A new study about the abuse of Ritalin reiterates the medication's low risk potential when taken as directed but underscores the potential problems that may occur when the drug is abused. The article centers on an adult with ADHD who inhaled 700 mg of Ritalin — the equivalent of 70 crushed tablets of 10mg doses, or more medication than many patients would take in a month — over a 3-day binge, which was followed by another four days of continued abuse. Fortunately, the patient eventually sought medical attention at the University of Connecticut Health Center, where he was monitored and treated. A report of the case appears in the journal Substance Abuse.
The case presents some important implications for people who have ADHD, including recommendations for the treatment of ADHD patients who are addicts.
Methylphenidate does not appear to be a "gateway" drug
Some media sources have tried to sensationalize the prescribed use of methylphenidate as a "gateway" drug that leads to other addictions. Such is not the case, according to doctors and scientists who have researched methylphenidate and patterns of addiction. Even among abusers, methylphenidate does not appear to be the drug of first choice.
Yifrah Kaminer, M.D., one of the study's authors, notes that the majority of people who abuse methylphenidate had first used other illicit drugs and do not meet the criteria for ADHD. According to Kaminer, most patients who abuse the medication typically already have a history of drug abuse. Such was the case in this report. Although the 45-year-old man had been diagnosed with ADHD as a child, he had discontinued methylphenidate use four years before he began using other drugs. He had developed a long and extensive history of drug abuse before he began inhaling methylphenidate. In fact, his three-day methylphenidate binge was proceeded by a one month period during which he took a reported six tablets of Vicodin per day.
Abuse began when treatment was discontinued
The patient in the study had been prescribed Ritalin when he was a child. The medication improved his concentration, decreased his restlessness, and produced other beneficial results. Medication treatment was discontinued when he reached thirteen years of age. He was unmedicated and reportedly did not use illicit drugs until he was 17.
According to the patient, he began abusing drugs at age 17-year-old, four years after he had discontinued his medication for ADHD. He tried various recreational drugs, including cocaine, amphetamines, and opiates. In addition to raiding his parent's medicine cabinet for Quaaludes and other prescription drugs, he also claims to have smoked marijuana daily between the ages of 17 and 37, except for one 3-year period of sobriety.
It is impossible to predict whether this man would have developed a substance abuse disorder if he had continued treatment for his ADHD. However, two things are clear. 1) He did not have a problem with substance abuse when he was taking medication, and 2) discontinuing medication did not result in his immediately beginning to abuse other drugs. In fact, according to the patient, his pattern of drug use began when he was attempting to self-medicate his depression and anxiety.
Health risks of stimulants increase dramatically when these medications are abused
When taken as directed, methylphenidate has a relatively slow onset and does not produce a "high" like cocaine. However, the profile of the medication changes dramatically when the tablets are crushed and inhaled. The result is both dangerous and potentially addictive.
Many drug abusers come from families with histories of drug abuse
Like ADHD, substance abuse tends to run in families. Individuals with a family history of drug abuse should use caution when taking stimulant medications. The patient in this case had parents with histories of alcoholism and substance abuse.
Can recovering addicts use methylphenidate?
Yes, but certain precautions must be taken to ensure that the patient not fall into a pattern of abuse. Kaminer makes the following recommendations for treating ADHD patients who have a history of substance abuse.
- Use long-lasting medications as they help reduce the potential for abuse. Kaminer and the other authors of the study recommend that patients with ADHD who also have substance abuse disorders be treated long-acting, slow-release stimulants. Bupropion (Wellbutrin) and Clonidine are also suggested as possible alternatives.
- Physicians should make patients sign a written therapeutic contract with clearly defined consequences if abuse or violations of the agreement should occur. The contract should be kept on file and periodically reviewed with the patient.
- At the patient's home, stimulants should be kept in a safe place. For example, a recovering addict may ask a friend or family member to store the medication for the patient and only allow the patient to have the medication according to the prescription.
- Physicians should write prescriptions for only one week at a time, rather than prescribing the usual one month's supply of Ritalin. Kaminer recommends that physicians should notice any repeated untimely requests for refills (such as patients who might say, "I'm going out of town. Can you write me a prescription before I leave?"), excuses ("I lost my prescription") or other behaviors that might suggest drug abuse. The patient in the Substance Abuse article obtained the extra methylphenidate by first lying to his prescriber before the binge and then persuading an Emergency Room doctor to give him another prescription while the binge was in process.
- Physicians and family members should learn to recognize drug-seeking behaviors. Self-medication should not be tolerated.
- Medications should be taken under the supervision of a responsible adult who can administer the medication properly and monitor how much and when the medication is actually taken. Monitors should be aware that addicts will sometimes attempt to store medications for future abuse by not swallowing the pills when they are administered.