Attention-Deficit Hyperactivity Disorder, Disruptive Behaviors, and Drug Shortage.

CASE: Kyle is a 10-year-old boy with Down syndrome and intellectual disability who is being followed up by a developmental behavioral pediatrician for attention-deficit hyperactivity disorder (ADHD) and anxiety. Kyle was initially taking a long-acting liquid formulation of methylphenidate for ADHD and fluoxetine for anxiety. Several months ago, the liquid formulation was on back order, and the methylphenidate formulation was changed to an equal dose of a long-acting capsule. Kyle is not able to swallow pills; therefore, the contents of the capsule were sprinkled onto 1 bite of yogurt each morning. Over the course of the next month, Kyle's behaviors became increasingly difficult. He was not able to tolerate loud or crowded places, and despite a visual schedule and warnings, he would become aggressive toward adults when directed to transition away from preferred activities. Fluoxetine was increased from 0.4 to 0.6 mg/kg/day at that time.One month later, his parents reported that although there may have been slight improvement in Kyle's irritability since the increase in fluoxetine, they felt he was nonetheless more aggressive and less cooperative than his previous baseline. Kyle was returned to the long-acting liquid formulation of methylphenidate at that time, and a follow-up was scheduled 2 weeks later.On return to clinic, his parents reported that Kyle's behaviors had continued to become increasingly difficult. He was described as uncooperative and aggressive at home and school. Kyle was easily upset any time he was not given his way, his behavior was corrected, or he felt that he was not the center of attention. When upset, he would yell, bite, kick, spit, or throw his body to the ground and refuse to move. At 110 pounds, Kyle's parents were no longer able to physically move his body when he dropped to the ground. This was a safety concern for his parents because he had displayed this behavior in the parking lot of a busy shopping area. Because of Kyle's aggressive and unpredictable behavior, parents no longer felt comfortable taking him to public places. Family members who had previously been comfortable staying with Kyle while his parents were out for short periods would no longer stay with him. Overall, the behaviors resulted in parents being unable to go to dinner as a couple or provide individual attention to their other children. The parents described the family as "on edge." How would you approach Kyle's management?

Ethylphenidate: availability, patterns of use, and acute effects of this novel psychoactive substance.

PURPOSE: Ethylphenidate is a novel psychoactive substance that is an analogue of methylphenidate. This paper describes its availability, patterns of use, and acute effects. METHODS: Searches of the scientific and grey literature (publicly accessible Internet resources) were undertaken, using the keywords "Ethylphenidate", "Ethyl phenidate", "Ethyl phenyl(piperidin-2-yl)acetate", and "Nopaine", to identify information on the prevalence and patterns of use, desired effects, and toxicity of ethylphenidate. An Internet snapshot survey was performed on 10 February 2015 to provide information on availability and cost of ethylphenidate. RESULTS: The literature search identified 1 case series of acute recreational ethylphenidate toxicity, 1 case report of ethylphenidate dependence, 1 qualitative analysis of user reports on Internet drug forums, 2 conference abstracts for surveillance studies, 1 report of two cases of ethylphenidate detected in post-mortem analyses, and 198 user reports on Internet discussion forums and social media sites. The Internet snapshot survey found 83 websites selling ethylphenidate, with purchase prices ranging from £28.20 ± 0.63 (€37.71 ± 0.85) per gram for a 500-mg amount to £2.64 ± 0.57 (€3.53 ± 0.77) per gram for 1 kg. The published cases and Internet user reports suggest the acute effects of ethylphenidate are similar to other stimulant drugs; the most common route of use was by nasal insufflation. The most common desired effects were euphoria, stimulation, and increased concentration, sociability, and energy levels; the most common unwanted effects included anxiety, palpitations, insomnia, and paranoia. CONCLUSION: This review of the scientific and grey literature has demonstrated that the acute harms associated with its use are stimulant in nature and that ethylphenidate is widely available to users over the Internet, with significant discounts for bulk purchases.

Everyday drug diversions: a qualitative study of the illicit exchange and non-medical use of prescription stimulants on a university campus.

This article investigates everyday experiences and practises that are associated with processes of pharmaceuticalization and with practices of 'drug diversion'--that is, the illicit exchange and non-medical use of prescription drugs. It reports results from a qualitative study that was designed to examine the everyday dimensions of non-medical prescription stimulant use among students on an American university campus, which involved 38 semi-structured interviews with individuals who used prescription stimulants as a means of improving academic performance. While discussions of drug diversion are often framed in terms of broad, population-level patterns and demographic trends, the present analysis provides a complementary sociocultural perspective that is attuned to the local and everyday phenomena. Results are reported in relation to the acquisition of supplies of medications intended for nonmedical use. An analysis is provided which identifies four different sources of diverted medications (friends; family members; black-market vendors; deceived clinicians), and describes particular sets of understandings, practices and experiences that arise in relation to each different source. Findings suggest that at the level of everyday experience and practice, the phenomenon of prescription stimulant diversion is characterised by a significant degree of complexity and heterogeneity.

The discrepancy in attention deficit hyperactivity disorder (ADHD) medications diffusion: 1994-2003--a global pharmaceutical data analysis.

OBJECTIVE: The purpose of this paper was to examine the patterns of spending, price, and the utilization of ADHD medications during the 10-year period, from 1994 to 2003 among 4 different per capita GDP group countries. METHODS: This study used the IMS Health database and included both branded and generic ADHD medications. We examined the changes in quantity and price as well as the mixed effects of these changes in the U.S.A. and 3 other groups of countries classified according to their level of per capita GDP. RESULTS: During this study (1994-2003), the U.S. expenditures for ADHD medications increased 594%; sales volume rose by 80%; and price increased by 285%. In other high GDP countries, expenditures increased 493%, sales volume 328%, and price increased by 39%. In the middle GDP countries, expenditures increased 164%, sales volume 141%, and price increased by 9%. In the countries with a lower per capita GDP, expenditures increased 149%, sales volume 464%, however price decreased by 37%. CONCLUSIONS: The launch of long-acting ADHD medications has dramatically increased the total medication expenditure in the U.S. as well as in other high GDP markets. In the other countries quantity was the most important growth factor.

From attention-deficit/hyperactivity disorder to medical stimulant use to the diversion of prescribed stimulants to non-medical stimulant use: connecting the dots.

AIMS: To describe the connections among the likelihood of attention deficit/hyperactivity disorder (ADHD), medical and non-medical methylphenidate and amphetamine use and the diversion of prescribed methylphenidate in the general adolescent population. DESIGN: Cross-sectional self-reported anonymous data from the 2002 Student Drug Use Survey in the Atlantic Provinces. SETTING: The Atlantic provinces of Canada. PARTICIPANTS: A total of 12,990 students participated. MEASUREMENTS: The outcomes were a positive ADHD screening test, medical and non-medical use of methylphenidate, medical and non-medical use of amphetamine and the giving and selling of methylphenidate medication by students with a prescription. The Ontario Child Health Study Hyperactivity Scale was used to screen for ADHD. FINDINGS: The prevalence of a positive ADHD screening test was 6% with no significant gender difference. The prevalence of medical and non-medical methylphenidate use and medical and non-medical amphetamine use was 2.0%, 6.6%, 1.2% and 8.7%, respectively. A positive ADHD screening test was independently predictive of these four patterns of use. About 26% of students with prescribed methylphenidate gave or sold some of their medication. Students in a class where at least one student had given or sold some of their prescribed pills had a 1.52-fold increased risk of non-medical methylphenidate use than their counterparts in classes where no giving or selling had taken place. CONCLUSIONS: Connections were demonstrated at the population level between ADHD, medical methylphenidate use, the diversion of prescribed methylphenidate and the non-medical use of methylphenidate. The appropriate assessment and management of ADHD are essential to minimize both the risk of diversion and of substance use associated with unrecognized or untreated ADHD.

Correlates of methylphenidate use in Canadian children: a cross-sectional study.

OBJECTIVES: This study aimed to estimate the prevalence of methylphenidate (MPH) use among Canadian children aged 2 to 11 years, from 1994-1995 to 1998-1999 and to identify sociodemographic, child, and parent-family correlates are identified. METHODS: Cross-sectional data collections from the National Longitudinal Survey of Children and Youth (NLSCY) for 1994-1995, 1996-1997, and 1998-1999 were used and samples weighted up to population levels (n=17,814 in 1994-1995, 13,575 in 1996-1997, and 18,980 in 1998-1999). Logistic regression identified correlates of parent-reported MPH use in each time period. RESULTS: MPH use by Canadian children increased from 1.33% (95% confidence interval [CI], 1.17% to 1.50%) in 1994-1995 to 1.60% (95% CI, 1.42% to 1.78%) in 1998-1999. Use among school children aged 6 to 11 years increased from 1.94% (95% CI, 1.68% to 2.20%) in 1994-1995 to 2.42% (95% CI, 2.14% to 2.71%) in 1998-1999. Use of MPH increased among girls, from 0.52% (95% CI, 0.32% to 0.67%) in 1994-1995 to 0.97% (95% CI, 0.77% to 1.17%) in 1998-1999. For a child with parent-reported hyperactivity, the odds ratios for using MPH were 6.30 (95% CI, 4.94 to 8.90) in 1994-1995 and 12.54 (95% CI, 9.74 to 16.16) in 1998-1999. Age 6 to 11 years, male sex, and absence of parental alcohol use were significant correlates of MPH use in all time periods. Parental smoking correlated with MPH use in 1994-1995 and in 1998-1999. CONCLUSIONS: Less than 2% of Canadian children used MPH between 1994 and 1999. Some increase in use occurred among school-aged children and girls. Parent-reported hyperactivity was the most important correlate of MPH use.

[Increasing trend in prescription of methylphenidate in general practices in the north-east of The Netherlands, 1998-2003]. / Toenemend aantal voorschriften voor methylfenidaat in huisartspraktijken in Noordoost-Nederland, 1998-2003.

OBJECTIVE: To obtain information on the frequency of and the indications for prescription of methylphenidate in general practices in the north-east of The Netherlands. DESIGN: Descriptive. METHOD: Data were collected from 1998 to 2003 from 6 general practices in the north-east of The Netherlands (17 general practitioners, approximately 30,000 patients) that were affiliated to the Registration Network in Groningen. The number of new and existing patients who were prescribed methylphenidate was calculated by age group per 1000 person-years per calendar year. The indication on which the drug was prescribed was looked at, as was the number of patients who were referred to a specialist on that indication. RESULTS: The number of new users per 1000 person-years more than doubled from 17 in 1999 to 42 in 2003. In all years studied the highest number of new users fell into the age group 5-9 years. The total number of users per 1000 person-years tripled (boys: 1.8 in 1998 and 6.2 in 2003; girls: 0.5 in 1998 and 0.8 in 2003). The prevalence of use in boys was 3 to 8 times as high as that of girls and increasing more quickly. In people under 59 years of age attention deficit hyperactivity disorder (ADHD) was the most frequent indication (55%). In the group aged > or = 60 years methylphenidate was mainly prescribed in the palliative phase of somatic morbidity. Over half of the 140 new patients (57%) were referred nor to a specialist in the year before neither in the year after the first prescription of methylphenidate.

[The use of methylphenidate in children: analysis of prescription usage based in routine data of the statutory health insurance bodies concerning drug prescriptions]. / Der Einsatz von Methylphenidat im Kindesalter: Analyse des Verordnungsverhaltens auf der Basis von Routinedaten der gesetzlichen Krankenkassen zu Arzneimittelverordungen.

UNLABELLED: In Germany only few data is available on the use of stimulants in the treatment of Attention Deficit/Hyperactivity Disorder. For the first time a full survey of health insurance data was carried out on methylphenidate prescriptions from 2000 to 2001 in an East German District. 783 patients of the total cohort received at least one prescription for methylphenidate. In our sample, the treatment prevalence more than doubled in the observation period from 0.6 % to 1.4 % in children aged between 5 and 15 years, this age group representing the largest treatment group. Younger children, adolescents and adults were only rarely treated. The treatment was undertaken predominantly by paediatricians, general practitioners and neurologists/psychiatrists/child psychiatrists. Prescriptions were issued by one, or by not more than two doctors. CONCLUSION: In Mecklenburg-Vorpommern the prevalence of stimulant treatment has clearly increased. Since diagnosis-related data is not available it is not possible to assess the indications for treatment. Further studies should serve to evaluate the correspondence between diagnosis and therapy in relation to stimulant medication.