A 20-year-old man comes for an initial visit for treatment of attention-deficit hyperactivity disorder. He is currently in his third year of college and says that he is doing well, but his inattentive symptoms are causing significant problems. Specifically, he frequently loses focus while studying and it takes him much longer than it should to complete assignments. The patient describes a history of hyperactive and inattentive symptoms since second grade. He says, "I could never sit still. I was always running around and getting into trouble with teachers for not listening. I have taken stimulants for most of my life and function better on medication." The patient tolerates stimulants well and has never experienced side effects. He has tried many different stimulant formulations of methylphenidate and amphetamines. He usually needs a high dose, and immediate-release formulations work best. The patient has no other psychiatric symptoms or history. He takes no medications and does not use illicit drugs. Physical examination is normal. Before prescribing medication, which of the following is the most appropriate course of action?

Question

A 20-year-old man comes for an initial visit for treatment of attention-deficit hyperactivity disorder.  He is currently in his third year of college and says that he is doing well, but his inattentive symptoms are causing significant problems.  Specifically, he frequently loses focus while studying and it takes him much longer than it should to complete assignments.  The patient describes a history of hyperactive and inattentive symptoms since second grade.  He says, "I could never sit still.  I was always running around and getting into trouble with teachers for not listening.  I have taken stimulants for most of my life and function better on medication."  The patient tolerates stimulants well and has never experienced side effects.  He has tried many different stimulant formulations of methylphenidate and amphetamines.  He usually needs a high dose, and immediate-release formulations work best.  The patient has no other psychiatric symptoms or history.  He takes no medications and does not use illicit drugs.  Physical examination is normal.  Before prescribing medication, which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: This patient requests stimulant medication and describes a classic history of attention-deficit hyperactivity disorder (ADHD). His request for a high dose, preference for immediate-release formulations, and absence of common side effects raise suspicion for nonmedical use. Physicians must be aware that patients both with and without a history of ADHD may feign or exaggerate symptoms and request stimulants for nontherapeutic purposes, including diversion, misuse, and abuse. Diversion involves transferring medication from the patient to another individual. Misuse consists of taking higher doses to achieve euphoric effects alone or in combination with illicit drugs and is more commonly seen with immediate-release preparations. Students, in particular, may become involved in misusing, sharing, or selling stimulants to peers. Studies indicate that up to one-third of college-age individuals have reported nonprescribed stimulant use. The best approach is to obtain collateral information of a childhood ADHD diagnosis and confirm the dosages of stimulants used. The physician should confirm the long-standing nature of symptoms (DSM-5 requires the presence of symptoms before age 12) and clear impairment in childhood functioning. In addition, the physician must carefully assess the patient's current level of functioning and determine that symptoms currently cause impairment in multiple areas, not just academic performance. The risk of stimulant diversion and misuse can be minimized by prescribing long-acting stimulants with less abuse potential and monitoring prescription refills closely. (Choice A) This patient's presentation raises concern for stimulant misuse and diversion. Although discussing the abuse potential of stimulants would be appropriate, it is more important to confirm the diagnosis prior to prescribing medication. (Choice B) Common stimulant side effects in adults include decreased appetite, insomnia, dry mouth, and irritability. However, confirming the ADHD diagnosis takes priority before prescribing stimulants or discussing side effects. (Choice C) Stimulants are associated with modest increases in blood pressure and pulse; physicians should obtain a cardiac history and physical examination prior to starting stimulants. Routine ECG is not indicated in patients without a history of cardiac disease. (Choice E) A urine drug test would be helpful in identifying current substance use but would not address the question of ADHD diagnosis and treatment. Educational objective: Physicians must consider the possibilities of misuse, abuse, and diversion when confronted with new patients requesting stimulant prescriptions. They should obtain confirmation of childhood diagnosis and treatment of attention-deficit hyperactivity disorder and carefully assess current functioning before prescribing stimulants. References: Stimulant prescription cautions: addressing misuse, diversion and malingering. (http://www.ncbi.nlm.nih.gov/pubmed/23712725) The potential for misuse and abuse of medications in ADHD: a review. (http://www.ncbi.nlm.nih.gov/pubmed/25295651) Misuse of stimulant medication among college students: a comprehensive review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25575768)

A 20-Year-Old Man Comes for an Initial Visit for Treatment