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Attention-Deficit/Hyperactivity Disorder and Substance Use Disorders in Adolescents: Page 2 of 2

Attention-Deficit/Hyperactivity Disorder and Substance Use Disorders in Adolescents: Page 2 of 2

Diagnosis and Treatment Guidelines

Evaluation and treatment of comorbid ADHD and SUDs should be part of a plan in which consideration is given to all aspects of the teen-ager's life. Any intervention in this group should follow a careful evaluation of the adolescent including psychiatric, addiction, social, cognitive, educational and family evaluations. A thorough history of substance use should be obtained that includes past and current usage and treatments. Although no specific guidelines exist for evaluating the patient with an active SUD, in my experience at least one month of abstinence is useful in accurately and reliably assessing for ADHD symptoms. Semi-structured psychiatric interviews or validated rating scales of ADHD are invaluable aids for the systematic diagnostic assessments of this group.

The treatment needs of individuals with SUDs and ADHD need to be considered simultaneously; however, the SUD needs to be addressed initially (Riggs, 1998). If the SUD is active, immediate attention needs to be paid to stabilization of the addiction(s). Depending on the severity and duration of the SUD, adolescents may require inpatient treatment. Self-help groups offer a helpful treatment modality for many with SUDs. In tandem with addiction treatment, adolescents with co-occurring SUDs and ADHD require intervention(s) for the ADHD as well as other co-occurring psychiatric disorders.

Medication serves an important role in reducing the symptoms of ADHD and other concurrent psychiatric disorders. Effective agents for adolescents with ADHD include the stimulants, noradrenergic agents and catecholaminergic antidepressants (Wilens et al., 2002). Findings from a meta-analysis of 10 studies of open and controlled trials suggest that medications used in adolescents and adults with ADHD plus SUDs have only a meager effect on the ADHD, but have little effect on substance use or cravings (Riggs et al., 2004; Schubiner et al., 2002; Wilens et al., 2005). Of interest, no evidence exists that treating ADHD pharmacologically through an active SUD exacerbates the SUD. This is consistent with the work of Grabowski et al. (2004), who used stimulants to block cocaine and amphetamine abuse. Also consistent with these findings, earlier work by Volkow et al. (1998) demonstrated significant differences between binding at the dopamine transporter between methylphenidate and cocaine, suggesting a much smaller abuse risk for methylphenidate in contrast to cocaine.

In ADHD adults with SUDs, the nonstimulant agents (atomoxetine [Strattera]), antidepressants (bupropion [Wellbutrin]), and extended-release or longer-acting stimulants with lower abuse liability and diversion potential are preferable (Riggs, 1998). While of particular interest because of the drug's broad spectrum of activity in ADHD and lack of abuse liability (Heil et al., 2002), results from ongoing trials of atomoxetine in SUDs are not yet available. In individuals with SUDs and ADHD, frequent monitoring of pharmacotherapy should be undertaken--including evaluation of compliance with treatment, use of questionnaires (Gignac et al., 2005), random toxicology screens as indicated, and coordination of care with addiction counselors and other caregivers.

Issues of diversion. Surprisingly, limited information is available on the inappropriate use of stimulants in terms of the magnitude of the problem and the characteristics of misuse in individuals for whom they are prescribed. Musser et al. (1998) surveyed 161 children with ADHD responding to methylphenidate in order to assess diversion. The authors reported that 16% of children had been approached to sell or give away their prescribed medication; however, the actual rates of diversion were not reported. Marsh et al. (2000), using a retrospective review of the medical charts of 240 adolescents with ADHD, reported that 12% had misused their methylphenidate, although the characteristics of those youth were not reported. Poulin (2001) surveyed 13,549 students in grades 7 through 12 and found that 8.5% had used nonprescribed stimulants in the year prior to the survey. Of those students who were receiving prescribed stimulants, 14.7% had given their medications and 7.3% had sold their medication to other students. Similar to other studies, those to whom the stimulants were diverted misused the stimulants in context with other substances of abuse.

Similarly, we recently found that 11% of adolescents and young adults with ADHD diverted (sold) and 22% had misused their stimulants (e.g., escalated dose, used with other substances, became euphoric) (Wilens et al., in press-a). We also found that ADHD individuals with conduct disorder or SUDs accounted for the misuse and diversion and that there appeared to be more misuse and diversion of immediate-release compared to extended-release stimulants (Wilens et al., in press-a).

Summary

There is a strong literature supporting a relationship between ADHD and SUDs. Both family/genetic and self-medication influences may be operational in the development and continuation of SUDs in ADHD. Adolescents with ADHD and SUDs require multimodal interventions incorporating addiction and mental health treatment. Pharmacotherapy in individuals with ADHD and SUDs needs to take into consideration timing, misuse and diversion liability, potential drug interactions, and compliance concerns.

While the existing literature has provided important information on the relationship of ADHD and SUDs, it also points to a number of areas in need of further study. The mechanism by which untreated ADHD leads to SUDs, as well as the risk reduction of ADHD treatment on cigarette smoking and SUDs, needs to be better understood. Given the prevalence and major morbidity and impairment caused by SUDs and ADHD, prevention and treatment strategies for these adolescents need to be further developed and evaluated.

Acknowledgements

This research was supported by National Institutes of Health grants R01 DA14419 and K24 DA016264 to Dr. Wilens.

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References

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