More physicians and advanced practice clinicians are eating meals funded by the makers of attention-deficit/hyperactivity disorder (ADHD) drugs.

Manufacturers of ADHD medications more than doubled their marketing payments to physicians from $1.8 million in 2021 to $3.6 million in 2023, according to a new study published in JAMA Pediatrics. Payments to advanced practice clinicians tripled from $500,000 in 2021 to $1.6 million in 2023.

“What stood out in our findings was the increasing role of marketing payments directed toward advanced practice clinicians,” said J. Travis Donahoe, PhD, MPH, assistant professor of health policy and management at the University of Pittsburgh School of Public Health in Pittsburgh and the lead author of the study.

A little over 10% of physicians working in adolescent medicine reported receiving a marketing payment, followed by adolescent psychiatry (9.9%), pediatrics (8.2%), psychiatry (5.95%), and family medicine (3%). Overall, physicians received nearly triple the payments of advanced practice clinicians. But payments to nurse practitioners increased by 300%.

While increased prescribing by nurse practitioners is consistent with efforts to expand prescriptive authority, “the magnitude of the shift is striking,” Donahoe said.

Most payments (98.7%) were for food and beverage, while the remaining were directed to travel and lodging, speaker fees, honoraria, consulting fees, and educational programs, Donahoe told Medscape Medical News.

Donahoe and his colleagues calculated the annual total value of payments for physicians and advanced practice clinicians by specialty and drug using data from the US Centers for Medicare & Medicaid. Marketing payments were the highest for serdexmethylphenidate-dexmethylphenidate (Azstarys), which was approved by the FDA in 2021.

Prior research found annual marketing spending by the pharmaceutical industry to physicians for stimulants peaked at $4.8 million in 2016.

“The payments themselves are not inherently concerning as some marketing activities may be primarily educational. The key question for future research is whether any prescribing increases associated with these payments result in meaningful clinical benefit or contribute to overprescribing,” Donahoe said.

Research from the CDC in 2016 found 8.4% of children aged 2-17 years had ADHD, representing 5.4 million children.

Behind Marketing Trends

Several factors may account for the increase in marketing of ADHD drugs to nurse practitioners and other advance practice clinicians, said Andrew Adesman, MD, chief of developmental and behavioral pediatrics at Cohen Children’s Medical Center in New Hyde Park, New York.

In recent years, several states, including Kansas, Utah, and New York, allowed nurse practitioners without a collaborative agreement to prescribe Schedule II controlled substances, which include many ADHD medications.

The growth in prescriptive authority may account for the increase in marketing to these clinicians, Adesman said.

Three new ADHD drugs were also approved by the FDA between 2021 and 2023, including serdexmethylphenidate-dexmethylphenidate (Azstarys) in 2021, and dextroamphetamine (Xelstrym) and methylphenidate (Relexxii) in 2022. Adesman said these likely skew the data as marketing efforts are linked to the release of medications.

Adesman also noted a recent report from IQVIA, a clinical research firm, which showed that nurse practitioners were the fastest-growing group of stimulant prescribers in 2022, surpassing psychiatrists by number of prescriptions written. But he said many of these prescriptions are likely renewals of prescriptions initiated by a psychiatrist.

Many nurse practitioners and other advanced practice clinicians may not have had formal training and experience prescribing ADHD drugs and may have been targeted for educational programs or marketing.

Under or Over Prescribing?

Donahoe and his colleagues said stimulant prescribing increased sharply since the COVID-19 pandemic, citing the IQVIA report. They said this trend might partly be attributable to a rise in telehealth, but that pharmaceutical marketing could be a factor.

According to the IQVIA report, overall dispensing of stimulants increased by 60% from 50.4 million to 80.8 million prescriptions between 2012 and 2022. The biggest increase was between 2022 and 2023, when the number of patients receiving a prescription rose by 18%.

Whether ADHD medications are under or over prescribed remains unclear. A meta-analysis of 18 studies published in 2021 found that 19.1% of school-age children and adolescents with ADHD received a pharmacologic treatment, while 0.9% of those without an ADHD diagnosis received a drug.

Authors of a 2014 review of clinical and scientific literature said overuse is associated with economic forces affecting prescribers, while underuse may be due to overestimating the hazard of drugs, overestimating the value of nonpharmaceutical interventions, or underestimating the severity of the disorder. 

The American Academy of Pediatrics’ 2019 Guideline for the Diagnosis, Evaluation, and Treatment of ADHD recommends two first-line treatments for children with ADHD aged between 4 and 6 years: parent training in behavior management and behavioral interventions in the classroom. For elementary and middle school-aged children, it says clinicians should prescribe FDA-approved medications, along with interventions for parents and in the classroom. The guideline says clinicians should prescribe medications to adolescents with their consent.

The study was funded by a grant from the National Institute on Aging. Donahoe reported receiving personal fees from Greylock McKinnon Associates. Adesman reported having no relevant financial disclosures.

Brenda Sandburg is a freelance journalist who has written about the biopharmaceutical industry and legal issues for The Pink Sheet and The American Lawyer.