Psychiatric Times.
No. 4
CLINICAL
ADHD and Comorbid Substance Use Disorder
The Role of Stimulants in Treating Both Disorders
By Anthony M. Ocana, MD, MSc |
April 7, 2010
Dr Ocana is codirector of the North Shore ADHD Clinic in West Vancouver, British Columbia. Dr Ocana reports that he is a con-sultant or has received honoraria from Lilly, Shire, Janssen, Purdue, Lundbeck, Glaxo-SmithKline, and AstraZeneca.
Use of extended-release psychostimulants to manage ADHD is not contraindicated in patients with a past history of stimulant abuse (eg, cocaine, methamphetamine, MDMA) as long as they are 4 months stimulant-free. Stimulants may improve retention in addiction treatment, and in some cases, may decrease harm from substance use.32,33 However, stimulants have not been particularly effective in decreasing drug use per se; this may be because the prevalence of comorbidities is high in ADHD.34 There is a relatively high rate of treatment dropouts in this population, which suggests that these risk management strategies—while necessary—may not be sufficient.
Pretreating the patient with ADHD and comorbid substance abuse with a mood stabilizer before the addiction of a psychostimulant will increase the safety of this intervention significantly and may result in a number of other benefits, including increased positive outcomes and fewer adverse effects, relapses, and dropouts. Anecdotally, the addition of mood stabilizers appears to help reduce cravings, emotional volatility, and impulsivity.
CASE VIGNETTE
Janice is a 26-year-old with ADHD. She began to use crystal methamphetamine as a teenager and reported that the drug gave her a sense of clarity and calmness that she had never known before. She ended up using “meth” day and night for 6 years.
Before she started to use drugs, she had a history of depression, obsession, and temper tantrums. In school, she was easily distracted and could not complete assignments. Despite her best efforts, she lost interest and dropped out of school at age 16. Janice has a maternal and paternal family history of ADHD, depression, and severe alcohol(Drug information on alcohol)ism.
On presentation, Janice complained of an inability to focus. She said she is easily distracted and has a problem completing tasks. She forgets instructions, loses things, and can’t pay attention, even when she tries. She has not used methamphetamines for 3 years.
Stimulant treatment that was adequate to treat Janice’s ADHD symptoms increased her obsessions and triggered paranoia. Withdrawal of the stimulant and treatment of her obsessions with an SSRI triggered hypomania. Subsequently, withdrawal of the SSRI and treatment with the glutamate-blocker lamotrigine(Drug information on lamotrigine) stabilized her mood and allowed successful reintroduction of the SSRI as well as the stimulant. Within a few months, ADHD symptoms, obsessions, depression, and irritability had completely resolved.
Mood stabilizers can increase GABA (as with divalproate), decrease glutamate (as with lamotrigine), or do both (as with topiramate(Drug information on topiramate)).5 Neurobiologically, increased glutamate mediates stimulation of dopamine(Drug information on dopamine) transmission and decreases GABA- mediated inhibition of dopamine, which are responsible for relapse in cocaine use associated with cocaine cues.15 Thus, the benefits are mediated through the reversal of these risk factors.
In Janice’s case, it required the benefits of counseling, group support, lifestyle modification, and strategic polypharmacy aimed at her specific comorbidities. The combination of stimulants with an SSRI and a mood stabilizer seems to have produced results difficult to obtain with any one of the drugs alone.
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