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ADHD medication overdose and misuse: the NSW Poisons Information Centre experience, 2004–2014

Rose Cairns, Benjamin Daniels, Danielle A Wood and Jonathan Brett
Med J Aust 2016; 204 (4): 154. || doi: 10.5694/mja15.00791

Summary

Objectives: To describe Australian trends in overdoses with medications used to treat attention deficit hyperactivity disorder (ADHD).

Design, setting and participants: This was a retrospective observational study of intentional exposures to methylphenidate, dexamphetamine, modafinil and atomoxetine reported to the New South Wales Poisons Information Centre (NSWPIC) from 1 January 2004 to 31 December 2014. The NSWPIC takes calls from New South Wales, Tasmania and the Australian Capital Territory between 6 am and midnight each day, and, as part of a national after-hours roster, from all Australian states between midnight and 6 am on seven nights each fortnight. The target population included Australian residents aged 10–75 years.

Main outcome measures: Demographic characteristics of the patients, changes in numbers of exposures with time, co-ingestants, route of exposure, and disposition of patients.

Results: During the 11-year study period, 1735 intentional exposures to the four medications were reported to NSWPIC. There was a 210% increase in intentional exposures to methylphenidate over this period, whereas the number of dexamphetamine exposures declined by 25%. Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429% across the study period. At least 93% of overdose patients required hospitalisation. Trends in exposures paralleled trends in the dispensing of these medications, as recorded in Pharmaceutical Benefits Scheme data.

Conclusions: NSWPIC data show a dramatic increase in intentional exposures to ADHD medications between 2004 and 2014, mainly to methylphenidate. Further, the data suggest that illicit use of these substances is increasing. The potential harm related to misuse of prescription stimulants and the close correlation between these exposures and the prescribing of these drugs causes concerns about their diversion, and highlights the importance of the quality use of medicines (ie, ensuring that they are used safely, appropriately and in an evidence-based manner, including considering non-medical or non-stimulant alternatives) and of risk assessment for misuse when prescribing ADHD drugs.

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  • Rose Cairns1
  • Benjamin Daniels2
  • Danielle A Wood3
  • Jonathan Brett2,4

  • 1 NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
  • 2 University of Sydney, Sydney, NSW
  • 3 Prince of Wales Hospital, Sydney, NSW
  • 4 Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW


Acknowledgements: 

The authors thank the staff at the NSW Poisons Information Centre. Benjamin Daniels is supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Medicines and Ageing (reference 1060407), the NHMRC (grant 1094325), and Sydney Catalyst.

Competing interests:

No relevant disclosures.

  • 1. Scheffler RM, Hinshaw SP, Modrek S, Levine P. The global market for ADHD medications. Health Aff 2007; 26: 450-457.
  • 2. Stephenson CP, Karanges E, McGregor IS. Trends in the utilisation of psychotropic medications in Australia from 2000 to 2011. Aust N Z J Psychiatry 2013; 47: 74-87.
  • 3. Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 2010; 10: 67.
  • 4. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013; 347: f6172.
  • 5. Sembower MA, Ertischek MD, Buchholtz C, et al. Surveillance of diversion and nonmedical use of extended-release prescription amphetamine and oral methylphenidate in the United States. J Addict Dis 2013; 32: 26-38.
  • 6. Australian Broadcasting Corporation. Man’s death after injecting Ritalin prompts fresh call for education campaign. ABC News [internet]. 2015; 7 July. http://www.abc.net.au/news/2015-07-07/death-after-injecting-ritalin-prompts-renewed-warning-from-court/6601466 (accessed July 2015).
  • 7. Degenhardt L, Baxter AJ, Lee YY, et al. The global epidemiology and burden of psychostimulant dependence: Findings from the Global Burden of Disease Study 2010. Drug Alcohol Depend 2014; 137: 36-47.
  • 8. Australian Crime Commission. 2013–14 illicit drug report data report. Canberra: ACC, 2015. https://crimecommission.gov.au/sites/default/files/IDDR-201314-Complete_0.pdf (accessed July 2015).
  • 9. Scott N, Caulkins JP, Ritter A, et al. High-frequency drug purity and price series as tools for explaining drug trends and harms in Victoria, Australia. Addiction 2015; 110: 120-128.
  • 10. Heath I. Overdiagnosis: when good intentions meet vested interests — an essay by Iona Heath. BMJ 2013; 347: f6361.
  • 11. Australian Government Department of Health. PBS Statistics [website]. http://www.pbs.gov.au/info/browse/statistics (accessed Feb 2014).
  • 12. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19: 335-351 (correction: 2001; 20: 655).
  • 13. Jensen LS, Pagsberg AK, Dalhoff KP. Differences in abuse potential of ADHD drugs measured by contrasting poison centre and therapeutic use data. Clin Toxicol 2015; 53: 210-214.
  • 14. Bruggisser M, Ceschi A, Bodmer M, et al. Retrospective analysis of stimulant abuse cases reported to the Swiss Toxicological Information Centre during 1997–2009. Swiss Med Wkly 2010; 140: w13115.
  • 15. Jensen LS, Pagsberg AK, Dalhoff K. Methylphenidate misuse in adult patients and the impact of therapeutic use. Hum Exp Toxciol 2015; 34: 460-467.
  • 16. Parran TV, Jasinski DR. Intravenous methylphenidate abuse: prototype for prescription drug abuse. Arch Internal Med 1991; 151: 781-783.
  • 17. Sindicich N, Burns DL. Australian trends in ecstasy and related drug markets 2013: findings from the Ecstasy and Related Drugs Reporting System (EDRS). (Australian Drug Trends Series No. 118). Sydney: National Drug and Alcohol Research Centre, UNSW, 2014. https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/National_EDRS_2013.pdf (accessed Dec 2015).
  • 18. Sweeney CT, Sembower MA, Ertischek MD, et al. Nonmedical use of prescription ADHD stimulants and preexisting patterns of drug abuse. J Addict Dis 2013; 32: 1-10.
  • 19. Kaye S, Darke S. The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care? Addiction 2012; 107: 467-477.
  • 20. Stafford J, Burns L. Australia drug trends 2014: findings from the Illicit Drug Reporting System (IDRS). (Australian Drug Trends Series No. 127). Sydney: National Drug and Alcohol Research Centre, University of New South Wales, 2015. https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/National_IDRS_2014.pdf (accessed Dec 2015).
  • 21. Bright GM. Abuse of medications employed for the treatment of ADHD: results from a large-scale community survey. Medscape J Med 2008; 10: 111.
  • 22. Chang Z, Lichtenstein P, Halldner L, et al. Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry 2014; 55: 878-885.
  • 23. Hanwella R, Senanayake M, de Silva V. Comparative efficacy and acceptability of methylphenidate and atomoxetine in treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis. BMC Psychiatry 2011; 11: 176.
  • 24. Jasinski DR, Faries DE, Moore RJ, et al. Abuse liability assessment of atomoxetine in a drug-abusing population. Drug Alcohol Depend 2008; 95: 140-146.
  • 25. Stojanovski SD, Robinson RF, Baker SD, et al. Children and adolescent exposures to atomoxetine hydrochloride reported to a poison control center. Clin Toxicol 2006; 44: 243-247.
  • 26. Buckley NA, Whyte IM, Dawson AH, Isbister GK. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c’est la même chose. Med J Aust 2015; 202: 438-442. <MJA full text>
  • 27. Calver J, Sanfilippo F, Preen D, Bulsara M. Prescribed stimulant use by Western Australians with attention deficit hyperactivity disorder (ADHD): does amount dispensed exceed the expected authorised use? Aust N Z J Public Health 2007; 31: 533-539.

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