Misuse of Stimulant Medication Among College Students a Comprehensive Review and Meta-analysis

Introduction

Non-medical apply (NMU) of prescription stimulant medications is a standing public health concern (1–3). Emergency section (ED) visits related to NMU of stimulant medications increased 200% from 2005 to 2010 (4). Between 2006 and 2011, despite no change in treatment visits for adults involving prescriptions of dextroamphetamine, amphetamine or methylphenidate, NMU of prescription stimulants increased 67% and ED visits increased 156% (5). College students are particularly likely to engage in NMU of prescription stimulants (5–10). By-year NMU of prescription stimulants is more than mutual among eighteen–25 twelvemonth-olds (~7.5%) compared with younger and older age groups (both ≤ two%) (11).

Stimulant medications prescribed for attention-deficit/hyperactivity disorder (ADHD) are widely available on college campuses (12). One longitudinal study (xiii, 14) followed a single cohort of higher freshmen for 4 years. Over the follow-up menstruum, nearly two-thirds were offered prescription stimulants for NMU and 31% reported NMU, a prevalence echoed by other surveys (15).

I motivation for stimulant NMU is enhanced academic functioning (1, 16), despite testify that stimulant NMU does not improve bookish operation (7, 10, 17). Stimulant NMU is associated with other drug use and/or heavy drinking (xviii, 19).

While near stimulant NMU is by oral routes, non-oral NMU has been noted (6, 14, 20). Simply a few studies of college students have evaluated non-oral ROAs of prescription stimulants (14, twenty), usually snorting and less often injection and smoking (vii, 21). Drugs taken via injection, smoking and snorting accept a more than rapid onset than oral ingestion, resulting in greater reinforcement for getting loftier and addictive potential (22). Non-oral routes also raise the risk of cardiovascular failure, cardiac arrhythmia, high blood pressure, paranoia (10) also as hospitalization and death (23). Levels of prescription stimulant smoking or injection (when reported) in the general population of adults (6) and among college students (20) have been low (<half dozen%). Estimates of snorting by higher students range from 17% (14) to ~40% (20, 21).

The Nutrient and Drug Administration (FDA) has declared NMU of prescription stimulants a serious public wellness business organisation and has called for the cess of the potential impact of abuse deterrent formulations (ADFs) for prescription stimulants (24). ADFs, designed to deter not-oral use, have demonstrated benefits in reducing corruption of prescription drugs and associated adverse consequences, especially for prescription opioids (25–27). Examination of not-oral ROAs of prescription stimulants by higher students has been previously identified every bit useful for determining the potential value of abuse deterrent formulations (ADFs) (16, 19). Surprisingly, little enquiry has considered the characteristics or practices of college students who use non-oral ROAs.

One such characteristic is polydrug use, which is the misuse of more than one class of psychoactive prescription drugs (28). Toward this end we examined prescription stimulant NMU in the context of polydrug employ by college students. We sought to investigate, descriptively, pathways of not-medical use and abuse of other non-alcohol substances. This may be peculiarly important given that initial exposure to prescription stimulants may occur via legitimate treatment for ADHD symptoms, as opposed to the traditional "gateway hypothesis" (29) which posits that early on experimentation with alcohol, tobacco or marijuana is associated in a causal way to increased substance involvement later in life.

The nowadays cross-sectional report used a self-report, online survey to narrate a sample of college students reporting NMU of prescription stimulants to gain a preliminary view of respondents' routes of administration, factors contributing to the NMU, and pathways of initiation associated with specific patterns of non-oral use. Nosotros particularly sought to consider whether prescription stimulant NMU past college students is the just blazon of misuse/abuse of not-alcohol substances, is an initial foray into misuse/abuse of other substances or occurs within the context of ongoing polysubstance abuse. Finally, we sought to examine the associations among dissimilar ROAs, motivations for NMU and sources of procurement of the prescription stimulants being misused.

Methods

Definition of Not-medical Use and Non-oral Use

Following the convention employed by the National Survey on Drug Utilise and Health (NSDUH) (30), medication NMU was divers as meeting at least 1 of three criteria within the respondents' lifetime: (1) employ for any reason, fifty-fifty once, without i's own prescription; (2) utilize in ways other than prescribed, such as taking more prescribed or more frequently than prescribed; and (3) apply for the feeling or experience that the medication caused, such every bit feeling high, enhancement of other drugs, or prevention or treatment of withdrawal symptoms or other feelings. Non-oral use was defined as employ past smoking, snorting and/or injection (31). Oral employ included swallowing whole, chewing, and dissolving in liquid and then swallowing.

Report Population

An online survey of college students was conducted using an opt-in panel operated by YouGov^®, an Internet-based market inquiry and data analytics firm. The sample was created by YouGov from a puddle of 3,379 respondents, who were matched to a sampling frame constructed from the 18–26-twelvemonth-old, higher student sample of the 2016 American Community Survey (ACS). The matched cases were weighted to the sampling frame using propensity scores based on age, gender, race/ethnicity, years of didactics, and region. The current report includes a subsample of 486 respondents who met inclusion criteria (historic period 18–26 years, currently enrolled in college, and reported prescription stimulant NMU at any time in their lifetime).

Participants are not paid to join the YouGov panel but receive points for completing surveys that can be redeemed for greenbacks or charitable contributions. All participants provided electronic informed consent, however, respondents remained bearding to the researchers. The consent grade and study received approving by the New England Institutional Review Board (NEIRB).

Questionnaire

The author-constructed survey took <15 min to complete. Respondents provided demographic information, college characteristics, and medical history, including self-report of lifetime substance use disorder (SUD) and psychiatric diagnoses. All participants reported lifetime prescription stimulant NMU and were asked about the time frame of use, motivations for NMU, sources of medication procurement, and ROA. The survey was express to Schedule II pharmaceutical products that are FDA approved for ADHD and are in tablet or capsule course intended for oral assistants. Other products or compounds, such every bit the methylphenidate analogs (32), were not included as part of the survey. Respondents were asked almost lifetime NMU of prescription opioids, rampage alcohol utilize in the past 30 days (five or more drinks in a single occasion), lifetime marijuana use, and lifetime "illegal drug" use, including cocaine/crack, heroin, street fentanyl, inhalants, amphetamines/methamphetamines, hallucinogens, sedatives, or other illegal substances. Students estimated their age at first NMU of prescription drugs, marijuana, and illegal drugs, in order to calculate drug initiation pathways of prescription stimulant NMU for polysubstance users.

Statistical Assay

Sample characteristics are presented as frequencies and proportions. Self-reported pathways of initiation of prescription stimulant NMU are presented descriptively based on retrospective answers to the age-at-first-apply question. Univariate pairwise comparisons of ROA subgroups (oral-only, snorting with no injection, and injection) used chi-foursquare tests, Fisher'southward exact tests, or t-tests as appropriate.

Logistic regression models evaluated factors associated with non-oral vs. oral-simply prescription stimulant NMU, including: historic period; sexual practice; race; diagnoses of ADHD, lifetime psychiatric disorder (low, feet or bipolar disorder), alcohol or substance use disorder, or conduct or oppositional defiant disorder; binge alcohol employ in the past xxx days; lifetime marijuana employ, lifetime use of cocaine, heroin, or illegal stimulant, and lifetime NMU of prescription opioids. Findings are presented as odds ratios (OR) and 95% confidence intervals (CI).

Statistical analyses were conducted using Statistical Analysis Software (SAS) Enterprise Guide Version 7.1 (SAS Institute, Cary, NC). For logistic regression models, p-values were two-sided and considered pregnant at p-values < 0.05. To explore correlates associated with various ROAs employed by participants, we conducted a high number of pairwise comparisons. Bonferroni adapted p-values were used for analyses of medication procurement and motivation (p < 0.006). Exploratory analyses of factors associated with different ROA use employed an adjusted p-value of 0.003. Otherwise, p-values < 0.05 are presented in the tables.

Results

Survey Sample Characteristics

Among the 486 college students reporting lifetime prescription stimulant NMU, 59.9% were women; well-nigh were white, single, and full-time undergraduates from public schools (Table 1). Colleges were in the South (39.nine%), Midwest (21.4%), Due west (20.8%) and Northeast (17.9%). 2-hundred-ten students (43.2%) reported a lifetime diagnosis of ADHD, of which 70% were diagnosed at age 16 or older. More than than three-quarters (77.6%) reported a lifetime psychiatric diagnosis (depression, anxiety, or bipolar disorder), while 29.vi% reported a lifetime alcohol or substance utilise disorder. Binge alcohol utilise in the past 30 days was reported by 12%, while lifetime apply of cocaine, heroin and illicit stimulants ranged from fifteen.viii% for heroin to 35.iv% for cocaine. Lifetime NMU of prescription opioid medication was 58.half dozen%, and marijuana use was reported past 73.seven%.

Table i. Characteristics of college students by lifetime non-medical use of prescription stimulants.

Factors Associated With Use by Non-oral Routes

For the logistic regression and ROA analyses, 99.2% of all respondents (n = 482) were included in the analyses (four were excluded due to missing information). Amidst college students reporting prescription stimulant NMU included in the logistic regression analyses, 23.ii% (northward = 112) reported at to the lowest degree one non-oral ROA. Univariate results of the logistic regression (Table ii) identified factors associated with non-oral ROAs, including male gender (OR: 0.49, 95% CI: 0.32–0.076), lifetime diagnoses of alcohol or other substance use disorder (OR: 3.14, 95% CI: 2.02–4.88), conduct/oppositional defiant disorder (OR: 3.65, 95% CI: 2.32–v.74), and lifetime utilize of illegal drugs (i.e., cocaine, heroin or illegal stimulants; OR: ii.forty, 95% CI:1.56–3.69). A lifetime diagnosis of ADHD (OR: ane.92, 95% CI: one.26–two.95) and a history of NMU of prescription opioids (OR: i.85, 95% CI: 1.18–ii.90) were also significantly associated with employ past a non-oral ROA, albeit to a bottom degree. Multivariable analyses yielded meaning adjusted ORs for merely ii factors: lifetime diagnosis of conduct/oppositional defiant disorder (adjusted OR: 2.27, 95% CI: one.15–4.48) and lifetime utilise of illicit drugs (adjusted OR: ane.99, 95% CI: 1.18–three.37) (Table 2), implying a relatively high cyclopedia between many of the various factors investigated (r _s amongst the significant variables in the univariate analysis ranged from 0.17 to 0.66, all p < 0.001) (33).

Table 2. Factors associated with lifetime non-medical use of prescription stimulants via non-oral routes* compared with oral routes only among college students (Due north = 482**).

Not-oral ROAs Reported

While most of the 486 college students reported NMU of stimulants via oral routes (92.0%), 23.0% reported any non-oral use: snorting (20.4%), smoking (6.0%) and/or injection (3.v%). Among those reporting non-oral NMU of prescription stimulants, two-thirds (66.ane%) also reported oral NMU. Among the 112 not-oral users, 88.four% reported snorting, 25.9% reported smoking, and 15.ii% reported injecting. Since individuals often report more than one ROA, percentages do not add together to 100%.

Source of Procurement for Prescription Stimulants

Overall, most respondents (67.3%) reported obtaining the medication from a family member or friend, followed past their own prescription (39.7%). Table 3 (top) presents comparisons of drug source in respondents who utilize oral routes but with those who snort merely do not inject, and those who inject. Respondents reporting injecting and/or snorting were more likely than oral-only respondents to obtain their drug from a dealer, to have bought online without a prescription, or to have faked a prescription (p < 0.001). Report of injection was more often than oral-only use to be associated with stealing the drug (p = 0.004). Those who reported snorting were more than probable than oral-only users to have traded for the drug (p = 0.001). Significant differences were not plant for snorting only vs. injection.

Table iii. Source of procurement and motivations for NMU of prescription stimulants by route.

Motivations for NMU of Prescription Stimulants

Nearly one-half (47.7%) of all respondents listed enhancing work or school performance as a motivation for prescription stimulant NMU, 23.3% for increased energy, and xiv.half-dozen% for getting high or enhancing the effect of other drugs. Comparisons across ROA patterns (Tabular array 3 lower) revealed that those who snort and/or inject were more than probable than oral-only users to study getting high, enhancing the effect of other drugs, and controlling appetite equally motivations for NMU. Those injecting were more likely than oral-only users to study motivation for energy, to treat withdrawal symptoms, and to report using the drug by error (i.e., "forgot they already took it").

Factors Associated With Prescription Stimulant NMU Route of Assistants

Oral ROA was reported past 92.0% of respondents: 83.iv% swallowed whole, 14.viii% past chewing, and 18.iii% dissolved in liquid to potable. Non-oral NMU was observed in 23.0% of all respondents. Within each group, 20.4% of the whole sample and 88.4% of the not-oral sample reported snorting; 6.0% of the whole sample and 25.9% of the non-oral group smoked. Injection was reported past 3.five% of the whole group and 15.2% of the non-oral NMU respondents.

Comparing characteristics of individuals who use oral routes merely with those who snort but do not inject and those who inject are presented in Tabular array 4. Compared with respondents reporting oral routes only, college students who reported injecting stimulants were more likely to be men, to exist a member of a Greek organization, to have an ADHD diagnosis, to have a lifetime substance use diagnosis, and to take a history of NMU of prescription opioids. Those who injected were more likely than the oral-only group and the snorting/no injection group to report use of heroin, sedatives, and street fentanyl. Snorting/no injection respondents more often reported a substance apply diagnosis and apply of cocaine/crack than those reporting oral ROA only.

Table 4. Exploratory factors associated with ROA patterns reported for prescription stimulants.

Pathways of Initiation

Most respondents (due north = 444, 91.iv%) reported non-alcohol polysubstance employ. Seventeen percentage (n = 76) of the polysubstance users started prescription stimulant NMU at an age before than any of the other drugs endorsed. Some other 12.2% (n = 54) first engaged in prescription stimulant NMU at the same age as at to the lowest degree one of the other drug categories. While the majority of those reporting polysubstance use as well reported abusing other drugs before prescription stimulant NMU, 27.9% either initiated prescription stimulant NMU first or initiated polysubstance utilize concurrently with prescription stimulant NMU.

Table 5 presents an overview of the three sequences of misuse/corruption of prescription stimulants and other drugs for all polysubstance users and by ROA - i.e., prior to, coincident with, or following starting time NMU of prescription stimulants. Nearly 2-thirds (64.2%) of all polysubstance users reported NMU of prescription opioids, of whom 38.6% initiated prescription opioid NMU prior to NMU of prescription stimulants, 16.1% initiated NMU of these medications at the same age, and 45.3% started NMU of prescription stimulants first. Among those who used illicit drugs other than marijuana (55.0% of all polysubstance users), 43.3% used such drugs prior to prescription stimulants, 24.six% at the same age, and 32.0% started NMU of prescription stimulants prior to using illicit drugs.

Table 5. Pathways of multi-drug apply that involved prescription stimulant NMU* for all respondents and by ROA.

Lifetime marijuana use was reported past 80.vi% of all polysubstance users, and 56.1% reported using marijuana or marijuana plus some other substance prior to initiating prescription stimulant NMU. Amid all marijuana users, ~70% reported using marijuana prior to prescription stimulant NMU, while nearly 20% reported NMU of prescription stimulants prior to marijuana use. Nigh i in 5 (eighteen.7%) of all polysubstance users reported marijuana use and prescription stimulant NMU merely, while 14.6% used marijuana prior to prescription stimulant NMU, 3.2% reported initiating prescription stimulant NMU prior to marijuana, and 0.ix% initiated use of both substances at the same age.

The breakup of the drug-use sequences in Table v by ROA blueprint revealed no significant differences between those who study NMU of prescription stimulants orally only, those who snort but do non inject, and those who inject. While the percentages of those who used illicit drugs other than marijuana prior to NMU of prescription stimulants were much greater for those who inject (i.e., 45.0% for oral-but and 33.three% for snort/no inject vs. 72.seven% for those who inject), these differences did non accomplish statistical significance.

Discussion

This cross-exclusive, online survey evaluated prescription stimulant NMU among college students in the United states of america. Pathways of initiation of prescription stimulant NMU were presented, as well every bit characteristics of non-oral use.

All respondents to this survey engaged in NMU of stimulants, while nearly one in iv (23%) reported non-oral use. Non-oral use was consistently associated with increased likelihood of serious, non-alcohol substance apply. Although other studies have found ADHD diagnosis, gender, race, depression, anxiety, marijuana and booze use to be associated with prescription stimulant NMU (34), in this report historic period, race, recent alcohol binge drinking, and marijuana utilize did not differentiate oral and non-oral NMU. Univariate analyses revealed associations of major factors with reports of non-oral ROA, especially being male, lifetime diagnoses of ADHD, alcohol or other substance disorder as well as comport/oppositional defiant disorder, and history of prescription opioid NMU.

The finding that women students were less likely overall to report non-oral NMU practices, may be an underlying feature common to many of the other factors investigated. For instance, women are less likely to be diagnosed with ADHD and, women diagnosed with ADHD appear to exhibit lower levels of conduct problems than their male counterparts (35), both factors that were associated with not-oral ROA NMU in this survey. Women were significantly less likely to inject, even if they reported snorting prescription stimulants, however, oral-merely ROA vs. snorting but not injection were not significantly dissimilar by gender. Injecting may be associated with higher risk-taking beliefs in men with ADHD (35). On the other mitt, other studies of gender differences in adults with ADHD (36) have found women with an ADHD diagnosis to be much more likely than women without one to express suicidal ideation, which may be a very dissimilar phenomenon than male run a risk-taking behavior.

Of those reporting not-oral prescription stimulant NMU, the large majority (88%) snorted the medication, with a quarter reporting smoking and 15% injecting. Our findings are consistent with those from the few studies investigating injection of prescription stimulants, suggesting that injection of these medications is relatively rare (6, 20, 23). Because the small number of college students who inject prescription stimulants in this sample resulted in signal estimates that may non be stable, the findings reported for non-oral injection users should be considered preliminary and used to stimulate further research. However, even though injection may be rare, it is associated with much higher risk and agreement what motivates this behavior may inform prevention and handling strategies.

Compared with oral-only users, respondents reporting whatsoever not-oral route were more likely to have more than serious substance use histories and drug-use patterns. Non-oral use is consistently associated with serious adverse consequences (10), increased prevalence of overdose (37), addictive potential (38) and meaning hazard of morbidity and mortality (23). Note that in the electric current study, the large majority of those who reported NMU of prescription stimulants via non-oral routes snorted the drug. Further research into this type of not-oral prescription stimulant NMU is warranted, every bit such work may clarify a function that ADF formulations can have in reducing the serious adverse consequences of non-oral prescription stimulant NMU (16, nineteen, 23, 24).

Consistent with findings of before enquiry (7, ten, 39), two-thirds of NMU respondents obtained the prescription stimulant from a family unit fellow member or friend (either bought, given, or stolen). Virtually twoscore% obtained the stimulant through a legitimate prescription. Non-oral users, on the other hand, endorsed other sources, specially getting the drug from a "dealer," and online purchases, while likewise obtaining prescription stimulants through the usual sources of friends, family, and providers.

The motivation most often reported for NMU by oral routes and snorting was functioning enhancement, equally others have noted (three, 7, 10, twoscore). Such oral NMU of prescription stimulants for performance enhancement may bespeak the lack of adequate resources or supports for students in a highly artificial (due east.g., memory-based functioning testing), loftier stress environment, where academic outcomes tin take life-altering consequences. NMU for operation enhancement past students with ADHD using oral routes as well raises questions regarding the perceptions by these patients as to the adequacy of their treatment (16). It may also be relevant that learning issues often associated with an ADHD diagnosis may be more responsive to treatments other than medication (35). Although not among the nigh often reported motivations past those who inject, performance enhancement was reported equally a motivation for NMU by nearly a quarter of those respondents. Those reporting snorting and injection were significantly more than likely than the oral-but grouping to report motivations to get high or to enhance the effects of other drugs. These motivations and the college likelihood of polysubstance use in not-oral users are indicative of higher adventure behaviors ofttimes associated with having or developing significant substance employ bug.

More 90% of prescription stimulant NMU was observed in the context of polysubstance use (not including alcohol); a finding consequent with results of a population-based survey (41). Amongst polysubstance users, eighteen.7% reported marijuana equally the only other drug used. While 80.6% of polysubstance users reported marijuana use, and 69.6% of those reported marijuana employ prior to prescription stimulant NMU, marijuana was considered separately in this study, given its legal condition in many states for utilise past at to the lowest degree some individuals in the examined age range as well as changing views of marijuana apply by the public (42, 43). Even so, information technology is noteworthy that prescription stimulant NMU preceded prescription opioid NMU 45% of the time and preceded illegal drug use 32% of the fourth dimension. Our pathways analyses are conceptually similar to the and so-called "gateway hypothesis" (29), which proposes that a child or adolescent's early experimentation with or exposure to alcohol, tobacco, or cannabis leads to more addictive illicit drugs later in adulthood (44, 45). Empirical test of the gateway hypothesis has yielded conflicting and ambiguous results (45, 46), suggesting that a simple, causal role of early exposure to abusable or addictive substances is unlikely. Interpretation of early prescription stimulant NMU in the pathway toward utilise of illegal drugs, NMU of other prescription drugs or utilize by non-oral routes is complex. There is evidence from this survey and other enquiry (47) that an ADHD diagnosis maybe a hazard cistron for afterwards serious drug interest (i.east., polysubstance utilize and non-oral ROA use). Specifically investigating exposure to ADHD medications in childhood and adolescence, McCabe et al. (48) found that children who initiated stimulant medication for ADHD early (aged nine or less) and for longer elapsing (6 or more than years) did not differ between population controls (youth without ADHD and unmedicated youth with ADHD).

The pathway findings among the 90% of survey respondents reporting polydrug utilize in this report support other studies that suggest primary care physicians largely underestimate the potential for NMU and diversion of ADHD medications by their patients (sixteen). Thus, the findings presented here suggest that prescription stimulant NMU coincided with a more general pattern of substance misuse/corruption. Prescribers should at least exist cognizant of the potential for current or later escalation of substance use past their patients. This study shares the limitations of other online surveys, including self-selection bias, self-report of drug utilise and medical diagnoses, and the use of an online panel. Although efforts were made to establish a representative sampling frame from which to draw respondents, the last sample may non be representative of higher students who appoint in NMU. While many of the findings are consistent with those from other studies, generalization should exist approached cautiously. Apply of a cross-exclusive survey to explore retrospective recall of pathways of drug initiation across time is, by definition, limited, and can only exist considered suggestive. In understanding with other authors (9), our apply of the Internet console survey is intended to complement, not supervene upon, national probability studies.

Conclusions

A number of authors have proposed policies and interventions to address college pupil prescription NMU that are often educational in nature, stressing legal and ethical concerns (i.e., is NMU "cheating?") and combating the "misinformation" that prescription stimulant NMU is harmless (x). Over-estimation of the extent to which stimulant products heighten memory, attention and creativity for individuals outside the treatment of ADHD (49) may take important implications for educational interventions. Identifying and providing services to those at take chances for mental health and substance utilize bug has likewise been proposed (10). A comprehensive strategic planning guide has recently been published online by the Drug Enforcement Assistants (fifty) to address prescription stimulant NMU. The guide covers assessment, building capacity and programs, implementation, and evaluating the impact of interventions. Some authors take stressed viewing NMU equally a "scarlet flag" for possible involvement in other illicit drug use, poor academic performance, and mental health problems (xviii, 19) and called for better diagnostic practices for ADHD (vii), which can present challenges in adults (51, 52).

Our finding that well-nigh a quarter of NMU involved non-oral routes highlights the importance of non-oral NMU of prescription stimulants. This concerning rate of non-oral NMU suggests that farther piece of work should explore methods to reduce such use and the deleterious outcomes associated with snorting or injecting the drugs. Promising efforts to reduce the prevalence and negative impacts of prescription stimulant NMU among college students likely include a range of preventive approaches addressing policy, didactics, diagnostic practices and detection of malingering, paired with handling approaches utilizing cerebral behavior therapy (53, 54), interventions geared to patients' specific needs, such equally personality-targeted interventions (55), sensitivity to the unique needs of women with ADHD, who, for case, appear to be more impacted past parenting style (56) than male ADHD patients, use of therapies other than medications when learning bug are a major presenting complaint (35), and, possibly, medication formulations that present barriers to non-oral use (16, 19, 23, 24).

Data Availability Statement

The raw data supporting the conclusions of this article will exist made available by the authors, without undue reservation.

Ethics Statement

The studies involving man participants were reviewed and canonical by New England Institutional Review Lath (NEIRB). The patients/participants provided electronic informed consent to participate in this report.

Author Contributions

SB, SF, AR, JN, KA, and JG contributed to conception and pattern of the report. SB and RR performed the statistical assay. SB wrote the first draft of the manuscript. SF, AR, JN, and JG wrote sections of the manuscript and provided specific edits/revisions. All authors contributed to the article and canonical the submitted version.

Funding

Arbor Pharmaceuticals LLC funded the enquiry and product of this manuscript. The funding sources had no role in the study pattern, information collection, analysis, or interpretation of information, writing of the manuscript, or decision to submit the manuscript for submission.

Conflict of Interest

SB is a consultant to Inflexxion, an IBH Company. Inflexxion contracts with FDA and multiple companies with interests in some of the products included in the compounds evaluated for this commodity. In the past year, SF received income, potential income, travel expenses standing didactics support and/or inquiry support from, Akili, Arbor, Genomind, Ironshore, Ondosis, Otsuka, Rhodes, Shire/Takeda, Sunovion, Supernus, Tris, and Vallon. With his establishment, he has U.s.a. patent US20130217707 A1 for the use of sodium-hydrogen exchange inhibitors in the treatment of ADHD. In previous years, he received support from: Alcobra, CogCubed, Eli Lilly, Enzymotec, Janssen, KemPharm, Lundbeck/Takeda, McNeil, Neurolifesciences, Neurovance, Novartis, Pfizer, and Vaya. In the by ii years, JN is/has been an advisor and/or consultant for Adlon Therapeutics, Akili Interactive, Arbor, Enzymotec, Ironshore, Medice, NLS, OnDosis, Pfizer, Rhodes, Shire, and Supernus. He was a DSMB member for Pfizer and Sunovion, and received research funds from Enzymotec, Otsuka, Shire and Supernus. He also has received speaker fees from Shire for disease-country presentations and served as a consultant for the US National Football League. KA has current investigator-initiated enquiry funding from Takeda Pharmaceutical Company and serves as an advisory board member for Arbor Pharmaceutical Company. AR reports book royalties (Routedge/Taylor Francis Group), scientific board honoraria (Shire/Takeda, Arbor), consultant honoraria (Tris Pharmaceuticals and National Football League), and CME presentations (APA, Shire/Takeda, Globala Medical Instruction, and US Psychiatric Congress). RR is a Senior Epidemiologist at Inflexxion, an IBH Company. Inflexxion contracts with FDA and multiple companies with interests in some of the products included in the compounds evaluated for this article. JG is the Chief Scientific Officer at Inflexxion, an IBH Company. Inflexxion contracts with FDA and multiple companies with interests in some of the products included in the compounds evaluated for this commodity. JG has served as an good witness on behalf of two manufacturers of prescription opioid medications.

Publisher's Note

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