Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults

United States, 2016-2021

Melissa L. Danielson, MSPH; Michele K. Bohm, MPH; Kimberly Newsome, MPH; Angelika H. Claussen, PhD; Jennifer W. Kaminski, PhD; Scott D. Grosse, PhD; Lila Siwakoti, MPH; Aziza Arifkhanova, PhD; Rebecca H. Bitsko, PhD; Lara R. Robinson, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2023;72(13):327-332.

Abstract and Introduction

Introduction

Prescription stimulant use, primarily for the treatment of attention-deficit/hyperactivity disorder (ADHD), has increased among adults in the United States during recent decades, while remaining stable or declining among children and adolescents.^[1,2] MarketScan commercial claims data were analyzed to describe trends in prescription stimulant fills before and during the COVID-19 pandemic (2016–2021) by calculating annual percentages of enrollees aged 5–64 years in employer-sponsored health plans who had one or more prescription stimulant fills overall and by sex and age group. Overall, the percentage of enrollees with one or more prescription stimulant fills increased from 3.6% in 2016 to 4.1% in 2021. The percentages of females aged 15–44 years and males aged 25–44 years with prescription stimulant fills increased by more than 10% during 2020–2021. Future evaluation could determine if policy and health system reimbursement changes enacted during the pandemic contributed to the increase in stimulant prescriptions. Stimulants can offer substantial benefits for persons with ADHD, but also pose potential harms, including adverse effects, medication interactions, diversion and misuse, and overdoses. Well-established clinical guidelines exist for ADHD care, but only for children and adolescents*;^[3] clinical practice guidelines for adult ADHD could help adults also receive accurate diagnoses and appropriate treatment.

CDC analyzed claims data from the Merative MarketScan Commercial Database, a national convenience sample of deidentified health care claims from enrollees in employer-sponsored insurance plans. CDC accessed 2016–2021 MarketScan data using Treatment Pathways 4.0, an online analytic platform that includes plans with complete data on prescription drug fills, to calculate the annual percentages of persons continuously enrolled throughout the calendar year with one or more prescription stimulant^† fills. All prescription stimulants were included in the analyses, regardless of whether the enrollee had any claims with an ADHD diagnosis code present. Percentages and annual percent change (APC) were calculated for enrollees aged 5–64 years overall and by sex and age group; primary results were calculated by 5-year age groups, but some results were summarized by wider age groups to describe broader patterns. Among persons with one or more prescription stimulant fills during the calendar year, the mean number of prescription stimulant fills during that year and the percentage of persons who met a case definition for receipt of care for ADHD^§ were calculated. Statistical testing was not performed because the size of the MarketScan database often results in significant p-values that are not clinically meaningful. All point estimates are presented, and changes >10% are highlighted. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶

Across all years, the percentages of male and female enrollees with one or more prescription stimulant fills were highest among those aged 5–19 and 15–24 years, respectively. Overall, the percentage of enrollees with prescription stimulant fills increased from 3.6% in 2016 to 4.1% in 2021, with percentages and APC varying by sex and age (Table) (Figure 1) (Figure 2). During 2016–2020, percentages remained stable or decreased among females aged ≤24 years (average APC range = −1.8% to 0.1%) and increased modestly among those aged 25–64 years (average APC range = 2.3% to 6.6%). However, during 2020–2021, the percentage of females with one or more prescription stimulant fills increased substantially among most age groups, with the largest changes among those aged 15–44 and 50–54 years (APC range = 14.3% to 19.2%).

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Figure 1.

Percentage of persons aged 5–64 years with at least one stimulant prescription fill, by sex, age group, and calendar year — MarketScan commercial databases, United States, 2016–2021

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Figure 2.

Relative annual percent change in percentage of persons aged 5–64 years with at least one stimulant prescription fill, by sex and age group — MarketScan commercial databases, United States, 2016–2021

During 2016–2020, the pattern among males was similar to that among comparably aged females: the percentage with prescription stimulant fills decreased slightly among those aged ≤24 years (average APC range = –3.8% to –1.7%) and remained stable or increased modestly among those aged ≥25 years (average APC range = 0% to 6.5%). During 2020–2021, the percentage of males with prescription fills decreased among those aged ≤19 years and increased substantially among those aged 25–44 years and 50–54 years (APC range = 11.1% to 14.7%).

Among persons with one or more prescription stimulant fills, the annual mean number of fills ranged from 7.4 to 7.6 (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/125800). Most persons aged 5–19 years (≥75%) and adults aged 20–64 years (53%–77%) with one or more prescription stimulant fills met the case definition for receipt of ADHD care in the preceding or current calendar year; these percentages were relatively stable during the study period (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/125800).

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Abstract and Introduction
Discussion
References
Sidebar

*https://chadd.org/for-professionals/clinical-practice-guidelines/
^†Prescription stimulants included in this analysis were amphetamine and mixed amphetamine salts, dexmethylphenidate, dextroamphetamine, lisdexamfetamine, methamphetamine, and methylphenidate.
^§To meet the case definition for receipt of ADHD care, enrollees were required to have two or more health care encounters with an ADHD International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 314.X or an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of F90 occurring ≥7 days apart, or one or more visits with an ADHD diagnosis code and two or more prescriptions for ADHD medications (any stimulant included in the analysis or atomoxetine, clonidine, or guanfacine) filled ≥14 days apart; these criteria had to be met during the preceding or current calendar year.
^¶45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

Table. Percentage of persons aged 5–64 years with at least one stimulant prescription fill, by sex, age group, calendar year, average annual percent change (2016–2020), and annual percent change (2020–2021) — MarketScan commercial databases, United States, 2016–2021
Sex and age group, yrs	Percentage, by year						Average annual % change,* 2016–2020	Annual % change,* 2020–2021
Sex and age group, yrs	2016	2017	2018	2019	2020	2021	Average annual % change,* 2016–2020	Annual % change,* 2020–2021
Sample size (millions)	20.7	19.0	17.4	16.0	15.6	13.3	—	—
Both sexes, all ages	3.6	3.7	3.6	3.7	3.8	4.1	1.4	7.9
Female, all	3.2	3.3	3.3	3.4	3.6	4.1	3.0	13.9
5–9	3.0	3.0	2.9	2.9	2.9	2.9	−0.8	0
10–14	4.8	4.9	4.7	4.8	4.8	5.2	0	8.3
15–19	5.3	5.2	4.9	5.1	5.3	6.1	0.1	15.1
20–24	5.6	5.5	5.2	5.1	5.2	6.2	−1.8	19.2
25–29	4.2	4.4	4.4	4.5	4.6	5.4	2.3	17.4
30–34	3.5	3.8	3.9	4.1	4.4	5.1	5.9	15.9
35–39	3.1	3.4	3.5	3.7	4.0	4.7	6.6	17.5
40–44	3.0	3.1	3.1	3.3	3.5	4.0	4.0	14.3
45–49	2.6	2.8	2.9	3.0	3.2	3.5	5.3	9.4
50–54	2.1	2.2	2.2	2.4	2.5	2.9	4.5	16.0
55–59	1.6	1.7	1.7	1.8	1.9	2.0	4.4	5.3
60–64	1.2	1.3	1.3	1.4	1.4	1.5	4.0	7.1
Male, all	3.9	4.0	4.0	4.0	4.0	4.2	0.6	5.0
5–9	7.3	7.3	7.0	7.1	6.8	6.7	−1.7	−1.5
10–14	10.8	10.9	10.6	10.7	10.2	9.9	−1.4	−2.9
15–19	7.9	7.8	7.5	7.4	7.2	7.1	−2.3	−1.4
20–24	5.6	5.5	5.2	5.0	4.8	5.0	−3.8	4.2
25–29	4.0	4.1	4.1	4.1	4.2	4.7	1.2	11.9
30–34	3.4	3.6	3.8	3.9	4.1	4.7	4.8	14.6
35–39	2.7	2.9	3.0	3.3	3.4	3.9	6.0	14.7
40–44	2.1	2.2	2.3	2.5	2.7	3.0	6.5	11.1
45–49	1.7	1.8	1.9	2.1	2.1	2.3	5.5	9.5
50–54	1.3	1.4	1.4	1.5	1.6	1.8	5.4	12.5
55–59	1.0	1.0	1.1	1.1	1.2	1.3	4.8	8.3
60–64	0.9	0.9	0.9	0.9	0.9	0.9	0	0

*Annual percent change is calculated as the difference between percentage in one year and that in the preceding year, divided by the previous year's percentage.