Advertisement

Pediatric Primary Care Providers Play a Central Role in Reducing Stimulant Diversion

      See Related Article on p.808
      When used as prescribed, stimulant medications such as methylphenidate and amphetamine salts are safe, effective, and Food and Drug Administration approved for attention deficit hyperactivity disorder (ADHD) treatment [
      • Wolraich M.L.
      • Hagan Jr., J.F.
      • Allan C.
      • et al.
      Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
      ]. At the same time, stimulant medications are also increasingly being used nonmedically. Recent epidemiological data suggesting that one in 20 high school seniors reports past-year nonmedical use (NMU) of a stimulant [
      • Teter C.J.
      • DiRaimo C.G.
      • West B.T.
      • et al.
      Nonmedical use of prescription stimulants among US high school students to help study: Results from a national survey.
      ]. Unlike college student motives for perceived academic performance enhancement, motives for high school student stimulant NMU are more aligned with classic substance abuse motives (e.g., “get high”) and substance abuse correlates (e.g., binge drinking, cannabis use) [
      • Teter C.J.
      • DiRaimo C.G.
      • West B.T.
      • et al.
      Nonmedical use of prescription stimulants among US high school students to help study: Results from a national survey.
      ]. Stimulant diversion, or the act of taking medication prescribed to one person and intentionally providing it to another person, is consistently detailed as the most common source of stimulant NMU [
      • Faraone S.V.
      • Rostain A.L.
      • Montano C.B.
      • et al.
      Systematic review: Nonmedical use of prescription stimulants: Risk factors, outcomes, and risk reduction strategies.
      ]. Therefore, reducing stimulant diversion has the potential to subsequently reduce stimulant NMU.
      Stimulant medication prescription rates doubled between 2006 and 2016 [
      • Piper B.J.
      • Ogden C.L.
      • Simoyan O.M.
      • et al.
      Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016.
      ] and the growth has been especially high in adolescents [
      • Zuvekas S.H.
      • Vitiello B.
      Stimulant medication use in children: A 12-year perspective.
      ]. Pediatric ADHD is most often managed in the primary care setting; pediatric primary care physicians (PCPs) are the sole health care providers for more than 40% of youth aged 2–21 years with ADHD [
      • Anderson L.E.
      • Chen M.L.
      • Perrin J.M.
      • Van Cleave J.
      Outpatient visits and medication prescribing for US children with mental health conditions.
      ]. Pediatric PCPs already monitor other concerning behaviors, including adolescent substance use and risky sexual activities [
      • Henry-Reid L.M.
      • O'Connor K.G.
      • Klein J.D.
      • et al.
      Current pediatrician practices in identifying high-risk behaviors of adolescents.
      ], and given their connection to stimulant prescriptions, pediatric PCPs represent a natural ally toward reducing stimulant medication diversion. The American Academy of Pediatrics (AAP) recommends that pediatric PCPs “monitor the adolescent's symptoms and prescription refill requests for signs of misuse or diversion of ADHD medication” (p. 15) and further directs prescribers to two strategies: (1) statewide prescription drug monitoring programs and (2) the use of nonstimulant medications such as atomoxetine and guanfacine [
      • Wolraich M.L.
      • Hagan Jr., J.F.
      • Allan C.
      • et al.
      Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
      ]. This is the only guidance provided to pediatric PCPs regarding stimulant diversion in the most recently updated AAP clinical practice guideline.
      As an initial step toward better understanding the role of pediatric PCPs in reducing stimulant medication diversion (and ultimately stimulant NMU), in this issue of the Journal of Adolescent Health, McGuier et al. [
      • McGuier E.A.
      • Kolko D.J.
      • Joseph H.M.
      • et al.
      Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
      ] provide descriptive data regarding the past 6-month frequency of stimulant diversion prevention strategy use in 76 pediatric PCPs (54 physicians, 22 advanced practice providers). Four categories of diversion prevention strategies were rated by participating PCPs, including (1) the use of patient/family education, (2) medication management/monitoring, (3) assessment of mental health symptoms/functioning, and (4) assessment of risky behaviors. These four categories of strategies were previously developed and used in a stimulant diversion reduction clinical trial aimed at PCPs for college students with ADHD based on their perceived direct or indirect relevance to diversion [
      • Molina B.S.G.
      • Kipp H.L.
      • Joseph H.M.
      • et al.
      Stimulant diversion risk Among college students treated for ADHD: Primary care provider prevention training.
      ].
      The results indicated that pediatric PCPs assessed mental health symptoms/functioning and risky behaviors most or all of the time. Medication management and monitoring and especially the use of patient/family education were done less often by the pediatric PCPs. Provider demographics (age, gender, and years in practice) were not associated with any category of diversion prevention strategy. These descriptive results indicate that pediatric PCPs were using stimulant diversion-specific strategies less often than strategies, which are more universally associated with good quality of care and current practice parameters [
      • Wolraich M.L.
      • Hagan Jr., J.F.
      • Allan C.
      • et al.
      Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
      ].
      A second aim of the McGuier et al.’s [
      • McGuier E.A.
      • Kolko D.J.
      • Joseph H.M.
      • et al.
      Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
      ] study considered determinants of diversion strategy use from a Theory of Planned Behavior (TPB) [
      • Ajzen I.
      The theory of planned behavior.
      ] framework. Attitudes (perceived effectiveness and perceived importance), subjective norms (implementation climate and perceptions about how colleagues view diversion prevention strategy use), and perceived behavioral control (resource barriers, knowledge/skill in diversion prevention) toward diversion strategy use were measured. Unlike reported strategy use, provider characteristics were associated with results. Female PCPs had more positive attitudes about the effectiveness and reported more positive subjective norms (implementation climate). Subjective norms and PCPs diversion knowledge/skill levels were both associated positively with more frequent use of all diversion reduction categories. However, when considered simultaneously, only self-reported knowledge/skill was associated with strategy use. Importantly, resource constraints were perceived to be modest and were not associated with any other TPB factor. Thus, when viewed from the lens of the TPB, efforts to improve PCP knowledge/skill in diversion prevention emerged as a possible intervention consideration.
      McGuier et al. [
      • McGuier E.A.
      • Kolko D.J.
      • Joseph H.M.
      • et al.
      Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
      ] provide the field some much needed direction for stimulant diversion prevention efforts and concluded that the pediatric primary care setting may be a suitable setting for diversion prevention efforts. Brooke Molina et al. at the University of Pittsburgh are currently conducting a National Institute on Drug Abuse-funded longitudinal project investigating if PCP training in diversion prevention strategies impacts TPB factors and ultimately reduces adolescent stimulant diversion (the outcome of paramount magnitude). While we await the results of this trial, PCP knowledge/skill in diversion prevention has emerged as an important proximal target for diversion reduction efforts.
      That pediatric PCP knowledge/skill in diversion prevention is suggested to be a central factor for stimulant diversion reduction is not surprising. In fact, the importance of pediatric PCP knowledge/skill for serving the behavioral and mental health needs of youth has been well known for decades [
      • McMillan J.A.
      • Land Jr., M.
      • Leslie L.K.
      Pediatric residency education and the behavioral and mental health crisis: A call to action.
      ]. Nonetheless, despite making progress in behavioral and mental health knowledge/skill, pediatric PCPs still report low levels of confidence, addressing behavioral and mental health issues [
      • Horwitz S.M.
      • Storfer-Isser A.
      • Kerker B.D.
      • et al.
      Barriers to the identification and management of psychosocial problems: Changes from 2004 to 2013.
      ]. It is encouraging that McGuier et al. [
      • McGuier E.A.
      • Kolko D.J.
      • Joseph H.M.
      • et al.
      Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
      ] did not report structural barriers related to funding were associated with any preventive strategy. Nonetheless, pediatric PCP behavioral and mental health preventive efforts have historically been underfunded [
      • Leslie L.K.
      • Mehus C.J.
      • Hawkins J.D.
      • et al.
      Primary health care: Potential home for family-focused preventive interventions.
      ]. Efforts to improve stimulant diversion prevention in pediatric PCP offices will almost assuredly require rewarding these behaviors.
      Finally, while McGuieret al. [
      • McGuier E.A.
      • Kolko D.J.
      • Joseph H.M.
      • et al.
      Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
      ] grouped PCP knowledge and skill together into one variable, it is possible that efforts to increase knowledge may not automatically increase skill. Relevant PCP knowledge bases of stimulant diversion risk should include (1) general knowledge of parenting behaviors (e.g., monitoring, discipline, and communication) and qualities of parent–teen relationships (e.g., warmth, acceptance, and support) associated with lowered risk for engagement in risky behaviors [
      • Kumpfer K.L.
      • Alvarado R.
      Family-strengthening approaches for the prevention of youth problem behaviors.
      ], (2) specific knowledge about stimulant diversion risk factors such as frequent peer victimization (most days or daily) [
      • Epstein-Ngo Q.M.
      • McCabe S.E.
      • Veliz P.T.
      • et al.
      Diversion of ADHD stimulants and victimization among adolescents.
      ], and (3) comorbid conduct disorder and/or substance use disorder [
      • Wilens T.E.
      • Gignac M.
      • Swezey A.
      • et al.
      Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications.
      ].
      PCP skills for reducing stimulant diversion are presently less empirically supported yet likely could include (1) having ongoing conversations with the adolescent about diversion risk reduction behaviors such as not publicizing stimulant prescriptions to peers and storing medication in a concealed, locked container; (2) role-playing scenarios with the adolescent related to diversion (e.g., peer pressures teen to share medications); and (3) having conversations about the legal and health risks associated with diversion using a motivational interviewing framework, which explores and resolves ambivalence about stimulant diversion. Motivational interviewing is a particularly useful skill for adolescents as it balances their need for independence and the often accompanying psychological reactance [
      • Naar-King S.
      • Suarez M.
      Motivational interviewing with adolescents and young adults.
      ].

      References

        • Wolraich M.L.
        • Hagan Jr., J.F.
        • Allan C.
        • et al.
        Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
        Pediatrics. 2019; 144: e20192528
        • Teter C.J.
        • DiRaimo C.G.
        • West B.T.
        • et al.
        Nonmedical use of prescription stimulants among US high school students to help study: Results from a national survey.
        J Pharm Pract. 2020; 33: 38-47
        • Faraone S.V.
        • Rostain A.L.
        • Montano C.B.
        • et al.
        Systematic review: Nonmedical use of prescription stimulants: Risk factors, outcomes, and risk reduction strategies.
        J Am Acad Child Adolesc Psychiatry. 2020; 59: 100-112
        • Piper B.J.
        • Ogden C.L.
        • Simoyan O.M.
        • et al.
        Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016.
        PLoS One. 2018; 13: e0206100
        • Zuvekas S.H.
        • Vitiello B.
        Stimulant medication use in children: A 12-year perspective.
        Am J Psychiatry. 2012; 169: 160-166
        • Anderson L.E.
        • Chen M.L.
        • Perrin J.M.
        • Van Cleave J.
        Outpatient visits and medication prescribing for US children with mental health conditions.
        Pediatrics. 2015; 136: e1178-e1185
        • Henry-Reid L.M.
        • O'Connor K.G.
        • Klein J.D.
        • et al.
        Current pediatrician practices in identifying high-risk behaviors of adolescents.
        Pediatrics. 2010; 125: e741-e747
        • McGuier E.A.
        • Kolko D.J.
        • Joseph H.M.
        • et al.
        Use of stimulant diversion prevention strategies in pediatric primary care and associations with provider characteristics.
        J Adolesc Health. 2021; 68: 808-815
        • Molina B.S.G.
        • Kipp H.L.
        • Joseph H.M.
        • et al.
        Stimulant diversion risk Among college students treated for ADHD: Primary care provider prevention training.
        Acad Pediatr. 2020; 20: 119-127
        • Ajzen I.
        The theory of planned behavior.
        Organizational Behav Hum Decis Process. 1991; 50: 179-211
        • McMillan J.A.
        • Land Jr., M.
        • Leslie L.K.
        Pediatric residency education and the behavioral and mental health crisis: A call to action.
        Pediatrics. 2017; 139: e20162141
        • Horwitz S.M.
        • Storfer-Isser A.
        • Kerker B.D.
        • et al.
        Barriers to the identification and management of psychosocial problems: Changes from 2004 to 2013.
        Acad Pediatr. 2015; 15: 613-620
        • Leslie L.K.
        • Mehus C.J.
        • Hawkins J.D.
        • et al.
        Primary health care: Potential home for family-focused preventive interventions.
        Am J Prev Med. 2016; 51: S106-S118
        • Kumpfer K.L.
        • Alvarado R.
        Family-strengthening approaches for the prevention of youth problem behaviors.
        Am Psychol. 2003; 58: 457-465
        • Epstein-Ngo Q.M.
        • McCabe S.E.
        • Veliz P.T.
        • et al.
        Diversion of ADHD stimulants and victimization among adolescents.
        J Pediatr Psychol. 2016; 41: 786-798
        • Wilens T.E.
        • Gignac M.
        • Swezey A.
        • et al.
        Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications.
        J Am Acad Child Adolesc Psychiatry. 2006; 45: 408-414
        • Naar-King S.
        • Suarez M.
        Motivational interviewing with adolescents and young adults.
        Guilford Press, New York2011

      Linked Article