A new study has found that large numbers of US adults are prescribed drugs such as amphetamines, which have a risk of abuse, along with medications for depression and anxiety.
The practice, the authors say, could lead to higher rates of abuse and addiction and cause unknown side effects.
Amphetamines and methylphenidate are classified by the Drug Enforcement Administration as Schedule II controlled substances, the same designation given to cocaine, OxyContin and fentanyl.
These drugs, which stimulate the body’s nervous system, are prescribed for a variety of conditions including ADHD, sleep disorders and nasal congestion, but are sometimes prescribed off-label to help treat ailments such as depression and anxiety in combination with other drugs. Off-label prescribing refers to drugs that are prescribed for uses other than those for which they were approved.
“We are concerned about the risks of these drugs,” said the study’s lead author, Thomas Moore, a research scientist at Johns Hopkins University’s Center for Drug Safety and Effectiveness, noting that prescription stimulants are “very potent” and data on their use in combination with other psychiatric drugs is limited. The research was published on Monday in BMJ Open.
“These drugs have a high potential for physical and psychological dependence,” he said. The use of prescription stimulants in combination with other drugs appears to be on the rise, she said, although the study did not compare use with previous years.
The study results were based on claims data from more than 9.1 million adults with private health insurance from October 1, 2019 to December 21, 2020.
Prescription stimulant use was defined as adults filling one or more prescriptions of stimulants that contained amphetamines and methylphenidate, which is the active ingredient in Ritalin.
The researchers found that more than 276,000 adults were using a Schedule II prescription stimulant. Among those adults, just under half — about 45 percent — used the drugs in conjunction with other psychiatric medications, including antidepressants, anti-anxiety medications and opioids.
Some doctors may prescribe a stimulant to treat the side effects of another psychiatric drug or to boost it. This is sometimes called a “prescriptive cascade,” Moore said.
“An antidepressant is prescribed for a patient and maybe one of the side effects is sedation and then they add a stimulant, like amphetamines,” he said. “Or maybe the drug has fairly modest effects and so they add an amphetamine and they’ll get a little more excitement out of it.”
Is depression linked to ADHD?
It’s common for conditions like depression to exacerbate another mental disorder someone might have, said Robert Bassett, associate medical director of the Poison Control Center at Children’s Hospital of Philadelphia.
If one “has worsening or untreated depression, depressive symptoms can make the ability to concentrate more difficult, leading to worsening ADHD symptoms,” she said.
More females, at 52.6%, were using both stimulants and other psychiatric drugs than males, at 36.2%, according to the study.
Additionally, younger people, particularly those between the ages of 19 and 34, were more likely than older adults to take a combination of drugs.
Amphetamine products accounted for 86.4% of stimulant prescriptions, while methylphenidate products accounted for 13.6% of prescriptions.
Dr. Scott Hadland, an addiction specialist at Mass General for Children in Boston who was not involved in the study, stressed “caution” in interpreting the study’s findings.
The study looked at how common it is for people to receive a prescription stimulant in addition to another psychiatric drug, but it didn’t look at whether people abused or were addicted to these drugs, she said.
He also noted that prescribing rates of stimulants like Adderall are on the rise in the United States overall, so someone is more likely to take one or more drugs at the same time. A study published in 2021 found a 79 percent increase in prescription stimulant use among adults from 2013 to 2018.
“It’s not uncommon for people with ADHD to have another condition like depression,” she said.
Moore said he’s concerned about the practice because stimulants along with drugs for conditions like depression and anxiety haven’t been thoroughly tested in clinical trials. Used together, people could experience unpleasant side effects or potentially abuse the drugs.
“We have very little scientific information that this practice is safe and effective,” Moore said.
He noted that while the study is based on commercial health insurance data, it may not represent people participating in government health programs, such as Medicare and Medicaid, or people who are uninsured.
Doctors should prescribe the lowest effective dose possible, Bassett said.
Hadland, of Mass General for Children, said doctors should make sure they are prescribing stimulants “appropriately” and are aware of any other medications a patient may be receiving.
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