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ADHD and Substance Use: Current Evidence and Treatment Considerations

ADHD and Substance Use: Current Evidence and Treatment Considerations

FIGURE
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRISTSIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

The presence of comorbid disorders is often the rule rather than the exception in individuals with ADHD. Of particular concern is problematic substance use; alcohol, cannabis, cocaine, and nicotine represent some of the most commonly abused substances. Elevated substance use significantly complicates a patient’s symptom presentation, making the accurate diagnosis, prognosis, and treatment of ADHD challenging even for the most skilled practitioners.

The link between ADHD and substance use disorders

Children with ADHD are at increased risk for alcohol use disorder as they get older, and they are more than twice as likely to develop nicotine dependence and marijuana or cocaine abuse or dependence (Figure). Approximately 15% of adolescents and young adults with ADHD have a comorbid substance use disorder (SUD), while 11% of individuals with an SUD also meet the criteria for ADHD.1 Findings indicate that the overlap between these disorders is not random, and several explanations have been posited for their link.

ADHD and SUD have been described as disorders of disinhibition, which suggests an underlying vulnerability that is shared by both disorders. Alternatively, features of ADHD, such as impulsivity, may increase the risk of initiating substance use. In fact, children with ADHD are significantly more likely to try a range of substances during their lifetime compared with their non- ADHD counterparts (see Figure).

The mechanisms underlying the increased risk of SUD among those with a history or current diagnosis of ADHD are not well understood. Persistent ADHD, which might be a marker of increased vulnerability and/or of reduced access or responsiveness to intervention, is associated with much higher rates of SUD.2 The high co-occurrence between ADHD and SUD merits special consideration.

Issues in identifying suspected SUD

Assessment for ADHD requires the ability to distinguish between ADHD and other disorders that demonstrate significant symptomatic overlap. Among individuals who present with active substance abuse, it is critical to distinguish between a valid ADHD diagnosis and substance-induced impairments that can negatively affect attention, concentration, and impulsivity. Many psychoactive substances have acute effects that can mimic the symptoms of ADHD, such as chronic marijuana use, which has been associated with deficits in problem-solving, organization, and sustained attention that may persist even after 3 weeks of abstinence. Because of this, practitioners might want to prioritize the treatment of substance use and then re-evaluate patients for ADHD after a period of prolonged abstinence.

Unfortunately, this approach is sometimes not feasible, particularly for patients who present with significant and untreated ADHD symptoms that may impair the ability to engage in and benefit from SUD treatment. Thus, a comprehensive evaluation of ADHD symptoms during prior periods of abstinence may be the next best approach for assessing co-occurring SUD and ADHD, with a focus on whether the ADHD symptoms preceded the onset of substance use. While this is a reasonable recommendation, this approach is not without challenges, as it requires patients to recall the onset and severity of their initial symptoms. This may be especially challenging for patients with ADHD and substance abuse because both are associated with neurocognitive deficits.

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