Some adults who take prescription drugs for attention deficit/hyperactivity disorder are required to have their urine tested for drugs several times a year. Others are never tested.

Such tests are designed to check whether ADHD patients are taking their pills safely, such as Adderall, and not selling them, taking too many, or using other drugs.

Several doctors told KHN that opinions differ and there are no national standards for the role of urine tests in monitoring adults taking ADHD medication. Therefore, patients face radically different requirements, depending on the policies of their clinics and health insurers.

“There really isn’t a lot of literature to guide you on how to do this,” said Dr. Margaret Chaplin, a Connecticut psychiatrist who treats patients with ADHD, mental illness or substance use disorders.

Chaplin first noticed the lack of proof standards about eight years ago, when she and her colleagues proposed paths to prevent stimulant abuse in adult patients with ADHD.

His team recommended urine testing only if patients display «red flag behavior» such as appearing intoxicated, repeatedly reporting lost prescriptions, or frequently changing doctors. Some doctors and clinics make testing decisions on a patient-by-patient basis based on warning signs or patient history. Others apply universal policies, which may be aimed at preventing discrimination. Some insurance companies and state Medicaid systems they also have testing requirements.

ADHD stimulants, opioid pain relievers, and some other drugs are classified as controlled substances, which are strictly regulated because they can be addictive or misused.

ADHD patients who undergo frequent drug tests say that testing can be time consuming and expensive. Some feel stigmatized.

AC Shilton was relieved when she was diagnosed with ADHD at age 30. The freelance farmer and journalist from rural Tennessee said her diagnosis explained why she felt so disorganized and forgetful, and as if her brain was a motor running all day. Shilton said her medication slows down that motor.

The 38-year-old Jamestown resident said her first doctor ordered urine tests once a year. That doctor eventually shut down her practice, and Shilton said her next doctor had her tested at almost every visit.

“You’re going to get the standard of care, which is this medication, and they treat you like you’re a bad person again; there’s some shame associated with that,» Shilton said.

AC Shilton poses with "Chicki Minaj" on his farm in Tennessee.
AC Shilton poses with «Chicki Minaj» on her farm in Tennessee.AC Shilton

She was also upset after learning that office employees were wrong when they told her urine testing was required by law, something other ADHD patients who posted on social media forums said had happened to them as well.

Shilton said few doctors treat adult ADHD patients in his rural community. She now drives over an hour to a different clinic, which doesn’t require as many drug tests.

Travis Gordon, 47, of Charlotte, North Carolina, has been going to the same ADHD clinic for more than 10 years. Gordon said that he did not take drug tests in the early years. Then, for several years, he had to give a urine sample every three months. For much of the covid-19 pandemic, he was not tested. Now, he is examined every six months.

“We shouldn’t have to feel like street criminals to get the drugs we need for our daily success,” Gordon said.

Gordon said it would make sense for doctors to order tests more frequently as they meet new patients. But he said he doesn’t understand why such trials should continue for people like him, established patients who are taking their medications correctly.

Traci Camper, 50, of northeast Tennessee, said she has «never tried a cigarette,» let alone used illicit drugs, but her doctor has ordered urine tests every three months for more than 10 years. Camper said the process can be inconvenient, but she’s ultimately okay with the tests, especially since she lives in an area with high rates of drug abuse.

The clinics Shilton, Gordon and Camper went to did not respond to KHN’s requests for interviews about their testing policies.

Adults are diagnosed with ADHD if they have multiple and frequent symptoms so severe that they interfere with work, relationships, or other aspects of life. Treatments include therapy and medications, most often stimulants.

ADHD patients have been affected by the opioid crisis response, leading to increased scrutiny of all controlled medications. Some have reported problems filling their prescriptions because drug companies limit sales to certain pharmacies. Some patients, especially rural ones, could face obstacles if the federal government return to pre-pandemic rules that require at least one face-to-face appointment to receive controlled medications via telehealth.

Chaplin said that clinicians treating ADHD may feel the need to be more vigilant with drug tests because of this increased scrutiny or the risk of misuse.

An estimated 3.7 million Americans ages 12 and older abused prescription stimulants in 2021, and 1.5 million suffered from prescription stimulant use disorder, according to the National Survey on Drug Use and Health. Americans are more likely to abuse or become addicted to prescription opioids, sedatives and tranquilizers, the agency said.

Adults with ADHD are more like have a substance use disorder than those without the condition, according to the Substance Abuse and Mental Health Services Administration.

Although there are no formal standards, several health care organizations and professionals have made recommendations to prevent and detect stimulant misuse for ADHD in adults. Suggestions include requiring patients to sign prescription agreement contracts and checking databases that show all the controlled medicines that each patient buys.

Chaplin said there is little research on the effectiveness of any method to prevent drug misuse.

A recent survey found that 42% of family physicians and 21% of university health professionals treating adult ADHD require their patients to undergo random urine drug screening.

Gordon, Camper and some ADHD patients on social media forums said their drug tests were done at predictable intervals, rather than randomly.

Dr. Sidarth Wakhlu, a psychiatrist who specializes in treating substance use disorders at the University of Texas Southwestern Medical Center in Dallas, said some of his patients also have ADHD. He suggests that most ADHD patients undergo drug testing once or twice a year. For “someone who has no history of addiction, no red flags, every three months is overkill,” he said.

The cost of drug testing is as variable as the frequency.

For example, Dr. Michael Fingerhood at Johns Hopkins University uses urine tests that cost as little as $60 before insurance. Fingerhood makes trial decisions on a case-by-case basis for patients taking controlled substances to treat ADHD, pain, or opioid addiction.

Gordon used to pay $110 for each of his tests when he had insurance that his doctor didn’t accept. Shilton’s insurance was billed $545 for one test. Shilton said he complained to a nurse who told him that, in the future, he could use a less expensive test.

Shilton said she responded, «Well, why aren’t we doing that to begin with? Why are we doing this extremely fancy drug test?

Wakhlu said the more expensive urine tests can identify specific types and amounts of drugs. Such tests are generally used to confirm the results of less expensive initial tests, according to the Centers for Disease Control and Prevention.

Wakhlu said that when test results show a patient might be abusing stimulants, doctors should engage in a non-accusatory conversation to discuss the results and, if necessary, offer help. She also said it’s important to emphasize safety, such as how it can be dangerous to take too much ADHD medication or combine it with other stimulants, such as methamphetamine.

KHN (Kaiser Health News) is a national newsroom that produces detailed journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the top three operating programs in KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.

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