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. 2025 Jan;34(1):e70079.
doi: 10.1002/pds.70079.

Predictors of Potentially Inappropriate Stimulant Prescribing Among Adults

Pavan V Thakkar  1 , Angelique E Boutzoukas  1   2 , Scott N Compton  3 , Ohviya Sivashankar  4 , Kanecia O Zimmerman  1   2 , Daniel K Benjamin Jr  1   2 , M Alan Brookhart  5
Affiliations

Predictors of Potentially Inappropriate Stimulant Prescribing Among Adults

Pavan V Thakkar et al. Pharmacoepidemiol Drug Saf. 2025 Jan.

Abstract

Purpose: Increases in adult stimulant prescribing pose a potential risk due to the higher prevalence of contraindicated conditions among this population. We sought to identify patient, provider, and visit characteristics predictive of potentially inappropriate adult stimulant prescriptions.

Methods: We conducted a repeated cross-sectional study using the National Ambulatory Medical Care Survey, a nationally representative weighted sample of 5 453 702 723 ambulatory care visits from 2012 to 2019. Potentially inappropriate prescriptions were defined as prescriptions to patients with potentially contraindicated conditions, as determined by US Food and Drug Administration stimulant labels.

Results: Of the 5 453 702 723 visits, stimulant use was prevalent at 121384694 (2.23%) visits and newly prescribed at 18880152 (0.34%) visits. Of these, 4 620 138 (24.47%) new stimulant prescriptions and 28 055 947 (23.11%) prevalent prescriptions were potentially inappropriate. Potentially inappropriate prescribing increased over time and with age. Visits to primary care providers (relative risk [RR] 1.65, 95% CI 1.05-2.59) were predictive of inappropriate prescribing. Non-Hispanic Black (RR 0.48, 95% CI 0.33-0.70) and Hispanic race/ethnicity (RR 0.46, 95% CI 0.35-0.60), coronary artery disease (RR 0.54, 95% CI 0.33-0.86), pregnancy (RR 0.05, 95% CI 0.03-0.11), hypertension (RR 0.69, 95% CI 0.56-0.84), and glaucoma (RR 0.07, 95% CI 0.02-0.24) were predictive of decreased prevalent stimulant prescriptions; substance abuse was predictive of new stimulant prescribing (RR 2.14, 95% CI 1.07-4.27).

Conclusions: The proportion of potentially inappropriate adult stimulant prescriptions increased over time and with patient age. Visits to primary care providers were predictive of potentially inappropriate prescribing, and a history of substance abuse was predictive of new stimulant prescriptions; therefore, quality improvement interventions regarding safe stimulant prescribing practices may be warranted.

Keywords: ADHD; ambulatory care; amphetamine; central nervous system stimulants; contraindications; inappropriate prescribing; psychotropic drugs.

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Conflict of interest statement

Dr. Benjamin, Jr. reports consultancy for Allergan, Melinta Therapeutics, and Sun Pharma Advanced Research Co. Dr. Zimmerman reports funding from the National Institutes of Health (NIH) and US Food and Drug Administration (FDA). Dr. Boutzoukas received salary support through the US government National Institute of Child Health and Human Development T32 training grant (1T32HD094671) during the conduct of this study, and receives funding from the NIH (HHSN275201000003I, UM1AI104681) and the Biogen foundation. M. Alan Brookhart serves on scientific advisory committees for American Academy of Allergy, Asthma & Immunology, Amgen, Brigham and Women’s Hospital, Gilead/Kite, Intercept, National Institute of Diabetes and Digestive and Kidney Diseases, and Regeneron; he owns equity in Accompany Health, Target RWE, and VitriVax.

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