What is the appropriate management for a patient with suspected diversion of stimulant medications, such as Ritalin (methylphenidate)?

From the Guidelines

When handling a patient with suspected diversion of stimulants, the most appropriate management is to document objective evidence of diversion behaviors, implement a controlled substance agreement, and consider switching to non-stimulant alternatives like atomoxetine (Strattera) 40-100 mg daily, as recommended by the most recent and highest quality study 1. The management of patients with suspected diversion of stimulant medications, such as Ritalin (methylphenidate), requires a comprehensive approach that prioritizes the patient's safety and well-being.

Key Considerations

• Documenting objective evidence of diversion behaviors, such as early refill requests, lost prescriptions, or inconsistent urine drug screens, is crucial in identifying patients at risk of diversion.
• Implementing a controlled substance agreement that outlines expectations and consequences of misuse can help prevent diversion and ensure patient safety.
• Considering non-stimulant alternatives, such as atomoxetine (Strattera) 40-100 mg daily, can minimize the risk of diversion and abuse, as these medications have a lower potential for abuse and diversion compared to stimulants 1.

Medication Options

• Non-stimulant alternatives, such as atomoxetine (Strattera) 40-100 mg daily, bupropion (Wellbutrin) 150-300 mg daily, or guanfacine (Intuniv) 1-4 mg daily, can be effective in managing ADHD symptoms while minimizing the risk of diversion and abuse.
• If continuing stimulants is necessary, consider long-acting formulations that are less easily diverted, such as Concerta, Vyvanse, or Adderall XR, as recommended by previous studies 1.

Monitoring and Referral

• Regular monitoring, including frequent office visits, random urine drug testing, and pill counts, can help identify and prevent diversion.
• In cases of confirmed diversion, a referral to addiction medicine may be appropriate while maintaining treatment for the underlying condition, as stimulant diversion is common due to their high street value and abuse potential as Schedule II controlled substances 1.

From the FDA Drug Label

Before prescribing methylphenidate hydrochloride oral solution, assess each patient’s risk for abuse, misuse, and addiction Educate patients and their families about these risks and proper disposal of any unused drug. Advise patients to store methylphenidate hydrochloride oral solution in a safe place, preferably locked, and instruct patients to not give methylphenidate hydrochloride oral solution to anyone else Throughout methylphenidate hydrochloride treatment, reassess each patient’s risk of abuse, misuse, and addiction and frequently monitor for signs and symptoms of abuse, misuse, and addiction.

The appropriate management for a patient with suspected diversion of stimulant medications, such as Ritalin (methylphenidate), includes:

• Assessing the patient's risk for abuse, misuse, and addiction
• Educating the patient and their family about the risks and proper disposal of unused medication
• Monitoring for signs and symptoms of abuse, misuse, and addiction
• Storing the medication in a safe place, preferably locked, and advising the patient not to share it with others
• Reassessing the patient's risk regularly throughout treatment 2, 2.

From the Research

Appropriate Management for Suspected Diversion of Stimulant Medications

• The management of patients with suspected diversion of stimulant medications, such as Ritalin (methylphenidate), is a complex issue that requires a multifaceted approach 3, 4, 5, 6, 7.
• Physicians play a crucial role in preventing the diversion and misuse of prescription stimulants, and they should assume greater responsibility in this area 3.
• The use of medication contracts and distributing print materials to patients with ADHD is not commonly practiced by physicians, with 85.2% and 81.0% of physicians reporting that they "never" or "rarely" use these methods, respectively 3.
• Prescribing long-acting instead of immediate-release stimulants and prescribing non-stimulants are the leading prevention practices implemented by physicians when they suspect stimulant misuse and/or diversion, with 79.2% and 71.9% of physicians reporting that they use these methods at least "often", respectively 3.
• Physicians' perceptions of the effectiveness of prevention practices vary, with 71.4% of respondents believing that prescribing non-stimulants is "very effective" at preventing misuse and diversion, while 53.4% and 31.5% of physicians labeled using a medication contract and distributing print materials as "not likely effective", respectively 3.

Strategies to Address Diversion

• Monitoring for diversion is an essential step in addressing the issue, but there is little consistency in how monitoring is done, and reported strategies do not differ between telemedicine and in-person care 7.
• When physicians suspect diversion, there is wide variation in responses, ranging from not taking any action to imposing more requirements on patients, no longer prescribing the controlled substance, or terminating the patient from their practice 7.
• Few physicians have ever reported a case of suspected diversion to law enforcement, highlighting the need for clearer reporting requirements and guidance on how to respond to suspected diversion 7.

Prevention Practices

• Child and adolescent psychiatrists are more likely to implement certain prevention practices compared to other subspecialists, and they are also more likely to have received formal training on prescription drug diversion and feel better qualified to educate patients on the health and legal consequences of stimulant misuse and diversion 3, 5.
• Increased training is needed to enable physicians to effectively educate patients with ADHD on the risks of stimulant misuse and diversion, and to provide them with the skills and knowledge necessary to prevent these issues 5.
• Non-stimulant medications may be an appropriate alternative for patients with concerns about abuse and diversion, as they lack the mechanism of action linked to abuse potential and are less likely to be misused 6.