Editorial: Time for a New Conversation on Stimulant Use

Abstract

Psychostimulants are one of the safest and most efficacious pharmacological interventions for a psychiatric disorder. In 1999, the groundbreaking Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder (MTA) Study set the standard of care for long-term treatment for children with attention-deficit/hyperactivity disorder (ADHD).¹ Since then, stimulant use has increased substantially around the world.² Because ADHD is a chronic condition, guidelines recommend re-evaluating the continued use of stimulant medications over many years to assess symptom relief and associated poor academic, social and work-life functioning.³ Although few long-term adverse effects have been identified, growth suppression was documented in early adulthood in the MTA cohort, with the stimulant-treated group showing an average height decrement from the untreated group of 2.55 cm or 1.00 inch.⁴ In the current issue of JAACAP, Greenhill et al. build on this earlier report.⁵ They compare growth trajectories for the self-selected ADHD stimulant medication groups and a normative comparison group. The study demonstrates differences in the shape of growth trajectories, especially during puberty, and finds that a greater total lifetime dose of stimulants is associated with increased height suppression and, not previously described, greater gain in weight and body mass index (BMI).⁵ In young adulthood, consistent stimulant users were shorter than negligible users by an estimated 4.06 cm or 1.60 inches and heavier by an estimated 4.50 kg or 9.95 pounds. The clinical implications of these findings may be significant, and certainly call for replication, funded by sources other than pharmaceutical companies. Our conversations with parents, children, and youths about the risks of long-term stimulant use should continue to mention height suppression but now include weight gain. The evidence provided suggests that the negative impact may be ameliorated through limiting total lifetime dose of stimulant medication, especially at times of rapid growth such as puberty. In view of these data, the search for evidence-based nonmedication interventions ought to intensify. Future research should be geared toward treatment goals not based solely on ADHD symptom relief but should also target overall functioning and quality of life.