As ADHD awareness grows and telehealth expands, a large population study reveals how the pandemic reshaped stimulant prescribing patterns among adults, especially younger women, prompting new questions about diagnosis, access to care, and appropriate use.
Study: Patterns of prescription stimulant initiation before and during the COVID-19 pandemic: a population-based time-series analysis. Image credit: Neirfy/Shutterstock.com
Rates of new stimulant prescriptions for adults in Ontario climbed rapidly during the coronavirus disease 2019 (COVID-19) pandemic, highlighting the need for careful monitoring to ensure safe and appropriate use, according to a study published in the Canadian Medical Association Journal (CMAJ).
Evolving Patterns in Adult ADHD Diagnosis and Stimulant Utilization
Prescribed stimulants, including amphetamine salts and methylphenidate, are central nervous system agents primarily used for managing attention-deficit/hyperactivity disorder (ADHD). These agents function by enhancing synaptic concentrations of dopamine and norepinephrine, thereby improving attention and reducing hyperactivity and impulsivity. In some cases, they are prescribed to treat narcolepsy, a sleep disorder characterized by excessive daytime sleepiness.
Stimulants are sometimes employed off-label as adjunctive therapies in major depressive disorders, particularly when conventional antidepressant regimens yield suboptimal responses. These medications were predominantly prescribed to pediatric populations, but the past two decades have seen a consistent global increase in ADHD diagnoses and stimulant prescriptions among adults.
The increase in ADHD diagnoses among adults may reflect improved recognition of the disorder in this population, a greater number of adults receiving their first diagnosis, advancements in diagnostic approaches, and increased societal awareness of ADHD. Despite these trends, the underlying factors and potential ramifications associated with increased stimulant prescribing in adults remain incompletely understood.
Assessing the Trend in Stimulant Prescriptions During the COVID-19 Pandemic
Emerging international data reveal a marked increase in stimulant prescriptions after the onset of the COVID-19 pandemic. While greater accessibility to ADHD diagnosis and treatment may partly account for this surge, there are ongoing concerns about inappropriate prescribing and the potential long-term consequences of stimulant use.
To understand provincial prescribing trends and how they fit within broader international patterns, the current study conducted a population-based, repeated cross-sectional study of prescription stimulant use among adults in Ontario, Canada, from 2016 to 2024. Using the Narcotics Monitoring System (NMS) and comprehensive provincial health databases, the authors obtained demographic and clinical characteristics of new and ongoing recipients. Monthly stimulant dispensing rates were evaluated. Outcomes were reported as rates per 1,000 eligible adults, stratified by age and sex.
Individuals aged under 18 or over 105 years, non-residents, and those lacking recent provincial health coverage were excluded. New stimulant recipients were defined as adults with no stimulant prescriptions in the preceding three years to ensure a robust incident cohort. Analyses compared trends before and after the onset of the COVID-19 pandemic, adjusting for confounders such as sex, prescriber specialty, and prior hospital-treated mental health diagnoses.
Shifting Patterns in Adult Stimulant Initiation and Prescribing Practices
Between 2016 and 2024, 327,053 adults in Ontario began stimulant treatment, mostly women in their early 30s from urban areas. Long-acting stimulants, primarily lisdexamfetamine and methylphenidate, were prescribed mainly by primary care or psychiatry for ADHD or anxiety/depression. Just under a third had prior ADHD care, meaning fewer had a documented ADHD-related health care interaction in the administrative data before starting treatment, although the study could not determine whether this reflected new diagnoses, delayed recognition, care received outside captured records, or incomplete diagnostic histories.
During the pandemic, more women and adults aged 24–34 started using stimulants. Psychiatrist prescriptions declined while nurse practitioners' roles grew. The pandemic accelerated changes in who prescribed stimulants and how quickly patients were able to access treatment, raising questions about the appropriateness and consistency of diagnostic practices.
New adult stimulant use rates were first stable, then dropped briefly but rebounded, with the monthly rate of increase after the pandemic estimated to be 7.3 times faster than the pre-pandemic trend, reaching 0.44 new stimulant dispensations for every 1,000 adults by June 2024. After the pandemic began, adults aged 18 to 24, 25 to 34, and 35 to 44 saw the largest increases in new stimulant use. Young adults were a key demographic driving increased stimulant use.
Before the pandemic, stimulant use rates were similar for males and females. During the pandemic, rates rose faster among females, who surpassed males in all age groups by June 2024. Among young adults aged 18 to 24, for every 1,000 people, 1.31 young women started stimulants compared to 0.97 young men.
During the pandemic, the share of new stimulant users with ADHD or childhood behavioral diagnoses jumped from 23.8 % to 31.3 %, tripling in absolute numbers. While the proportion with anxiety or depression fell, their numbers still increased by 74 %. By June 2024, 10.4 out of every 1,000 adults were dispensed stimulants monthly, with the highest monthly rates among those aged 18 to 24 (22.1 out of 1,000), 25 to 34 (17.9 out of 1,000), and 35 to 44 (14.3 out of 1,000). Stimulant use continues to grow among adults, especially younger age groups, signaling increased and sustained demand.
Conclusions
The current study highlighted a significant rise in stimulant dispensations among adults in Ontario during the COVID-19 pandemic, primarily prescribed for the treatment of ADHD. While the trend could suggest reduced stigma for ADHD and anxiety disorders and better access to care, it unfolds amid growing societal and digital influences that may shape demand and diagnostic practices.
Because the study measured medication dispensations rather than confirmed medication use and relied on administrative health records that may not capture every diagnostic interaction, the relative contribution of improved recognition versus potential overdiagnosis or inappropriate prescribing remains uncertain.
In the future, research should focus on identifying the underlying drivers, assessing long-term outcomes, and developing strategies to ensure appropriate ADHD diagnosis and treatment, while minimizing the risk of harm and supporting optimal patient care.
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