How to continue urine drug screens (UDS) on patients on stimulant therapy, such as Vyvanse (lisdexamfetamine), with a history of methamphetamine abuse, and will Vyvanse show up as amphetamine on UDS?

Managing Urine Drug Screens for Patients on Stimulant Therapy with History of Methamphetamine Abuse

For patients with a history of methamphetamine abuse who require stimulant therapy for ADHD, use lisdexamfetamine (Vyvanse) as the preferred medication and implement confirmatory testing with GC-MS or LC-MS/MS for all positive amphetamine screens.

Medication Selection for ADHD with History of Substance Abuse

When treating ADHD in patients with a history of methamphetamine abuse, medication selection is critical:

• Lisdexamfetamine (Vyvanse) is the preferred stimulant medication due to its lower abuse potential 1

  • As a prodrug, it requires enzymatic conversion in the bloodstream to become active
  • Cannot be easily diverted or abused through alternative routes of administration
  • Has been shown to effectively treat ADHD symptoms while potentially reducing cravings for illicit stimulants 2

• Alternative medications with less abuse potential:

  • Atomoxetine (Strattera) - non-stimulant option
  • Extended-release guanfacine (Intuniv)
  • Extended-release clonidine (Kapvay)
  • OROS methylphenidate (Concerta)
  • Dermal methylphenidate (Daytrana)

Urine Drug Screen Considerations

Detection Windows and Cross-Reactivity

• Prescription stimulants like Vyvanse will show up as amphetamines on standard urine drug screens 3
• Amphetamines typically remain detectable for up to 47.5 hours after dosing 3
• Standard immunoassays cannot distinguish between:
  • Prescribed amphetamines (Adderall, Vyvanse)
  • Illicit methamphetamine use

Testing Protocol for Patients on Stimulant Therapy

1. Baseline testing:

   • Perform comprehensive urine drug testing before initiating stimulant therapy 3
   • Document all current medications that could affect test results

2. Regular monitoring:

   • For moderate-risk patients, conduct presumptive urine drug testing approximately 8 times per year 3
   • Always use confirmatory testing (GC-MS or LC-MS/MS) for positive amphetamine screens

3. Confirmatory testing is essential:

   • Gas chromatography/mass spectrometry (GC-MS) or liquid chromatography/mass spectrometry (LC-MS/MS) can definitively distinguish between:
     • Prescribed lisdexamfetamine metabolites
     • Illicit methamphetamine 3
   • Chiral testing can differentiate between d-methamphetamine (illicit) and l-methamphetamine (found in some OTC products) 4

4. Interpreting results:

   • A patient taking Vyvanse should test positive for d-amphetamine but negative for methamphetamine
   • Presence of d-methamphetamine indicates potential illicit use 4
   • Document the ratio of amphetamine to methamphetamine, as this can help identify the source 5

Clinical Management Approach

1. Establish clear expectations:

   • Document the testing protocol in a treatment agreement
   • Explain that Vyvanse will cause positive amphetamine screens
   • Clarify that confirmatory testing will be used to verify compliance

2. Response to unexpected results:

   • Discuss unexpected results with the patient before taking action 3
   • Consider timing of medication ingestion relative to testing
   • Evaluate for potential false positives from other medications

3. Managing positive methamphetamine screens:

   • If confirmed positive for illicit methamphetamine:
     • Intensify monitoring and frequency of visits
     • Consider referral to addiction treatment
     • Do not immediately discontinue ADHD treatment, as this could worsen outcomes 1

4. Documentation:

   • Maintain detailed records of all test results
   • Document discussions with the patient about test results
   • Record any changes to the treatment plan based on test findings

Special Considerations

• False positives can occur with certain medications:

  • Some non-stimulant medications like atomoxetine have been reported to cause false-positive amphetamine results 6
  • Always verify positive screens with confirmatory testing

• Communication with other providers:

  • Inform all healthcare providers about the patient's ADHD medication
  • Coordinate care with addiction treatment providers if applicable

• Avoid patient abandonment:

  • Never dismiss patients from care based solely on urine drug test results 3
  • Work with patients to address substance use issues while continuing to treat ADHD when appropriate

By using lisdexamfetamine and implementing a rigorous testing protocol with confirmatory testing, clinicians can effectively manage ADHD in patients with a history of methamphetamine abuse while minimizing risks of diversion and relapse.