What are the next steps for a patient taking Adderall (amphetamine/dextroamphetamine) and Vyvanse (lisdexamfetamine) with a urine amphetamine level indicating potential misuse?

From the Guidelines

The patient should undergo a comprehensive medication review and clinical assessment to evaluate potential medication misuse, and the provider should consider implementing more frequent office visits, random urine drug testing, and possibly switching to a single stimulant medication with a structured dispensing schedule. The provider should schedule an immediate follow-up appointment to discuss the test results and evaluate for potential medication misuse. During this visit, the clinician should conduct a non-judgmental interview about actual medication usage patterns, including timing, dosage, and any supplemental sources of stimulants. A detailed review of prescription records through the state's Prescription Drug Monitoring Program is essential to identify any pattern of early refills or multiple prescribers, as noted in the 2019 clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents 1. The approach is necessary because concurrent use of two amphetamine-based medications (Adderall and Vyvanse) is generally not standard practice and increases risk of side effects and potential for misuse, as discussed in the 2022 evidence-based pharmacological treatment options for ADHD in children and adolescents 1. Additionally, abnormal urine levels may indicate either medication diversion or taking more than prescribed, both requiring intervention to ensure patient safety and appropriate ADHD management. Some key points to consider in the management of ADHD and potential misuse of stimulant medications include:

• Monitoring symptoms and prescription refill requests for signs of misuse or diversion of ADHD medication, as recommended in the 2011 ADHD clinical practice guideline 1
• Considering prescribing nonstimulant medications that minimize abuse potential, such as atomoxetine and extended-release guanfacine or extended-release clonidine, as suggested in the 2019 clinical practice guideline 1
• Providing a schedule for initial titration and monitoring, as well as a schedule for monitoring the drug maintenance phase, as outlined in the 2002 practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults 1
• Assessing medication adherence and potential issues in adherence, and discussing these openly with the patient, as recommended in the 2022 evidence-based pharmacological treatment options for ADHD in children and adolescents 1.

From the FDA Drug Label

WARNING AMPHETAMINES HAVE A HIGH POTENTIAL FOR ABUSE. ADMINISTRATION OF AMPHETAMINES FOR PROLONGED PERIODS OF TIME MAY LEAD TO DRUG DEPENDENCE AND MUST BE AVOIDED. PARTICULAR ATTENTION SHOULD BE PAID TO THE POSSIBILITY OF SUBJECTS OBTAINING AMPHETAMINES FOR NON-THERAPEUTIC USE OR DISTRIBUTION TO OTHERS, AND THE DRUGS SHOULD BE PRESCRIBED OR DISPENSED SPARINGLY. MISUSE OF AMPHETAMINE MAY CAUSE SUDDEN DEATH AND SERIOUS CARDIOVASCULAR ADVERSE EVENTS. OVERDOSAGE Individual patient response to amphetamines varies widely. While toxic symptoms occasionally occur as an idiosyncrasy at doses as low as 2 mg, they are rare with doses of less than 15 mg; 30 mg can produce severe reactions, yet doses of 400 mg to 500 mg are not necessarily fatal.

The next steps for a patient taking Adderall and Vyvanse with a urine amphetamine level indicating potential misuse are:

• Monitor the patient closely for signs of amphetamine toxicity or overdose, such as restlessness, tremor, hyperreflexia, rhabdomyolysis, rapid respiration, hyperpyrexia, confusion, assaultiveness, hallucinations, panic states 2.
• Assess the patient's adherence to the prescribed regimen and counsel them on the risks of misuse and abuse of amphetamines 2.
• Consider alternative treatment options or adjusting the current dosage regimen to minimize the risk of misuse or abuse.
• Be aware of the potential for severe cardiovascular adverse events and sudden death associated with amphetamine misuse 2.

From the Research

Next Steps for Patient Taking Adderall and Vyvanse

The patient's urine amphetamine level of 300 indicates potential misuse of their prescribed medications, Adderall (amphetamine/dextroamphetamine) and Vyvanse (lisdexamfetamine) 3. To address this issue, the following steps can be taken:

• Review the patient's medication regimen and medical history to determine if the prescribed doses are being taken correctly and if there are any potential interactions with other medications.
• Consider conducting further testing, such as blood or hair analysis, to confirm the presence of amphetamine and determine the enantiomer composition, which can help differentiate between legitimate use of Adderall and potential abuse of illicit amphetamine 4.
• Assess the patient's behavior and medical history to identify any signs of amphetamine toxicity or sympathomimetic toxidrome, which can occur with high levels of amphetamine exposure 5.
• Evaluate the patient's response to treatment and adjust the medication regimen as needed to ensure optimal therapeutic effects while minimizing the risk of misuse or abuse.

Potential Misuse or Abuse

The patient's urine amphetamine level of 300 may indicate potential misuse or abuse of their prescribed medications. Studies have shown that lisdexamfetamine, the active ingredient in Vyvanse, has a lower potential for abuse compared to other amphetamine-based medications 6. However, the combination of Adderall and Vyvanse may increase the risk of misuse or abuse. The patient's medical history and behavior should be carefully evaluated to determine the best course of action.

Monitoring and Follow-up

Regular monitoring and follow-up appointments can help ensure that the patient is taking their medications correctly and that the treatment regimen is effective. This can include:

• Regular urine testing to monitor amphetamine levels and enantiomer composition 3, 4.
• Blood tests to monitor for potential side effects or interactions with other medications.
• Behavioral assessments to evaluate the patient's response to treatment and identify any signs of misuse or abuse.
• Adjustments to the medication regimen as needed to ensure optimal therapeutic effects while minimizing the risk of misuse or abuse.