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ADHD and Addiction: Diagnosis and Management


ADHD and Addiction: Diagnosis and Management Outline ADHD diagnosis and complications of diagnosis ADHD epidemiology and comorbid conditions ADHD and substance ... – PowerPoint PPT presentation

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Title: ADHD and Addiction: Diagnosis and Management

ADHD and Addiction Diagnosis and Management
  1. ADHD diagnosis and complications of diagnosis
  2. ADHD epidemiology and comorbid conditions
  3. ADHD and substance use disorder (SUD)
  4. Association between ADHD and SUDs determining
    causality and functional impact
  5. Potential explanations for the ADHD/SUD
  6. Stimulant treatment and the risk for SUDs
  7. Diversion and misuse of stimulant medications
  8. Treatment recommendations

Making the ADHD diagnosisDSM criteria
Inattention symptoms
  • Six (or more) of the following symptoms of
    inattention have persisted for at least 6 months
  • fails to give close attention to details or makes
    careless mistakes
  • difficulty sustaining attention
  • does not seem to listen when spoken to directly
  • does not follow through on instructions and fails
    to finish schoolwork, chores, or duties in the
  • has difficulty organizing tasks and activities
  • avoids, dislikes, or is reluctant to engage in
    tasks that require sustained mental effort (such
    as schoolwork or homework)
  • loses things necessary for tasks or activities
  • often easily distracted by extraneous stimuli
  • often forgetful in daily activities

Hyperactivity/Impulsivity Symptoms
  • Six (or more) of the following symptoms of
    hyperactivity/impulsivity have persisted for at
    least 6 months
  • Hyperactivity
  • fidgets or squirms in seat
  • leaves seat
  • Often runs about or climbs excessively (in
    adolescents or adults, may be limited to
    subjective feelings of restlessness)
  • has difficulty playing or engaging in leisure
    activities quietly
  • "on the go" or often acts as if "driven by a
  • talks excessively
  • Impulsivity
  • blurts out answers before questions have been
  • has difficulty awaiting turn
  • interrupts or intrudes on others

DSM-IV Diagnosis
  • Symptoms that caused impairment were present
    before age 7 years.
  • Evidence of clinically significant impairment in
    social, academic, or occupational functioning.
  • Impairment present in two or more settings (e.g.,
    at school or work and at home).
  • The symptoms do not occur exclusively during the
    course of a Pervasive Developmental Disorder,
    Schizophrenia, or other Psychotic Disorder and
    are not better accounted for by another mental
    disorder (e.g., Mood Disorder, Anxiety Disorder,
    Dissociative Disorder, or a Personality
  • Subtypes Primarily Inattentive (6),
    Hyperactive/Impulsive (6), or Combined Type (66)

Making the ADHD diagnosis(general points)
  • ADHD is a disorder of both childhood and
  • ADHD is highly comorbid with substance use
  • Follow the general rule of evaluating sxs during
    periods of sobriety
  • Collateral hx can be crucial as the sxs should
    have been present prior to age 7
  • The diagnosis is a CLINICAL one ie. neuropsych
    can be a helpful adjunct but is insufficient
    alone to make the dx.
  • ADHD may be better described as a dimensional
    rather than categorical diagnosis

Making the ADHD diagnosis(clinical reality!)
  • Sxs in adults can present differently1
  • Hyperactive sxs may resolve, or may be adapted
    to with life changes
  • Impulsivity can present functionally (ending
    relationships, quitting jobs, arrests, driving
    violations) and may be better elicited as such
  • Adult ADHD may actually be better dxd with
    either different or perhaps less stringent
  • Adults frequently can not recall sxs prior to age
    7 particularly in chaotic households!
  • Again, collateral data wherever possible,
    including report cards/testing results
  • Concept of late-onset ADHD challenges stringent
    age criteria, as research shows this population
    to be similar to full ADHD2

Making the ADHD diagnosis(clinical reality!)
  • Comorbidities may complicate diagnosis
  • Depression
  • attention/concentration are shared sxs
  • chronic suggests ADHD, guilt/worthlessness,
    suicidality all suggest depression
  • Bipolar Disorder
  • hyperactivity, inattention, talkativeness,
    impulsivity are shared
  • Grandiosity, expansive mood and a cyclical
    pattern vs chronicity suggest Bipolar Disorder
  • Pay attention to family history

Epidemiology of ADHD
  • Attention-Deficit Hyperactivity Disorder (ADHD)
    prevalence is approx. 3-7 in school age
  • 75 of children continue to have sxs into
    adolescence, approximately 50 into adulthood4
  • Adult prevalence is estimated to be 3-55
  • ADHD is over-represented in substance abusing
    populations and SUDs similarly in adults with ADHD

Epidemiology of ADHD (continued)
  • There are also high rates of other Axis I
    disorders among adult ADHD populations (NCS-R)5
  • 38 12-month prevalence for any mood disorder
  • 19 for MDD, 19 for Bipolar Disorder
  • 47 12-month prevalence for any anxiety disorder
  • Conduct disorder is also highly comorbid with
    ADHD reportedly 30-50 in adolescents6

ADHD and SUD comorbidity
  • NCS-R data5
  • Among adults with ADHD, 12-month prevalence for
    any SUD is 15 vs 5 in non-ADHD responders
  • Among those w/SUDs, ADHD prevalence is 11 vs 4
  • In clinical samples, percentages are higher!7
  • 17-45 ADHD adults have h/o EtOH abuse or
  • 9-30 ADHD adults have h/o drug abuse/dependence
  • Opioid dependent pts 5-22 with ADHD8
  • Cocaine dependent pts 10-358
  • EtOH dependent pts 33-718

Potential impact of ADHD on SUDs
  • Given the bidirectional preponderance, early work
    reported associations, but also assumed
  • Early work reported that individuals with
    co-occurring ADHD had
  • Earlier onset of substance use
  • More severe course of SUD
  • Poorer treatment adherence
  • More difficulty achieving treatment goals
  • Examples Carroll Rounsaville (cocaine)9, Wise
    et al. (adolescents seeking residential
  • Criticisms
  • Retrospective studies prone to possible recall
  • Often failed to account for comorbidies ie
    Conduct Disoder!
  • Fail to look at individual drugs, gender and
    dimensional ADHD sxs or subtypes

Rethinking old data, and new research
  1. The role of conduct d/o
  2. ADHD symptom dimensions vs categorical diagnosis
  3. Specific substances of abuse/dependence

Conduct Disorder A complicating factor?
  • Given that Conduct Disorder is so highly comorbid
    with ADHD and also with SUDs, could this account
    for the association?
  • Flory and Lynams 2003 review suggests that ADHD
    alone (controlling for Conduct D/O) is not
    associated with a significant risk for SUDs,
    although ADHD CD may afford higher risk then
    either alone11
  • 2 subsequent prospective studies support this
  • August et al. (2006)12 ADHDCD group at higher
    risk for SUD, but risk disappears when CD
    controlled for
  • Barkley et al. (2004)13 also ADHDCD with
    increased risk, and not ADHD alone, although ADHD
    severity independently linked to drug related
    antisocial activity

Conduct Disorder A complicating
  • To the contrary
  • Even within the body of data reviewed by Flory
    and Lynam11 , multiple studies show that ADHD
    predicts earlier tobacco use and dependence,
    independent of CD
  • More recent studies
  • Molina Pelham (2003)14 prospectively study 142
  • Inattentive sxs predict ealier use of drugs,
    frequency of EtOH/MJ use and heavier tobacco use
    even controlling for CD.
  • CDADHD more use and problems.

Conduct Disorder A complicating
  • More recent studies (cont)
  • Elkins et al. (2007)15 use Minnesota twin data to
    examine dimensional aspects of ADHD/CD (760F,
  • Initiation of use Hyperactive/imp sxs
    significantly predict use of tobacco/EtOH/illicit
    drugs, as does CD, inattentive sxs only EtOH and
    ADHD dx tobacco/illicit drugs only
  • SUDs HI sxs predict tobacco/MJ, inattentive
    predict no SUDs, CD predict tobacco/MJ/EtOH, ADHD
    dx predicts none
  • Hyperactive/impulsive sxs emerge as important
  • Arias et al. (2008) retrospective analysis of
    2047 individuals ascertained in siblings pairs
    from community sample (although only 92 pts dxd
    with ADHD)
  • ADHD associated with earlier age of substance
    use, more SUD dxs, more psych dxs, more suicide
  • ADHD/SUD pts may represent a more severe
    phenotype of addicted patients

What to make of all this?!?
  • Conduct D/O independently and significantly
    predicts risk of SUDs
  • ADHD may independently predict SUDs, in
    particular nicotine use/dependence
  • Investigation of IN/HI sxs subsets is clearly
    important, and recent data suggests
    hyperactivity/impulsivity as significant risks
    for SUDs
  • ADHD in combination with CD likely predicts a
    risk of SUDs/outcomes greater than ADHD or CD

Why the relationship between SUD and ADHD?
  • Self medication?
  • Anecdotal theories pts use nicotine/MJ/cocaine
    to increase focus/attention, EtOH/MJ/opioids to
    calm internal sense of restlessness, or that
    impulsivity predisposes to use
  • Some supporting data Wilens et al. (2007)16 find
    on self-report scales that 36 of ADHD pts cited
    self-medication as a motivation to use vs. 25
    to get high
  • Familial link?
  • Recent work by Biederman et al. (2008)17 suggests
    a variable expressivity model for ADHD and drug
    dependence (shared risk factors), but independent
    transmission for EtOH dependence
  • This work suggests shared risks but does not
    necessarily imply genetic links ie environment
    can not be ruled out

ADHD and Substance Abuse Potential biological
  • Dopamine (DA) pathways
  • ADHD is almost certainly a polygenic disorder
    (multiple different genes interacting with
    environmental stressors)
  • Genes implicated include DA transporter and
    receptor genes, enzymes involved in metabolism,
    although also serotonin receptor/transporter
  • However, DA is particularly interesting given the
    DA dysfxn associated with addictive disorders
  • Specifically, DA dysfunction in prefrontal
    regions, subcortical structures (dorsal/ventral
    striatum) and connecting circuits may provide a
    common pathway between ADHD and addictive

ADHD and Substance Abuse Potential biological
  • Preliminary research
  • Adults with ADHD have been found to have
    decreased DA synthesis/metabolism in prefrontal
    cortex18 in addition to decreased DA release in
    the caudate and decreased DA receptor
    availability (D2/D3)19
  • Decreased DA release in caudate correlates with
    inattentive sxs AND drug liking responses to IV
    methylphenidate (Ritalin)19
  • Decreased DA in these regions (or decreased
    receptor availability) may modulate reinforcing
    effect of substances of abuse
  • Both alcohol and cocaine dependence are
    associated with decreased dopamine receptor
    availability (D2/D3) and decreased DA release in
    the ventral striatum (NAc) and putamen21,22

Relationship between stimulant treatment and SUDs
  • Does stimulant tx decrease, increase or have no
    effect on the risk of developing a SUD?

Relationship between stimulant treatment and SUDs
  • Concern stems from sensitization hypothesis
    that early exposure to stimulants alters DA
    system, increasing reinforcing effects of
  • In some rat models, adolescent animals exposed to
    methylphidate are more likely to self administer
    cocaine as adults22
  • However, even in rat models, data is at times
  • Route of administration is likely important (IM
    vs oral)
  • Length of exposure also likely important, as is
    age of exposure
  • Dose/pharmacokinetics are hard to match up with
  • Thanos et al. (2007) find that 2 mo oral
    treatment in adolescent rats lead to increased
    cocaine self-administration, while 8 mo of
    treatment actually decreased cocaine SA23

Relationship between stimulant treatment and SUDs
  • Studies in humans
  • Through 80s and 90s conflicting data emerged,
    showing increased risk/no risk/decreased risk of
    SUD associated with prior stimulant tx
  • 2003 Wilens et al. perform meta-analysis
    revealing small protective effect of stimulant tx
    on later SUDs24
  • Only 6 studies included
  • Protective effect much greater on adolescent use
    than adult use
  • Why?
  • Adolescents more closely monitored by parents?
  • Adolescents hadnt passed through full risk

Relationship between stimulant treatment and SUDs
  • More recent studies
  • Faraone et al. (2007)25 retrospective data in
    adults with ADHD (n206), separated by exposure
    to stimulant tx
  • No differences in prevalence of
    nicotine/EtOH/drug use/abuse/dep
  • Also no protective effect
  • Biederman et al. (2008)26 10 year f/u data from
    prospective study of boys with ADHD
  • At f/u subjects were in early 20s
  • No evidence of increased SUDs but also no
    protective effect
  • 4 year f/u data actually showed protective
    effect, again suggesting that stimulant tx may
    delay onset of substance use

Relationship between stimulant treatment and SUDs
  • More recent studies
  • Wilens et al. (2008)27 5 year f/u data from
    prospective study of girls with ADHD (mean age
  • Stimulant tx associated with decreased risk of
  • Mannuzza et al (2008)28 f/u data of boys
    ascertained in 1970s, evaluated in late
    adolescence and adulthood (20s)
  • Risk of SUD was associated with age of stimulant
    tx ie kids treated later had a significantly
    higher risk
  • Development of antisocial personality disorder
    largely accounted for the increased risk ie
    kids who were treated were less likely to develop
    ASPD and then SUDs
  • Conclusions At this time there is no convincing
    evidence that stimulant treatment increases the
    risk for SUDs, but also no conclusive evidence of
    a decreased risk.

Concerns about diversion/misuse of stimulants
  • Among middle school and HS students, 23 of those
    prescribed stimulants were asked for their meds,
    4.5 of total sample reported misuse/diversion29
  • Among college students lifetime prevalence of
    stimulant misuse between 6-1630, 31, 32
  • More likely to be white, male, fraternities/sorori
    ties and lower grades
  • In Biedermans 10-year prospective study of boys
    with ADHD, 22 admitted misusing their
    medications, 11 diverting33
  • All of misuse attributed to conduct disorders or
    substance use disorders and occurred with
    immediate release meds
  • Little clinical data available about risks in pts
    with SUDs and ADHD

Treatment Recommendations
  • Careful thoughtful diagnosis with collateral data
  • Include loved ones/family members in tx plans,
    w/close f/u/monitoring
  • Unfortunately, relatively few DB, placebo
    controlled trials available for adults with
    ADHD/SUDs, and data is underwhelming.34
  • Avoid stimulant rx if pt actively using, consider
    non-stimulant tx in those in recent recovery
    (Wellbutrin, Strattera)
  • Extended release preparations are preferred among
    stimulants (Concerta, Adderall XR, Vyvanse)
  • Clinical data and imaging/binding studies suggest
    rate of administration correlates with
    likability of stimulants
  • ER vs IR have slower onset curves and are less
  • ER formulations much harder to crush and then

  • ADHD persists into adulthood and is associated
    with significant (-) functional impairments
  • ADHD can be difficult to diagnose in adults but
    careful dx is essential, with caveat that sxs
    often present differently
  • ADHD and substance use disorders are each
    overrepresented in samples of the other
  • In the ADHD/SUD samples, pts have more severe
    SUDs which are much harder to treat
  • The ADHD/SUD relationship is complex conduct
    disorder clearly accounts for some of the
    overlap, but those with ADHDCD may represent a
    more severe phenotype of ADHD/SUD pts

  • The reasons for the ADHD/SUD are not clear
    although self-medication and/or common biological
    pathways are leading hypotheses
  • At this time there is no convincing evidence that
    stimulant treatment increases the risk for SUDs,
    but also no conclusive evidence of a decreased
  • Stimulant medications are abused/diverted at a
    fairly high rate, and misuse among those
    prescribed may be as high as 25. However, 75 do
    NOT abuse their meds!
  • Treatment recommendations focus on careful
    diagnosis, close follow up and careful choice of
    medication to minimize risks.
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