Stimulant diversion by young adults with ADHD: piloting primary care prevention

描述（由申请人提供）：非医学使用精神活性兴奋剂药物（用于治疗注意力缺陷/多动障碍；ADHD的药物）是年轻人尤其是大学生中越来越普遍的处方药滥用形式（Smith & Farah, 2011; Wilens et al., 2008）。大学校园非医疗使用（无处方使用）的流行率正在上升（例如，DeSantis等人，2008年）。近年来，与兴奋剂相关的急诊就诊增加了三倍（SAMHSA, 2013）。拿着处方的大学生是兴奋剂转移的主要来源（赠送或出售自己的药物）。然而，目前还没有针对初级保健提供者的管理这一问题的临床策略。初级保健提供者是一个经常治疗ADHD的专业人群，也是NIDA的目标人群（Volkow, 2012），特别是关于包括兴奋剂在内的处方药的非医疗使用（Volkow, 2010）。我们与初级保健提供者的初步焦点小组显示，要么缺乏对兴奋剂转移/滥用的认识，要么缺乏解决这一问题的策略；所有人都表示担忧。这项R34申请提出了简短临床策略的初步发展，初级保健提供者可以使用它来防止ADHD患者转移兴奋剂。我们的重点是家庭医学和儿科提供者治疗18-25岁的中学后教育。在R34项目公告PA-12-171“预防药物和酒精滥用试验准备的试点和可行性研究”的背景下，我们将1)调查提供者及其医师扩展者（执业护士和医师助理）目前的做法；2)制定和试点测试策略，以防止在提供者和患者关系的背景下使用转移；3)利用实施后调查和电子病历数据，检查与可行性、满意度和实施相关的提供者、实践和患者变量。我们根据Weiner的创新实施理论（Weiner et al., 2009）选择战略制定和评估中要考虑的变量。我们建议让主要持份者（社区提供者）和相关顾问参与发展过程，以加强创新的可行性和实施。这些策略的发展将是创新的，因为它们在基于证据的ADHD治疗指南文献中完全缺失。该项目解决了一个迫在眉睫的公共卫生问题：大学生对附表II处方药（中枢神经系统兴奋剂）的非处方使用不断升级。在R01资助的有效性和调节因素的有力研究之后，解决这一知识差距具有最终潜力，可以提供一种实用、低成本和高度可传播的方法，通过这种方法可以减少处方兴奋剂的转移。

DESCRIPTION (provided by applicant): Nonmedical use of psychoactive stimulant medication (medication that is prescribed for the treatment of Attention-Deficit/Hyperactivity Disorder; ADHD) is an increasingly prevalent form of prescription drug misuse among young adults and in particular college students (Smith & Farah, 2011; Wilens et al., 2008). Prevalence rates of nonmedical use (use without a prescription) on college campuses are rising (e.g., DeSantis et al., 2008). Stimulant-related emergency department visits have increased threefold in recent years (SAMHSA, 2013a). College students with prescriptions are the primary source of stimulant diversion (giving away or selling one's medication). However, no clinical strategies for management of this problem have been developed for primary care providers - a professional population that frequently treats ADHD and that is being targeted by NIDA (Volkow, 2012), especially with regard to nonmedical use of prescription drugs including stimulants (Volkow, 2010). Our preliminary focus groups with primary care providers revealed either lack of awareness about stimulant diversion/misuse or lack of strategies for addressing it; all indicated concern. This R34 application proposes the initial development of brief clinical strategies that primary care providers may use to prevent diversion of stimulants by their patients with ADHD. We focus on family medicine and pediatric providers treating 18-25 year olds in post-secondary education. Within the context of the R34 Program Announcement PA-12-171, Pilot and Feasibility Studies in Preparation for Drug and Alcohol Abuse Prevention Trials, we will 1) survey providers and their physician-extenders (nurse practitioners and physician assistants) about their current practices; 2) develop and pilot test strategies for prevention of diversion to e utilized within the context of the provider:patient relationship; and 3) examine, using post- implementation survey and EMR data, provider, practice, and patient variables associated with feasibility, satisfaction, and implementation. We base our selection of variables to consider in strategy development and evaluation on Weiner's theory of innovation implementation (Weiner et al., 2009). We propose inclusion of key stakeholders (community providers) and relevant consultants in the development process to enhance innovation feasibility and implementation. The development of these strategies will be innovative due to their complete absence in the evidence-based ADHD treatment guidelines literature. The project addresses an immediate public health concern: escalating non-prescribed use of a Schedule II prescription medication (CNS stimulants) by college students. Addressing this knowledge gap has the ultimate potential, following an R01- funded well-powered study of effectiveness and moderators, to provide one pragmatic, low cost, and highly disseminable means by which prescription stimulant diversion may be decreased.