Alyssa M. Peckham

Diagnosis and Treatment of ADHD in the United States: Update by Gender and Race

Objective: The aim of this article is to update ADHD diagnosis/treatment trends by age, gender, and race. Method: National Ambulatory Medical Care Survey data were obtained for 2008-2009 to 2012-2013. Physician office visits including ADHD diagnosis and pharmacotherapy were measured per 1,000 population and per 1,000 office visits overall, and by demographic group. Logistic regression models controlled for demographics, psychiatric comorbidities, insurance type, and time period. Interactions of time, demographics, comorbidities, and insurance type were tested. Results: Diagnoses of ADHD increased by 36% in adults and 18% in youth, and diagnosis + drug by 29% in female and 10% in male youths. ADHD diagnosis was 77% less likely among Black than White adults but 24% more likely among Black than White youths in 2012-2013. Conduct disorder (CD) in youths multiplied odds of diagnosis + drug by 3.31; interaction of Black race × CD by 3.78. Conclusion: Upward trends in ADHD diagnosis and treatment have continued but vary markedly by group. Studies of undertreatment/overtreatment are needed.

Policies to mitigate nonmedical use of prescription medications: how should emerging evidence of gabapentin misuse be addressed?

ABSTRACT Introduction: Over the past decade, increased prescription supply has facilitated an epidemic of nonmedical use of controlled substances, including predominantly opioids, as well as benzodiazepines, z-hypnotics, and stimulants. Areas covered: More recently, misuse of noncontrolled prescriptions, such as gabapentin, has been detected. Gabapentin misuse has been associated with drug-related harm and increased healthcare service utilization in a few studies, including a recent large-sample analysis of commercially insured enrollees in the United States (U.S.) Responding to this emerging base of evidence, a small number of U.S. states have acted to prevent or detect gabapentin misuse by requiring the inclusion of gabapentin utilization in reporting to local Prescription Drug Monitoring Programs (PDMPs) and/or imposing other restrictions on gabapentin prescribing (e.g., classification as a controlled substance, quantity limits). These efforts may result in unintentional harm by (1) encouraging ‘doctor shopping’ across state lines to seek lenient regulatory policies and (2) placing the burden for mitigating misuse on individual practitioners. Expert opinion: We call for a unified national approach, comprising federal regulation and enhanced PDMP reporting to address gabapentin misuse, while laying the groundwork for management of new medications of abuse that the healthcare industry may encounter in the future.

Predictors of gabapentin overuse with or without concomitant opioids ina commercially-insured US population

Research suggests the medical consequences of gabapentin overuse depend on whether gabapentin is abused alone or with opioids to potentiate an opioid “high.” The objective of this study was to assess predictors of gabapentin overuse with or without concomitant opioids.

VMAT2 Inhibitors for Tardive Dyskinesia—Practice Implications

Tardive dyskinesia is a potentially irreversible, debilitating, hyperkinetic movement disorder that can result from dopamine receptor antagonists. Prompt recognition and resolution of symptoms are instrumental in preventing disease irreversibility, though current treatment options have fallen short of robust, effective, and long-term symptom control. In April 2017, the Food and Drug Administration (FDA) approved 2 new vesicular monoamine transporter 2 (VMAT2) inhibitors, deutetrabenazine and valbenazine, for chorea related to Huntington’s disease and tardive dyskinesia, respectively. These agents were pharmacologically modified from tetrabenazine, a VMAT2 inhibitor used off-label in the treatment of tardive dyskinesia. Despite FDA-labeled indications of deutetrabenazine and valbenazine, each agent was explored as a treatment option for those with tardive dyskinesia. In this study, the pharmacologic modifications of the 2 new VMAT2 inhibitors are described, with detailed explanation as to how these may impact clinical practice. The associated case series, observational studies, and clinical trials exploring their use in the treatment of tardive dyskinesia are reported with expert opinion on practice implication.

Call for increased pharmacovigilance of gabapentin

Huybrechts and colleagues find increased risk of neonatal drug withdrawal when gabapentin and opioids are co-prescribed.1 We conducted the first large scale assessment of the prevalence and clinical consequences of gabapentin misuse.23 The top 1% of gabapentin users consumed or diverted 19% of total gabapentin supply at mean (median) 11 274 (9534) mg/day; nearly 25% of these users exceeded 12 822 mg/day.2 Additionally, 24% …

Gabapentin use, abuse, and the US opioid epidemic: the case for reclassification as a controlled substance and the need for pharmacovigilance

The abuse potential of gabapentin is well documented; with gabapentin having been noted as an agent highly sought after for use in potentiating opioids. When combined with opioids, the risk of respiratory depression and opioid-related mortality increases significantly. In the US, gabapentin was approved by the Food and Drug Administration as a non-controlled substance. To date, and in spite of empirical evidence suggestive of diversion and abuse with opioids, gabapentin remains a non-controlled substance at the federal level. This has forced individual US states and jurisdictions – often significantly impacted by the opioid epidemic – to forge ahead with legislative initiatives designed to reclassify and/or monitor the use of gabapentin. Since August 1, 2016, 14 of 51 US states and jurisdictions have either implemented legislative mandates requiring pharmacovigilance programs, amended rules and regulations, are in the throes of crafting policy, or are in the midst of gathering additional data for decision making. This fragmented geographic approach yields only a modest benefit in combating the abuse of gabapentin and/or the national opioid epidemic. Herein, we report state-by-state efforts to enhance pharmacovigilance and call for a re-evaluation of the schedule status of gabapentin at the federal level, and design and implementation of a national pharmacovigilance program.

Delta-9-tetrahydrocannabinol and cannabidiol: Separating the chemicals from the “weed,” a pharmacodynamic discussion

Cannabis is being increasingly used as a medical treatment for a variety of illnesses. However, the cannabis plant has more than 70 different phytocannabinoids with potential pharmacologic activity. Two of the most researched phytocannabinoids are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Evidence suggests CBD can decrease some of the psychomimetic effects of THC. This has led to the development of a new drug, Nabiximols, for the treatment of moderate to severe spasticity due to multiple sclerosis. A discussion of evidence supporting proposed pharmacodynamic interplay between CBD and THC is presented.