Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults — United States, 2016–2021

Discussion

The percentage of persons with employer-sponsored insurance who received prescription stimulants increased during 2016–2021, with notable increases among adolescent and adult females and adult males. The largest single-year increases occurred during 2020–2021, with the annual change exceeding 10% in many age groups. Consistently across the study period, most persons with prescription stimulant fills had health care encounters with ADHD diagnosis codes, and persons with prescription stimulant fills averaged more than seven fills per year, suggesting that most were receiving ongoing care for ADHD.

During this study period, the highest percentages of stimulant prescriptions were among males aged 5–19 years, although these percentages decreased over time. Historically, ADHD has been defined as a childhood disorder more common among boys (3), but it is increasingly recognized as a potentially lifelong condition that might be underdiagnosed or undertreated in both girls and adults (3,4). Appropriate diagnosis and effective treatment can help improve functioning for persons with ADHD (3); prescription stimulants have demonstrated effectiveness in reducing ADHD symptoms in children and adults (3,4).

The prevalence of diagnosed ADHD and associated treatment in adults has increased in recent decades (1,2,5). The current study adds to evidence** that the increasing trend in the percentage of adults receiving prescriptions for stimulants has continued during the COVID-19 pandemic, with a notable upturn during 2020–2021. The pandemic has had negative impacts on mental health (6,7), which might have led to or exacerbated ADHD symptoms. To adapt to the pandemic environment, policy and health system reimbursement changes were implemented, such as expansion of telehealth and easing of the requirement for having an in-person visit with a clinician before receiving a prescription for stimulants or other Schedule II controlled substances^†† (8). The combination of potential increased need and reduced barriers to access prescription stimulants might have encouraged more adults with ADHD symptoms to seek diagnosis and treatment. Although improved access to ADHD care through telehealth during the pandemic might have benefitted some persons with ADHD symptoms, it might have also introduced the potential for inadequate ADHD evaluations and inappropriate stimulant prescribing. Continued evaluation of public health emergency response policies and their use beyond the immediate emergency, such as expanded use of telehealth for prescribing, could increase understanding of long-term benefits or harms of these policies, including whether these policies increase equitable access to mental health care and the parameters needed to promote best practices (8).

The large increase in the percentage of adults receiving prescription stimulants during the COVID-19 pandemic draws attention to the need for clinical practice guidelines for ADHD in adults. Well-established professional guidelines for diagnostic procedures and treatment algorithms exist for children and adolescents with ADHD (3); however, no similar diagnostic and treatment guidelines for ADHD among adults are available in the United States (9). This gap in guidance for adult ADHD care is a public health concern because of challenges associated with the differential diagnosis of ADHD (4,9) and general inadequate access to mental health providers (10) trained to diagnose and manage ADHD. Clinicians from varying specialties are approached for ADHD care, and report differing levels of training and relative comfort with diagnosing and managing ADHD (1,2,9). Stimulants are one type of treatment that can benefit persons with ADHD, but the potential harms associated with these medications, including adverse effects, interactions with other medications, and risk of diversion, misuse, and overdose (1–4) necessitate judicious prescribing and patient monitoring. Clinical guidelines similar to those developed for children and adolescents by pediatric medical associations could help clinicians provide best practice care for adult ADHD and support their patients to achieve better outcomes.

The findings in this report are subject to at least seven limitations. First, the data were derived from a large convenience sample of persons with employer-sponsored insurance whose health care use patterns might differ from those of persons with other types of insurance or no insurance. Second, the data do not include the necessary demographic information to examine these trends by race and ethnicity, socioeconomic status, or other characteristics beyond sex and age, in which differences in equity might exist. Third, prescribing policy changes related to the pandemic varied by state (8) and might have differential effects, but state-level results are not reported here. Fourth, these results are based on insurance claims, and will not include medications or other ADHD care procured out-of-pocket or obtained through other means. Fifth, the claims data do not include information on the presence of or changes in ADHD symptoms, environmental changes that might have influenced impairment, access to diagnosis and treatment, quality of care, prescribing provider type, or if stimulants were prescribed to treat something other than ADHD; these factors might have varied throughout the study period. In addition, these data do not contain information on whether the encounter during which the prescription was made occurred via telehealth; therefore, the changes in stimulant prescribing patterns described in this study cannot be directly attributed to changes in telehealth availability and related policies. Sixth, because diagnosis codes are not included on prescription drug claims, it cannot be assumed that all prescription stimulants were prescribed to treat ADHD. However, fills for any ADHD medication, including prescription stimulants, were included as part of the case definition for ADHD care. Finally, APC is sensitive to baseline percentage; small absolute fluctuations in groups with lower baseline percentages will result in larger relative percent changes; thus, APC should be interpreted with caution when comparing across groups.

The percentage of persons receiving prescription stimulant fills increased during 2016–2021, including large increases during 2020–2021 and among adolescent and adult females and adult males. These results could guide continued monitoring of and research concerning factors contributing to increases in stimulant prescribing and other changes in care for ADHD symptoms before and during the pandemic, and how they might differ among adults and adolescent females. This study also suggests a growing need for resources to help clinicians accurately diagnose, manage, and treat adults with ADHD. The development and implementation of clinical practice guidelines for adult ADHD could be one component of an approach to facilitating the provision of high-quality care to adults with ADHD.