Associations between prescription stimulant use as prescribed, nonmedical use, and illicit stimulant use among adults evaluated for substance use treatment, 2017-2021

Background: Limited data exist on risk factors for illicit stimulant use, including associations between prescription stimulant use/nonmedical use (NMU) and illicit stimulant use.Methods: We used 2017-2021 data from adults assessed for substance use disorder (SUD) treatment using the National Addictions Vigilance Intervention and Prevention Program Addiction Severity Index-Multimedia Version (R) tool. Multivariable Poisson regression models analyzed associations between past 30-day prescription stimulant use as prescribed or NMU and past 30-day illicit stimulant use. Separate models examined past 30-day illicit stimulant, methamphetamine, and cocaine use. We explored problem severity across seven biopsychosocial domains (e.g., drug, psychiatric, family) by past 30-day prescription stimulant use/NMU and illicit stimulant use.Results: Among 218,981 assessments, 1.8% reported prescription stimulant NMU; 1.6% reported use as pre-scribed. Past 30-day prescription stimulant NMU (vs. no use) was associated with past 30-day illicit stimulant use (adjusted prevalence ratio [aPR] [95% CI]: 2.67 [2.59, 2.75]), methamphetamine use (aPR: 2.81 [2.71, 2.92]), and cocaine use (aPR: 3.53 [3.33, 3.74]). Prescription stimulant use as prescribed (vs. no use) was associated with lower prevalence of past 30-day illicit stimulant use. Assessments reporting prescription stimulant NMU (vs. no use, or use as prescribed) appeared more likely to have moderate-to-extreme problem scores across biopsychosocial domains, indicating greater need for treatment or assistance. Assessments reporting prescription stimulant use as prescribed or NMU frequently reported opioids, alcohol, or other substances as their primary substance problem.Conclusions: Adults using illicit stimulants/nonmedically using prescription stimulants may benefit from care addressing polysubstance use, mental health, social, and recovery support services.