Dispensing of psychotropic medications to Australian children and adolescents before and during the COVID-19 pandemic, 2013-2021: a retrospective cohort study.

OBJECTIVE: To determine longitudinal patterns of dispensing of antidepressant, anxiolytic, antipsychotic, psychostimulant, and hypnotic/sedative medications to children and adolescents in Australia during 2013-2021. DESIGN: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. PARTICIPANTS, SETTING: People aged 18 years or younger dispensed PBS-subsidised psychotropic medications in Australia, 2013-2021. MAIN OUTCOME MEASURES: Population prevalence of dispensing of psychotropic medications to children and adolescents, by psychotropic class, gender, and age group (0-6, 7-12, 13-18 years). RESULTS: The overall prevalence of psychotropic dispensing to children and adolescents was 33.8 per 1000 boys and 25.2 per 1000 girls in 2013, and 60.0 per 1000 boys and 48.3 per 1000 girls in 2021. The prevalence of psychotropic polypharmacy was 5.4 per 1000 boys and 3.7 per 1000 girls in 2013, and 10.4 per 1000 boys and 8.3 per 1000 girls in 2021. Prevalent dispensing during 2021 was highest for psychostimulants (boys, 44.0 per 1000; girls, 17.4 per 1000) and antidepressants (boys, 20.4 per 1000; girls, 33.8 per 1000). During 2021, the prevalence of dispensing was higher than predicted by extrapolation of 2013-2019 data for many classes, including antidepressants (boys: +6.1%; 95% CI, 1.1-11.1%; girls: +22.2%; 95% CI, 17.4-26.9%), and psychostimulants (boys: +14.5%; 95% CI, 8.0-21.1%; girls: +27.7%; 95% CI, 18.9-36.6%). The increases were greatest for girls aged 13-18 years (antidepressants: +20.3%; 95% CI, 16.9-23.7%; psychostimulants: +39.0%; 95% CI, 27.9-50.0%). CONCLUSIONS: The prevalence of both psychotropic dispensing and psychotropic polypharmacy for children and adolescents were twice as high in 2021 as in 2013. The reasons and appropriateness of the marked increases in psychotropic dispensing during the COVID-19 pandemic, particularly to adolescent girls, should be investigated.

Perspectives of French adolescents with ADHD and child and adolescent psychiatrists regarding methylphenidate use.

Many studies have demonstrated the short-term efficacy and tolerability of methylphenidate treatment adolescents with attention deficit hyperactivity disorder (ADHD). Qualitative literature on this matter focused on school outcomes, long-term side effects, family conflicts, personality changes and stigmatization. Yet, no qualitative study has crossed the perspectives of child and adolescent psychiatrists (CAPs) prescribing methylphenidate and adolescents with ADHD. This French qualitative study followed the five stages IPSE-Inductive Process to analyze the Structure of lived Experience-approach. Fifteen adolescents with ADHD and 11 CAPs were interviewed. Data collection by purposive sampling continued until data saturation was reached. Data analysis, based on a descriptive and structuring procedure to determine the structure of lived experience characterized by the central axes of experience, produced two axes: (1) The process of methylphenidate prescription, highlighting how this prescription was motivated from the exterior, experienced as passive by the adolescents and required commitment from the CAPs; and (2) the perceived effects of methylphenidate treatment, in three domains: at school, in relationships and in the sense of self. Findings raised both the issues of the epistemic position and social representation of the adolescents about ADHD and methylphenidate within this specific French context, and the self-awareness and perception of the adolescents with ADHD. We conclude that these two issues need to be regularly addressed by the CAPs prescribing methylphenidate to avoid epistemic injustice and prevent the harmful effects of stigmatization.

An Overview of Adolescent Psychostimulant Use.

Adolescence marks a period of significant neural maturation and development of lifelong habits, including the potential use of recreational psychostimulant drugs. Increased prevalence of drug adulteration and fatalities related to drug overdose pose new challenges for individuals who use drugs recreationally. As the prevalence of recreational psychostimulant use drastically increases during young adulthood, pediatric and adolescent health care providers can play a crucial role in the lifelong well-being of their patients by identifying those with risk factors for consequences associated with substance use at an early age. This article discusses the epidemiology, pharmacology, clinical manifestations, complications, and common methods of use for three types of psychostimulant drugs-amphetamines, methamphetamine, and 3,4-Methylenedioxymethamphetamine. This article aims to provide pediatric and adolescent health care providers with practical knowledge to effectively perform substance use screening, brief intervention, and referral to treatment with the goal of reducing drug-related morbidity and mortality among the adolescent age group. [Pediatr Ann. 2023;52(5):170-e177.].

Successful Treatment of Post-COVID-19 ADHD-like Syndrome: A Case Report.

Despite inattention being one of the most common symptoms of Post-COVID-19 Syndrome (PCS), there is a gap in the literature regarding its treatment. This report presents a case of attentional symptoms and fatigue that emerged after the SARS-CoV-2 infection. The symptoms were similar to ADHD in adults, although the 61-year-old patient had never experienced inattention symptoms before. The patient was initially treated with Methylphenidate and then Lisdexamfetamine. Both were adapted to the needs and treatment response presented by the patient. After several changes in the therapeutic regimen, including the addition of Bupropion, the patient achieved remission of his symptoms. This case highlights the importance of treating PCS inattention and fatigue as an ADHD-like syndrome, despite the evident different etiology of symptoms. It would be necessary to replicate these findings to confirm our results, thus benefiting other patients currently affected by this syndrome.

Prevalence and Correlates of Prescription Stimulant Misuse Among US College Students: Results From a National Survey.

Objective: There is a high prevalence of prescription stimulant misuse (PSM) among college students in the United States (US). Preventing and identifying PSM requires an understanding of risk factors and correlates, but large-scale surveys regarding this issue have been lacking. We present the largest multi-institution study to date on the correlates of PSM among US college students.Methods: We performed a secondary analysis of the 2017 American College Health Association-National College Health Assessment (ACHA-NCHA), an annual national survey on the demographics, health, and academic experiences of US college students. Logistic regression models examined associations between past-year PSM in 40,645 undergraduate college students and hypothesized risk factors.Results: PSM was reported in 8% of college students. PSM was associated with past-year diagnosis or treatment of depression (adjusted odds ratio [AOR] = 1.16; 99% CI, 1.01-1.33), anorexia (AOR = 1.44; 99% CI, 1.02-2.03), attention-deficit/hyperactivity disorder (AOR = 1.66; 99% CI, 1.41-1.95), and substance use disorder/other addiction (AOR = 1.79; 99% CI, 1.30-2.46). The odds of PSM were 5.5 times higher for students who endorsed past-month use of "Legal drugs" and 8 times higher for students who endorsed past-month use of "Illegal drugs" than for those who did not. Other factors associated with PSM included academic difficulty, daytime sleepiness, fraternity or sorority involvement, White race, and cis-male gender.Conclusions: This study identifies many potential risk factors for PSM among US undergraduate college students. Targeted outreach, prevention, and clinical management are discussed. As the COVID-19 pandemic has exacerbated psychiatric distress, sleep difficulties, substance use, and attentional challenges among college students, this study may serve as a baseline for future studies examining the impact of COVID-19 on PSM among college students.

Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults - United States, 2016-2021.

Prescription stimulant use, primarily for the treatment of attention-deficit/hyperactivity disorder (ADHD), has increased among adults in the United States during recent decades, while remaining stable or declining among children and adolescents (1,2). MarketScan commercial claims data were analyzed to describe trends in prescription stimulant fills before and during the COVID-19 pandemic (2016-2021) by calculating annual percentages of enrollees aged 5-64 years in employer-sponsored health plans who had one or more prescription stimulant fills overall and by sex and age group. Overall, the percentage of enrollees with one or more prescription stimulant fills increased from 3.6% in 2016 to 4.1% in 2021. The percentages of females aged 15-44 years and males aged 25-44 years with prescription stimulant fills increased by more than 10% during 2020-2021. Future evaluation could determine if policy and health system reimbursement changes enacted during the pandemic contributed to the increase in stimulant prescriptions. Stimulants can offer substantial benefits for persons with ADHD, but also pose potential harms, including adverse effects, medication interactions, diversion and misuse, and overdoses. Well-established clinical guidelines exist for ADHD care, but only for children and adolescents* (3); clinical practice guidelines for adult ADHD could help adults also receive accurate diagnoses and appropriate treatment.

Patient visits and prescriptions for attention-deficit/hyperactivity disorder from 2017-2021: Impacts of COVID-19 pandemic in primary care.

OBJECTIVE: To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic. METHODS: Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes. RESULTS: The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic. CONCLUSION: Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

Treatment with stimulants and the risk of COVID-19 complications in adults with ADHD.

Adults with attention deficit hyperactivity disorder (ADHD) have shown higher infection rates and worse outcomes from COVID-19. Stimulant medications are prescribed as the first-line treatment for ADHD in adults and mitigate risk of negative ADHD-related health outcomes, but little is known about the association between stimulant medications and COVID-19 outcomes. The objective of this study was to assess the risks of severe COVID-19 outcomes among people with ADHD who were prescribed stimulant medications versus those who were not. This retrospective cohort study used electronic health records in the TriNetX research database. We assessed records of adults with ADHD diagnosed with COVID-19 between January 1, 2020 and June 30, 2021. The stimulant cohort consisted of 28,011 people with at least one stimulant prescription; the unmedicated cohort comprised 42,258 people without prescribed stimulants within 12 months prior to their COVID infection. Multiple logistic regression modeling was utilized to assess the presence of critical care services or death within 30 days after the onset of COVID diagnoses, controlling for patient demographics, and comorbid medical and mental health conditions. The stimulant cohort was less likely to utilize emergency department, hospital, and intensive care services than the unmedicated cohort, and had significantly lower 30-day mortality. Further research, including prospective studies, is needed to confirm and refine these findings.

Addressing the Treatment and Service Needs of Young Adults with Attention Deficit Hyperactivity Disorder.

The transition from adolescence to adulthood is a complex period in which multiple changes take place (education, work, independent living, and social relations). This stage is especially difficult for adolescents suffering from attention deficit hyperactivity disorder (ADHD), who have to move on from child and adolescent mental health services to adult mental health services. This review analyzes developmental and environmental risk and protective factors as well as critical variables such as executive functioning and self-monitoring that influence the course of ADHD in transitional age youth and guide the priorities for an optimal transition of care. The influence of the COVID-19 pandemic is also discussed. We reflect on the unmet needs for an optimal transition of care and propose practice and policy recommendations to achieve this goal.

Primary Care Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in School-Age Children: Trends and Disparities During the COVID-19 Pandemic.

OBJECTIVE: The aim of this study was to assess rates of primary care provider (PCP) diagnosis and treatment of school-age children with attention-deficit/hyperactivity disorder (ADHD) during the COVID-19 pandemic compared with prepandemic years and to investigate disparities in care. METHOD: We retrospectively analyzed electronic health records from all primary care visits (in-person and telehealth) of children aged 6 to 17 years seen between January 2016 and March 2021 in a community-based primary health care network (n = 77,298 patients). Study outcomes are as follows: (1) number of primary care visits, (2) number of visits with ADHD diagnosis (ADHD-related visits), (3) number of PCP prescriptions for ADHD medications, (4) number of patients with first ADHD diagnoses, and (5) number of first PCP prescriptions of ADHD medications. Interrupted time series analysis evaluated changes in rates of study outcomes during 4 quarters of the pandemic year (March 15, 2020-March 15, 2021) compared with prepandemic years (January 1, 2016-March 14, 2020). Patient demographic characteristics during prepandemic and pandemic years were compared. RESULTS: ADHD-related visits dropped in the first quarter of the pandemic year by 33% (95% confidence interval, 22.2%-43.6%), returning to prepandemic rates in subsequent quarters. ADHD medication prescription rates remained stable throughout the pandemic year. Conversely, rates of first ADHD diagnoses and first medication prescriptions remained significantly lower than prepandemic rates. The proportion of ADHD-related visits for patients living in low-income neighborhoods was lower in the pandemic year compared with prepandemic years. CONCLUSION: Ongoing treatment for school-age children with ADHD was maintained during the pandemic, especially in high-income families. Socioeconomic differences in ADHD-related care emphasize the need to improve access to care for all children with ADHD in the ongoing pandemic and beyond.

Temporal monitoring of stimulants during the COVID-19 pandemic in Belgium through the analysis of influent wastewater.

BACKGROUND AND AIMS: Wastewater-based epidemiology (WBE) is a complementary epidemiological data source to monitor stimulant consumption. The aims were to: (i) study intra- and inter-year temporal changes in stimulant use in Belgium during the first wave of the COVID-19 pandemic; and (ii) evaluate the effect of COVID-19 restrictive measures on stimulant consumption. METHODS: The study population corresponded to the catchments of four wastewater treatment plants corresponding with four Belgian cities (i.e., Antwerp-Zuid, Boom, Brussels, Leuven). Daily 24-h composite influent wastewater samples collected over one week in September 2019 and March through June 2020 during the first wave of the COVID-19 pandemic were analyzed for biomarkers of amphetamine, cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA). Measured concentrations were converted to population-normalized mass loads by considering the daily flow rate and the catchment population size. Mobile network data was used to accurately capture population movements in the different catchment areas. Temporal changes were assessed with multiple linear regression models, and the effect of the COVID-19 interventions on stimulant consumption were investigated. RESULTS: An increase in amphetamine use was observed in three cities during governmental restrictions, with highest consumption predominantly during lockdown. Similarly, cocaine consumption was higher after the pandemic started, with highest consumption noted during the lockdown period in Boom and Leuven. Consumption of MDMA was similar in Antwerp-Zuid, Brussels and Leuven throughout the entire sampled period. In Boom, the highest consumption was observed during the full lockdown period. CONCLUSIONS: The present study shows the potential of WBE to assess the impact of stringent lockdown measures on stimulant use in Belgium. This paper shows that strong restrictive measures did not have a profound effect on stimulant consumption.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis.

PURPOSE OF REVIEW: This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment. RECENT FINDINGS: Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder. SUMMARY: A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

Impact of the COVID-19 pandemic in the Portuguese population: Consumption of alcohol, stimulant drinks, illegal substances, and pharmaceuticals.

BACKGROUND: The measures implemented by governments worldwide to control and prevent the spread of the COVID-19 have impacted the populations and directly influenced individuals' quality of life and consumption habits. OBJECTIVE: This work investigates the Portuguese population's changes in alcohol, stimulants drinks, illegal substances, and pharmaceutical consumptions habits during the COVID-19 pandemic. METHODS: An online questionnaire comprising seven groups of questions-with one group referring to alcohol, stimulant drinks, illegal substances, and pharmaceuticals consumption habits-was made available to the general adult population of mainland Portugal from the 26th January through the 31st of March 2021. After applying the inclusion criteria, 1666 questionnaires were selected and analysed using descriptive and inferential statistics. RESULTS: Our results show that 48.9% of the participants have alcohol drinking habits and increased their alcohol consumption by 16% after the beginning of the COVID-19 pandemic lockdown. Furthermore, 8.7% of the respondents felt the need to increase their consumption of stimulant drinks, especially coffee, the most consumed stimulant drink (77.9%). We also observed that of the 3.1% of respondents who are usual consumers of illegal substances, 26.9% increased their consumption of these substances during the COVID-19 pandemic. Concerning pharmaceuticals, 23.2% of the respondents expressed their need to take a therapeutic drug after the start of the COVID-19 pandemic. The profile of common consumers of alcohol, stimulant drinks, illegal substances, and pharmaceuticals in the COVID-19 pandemic context is contrasting and varies according to gender, age, and employment status. CONCLUSIONS: The COVID-19 pandemic led to an increase in the consumption of alcohol, stimulant drinks, illegal substances, and pharmaceuticals prescribed to treat anxiety, depression, and sleep changes in the Portuguese population. These new consumption patterns have probably aggravated domestic violence, mental diseases, and impairment of family quality of life in the Portuguese population.

Modulatory Effects of Caffeine and Pentoxifylline on Aromatic Antibiotics: A Role for Hetero-Complex Formation.

Antimicrobial resistance is a major healthcare threat globally. Xanthines, including caffeine and pentoxifylline, are attractive candidates for drug repurposing, given their well-established safety and pharmacological profiles. This study aimed to analyze potential interactions between xanthines and aromatic antibiotics (i.e., tetracycline and ciprofloxacin), and their impact on antibiotic antibacterial activity. UV-vis spectroscopy, statistical-thermodynamical modeling, and isothermal titration calorimetry were used to quantitatively evaluate xanthine-antibiotic interactions. The antibacterial profiles of xanthines, and xanthine-antibiotic mixtures, towards important human pathogens Staphylococcus aureus, Enterococcus faecium, Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae, and Enterobacter cloacae were examined. Caffeine and pentoxifylline directly interact with ciprofloxacin and tetracycline, with neighborhood association constant values of 15.8-45.6 M-1 and enthalpy change values up to -4 kJ·M-1. Caffeine, used in mixtures with tested antibiotics, enhanced their antibacterial activity in most pathogens tested. However, antagonistic effects of caffeine were also observed, but only with ciprofloxacin toward Gram-positive pathogens. Xanthines interact with aromatic antibiotics at the molecular and in vitro antibacterial activity level. Given considerable exposure to caffeine and pentoxifylline, these interactions might be relevant for the effectiveness of antibacterial pharmacotherapy, and may help to identify optimal treatment regimens in the era of multidrug resistance.

Risk of Respiratory Infectious Diseases and the Role of Methylphenidate in Children with Attention-Deficit/Hyperactivity Disorder: A Population-Based Cohort Study.

Children with attention-deficit/hyperactivity disorder (ADHD) are commonly affected by medical illness. The aim of the present study was to explore the risks of contracting respiratory infectious diseases (RIDs), including upper and lower RIDs and influenza, in children with ADHD. We also examined whether methylphenidate has a protective effect regarding the risk of contracting RIDs among children with ADHD who have a history of methylphenidate treatment. Children in the Taiwan Maternal and Child Health Database from 2004 to 2016 were included in the present study. Upper and lower RIDs, influenza, ADHD, age, sex, and records of methylphenidate prescription were identified. A Cox proportional hazards regression model was used to estimate the significance of the risk of RIDs among children with ADHD in comparison with that among children without ADHD after adjustment for sex and age. The self-controlled case series analysis was conducted to examine the protective effect of methylphenidate treatment against RIDs. In total, 85,853 children with ADHD and 1,458,750 children without ADHD were included in the study. After controlling for sociodemographic variables, we observed that children with ADHD had significantly higher risks of upper RIDs, lower RIDs, and influenza infection than did those without ADHD. Among the children with ADHD who had a history of methylphenidate treatment, the risk of contracting RIDs was lower during the methylphenidate treatment period than during the nontreatment period. Children with ADHD had a higher RID risk than those without ADHD. Methylphenidate might reduce the risk of RIDs among children with ADHD who have a history of methylphenidate treatment.

Indole Tryptophan Metabolism and Cytokine S100B in Children with Attention-Deficit/Hyperactivity Disorder: Daily Fluctuations, Responses to Methylphenidate, and Interrelationship with Depressive Symptomatology.

Background: Indole tryptophan metabolites (ITMs), mainly produced at the gastrointestinal level, participate in bidirectional gut-brain communication and have been implicated in neuropsychiatric pathologies, including attention-deficit/hyperactivity disorder (ADHD). Method: A total of 179 children, 5-14 years of age, including a healthy control group (CG, n = 49), and 107 patients with ADHD participated in the study. The ADHD group was further subdivided into predominantly attention deficit (PAD) and predominantly hyperactive impulsive (PHI) subgroups. Blood samples were drawn at 20:00 and 09:00 hours, and urine was collected between blood draws, at baseline and after 4.63 ± 2.3 months of methylphenidate treatment in the ADHD group. Levels and daily fluctuations of ITM were measured by tandem mass spectrometer, and S100B (as a glial inflammatory marker) by enzyme-linked immunosorbent assay. Factorial analysis of variance (Stata 12.0) was performed with groups/subgroups, time (baseline/after treatment), hour of day (morning/evening), and presence of depressive symptoms (DS; no/yes) as factors. Results: Tryptamine and indoleacetic acid (IAA) showed no differences between the CG and ADHD groups. Tryptamine exhibited higher evening values (p < 0.0001) in both groups. No changes were associated with methylphenidate or DS. At baseline, in comparison with the rest of study sample, PHI with DS+ group showed among them much greater morning than evening IAA (p < 0.0001), with treatment causing a 50% decrease (p = 0.002). Concerning indolepropionic acid (IPA) MPH was associated with a morning IPA decrease and restored the daily profile observed in the CG. S100B protein showed greater morning than evening concentrations (p = 0.001) in both groups. Conclusion: Variations in ITM may reflect changes associated with the presence of DS, including improvement, among ADHD patients.

Spontaneously Hypertensive Rat substrains show differences in model traits for addiction risk and cocaine self-administration: Implications for a novel rat reduced complexity cross.

Forward genetic mapping of F2 crosses between closely related substrains of inbred rodents - referred to as a reduced complexity cross (RCC) - is a relatively new strategy for accelerating the pace of gene discovery for complex traits, such as drug addiction. RCCs to date were generated in mice, but rats are thought to be optimal for addiction genetic studies. Based on past literature, one inbred Spontaneously Hypertensive Rat substrain, SHR/NCrl, is predicted to exhibit a distinct behavioral profile as it relates to cocaine self-administration traits relative to another substrain, SHR/NHsd. Direct substrain comparisons are a necessary first step before implementing an RCC. We evaluated model traits for cocaine addiction risk and cocaine self-administration behaviors using a longitudinal within-subjects design. Impulsive-like and compulsive-like traits were greater in SHR/NCrl than SHR/NHsd, as were reactivity to sucrose reward, sensitivity to acute psychostimulant effects of cocaine, and cocaine use studied under fixed-ratio and tandem schedules of cocaine self-administration. Compulsive-like behavior correlated with the acute psychostimulant effects of cocaine, which in turn correlated with cocaine taking under the tandem schedule. Compulsive-like behavior also was the best predictor of cocaine seeking responses. Heritability estimates indicated that 22 %-40 % of the variances for the above phenotypes can be explained by additive genetic factors, providing sufficient genetic variance to conduct genetic mapping in F2 crosses of SHR/NCrl and SHR/NHsd. These results provide compelling support for using an RCC approach in SHR substrains to uncover candidate genes and variants that are of relevance to cocaine use disorders.

Patient access to chronic medications during the Covid-19 pandemic: Evidence from a comprehensive dataset of US insurance claims.

Patient access and adherence to chronic medications is critical. In this work, we evaluate whether disruptions related to Covid-19 have affected new and existing patients' access to pharmacological therapies without interruption. We do so by performing a retrospective analysis on a dataset of 9.4 billion US prescription drug claims from 252 million patients from May, 2019 through August, 2020 (about 93% of prescriptions dispensed within those months). Using fixed effect (conditional likelihood) linear models, we evaluate continuity of care, how many days of supply patients received, and the likelihood of discontinuing therapy for drugs from classes with significant population health impacts. Findings indicate that more prescriptions were filled in March 2020 than in any prior month, followed by a significant drop in monthly dispensing. Compared to the pre-Covid era, a patient's likelihood of discontinuing some medications increased after the spread of Covid: norgestrel-ethinyl estradiol (hormonal contraceptive) discontinuation increased 0.62% (95% CI: 0.59% to 0.65%, p<0.001); dexmethylphenidate HCL (ADHD stimulant treatment) discontinuation increased 2.84% (95% CI: 2.79% to 2.89%, p<0.001); escitalopram oxalate (SSRI antidepressant) discontinuation increased 0.57% (95% CI: 0.561% to 0.578%, p<0.001); and haloperidol (antipsychotic) discontinuation increased 1.49% (95% CI: 1.41% to 1.57%, p<0.001). In contrast, the likelihood of discontinuing tacrolimus (immunosuppressant) decreased 0.15% (95% CI: 0.12% to 0.19%, p<0.001). The likelihood of discontinuing buprenorphine/naloxone (opioid addiction therapy) decreased 0.59% (95% CI: 0.55% to 0.62% decrease, p<0.001). We also observe a notable decline in new patients accessing these latter two therapies. Most US patients were able to access chronic medications during the early months of Covid-19, but still were more likely to discontinue their therapies than in previous months. Further, fewer than normal new patients started taking medications that may be vital to their care. Providers would do well to inquire about adherence and provide prompt, nonjudgmental, re-initiation of medications. From a policy perspective, opioid management programs seem to demonstrate a robust ability to manage existing patients in spite of disruption.

Treatment of unexplained coma and hypokinetic-rigid syndrome in a patient with COVID-19.

The COVID-19 pandemic has dealt a devastating blow to healthcare systems globally. Approximately 3.2% of patients infected with COVID-19 require invasive ventilation during the course of the illness. Within this population, 25% of patients are affected with neurological manifestations. Among those who are affected by severe neurological manifestations, some may have acute cerebrovascular complications (5%), impaired consciousness (15%) or exhibit skeletal muscle hypokinesis (20%). The cause of the severe cognitive impairment and hypokinesis is unknown at this time. Potential causes include COVID-19 viral encephalopathy, toxic metabolic encephalopathy, post-intensive care unit syndrome and cerebrovascular pathology. We present a case of a 60 year old patient who sustained a prolonged hospitalization with COVID-19, had a cerebrovascular event and developed a persistent unexplained encephalopathy along with a hypokinetic state. He was treated successfully with modafinil and carbidopa/levodopa showing clinical improvement within 3-7 days and ultimately was able to successfully discharge home.