prodrug lisdexamfetamine dimesylate to address continuing clinical challenges. Atten Defic Hyperact Disord. 2013;5:249-265.

15. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90:456-464.

16. Spencer T, Biederman J, Wilens T. Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27:373-383.

17. Withrow LM, Hash PA, Holten KB. Managing ADHD in children: are you doing enough? J Fam Pract. 2011;60:E1-E3.

18. McCabe SE, West BT. Medical and nonmedical use of prescription stimulants: results from a national multicohort study. J Am Acad Child Adolesc Psychiatry. 2013;52:1272-1280.

19. Aldridge AP, Kroutil LA, Cowell AJ, et al. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. Pharmacoeconomics. 2011;29:621-635.

20. Garnier LM, Arria AM, Caldeira KM, et al. Sharing and selling of prescription medications in a college student sample. J Clin Psychiatry. 2010;71:262-269.

21. Molina BSG, Hinshaw SP, Arnold LE, et al. Adolescent substance use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52:250-263.

22. Brahmbhatt K, Hilty DM, Hah M, et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: a concise review. J Adolesc Health. 2016;59:135-143.

23. Post RE, Kurlansik SL. Diagnosis and management of attention-deficit/hyperactivity disorder in adults. Am Fam Physician. 2012;85:890-896.

24. Cepeda MS, Fife D, Berwaerts J, et al. Doctor shopping for medications used in the treatment of attention deficit hyperactivity disorder: shoppers often pay in cash and cross state lines. Am J Drug Alcohol Abuse. 2015;41:226-229.

25. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. 2010;304:875-880.

26. Ross-Durow PL, McCabe SE, Boyd CJ. Adolescents’ access to their own prescription medication in the home. J Adolesc Health. 2013;53:260-264.

Minimize the risk for abuse, diversion using these strategies

As with any drug regimen, it is important to monitor the patient’s response to treatment and minimize adverse effects and outcomes. When the drug is a psychostimulant for adults diagnosed with ADHD, it’s also important to minimize the risk for abuse and diversion. The following steps can help:

Obtain a signed controlled substance agreement.²³ This agreement between the physician and the patient usually outlines such specifics as frequency of office visits, circumstances surrounding medication refills, urine drug monitoring, and pill counts. (For more on the specifics of a controlled substance agreement, see "Key points of a controlled substance agreement.")
Schedule frequent follow-up appointments with open communication about abuse and diversion.^20,23 The age-old adage, “Start low, go slow,” applies to stimulant medications for ADHD. Medication dosage may vary and necessitate titration depending on the person’s weight and tolerance. At the onset of treatment, frequent office visits allow the physician to gauge treatment response and the patient’s commitment to therapy.
Review your state’s prescription drug monitoring program.²⁴ It is imperative that providers check their state’s medical board rules for prescribing controlled medications to ensure practice compliance. As diversion rates of controlled medications have risen in this country, most states have established monitoring systems through their pharmacy boards.²⁴ Although the names of the programs vary, these prescription drug monitoring programs provide information on any medication prescribed. This allows the prescribing physician to ensure patient compliance and ascertain that no other controlled medications are being prescribed that could interfere with treatment. (For more information about state prescription drug monitoring programs, see https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm.)
Perform random urine drug screenings (UDS).^20,23 An important strategy for ensuring adherence to the treatment plan and the controlled substance contract is UDS. Explain to patients that this is a way of making sure they are taking the medication exactly as prescribed. If the UDS indicates that the patient has not been taking the medication, then the provider should intervene by either restricting or discontinuing the controlled substance to prevent or counteract potential diversion. Similarly, if a higher dose is requested by a patient, the provider can closely monitor the situation to determine whether the additional drug is actually being taken and whether the dose is optimal. (See JFP’s October 2016 “3 in 3” video on urine drug testing at: http://bit.ly/2iDnfgD.)
Employ a team-based, multimodal approach.²⁵ A referral to a mental health professional and multimodal treatment are often recommended in the literature as best practices.²⁵ Behavioral therapies are a cornerstone of treatment in adults with ADHD and often serve as important adjuncts to pharmacotherapy. Also, a referral provides a second professional opinion about the patient’s motivations, adherence, and response to treatment.

Trained cognitive behavioral therapists (eg, psychologists, counselors) can be helpful with treatment for ADHD.²³ Therapists can be useful in setting goals for the patient regarding adherence, organization, impulse control, and social skills training. Therapists may wish to involve the family in treatment, depending on the nature of the patient’s presenting issues.

SIDEBAR
Key points of a controlled substance agreementThe primary purpose of a controlled substance agreement is to provide clarity for the provider and the patient regarding the use of controlled medications. The document is meant to prevent potential problems and confusion down the road. There are generally 3 parts:

a doctor/patient agreement
information about medications
patient consent to utilize controlled substances that the provider believes would be beneficial.

Patients are typically told of the potential value of controlled medications in helping them and are warned about the potential for problems should the medications be used in ways other than intended. While wording may differ, patients are generally asked to agree to variations of the following 10 guidelines:

I will talk with my doctor before using more than the prescribed amount of the medicine or discontinuing its use.
I will tell my doctor if new medications are prescribed by another provider.
I will tell the doctor if I become pregnant, so that any necessary medication adjustments can be made.
If I abuse this drug, I understand that the doctor may need to stop treatment.
I will uphold the visit schedule to the office/clinic according to guidelines for controlled substances (eg, every 90 days).
I will refrain from using illicit drugs including marijuana and excessive quantities of alcohol.
I will refrain from sharing, trading, or selling controlled substances.
I will submit to regular urine drug screens as requested by the doctor.
I understand that a failed drug screen may mean discontinuation of treatment.
I will be forthright and honest about how the treatment is going, adverse effects, and how I am taking the medication.

Adapted from: https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf.

Don’t tempt fate. As with any controlled medication, safe storage of psychostimulants is paramount. Patients should be urged to keep their medication in a locked box or cupboard that is accessible to only the adult for whom the drug is prescribed. Prior research cautions that open access to controlled substances can lead to larger issues with abuse and diversion, particularly when adolescents are in the home.²⁶

Men are more than twice as likely to divert medication as women. Consider atomoxetine. Research has also demonstrated that the non-stimulant medication atomoxetine has some benefit in the treatment of ADHD.¹² Unlike psychostimulants that act on the neurotransmitter dopamine, atomoxetine acts on the neurotransmitter norepinephrine. This different mechanism of action results in a lower potential for abuse and diversion.

CORRESPONDENCE
Scott A. Fields, PhD, 3200 MacCorkle Avenue Southeast, 5th Floor, Robert C. Byrd Clinical Teaching Center, Department of Family Medicine, Charleston, WV 25304; sfields@hsc.wvu.edu.