Knowledge, Attitudes, and Practice Patterns of Health Professionals Toward Medical and Non-medical Stimulant Use by Young Adults

Natalia Y. Loskutova; Jason Waterman; Elisabeth Callen; Elizabeth W. Staton; Emily Bullard; Joel Shields

doi:10.3122/jabfm.2020.01.190071

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Figure 1.
FPs' frequency in prescribing ADHD medications. Abbreviations: FPs, family physicians; ADHD, attention deficit hyperactivity disorder.
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Figure 2.
CHPs' frequency in prescribing ADHD medications. Abbreviations: CHPs, college health professionals; ADHD, attention deficit hyperactivity disorder.

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Table 1.

Respondent Demographic Characteristics

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Clinician Age Group
<40 years old	104 (15.9)	12 (9.4)	116 (14.9)
40 to 49 years old	159 (24.3)	35 (27.6)	194 (24.8)
50 to 59 years old	220 (33.6)	52 (40.9)	272 (34.8)
60 years and older	171 (26.1)	28 (22.0)	199 (25.5)
Total	654	127	781
			t = −0.62
Gender
Male	364 (55.2)	26 (19.8)	390 (49.4)
Female	295 (44.8)	105 (80.2)	400 (50.6)
Total	659	131	790
			Χ² = 0.00
Race/Ethnicity
American Indian or Alaskan Native	10 (1.5)	2 (1.5)	12 (1.5)
Asian	53 (8.0)	3 (2.3)	56 (7.1)
Black or African American	25 (3.8)	7 (5.3)	32 (4.0)
Spanish, Hispanic, or Latino	18 (2.7)	0 (0.0)	18 (2.3)
White	524 (79.0)	111 (84.7)	635 (80.0)
Native Hawaiian or Pacific Islander	1 (0.2)	5 (3.8)	6 (0.8)
Multiple races	21 (3.2)	0 (0.0)	21 (2.6)
Some other race or origin	11 (1.7)	3 (2.3)	14 (1.8)
Total	663	131	794
			t = −1.68
Practice Region (Census Region)
Northeast	75 (11.5)	44 (34.1)	119 (15.2)
Midwest	212 (32.4)	28 (21.7)	240 (30.7)
South	219 (33.5)	44 (34.1)	263 (33.6)
West	148 (22.6)	13 (10.1)	161 (20.6)
Total	654	129	783
			t = 5.08^*
Years since residency
0 to 10 years	156 (23.9)	20 (19.0)	176 (23.2)
11 to 20 years	192 (29.4)	43 (41.0)	235 (31.0)
21 to 30 years	184 (28.1)	26 (24.8)	320 (27.7)
31 years or more	122 (18.7)	16 (15.2)	138 (18.2)
Total	654	105	759
			t = 0.53
Which of the following duties account for most of your time in a typical week?
Outpatient primary care in office-based practice	523 (79.6)	70 (55.6)	593 (75.7)
Administration or managerial tasks not directly related to patient care	16 (2.4)	16 (12.7)	32 (4.1)
Research	1 (0.2)	0 (0.0)	1 (0.1)
Teaching	15 (2.3)	0 (0.0)	15 (1.9)
Urgent Care	26 (4.0)	4 (3.2)	30 (3.8)
Emergency Care	21 (3.2)	0 (0.0)	21 (2.7)
Other	55 (8.4)	36 (28.6)	91 (11.6)
Total	657	126	783
			t = −4.22^*
Which of the following best describes your role in the ownership of your primary clinical practice?
A full or partial owner of your practice	199 (30.1)	2 (1.6)	201 (25.4)
Employee of a physician-owned practice	70 (10.6)	6 (4.7)	76 (9.6)
Employee of a hospital, clinic, or university	301 (45.5)	107 (82.9)	408 (51.6)
Employee of a managed care organization or insurance company	36 (5.4)	1 (0.8)	37 (4.7)
None of these	55 (8.3)	13 (10.1)	68 (8.6)
Total	661	129	790
			t = −7.90^*
About how much of your time in practice is spent working with patients 17 to 24 years of age?
None	11 (1.7)	1 (0.8)	12 (1.5)
Less than 25%	490 (74.0)	5 (3.9)	495 (62.6)
25% to 49%	127 (19.2)	7 (5.4)	134 (16.9)
50% to 74%	14 (2.1)	12 (9.3)	26 (3.3)
75% to 100%	17 (2.6)	104 (80.6)	121 (15.3)
Other	3 (0.5)	0 (0.0)	3 (0.4)
Total	662	129	791
			t = −33.48^*

AAFP, American Academy of Family Physicians; ACHA, American College Health Association.
↵* P < .05.

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Table 2.

Analysis Results of Likert Scale Questions

	AAFP		ACHA		Differences
	Mean	SD	Mean	SD	Mean	SD	T
Please select how often you offer or perform any of the following with the patients with ADHD in your practice:
Seek expert consultation in diagnosing and treating.	2.52	1.09	1.91	1.04	0.61	0.11	5.77^*
Follow a medication treatment algorithm such as the Texas algorithm or other recommendations.	3.88	1.11	3.55	1.47	0.33	0.14	2.26^*
Make a specific visit to evaluate for ADHD	2.52	1.33	2.92	1.73	−0.40	0.17	−2.40^*
Initiate any type of drug therapy for ADHD	3.04	1.10	3.78	1.33	−0.75	0.13	−5.79^*
Use a stimulant as your first choice for ADHD treatment.	2.73	1.14	3.49	1.39	−0.76	0.14	−5.54^*
Combine medication with other treatment recommendations such as organizational skills training, behavioral counseling.	2.65	1.15	2.83	1.44	−0.19	0.14	−1.34
Discuss side effects with patients.	1.71	1.04	1.99	1.22	−0.28	0.12	−2.35^*
Please select how well each of the following describes you:
I feel comfortable about prescribing stimulant medication.	3.17	1.20	3.64	1.37	−0.47	0.14	−3.45^*
I tend to try medication even when uncertain about the diagnosis.	4.51	0.77	4.79	0.50	−0.28	0.06	−5.03^*
I believe treatment should be withdrawn if side effects emerge.	2.72	1.12	3.42	1.20	−0.70	0.12	−6.09^*
The emergence of common side effects does not alter my treatment plan.	3.95	1.02	3.94	1.08	0.02	0.11	0.14
I am not prescribing stimulant medications because I have many concerns about side effects.	4.48	1.00	4.52	0.95	−0.04	0.10	−0.41
I always screen for depression before prescribing ADHD medication.	2.62	1.25	2.77	1.61	−0.15	0.16	−0.91
I always screen for suicidal ideation before prescribing ADHD medication.	2.64	1.30	2.76	1.63	−0.12	0.16	−0.76
I am not concerned with suicidal ideation or depression when prescribing ADHD medication.	4.50	0.91	4.77	0.66	−0.27	0.07	−3.70^*
I believe “medication holidays” are acceptable.	2.52	1.23	3.31	1.38	−0.79	0.14	−5.70^*
The following questions pertain to the college students 17 to 26 years of age. Please select how well each of the following statements describes you:
I always ask about patient's use of other substances.	2.16	1.11	1.86	1.08	0.30	0.11	2.74^*
I always discuss the stimulant diversion and misuse with my ADHD patients.	2.66	1.29	2.51	1.48	0.15	0.15	1.03
I always suggest available resources and support services (behavioral therapy, counseling) to my patients with ADHD.	2.55	1.24	2.04	1.21	0.51	0.12	4.15^*
How often do you feel education about ADHD or ADHD medication should occur?	2.91	1.21	3.39	1.10	−0.48	0.12	−4.11^*
How well do you feel you are equipped to provide patient education about each of the following:
Nature of ADHD	2.56	0.88	2.58	0.95	−0.03	0.09	−0.28
Effects and side-effects of stimulant medications.	2.35	0.84	2.38	0.94	−0.04	0.09	−0.39
Decisions about pharmacotherapy or behavioral therapy choices.	2.61	0.88	2.69	1.09	−0.08	0.11	−0.78
General expectations for college life such as stress, academic performance, conduct, life skills and preparation strategies.	2.44	0.87	1.90	0.82	0.54	0.08	6.41^*
Risky behaviors, drug abuse, medication misuse and prevention strategies.	2.52	0.83	2.24	0.94	0.28	0.09	3.08^*

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder; SD, Standard deviation; T, T-value (t-statistic).
The mean was calculated for each group for each question. The lower the value of the mean, the more the agreeable the statement is to the group's perceptions, feelings, or knowledge. Scale is 1 to 5 with 1 = Describes me completely/Always/Very likely to 5 = Does not describe me at all/Never/Very unlikely.
↵* P < .05.

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Table 3.

Analysis Results of Binary Scale Questions

	AAFP, %	ACHA, %	Pearson χ²
	AAFP, %	ACHA, %	Value	Sig.
How do you monitor your ADHD patient's medication compliance (please select all that apply):
I use a state medication registry to track patient prescription drug use.	62.1	40.2	20.31	0.00^*
I use random urine drug testing (UDT).	42.3	21.3	18.96	0.00^*
I use pill counts.	18.6	9.8	5.48	0.02^*
Which factors contribute to your decisions on which stimulant medication to use (can choose more than one answer):
Preference for fast acting over slow release stimulants.	9.3	14.9	3.42	0.06
Preference for slow release over fast acting stimulants.	40.1	35.5	0.9	0.34
Do you feel it is your responsibility to educate patients with ADHD?	95.1	90.4	4.36	0.04^*
If yes, what do you feel you are responsible for?
Educating about legal risks of misusing the medicine.	67.2	74.3	2.23	0.14
Educating about the health and physical risks of misusing the medicine.	92.2	88.5	1.72	0.19
Educating about the mental effects of not using the medicine properly.	73.2	72.6	0.02	0.89
Educating about how misusing medicine can affect social life and relationships such as family, job, friends and significant others.	63.6	66.4	0.32	0.57
What do you feel is the best way to educate patients about ADHD (please select all that apply):
Pamphlets and handouts.	47.9	38.7	3.54	0.06
Education or counseling session at visits where prescription is written.	83	87.9	1.86	0.17
Give the patient links to web resources.	46.7	48.4	0.13	0.72
Mass media such as television and magazines.	6.4	4	1.01	0.32
Social media such as Facebook and Twitter.	6.4	16.1	13.43	0.00^*
What do you feel you personally should be doing to reduce the misuse of ADHD medications (please select all that apply):
Evaluate each patient with suspected ADHD to confirm diagnosis before prescribing.	83.5	67.2	17.42	0.00^*
Refer all ADHD patients to mental health professionals for care.	26.9	37.7	5.87	0.02^*
Educate patients with ADHD about how the stimulants should and should not be used.	76.9	79.5	0.38	0.54
Provide clear instructions regarding sharing and selling medications to patients with ADHD.	67.4	59.8	2.62	0.11
Provide specific instructions on how to dispose of any unneeded medications.	39.7	43.4	0.58	0.45
Strictly monitor patient's prescription medication use with urine drug tests and state registries.	49	28.7	16.93	0.00^*
Educate all patients of college age about misuse and risk of misusing stimulants.	66.5	76.2	4.49	0.03^*
Discourage “medication holidays.”	11.1	18	4.53	0.03^*

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.
↵* P < .05.

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Appendix Table 1.

Based on Your Understanding, How Prevalent is ADHD in Adults?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Less than 1%	51 (7.7)	2 (1.6)	53 (6.7)
1% to 5%	330 (50.1)	41 (32.0)	371 (47.1)
6% to 10%	215 (27.3)	49 (38.3)	264 (33.5)
11% to 20%	50 (6.4)	22 (17.2)	72 (9.1)
Greater than 20%	11 (1.4)	12 (9.4)	23 (2.9)
Other	2 (0.3)	2 (1.6)	4 (0.5)
Total	659	128	787

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix Table 2.

Based on Your Best Understanding, How Prevalent is ADHD Among College Students?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Less than 1%	39 (5.9)	2 (1.6)	41 (5.2)
1% to 5%	281 (42.7)	28 (22.4)	309 (39.5)
6% to 10%	250 (38.0)	53 (42.4)	303 (38.7)
11% to 20%	72 (10.9)	27 (21.6)	99 (12.6)
Greater than 20%	16 (2.4)	15 (12.0)	31 (4.0)
Total	658	125	783

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix 3.

How Likely Is it That You Have Adult Patients with Undiagnosed ADHD in Your General Practice?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Very likely	197 (30.1)	41 (32.3)	238 (30.4)
Likely	316 (48.2)	61 (48.0)	377 (48.2)
Neither likely nor unlikely	67 (10.2)	10 (7.9)	77 (9.8)
Unlikely	63 (9.6)	11 (8.7)	74 (9.5)
Very unlikely	12 (1.8)	4 (3.1)	16 (2.0)
Total	655	127	782

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix 4.

Please Select to What Extent You Agree or Disagree with the Following Statements

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
ADHD is overdiagnosed in teens and young adults.
Strongly agree	99 (15.1)	15 (12.1)	114 (14.7)
Agree	264 (40.4)	45 (36.3)	309 (39.7)
Neither agree nor disagree	172 (26.3)	35 (28.2)	207 (26.6)
Disagree	114 (17.4)	29 (23.4)	143 (18.4)
Strongly disagree	5 (0.8)	0 (0.0)	5 (0.6)
Total	654	124	778
Untreated ADHD affects quality of life.
Strongly agree	171 (26.4)	39 (31.5)	210 (27.2)
Agree	419 (64.8)	78 (62.9)	497 (64.5)
Neither agree nor disagree	47 (7.3)	7 (5.6)	54 (7.0)
Disagree	4 (0.6)	0 (0.0)	4 (0.5)
Strongly disagree	6 (0.9)	0 (0.0)	6 (0.8)
Total	647	124	771
Untreated ADHD is often associated with risky behaviors.
Strongly agree	131 (20.3)	34 (27.9)	165 (21.5)
Agree	361 (56.0)	60 (49.2)	421 (54.9)
Neither agree nor disagree	124 (19.2)	24 (19.7)	148 (19.3)
Disagree	24 (3.7)	4 (3.3)	28 (3.7)
Strongly disagree	5 (0.8)	0 (0.0)	5 (0.7)
Total	645	122	767
ADHD is easy to “fake” for drug-seeking patients.
Strongly agree	106 (16.4)	13 (10.5)	119 (15.5)
Agree	325 (50.3)	50 (40.3)	375 (48.7)
Neither agree nor disagree	146 (22.6)	40 (32.3)	186 (24.2)
Disagree	67 (10.4)	21 (16.9)	88 (11.4)
Strongly disagree	2 (0.3)	0 (0.0)	7 (0.3)
Total	646	124	770
It is difficult to determine when a patient is “faking” the symptoms of ADHD.
Strongly agree	69 (10.7)	6 (4.9)	75 (9.8)
Agree	347 (53.8)	47 (38.2)	394 (51.3)
Neither agree nor disagree	156 (24.2)	42 (34.1)	198 (25.8)
Disagree	71 (11.0)	28 (22.8)	99 (12.9)
Strongly disagree	2 (0.3)	0 (0.0)	2 (0.3)
Total	645	123	768

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix 5.

Please Select How Often You Offer or Perform Any of the Following with the Patients with ADHD in Your Practice

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Seek expert consultation in diagnosing and treating.
Always	123 (19.1)	59 (48.0)	182 (23.7)
Very often	210 (32.6)	26 (21.1)	236 (30.7)
Sometimes	192 (29.8)	31 (25.2)	223 (29.0)
Rarely	91 (14.1)	4 (3.3)	95 (12.4)
Never	29 (4.5)	3 (2.4)	32 (4.2)
Total	645	123	768
Follow a medication treatment algorithm such as the Texas algorithm or other recommendations.
Always	14 (2.2)	13 (11.4)	27 (3.6)
Very often	74 (11.6)	20 (17.5)	94 (12.5)
Sometimes	129 (20.2)	21 (18.4)	150 (19.9)
Rarely	180 (28.2)	11 (9.6)	191 (25.4)
Never	242 (37.9)	49 (43.0)	291 (38.6)
Total	639	114	753
Make a specific visit to evaluate for ADHD.
Always	166(25.9)	39 (32.8)	205 (27.0)
Very often	211 (33.0)	22 (18.5)	233 (30.7)
Sometimes	109 (17.0)	9 (7.6)	118 (15.5)
Rarely	70 (10.9)	7 (5.9)	77 (10.1)
Never	84 (13.1)	42 (5.5)	126 (16.6)
Total	640	119	759
Initiate any type of drug therapy for ADHD.
Always	28 (4.4)	7 (5.8)	35 (4.6)
Very often	192 (30.0)	21 (17.5)	213 (28.0)
Sometimes	246 (38.4)	16 (13.3)	262 (34.4)
Rarely	72 (12.2)	23 (19.2)	101 (13.3)
Never	97 (15.1)	53 (44.2)	150 (19.7)
Total	641	120	761
Use a stimulant as your first choice for ADHD treatment.
Always	44 (6.9)	9 (7.7)	53 (7.0)
Very often	304 (47.9)	27 (23.1)	331 (44.0)
Sometimes	149 (23.5)	23 (19.7)	172 (22.9)
Rarely	55 (8.7)	14 (12.0)	69 (9.2)
Never	83 (13.1)	44 (37.6)	127 (16.9)
Total	635	117	752
Combine medication with other treatment recommendations such as organizational skills training, behavioral counseling.
Always	92 (14.4)	23 (19.2)	115 (15.2)
Very often	238 (37.2)	37 (30.8)	275 (36.2)
Sometimes	176 (27.5)	26 (21.7)	202 (26.6)
Rarely	70 (11.0)	5 (4.2)	75 (9.9)
Never	63 (9.9)	29 (24.2)	92 (12.1)
Total	639	120	759
Discuss effects and side effects of stimulants with patients.
Always	353 (55.2)	61 (50.0)	414 (54.3)
Very often	196 (30.6)	24 (19.7)	220 (28.9)
Sometimes	42 (6.6)	21 (17.2)	63 (8.3)
Rarely	19 (3.0)	9 (7.4)	28 (3.7)
Never	30 (4.7)	7 (5.7)	37 (4.9)
Total	640	122	762

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix 6.

Please Select to What Extent You Agree or Disagree with the Following Statements

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
ADHD often occurs with another mental health problem.
Strongly agree	102 (15.8)	20 (16.1)	122 (15.9)
Agree	378 (58.6)	62 (50.0)	440 (57.2)
Neither agree nor disagree	122 (18.9)	31 (25.0)	153 (19.9)
Disagree	40 (6.2)	10 (8.1)	50 (6.5)
Strongly disagree	3 (0.5)	1 (0.8)	4 (0.5)
Total	645	124	769
Stimulants have the potential for abuse.
Strongly agree	353 (54.5)	71 (57.3)	424 (54.9)
Agree	289 (44.6)	49 (39.5)	338 (43.8)
Neither agree nor disagree	4 (0.6)	3 (2.4)	7 (0.9)
Disagree	2 (0.3)	1 (0.8)	3 (0.4)
Strongly disagree	0 (0.0)	0 (0.0)	0 (0.0)
Total	648	124	772
Stimulants are additive.
Strongly agree	161 (24.9)	36 (29.0)	197 (25.6)
Agree	302 (46.7)	53 (42.7)	355 (46.1)
Neither agree nor disagree	133 (20.6)	25 (20.2)	158 (20.5)
Disagree	49 (7.6)	10 (8.1)	59 (7.7)
Strongly disagree	1 (0.2)	0 (0.0)	1 (0.1)
Total	646	124	770
There is a clear difference between diversion, misuse and abuse.
Strongly agree	122 (18.9)	28 (22.6)	150 (19.5)
Agree	295 (45.6)	59 (47.6)	354 (45.9)
Neither agree nor disagree	121 (18.7)	23 (18.5)	144 (18.7)
Disagree	98 (15.1)	13 (10.5)	111 (14.4)
Strongly disagree	11 (1.7)	1 (0.8)	12 (1.6)
Total	647	124	771
Diversion or abuse is a problem overall.
Strongly agree	190 (29.4)	21 (16.9)	211 (27.4)
Agree	357 (55.3)	80 (64.5)	437 (56.8)
Neither agree nor disagree	82 (12.7)	18 (14.5)	100 (13.0)
Disagree	16 (2.5)	5 (4.0)	21 (2.7)
Strongly disagree	1 (0.2)	0 (0.0)	1 (0.1)
Total	646	124	770
Diversion is a more serious issue than misuse or abuse.
Strongly agree	61 (9.5)	16 (12.9)	77 (10.0)
Agree	168 (26.1)	37 (29.8)	205 (26.7)
Neither agree nor disagree	304 (47.3)	52 (41.9)	356 (46.4)
Disagree	103 (16.0)	17 (13.7)	120 (15.6)
Strongly disagree	7 (1.1)	2 (1.6)	9 (1.2)
Total	643	124	767
The legal consequences of diversion for both yourself and patient are serious.
Strongly agree	173 (26.7)	43 (35.5)	216 (28.1)
Agree	366 (56.6)	60 (49.6)	426 (55.5)
Neither agree nor disagree	90 (13.9)	15 (12.4)	105 (13.7)
Disagree	16 (2.5)	3 (2.5)	19 (2.5)
Strongly disagree	2 (0.3)	0 (0.0)	2 (0.3)
Total	647	121	768
You have concerns about diversion with ADHD medications.
Strongly agree	164 (25.4)	37 (30.3)	201 (26.2)
Agree	360 (55.8)	62 (50.8)	422 (55.0)
Neither agree nor disagree	92 (14.3)	20 (16.4)	112 (14.6)
Disagree	29 (4.5)	2 (1.6)	31 (4.0)
Strongly disagree	0 (0.0)	1 (0.8)	1 (0.1)
Total	645	122	767

AAFP, American Academy of Family Physicians; ACHA, American College Health Association; ADHD, attention deficit hyperactivity disorder.

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Appendix 7.

Based on Your Best Understanding, for Each Statement Below Please Select Whether the Definition is True or False

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Misuse is intentional or unintentional use of stimulants in a way other than prescribed.
TRUE	635 (98.4)	116 (95.1)	751 (97.9)
FALSE	10 (1.6)	6 (4.9)	16 (2.1)
Total	645	122	767
Abuse is the recurrent nonmedical use of stimulants to alter one's state of consciousness (“get high”).
TRUE	616 (95.8)	118 (95.9)	734 (95.8)
FALSE	27 (4.2)	5 (4.1)	32 (4.2)
Total	643	123	766
Diversion is redirection of a stimulant from its lawful purpose to nonmedical or illicit use.
TRUE	615 (95.6)	117 (95.1)	732 (95.6)
FALSE	28 (4.4)	6 (4.9)	34 (4.4)
Total	643	123	766

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Appendix 8.

Please Select All That Apply When Evaluating a Patient Prior to Prescribing Medical Treatment for ADHD

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
I prescribe after confirming that patients' complaints are consistent with ADHD symptoms via an office visit.
Not Selected	268 (41.6)	102 (82.9)	370 (48.2)
Selected	377 (58.4)	21 (17.1)	398 (51.8)
Total	645	123	768
I prescribe after the first evaluation without any confirmatory data.
Not Selected	600 (93.0)	123 (100.0)	723 (94.1)
Selected	45 (7.0)	0 (0.0)	45 (5.9)
Total	645	123	768
I wait for the evaluation report.
Not Selected	369 (57.2)	75 (75)	444 (57.8)
Selected	276 (42.8)	48 (48)	324 (42.2)
Total	645	123	768
I use multiple sessions to determine if treatment is necessary.
Not Selected	492 (76.3)	104 (84.6)	596 (77.6)
Selected	153 (23.7)	19 (15.4)	172 (22.4)
Total	645	123	768
I refer out for diagnosis.
Not Selected	309 (47.9)	36 (29.3)	345 (44.9)
Selected	336 (52.1)	87 (70.7)	423 (55.1)
Total	645	123	768
None of the above.
Not Selected	636 (98.6)	121 (98.4)	757 (98.6)
Selected	9 (1.4)	2 (1.6)	11 (1.4)
Total	645	123	768
Not applicable.
Not Selected	605 (93.8)	102 (82.9)	707 (92.1)
Selected	40 (6.2)	21 (17.1)	61 (7.9)
Total	645	123	768

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Appendix 9.

When You Are Following a Patient for Their ADHD Medication, How Frequently Do You See Them for Follow-Up Monitoring?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Every month	130 (20.1)	44 (35.8)	174 (22.6)
Every 3 months	327 (50.5)	30 (24.4)	357 (46.3)
Every 6 months	99 (15.3)	4 (3.3)	103 (13.4)
Every year	14 (2.2)	0 (0.0)	14 (1.8)
When they decide to make an appointment	1 (0.2)	0 (0.0)	1 (0.1)
Never	1 (0.2)	1 (0.8)	2 (0.3)
Not applicable	76 (11.7)	44 (35.8)	120 (15.6)
Total	648	123	771

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Appendix 10.

How Do You Monitor Your ADHD Patient's Medication Compliance? (Please Select All That Apply)

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
I use a state medication registry to track patient prescription drug use.
Not Selected	241 (37.9)	73 (59.8)	314 (41.4)
Selected	395 (62.1)	49 (40.2)	444 (58.6)
Total	636	122	758
I use random urine drug testing (UDT).
Not Selected	367 (57.7)	96 (78.7)	463 (61.1)
Selected	269 (42.3)	26 (21.3)	295 (38.9)
Total	636	122	758
I use urine drug testing (UDT) at every monitoring visit for a patient on ADHD medications.
Not Selected	603 (94.8)	119 (97.5)	722 (95.3)
Selected	33 (5.2)	3 (2.5)	36 (4.7)
Total	636	122	758
I use pill counts.
Not Selected	518 (81.4)	110 (90.2)	628 (82.8)
Selected	118 (18.6)	12 (9.8)	130 (17.2)
Total	636	122	758
Not applicable.
Not Selected	497 (78.1)	66 (54.1)	563 (74.3)
Selected	139 (21.9)	56 (45.9)	195 (25.7)
Total	636	122	758
Other.
Not Selected	577 (90.7)	106 (86.9)	683 (90.1)
Selected	59 (9.3)	16 (13.1)	75 (9.9)

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Appendix 11.

How Do You Evaluate Whether Your Treatment Is Working? (Please Select All That Apply)

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Patient self-report.
Not Selected	88 (13.6)	42 (34.1)	130 (16.9)
Selected	558 (86.4)	81 (65.9)	639 (83.1)
Total	646	123	769
Report cards for young adults.
Not Selected	440 (68.1)	105 (85.4)	545 (70.9)
Selected	206 (31.9)	18 (14.6)	224 (29.1)
Total	646	123	769
Work performance evaluations.
Not Selected	519 (80.3)	115 (93.5)	634 (82.4)
Selected	127 (19.7)	8 (6.5)	135 (17.6)
Total	646	123	769
Ask their significant other.
Not Selected	395 (61.1)	115 (93.5)	510 (66.3)
Selected	251 (38.9)	8 (6.5)	259 (33.7)
Total	646	123	769
Ask their parents.
Not Selected	281 (43.5)	115 (93.5)	396 (51.5)
Selected	365 (56.5)	8 (6.5)	373 (48.5)
Total	646	123	769
Not applicable.
Not Selected	555 (85.9)	82 (66.7)	637 (82.8)
Selected	91 (14.1)	41 (33.3)	132 (17.2)
Total	646	123	769
Other.
Not Selected	593 (91.8)	111 (90.2)	704 (91.5)
Selected	53 (8.2)	12 (9.8)	65 (8.5)
Total	646	123	769

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Appendix 12.

How Frequently Do You Reassess Your Patients with ADHD if They Are:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Children (0 to 13 y.o.).
Monthly	72 (11.4)	5 (4.6)	77 (10.4)
Every 2 to 3 months	207 (32.9)	6 (5.5)	213 (28.8)
Every 3 to 6 months	164 (26.0)	2 (1.8)	166 (22.5)
Every 6 to 9 months	29 (4.6)	1 (0.9)	30 (4.1)
Never	5 (0.8)	1 (0.9)	6 (0.8)
Not applicable	153 (24.3)	94 (86.2)	247 (33.4)
Total	630	109	739
Teenagers (13 to 18 y.o.).
Monthly	74 (11.8)	19 (17.1)	93 (12.6)
Every 2 to 3 months	201 (32.0)	12 (10.8)	213 (28.8)
Every 3 to 6 months	191 (30.4)	6 (5.4)	197 (26.7)
Every 6 to 9 months	42 (6.7)	1 (0.9)	43 (5.8)
Never	2 (0.3)	1 (0.9)	3 (0.4)
Not applicable	118 (18.8)	72 (64.9)	190 (25.7)
Total	628	111	739
Young adult (17 to 26 y.o.).
Monthly	58 (9.2)	35 (30.2)	93 (12.5)
Every 2 to 3 months	205 (32.5)	20 (17.2)	225 (30.2)
Every 3 to 6 months	208 (33.0)	15 (12.9)	223 (29.9)
Every 6 to 9 months	66 (10.5)	4 (3.4)	70 (9.4)
Never	2 (0.3)	1 (0.9)	3 (0.4)
Not applicable	91 (14.4)	41 (35.3)	132 (17.7)
Total	630	116	746
Adult (26 and older y.o.).
Monthly	47 (7.5)	15 (13.4)	62 (8.4)
Every 2 to 3 months	173 (27.5)	22 (19.6)	195 (26.4)
Every 3 to 6 months	215 (34.2)	18 (16.1)	233 (31.5)
Every 6 to 9 months	96 (15.3)	4 (3.6)	100 (13.5)
Never	3 (0.5)	2 (1.8)	5 (0.7)
Not applicable	94 (15.0)	51 (45.5)	145 (19.6)
Total	628	112	740
On ADHD stimulant medication.
Monthly	67 (10.7)	34 (30.4)	101 (13.6)
Every 2 to 3 months	202 (32.1)	20 (17.9)	222 (30.0)
Every 3 to 6 months	212 (33.7)	13 (11.6)	225 (30.4)
Every 6 to 9 months	61 (9.7)	3 (2.7)	64 (8.6)
Never	2 (0.3)	1 (0.9)	3 (0.4)
Not applicable	85 (13.5)	41 (36.6)	126 (17.0)
Total	629	112	741
Just initiating treatment.
Monthly	424 (67.5)	58 (52.3)	482 (65.2)
Every 2 to 3 months	81 (12.9)	3 (2.7)	84 (11.4)
Every 3 to 6 months	21 (3.3)	0 (0.0)	21 (2.8)
Every 6 to 9 months	5 (0.8)	2 (1.8)	7 (0.9)
Never	2 (0.3)	1 (0.9)	3 (0.4)
Not applicable	95 (15.1)	47 (42.3)	142 (19.2)
Total	628	111	739
In their first 2 years of treatment.
Monthly	54 (8.6)	23 (20.7)	77 (10.5)
Every 2 to 3 months	235 (37.6)	28 (25.2)	263 (35.7)
Every 3 to 6 months	215 (34.4)	14 (12.6)	229 (31.1)
Every 6 to 9 months	35 (5.6)	4 (3.6)	39 (5.3)
Never	2 (0.3)	2 (1.8)	4 (0.5)
Not applicable	84 (13.4)	40 (36.0)	124 (16.8)
Total	625	111	736
Stable on treatment after 2 years.
Monthly	18 (2.9)	14 (12.6)	32 (4.4)
Every 2 to 3 months	150 (24.1)	20 (18.0)	170 (23.2)
Every 3 to 6 months	227 (36.4)	23 (20.7)	250 (34.1)
Every 6 to 9 months	141 (22.6)	13 (11.7)	154 (21.0)
Never	3 (0.5)	1 (0.9)	4 (0.5)
Not applicable	84 (13.5)	40 (36.0)	124 (16.9)
Total	623	111	734

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Appendix 13.

Based on Your Best Understanding, How Frequently Do Patients Engage in Any of the Following:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Misuse ADHD medication.
Very frequently	21 (3.3)	5 (4.1)	26 (3.4)
Frequently	111 (17.3)	32 (26.2)	143 (18.7)
Occasionally	401 (62.5)	75 (61.5)	476 (62.3)
Rarely	105 (16.4)	8 (6.6)	113 (14.8)
Never	4 (0.6)	2 (1.6)	6 (0.8)
Total	642	122	764
Abuse prescribed stimulants.
Very frequently	17 (2.6)	5 (4.1)	22 (2.9)
Frequently	93 (14.5)	22 (18.0)	115 (15.0)
Occasionally	368 (57.2)	71 (58.2)	439 (57.4)
Rarely	162 (25.2)	22 (18.0)	184 (24.1)
Never	3 (0.5)	2 (1.6)	5 (0.7)
Total	643	122	765
Diversion of prescribed stimulants to friends or sell to other people.
Very frequently	21 (3.3)	8 (6.7)	29 (3.8)
Frequently	86 (13.4)	30 (25.0)	116 (15.3)
Occasionally	341 (53.3)	61 (50.8)	402 (52.9)
Rarely	184 (28.7)	19 (15.8)	203 (26.7)
Never	8 (1.3)	2 (1.7)	10 (1.3)
Total	640	120	760

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Appendix 14.

Why Do You Think People Misuse ADHD Medication? (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Lack of knowledge about effects vs side effects.
Not Selected	375 (59.4)	67 (53.2)	442 (58.4)
Selected	256 (40.6)	59 (46.8)	315 (41.6)
Total	631	126	757
Feeling the medicine isn't working appropriately or losing effectiveness.
Not Selected	214 (33.9)	58 (46.0)	272 (35.9)
Selected	417 (66.1)	68 (54.0)	485 (64.1)
Total	631	126	757
To “get high” or because of how the medicine makes them feel.
Not Selected	388 (61.5)	82 (65.1)	470 (62.1)
Selected	243 (38.5)	44 (34.9)	287 (37.9)
Total	631	126	757
Unintentionally not remembering the recommendations.
Not Selected	508 (80.5)	101 (80.2)	609 (80.4)
Selected	123 (19.5)	25 (19.8)	148 (19.6)
Total	631	126	757
For performance enhancement.
Not Selected	164 (26.0)	35 (27.8)	199 (26.3)
Selected	467 (74.0)	91 (72.2)	558 (73.7)
Total	631	126	757
For losing weight.
Not Selected	283 (44.8)	72 (57.1)	355 (46.9)
Selected	348 (55.2)	54 (42.9)	402 (53.1)
Total	631	126	757
To pull an “all-nighter.”
Not Selected	288 (45.6)	41 (32.5)	329 (43.5)
Selected	343 (54.4)	85 (67.5)	428 (56.5)
Total	631	126	757
To enhance academic performance.
Not Selected	270 (42.8)	36 (28.6)	306 (40.4)
Selected	361 (57.2)	90 (71.4)	451 (59.6)
Total	631	126	757
Other.
Not Selected	552 (87.5)	113 (89.7)	665 (87.8)
Selected	79 (12.5)	13 (10.3)	92 (12.2)
Total	631	126	757

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Appendix 15.

Based On Your Best Understanding, Please Select the Characteristics of Patients That Predict Abuse or Diversion? (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
History of drug use.
Not Selected	123 (19.2)	47 (37.9)	170 (22.2)
Selected	518 (80.8)	77 (62.1)	595 (77.8)
Total	641	124	765
Low income.
Not Selected	467 (72.9)	106 (85.5)	573 (74.9)
Selected	174 (27.1)	18 (14.5)	192 (25.1)
Total	641	124	765
Non-white race.
Not Selected	472 (73.6)	102 (82.3)	574 (75.0)
Selected	169 (26.4)	22 (17.7)	191 (25.0)
Total	641	124	765
History of mental illness.
Not Selected	250 (39.0)	77 (62.1)	327 (42.7)
Selected	391 (61.0)	47 (37.9)	438 (57.3)
Total	641	124	765
Male gender.
Not Selected	325 (50.7)	68 (54.8)	393 (51.4)
Selected	316 (49.3)	56 (45.2)	372 (48.6)
Total	641	124	765
Affiliation with a fraternity or sorority.
Not Selected	492 (76.8)	86 (69.4)	578 (75.6)
Selected	149 (23.2)	38 (30.6)	187 (24.4)
Total	641	124	765
Low GPA.
Not Selected	570 (88.9)	101 (81.5)	671 (87.7)
Selected	71 (11.1)	23 (18.5)	94 (12.3)
Total	641	124	765
Competitive school or program.
Not Selected	433 (67.6)	48 (38.7)	481 (62.9)
Selected	208 (32.4)	76 (61.3)	284 (37.1)
Total	641	124	765
Other.
Not Selected	600 (93.6)	115 (92.7)	715 (93.5)
Selected	41 (6.4)	9 (7.3)	50 (6.5)
Total	641	124	765

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Appendix 16.

Please Select How Well Each of the Following Describes You:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
I feel comfortable about prescribing stimulant medication.
Describes me completely	43 (6.8)	9 (7.8)	52 (7.0)
Describes me well	164 (26.1)	19 (16.5)	183 (24.6)
Describes me fairly well	174 (27.7)	23 (20.0)	197 (26.5)
Describes me somewhat	136 (21.6)	17 (14.8)	153 (20.6)
Does not describe me at all	112 (17.8)	47 (40.9)	159 (21.4)
Total	629	115	744
I tend to try medication even when uncertain about the diagnosis.
Describes me completely	3 (0.5)	0 (0.0)	3 (0.4)
Describes me well	16 (2.5)	1 (0.9)	17 (2.3)
Describes me fairly well	40 (6.4)	2 (1.7)	42 (5.6)
Describes me somewhat	166 (26.4)	17 (14.7)	183 (24.6)
Does not describe me at all	403 (64.2)	96 (82.8)	499 (67.1)
Total	628	116	744
I believe serious uncommon side effects may influence my prescribing practice.
Describes me completely	43 (6.9)	8 (7.0)	51 (6.9)
Describes me well	78 (12.4)	14 (12.2)	92 (12.4)
Describes me fairly well	141 (22.5)	19 (16.5)	160 (21.6)
Describes me somewhat	219 (34.9)	39 (33.9)	258 (34.8)
Does not describe me at all	146 (23.3)	35 (30.4)	181 (24.4)
Total	627	115	742
I believe treatment should be withdrawn if side effects emerge.
Describes me completely	88 (14.1)	7 (6.1)	95 (12.9)
Describes me well	205 (33.0)	21 (18.4)	226 (30.7)
Describes me fairly well	155 (24.9)	29 (25.4)	184 (25.0)
Describes me somewhat	142 (22.8)	31 (27.2)	173 (23.5)
Does not describe me at all	32 (5.1)	26 (22.8)	58 (7.9)
Total	622	114	736
The emergence of common side effects does not alter my treatment plan.
Describes me completely	8 (1.3)	2 (1.8)	10 (1.4)
Describes me well	50 (8.0)	11 (9.6)	61 (8.3)
Describes me fairly well	143 (22.9)	24 (21.1)	167 (22.6)
Describes me somewhat	185 (29.6)	32 (28.1)	217 (29.4)
Does not describe me at all	238 (38.1)	45 (39.5)	283 (38.3)
Total	624	114	738
I am not prescribing stimulant medications because I have many concerns about side effects.
Describes me completely	23 (3.7)	2 (1.8)	25 (3.4)
Describes me well	21 (3.4)	6 (5.4)	27 (3.7)
Describes me fairly well	30 (4.8)	6 (5.4)	36 (4.9)
Describes me somewhat	112 (17.9)	16 (14.3)	128 (17.4)
Does not describe me at all	439 (70.2)	82 (73.2)	521 (70.7)
Total	625	112	737
I always screen for depression before prescribing ADHD medication.
Describes me completely	128 (20.6)	33 (29.7)	161 (22.0)
Describes me well	196 (31.5)	29 (26.1)	225 (30.7)
Describes me fairly well	148 (23.8)	11 (9.9)	159 (21.7)
Describes me somewhat	85 (13.7)	7 (6.3)	92 (12.6)
Does not describe me at all	65 (10.5)	31 (27.9)	96 (13.1)
Total	622	111	733
I always screen for suicidal ideation before prescribing ADHD medication.
Describes me completely	145 (23.4)	35 (31.3)	180 (24.7)
Describes me well	168 (27.2)	27 (24.1)	195 (26.7)
Describes me fairly well	139 (22.5)	12 (10.7)	151 (20.7)
Describes me somewhat	97 (15.7)	6 (5.4)	103 (14.1)
Does not describe me at all	68 (11.0)	32 (28.6)	100 (13.7)
Total	617	112	729
I am not concerned with suicidal ideation or depression when prescribing ADHD medication.
Describes me completely	9 (1.5)	0 (0.0)	9 (1.2)
Describes me well	22 (3.6)	3 (2.7)	25 (3.4)
Describes me fairly well	56 (9.1)	5 (4.5)	61 (8.4)
Describes me somewhat	94 (15.2)	7 (6.3)	101 (13.8)
Does not describe me at all	437 (70.7)	97 (86.6)	534 (73.2)
Total	618	112	730
I often conduct the reassessment via an alternative encounter (email, phone, telemedicine, remote virtual meeting, etc.)
Describes me completely	12 (2.0)	5 (4.5)	17 (2.3)
Describes me well	21 (3.4)	7 (6.3)	28 (3.9)
Describes me fairly well	35 (5.7)	4 (3.6)	39 (5.4)
Describes me somewhat	78 (12.7)	11 (9.9)	89 (12.3)
Does not describes me at all	469 (76.3)	84 (75.7)	553 (76.2)
Total	615	111	726
I believe “medication holidays” are acceptable.
Describes me completely	143 (23.0)	13 (11.5)	156 (21.3)
Describes me well	208 (33.5)	23 (20.4)	231 (31.5)
Describes me fairly well	126 (20.3)	25 (22.1)	151 (20.6)
Describes me somewhat	92 (14.8)	20 (17.7)	112 (15.3)
Does not describe me at all	52 (8.4)	32 (28.3)	84 (11.4)
	621	113	734

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Appendix 17.

Please Select How Likely or Unlikely Is Each of the Following Situations:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
You would prescribe ADHD medication for a problem patient (e.g., patient with a history of substance abuse, mental illness, non-compliant, etc.).
Very likely	0 (0.0)	2 (1.9)	2 (0.3)
Likely	18 (2.9)	1 (0.9)	19 (2.6)
Neither likely nor unlikely	47 (7.5)	14 (13.1)	61 (8.3)
Unlikely	248 (39.6)	32 (29.9)	280 (38.2)
Very unlikely	313 (50.0)	58 (54.2)	371 (50.6)
Total	626	107	733
You give your patients more than a 30 day supply of their ADHD stimulant medications.
Very likely	12 (1.9)	3 (2.7)	15 (2.0)
Likely	87 (14.0)	5 (4.5)	92 (12.6)
Neither likely nor unlikely	48 (7.7)	10 (9.1)	58 (7.9)
Unlikely	129 (20.7)	19 (17.3)	148 (20.2)
Very unlikely	347 (55.7)	73 (66.4)	420 (57.3)
Total	623	110	733
You give refills on ADHD medications.
Very likely	18 (3.0)	10 (10.4)	28 (4.1)
Likely	131 (22.1)	8 (8.3)	139 (20.2)
Neither likely nor unlikely	54 (9.1)	14 (14.6)	68 (9.9)
Unlikely	322 (54.3)	48 (50.0)	370 (53.7)
Very unlikely	68 (11.5)	16 (16.7)	84 (12.2)
Total	593	96	689
If a patient is on a stimulant, you add other non-stimulant ADHD medication.
Very likely	5 (0.8)	0 (0.0)	5 (0.7)
Likely	85 (13.8)	6 (5.8)	91 (12.6)
Neither likely nor unlikely	159 (25.8)	28 (27.2)	187 (26.0)
Unlikely	181 (29.3)	23 (22.3)	204 (28.3)
Very unlikely	187 (30.3)	46 (44.7)	233 (32.4)
Total	617	103	720
If a patient is on a stimulant, you prescribe a second stimulant.
Very likely	0 (0.0)	0 (0.0)	0 (0.0)
Likely	6 (1.0)	1 (1.0)	7 (1.0)
Neither likely nor unlikely	31 (5.0)	10 (9.5)	41 (5.7)
Unlikely	143 (23.2)	22 (21.0)	165 (22.9)
Very unlikely	436 (70.8)	72 (68.6)	508 (70.5)
Total	616	105	721
If a patient is on a non-stimulant, you add a stimulant.
Very likely	5 (0.8)	2 (2.0)	7 (1.0)
Likely	119 (19.6)	11 (11.0)	130 (18.4)
Neither likely nor unlikely	171 (28.1)	28 (28.0)	199 (28.1)
Unlikely	151 (24.8)	17 (17.0)	168 (23.7)
Very unlikely	162 (26.6)	42 (42.0)	204 (28.8)
Total	608	100	708
If someone is misusing stimulant medication, you inquire about if they are using other substances (including alcohol).
Very likely	300 (48.5)	61 (57.5)	361 (49.9)
Likely	254 (41.1)	30 (28.3)	284 (39.2)
Neither likely nor unlikely	33 (5.3)	2 (1.9)	35 (4.8)
Unlikely	9 (1.5)	1 (0.9)	10 (1.4)
Very unlikely	22 (3.6)	12 (11.3)	34 (4.7)
Total	618	106	724
You ask all adult patients with ADHD about use of other substances.
Very likely	329 (52.9)	58 (54.2)	387 (53.1)
Likely	211 (33.9)	34 (31.8)	245 (33.6)
Neither likely nor unlikely	57 (9.2)	5 (4.7)	62 (8.5)
Unlikely	6 (1.0)	1 (0.9)	7 (1.0)
Very unlikely	19 (3.1)	9 (8.4)	29 (3.8)
Total	622	107	729

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Appendix 18.

How Often Do You Prescribe Each of the Following Medications for Teenage and Young Adult Patients with ADHD?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Adderall.
75% to 100% of the time	31 (5.1)	3 (1.8)	33 (4.6)
51% to 74% of the time	65 (10.6)	14 (12.4)	79 (10.9)
50% of the time	57 (9.3)	3 (2.7)	60 (8.3)
25% to 49% of the time	114 (18.6)	24 (21.2)	138 (19.0)
Less than 25% of the time	221 (36.1)	16 (14.2)	237 (32.7)
Never	54 (8.8)	7 (6.2)	61 (8.4)
Not applicable	70 (11.4)	47 (41.6)	117 (16.1)
Total	612	113	725
Adderall XR.
75% to 100% of the time	35 (5.7)	3 (2.5)	38 (5.2)
51% to 74% of the time	62 (10.1)	18 (15.3)	80 (10.9)
50% of the time	59 (9.6)	9 (7.6)	68 (8.3)
25% to 49% of the time	148 (24.1)	22 (18.6)	170 (23.2)
Less than 25% of the time	195 (31.7)	12 (10.2)	207 (28.2)
Never	42 (6.8)	6 (5.1)	48 (6.5)
Not applicable	74 (12.0)	48 (40.7)	122 (16.6)
Total	615	118	733
Concerta.
75% to 100% of the time	17 (2.9)	1 (0.9)	18 (2.5)
51% to 74% of the time	32 (5.4)	1 (0.9)	33 (4.6)
50% of the time	43 (7.2)	3 (2.6)	46 (6.5)
25% to 49% of the time	91 (15.3)	15 (13.0)	106 (14.9)
Less than 25% of the time	285 (47.9)	35 (30.4)	320 (45.1)
Never	54 (9.1)	11 (9.6)	65 (9.2)
Not applicable	73 (12.3)	49 (42.6)	122 (17.2)
Total	595	115	710
Desoxyn.
75% to 100% of the time	0 (0.0)	0 (0.0)	0 (0.0)
51% to 74% of the time	0 (0.0)	0 (0.0)	0 (0.0)
50% of the time	3 (0.5)	0 (0.0)	3 (0.4)
25% to 49% of the time	0 (0.0)	0 (0.0)	0 (0.0)
Less than 25% of the time	33 (5.9)	7 (6.1)	40 (5.9)
Never	412 (73.7)	51 (44.7)	463 (68.8)
Not applicable	111 (19.9)	56 (49.1)	167 (24.8)
Total	559	114	673
Focalin XR.
75% to 100% of the time	2 (0.4)	0 (0.0)	2 (0.9)
51% to 74% of the time	7 (1.2)	0 (0.0)	7 (1.0)
50% of the time	1 (0.2)	0 (0.0)	1 (0.1)
25% to 49% of the time	15 (2.7)	4 (3.5)	19 (2.8)
Less than 25% of the time	173 (30.7)	27 (23.7)	200 (29.5)
Never	226 (47.2)	29 (25.4)	295 (43.5)
Not applicable	100 (17.7)	54 (47.7)	154 (22.7)
Total	564	114	678
Ritalin.
75% to 100% of the time	11 (1.8)	0 (0.0)	11 (1.5)
51% to 74% of the time	19 (3.2)	1 (0.9)	20 (2.8)
50% of the time	34 (5.7)	0 (0.0)	34 (4.8)
25% to 49% of the time	92 (15.4)	8 (7.0)	100 (14.1)
Less than 25% of the time	265 (44.4)	36 (31.6)	301 (42.3)
Never	100 (16.8)	18 (15.8)	118 (16.6)
Not applicable	76 (12.7)	51 (44.7)	127 (17.9)
Total	597	114	711
Ritalin SR.
75% to 100% of the time	7 (1.2)	0 (0.0)	7 (1.0)
51% to 74% of the time	16 (2.8)	0 (0.0)	16 (2.3)
50% of the time	26 (4.5)	0 (0.0)	26 (3.8)
25% to 49% of the time	67 (11.6)	5 (4.5)	72 (10.4)
Less than 25% of the time	248 (42.9)	35 (31.3)	283 (41.0)
Never	131 (22.7)	20 (17.9)	151 (21.9)
Not applicable	83 (14.4)	52 (46.4)	135 (19.6)
Total	578	112	690
Stratera.
75% to 100% of the time	10 (1.7)	1 (0.9)	11 (1.5)
51% to 74% of the time	16 (2.7)	0 (0.0)	16 (2.2)
50% of the time	22 (3.7)	2 (1.7)	24 (3.4)
25% to 49% of the time	66 (11.0)	9 (7.8)	75 (10.5)
Less than 25% of the time	320 (53.5)	39 (33.6)	359 (50.3)
Never	85 (14.2)	16 (13.8)	101 (14.1)
Not applicable	79 (13.2)	49 (42.2)	128 (17.9)
Total	598	116	714
Vyvanse.
75% to 100% of the time	16 (2.7)	2 (1.7)	18 (2.5)
51% to 74% of the time	22 (3.6)	3 (2.5)	25 (3.5)
50% of the time	38 (6.3)	5 (4.2)	43 (6.0)
25% to 49% of the time	81 (13.4)	18 (15.3)	99 (13.7)
Less than 25% of the time	270 (44.8)	31 (26.3)	301 (41.7)
Never	97 (16.1)	8 (6.8)	105 (14.6)
Not applicable	79 (13.1)	51 (43.2)	130 (18.0)
Total	603	118	721

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Appendix 19.

Which Factors Contribute to Your Decisions on Which Stimulant Medication to Use (Can Choose More Than One Answer):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Comfort with medicine.
Not Selected	160 (25.3)	69 (57.0)	229 (30.4)
Selected	473 (74.7)	52 (43.0)	525 (69.6)
Total	633	121	754
Previous success with same medicine.
Not Selected	157 (24.8)	61 (50.4)	218 (28.9)
Selected	476 (75.2)	60 (49.6)	536 (71.1)
Total	633	121	754
Patient preference.
Not Selected	400 (63.2)	97 (80.2)	497 (65.9)
Selected	233 (36.8)	24 (19.8)	257 (34.1)
Total	633	121	754
Organizational culture.
Not Selected	595 (94.0)	114 (94.2)	709 (94.0)
Selected	38 (6.0)	7 (5.8)	45 (6.0)
Total	633	121	754
Insurance coverage or coverage restrictions
Not Selected	172 (27.2)	70 (57.9)	242 (32.1)
Selected	461 (72.8)	51 (42.1)	512 (67.9)
Total	633	121	754
Cost.
Not Selected	236 (37.3)	73 (60.3)	309 (41.0)
Selected	397 (62.7)	48 (39.7)	445 (59.0)
Total	633	121	754
Preference for branded over generic.
Not Selected	604 (95.4)	116 (95.9)	720 (95.5)
Selected	29 (4.6)	5 (4.1)	34 (4.5)
Total	633	121	754
Preference for generic over branded.
Not Selected	444 (70.1)	95 (78.5)	539 (71.5)
Selected	189 (29.9)	26 (21.5)	215 (28.5)
Total	633	121	754
Evidence-based guidelines.
Not Selected	432 (68.2)	77 (63.6)	509 (67.5)
Selected	201 (31.8)	44 (36.4)	245 (32.5)
Total	633	121	754
Own experience.
Not Selected	377 (59.6)	96 (79.3)	473 (62.7)
Selected	256 (40.4)	25 (20.7)	281 (37.3)
Total	633	121	754
Preference for fast acting over slow release stimulants.
Not Selected	574 (90.7)	103 (85.1)	677 (89.8)
Selected	59 (9.3)	18 (14.9)	77 (10.2)
Total	633	121	754
Preference for slow release over fast acting stimulants.
Not Selected	379 (59.9)	78 (64.5)	457 (60.6)
Selected	254 (40.1)	43 (35.5)	297 (39.4)
Total	633	121	754
Not applicable.
Not Selected	573 (90.5)	78 (64.5)	651 (86.3)
Selected	60 (9.5)	43 (35.5)	103 (13.7)
Total	633	121	754
Other.
Not Selected	597 (94.3)	103 (85.1)	700 (92.8)
Selected	36 (5.7)	18 (14.9)	54 (7.2)
Total	633	121	754

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Appendix 20.

How Often Do You Use Any of the Following to Monitor for Possible Medication Abuse in Your ADHD Patients:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
I use a state medication registry to tract patient prescription drug use.
Always	167 (26.9)	28 (24.8)	195 (26.6)
Very frequently	178 (28.7)	19 (16.8)	197 (26.8)
Occasionally	124 (20.0)	6 (5.3)	130 (17.7)
Rarely	31 (5.0)	5 (4.4)	36 (4.9)
Never	48 (7.7)	10 (8.8)	58 (7.9)
Not applicable	73 (11.8)	45 (39.8)	118 (16.1)
Total	621	113	734
I use random urine drug testing (UDT).
Always	76 (12.3)	5 (4.4)	81 (11.1)
Very frequently	97 (15.7)	3 (2.7)	100 (13.7)
Occasionally	137 (22.2)	19 (16.8)	156 (21.3)
Rarely	106 (17.2)	11 (9.7)	117 (16.0)
Never	133 (21.5)	27 (23.9)	160 (21.9)
Not applicable	69 (11.2)	48 (42.5)	117 (16.0)
Total	618	113	731
I use urine drug testing for all patients with ADHD without exceptions.
Always	51 (8.6)	9 (8.2)	60 (8.5)
Very frequently	62 (10.5)	4 (3.6)	66 (9.4)
Occasionally	69 (11.6)	4 (3.6)	73 (10.4)
Rarely	87 (14.7)	11 (10.0)	98 (13.9)
Never	231 (39.0)	32 (29.1)	263 (37.4)
Not applicable	93 (15.7)	50 (45.5)	143 (20.3)
Total	593	110	703
I rely on patient self-reports.
Always	79 (13.3)	18 (16.1)	97 (13.8)
Very frequently	220 (37.1)	24 (21.4)	244 (34.6)
Occasionally	107 (18.0)	16 (14.3)	123 (17.4)
Rarely	60 (10.1)	7 (6.3)	67 (9.5)
Never	61 (10.3)	8 (7.1)	69 (9.8)
Not applicable	66 (11.1)	39 (34.8)	105 (14.9)
Total	593	112	705

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Appendix 21.

The Following Questions Pertain to the College Students 17 to 26 Years of Age. Please Select How Well Each of the Following Statements Describes You:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
I remain the primary prescriber for patients with ADHD on medication going to college.
Describes me completely	46 (7.5)	9 (8.0)	55 (7.6)
Describes me well	159 (25.9)	15 (13.3)	174 (23.9)
Describes me fairly well	150 (24.4)	14 (12.4)	164 (22.6)
Describes me somewhat	118 (19.2)	8 (7.1)	126 (17.3)
Does not describe me at all	141 (23.0)	67 (59.3)	208 (28.6)
Total	614	113	727
I always help/advise patients find a doctor in the college location for their ADHD medication needs.
Describes me completely	44 (7.2)	32 (27.8)	76 (10.5)
Describes me well	103 (16.9)	23 (20.0)	126 (17.4)
Describes me fairly well	107 (17.6)	19 (16.5)	126 (17.4)
Describes me somewhat	148 (24.3)	10 (8.7)	158 (21.9)
Does not describe me at all	206 (33.9)	31 (27.0)	237 (32.8)
Total	608	115	723
I always ask patients if they are seeing another doctor for their ADHD medications.
Describes me completely	137 (22.2)	53 (45.3)	190 (25.9)
Describes me well	196 (31.8)	31 (26.5)	227 (31.0)
Describes me fairly well	115 (18.7)	12 (10.3)	127 (17.3)
Describes me somewhat	85 (13.8)	7 (6.0)	92 (12.6)
Does not describe me at all	83 (13.5)	14 (12.0)	97 (13.2)
Total	616	117	733
I always ask patients about their stimulant use.
Describes me completely	149 (24.3)	44 (36.4)	193 (26.3)
Describes me well	226 (36.8)	44 (36.4)	270 (36.7)
Describes me fairly well	123 (20.0)	14 (11.6)	137 (18.6)
Describes me somewhat	63 (10.3)	8 (6.6)	71 (9.7)
Does not describe me at all	53 (8.6)	11 (9.1)	64 (8.7)
Total	614	121	735
I always ask about patient's use of other substances.
Describes me completely	202 (32.6)	58 (48.3)	260 (35.2)
Describes me well	222 (35.9)	37 (30.8)	259 (35.0)
Describes me fairly well	120 (19.4)	14 (11.7)	134 (18.1)
Describes me somewhat	44 (7.1)	6 (5.0)	50 (6.8)
Does not describe me at all	31 (5.0)	5 (4.2)	36 (4.9)
Total	619	120	739
I always discuss the stimulant diversion and misuse with my ADHD patients.
Describes me completely	137 (22.3)	43 (36.1)	180 (24.5)
Describes me well	168 (27.3)	24 (20.2)	192 (26.2)
Describes me fairly well	143 (23.3)	20 (16.8)	163 (22.2)
Describes me somewhat	100 (16.3)	12 (10.1)	112 (15.3)
Does not describe me at all	67 (10.9)	20 (16.8)	87 (11.9)
Total	615	119	734
I always suggest available resources and support services (behavioral therapy, counseling) to my patients with ADHD.
Describes me completely	142 (23.2)	52 (43.3)	194 (26.5)
Describes m well	188 (30.7)	34 (28.3)	222 (30.3)
Describes me fairly well	140 (22.8)	20 (16.7)	160 (21.8)
Describes me somewhat	88 (14.4)	5 (4.2)	93 (12.7)
Does not describe me at all	55 (9.0)	9 (7.5)	64 (8.7)
Total	613	120	733

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Appendix 22.

What Do You Feel Is the Best Way to Educate Patients about ADHD (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Pamphlets and handouts
Not Selected	327 (52.1)	76 (61.3)	403 (53.6)
Selected	301 (47.9)	48 (38.7)	349 (46.4)
Total	628	124	752
Education or counseling session at visits where prescription is written.
Not Selected	107 (17.0)	15 (12.1)	122 (16.2)
Selected	521 (83.0)	109 (87.9)	630 (83.8)
Total	628	124	752
Give the patient links to web resources.
Not Selected	335 (53.3)	64 (51.6)	399 (53.1)
Selected	293 (46.7)	60 (48.4)	353 (46.9)
Total	628	124	752
Mass media such as television and magazines.
Not Selected	588 (93.6)	119 (96.0)	707 (94.0)
Selected	40 (6.4)	5 (4.0)	45 (6.0)
Total	628	124	752
Social media such as Facebook and Twitter.
Not Selected	588 (93.6)	104 (83.9)	692 (92.0)
Selected	40 (6.4)	20 (16.1)	60 (8.0)
Total	628	124	752
Other.
Not Selected	594 (94.6)	116 (93.5)	710 (94.4)
Selected	34 (5.4)	8 (6.5)	42 (5.6)
Total	628	124	752
Do you feel it is your responsibility to educate patients with ADHD?
No	31 (4.9)	12 (9.6)	43 (5.7)
Yes	604 (95.1)	113 (90.4)	717 (94.3)
Total	635	125	760

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Appendix 23.

If Yes to Question 32, What Do You Feel You Are Responsible For (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Educating about legal risks of misusing the medicine.
Not Selected	198 (32.8)	29 (25.7)	227 (31.7)
Selected	406 (67.2)	84 (74.3)	490 (68.3)
Total	604	113	717
Educating about the health and physical risks of misusing the medicine.
Not Selected	47 (7.8)	13 (11.5)	60 (8.4)
Selected	557 (92.2)	100 (88.5)	657 (91.6)
Total	604	113	717
Educating about the mental effects of not using the medicines properly.
Not Selected	162 (26.8)	31 (27.4)	193 (26.9)
Selected	442 (73.2)	82 (72.6)	524 (73.1)
Total	604	113	717
Educating about how misusing medicine can affect social life and relationships such as family, job, friends and significant others.
Not Selected	220 (36.4)	38 (33.6)	258 (36.0)
Selected	384 (63.6)	75 (66.4)	459 (64.0)
Total	604	113	717
None of the above.
Not Selected	591 (97.8)	109 (96.5)	700 (97.6)
Selected	13 (2.2)	4 (3.5)	17 (2.4)
Total	604	113	717
Other.
Not Selected	587 (97.2)	106 (93.8)	693 (96.7)
Selected	17 (2.8)	7 (6.2)	24 (3.3)
Total	604	113	717

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Appendix 24.

If No to Question 32, Who Do You Feel Is Responsible (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Psychologist or other mental health counselor who is doing any counseling in conjunction with the medicine for treatment.
Not Selected	10 (31.3)	3 (25.0)	13 (29.5)
Selected	22 (68.8)	9 (75.0)	31 (70.5)
Total	32	12	44
The other health care provider who prescribed the medication in the first place.
Not Selected	15 (46.9)	4 (33.3)	19 (43.2)
Selected	17 (53.1)	8 (66.7)	25 (56.8)
Total	32	12	44
The patient themselves.
Not Selected	23 (71.9)	8 (66.7)	31 (70.5)
Selected	9 (28.1)	4 (33.3)	13 (29.5)
Total	32	12	44
It is not anyone's responsibility.
Not Selected	30 (93.8)	10 (83.3)	40 (90.9)
Selected	2 (6.3)	2 (16.7)	4 (9.1)
Total	32	12	44
Unsure.
Not Selected	29 (90.6)	12 (100.0)	41 (93.2)
Selected	3 (9.4)	0 (0.0)	3 (6.8)
Total	32	12	44
Other.
Not Selected	29 (90.6)	11 (91.7)	40 (90.9)
Selected	3 (9.4)	1 (8.3)	4 (9.1)
Total	32	12	44

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Appendix 25.
Do You Feel it Is Your Responsibility to Prevent Misuse of ADHD Medications?
AAFP, N (%) ACHA, N (%) Total, N (%)
No 12 (6.8) 0 (0.0) 12 (5.7)
Yes 165 (93.2) 32 (100.0) 197 (94.3)
Total 177 32 209

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Appendix 26.

What Do You Feel You Personally Should Be Doing to Reduce the Misuse of ADHD Medications (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Evaluate each patient with suspected ADHD to confirm diagnosis before prescribing.
Not Selected	104 (16.5)	40 (32.8)	144 (19.2)
Selected	525 (83.5)	82 (67.2)	607 (80.8)
Total	629	122	751
Refer all ADHD patients to mental health professionals for care.
Not Selected	460 (73.1)	76 (62.3)	536 (71.4)
Selected	169 (26.9)	46 (37.7)	215 (28.6)
Total	629	122	751
Educate patients with ADHD about how the stimulants should and should not be used.
Not Selected	145 (23.1)	25 (20.5)	170 (22.6)
Selected	484 (76.9)	97 (79.5)	581 (77.4)
Total	629	122	751
Provide clear instructions regarding sharing and selling medications to patients with ADHD.
Not Selected	205 (32.6)	49 (40.2)	254 (33.8)
Selected	424 (67.4)	73 (59.8)	497 (66.2)
Total	629	122	751
Provide specific instructions on how to dispose of any unneeded medications.
Not Selected	379 (60.3)	69 (56.6)	448 (59.7)
Selected	250 (39.7)	53 (43.4)	303 (40.3)
Total	629	122	751
Strictly monitor patient's prescription medication use with urine drug tests and state registries.
Not Selected	321 (51.0)	87 (71.3)	408 (54.3)
Selected	308 (49.0)	35 (28.7)	343 (45.7)
Total	629	122	751
Educate all patients of college age about misuse and risk of misusing of stimulants.
Not Selected	211 (33.5)	29 (23.8)	240 (32.0)
Selected	418 (66.5)	93 (76.2)	511 (68.0)
Total	629	122	751
Discourage “medication holidays.”
Not Selected	559 (88.9)	100 (82.0)	659 (87.7)
Selected	70 (11.1)	22 (18.0)	92 (12.3)
Total	629	122	751
Other.
Not Selected	602 (95.7)	116 (95.1)	718 (95.6)
Selected	27 (4.3)	6 (4.9)	33 (4.4)
Total	629	122	751

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Appendix 27.

How Often Do You Feel Education about ADHD or ADHD Medication Should Occur?

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Yearly	115 (18.2)	11 (8.9)	126 (16.7)
Quarterly	109 (17.2)	16 (13.0)	125 (16.6)
Every 6 months	154 (24.4)	20 (16.3)	174 (23.0)
Every time a prescription is given	222 (35.1)	66 (53.7)	288 (38.1)
Never	1 (0.2)	0 (0.0)	1 (0.1)
Other	31 (4.9)	10 (8.1)	41 (5.4)
Total	632	123	755

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Appendix 28.
Do You Think it's Important to Educate About the Legal Ramifications of Diversion?
AAFP, N (%) ACHA, N (%) Total, N (%)
No 17 (2.7) 2 (1.6) 19 (2.5)
Yes 508 (79.9) 110 (88.0) 618 (81.2)
Unsure 111 (17.5) 13 (10.4) 124 (16.3)
Total 636 125 761

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Appendix 29.

How Well Do You Feel You Are Equipped to Provide Patient Education about Each of the Following:

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
Nature of ADHD.
Extremely well prepared	57 (9.0)	19 (15.3)	76 (10.0)
Well prepared	256 (40.3)	32 (25.8)	288 (37.9)
Somewhat prepared but can use help	257 (40.5)	58 (46.8)	315 (41.5)
Unprepared and can use substantial help	42 (6.6)	12 (9.7)	54 (7.1)
Not prepared at all	23 (3.6)	3 (2.4)	26 (3.4)
Total	635	124	759
Effects and side-effects of stimulant medications.
Extremely well prepared	79 (12.4)	26 (21.1)	105 (13.9)
Well prepared	312 (49.1)	35 (28.5)	347 (45.8)
Somewhat prepared but can use help	205 (32.3)	53 (43.1)	258 (34.0)
Unprepared and can use substantial help	23 (3.6)	7 (5.7)	30 (4.0)
Not prepared at all	16 (2.5)	2 (1.6)	18 (2.4)
Total	635	123	758
Decisions about pharmacotherapy or behavioral therapy choices.
Extremely well prepared	46 (7.3)	19 (15.7)	65 (8.7)
Well prepared	251 (39.8)	30 (24.8)	281 (37.4)
Somewhat prepared but can use help	260 (41.3)	49 (40.5)	309 (41.1)
Unprepared and can use substantial help	47 (7.5)	15 (12.4)	62 (8.3)
Not prepared at all	26 (4.1)	8 (6.6)	34 (4.5)
Total	630	121	751
General expectation for college life such as stress, academic performance, conduct, life skills and preparation strategies.
Extremely well prepared	71 (11.4)	44 (35.5)	115 (15.4)
Well prepared	274 (43.9)	51 (41.1)	325 (43.4)
Somewhat prepared but can use help	226 (36.2)	27 (21.8)	253 (33.8)
Unprepared and can use substantial help	37 (5.9)	1 (0.8)	38 (5.1)
Not prepared at all	16 (2.6)	1 (0.8)	17 (2.3)
Total	624	124	748
Risky behaviors, drug abuse, medication misuse and prevention strategies.
Extremely well prepared	63 (10.0)	31 (25.0)	94 (12.6)
Well prepared	237 (37.6)	42 (33.9)	279 (37.0)
Somewhat prepared but can use help	283 (44.8)	43 (34.7)	326 (43.2)
Unprepared and can use substantial help	35 (5.5)	6 (4.8)	41 (5.4)
Not prepared at all	13 (2.1)	2 (1.6)	15 (2.0)
Total	631	124	755

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Appendix 30.
Does Media Coverage Have the Potential to Affect Physician Views on Misuse Prevention?
AAFP, N (%) ACHA, N (%) Total, N (%)
No 54 (8.5) 12 (9.5) 66 (8.6)
Yes 422 (66.1) 80 (63.5) 502 (65.7)
Unsure 162 (25.4) 34 (27.0) 196 (25.7)
Total 638 126 764

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Appendix 31.

Please Select from the List What Would Have the Potential to Affect Physician Views on Misuse Prevention (Please Select All That Apply):

	AAFP, N (%)	ACHA, N (%)	Total, N (%)
CME/conferences.
Not Selected	46 (7.3)	5 (4.2)	51 (6.8)
Selected	588 (92.7)	114 (95.8)	702 (93.2)
Total	634	119	753
Drug representative meetings.
Not Selected	496 (78.2)	95 (79.8)	591 (78.5)
Selected	138 (21.8)	24 (20.2)	162 (21.5)
Total	634	119	753
Media (TV, internet).
Not Selected	461 (72.7)	89 (74.8)	550 (73.0)
Selected	173 (27.3)	30 (25.2)	203 (27.0)
Total	634	119	753
Other physicians (peer groups).
Not Selected	255 (40.2)	56 (47.1)	311 (41.3)
Selected	379 (59.8)	63 (52.9)	442 (58.7)
Total	634	119	753
Professional associations.
Not Selected	283 (44.6)	46 (38.7)	329 (43.7)
Selected	351 (55.4)	73 (61.3)	424 (56.3)
Total	634	119	753
Journal articles.
Not Selected	167 (26.3)	31 (26.1)	198 (26.3)
Selected	467 (73.7)	88 (73.9)	555 (73.7)
Total	634	119	753
Other.
Not Selected	606 (95.6)	113 (95.0)	719 (95.5)
Selected	28 (4.4)	6 (5.0)	34 (4.5)
Total	634	119	753