Subtypes of ADHD Related to Substance Use Disorders SUD: Results from the MGH Longitudinal Study of

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Subtypes of ADHD Related to Substance Use
Disorders (SUD) Results from the MGH
Longitudinal Study of Boys with ADHD

• Timothy E. Wilens, MD
• Massachusetts General Hospital
• Harvard Medical School

Funding NIDA RO1 DA1441 DA 11929 (TW)
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Disclosures

• Dr. Wilens has served as a consultant, speaker,
  or has received grant support from the following
• NIH (NIDA, NICMH, NIMH)
• Abbott, Celltech, Glaxo/SKB, Lilly, McNeil,
  Neurosearch, Novartis, Pfizer, Shire
• Some of the products discussed are not FDA
  approved for ADHD or other psychopathology
  others may not be FDA approved in the manner
  discussed (e.g. dosing, patient groups,
  combination therapy)

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ADHD Overview

• ADHD is the most common neurobehavioral disorder
  presenting for treatment in youth
• Prevalence 6-8 youth worldwide 4 of adults
• Associated with impairment in multiple domains
• Majority with comorbid learning disabilities
  psychiatric comorbidity including conduct
  disorder
• Treatment includes educational,
  psychotherapeutic, and psychopharmacological
  interventions

(Goldman, JAMA1998 Wilens et al Ann Rev Med,
2002 Faraone et al., World Psych 2003 Kessler
et al, APA 04)
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Overlap Between ADHDand Substance Use Disorders
(SUD)
Substance Abuse/Dep
ADHD

• Excessive overlap of ADHD in SA
• ADHDcomorbidity is a risk factor for SA

(Wilens et al., Psych Clin N Am 2004)
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Smoking in ADHD Adolescents (Mean 15 years)
(Conduct Disorder accounting for differences)
plt0.003 vs cntrls
Smoking
11
24
(Millberger et al., JAACAP 1997)
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Onset of Substance Abuse in ADHD
Adults(Retrospectively Derived)
ADHD
Control

plt.05 vs control
Probability
Age of Onset
Wilens TE, et al. J Nerv Ment Dis.
1997185(8)475-482.
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Lifetime Rates of SUD in Controlled Longitudinal
Studies of ADHD Adults
Mean age range at follow-up 18-26 years
Total ADHD N845, total Control N1085
with SUD
( from Wilens et al., Psych Clin N Am 2004)
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SUD in Young Adults with ADHD

• Methods
• Male subjects ascertained from an ongoing
  longitudinal family study of ADHD.
• Case matched controls (at baseline)
• Data obtained from year 10
• Diagnosis(es) by KSADS/SCID
• Raters blinded to ascertainment

(Wilens et al., APA 2004)
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SUD in Young Adults with ADHD

• SUD Monitoring
• Subjective measures
• Drug use severity index1
• Self-report measure
• Items including frequency and severity (problem)
• Items relative to initiation and continuation
• Module from DSM on SA
• Semi-structured interview
• Direct report of proband to interviewer
• Indirect report of parent to interviewer
• Best estimate diagnosis
• Objective measures
• Urine by radioimmunoassay (RIA)-hospital analysis
  including osmolality

1. Tarter RE, Hegedus AM. Alcohol Health Res
World. 19911565-73.
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Nicotine Use in Male Probands at 10 year
Follow-up (Age 21 yrs), Any Use
p0.039
Control
ADHD
(Wilens et al., APA 2004)
p0.039 vs. No Use, controlling for SES and
Conduct Disorder
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Nicotine Use in Male Probands at 10 year
Follow-up (Age 21 yrs), Stratified by Frequency
of Use
OR3.2 p0.04
(Wilens et al., APA 2004)
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Nicotine Use in Male Probands at 10 year
Follow-up (Age 21yrs), Stratified by Comorbidity
with Conduct Disorder (CD)
p0.359
p0.141
(Wilens et al., APA 2004)
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Marijuana Use in Male Probands at 10 year
Follow-up, Any Use
p0.04
Controls
ADHD
(Wilens et al., APA 2004)
p0.04 vs. No Use, controlling for age, SES and
Conduct Disorder
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Marijuana Use in Male Probands at 10 year
Follow-up, Stratified by Frequency of Use
OR2.7 p0.114
(Wilens et al., APA 2004)
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Marijuana Use in Male Probands at 10 year
Follow-up, Stratified by Comorbidity with
Conduct Disorder (CD)
(Wilens et al., APA 2004)
p0.012
p0.801
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Reason for First Use of Preferred DrugTo Get
High
OR2.0 p0.1
p0.1 controlling for age, SES and Conduct
Disorder
(Wilens et al., APA 2004)
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Reason for First Use of Preferred DrugTo Change
Mood
OR2.8 p0.058
(Wilens et al., APA 2004)
p0.058 controlling for age, SES and Conduct
Disorder
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Reason for First Use of Preferred DrugTo Sleep
Better
OR5.4 p0.061
p0.061 controlling for age, SES and Conduct
Disorder
(Wilens et al., APA 2004)
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Continued Use of Preferred DrugTo Get High
OR1.7 p0.316
p0.316 controlling for age, SES and Conduct
Disorder
(Wilens et al., APA 2004)
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Continued Use of Preferred DrugTo Change Mood
OR2.4 p0.121
p0.121 controlling for age, SES and Conduct
Disorder
(Wilens et al., APA 2004)
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Continued Use of Preferred DrugTo Sleep Better
OR5.7 p0.03
p0.03 controlling for age, SES and Conduct
Disorder
(Wilens et al., APA 2004)
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Apparent ages of risk for SUD related to ADHD and
ADHD comorbidity (BPD, CD, BPDCD)

• Age of SA onset
• Comorbid ADHD 12-16 years
• Noncomorbid ADHD 17-22 years
• Females earlier onset than males
• ADHD impact starts approximating comorbidity
• Start talking about it in 10-12 year olds
• Cigarette use
• 50 of stable cigarette users with ADHD manifest
  SUD

(Wilens TE. Psych Clin N Am 2004).
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MGH Longitudinal Study of ADHDMedication
Questionnaire

• Query of medication use
• Pilot data
• Seven questions regarding appropriate use of
  prescribed medications
• Self-report on those who were taking meds
• Not psychometrically validated
• Longitudinal study of ADHD (and controls)
• 10 year follow-up data (mean age 19 years)
• Data available on 55 ADHD and 43 controls
• Psychopathology by KSADS (baseline)

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MGH Longitudinal Study of ADHDMedication
Questionnaire
(continued)

• Have you sold the medication prescribed by your
  doctor?
• Have you used more of your medication than you
  were supposed to?
• Have you gotten high on your medication?
• Have you misused your medication?

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MGH Longitudinal Study of ADHD Medication
Questionnaire(continued)

• Have you not taken your medication so that you
  could use drugs or alcohol?
• Have you used alcohol or drugs on the days you
  take your medication?
• Have you had a reaction to drugs or alcohol
  while taking your medication?

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Sold Prescribed Medication
p0.025
11
0
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Misused Medication
p0.006
22
2
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Used More Medication
p0.018
22
5
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Gotten High From Medication
p0.414
9
5
30
Skipped Medication to UseAlcohol or Drugs
p0.027
16
2
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Used Medication with Alcohol or Drugs
p0.6
31
26
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Reaction to Alcohol or Drugs with Medication
p0.125
5
0
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Diverting medication Who is at risk?
14
11
10
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Diversion of Medications and ADHD Comorbidity
100
83
83
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Misuse of Medication Who is at risk?
22
21
14
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Misuse of Medication and ADHD Comorbidity
83
75
59
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Diversion and Misuse of Medications in ADHD

• All cases receiving immediate-release stimulants
• Methylphenidate
• Amphetamine
• No evidence of diversion or misuse of
• Extended-release stimulants (e.g. OROS MPH)
• Nonstimulants (TCA, bupropion, clonidine)

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Limitations

• Relatively small sample size
• Especially for med questionnaire
• Data generalize to males only
• Data from middle class sample
• Data presented today based on self report
• Medication questionnaire not psychometrically
  validated
• Other comorbidities and mediators of SUD not
  examined for these analyses

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Summary ADHDSubstance Abuse

• ADHD is a risk factor for Cigarette Smoking
• ADHD is a risk factor for any and heavy substance
  use
• Adolescent-onset clearly linked to conduct
  disorder (and Bipolar disorder)
• Later onset probably more linked to ADHD
• Evidence of self medication
• Attenuation of mood
• Soporiphic effects of medication
• Evidence of diversion and misuse of immediate
  release stimulant medication in ADHD
• High risk groups (those with ADHDSUDConduct)
• Need to discuss proper storage and use of
  medications

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QUESTIONS?