Patterns and trends in prevalent central nervous system stimulant use in US veterans with traumatic brain injury

Patients with chronic mild traumatic brain injury (TBI) may experience cognitive and behavioral symptoms resembling attention-deficit/hyperactivity disorder (ADHD). Central nervous system (CNS) stimulants, used for ADHD, are not recommended for TBI but are prescribed off-label. We examined patterns and trends of prevalent stimulant use among veterans with TBI.

Of the 966,953 US veterans with TBI (2001-2023), 11,710 were prevalent users of CNS stimulants, defined as prescription fills during six months before first TBI diagnosis in the Veterans Affairs (VA) healthcare system. Patients were categorized into 2001-2014 (major active combat operatoins in Iraq and Afghanistan wars), 2015-2019 (post-combat), and 2020-2023 (COVID-19 pandemic). Prevalence (95% CI) of stimulant use per 10,000 Veterans with TBI and yearly temporal trends were estimated. Estimates during 2015-2019 and 2020-2023 were compared with 2001-2014 using absolute standardized differences (ASD; ≥10% suggesting clinically significant difference).

Prevalent CNS stimulant use (95 % CI) during 2001-2014, 2015-2019, and 2020-2023 were 83 (81-85), 150 (145-155; ASD = 6 %) and 194 (188-200; ASD = 10 %) per 10,000 Veterans, respectively. Respective rates in subgroups with opioid use disorder were 174 (165-182), 351 (333-369; ASD = 11 %), and 457 (434-480; ASD = 16 %), and attention-deficit/hyperactivity disorder were 2054 (1934-2174), 1764 (1681-1847; ASD = 7 %), and 1950 (1871-2029; ASD = 3 %).

Prevalent CNS stimulant use among Veterans with TBI is low, despite higher temporal trends, including in high-risk subgroups. Future studies need to examine patterns and trends of incident CNS stimulant use, as well as their safety and effectiveness.