Attention-Deficit/Hyperactivity Disorder and Substance Use Disorders in Adolescents
By Timothy Wilens, M.D.
January 1, 2006
is director of Substance Abuse Services at Massachusetts
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
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).
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.
This research was supported by
National Institutes of Health grants R01 DA14419 and K24 DA016264 to Dr. Wilens.
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