RD486 - ADHD Prevalence and Risks of ADHD Medications in Virginia

Executive Summary:

In 2017, HB 1500 (Item 30[A]) requested that the JCHC identify methods to: raise awareness of health/addiction risks of Attention Deficit Hyperactivity Disorder (ADHD) medication use; compile/track statistics on Virginia school children diagnosed with ADHD; limit antipsychotic use; and identify the incidence/prevalence of prescribing anti-psychotics for off-label use. HB 1500 was passed by the General Assembly and signed by the Governor on April 28, 2017.

ADHD is the most commonly diagnosed neurodevelopmental childhood disorders in the United States, with an estimated childhood/adolescent prevalence of around 5%. With around 60% of those diagnosed with childhood ADHD experiencing symptom persistence into adulthood, ADHD has been found to have adverse impacts on health, academic achievement, employment and criminality.

Use of ADHD stimulant medications has risen dramatically in recent decades. While ADHD medications and psychotherapy have been found to reduce symptoms in the short-term, evidence of positive longer-term effects is less consistent. ADHD can cause short-term growth reductions in children, but longer-term effects on growth is less well-established and there is little evidence that ADHD medication use is associated with other health risks. Additionally, there is evidence that sizeable percentages of college-aged individuals misuse ADHD medications, although little evidence that addiction to ADHD stimulants is of widespread concern.

ADHD is one of the most common mental health diagnoses among youth prescribed atypical antipsychotic (AAP) medications. AAPs likely reduce conduct problems, aggression and clinical severity in children with ADHD, however, they are also associated with a variety of health risks. Virginia data from insured populations indicate that 30% to 55% of those prescribed AAPs did not have a FDA-indicated diagnosis for the prescribed AAP. Additionally, foster youth populations have historically had particularly high rates of use of psychotropic medications, including AAPs.

Methods to raise awareness of ADHD medications risks include FDA safety communications and pharmaceutical labeling regulations, as well as initiatives taken at some institutions of higher learning (e.g., ADHD medication contracts). Methods used by some States to track ADHD among school children involve collaborations between health and education agencies, although the quality of those data collected is unknown. Methods used by payers to limit antipsychotic use include service authorization (i.e., prescription pre-approval), peer review (i.e., manual clinician review of prior authorization requests), and Drug Utilization Review (DUR) Programs (i.e., a process conducted by all State Medicaid agencies involving prospective screening of prescription drug claims to identify potential problems and retrospective review of claims data). There are few established methods to identify off-label prescribing of antipsychotics from payers’ data because diagnosis codes are not generally required data elements on prescription claims.

Six policy options were presented for consideration by members of the Joint Commission on Health Care, who voted to take no action.