Attention-Deficit/Hyperactivity Disorder and Substance Use Disorders in Adolescents

By Timothy Wilens, M.D.
| January 1, 2006

Dr. Wilens is director of Substance Abuse Services at Massachusetts General Hospital's Pediatric Psychopharmacology Clinic and associate professor of psychiatry at Harvard Medical School.

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(Drug information on dopamine) transporter between methylphenidate(Drug information on 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(Drug information on 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.

Pages: 1 2

References
1. Anderson JC, Williams S, McGee R, Silva PA (1987), DSM-III disorders in preadolescent children. Prevalence in a large sample from the general population. Arch Gen Psychiatry 44(1):69-76.
2. Biederman J, Monuteaux M, Mick E et al. (in press-a), Young adult outcome of attention deficit hyperactivity disorder: a controlled 10 year prospective follow-up study. Psychol Med.
3. Biederman J, Monuteaux M, Mick E et al. (in press-b), Is cigarette smoking a gateway drug to subsequent alcohol and illicit drug use disorders? A controlled study of youths with and without ADHD. Biol Psychiatry.
4. Biederman J, Wilens T, Mick E et al. (1997), Is ADHD a risk for psychoactive substance use disorder? Findings from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 36(1):21-29.
5. Carroll KM, Rounsaville BJ (1993), History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers. Compr Psychiatry 34(2):75-82.
6. DeMilio L (1989), Psychiatric syndromes in adolescent substance abusers. Am J Psychiatry 146(9):1212-1214.
7. Drug Enforcement Administration (1995), Methylphenidate Review Document. Washington, D.C.: Office of Diversion Control, Drug and Chemical Evaluation Section.
8. Faraone SV, Wilens T (2003), Does stimulant treatment lead to substance use disorders? J Clin Psychiatry 64(suppl 11):9-13.
.9 Gignac M, Wilens TE, Biederman J et al. (2005), Assessing cannabis use in adolescents and young adults: what do urine screen and parental report tell you? J Child Adolesc Psychopharmacol 15(5):742-750.
10. Grabowski J, Shearer J, Merrill J, Negus SS (2004), Agonist-like, replacement pharmacotherapy for stimulant abuse and dependence. Addict Behav 29(7):1439-1464.
11. Heil SH, Holmes HW, Bickel WK et al. (2002), Comparison of the subjective, physiological, and psychomotor effects of atomoxetine and methylphenidate in light drug users. Drug Alcohol Depend 67(2):149-156.
12. Katusic SK, Barbaresi WJ, Colligan RC et al. (2005), Psychostimulant treatment and risk for substance abuse among young adults with a history of attention-deficit/hyperactivity disorder: a population based, birth cohort study. J Child Adolesc Psychopharmacol 15(5):764-776.
13. Kessler R (in press), A recent replication of the National Comorbidity Study estimating the prevalence of adult ADHD among persons 18-44 in the US. Psychol Med.
14. Kessler RC (2004), The epidemiology of dual diagnosis. Biol Psychiatry 56(10):730-737.
15. Levin FR, Evans SM (2001), Diagnostic and treatment issues in comorbid substance abuse and adult attention-deficit hyperactivity disorder. Psychiatric Annals 31(5):303-312.
16. Mannuzza S, Klein RG, Bessler A et al. (1993), Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 50(7):565-576.
17. Marsh LD, Kay JD, Payne TP (2000), Methylphenidate misuse in substance abusing adolescents. Journal of Child and Adolescent Substance Abuse 9(3):1-14.
18. Milberger S, Biederman J, Faraone SV et al. (1997a), ADHD is associated with early initiation of cigarette smoking in children and adolescents. J Am Acad Child Adolesc Psychiatry 36(1):37-44.
19. Milberger S, Biederman J, Faraone SV et al. (1997b), Associations between ADHD and psychoactive substance use disorders. Findings from a longitudinal study of high-risk siblings of ADHD children. Am J Addict 6(4):318-329.
20. Milin R, Halikas JA, Meller JE, Morse C (1991), Psychopathology among substance abusing juvenile offenders. J Am Acad Child Adolesc Psychiatry 30(4):569-574.
21. Molina BS, Pelham WE (2003), Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol 112(3):497-507.
22. Monuteaux MC (2004), A randomized, double-blind, placebo-controlled clinical trial of bupropion for the prevention of smoking in youth with attention-deficit/hyperactivity disorder. Presented at the National Cancer Institute's Tobacco Investigators' Meeting: Synthesizing Research for the Public's Health. San Diego; June 2-4.
23. Musser CJ, Ahmann PA, Theye FW et al. (1998), Stimulant use and potential for abuse in Wisconsin as reported by school administrators and longitudinally followed children. J Dev Behav Pediatr 19(3):187-192.
24. Poulin C (2001), Medical and nonmedical stimulant use among adolescents: from sanctioned to unsanctioned use. CMAJ 165(8):1039-1044 [see comment].
25. Riggs PD (1998), Clinical approach to treatment of ADHD in adolescents with substance use disorders and conduct disorder. J Am Acad Child Adolesc Psychiatry 37(3):331-332.
26. Riggs PD, Hall SK, Mikulich-Gilbertson SK et al. (2004), A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry 43(4):420-429.
27. Schubiner H, Saules KK, Arfken CL et al. (2002), Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. Exp Clin Psychopharmacol 10(3):286-294.
28. Trauth JA, Seidler FJ, Slotkin TA (2000), Persistent and delayed behavioral changes after nicotine treatment in adolescent rats. Brain Res 880(1-2):167-172.
29. Vitiello B (2001), Long-term effects of stimulant medications on the brain: possible relevance to the treatment of attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 11(1):25-34.
30. Volkow ND, Wang GJ, Fowler JS et al. (1998), Dopamine transporter occupancies in the human brain induced by therapeutic doses of oral methylphenidate. Am J Psychiatry 155(10):1325-1331.
31. Weiss G (1992), Child and Adolescent Psychiatric Clinics of North America: Attention-Deficit/Hyperactivity Disorder. Philadelphia: W.B. Saunders Company.
32. Wilens TE, Biederman J, Spencer TJ (2002), Attention deficit/hyperactivity disorder across the lifespan. Annu Rev Med 53:113-131.
33. Wilens TE, Faraone SV, Biederman J, Gunawardene S (2003), Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 111(1):179-185.
34. Wilens TE, Gignac M, Swezey A et al. (in press-a), Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. J Am Acad Child Adolesc Psychiatry.
35. Wilens TE, Monuteaux MC, Snyder LE, Moore H (2005), The clinical dilemma of using medications in substance abusing adolescents and adults with ADHD: what does the literature tell us? J Child Adolesc Psychopharmacol 15(5):787-798.
36. Wilens TE, Verlinden MH, Adler LA et al. (in press-b), ABT-089, a neuronal nicotinic receptor modulator, for the treatment of ADHD in adults: results of a pilot study. Biol Psychiatry.

FROM PHYSICIANS PRACTICE

Five Steps to Improving Patient Access
Judy Capko, May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.

Growing HIPAA Threat – Ignore Windows XP at Your Own Peril
Marion K. Jenkins, May 21, 2013
Chances are good that you have some major ticking software time bombs lurking in your medical practice's computer environment, namely Windows XP and Server 2003.

Finding Physician Work-Life Balance in the Small Moments
Jennifer Frank, MD, May 21, 2013
At my practice and at home, things are always busy. There's laundry or homework, or a patient with needs.

Three Areas to Reduce Costs at Your Medical Practice
Greg Mertz, May 19, 2013
By taking a hard look at reducing costs for staffing, overhead, and technology at your medical practice, you may see increased physician compensation.

Dos and Don’ts for Starting a Physician Blog
Michael Woo-Ming, MD, May 18, 2013
Starting a physician blog can provide your medical practice with marketing benefits, but it's important to do it right.

Attention-Deficit/Hyperactivity Disorder and Substance Use Disorders in Adolescents

Join the Conversation