The DAWN Report: Emergency Department Visits Involving Attention Deficit/Hyperactivity Disorder Stimulant Medications
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The DAWN Report: Emergency Department Visits Involving Attention Deficit/Hyperactivity Disorder Stimulant Medications
January 24, 2013
Emergency Department Visits Involving Attention Deficit/Hyperactivity Disorder Stimulant Medications
Attention deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder marked by excessive hyperactivity,
IN BRIEF
impulsivity, or inattention.¹Although these disorders are typically
| diagnosed in childhood, symptoms may persist into adulthood.¹ | X Between 2005 and 2010, |
|---|---|
| About two thirds (66 percent) of children aged 4 to 17 diagnosed | the number of emergency |
| with ADHD took medication for the disorder in 2007,²and | department (ED) visits involving |
attention deficit/hyperactivity stimulant medications remain the first-line treatment for these disorder (ADHD) stimulant disorders in both children and adults.³When used as directed, medications increased from ADHD stimulant medications can be effective treatment, but 13,379 to 31,244 visits they can also have negative side effects, such as nervousness,
insomnia, dizziness, and cardiovascular or psychiatric problems.4,5 X The number of ED visits involving ADHD stimulant ADHD stimulant medications can also be misused to suppress medications increased appetite, enhance alertness, or cause feelings of euphoria.⁶Past significantly for adults aged year nonmedical use of Adderall®, a common ADHD stimulant 18 or older between 2005
| medication, increased among adults from 2006 to 2010, particularly | and 2010, but no significant |
|---|---|
| among young adults aged 18 to 25.⁷Whether ADHD stimulant | increases were seen among |
| medications are misused or adverse reactions occur when the | children younger than 18 |
medication is taken as prescribed, monitoring dangerous health
X Between 2005 and 2010, the
effects that require immediate medical attention can help guide number of ED visits related to intervention efforts. ADHD stimulant medications that involved nonmedical use The Drug Abuse Warning Network (DAWN) is a public health increased from 5,212 to 15,585 surveillance system that monitors drug-related emergency visits; those involving adverse
| department (ED) visits in the United States and can be used to | reactions increased from 5,085 |
|---|---|
| track ED visits related to ADHD stimulant medications. To be a | to 9,181 visits |
DAWN case, an ED visit must have involved a drug, either as the
X Other pharmaceutical drugs
direct cause of the visit or as a contributing factor. This issue of were involved in nearly half (45 The DAWN Report examines trends in ED visits involving ADHD percent) of ED visits involving stimulant medications, including methylphenidate (e.g., Ritalin®, ADHD stimulant medications Concerta®), amphetamine-dextroamphetamine (e.g., Adderall®), and about one fifth involved
| dexmethylphenidate (e.g., Focalin®), and dextroamphetamine | illicit drugs (21 percent) or |
|---|---|
| (e.g., Dexedrine®). | alcohol (19 percent) |
DAWN_073
Overview and Demographic Characteristics Although the number of ED visits involving ADHD The number of ED visits involving ADHD stimulant stimulant medications did not increase significantly
| medications increased between 2005 and 2010 from | for children younger than 18 between 2005 and 2010, |
|---|---|
| 13,379 to 31,244 visits (Figure 1). The number of | increases were seen among multiple age groups for |
| ED visits involving ADHD stimulant medications | persons aged 18 or older (Figure 2). Specifically, visits |
| increased among both males and females: visits among | increased from 2,131 to 8,148 visits among persons |
| females increased between 2005 and 2010 from 4,315 | aged 18 to 25, from 1,754 to 6,094 visits among |
| to 14,068 visits, and visits among males nearly doubled | persons aged 26 to 34, and from 2,519 to 7,957 visits |
| from 9,059 to 17,174 visits. | among adults aged 35 or older. |
Figure 1. Emergency Department (ED) Visits Related to Attention Deficit/Hyperactivity Disorder (ADHD) Stimulant Medications, by Gender*: 2005 to 2010
35,000 31,244
30,000 26,711 26,369 23,735 25,000 All**
| 20,000 | 16,947 | 17,174 |
|---|---|---|
| 14,979 | 14,503 | Males** |
13,379
| 15,000 | 12,287 | |
|---|---|---|
| 10,614 | Females** | |
| 9,059 | 14,068 | |
| 10,000 | 12,208 | |
| Number of ED Visits | 11,390 | 11,448 |
5,000 6,332 4,315 0
2005 2006 2007 2008 2009 2010
- Because gender is unknown in a small number of visits, estimates for males and females do not add to the total. ** The change from 2005 to 2010 is statistically significant at the .05 level. Source: 2005 to 2010 SAMHSA Drug Abuse Warning Network (DAWN).
Figure 2. Emergency Department (ED) Visits Related to Attention Deficit/Hyperactivity Disorder (ADHD) Stimulant Medications, by Age Group: 2005 and 2010
9,000
8,148 7,957
6,094 6,000
2005 3,791
3,461 2010 3,322
3,000 2,702 2,519 2,131
Number of ED Visits 1,754
0
Aged 5 to 11 Aged 12 to 17 Aged 18 to 25* Aged 26 to 34* Aged 35 or Older*
- The change from 2005 to 2010 is statistically significant at the .05 level. Source: 2005 and 2010 SAMHSA Drug Abuse Warning Network (DAWN).
| Reasons for ED Visits | involved two or more other drugs (Table 2). Other |
|---|---|
| In 2010, half of ADHD stimulant medication-related | pharmaceutical drugs were involved in nearly half |
| ED visits involved nonmedical use of pharmaceuticals⁸ | (45 percent) of visits; one quarter (26 percent) involved |
| (50 percent), and nearly one third involved adverse | anti-anxiety and insomnia medications, and about one |
| reactions⁹(29 percent) (Figure 3). The number of | sixth (16 percent) involved narcotic pain relievers.¹⁰ |
ED visits related to ADHD stimulant medications involving nonmedical use of pharmaceuticals increased
| significantly from 5,212 visits in 2005 to 15,585 visits | Table 1. Reason for Emergency Department (ED) Visits |
|---|---|
| in 2010 (Table 1). Among demographic subgroups, | Related to Attention Deficit/Hyperactivity Disorder |
(ADHD) Stimulant Medications, by Gender and Age ED visits involving nonmedical use of pharmaceuticals Group*: 2005 and 2010 increased significantly among males, females, and adults aged 18 or older.
Nonmedical Use in Nonmedical Use in
Demographic 2005: Number of 2010: Number of The number of ED visits related to ADHD stimulant Characteristic ED Visits ED Visits medications involving adverse reactions increased
significantly from 5,085 visits in 2005 to 9,181 visits in Total ED Visits 5,212 15,585** 2010 (Table 1). Among demographic subgroups, ED
Male 3,770 8,650** visits for adverse reactions increased significantly among
Female 1,439 6,932** females and adults aged 18 or older.
| Aged 5 to 11 | *** | *** | |
|---|---|---|---|
| Drug Combinations with ADHD Stimulant | Aged 12 to 17 | 1,578 | 1,830 |
| Medications | Aged 12 to 14 | 429 | 534 |
| Aged 15 to 17 | 1,149 | 1,296 |
Of the 31,244 ED visits involving ADHD stimulant
Aged 18 or Older 3,175 13,570** medications in 2010, one quarter (25 percent) involved
Aged 18 to 25 1,310 5,766** one other drug, and nearly two fifths (38 percent)
| Aged 26 to 34 | 851 | 3,556** |
|---|---|---|
| Aged 35 or Older | 1,014 | 4,248** |
| Figure 3. Emergency Department (ED) Visits Related | Adverse Reactions | Adverse Reactions |
| Demographic | in 2005: Number of | in 2010: Number of |
to Attention Deficit/Hyperactivity Disorder (ADHD) Characteristic ED Visits ED Visits Stimulant Medications, by Reason for Visit: 2010
Total ED Visits 5,085 9,181** Nonmedical Use
| 50% | Male | 3,500 | 5,234 |
|---|---|---|---|
| Female | 1,584 | 3,947** | |
| Aged 5 to 11 | 2,630 | 3,513 | |
| Aged 12 to 17 | 647 | 685 | |
| Aged 12 to 14 | *** | 459 | |
| Aged 15 to 17 | 436 | 226 | |
| Aged 18 or Older | 1,637 | 4,983** | |
| Aged 18 to 25 | 539 | 1,264 | |
| Aged 26 to 34 | *** | 1,122 |
Adverse Other*
Reactions Aged 35 or Older 790 2,597** 21% 29% * Because gender or age is unknown in a small number of visits, estimates do not add to the total.
- Includes accidental ingestions and suicide attempts. ** The change from 2005 to 2010 is statistically significant at the .05 level.
*** Estimate not reported due to low precision.
Source: 2010 SAMHSA Drug Abuse Warning Network (DAWN).
Source: 2005 and 2010 SAMHSA Drug Abuse Warning Network (DAWN).
| About one fifth involved illicit drugs (21 percent), | combined with ADHD stimulant medications among |
|---|---|
| and 14 percent involved marijuana. Nearly one fifth | adults aged 26 to 34 (44 percent) and those aged 35 |
| involved alcohol (19 percent). | or older (31 percent). Visits for children aged 14 or |
younger did not yield statistically reliable estimates for Drug combinations involved in ED visits related drug combinations with ADHD stimulant medications.
to ADHD stimulant medications varied across age groups. Marijuana was the most common drug Discussion combined with ADHD stimulant medications among Because ADHD stimulant medications have historically adolescents aged 15 to 17 (32 percent), and alcohol been prescribed for developmental disorders in was the most common drug combined with ADHD children, nonmedical use among adolescents and young stimulant medications among young adults aged 18 adults has received much attention.¹¹This report shows to 25 (30 percent) (data not shown). Anti-anxiety and that ED visits for nonmedical use have not increased insomnia medications were the most common drug among children and adolescents, but they have increased among adults aged 18 or older. This suggests a need for increased attention toward efforts to prevent Table 2. Number and Percentage of Selected Drugs diversion and misuse among adults.
Involved in Emergency Department (ED) Visits Related to Attention Deficit/Hyperactivity Disorder (ADHD) Even when taken as directed, ADHD stimulant
Stimulant Medications: 2010 4 medications entail some risk, and the data in this report show that the number of visits involving adverse Estimated
| Number of Percentage | reactions increased between 2005 and 2010, especially | ||
|---|---|---|---|
| Drug Combination | ED Visits | of Visits | for adults aged 18 and older. As treatment for ADHD |
among adults becomes more widespread,³prescribing
Total ED Visits 31,244 100% physicians (including psychiatrists and other mental
ADHD Stimulant Medication Only 11,644 37% health professionals) may carefully consider associated
| ADHD Stimulant Medication with One | 7,667 | 25% | |
|---|---|---|---|
| Other Drug | risks among those who have chronic health conditions | ||
| ADHD Stimulant Medication with Two or | 11,933 | 38% | and/or take other medications that may interact with |
More Other Drugs ADHD stimulant medications. A variety of treatment ADHD Stimulant Medication with Other Drugs options, both pharmaceutical and nonpharmaceutical, 3,12
| Other Pharmaceutical Drugs | 14,010 | 45% | are available for adults with ADHD. |
|---|---|---|---|
| Anti-anxiety and Insomnia Medications | 8,083 | 26% |
End Notes
Narcotic Pain Relievers 5,140 16% 1. Centers for Disease Control and Prevention. (2010). Attention-deficit/
Antidepressants 3,199 10% hyperactivity disorder (ADHD): Facts about ADHD. Retrieved from
| Antipsychotics | 2,050 | 7% | http://www.cdc.gov/ncbddd/adhd/facts.html |
|---|---|---|---|
| Cardiovascular Agents | 1,741 | 6% | 2. Visser, S. N., Bitsko, R. H., Danielson, M. L., Perou, R., & |
| Anticonvulsants | 1,150 | 4% | Blumberg, S. J. (2010). Increasing prevalence of parent-reported |
attention-deficit/hyperactivity disorder among children—United
Respiratory Agents 1,063 3% States, 2003 and 2007. Morbidity and Mortality Weekly Report,
| Illicit Drugs | 6,683 | 21% | 59(44), 1439-1443. |
|---|---|---|---|
| Marijuana | 4,228 | 14% |
- Antshel, K. M., Hargrave, T. M., Simonescu, M., Kaul, P., Hendricks, K.,
Stimulants 1,306 4% & Faraone, S. V. (2011). Advances in understanding and treating ADHD. BMC Medicine, 9, 72.
Cocaine 1,277 4% 4. Food and Drug Administration Press Release. (2007). FDA directs
Heroin 770 3% ADHD drug manufacturers to notify patients about cardiovascular
Alcohol 5,783 19% adverse events and psychiatric adverse events. Retrieved from http:// www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/
Note: Because multiple drugs may be involved in each visit, estimates of visits by ucm108849.htm drug add to more than the total, and percentages add to more than 100 percent. Source: 2010 SAMHSA Drug Abuse Warning Network (DAWN).
- MedlinePlus. (2011). Methylphenidate. Retrieved from http://www. Suggested Citation nlm.nih.gov/medlineplus/druginfo/meds/a682188.html#overdose Substance Abuse and Mental Health Services Administration, Center
| 6. National Institute on Drug Abuse. (2009). DrugFacts: Stimulant ADHD | for Behavioral Health Statistics and Quality. (January 24, 2013). The |
|---|---|
| medications—Methylphenidate and amphetamines. Retrieved from | DAWN Report: Emergency Department Visits Involving Attention Deficit/ |
| http://www.drugabuse.gov/publications/drugfacts/stimulant-adhd- | Hyperactivity Disorder Stimulant Medications. Rockville, MD. |
medications-methylphenidate-amphetamines
- Center for Behavioral Health Statistics and Quality. (2011). Results
from the 2010 National Survey on Drug Use and Health: Detailed The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related morbidity and mortality. DAWN uses tables. Rockville, MD: Substance Abuse and Mental Health Services a probability sample of hospitals to produce estimates of drug-related Administration. Retrieved from http://www.samhsa.gov/data/ emergency department (ED) visits for the United States and selected
nsduh/2k10NSDUH/tabs/Cover.pdf metropolitan areas annually. DAWN also produces annual profiles of drug-related deaths reviewed by medical examiners or coroners in selected 8. Nonmedical use includes taking more than the prescribed dose of metropolitan areas and States.
a prescription medication or more than the recommended dose of Any ED visit related to recent drug use is included in DAWN. All types of an OTC medication or supplement; taking more than the prescribed drugs—licit and illicit—are covered. Alcohol involvement is documented for dose of a prescription medication or more than the recommended patients of all ages if it occurs with another drug. Alcohol is considered an dose of an OTC medication or supplement; taking a prescription illicit drug for minors and is documented even if no other drug is involved. medication prescribed for another individual; being deliberately The classification of drugs used in DAWN is derived from the Multum Lexicon, copyright 2010 Lexi-Comp, Inc., and/or Cerner Multum, Inc. The poisoned with a pharmaceutical by another person; and misusing or Multum Licensing Agreement governing use of the Lexicon can be found at abusing a prescription medication, an OTC medication, or a dietary http://www.samhsa.gov/data/DAWN.aspx.
supplement.
DAWN is one of three major surveys conducted by the Substance Abuse
| 9. Adverse reactions are defined as ED visits in which an adverse | and Mental Health Services Administration’s Center for Behavioral Health |
|---|---|
| health consequence results from taking prescription drugs, OTC | Statistics and Quality (SAMHSA/CBHSQ). For more information on other |
CBHSQ surveys, go to http://www.samhsa.gov/data/. SAMHSA has medications, or dietary supplements as prescribed or recommended.
contracts with Westat (Rockville, MD) and RTI International (Research A visit is not included in this category if an illicit drug is involved.
Triangle Park, NC) to operate the DAWN system and produce publications.
| 10.If a visit for nonmedical use of pharmaceuticals involves more than | For publications and additional information about DAWN, go to http://www. |
|---|---|
| one pharmaceutical, DAWN does not specify which pharmaceutical | samhsa.gov/data/DAWN.aspx. |
was used nonmedically.
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
11.Wilens, T. E., Adler, L. A., Adams, J., Sgambati, S., Rotrosen, J., Substance Abuse & Mental Health Services Administration Center for Behavioral Health Statistics and Quality
Sawtelle, R., Utzinger, L., & Fusillo, S. (2008). Misuse and diversion of www.samhsa.gov/data stimulants prescribed for ADHD: A systematic review of the literature. Journal of the American Academy of Child and Adolescent Psychiatry, 47(1), 21-31.
12.National Institute of Mental Health. (2009). Attention deficit hyperactivity disorder: Can adults have ADHD? Retrieved from http:// www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/can-adults-have-adhd.shtml
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