Central Nervous System: Stimulant Use on the Rise
Medications such as Adderall® and Ritalin® pose risks to work comp patients if not prescribed properly.
Often, opioids are at the center of focus in attempts to manage medication utilization and spend in workers’ compensation. However, they are not the only class of medication that can be both costly and dangerous. Central Nervous System stimulants, or CNS stimulants, pose significant health risks and are increasingly abused.
CNS stimulants include medications used to treat attention-deficit hyperactivity disorder (ADHD), narcolepsy and weight loss. Based on their intended use, it may seem surprising that this class of medications is often used to treat workers’ compensation patients — but they are prescribed, and frequently the subject of abuse and misuse.
A Real-World Problem
A recent New York Times article titled “Drowned in a Stream of Prescriptions,” tells the tragic tale of a 24-year-old college graduate who developed an addiction to CNS stimulants, suffered a mental breakdown, and subsequently committed suicide.1 The tragedy was compounded because the individual was not stealing or buying these medications off the street. Instead, they were being prescribed to him — despite the facts that he was taking more than prescribed, was becoming psychotic, and his family had voiced their concerns to the prescriber. This example illustrates the extreme consequences of disease state mismanagement and potential drug abuse that can occur with CNS stimulants.
An increase in the abuse of CNS stimulants is apparent when examining findings on drug-related emergency department visits. The rate of emergency department visits in the U.S. involving drug misuse (accidental) or abuse increased significantly from 2004 to 2011, with cases involving CNS stimulants increasing by 292% – a larger increase than any other drug class.2 Between 2005 and 2010, the number of visits involving CNS stimulants increased from 13,379 to 31,244, about half of these cases are the result of “nonmedical use,” which in many cases can be attributed to abuse.3
CNS stimulants are having a huge impact on increased emergency department visits.
Commonly Prescribed CNS Stimulants4
Why are we seeing the rapid increase in the use of CNS stimulants? One reason may include the fact that people are being diagnosed more often with the conditions that these drugs are intended to treat, particularly ADHD. For many people, certain effects of these drugs are desirable, including loss of appetite (to assist in weight loss), a feeling of euphoria and increased alertness. Because of these factors, CNS stimulants are a desirable drug to abuse.
Gauging Appropriate Use
CNS stimulants may be prescribed to injured workers to manage shift-work sleep disorder or other work-related injuries that have resulted in excessive fatigue. Unfortunately, they are also often prescribed off-label (to be used for a reason other than what the drug was approved for) to counteract the sedation caused by large amounts of CNS depressants. When a patient is prescribed a depressant such as opioids, benzodiazepines and hypnotics a side effect is often daytime fatigue – and prescribing a CNS stimulant will counteract the depressant. This is not an appropriate practice, and is strongly discouraged. The medications causing sedation should be adjusted, rather than adding a CNS stimulant with its own risks and adverse effects.
Injured workers need to be assessed prior to prescribing a CNS stimulant. Screening the patient for a history of substance abuse is important, since certain types of CNS stimulants should be withheld in these cases (see table). Even if they are not abused, these medications carry a high risk of dependence, and cannot be abruptly stopped, as this could result in withdrawal, agitation, anxiety and depression. Even when taken as prescribed, this class of medications can cause increased heart rate, insomnia and agitation. It was reported that about one third of emergency department visits related to CNS stimulants between 2005 and 2010 were the result of adverse reactions alone, drawing attention to the risks associated with even appropriate use. The example given in the New York Times article illustrates the fact that there can never be enough checks and balances in place to assure appropriate therapy. A pharmacy benefits manager is part of this checks and balance process, and should play a significant role in identifying potential risks, drug and drug-disease interactions and inappropriate use of these medications. It is important to ensure that injured workers are prescribed these medications for appropriate reasons, and that all other medication options have been tried before a CNS stimulant is used. The safety of the injured worker and appropriate management is critical to recovery.