Depending on your practice setting, you are likely to encounter adults who seek stimulants for various “non-medical” uses, from cognitive enhancement to recreational abuse to outright diversion.

Abuse and diversion are easier to detect these days with the controlled substance databases available in most states. Abuse of stimulants is relatively rare. Over 90% of recreational stimulant users do not meet DSM-5 criteria for abuse (Arria AM and DuPont RL, Am J Psychiatry 2018;175(8):707–708). Instead, many are using them to enhance their cognitive performance. This kind of “cosmetic psychopharmacology” is so common in the college years (20%–30% of students) that stimulant prescriptions are banned or severely restricted at many college mental health centers.

High-achieving adults are also at risk. When the journal Nature polled its readers anonymously, 1 in 5 were taking non-prescribed stimulants to enhance their focus, memory, and concentration (Maher B, Nature 2008;452(7188):674–675). Elvis Presley, John F. Kennedy, and Hugh Hefner all took stimulants to enhance their performance. Kennedy and Hefner stopped when their associates noticed signs of irritability and paranoia, but the King’s use went largely unchecked and may have contributed to his erratic behavior in the 1970s.

Contrary to popular belief, stimulants do not always improve mental functioning in healthy individuals. Overall, meta-analyses have failed to support a significant improvement, although they do appear to work in situations that require sustained attention to boring, repetitive tasks. Stimulants can also reverse some of the effects of sleep deprivation, but a new placebo-controlled study suggests they may impair cognition by disrupting sleep the next day. A single dose of dextroamphetamine 20 mg was enough to impair sleep and, on the day after, working memory, even when given as an instant release in the morning (Tselha T et al, Behav Brain Res 2019;370:111940).

More concerning are the long-term risks of stimulants when used outside of ADHD. Their abuse potential and cardiovascular risks are well known. Rarely, they can cause psychosis, and in high doses they have neurotoxic effects, causing apoptosis (ie, cell death) in the brain. Both of these risks are greater with the amphetamines (eg, Adderall and Vyvanse) than the methylphenidates (eg, Ritalin, Focalin, Concerta) (He W et al, Neurotox Res 2018;34(2):233–240; Moran LV et al, N Engl J Med 2019;380(12):1128–1138).