This study analysed data from a cluster-randomised clinical trial of a stimulant diversion prevention workshop administered to paediatric primary care providers (NCT03080259). The aim of the study was to characterise risk variables for stimulant diversion, and their associations with age and sex, for adolescents with ADHD.
Variables included precursors with presumed immediate, direct influence (e.g., being approached to divert, treatment disclosure to peers and intent to divert) and proximal risk factors of intrapersonal (e.g., refusal skill self-efficacy), attitudinal/behavioural (e.g., perceived risk of harm from misuse) and social normative (e.g., descriptive and injunctive norms) influence, as well as distal and/or universal influences (e.g., substance use, sensation seeking, school performance). Adolescents with ADHD (n=357) were recruited from seven practices within 30 miles of the University of Pittsburgh, Pittsburgh, PA, USA. Data were collected over 8 weeks between October and December 2016 (cohort 1) and 2017 (cohort 2). Adolescents and one parent each (85% mothers) completed electronic surveys via separate hyperlinks; a high response rate (95.5%) was achieved through a combination of e-mailing and texting.
Baseline data were collected for 341 individuals (mean age 14.97 years; 75% male). Most had college-educated parents (64%) and an annual household income ≥$100,000 (48%). The majority of individuals were diagnosed with ADHD in elementary school (69%) and by a paediatrician (62%). In terms of Diagnostic and Statistical Manual of Mental Disorders – 5th Edition symptoms for ADHD, 74% met criteria for inattention, 47% for hyperactivity/impulsivity and 76% for inattention or hyperactivity/impulsivity. Amfetamines were prescribed to 37% of adolescents, and 35% reported that their medication was stored in a potentially unprotected or unmonitored location (e.g., out in the open or on top of the fridge).
Diversion and immediate precursors
Diversion was rare (1%), although 25 out of 341 (7%) adolescents reported being approached to divert their ADHD medication: 14 (9 male and 5 female) were approached to share medication, 3 were approached to sell their medication (all male), and 8 were approached for selling and sharing (6 male and 2 female). Of the 22 adolescents who were approached to share their medication, it was usually by an acquaintance (n=10) or close friend (n=6), at school (n=8) and for studying or test-taking (n=12). Of the 11 adolescents with ADHD who were approached to sell their medication, this was most frequently by an acquaintance (n=7), at school (n=5) and for partying (n=4) or studying/test-taking (n=3). Older adolescents (aged ≥15 years, n=194) were more often approached to divert than younger adolescents (aged 13–14, n=157; 11% vs 3%; correlation with age, r=0.25; p<0.001). On average, one group of associates knew about their prescription (51% reported small circle of friends) and, for some adolescents, this was most of their friends (29%) and a small circle of classmates (26%). Older age (aged ≥15 years) was associated with more disclosure of the adolescents’ taking of ADHD medication (r=0.12; p<0.05). Intentions to divert were low, with only 10% of adolescents indicating less certainty about refraining from medication diversion.
Intrapersonal proximal factors
Diversion refusal most commonly included responses such as “tell them no” (81%) and “I don’t give out my pills” (82%). The mean score on the diversion refusal self-efficacy scale was 3.53 (a score of 4 was “very easy”). The refusal skills most commonly endorsed were the same: “tell them no” (87%) and “I don’t give out my pills” (80%). The mean score on the diversion refusal skills subscale was 4.00 (a score of 5 was equivalent to “definitely”). Most adolescents indicated “I definitely would not” give away or sell their medication on the likelihood of diversion subscale (mean score 1.17), where a score of 1 was equivalent to “definitely not”. The situation with the greatest likelihood of diversion was “to a friend or family member who ran out of their medication” (14%).
Attitudinal/behavioural proximal factors
On average, adolescents reported that negative social consequences were “somewhat likely” to occur if they diverted their medication; 91% thought they would lose privileges or be grounded and 79% thought they would be suspended from school. The average rating of stimulant misuse and diversion was considered “somewhat wrong” to “very wrong”, although older adolescents were less intolerant than younger adolescents (r=-0.17; p<0.01).
Social/normative proximal factors
Few adolescents reported having any friends who used their ADHD medication non-prescribed (23%) or who shared or sold their own medication (13%). Older adolescents reported more medication misuse and diversion by friends (r=0.25; p<0.001) and substance use (r=0.34; p<0.001) than younger adolescents. In terms of schoolmates, 54% of adolescents reported having any schoolmates who used ADHD medication non-prescribed and 39% reported schoolmates who shared or sold their own medication. Again, older adolescents reported more misuse and diversion by their schoolmates than younger adolescents (r=0.35; p<0.001). Misuse and diversion by schoolmates was significantly higher than misuse and diversion by friends (t=12.04; p<0.001). Female adolescents reported more perceived disapproval of diversion or unprescribed medication use by their close friends than male adolescents (p<0.01). Older adolescents reported less friend intolerance of misuse and diversion (r=-0.15; p<0.01) and substance use (r=-0.22; p<0.001) than younger adolescents.
Distal and/or universal risk factors
Adolescents were treated for nearly 6 years on average without significant interruption, and female adolescents were treated for fewer years than males (p<0.05). Older adolescents reported higher depression symptom scores than younger adolescents (r=0.18; p<0.01). Adolescents engaged in <2 delinquent acts on average. Substance use was reported in 40% of adolescents and was higher in male versus female adolescents (p<0.05). Older adolescents reported more substance use (r=0.33; p<0.001) and alcohol or drug use problems (r=0.17; p<0.001) than younger adolescents.
Sex differences were minimal. Older age was associated with higher risk on variables relevant to stimulant treatment, such as treatment disclosure (r=0.12; p<0.05), tolerance for stimulant misuse and diversion (r=0.17; p<0.05), and peer norms favourable to stimulant misuse and diversion (r values=0.15–0.34; p<0.001).
A limitation of this study is that the sample was limited to a certain population of the United States and was of a certain demographic (mostly well-educated families, and only 20% were adolescents from racial or ethnic minority groups), which may limit the generalisability of these results.
In conclusion, although diversion was rare in this cohort of adolescents with ADHD treated in primary care, risk levels in this study appeared to be higher for older adolescents than younger adolescents. The authors suggested that prevention methods during adolescence may be effective by targeting psychosocial strengths and having discussions on stimulant-specific attitudes, behaviours and social norms before an adolescent’s vulnerability to diversion increases in the final years of high school and into college.
Molina BSG, Joseph HM, Kipp HL, et al. Adolescents treated for attention-deficit/hyperactivity disorder in pediatric primary care: characterizing risk for stimulant diversion. J Dev Behav Pediatr 2021; Epub ahead of print.