New research published in the Canadian Medical Association Journal (CMAJ) indicates a substantial increase in new stimulant prescriptions among adults in Ontario, primarily for the treatment of attention-deficit/hyperactivity disorder (ADHD), since the onset of the COVID-19 pandemic. The study, which covered the period from January 2016 to June 2024, identified 327,053 adults in Ontario who received at least one new stimulant prescription. While some researchers suggest this trend may reflect improved recognition and access to care for adult ADHD, others have raised questions regarding diagnostic practices and the appropriateness of all prescribing due to the rapid scale of growth.
Background on Stimulant Medications
Prescribed stimulants, which include amphetamine salts and methylphenidate, are central nervous system agents primarily utilized for managing ADHD and narcolepsy. These medications work by enhancing synaptic concentrations of dopamine and norepinephrine, contributing to improved attention and reduced hyperactivity. They are also occasionally used off-label as supplementary treatments for major depressive disorders. Globally, there has been a consistent increase in adult ADHD diagnoses and stimulant prescriptions over the past two decades, a trend that accelerated following the pandemic's start.
Key Findings and Trends
The study's analysis of provincial health databases revealed several notable trends:
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Overall Increase: After an initial decline at the pandemic's start, new stimulant prescriptions rapidly increased. The monthly rate of increase for new stimulant dispensations during the pandemic was estimated to be 7.3 times faster than the pre-pandemic trend, reaching 0.44 per 1,000 adults by June 2024. By June 2024, 10.4 out of every 1,000 adults were dispensed stimulants monthly.
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Demographics: Over half (55%) of new recipients were female, with a median age of 31. Most (91%) resided in urban areas.
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Age Groups: The increase was particularly pronounced in younger adults, with adults aged 18 to 24, 25 to 34, and 35 to 44 experiencing the largest increases. Rates were highest among those aged 18 to 24 (22.1 per 1,000), followed by 25 to 34 (17.9 per 1,000), and 35 to 44 (14.3 per 1,000) by June 2024.
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Gender Shift: Before the pandemic, stimulant use rates were similar for males and females. During the pandemic, rates rose faster among females, surpassing males in all age groups by June 2024.
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Associated Diagnoses: The proportion of new stimulant users with documented ADHD or childhood behavioral diagnoses increased from 23.8% to 31.3% during the pandemic. Approximately 25% of new stimulant recipients also had diagnoses of anxiety, depression, or both, suggesting use to manage these co-occurring conditions may be a factor.
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Prescribing Patterns: A shift in prescribing patterns was observed, with psychiatrists' share of stimulant prescriptions decreasing from 26% to 18% post-pandemic. Concurrently, the share of prescriptions by nurses and nurse practitioners increased from 2% to 10%.
Potential Contributing Factors and Expert Concerns
Researchers and authors of the study have offered several interpretations for the observed increase:
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Increased Awareness and Access: Dr. Tara Gomes from the Ontario Drug Policy Research Network suggested the findings may reflect improved recognition and treatment of adult ADHD. Coauthor Dr. Mina Tadrous noted that these findings align with global post-pandemic trends, likely influenced by increased awareness of adult ADHD and improved access to care following historical underdiagnosis, particularly in women.
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Virtual Care and Social Media Influence: Contributing factors cited include expanded access through virtual health services, increased screen time, and mental distress. Dr. Tadrous also suggested that social media influence on ADHD awareness among young adults and the rise of virtual health services supporting online assessments might contribute to misdiagnoses.
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Diagnostic Quality Concerns: Dr. Gomes cautioned that while greater awareness has facilitated timely care, the rapid increase in stimulant prescribing, combined with more non-specialist initiation, increased virtual care, and potentially shorter assessment timelines, raises concerns about the quality of diagnostic practices.
She emphasized the importance of rigorous assessment protocols for adult ADHD to ensure treatment decisions align with clinical standards.
Study Limitations and Future Research
The study's methodology involved a population-based, repeated cross-sectional analysis using the Narcotics Monitoring System (NMS) and comprehensive provincial health databases. Researchers defined new stimulant recipients as adults with no stimulant prescriptions in the preceding three years.
The authors acknowledge limitations, including the reliance on medication dispensations rather than confirmed use, and on administrative health records. This means the exact contributions of improved recognition versus potential overdiagnosis or inappropriate prescribing remain unclear.
The study authors recommend ongoing monitoring and evaluation to understand the root causes of rising stimulant use.
They also suggest future research should investigate underlying drivers, assess long-term outcomes, and develop strategies to ensure appropriate ADHD diagnosis and treatment, minimize harm, and support optimal patient care.