Household Diversion of Prescription Stimulants: Medication Misuse by Parents of Children with Attention-Deficit/Hyperactivity Disorder

Abstract

Objectives:

The primary objective of this study is to investigate household diversion of stimulant medication. Secondary objectives are to examine clinical/demographic predictors of diversion, types of formulations diverted, exposure to household diversion in the media, and storage of prescription stimulants within households.

Methods:

Questionnaires were completed by 180 parents of youth who were currently taking stimulant medication for treatment of attention-deficit/hyperactivity disorder (ADHD). Parents were asked whether they or another adult in the home had ever taken their child's stimulant medication or given one child's stimulant medication to another child in the home. Additionally, data regarding demographics, parental ADHD (diagnosed or suspected), past suspicions of missing medication, and medication storage were also collected. Responses were compared using Pearson's chi-squared test with Yates' continuity correction.

Results:

Sixteen percent of parents reported diversion of stimulant medication to another household member, with the majority admitting to taking the medication themselves. Another 13% had been tempted to illicitly self-administer their child's medication. Parents with suspected or diagnosed ADHD showed greater risk of self-administration or temptation to do so, compared to parents without (33% vs. 17%, p = 0.01). The majority of parents (71%) stored prescription stimulants “in plain sight,” or “out of sight but available to all.”

Conclusion:

Although previous research has focused on peer diversion among adolescents and young adults, clinicians must be vigilant for the possibility of diversion by parents of children treated with stimulant medication.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder among children in the United States, with estimates of lifetime prevalence ranging from 8.4% to 12.0% among children under 18 (Perou et al. 2013; Collins and Cleary 2015). Pharmacologic treatment of ADHD, especially with stimulant medications, has been shown to increase attention, decrease impulsivity, and reduce hyperactivity (The MTA Cooperative Group 1999; Brown et al. 2005; FDA 2015a, 2015b; Storebø et al. 2015). The recent increase in the number of people treated with medication (Visser et al. 2014) has led to concerns about stimulant misuse by individuals without ADHD illicitly seeking to enhance focus and academic performance. To prevent nonmedical use of stimulants, it is important to consider the source of these medications.

Diversion of stimulant medications—when those prescribed for one individual are given to or taken by another individual—has been frequently studied in recent years. Most research has focused on peer diversion, especially in secondary school and college (Musser et al. 1998; McCabe et al. 2004; Vrecko 2015). One study found that up to 15% of secondary school students prescribed stimulants for ADHD gave them away, and up to 7% sold them (Poulin 2001). In another study, 54% of undergraduate students who were prescribed stimulant medication for ADHD had been approached to divert their medication (McCabe et al. 2006). Among college and graduate students, the predominant motivations for nonmedical use of stimulants include improving academic performance, increasing alertness, enhancing concentration, creating “a high,” and experimentation (Teter et al. 2005, 2006; Boyd et al. 2006a; Tuttle et al. 2010).

Although peer diversion of prescription stimulants among adolescents and young adults has been repeatedly studied, the issue of diversion by family members of children with ADHD has not been examined. The phenomenon of household diversion of stimulant medication first received significant media attention when an episode of a popular television program (“Desperate Housewives”) depicted a mother taking her son's Ritalin to cope with her own everyday demands and stresses. Diversion and illicit use of enhancement drugs continues to be repeatedly portrayed and glorified in mainstream media (e.g., Adderall in Pretty Little Liars and the fictitious NZT-48 in Limitless). This is concerning since research has shown that media exposure to content such as explicit sexual activity or use of alcohol can predict initiation of those behaviors by viewers (Brown et al. 2006; Chang et al. 2014). In fact, numerous news articles have reported on the real-life stories of mothers who became addicted to their children's ADHD medication (Eldred 2012; Harris and Zak 2012; Samakow 2012).

There are several reasons to suspect that these reports of household diversion are not isolated incidents. First, research has shown that diversion of prescription pain medication between family members is commonplace. For example, a study on middle and high school students found that over a third of students who reported lifetime nonmedical use of prescription pain medication had received the medication from a family member (Boyd et al. 2006b). Another factor that may contribute to the feasibility of household diversion is improper storage of medication, especially controlled substances. Just as lack of stringent handling and storage of stimulant medication in schools has resulted in diversion, theft, and abuse by students, teachers, and administrators (Woodworth 2000), improper storage in the home may allow for individuals to obtain prescription stimulants either for themselves or to distribute to others.

Nonmedical use of prescription stimulants by adults has been well documented. Between 2005 and 2010, the number of emergency department visits linked to nonmedical use of stimulant medication nearly tripled from 5212 to 15,585; half of these visits were by adult patients aged 26 or older (SAMHSA 2013). The 2015 National Survey on Drug Use and Health found that 2.2 million adults aged 26 and over reported misusing stimulants within the past year (CBHSQ 2016), and another national analysis found that prescription stimulants comprised 18% of illicit drug use by older adults (Gfroerer et al. 2003). However, no research to date has focused specifically on the source of the stimulant medications abused by adults.

Given the evidence that household diversion occurs with pain medications and that stimulant medications are also misused by adults, it is important to examine household diversion as a source of prescription stimulants misused by adults—especially considering how many homes now include a child with ADHD on stimulant medication.

The primary purpose of this pilot study is to assess whether household diversion of stimulant medication occurs in homes with children, adolescents, or young adults who are being pharmacologically treated for ADHD. Secondary objectives of this study are to examine (1) clinical and demographic predictors of diversion, (2) the types of stimulant formulations being diverted, (3) the association between diverting behavior and exposure to household diversion in the media, and (4) the storage of prescription stimulants within households.

Methods

Given that household diversion of prescription stimulants is improper and illegal, data were gathered anonymously by questionnaire, and participation was voluntary. This protocol was reviewed and approved by the Institutional Review Board of the North Shore-LIJ Health System.

Participants

The cohort for this study was a convenience sample of individuals attending community-based educational presentations on ADHD in New York. The survey was given to roughly 300 individuals before the educational presentations, which were on topics unrelated to diversion. Two hundred forty respondents completed a Household Diversion Questionnaire (HDQ), yielding a response rate of about 80%. After the exclusion of 58 participants who were not parents of one or more individuals under 24 currently on stimulant medication, and 2 respondents who indicated on the final question of the HDQ that they did not answer all questions honestly, the final sample used for analysis comprised 180 parents of children, adolescents, or young adults currently on stimulant medication. Since 32 respondents reported that a spouse had also completed the survey, our sample represents 164 unique households.

Questionnaire

The HDQ was a survey designed for this study that consisted of 24 multiple-choice questions, including demographics, household composition, household stress levels (1 = “Very Calm” to 5 = ”Very Stressed & Disorganized”), medication storage in the home (“in plain sight,” “out of sight but available to all,” “hidden but not locked,” or “locked”), whether or not parents had suspected or noticed that stimulant medications were missing, and whether or not parents were familiar with the “Desperate Housewives” episode depicting household diversion. The HDQ also asked about frequency of stimulant medication diversion (never, 1–3 times, 4–10 times, or >10 times): how often the parent has personally used their child's medication (self-administration), how often another adult in the household has used their child's medication, how often the parent has given one child's medication to another child in the household, and how often another adult in the household has given one child's medication to another child in the household. Those who reported self-administration were asked to select the specific medication that they used from a comprehensive list of the different stimulant formulations. The final question on the HDQ asked to what extent the respondent's answers to the previous questions were honest.

Statistical analysis

All statistical analyses were performed using the R environment for statistical computing (R Core Team 2014). Comparisons of dichotomous responses between groups were computed using Pearson's chi-squared test with Yates' continuity correction to prevent overestimation of statistical significance for small data. Comparisons of Likert-scale responses between groups were computed using Wilcoxon–Mann–Whitney tests.

Results

Table 1 presents a summary of respondent demographics.

Table 1.

Sample Characteristics

Respondent demographics	% of Sample
Total sample (n = 180)	100
Gender
Female	81
Male	19
Age
30–39	28
40–49	56
50+	16
Race/ethnicity
Caucasian	88
Hispanic/Latino	5
African American	2
Asian American	2
Native American	1
Other	2
Education
No college or some college	21
College graduate or higher	79

Self-administration and temptation to self-administer ADHD medication

Of the 180 parents, 28 (16%) reported that one or more forms of household diversion of stimulant medication had ever occurred. The most common forms of diversion involved misuse by adults; specifically, 20 parents (11%) admitted to having tried their child's medication themselves and 9 (5%) responded that another adult in the household had used a stimulant medication that was prescribed for another family member. Diversion of medication to other children in the home was less common: six (3%) acknowledged having given a stimulant medication to another child within the household and four (2%) reported that another adult in the household had diverted medicine to another child in the household. Table 2 presents the reported frequency of these four types of diversion.

Table 2.

Household Diversion Frequency

Questionnaire items (n = 180^a)	Rarely 1–3 times	Occasionally 4–10 times	Frequently >10 times	Ever ≥1 time
Respondent has self-administered a child's stimulant medication.	15	5	0	20
Another adult in the household has self-administered a child's stimulant medication.	4	4	1	9
Respondent has given a child's stimulant medication to another child.	4	2	0	6
Another adult in the household has given a child's stimulant medication to another child.	2	1	1	4

Since 32 respondents reported that a spouse had also completed the survey, our sample represents 164 unique households.

In addition to the 20 parents who self-administered, another 24 (13%) acknowledged that they had been tempted to try their child's stimulant medication. The majority (22 of the 24) reported being tempted only “once or twice, on a really important or stressful day,” and 2 reported having been tempted 3–10 times.

When participants were asked whether or not they thought they had ADHD or attention deficit disorder (ADD), 16 (9%) responded “Yes” and that they had been diagnosed as having ADHD or ADD (“Diagnosed ADHD”), 69 (38%) responded either “Maybe” or “Yes” but that they had never been diagnosed with ADHD or ADD (“Suspected ADHD”), and 95 (53%) responded “No” (“No ADHD”). Parents with either “Suspected ADHD” or “Diagnosed ADHD” were 2.55 times more likely to be tempted or to self-administer compared to parents who neither suspected nor were diagnosed with ADHD, (33% vs. 17%, χ ² = 6.16, p = 0.01).

When the 20 respondents who reported self-administration were asked about their reasons for taking their child's stimulant medication, 9 indicated that they were self-medicating for suspected or diagnosed ADHD, 4 parents acknowledged that they were curious to see if they could get a “high or good feeling” from the medication, and 1 parent responded that they needed to get a lot of work done that day. Other reasons included wanting to try the medication before giving it to their child and concerns about side effects of the medication.

There were no differences in self-administration or temptation to self-administer stimulant medication across demographic characteristics including gender, race/ethnicity, age, or educational experience.

Household stress levels

The average household stress rating was 3.29 (1 = “Very Calm” to 5 = “Very Stressed & Disorganized”). There was no relationship between household stress levels and temptation to self-administer stimulant medication (p = 0.53), or between household stress levels and actual self-administration of stimulant medication (p = 0.13).

Types of formulations used for self-administration

Of the 20 parents who self-administered stimulant medication, 18 provided a response to the question asking them which stimulant formulation they used without a prescription. Fourteen parents (78%) used methylphenidate formulations exclusively, two (11%) used amphetamine formulations exclusively, and two (11%) used a combination of formulations. Seven parents (39%) used short-acting tablets exclusively, eight (44%) used long-acting capsules or caplets exclusively, and three (17%) used a combination of short- and long-acting medications.

Exposure to household diversion in the media

Of the 180 parents, 70 (39%) had seen the “Desperate Housewives” episode depicting prescription stimulant diversion. Participants who had previously viewed the episode were more likely to report either temptation to self-administer stimulant medication or actual self-administration of stimulant medication compared to those who had not (34% vs. 18%, χ ² = 4.97, p = 0.03).

Among the 70 parents who had seen the “Desperate Housewives” episode, the majority (53%) agreed with the statement that the episode “trivialized the danger of medication misuse,” 30 (43%) believed that “people will be more likely to try another person's ADHD medication,” 16 (23%) believed that the episode “heightened concerns about abuse of medications,” 11 (16%) believed that the episode had “no effect,” and 5 (7%) believed that it “reinforced the concern that medications are over-prescribed.”

Medication storage and missing pills

Of all parents, 51 (28%) kept medication “in plain sight,” 76 (42%) kept medication “out of sight but available to all,” 44 (24%) kept medication “hidden but not locked,” and only 6 (3%) kept medication “locked.” Three people did not provide storage information.

When parents were asked whether stimulant medication was ever missing, 11 (6%) stated that they had suspected or noticed pills missing on one or more occasions. While 20% of respondents with adolescents or young adults in the household reported suspecting or noticing missing pills, only 2% of those without adolescents or young adults reported the same; these differences could not be tested due to the small number of people who had suspected or noticed missing pills. It is notable that none of the 6 respondents who locked up medicine admitted to self-administering stimulant medication, compared to 7 (14%) of the 51 who kept medicine in plain sight.

Discussion

While previous studies looking at prescription stimulant misuse have focused on peer diversion among adolescents and young adults, this study is the first to focus specifically on diversion of stimulant medication within the household. The results suggest that household diversion of stimulant medication may be relatively common—occurring in more than one in six households in our sample of 164 unique households. While some instances consisted of parents giving one child's medication to another child within the household, the most common form of diversion involved self-administration by adults in the home.

In terms of demographic predictors of diversion, there were no significant differences in rates of self-administration across gender, age, race/ethnicity, or educational level. The lack of gender differences in this sample also suggests that the stereotype of the “stressed mother” abusing stimulant medication may understate the potential for abuse among fathers. Furthermore, our finding that household stress levels did not influence temptation to self-administer or actual self-administration suggests that factors other than parenting stress may be motivating the desire to misuse prescription stimulants. However, since respondents were not asked whether or not they were the primary caregiver in the household, it is unclear to what extent household stress levels accurately reflect the individual parent's stress levels. In terms of clinical predictors of diversion, respondents with “Suspected ADHD” or “Diagnosed ADHD” were more likely to admit to either temptation or actual self-administration of stimulant medication. In addition, respondents' reported reasons for self-administering stimulant medications suggest that the desire to self-medicate diagnosed or suspected ADHD may be a strong motivator for prescription stimulant misuse.

Potential for abuse across formulations

In recent years, with the marked increase in the number of stimulant formulations available for the treatment of ADHD, there has been a shift in treatment to once-a-day dosing using long-acting or extended release formulations. In addition to offering clinical advantages and convenience to patients, these newer formulations have also been seen as less prone to abuse since they do not provide the same immediacy of onset associated with brain “likeability” and they cannot be snorted (Mansbach and Moore 2006; Schuster 2006; Darredeau et al. 2007). These advantages notwithstanding, the newer once-a-day dosing formulations are still susceptible to misuse and diversion. In our sample, over half of the 20 respondents who self-administered a stimulant medication did so with one or more long-acting formulations.

The majority of those who self-administered a stimulant medication did so with a methylphenidate formulation. Although it is likely that this finding is a reflection of which medications were prescribed and not due to increased potential for methylphenidate misuse over amphetamine misuse, our data do not allow us to further investigate this issue.

Exposure to household diversion in the media

Respondents who saw the “Desperate Housewives” episode depicting household diversion were significantly more likely to admit to either temptation or actual self-administration of stimulant medication compared to respondents who had not seen the episode. Since we did not collect data regarding the timing of the self-administration incidents relative to their viewing of the program, it is unclear to what extent this is an example of “life imitating art.” As previous studies have found that media exposure to other risky behaviors can make people more likely to practice those behaviors (Brown et al. 2006; Chang et al. 2014), it is possible that this television series, which reached over 24 million viewers (Carter 2006), may have planted the seed in the minds of some viewers.

Storage of stimulant medication

Despite media attention and public concerns about diversion among teens, the overwhelming majority of respondents reported keeping prescription stimulants in the household “in plain sight” or “out of sight but available to all.” This finding is consistent with a recent study that reported that 73.7% of adolescents had unsupervised access to medications with abuse potential (Ross-Durow et al. 2013). Although the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) have general recommendations regarding safe storage of medication (i.e., out of reach and out of sight) (Centers for Disease Control and Prevention 2011; American Academy of Pediatrics 2015), these precautions may not be sufficient with respect to prescription stimulants, narcotics and other medications with abuse potential. The National Council on Patient Information and Education (NCPIE), a non-profit coalition focused on patient education, has more explicit guidelines regarding storage of controlled substances (National Council on Patient Information and Education 2008). Following these guidelines, clinicians may want to encourage the parent(s) in charge of medication management to keep these medications in a locked drawer or cabinet to limit the number of individuals with access to medications with abuse potential. Unfortunately, this prevention strategy will not be helpful if the person responsible for securing the medication is also the individual diverting the medication.

Limitations

A limitation of this study is the convenience sample, which was nonrandom, predominantly female, and relatively racially homogeneous. Although the sample may appear skewed, it nonetheless captured the phenomenon of household diversion in a population whose demographics do not deviate so greatly from that of the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, a nationally representative sample of children with ADHD gathered by the CDC (Centers for Disease Control and Prevention 2014). This survey showed that, among parents and guardians of children with ADHD, mothers were the primary survey respondents about 74% of the time. Similarly, about 72% of children with ADHD captured in the survey were White. Thus, while the respondents in our sample are predominantly White and female, the sample distribution does not depart greatly from the population of interest. While it is unclear to what extent the cohort of parents who would attend educational presentations on ADHD would be more or less likely to divert, these parents nonetheless represent, though not perfectly, the target population of adults who are able to readily access stimulant medication.

A second limitation of the study lies in the difficulty of surveying about a sensitive topic about illicit behavior. The HDQ is an instrument that was created specifically for the purposes of this study. As the issue of household diversion of stimulant medication had never yet been explored thoroughly, there were no fully formed, validated questionnaires for us to adapt. Since conducting in-person interviews would require participants to verbally acknowledge a criminal offense, we opted to use anonymous surveys. One downside of this method is the inability to follow-up with participants, validate responses, or check response reliability. Since diversion of a controlled substance is illegal, some under-reporting is also likely. However, we tried to minimize under-reporting by allowing for people to indicate to what extent they answered all questionnaire items honestly. Furthermore, as the questionnaire specifically addressed diversion by parents, the data may underestimate the true prevalence of household diversion by failing to capture instances of diversion by other family members, such as siblings. This data would have been especially interesting given that pills were observed to be missing more often (though not statistically tested due to small cell sizes) in households in which there were teens. Another limitation is that 32 respondents indicated that they had spouses who were also taking the survey. Because the survey was anonymous, we could not pair the duplicate household responses. However, only one of these 32 respondents answered affirmatively to questions about household diversion, and thus this limitation does not inflate the household diversion figures (since no two members from the same household reported diversion). Further research is needed to validate and fine-tune the survey instruments used to investigate the issue of stimulant medication diversion by household members.

Conclusion

Diversion of stimulant medication is not limited to adolescents and young adults sharing their medication with peers. A disconcerting number of parents in our sample admitted that they divert medication either to themselves or, less frequently, to other children in the household. Although this study needs to be replicated with a larger, more diverse sample, clinicians who treat ADHD must recognize that household diversion is a significant issue that can lead to prescription stimulant misuse.

Clinical Significance

Although previous research has found that prescription stimulant misuse is most common among adolescents and young adults (Kroutil et al. 2006), clinicians must also be vigilant for the possibility that one or more adults in the home may be self-administering their child's ADHD medication. It is important that physicians are aware of this phenomenon, which has been depicted in the media, yet is likely not often suspected by clinicians. Furthermore, given that the great majority of parents in our sample stored stimulant medication “in plain sight,” or “out of sight but available to all,” physicians should encourage parents not only to keep these controlled substances out of reach and out of sight as recommended by the CDC and AAP, but also in a locked drawer or cabinet, per guidelines by the National Council on Patient Information and Education.

Authors' Contributions

Tammy Pham: Ms. Pham carried out the statistical analyses, reviewed and revised the article, and approved the final article as submitted.

Ruth Milanaik: Dr. Milanaik assisted with the design of the survey materials, reviewed and revised the article, and approved the final article as submitted.

Alyson Kaplan: Ms. Kaplan drafted the initial article, reviewed and revised the article, and approved the final article as submitted.

Helen Papaioannou: Dr. Papaioannou revised the survey, assisted with data collection, reviewed and revised the article, and approved the final article as submitted.

Andrew Adesman: Dr. Adesman conceptualized and designed the study and survey, coordinated and supervised data collection, critically reviewed and revised the article, and approved the final article as submitted.

Footnotes

Disclosures

No competing financial interests exist.

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