7

Public Health Considerations and Harm Reduction Strategies

Discussions on key themes from throughout the workshop focused on considering next step opportunities for improving the diagnosis and treatment of adults with ADHD through a public health lens, including harm reduction strategies to curb misuse of prescription stimulants. Blanco introduced this session by saying that what is needed is “a roadmap about where we want to go next.”

A PUBLIC HEALTH APPROACH TO ADHD

The significantly shorter lifespan and health span of adults with ADHD (Barkley and Fischer, 2019), and the association of these statistics with unhealthy behaviors, indicates that ADHD is a public health issue in addition to a mental health issue, “and one that professionals in primary care need to be able to identify and address,” said Solanto. Citing a 2021 Surgeon General’s advisory that identified health misinformation as a public health threat (Office of the Surgeon General, 2021), Patel suggested that the amount of misinformation being circulated about adult ADHD itself constitutes a public health issue.

Indeed, the CDC began to focus on adult ADHD in the last few years using a public health framework, said Robinson. This framework describes a stepped process that begins by defining the problem on a population level, quantifying the prevalence of ADHD and other co-occurring conditions. Successive steps include identifying risk and protective factors, developing and testing prevention strategies, and working to ensure widespread adoption of these strategies. This is a cyclical model, said Robinson, in which each step feeds back on the previous step and informs the next, and a model that seeks to continuously improve access to information, support, and treatment.

The CDC has added three new items to its surveys to expand surveillance on adult ADHD, said Robinson. A survey using the NCHS Rapid Surveys System¹ should provide “very much needed new national prevalence estimates on adult ADHD,” information from patients themselves on the role of telehealth in their diagnosis and treatment and estimates of the impact of the U.S. stimulant medication shortage on adults with ADHD. Results will be available in the spring of 2024, she said. Data from the recently completed DocStyles survey of providers should provide information on providers’ comfort and knowledge on identifying and treating adult ADHD. Adult ADHD will also be included in the 2025 National Health Interview Survey, along with other questions on mental and physical health, to observe associations between ADHD and other conditions (NCHS, 2019). Additional potential content areas for questions include “diagnosis, type of provider who provided the diagnosis, severity and functional impairment, medication treatment, perceptions on effectiveness of treatment, telehealth, and . . . misuse and diversion,” she added.

Adopting Ethical Principles for Prescribing Drugs

So that ADHD patients can receive medical treatment that is in their best interest and aligns with managed care pharmacy, it could be helpful for insurers to adopt ethical principles that have been developed by the Institute for Clinical Economic Review, said Rubin. For example, prior authorization should not require that a patient step through a product that is less safe or more harmful than the intended product; the first product in a step-through should have a reasonable chance of working. Managed care “should be asked to adopt these guidelines through accreditation, policy, or law, and bring that relationship back to the first party, between patient and physician,” said Rubin.

Prescribing behaviors for ADHD have been influenced by the opioid crisis, said El-Sabawi. A public health approach to stimulant use should

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¹ Available at https://www.cdc.gov/nchs/surveys.htm (accessed February 20, 2024).

seek “to understand how we can reduce the harms of stimulant use . . . with respect and dignity for all people who use drugs,” centering their experience while “push[ing] back against the idea of drug seekers.”

The Impacts of the Prescription Stimulant Shortage

The FDA announced a shortage of Adderall on October 12, 2022 (FDA, 2022). Based on preliminary data analyzed by the CDC (Danielson et al., 2023), the Adderall shortage may have impacted trends in prescription stimulant fills, said Robinson. She noted that children ages 5–14 receive mostly methylphenidate-based stimulants, and their prescription fills rose predictably during the third and fourth quarters of 2022, reflective of seasonal trends with usage lower in the summer months and higher during the months coinciding with the school year. In contrast, individuals ages 15–49 are more likely to receive prescriptions for Adderall and other amphetamine-based stimulants, and these fills fell during the same period.

The prescription stimulant shortage has collided with the quagmire of prior authorization to create a “mess of epic proportions,” said Robin Weiss, past president of the Maryland Psychiatric Society. In Weiss’s home state of Maryland, pharmacies are “entirely erratic and unpredictable” in their stock of stimulants, so that providers and patients often do not know which drugs will be available or in which dosage forms. Mandatory electronic prescribing prevents patients from moving their prescriptions from one pharmacy to another. As a result, the provider must submit multiple electronic prescriptions for each patient to find a pharmacy that stocks the drug. Mahome receives “tons of messages every day from students . . . asking [me] to send the prescription to a different pharmacy.” Goodman relayed a story of a colleague of his who had to call 15 pharmacies to find medication for a single patient last week.

Rosier highlighted the irony of her clients’ facing difficult or unnecessary tasks to obtain medication for their ADHD while they are off medication. The shortage has been “very real—it has impacted a lot of us greatly,” said Mahome, who treats patients with ADHD and has ADHD herself. Mahome described her experience being off her medication for two and half months. “It’s overwhelming having ADHD and not being treated,” she said. She shared the difficult of dealing with a sudden switch from a 16-hour medication to one that she needs to take three times daily but usually remembers only once a day, “even with alarms.” ADDA has done extra training “to help people deal with all the chaos that goes along with them not being able to receive treatment” and to educate people about nonstimulant options, “but it’s been tough work,” said Obeng.

“We understand the impact of the shortages,” said Sokolowska, citing a joint FDA/DEA letter that emphasized how closely federal partners

are working together with industry to address this issue (FDA and DEA, 2023). She noted that the FDA has approved new stimulant and nonstimulant medication for ADHD and granted authorization for the first diagnostic device.

Regulation and Access to Treatment

The regulatory barriers put in place to address the opioid crisis have created roadblocks that severely impact access to stimulant medication, said El-Sabawi, sharing remarks provided by Jennifer Oliva, professor, Indiana University Maurer School of Law, who was unable to attend. Because prescription drug monitoring programs are developed at the state level, said El-Sabawi, states “have different rules, different flags, and they are quite complex.” Data on prescribing behavior are shared with law enforcement, and this engenders fear in physicians and a reluctance to prescribe any controlled substances. Some primary care practices have established hardline rules against prescribing stimulants and treating adults with ADHD, said El-Sabawi, noting that each physician’s office has different rules, “and some of these go all the way up to the hospital-owned outpatient practices,” where the hospital dictates the rules.

Given that filling stimulant prescriptions across state lines is complicated, students attending college outside their home states may have to establish themselves with a new provider to get refills on their existing prescriptions. At the same time, Gold said, “a lot of primary care providers [on college campuses] won’t touch stimulants with a ten-foot pole.” To ease this bottleneck while maintaining continuity of care, Gold advocated for universal licensing or telehealth prescriptions.

The rules imposed by state-level prescription drug monitoring programs also put pharmacists at risk, noted El-Sabawi. For example, in Florida, many state laws govern controlled substances. She said that pharmacies can lose their ability to order stimulant medications if they violate a state law, which could happen if they fill too many new stimulant prescriptions from one doctor. Further complicating matters, she added that “we don’t truly understand the number of regulatory barriers because they differ by state,” and interpretation of the regulations on the part of pharmacists can vary as well.

Distributors constitute another level of control, said El-Sabawi. After being sued over the opioid crisis, distributors developed proprietary software to monitor the supply of controlled substances. If this software flags a pharmacy, that pharmacy can be locked out from receiving a drug. This happened to the University of Miami pharmacy, which won a state contract to offer buprenorphine and as a result had a sudden increase in prescriptions, causing it to be flagged and locked out of

receiving the drug. “There’s no way around these new proprietary systems,” said El-Sabawi.

In addition to state prescription drug monitoring programs, the DEA is “the elephant in the room,” said El-Sabawi, with its own regulations, including a prohibition against transferring a prescription for a controlled substance from one pharmacy to another. Weiss noted that this rule was modified in August to allow patients to request a one-time prescription transfer, but none of the three pharmacies she contacted had heard of it.

Tension between Insurance Companies and Drug Enforcement

With insurance companies refusing to cover longer-acting stimulants and many nonstimulants, providers are being pushed to prescribe short-acting stimulants, but these are what are being criminalized, said Higgins. Furthermore, in the effort to shut down pill mills, law enforcement is targeting doctors. “It’s a very real threat when you hear of a colleague where [the DEA comes] in . . . and [drags] you out to the parking lot,” he said. This drives a fear of law enforcement that influences prescribing habits, and “we’re not talking enough about that.”

“The residents are scared to prescribe stimulant medication,” said Mahome. “Those that want to learn how to prescribe stimulant medication might get an hour to meet with someone like me . . . but they’re very discouraged from assessing for ADHD and treating it because of the potential risks.”

While misuse and abuse of stimulant medications are a “pressing issue,” Goodman warned against dealing with this by scaring physicians. “You, as a clinician, may read some popular literature that demeans ADHD in adults, that threatens your license because you are writing stimulant prescriptions.” The uneducated clinician will respond by giving up writing prescriptions for stimulant medications. “And if I cannot write the prescription, I do not make the diagnosis,” he said. These increased restrictions on medication “are being implemented in ways that discriminate as well,” added El-Sabawi. Due to implicit bias, she noted, people of color are less likely to get opioids for pain and more likely to be identified as drug seekers.

“Before we start restricting access for patients who need stimulants, based on the fear of replicating the opioid crisis, it’s incumbent on us—and by ‘us’ I mean researchers—to gather data on the actual prevalence of dangerous misuse of prescription stimulants. And I’m emphasizing the dangerous part,” said Weiss. “I don’t know if addiction is a huge problem with adults with ADHD,” said Gordon; “mostly we forget to take it, which is really not a sign of addiction.”

The Impact of Medication Access on Patients’ Lives

Patrick Kelly provided his perspective as an adult with ADHD and a history of SUD. He had open-heart surgery as a young child for a congenital heart defect, was subsequently diagnosed with ADHD, and has taken stimulant medication for most of his life despite the cardiovascular risk, because the benefit was determined to outweigh the risk. Kelly described his childhood self as “hyperactive, impulsive, and lacking any form of self-awareness.” He also had learning disabilities, and though he performed well on tests, his grades were low, and he was frequently sent to the principal’s office. Kelly emphasized that the fallout of his ADHD was “not limited to childhood. I’ve lost jobs, missed opportunities, had failed relationships and various other things, and struggled with executive function as an adult.” In college, Kelly discovered alcohol and often drank to excess “to numb the emotional pain that was caused by ADHD—the rejection, the disappointment, the constantly being told I had potential but finding it nowhere.” Kelly used his stimulant medication as prescribed from age 22 to 23 but then stopped taking it at 24 and drank heavily for several years after that. Nonetheless, he said, “the stimulant medication helped stabilize me during those years, and it helped me get sober at age 26. . . . The two most important things I do on a daily basis are stay sober and manage my ADHD. The way I do that is through medication, support groups, therapy, extensive personal education, and building a life around systems, habits, and routines that address those two things.”

Restricting access to stimulant medication threatens his survival, said Kelly: “When access to medication is restricted it puts my sobriety, and subsequently my life, at risk. When there’s prior authorization, specific time windows, when it’s classified as a Schedule II drug, or God forbid that I advocate for myself or state that I don’t think this medication is working or that this dose is not effective, I am looked at as a drug-seeking addict instead of someone with a severe developmental disorder tenaciously and with good intentions trying to fit into a neurotypical world that is not designed for me.”

The most important thing the FDA could do right now, from a public health perspective, is “to get people their medications,” said El-Sabawi, noting that “more and more people are turning to pressed pills because they cannot access their ADHD medication, and they are going to the dark web.” “Let’s not do the opioid crisis again,” she said, where “you close in on the supply of the prescribed medication, people go to the illicit market, and we get a spike in deaths.”

Training and Clinical Education on Adult ADHD

Training Psychiatric Residents

For physicians to become better at treating ADHD in adults, “we need to get the educational professional programs to acknowledge that adult ADHD is a real disorder for which you need to train,” said Goodman. The adult ADHD clinical practice guidelines currently in development seek not only to standardize care but “to standardize the validity of the diagnosis” and put pressure on accrediting agencies to get professional training programs to include adult ADHD “as a real focus for their curriculum,” he said. Solanto agreed, “Even when we have such guidelines, we’re going to need professionals who are trained and able to administer these treatments, and we . . . are far from having that sufficiently. It’s so important that training in diagnosis and treatment of ADHD be included in residency programs, which it is not.” This will require government agencies and organizations to commit “tens of millions of dollars of education,” and a concerted effort by a body of experts to develop national coursework, said Goodman.

Gold noted that psychiatric residents are trained primarily in inpatient care, which consists of “a lot of psychosis, a lot of bipolar, a lot of severe depression,” and very little ADHD. Given the paucity of even outpatient clinics focused on ADHD, this would likely require providing residents with specific opportunities to “see clinical cases with ADHD [and] make that a more specific focus for . . . residents with supervision.”

Training General Practitioners and Nurse Practitioners

Arnsten highlighted the “great need” for general practitioners to receive education in adult ADHD. Given that many adults are treated by general practitioners and nurse practitioners, she said, “this information has to go back to medical school, nursing school,” most of which “never even teach about prefrontal cortex,” leaving clinicians ignorant of the mechanisms that underlie ADHD therapeutics. Many “practitioners and patients don’t even know of nonstimulant possibilities,” said Arnsten.

Noting that “a lot of primary care providers won’t touch stimulants with a ten-foot pole,” creating a bottleneck of college students waiting to see psychiatrists just to have their long-standing prescriptions filled, Gold advocated for shared responsibility: it “would be really helpful if some of those patients could be in primary care.”

According to a recent study, the number of nurse practitioners in primary care is projected to exceed the number of physicians by a two-to-one ratio by 2030 (Pohl, 2023), said Schatz. That same study found

that in the period from 2013 to 2019, the number of physician psychiatrists increased by 15 percent while the number of psychiatric nurse practitioners increased by 134 percent (Pohl, 2023). “This looks like a train that is not going to stop,” said Schatz, and that makes it essential to “involve . . . the nursing voice and nursing perspective in everything . . . moving forward.”

Training the Existing Workforce

Adult ADHD is a huge part of what adult outpatient practitioners are expected to do,” said Cheyette. Therefore, patients “are often quite surprised” when their psychiatrist says, “I don’t really do that, or I haven’t been trained like that, or I don’t know a lot about it.” While this is “slowly changing,” he said, “there’s a backlog” of general psychiatrists and psychiatric mental health nurse practitioners with insufficient training in ADHD. To address this backlog in his practice, Cheyette developed a training program consisting of several required lectures that earn continuing medical education credit. Cheyette also designed resources for providers and supports them with monthly practice-wide case conferences. “That’s all helpful, but more is needed,” he said. Funding is needed for the national education of clinicians currently treating adult ADHD patients, agreed Goodman.

Given the current absence of adult ADHD from regular graduate or medical education, Ramsay emphasized the importance of training clinicians in the field. Training for adult ADHD remains “a niche specialty. You really have to . . . reach out to people,” he noted. However, “once somebody [learns] the executive functioning model of ADHD and a couple of tricks they can use, the clinicians feel empowered,” he said. “I’ve heard people say they change their practices [after] getting this information.” For a practicing clinician, it would be more valuable to have algorithms than guidelines, said Blanco. Guidelines are necessary for specific cases, but few people will read a 40-to-50-page document, he said. Algorithms would be more useful “for people like me . . . to know what to do in most cases.”

To illustrate how knowledge can impact clinical behavior, Goodman cited a comparison of electronic health records from adult ADHD patients in 2010 and 2020 that tracked adherence to 10 quality measures for diagnosing and treating ADHD in adults (Callen et al., 2023). In 2010 only 48 percent of records included 1 of these quality measures and 37 percent included 2 or more. By 2020, 90 percent recorded 1 quality measure and 75 percent recorded 2 or more. Treatment with a documented DSM-5 ADHD diagnosis increased from 52 percent to 97 percent over this period, and the number of patients seen within a month of their first prescription

doubled. Other behaviors, such as checking vital signs before starting the prescription and discussing the warnings for medication, showed little or no improvement. “Some measures improve with education, some measures don’t, which then goes to why we are doing the guidelines,” he said. “While we’re developing guidelines . . . it’s important for us to get the information to [professional societies] that oversee primary care and behavioral health professionals,” said LaTasha Seliby Perkins, assistant professor of medicine at Georgetown University School of Medicine, noting that the American Academy of Family Physicians is always looking for guidelines and tools to share with members.

Funding for Adult ADHD Education

When it comes to training health care providers to treat adults with ADHD, “who is the decision maker?” asked Zorn. He noted that Congress would need to give the FDA authority to extend the patent clock. But CHADD, ADDA, and other societies “with thousands of members with ADHD and associated caregivers” can influence regulatory opinion. Zorn suggested that “they and the rest of us step up and use these voices to call for this very high need for education.”

Training needs to be funded by sources outside the pharmaceutical industry, said Goodman. “We need government agencies and organizations to [commit] tens of millions of dollars for education” and a nationwide curriculum developed by a body of experts, he said. In response to the opioid crisis, the FDA worked with medical schools to increase the amount of education regarding treatment of pain, said Sokolowska. She suggested employing a similar model to enhance practitioners’ understanding of adult ADHD.

“A key message [from this workshop] has got to be education, education, education. How do we get it, who is going to do it, and who can take responsibility for that,” said Zorn. “Give us money, we’ll get education out there,” replied Childress.

AN INTEGRATED TREATMENT MODEL FOR ADULT ADHD

Collaborative care models have worked well in adult depression care for training primary care providers and increasing their confidence, said Olfson. In these models, frontline primary care providers are paired with mental health specialists who they can consult when in need of advice. “Over time, there’s a learning process that occurs,” said Olfson, noting that pediatricians often say they have gained confidence from collaborations with specialists. Olfson cautioned that this is a “longer-term educational process.”

The adult ADHD field needs to integrate diverse approaches to care, and there are models, like primary care behavioral health, that can help do this, said Schatz. Otherwise, the information is “great but . . . siloed,” he said. “Non-pharm presents on non-pharm. . . . Psycho-pharm presents on psycho-pharm. . . . We’re acknowledging the role for both, but I didn’t hear about a model that integrates both consistently.” One result of this disconnect may be seen in the data from Childress showing that “45 percent of clinicians were not able to identify the burden,” he said. “That piece is scary to me, that we’re potentially making this diagnosis without really understanding the patient’s story.” Schatz acknowledged health care providers’ time limitations, but “we have also heard from multiple people . . . about the importance of taking that time.” To build the capacity needed to address this problem, he said, will require “looking at alternative payment models [and] collaborative and integrative care. . . . We just need someone to build that integrated model that could be plugged into these frameworks.”

Integrated primary care and collaborative care models work well for ADHD treatment, said Chronis-Tuscano. Working within these models helped Seliby Perkins develop skills in motivational interviewing, which she learned from training with behavioral health professionals. Thanks to the skills she developed, Seliby Perkins can educate her patients about their condition and engage in shared decision making in the span of a 20-minute visit. “If you sit down and look at someone eye-to-eye and actually listen, it takes less time than you think,” she said. Furthermore, when a patient needs more than Seliby Perkins can provide, such as CBT, she has a team to refer them to. She emphasized the importance of “learning . . . from others, people on your team, and knowing when to send them to someone else.”

Underserved and Underinsured Patients

It is easy to keep the focus on college students, said Seliby Perkins, stressing the need to “keep all of our patients in the conversation” and to understand the hurdles that need to be jumped for the underserved and underinsured. These are individuals who lack access to testing and cannot afford their stimulants even with a reduced cost card. “We’re still fighting lots of stigmas for all of our racially underserved, marginalized, [and] gender-diverse patients,” she said.

Seliby Perkins emphasized the need for all adults with ADHD to access treatment. ADHD is a treatable diagnosis, and appropriate treatment can enable a person to excel in their life, “whether it’s a student or someone working at Safeway as a cashier. . . . They still have to be on top of [their lives].” If the child has trouble in school, the parent can volunteer

that “maybe my child has this . . . because I have it. But if they don’t know . . . then we’re missing a lot of things in our society in general,” she said.

Health systems need to figure out how to improve access and eliminate inequities while simultaneously ensuring quality of care that respects both patient preference and the evidence base, said Blanco. The insufficiency of provider training in adult ADHD care is particularly acute for members of underserved populations, who may not be able to access a provider with a high level of expertise (if they can access anyone), “and certainly not for an extended period of time,” said Walker. For these reasons, it is crucial that all primary care practitioners be educated on medication options for ADHD, she said.

Higgins stressed the importance of educating the public about ADHD, including immigrants who may not speak English well. “We have almost no research on what ADHD looks like in individuals who identify as women, racial and ethnic minorities, middle-age and older adults, and sexual and gender minorities,” said Sibley. This is contributing to “gaping health disparities.” More research is needed into the role of hormones in the expression of ADHD symptoms and the effectiveness of medication, said Julia Schechter, a clinical psychologist at Duke, who noted that this is the main question received by Duke’s Center for Girls and Women with ADHD.

“We need better normative data that is applicable to more than just the middle-class white population,” said Weisenbach. This will require recruiting more minorities for research studies. The problem of minority representation in research data is not unique to ADHD, she added, and fixing it requires that scientists learn how to engage underserved communities. Engagement will improve when members of underrepresented communities become providers, but “it starts with an investment,” said Sibley.

Seliby Perkins noted the value of shared decision making when addressing individuals from underserved populations. Seliby Perkins provides her patients with the same education as her medical students “because I feel they deserve the same information. . . . Here are the options . . . here’s a handout, and we’ll meet back and talk about it.” Shared decision making lets her form a bridge “using cultural humility instead of competency because . . . I’m not going to be as competent as I think I am. . . . The patient helps you be more humble about the decision.” It is important, she said, to take the information “and break it down into chewable bite sizes that everyone, no matter what their reading comprehension level is, can understand.”

HARM REDUCTION STRATEGIES TO CURB MISUSE

Substance use must be considered against the backdrop of the volatility of the illicit drug supply, said McNeil, noting the “horrible unrelenting spike in overdose deaths driven by synthetic opioids.” McNeil emphasized the need to limit harms caused by engagement with the illicit supply. This is particularly relevant in the context of the stimulant shortage, which may push people into buying pressed pills, “which seldom contain what . . . people think is in them,” he added. Another element of harm reduction emerges from noting that college students often misuse stimulants to perform better in class or stay up late and get work done. “Why? What are the broader pressures that are driving this, and how can we intervene . . . to create environments that are conducive to learning, to living, to thriving, that aren’t the hypercompetitive grind that people are on?” he asked, noting this broader context as “a point of intervention that we commonly overlook.”

Patients in Jeopardy

Goodman cautioned regulators to carefully assess the evidence regarding the risks and benefits of drug treatment for ADHD when addressing issues of misuse and abuse, and not to “put the cart in front of the horse . . . while we restrict access and frighten clinicians from prescribing medications.”

George Black, an attendee with lived experience, emphasized the wide-ranging benefits of stimulant medications for ADHD. He cited a recent study that found that diagnosis of adult ADHD correlated with an increased risk of dementia, but only in adults who did not receive stimulant medication (Levine et al., 2023), and another study that found that stimulant medication reduces suicidality in people with ADHD and bipolar disorder (Öhlund et al., 2020). He also noted a finding that the nonstimulant guanfacine reduced alcohol intake in rats (Fredriksson et al., 2015), and promising results from using guanfacine in combination with a methylphenidate stimulant (Michelini et al., 2023). Black himself nearly died in a car wreck due to unmedicated ADHD. “You don’t want to throw out the baby with the bathwater,” he said, cautioning against emphasizing the dangers of stimulants over their benefits. He noted that many of the worst adverse events caused by untreated ADHD, “suicide and car wrecks and all that . . . that’s adults, generally . . . [and] there’s not much discipline for underdiagnosis.” Black sought assurance that the APSARD guidelines would counter many providers’ reluctance to prescribe medications for ADHD when appropriate. El-Sabawi expressed a similar concern, noting that as a result of the opioid crackdown, patients

with hysterectomies are “being prescribed Tylenol and that’s the hospital policy. . . . We fear the same thing will happen with stimulants. . . . We have to be cautious about the narrative so we don’t get the same policy outcomes.”

Reconsidering Strategies for Curbing Misuse

Although the FDA does not control the supply of stimulants and therefore cannot directly address the shortage, it works closely with the DEA, which “has a big influence here,” said Baker. One role of the DEA is to limit how much controlled substances are made and set “a quota for the total amount of amphetamine and methylphenidate that can be manufactured in the country.” This is then allocated among the various manufacturers. The problem, Baker said, is that when one manufacturer has a problem meeting its quota, “other companies can’t step in because their [annual manufacturing] quotas have been set,” and changing them is a very long process. Therefore, Baker implored representatives from the FDA “to work with the controlled substances staff and FDA and with DEA . . . to allow for temporary increases in the manufacturing quota . . . so that when Manufacturer A has a problem, Manufacturers B, C, and D can temporarily step in.”

Prohibiting pharmacies from transferring electronic prescriptions makes it more difficult to fill prescriptions without necessarily decreasing misuse, said Mahome. Indeed, she said, making prescribers send prescriptions to multiple pharmacies to find one that carries the prescribed medication can result in duplicate prescriptions. “Sometimes if the system does not automatically cancel the [prescription] that was sent, patients will go later and get that other prescription as well.” She suggested that the DEA review this policy. Another area where the DEA might consider increasing oversight is in the issuing of controlled substance licenses, suggested Mahome. “Some providers should not be allowed to prescribe stimulants if they don’t know how to do so effectively and do it well.” She suggested requiring providers to answer questions about these drugs to receive a controlled substance license.

Starting with Nonstimulants

Given the problems of misuse and abuse associated with stimulant medications, Goodman suggested that nonstimulants be moved up in the armamentarium so that newly diagnosed patients would be started on a nonstimulant along with cognitive behavioral therapy and organizational techniques and move on from there. Starting patients on nonstimulants would be a very good idea, agreed Gordon, “because if that works, we’ll

stick with it forever.” Even just choosing an extended-release formulation of a stimulant instead of an immediate-release formulation is “a simple thing that adult prescribers could do if appropriate for the patient,” said Rubin, and could reduce the potential for misuse.

The old understanding of ADHD, which favors use of stimulants over nonstimulants, needs to change, said Arnsten. It is a mistake to focus on narrowing attention as a therapeutic effect, she said, which is based on old rating scales for stimulants. “Narrowing [of attention] is not always a good thing,” she added. “It can interfere with creative pursuits, it can interfere with social interactions. [Let’s] not narrow in on narrowing in,” and instead emphasize self-regulation, which may be more conducive to prescribing nonstimulants.

The FDA has put a black box warning on all antidepressants to highlight the possible risk of suicidal thinking or behavior in young people, said Matthew Rudorfer, chief of the Psychopharmacology, Somatic, and Integrated Treatment Research Program at the National Institute of Mental Health, and this may discourage clinicians from trying new treatments such as viloxazine, an antidepressant nonstimulant that is now being marketed for treatment of ADHD (Edinoff et al., 2021). He suggested that the FDA revisit the warning on antidepressants regarding increasing suicidality, “because if that is discouraging otherwise appropriate use [for adult ADHD], it would be a fixable problem.”

Untreated ADHD and Substance Use Disorder

McNeil highlighted “the extreme barriers to care that people experience across the life course” that can prevent them from being diagnosed with ADHD until late in life, if ever. These barriers are often shaped by structural racism and classism, he said, noting that untreated ADHD appears to underlie many individuals’ long history of illicit stimulant use. To illustrate the possible relationship between untreated ADHD and SUD, McNeil cited the experiences of people who used illicit stimulants in Vancouver, Canada (McNeil et al., 2022). As a harm reduction measure during the COVID-19 epidemic, guidelines were changed to allow these individuals to receive prescription stimulants, “to provide an alternative in the context of a very toxic and volatile drug supply.” McNeil found that many participants who received a stimulant prescription for the first time responded, “Oh my God, what is this, and why haven’t I had access to this my entire life?” McNeil challenged participants to consider the “carceral logic” embedded in the language of “diversion,” “misuse,” and “abuse” that criminalizes people based on what they are using, “and really consider that it’s use not as indicated, but it’s often being done for medical reasons.”

Harmful Use Is Not the Same as Abuse

“We are moving away from the word ‘abuse,’” said Molina. “Abuse” places full responsibility on the individual “rather than recognizing the external factors that drive the use of substances” and that sometimes compel movement from use to uncontrolled use, she said. These external factors are present at multiple levels, from environmental and societal all the way down to interpersonal, and include stressors related to discrimination. Molina prefers the term “harmful use,” although “misuse” is also employed.

Recreational misuse of stimulants to get high, experiment, or party longer occurs far less often than misuse to boost academic performance (Arria et al., 2008), said Molina. This trend contrasts starkly with pain medication, which is commonly misused to get high or to relieve pain. “We don’t see that kind of thing with stimulants. . . . They are very, very different substances,” she noted.

Stimulants are like electricity, suggested Blanco. The challenge is to use them effectively without being electrocuted. El-Sabawi pushed back on this. “Before we ask ourselves, ‘How do we not get burned?’” she said, “we need to ask ourselves who is touching the socket and why.” In particular, she noted that much of the research on ADHD is done on “White people, oftentimes White males, and we make policy recommendations based on the research . . . without understanding . . . if that study population is truly representative of the population that these policies are going to be impacting.”

Diagnostic tools need to be developed with the broader population in mind, said El-Sabawi, not just white college-aged folks. ADHD does not look the same in everybody, she said. It looks different in women and people in color. There might be particular barriers for diagnosis of immigrants, and “we haven’t talked about . . . how to make diagnosis and treatment more culturally sensitive. These are important conversations to have before we can talk about population-level regulatory changes or recommendations,” she added.

It is incredibly important to “understand what the electricity [stimulant] is and what that means for you,” said Seliby Perkins, a Black woman. “As an African American woman who’s a descendant of slaves, there are some real things that this medical system has done to my people which make them very, very mistrusting,” she noted. To build that trust, she uses shared decision making with all her patients so “they can educate me about what’s holding them back.”

Integrating a Concern for Stimulant Misuse into Clinical Assessments

Concerns about stimulant misuse should be addressed in the initial assessment of adults for ADHD, said Olfson. Often, he said, an individual seeking care fills out a self-report form to give the provider a sense of how severe their ADHD symptoms are. “That needs to be followed up with a [probing] clinical interview,” he continued, to better understand the severity, timing, length, and persistence of the symptoms identified. The interview will also allow the clinician to learn how the patient’s symptoms are affecting their life. Collateral information from relatives or coworkers can help document childhood onset and separate ADHD from other disorders, added Olfson, noting that “about half of adults with ADHD also have anxiety disorders [and] about a third have depression. . . . Separating out what is ADHD can be a difficult process.” Neuropsychological assessments may also help, he said. Olfson, like others, emphasized the importance of impairment in diagnosing adult ADHD, noting that it is not just about the symptoms on the symptom checklists but about “how [symptoms] are interfering with adaptive functioning” in a patient’s life. When evaluating impairment for people with ADHD, he said, “it’s important to assess broadly . . . how the symptoms of impulsivity and hyperactivity and inattention are affecting their ability to form healthy, stable, romantic relationships,” as well as the impact on friendships, work, parenting, and student achievement.

The evaluation should include a careful history of substance use, said Olfson, and this should be weighed in deciding whether to start a patient on a stimulant or nonstimulant medication. Noting that adults with ADHD are at increased risk for “motor vehicle accidents and other injuries, impulsive and risky sexual behavior, impulsive acts like shoplifting, and things like that,” Olfson observed that ADHD can create “a whole cascade of problems for people in their lives, and it’s important that we try to understand that and bring that into the clinical situation” to help people function better.

Training Physicians in Stimulant Diversion Prevention

The most common source of stimulants outside of a prescription is same-age peers with prescriptions for ADHD, which has implications for prevention, said Molina. However, she noted that nearly half of physician specialists surveyed in a recent study (Colaneri et al., 2018) felt inadequately qualified “to educate high-school-aged patients on the health risks and legal consequences of stimulant use and diversion.”

To help address these concerns, Molina worked with practicing physicians and physician-scientists to develop usable strategies for prevent-

ing diversion of stimulants by patients. For this initial study, researchers recruited 114 18-to-25-year-old college students who were being treated with stimulants for ADHD (Colaneri et al., 2018; Molina et al., 2020). Of these, 17 percent reported that they had diverted their stimulants. Molina and colleagues developed a training package, trained the students’ physicians, and reassessed the students. Although diversion was not significantly decreased by training, some risk factors decreased, including disclosure (letting others know that they had stimulants), the frequency with which they were approached to divert pills, and their intentions to divert pills.

To test the efficacy of physician training in preventing diversion, Molina and colleagues studied 341 13-to-18-year-olds in pediatric care in a total of 7 practices (McGuier et al., 2022). Following a baseline assessment, practices were randomly assigned to have all their providers trained or not. Noting that there is not a lot of stimulant diversion within this age group, Molina said, “this is a critical point in substance use prevention. You don’t wait till the horse is out of the barn. . . . You try to do it preven-tively, proactively.” At baseline, the researchers found that the older the children, the more likely they were to disclose their stimulant use and to be approached to share or sell their pills (Molina et al., 2021). They were also less likely to take their pills on a daily basis and thus were building up a supply that might create an opportunity for diversion. Older children were also more likely to have substance use problems and riskier peer environments (Molina et al., 2021).

Molina and colleagues developed a one-hour interactive stimulant diversion prevention (SDP) workshop for all physicians and staff in a pediatric care practice (McGuier et al., 2022). The SDP training boiled down to three essential points: 1) educate your patient, 2) be attentive to their supply of drugs, and 3) assess and manage their risk. Slides and video demonstrations offered providers advice for how to approach these tasks, with an emphasis on discussion and shared decision making. Physicians were given specific suggestions regarding patient and family education, medication management, assessment of mental health symptoms and functioning, and assessment of risky behavior.

In follow-up assessments (McGuier et al., 2022), the physicians who had been trained reported a change in patient-family education, which was “a pretty gratifying finding,” said Molina. Physicians’ attitudes regarding their ability to effect meaningful change also improved as a result of training. Molina noted that the trained physicians’ increase in knowledge and skill was the most important driver toward changing their behavior. Longitudinal follow-ups of both pediatric and adult studies are in progress to see whether SDP training reduced diversion.

Regarding the larger goal of harm reduction, Molina cautioned that SDP is just one piece of the solution and that “tackling any type of sub-

stance use needs a multilayered approach.” She also emphasized the importance of developing culturally sensitive approaches. “Ultimately,” she said, “we really do need to think about beginning early” with developmentally appropriate approaches and not wait until adulthood to prevent stimulant diversion. As for training, in addition to communicating these messages through continuing education and patient education, Molina recommended teaching SDP in graduate school and residency programs.

LOOKING TOWARD THE FUTURE

Informing Policies and Practice

The effort to formulate sensible solutions to improve treatment for ADHD and reduce misuse must be based on a solid foundation of knowledge, said Arria. She suggested crafting a research agenda to establish this foundation, based on a three-level framework: 1) the clinical level, 2) the provider level, and 3) the systems level.

At the clinical level, longitudinal studies should seek to understand predictors of heterogeneity in the long-term trajectories of people with ADHD, said Arria. Some examples of potential predictors could be management of psychiatric comorbidity or aspects of young people’s social and digital environments.

At the provider level, “we need a fuller understanding of the sources of information and misunderstanding that they have about ADHD,” she said. Implementation science should be employed “to proactively track provider behavior as new guidelines are rolled out,” to understand the facilitators and barriers to their adoption, and to identify which providers are “using an evidence-based mix of pharmacologic and nonpharmacologic strategies [and] collaborating with professionals . . . to maximize outcomes.”

At the systems level, it is important to understand how policies and practices are influencing the delivery of care to people with ADHD, said Arria. This includes the actions of educational systems and employers; accrediting bodies; and local, state, and federal agencies. Arria noted that “the most potent improvements in population-based health come through policies and practice change.” All research findings should be translated into “practical strategies to improve access to care and the lives of individuals with ADHD,” she said.

Increasing Academic, Industry, and Government Research on Adult ADHD

Goodman called NIH’s annual $5.5 million expenditure on ADHD research “appalling. . . in 2023, with 20 years of growing international

research.” He said adult ADHD research funding needs to be increased to parity with child ADHD; “otherwise we are not moving the needle.”

Diagnosis and treatment of ADHD in adults could be dramatically improved if a biomarker was available, said Farchione. “This is where the funding for research comes in. If we had a better understanding of the biology or more objective measures to use in clinical studies . . . it would be a game-changer,” she said. Given the complexity and heterogeneity of ADHD is subjective by its very nature, Goodman was skeptical about finding an objective measure. However, he noted, it might be possible to combine genetic, molecular, and imaging markers, with the help of artificial intelligence tools, “to sort out the connectomes that are disrupted and the genetics that contribute to that.”

Even if adult ADHD becomes widely recognized as a valid diagnosis, the relationship of risk to benefit of pharmacotherapy may be mismatched in people’s beliefs, said Winterstein. To overcome this, she said, research needs to be able to quantify the likely benefits of treatment as well as severity and frequency of safety concerns for each patient.

What the field of adult ADHD really needs is “a true outcomes trial” to study interventions, comparable to MTA trial of pediatric ADHD (Swanson et al., 2008), said Baker. “I suspect, with a three-to-four-year period to compare treatment versus nontreatment of ADHD . . . we would see tremendous outcomes,” he said. The impact of such a study, he said, could be comparable to that of the Scandinavian Simvastatin Survival Study trial, which showed that taking a statin to reduce cholesterol improved survival, thereby making a significant difference in the treatment of hypercholesterolemia (Pedersen et al., 2004). “There are twice as many adults with ADHD in the U.S. as kids,” he added, so “it is really a long time coming.”

Sokolowska noted the existence of data gaps even for treatments that have been FDA approved for certain populations and suggested that NIH and other organizations fill these gaps by extending the research to other populations and performing comparative evaluations of efficacy and risk. “We all would benefit from closing those gaps,” she said. A workshop participant suggested that information on ADHD could be included when data is collected for school research, mental health surveys, or depression studies. Childress encouraged women with ADHD who are pregnant to sign up with the National Pregnancy Registry for Psychiatric Medications (MGH, 2008). Registering would enable follow-up to track adverse events, side effects, or other problems, and provide more information for women in the future, she said.

Targeted Drug Studies for Adult ADHD

Many speakers agreed that new medications are needed to treat adult ADHD but that a more practical first step would be better implementing existing treatments. Guanfacine, for example, seems to be “underutilized” in adults, for whom its use is off-label, said Rudorfer. Likewise, he said, data presented at this meeting suggest that initiation of any medicine should perhaps be accompanied by CBT. While there are no data to address that specific question, he said, existing medications “probably have not [been] fully optimized.” ADHD should be treated more like depression, which has “so many different drugs,” said Seliby Perkins. “We have to do better with the treatments we have, but also continue to look for better, newer treatments,” she said.

“We need better ways to personalize treatment,” said Rudorfer, but because each treatment was developed in isolation, it is a challenge to integrate them. The fact that only 8 percent of adults with ADHD are treated with nonstimulants raises questions of “who are those 8 percent, [and] are those the right 8 percent?” He suggested that the nonstimulants guanfacine and clonidine, which have been approved for children and adolescents with ADHD, and other medicines like buproprion and modafinil be tested in adults. Some of these gaps in knowledge are confounded by the way medications are approved, which leaves little interest in studying drugs that are no longer on patent, he noted.

“Most advances in medication in psychiatry have been by accident, even the stimulants . . . and then we worked backwards to try to figure out . . . how come they’re working,” noted Rudorfer. Newer brain research offers a translational approach and the possibility of developing a treatment to address a specific biochemical deficit. Rudorfer praised the National Institute of Mental Health’s Research Domain Criteria initiative, which is “aimed at seeking pathology, especially in brain circuits, that might cut across diagnoses.” Given the way certain ADHD symptoms are also present in depression and other conditions, he said, this could help researchers “learn from each other or form new collaborations.” Rudorfer also suggested testing the external trigeminal nerve stimulation device, which was only approved for children with ADHD up to age 12, on older individuals (Loo et al., 2021).

Unlike the results of controlled clinical trials, “what we don’t have,” said Arria, is “a good understanding of providers in their natural habitat, what they do in their practice and what outcomes are resulting.” She suggested funding a prospective study of new enrollees to various types of practices, collecting data on patient history and all treatments they are given, and monitoring outcomes over 5 to 10 years “to see what mix of strategies works for what kind of patients.”

“We need more qualitative research . . . more observational research . . . [and] more researchers of color,” said El-Sabawi. “We need to stop funding the same people over and over again and get some people who are new and . . . have . . . ties to the communities.” El-Sabawi noted she is able to recruit people of color for her studies because she has spent years doing participatory action research and developing relationships with community groups. Seliby Perkins advocated for community-based participatory research, where “you can bring in a teacher, you can bring in the whole collaborative model; that is important.” Lee suggested identifying the first provider that individuals would come in contact with and then “reverse engineer” to develop early detection and treatment models, using community-based participatory research methods.

Incentivizing Studies of Adults with ADHD

Drug development will need innovation to catch up with the need for approved medications to treat adults with ADHD, said Rudorfer, noting that clinical trials for attention deficit disorder medications in the 1990s did not include subjects over the age of 17. Given that FDA can only act on the data it receives, he suggested that perhaps incentives for industry, such as a longer patent clock, to conduct studies to expand drug labeling for adults may be appropriate.

Arnsten pointed to the value for incentives to pursue new mechanisms for drug development, such that new types of drugs rather than additional stimulant formulations would receive higher-value rewards. Any new drug would have to be affordable for managed care pharmacy, so one approach could be for companies to maintain exclusive rights for a long enough period of time to make it worth the cost of development. As of now, she said, “there is little motivation for a company to take on that kind of risk.” An incentive that guarantees exclusivity for 10 years without competition from generics would require legislation. As an example, Lietzan pointed to the Generating Antibiotic Incentives Now Act, which was intended to spur innovation of new antibiotics by extending the exclusivity period for qualified infectious disease products. “The challenge will be making the case to policymakers,” she said. A case could be made in terms of the broad social cost associated with the immediate-release psychostimulants and the long-term social benefit that could be derived from incentivizing these other products, she added.