ADHD Weekly, April 20, 2023

Study shows only a small number of schools and students report higher-than-expected misuse of medications

Major news outlets recently carried stories on a University of Michigan ADHD study, frequently referring to the study’s findings as “a wake-up call” regarding stimulant medications in their headlines.

Two of CHADD’s experts reviewed the study and urge parents and school administrators to look more deeply at the study’s data and fifteen-year timespan. The reported numbers actually show a very small percentage—less than two percent—of American high schools have a serious problem with the diversion of stimulant medications, they say.

“That’s only a very small number of schools in a larger population,” says Max Wiznitzer, MD, co-chair of CHADD’s professional advisory board.

Wide variation in prescription medication misuse

The University of Michigan-led study on stimulant medication diversion—the sharing or selling of any prescription medication to someone other than for whom it was prescribed—collected information on student use and misuse of prescribed medication in 3,284 middle and high schools. It concluded that some schools had no instances of diversion or misuse of prescribed medication, and some schools had up to twenty-five percent of students misusing medication prescribed for ADHD.

The authors also concluded that in schools where more students than average were diagnosed with ADHD and prescribed medication, there was a greater chance of medication diversion or misused. The authors defined this nonmedical use of medications as having shared or taken medication not prescribed for a student at least once in the previous year. They also noted that schools in more affluent locations, and students whose parents had a higher education level, were more likely to misuse or divert their medications.

“I can tell you that a student’s experience will be different at a school with no peers who misuse stimulants versus a school where 1 in 4 peers misuse stimulants,” says Sean Esteban McCabe, PhD, director of the University of Michigan Center for the Study of Drugs, Alcohol, Smoking and Health.

Dr. Wiznitzer looked deeper into how many schools in the study actually had students reporting up to twenty-five percent of medication misuse or diversion.

“It was only fifty-eight schools who reported a higher nonmedical use of prescription stimulants rate,” he says, referring to the schools included in the study. “It’s only a small number of schools who have a greater than twenty percent nonmedical use of prescription stimulants rate.”

Students diverting their medications, and why

Maggie Sibley, PhD, is a member of CHADD’s professional advisory board and associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. She researches ADHD in college students, along with treatment and interventions that are effective for them. After reading the study, she says the results lined up with her expectations on medication misuse and diversion: Some regions and schools are contending with a higher rate of diverted medications and other regions and schools have a much lower rate of diversion, but there is not one given percentage of misuse that applies to every school.

“I think it’s important to point out places where it’s problematic, so it can be addressed,” she says. “But it’s not a widespread problem. You need to assess your student body and not assume a national statistic applies to your school.”

The students who are likely to misuse the medications in high school resemble the college students in her research, she says. They tend to be involved in campus clubs and fraternities or sororities, who already misuse or consume alcohol while underage, and have a low barrier to obtaining stimulant medications, either by faking symptoms or having classmates willing to share or sell their medications.

“There’s a correlation between people who use drugs and alcohol recreationally and people who misuse stimulant medications,” Dr. Sibley says. “Take that to high school and it’s the kids who are on that same track. There are going to be some locations where the factors are in place to create this, but those will be pockets. That doesn’t extrapolate to the rest of the United States. This paper even says that.”

Broader research has shown that students who are diverting stimulant medications or misusing them are generally not students with an ADHD diagnosis, she adds. The majority of students who have ADHD will not share or sell their medications, knowing the importance of maintaining their treatment plan and the educational and legal consequences of giving or selling prescribed medications.

“This is the biggest study of high school students use that I’ve seen,” says Dr. Sibley. “It confirms that in most schools, diversion is actually pretty low. It repeats the findings on college students, with a younger sample, on the factors that put someone at risk for this behavior.”

Dr. Wiznitzer points out that the study from the University of Michigan did not look into why students were seeking stimulant medications from their peers, or why some schools reported no misuse or diversion at all for ADHD medications.

Some high school students who seek stimulant medications from their peers may have ADHD themselves, he says, but have not been evaluated or diagnosed and are attempting to self-treat their symptoms. Other students may be under pressure from their parents to perform at an extraordinarily high level of academic achievement and have the mistaken idea that stimulant medications will give them an edge. Research has shown that stimulant medications do not give non-ADHD students an edge in academics.

“All this study tells us is that in high school there’s a concern for diversion,” Dr. Wiznitzer says. “If there’s a concern for diversion, we need to ask why the diversion is occurring and deal with the underlying reason.”

He also returned to the point in the study that broke down how many schools reported diversion and asked what are the characteristics of those schools. He noted that some schools reported not having any students who have ADHD—a statistical impossibility unless they are private schools that can select or reject potential students who demonstrate ADHD symptoms. On the other end of the possibilities, schools with a higher than statistically likely population of students with ADHD, Dr. Wiznitzer suggested, could be ones that have supportive programs for students with ADHD or learning disabilities, or they are schools for students who have had conduct problems.

Good data, but poor context

Dr. Wiznitzer, who frequently comments on ADHD research and concerns in the popular media on CHADD’s behalf, said the results of this study have been taken out of context in recent reporting.

“I don’t like the way the media is portraying it,” he says. “It’s a very interesting paper that didn’t get granular enough to answer all the questions we need answered about these rates of diversion. They just didn’t ask questions about the schools and the student population.”

Dr. Sibley also expressed disappointment in both the study conclusion and the reporting on the study.

“I believe the data,” she says, “but it has to be taken in context, and it was taken out of context. We also have to be aware that these data were collected during a really wide timespan. There could be changing landscapes over the years that influences this—that’s a question to raise: how has it changed through the years?”

The context of regional differences, individual schools, pressures placed on students, family resources, and local cultures were not included in when determining the study’s conclusion, both Dr. Sibley ad Dr. Wiznitzer noted. All of those factors would influence the level of diversion at an individual school, creating a higher or lower rate of diversion and misuse. But that data does not show widespread misuse of the medications, and the study itself even states the risk is “up to” twenty-five percent, but that amount is an outlier and not the most common experience.

“We don’t know anything about those schools in the study,” Dr. Wiznitzer says. “We don’t have proof that this is something running rampant in the schools. If I had reviewed this paper, I would have said make it more clear to the reader because it’s not clear how many people are [misusing or diverting medications]. I think the key message is you can’t look at a city and say this is the number for the city. You have to look at the individual schools.”

What does this mean for your high school student?

Most schools do not have a problem with diverted ADHD medications, according to this study. When students let their peers know they have ADHD, there is the possibility that a friend or classmate will ask them for their medication.

“It’s an important thing to talk with your kids in high school about diversion,” Dr. Sibley advises. “They have to be ready for it and know that it’s not okay to share their medication.”

This includes talking with your teenager about the risks of taking medications that are not prescribed for them, including health issues and legal consequences. Practice role-playing with them about how to turn down a request from a friend to share or sell medications, and how to say no to an offer to take someone else’s medication for an academic booster or recreation. Begin these conversations before middle school and continue them through high school and into college or early career.

“Prescription stimulant therapy for ADHD does help millions of people, including in my own family, and students, friends and colleagues,” says Dr. McCabe, the study’s lead author. “It’s critical to balance the need for access to these medications while reducing the risk for misuse.”

More information on preventing the misuse of stimulant medications:

• Preventing Medication Abuse and Diversion
• What ADHD Medication Can and Can’t Do
• Don’t Have ADHD? Meds Won’t Improve Grades
• Medication Could Help Lower the Risk of Substance Abuse
• Steps to Take Before Sending Your Student to College
• Webinar: ADHD Medication and College Students
• Podcast: The Risks of Misusing Stimulant Medication and Alcohol
• The Diversion of ADHD Medication: What You Need to Know
• Benefits and Risks of Medication Treatment
• Anger, Shame, and Other Drugs

Join the conversion: Have you talked with your child about the risks of sharing their medications? How do you suggest another parent begin that conversation?