Nonmedical use of psychoactive stimulant medication (medication that is prescribed for the treatment of Attention-Deficit/Hyperactivity Disorder;ADHD) is an increasingly prevalent form of prescription drug misuse among young adults and in particular college students (Smith &Farah, 2011;Wilens et al., 2008). Prevalence rates of nonmedical use (use without a prescription) on college campuses are rising (e.g., DeSantis et al., 2008). Stimulant-related emergency department visits have increased threefold in recent years (SAMHSA, 2013a). College students with prescriptions are the primary source of stimulant diversion (giving away or selling one's medication). However, no clinical strategies for management of this problem have been developed for primary care providers - a professional population that frequently treats ADHD and that is being targeted by NIDA (Volkow, 2012), especially with regard to nonmedical use of prescription drugs including stimulants (Volkow, 2010). Our preliminary focus groups with primary care providers revealed either lack of awareness about stimulant diversion/misuse or lack of strategies for addressing it;all indicated concern. This R34 application proposes the initial development of brief clinical strategies that primary care providers may use to prevent diversion of stimulants by their patients with ADHD. We focus on family medicine and pediatric providers treating 18-25 year olds in post-secondary education. Within the context of the R34 Program Announcement PA-12-171, Pilot and Feasibility Studies in Preparation for Drug and Alcohol Abuse Prevention Trials, we will 1) survey providers and their physician-extenders (nurse practitioners and physician assistants) about their current practices;2) develop and pilot test strategies for prevention of diversion to e utilized within the context of the provider:patient relationship;and 3) examine, using post- implementation survey and EMR data, provider, practice, and patient variables associated with feasibility, satisfaction, and implementation. We base our selection of variables to consider in strategy development and evaluation on Weiner's theory of innovation implementation (Weiner et al., 2009). We propose inclusion of key stakeholders (community providers) and relevant consultants in the development process to enhance innovation feasibility and implementation. The development of these strategies will be innovative due to their complete absence in the evidence-based ADHD treatment guidelines literature. The project addresses an immediate public health concern: escalating non-prescribed use of a Schedule II prescription medication (CNS stimulants) by college students. Addressing this knowledge gap has the ultimate potential, following an R01- funded well-powered study of effectiveness and moderators, to provide one pragmatic, low cost, and highly disseminable means by which prescription stimulant diversion may be decreased.
This study addresses the marked increase in diversion of prescription stimulant medications, particularly in post-secondary education, by young adults in treatment for ADHD. In complete absence of any type of clinical strategies or interventions to prevent or decrease stimulant diversion, this project will develop pragmatic, testable, and highly disseminable strategies within the primary care provider:patient relationship with the ultimate goal of reducing stimulant diversion and related consequences.