Safe Prescribing for Stimulants

Like any other medication, there are benefits and risks to stimulant treatment

Specifically, among those with ADHD, there are benefits of taking a stimulant across the lifespan.

Benefits – beyond symptom control:

Lower all-cause mortality rates
Improved occupational performance and job retention
Reduced risk of suicidal behaviors
Decreased substance use
Lower criminal convictions
Decreased motor vehicle crashes

Risks:

Serotonin Syndrome
Cardiovascular concerns
Psychosis
Mania
Weight loss/impaired growth
Sleep disturbances
Headaches

Make sure you have an accurate diagnosis

Children

The NICHQ Vanderbilt ADHD Assessment Scale is a recommended measure that is administered to both parents and teachers. Guidelines recommend primary care clinicians make the clinical diagnosis of ADHD in pediatric patients.

Adults

Appropriately trained primary care clinicians, psychologists, and neurologists are often involved in the diagnosis of ADHD in adults.

Take a look at other medical conditions

There are some medical conditions that may be affected by stimulant use. It’s important to collaborate with other specialists or perform other tests to monitor your patient effectively.

Cardiac conditions

blood pressure, heart rate, vascular and arterial disease

Consider collaboration with a patient’s cardiologist

Growth and metabolic conditions

height, weight, and appetite are often affected

Neuropsychiatric conditions

psychosis, mania, sleep, and substance use

When these are present, careful consideration of stimulant use is needed and collaboration with the providers responsible for these neuropsychiatric conditions is important

Choose a medication that you think will be best for your patient

There are many options for medications. This resource outlines some options, with notes on considerations.

Stimulants – Clinical Pearls

When switching stimulants, you don’t need to cross-taper

You can stop one stimulant and start another. If going from a stimulant to a non-stimulant, it can be helpful to start the non-stimulant before discontinuing the stimulant.

When discontinuing stimulants, you don’t necessarily need to taper

While patients tend to feel better if you taper stimulants, it is safe to stop the medication without a taper. In contrast, a taper is necessary when discontinuing medications such as opioids or benzodiazepines.

It may be necessary to monitor certain patients using a random urine drug screen

Review MAP and have a Controlled Substance Agreement on file

It is required to review MAP before prescribing a controlled substance. A controlled substance agreement is also required and should be on file.

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University of Washington: Opioids and Stimulants – What Are They and How Are People Using Them?

This document reviews recent trends in opioid and stimulant use, compares the two types of drugs, and examines the factors that might drive “co-use.” It also calls out the point that clinical guidelines and interventions often address just one drug, and ignore polysubstance use.