Stimulant prescriptions jumped during COVID-19 pandemic

Key takeaways:

• From 2020 to 2021, stimulant prescription fills rose more than 10% in certain age groups.
• Most patients who had prescription stimulant fills had health care encounters with ADHD diagnosis codes.

The percentage of people receiving prescription stimulants rose from 2016 to 2021, including large increases during the first year of the COVID-19 pandemic, particularly among adolescent girls and adult men and women, data show.

Melissa L. Danielson, MSPH, a statistician at CDC, and colleagues wrote that, in recent decades, prescription stimulant use — especially for ADHD treatment — has risen among adults in the United States and either remained stable or declined among adolescents and children.

“Stimulants are one type of treatment that can benefit persons with ADHD, but the potential harms associated with these medications, including adverse effects, interactions with other medications, and risk of diversion, misuse and overdose necessitate judicious prescribing and patient monitoring,” Danielson and colleagues wrote.

To describe trends in prescription stimulant fills both before and during the COVID-19 pandemic, the researchers used MarketScan commercial claims data from 2016 to 2021 to calculate the annual percentages of enrollees aged 5 to 64 years in employer-sponsored health plans who had at least one prescription stimulant fill.

Rates increased with the pandemic

Danielson and colleagues found that, in 2016, the percentage of enrollees with at least one prescription stimulant fill was 3.6%. In 2021, that number rose to 4.1%. The largest single-year increases occurred from 2020 to 2021, when prescription stimulant fills jumped by more than 10% in women and girls aged 15 to 44 years and men aged 25 to 44 years.

The researchers wrote that several factors could have contributed to the rise in prescription stimulant use from 2020 to 2021. Not only did the pandemic worsen mental health and possibly exacerbated ADHD symptoms, but changes in health care policy like telehealth flexibilities could have also contributed.

“Future evaluation could determine if policy and health system reimbursement changes enacted during the pandemic contributed to the increase in stimulant prescriptions,” the researchers wrote.

Adult ADHD care

Danielson and colleagues additionally noted that, consistently across the study period, most people who had prescription stimulant fills had health care encounters with ADHD diagnosis codes, and they averaged more than seven fills each year, “suggesting that most were receiving ongoing care for ADHD.”

“The combination of potential increased need and reduced barriers to access prescription stimulants might have encouraged more adults with ADHD symptoms to seek diagnosis and treatment,” they wrote. “Although improved access to ADHD care through telehealth during the pandemic might have benefited some persons with ADHD symptoms, it might have also introduced the potential for inadequate ADHD evaluations and inappropriate stimulant prescribing.”

Daniela and colleagues wrote that the large increase in the number of adults receiving prescription stimulants during the pandemic “draws attention to the need for clinical practice guidelines for ADHD in adults” and that “clinical guidelines similar to those developed for children and adolescents by pediatric medical associations could help clinicians provide best practice care for adult ADHD and support their patients to achieve better outcomes.”

“Well-established professional guidelines for diagnostic procedures and treatment algorithms exist for children and adolescents with ADHD; however, no similar diagnostic and treatment guidelines for ADHD among adults are available in the United States,” they wrote. “This gap in guidance for adult ADHD care is a public health concern because of challenges associated with the differential diagnosis of ADHD and general inadequate access to mental health providers trained to diagnose and manage ADHD.”

Clinical implications and recommendations

In a related editorial, Margaret H. Sibley, PhD, an associate professor of psychiatry and behavioral sciences at the University of Washington and Seattle Children’s Hospital, and colleagues wrote in the Journal of Attention Disorders that the study “highlights that ADHD has arrived as an adult psychiatric condition permeating everyday clinical practice” and “needs to now take its rightful and more central place in adult mental healthcare.”

“Despite its prevalence, clinicians rarely receive relevant specialized training, and may have misconceptions about, or not even recognize, adult ADHD,” they wrote. “Practitioners should understand that ADHD is typically chronic and persists into adulthood, but is often overshadowed by its sequalae (eg, addiction, depression, anxiety, personality disorders) or nontraditional presentations (ie, in women, minorities, older adults).”

Sibley and colleagues also echoed the need for clinical guidelines, writing that “the U.S. is one of the last developed nations without formal ADHD practice parameters for adults.” However, practice guidelines are currently being drafted by the American Professional Society for ADHD and Related Disorders in collaboration with Children and Adults with ADHD.

“Additional guidelines and education should address non-ADHD stimulant use (eg, narcolepsy, long COVID, chronic fatigue), including diversion, misuse, and abuse,” they noted.

To “elucidate the CDC’s findings and organize a public health response,” Sibley and colleagues recommended:

• further analysis of currently available data that answers unresolved questions;
• funding for research on adult ADHD;
• greater attention to the spread of misinformation about ADHD online; and
• collaboration across disciplines and support for adult ADHD practice guidelines and education initiatives for providers.

References:

• Danielson ML, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7213a1.
• Sibley MH, et al. J Atten Disord. 2023;doi:10.1177/10870547231164155.