Understanding Abuse Potential Across ADHD Therapies: What Clinicians Need to Know

As stimulant prescriptions for ADHD continue to rise, so does concern about their nonmedical use—particularly among adolescents and young adults. This article delivers an evidence-based exploration of the abuse potential associated with ADHD therapies, with a focus on how impulsivity and psychiatric comorbidities compound risk in this vulnerable population. 

Stimulants remain the cornerstone of ADHD treatment, but they also carry the highest risk of misuse among ADHD therapies.^1,2 The impulsivity characteristic of individuals with ADHD increases the likelihood of high-risk behaviors, including substance abuse, binge eating, reckless driving, and risky sexual activity.³ This presents a challenging paradox. The very medications that have the most therapeutic impact on ADHD symptoms overall are also the most susceptible to nonmedical use.  

The Who, How, and Why of Stimulant Misuse

Stimulant misuse often involves taking these medications without a prescription or exceeding the prescribed dose.⁴ The highest rates of abuse occur among individuals aged 18 to 25 years,⁵ a trend that reflects rising rates of stimulant prescribing in this age group. Prevalence estimates vary, but in several studies, stimulant misuse during the previous year was reported in 5% to 9% of secondary students, 5% to 35% of university students, and ~2% of adults.^1,4,5 

Nonmedical use of prescription stimulants often involves obtaining the drugs through informal channels, with most users (50% to 91%, depending on the estimate) getting them from family or friends.^4,6 College students often cite peers as a source, though the supplier isn’t always a close friend.⁴ A smaller portion (4% to 35%) report misusing their own prescriptions.⁴ It’s also common for people to give or sell their medication to others.⁴ Some individuals intentionally fake ADHD symptoms to obtain a prescription,⁴ and around 20% of US adults engaging in nonmedical use report acquiring their medication through fraudulent means.^4,6 Compared with other drugs of abuse, a far smaller percentage of users (<20%) obtain prescription stimulants through a dealer, and most users rate prescription stimulants as fairly easy to obtain.⁶ 

Motives for stimulant abuse have been well studied. In a survey of 3379 individuals aged 18 to 26 years, nearly half (47.7%) reported a desire to improve school or work performance as their motive,⁵ although nonmedical stimulant use does not improve and may actually worsen academic performance.^4,5 Substantial proportions of individuals also report wanting to increase energy or either get high or intensify the effects of other recreational drugs, and some report just being curious and wanting to experiment.^4-6  

Several factors increase the risk of stimulant abuse, most notably the use of short-acting formulations, comorbid psychiatric conditions and the medications used to treat them, and substance use disorders.¹ Short-acting stimulants are particularly prone to abuse due to their rapid onset of action,¹ but somewhat ironically, stimulants with a longer duration of action may be more difficult to obtain, even though they may also have a lower abuse potential.⁶  

As the risk of stimulant misuse escalates, so may the consequences. Some data suggest a link between dangerous methods of abusing stimulants and more deviant means of obtaining them. Individuals who snort or inject their stimulant rather than taking it orally are more likely to obtain it through deception or illegally, sometimes using a dealer, passing off a fake prescription, or obtaining the stimulant online.⁵ Insufflation is more often associated with trading, and injection is more often associated with stealing.⁵ Thus, as stimulant abuse escalates, so too may the abusers engage in riskier behaviors that expose them to legal consequences. 

Strategies for Mitigating Risk

To mitigate risk, it is recommended to avoid short-acting stimulants in individuals considered high-risk and to use long-acting formulations with caution. Nonetheless, long-acting agents still have abuse potential.⁴ Non-stimulant medications such as atomoxetine, guanfacine, and clonidine may be more appropriate as first-line options for those at elevated risk for misuse because they lack reinforcing qualities due to slower onset of action and no dopaminergic effects; in this way, non-stimulants are generally considered to have low abuse potential.^1,2 The latest non-stimulant entrant to the ADHD armamentarium, viloxazine, blocks norepinephrine reuptake and modulates serotonergic activity to address ADHD symptoms with a low abuse potential.⁷ Although atomoxetine has been misused recreationally, such cases remain infrequent compared to stimulant abuse.⁸ 

Encouragingly, in a survey of 828 US child and adolescent psychiatrists, child neurologists, and developmental-behavioral pediatricians, 79.2% endorsed prescribing long-acting stimulants instead of immediate-release agents as a preventive measure in adolescents suspected of misuse or diversion, and 71.9% endorsed prescribing non-stimulants such as atomoxetine or α-agonists.⁹ Eighty-nine percent actually prescribed long-acting stimulants, while 27% used non-stimulants to reduce the risk of misuse.^4,9  

However, that same survey found that while these types of pediatricians embraced careful selection of medications, a majority neglect other preventive measures when misuse or diversion is suspected: 85% reported “never” or “rarely” using medication contracts, 81% “never” or “rarely” distributed print materials, and 16% “never” or “rarely” referred patients for drug counseling or substance abuse treatment.⁹ Only 46% of respondents educated patients about the health risks of stimulant misuse, and only 44% did so about the legal risks.¹⁰  

This is unfortunate, as research suggests that addressing unrealistic expectations about stimulants enhancing academic performance can deter misuse, although the long-term effects were either unclear or not evaluated.^4,11,12 Similarly, evidence shows that patients asked a single question about whether they participated in diversion by healthcare providers were less likely to do so.^4,13 This suggests that even simple engagement of patients by providers may help reduce risk. Of course, screening individuals who have misused stimulants for ADHD and/or a substance use disorder is recommended.^4,14  

References:

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2. Mechler K, Banaschewski T, Hohmann S, Häge A. Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacol Ther. 2022:230:107940. doi:10.1016/j.pharmthera.2021.107940 
3. Soldati L, Deiber MP, Schockaert P, et al. Sexually Transmitted Diseases and Attention-Deficit/Hyperactivity Disorder: A Systematic Literature Review. J Psychiatr Pract. 2024;30(4):259-265. doi:10.1097/PRA.0000000000000789 
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12. Stock ML, Litt DM, Arlt V, Peterson LM, Sommerville J. The prototype/willingness model, academic versus health-risk information, and risk cognitions associated with nonmedical prescription stimulant use among college students. Br J Health Psychol. 2013;18:490-507. 
13. DeSantis AD, Anthony KE, Cohen EL. Illegal college ADHD stimulant distributors: characteristics and potential areas of intervention. Subst Use Misuse. 2013;48(6):446-456. doi:10.3109/10826084.2013.778281 
14. Wilens T, Zulauf C, Martelon M, et al. Nonmedical stimulant use in college students: association with attention-deficit/hyperactivity disorder and other disorders. J Clin Psychiatry. 2016;77(7):940-947. doi:10.4088/JCP.14m09559