The Complex Relationship Between ADHD & Substance Abuse

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Dr. Alan Zametkin of the Chesapeake ADHD Center (http://www.chesapeakeadd.com/) presented "The Complex Relationship Between ADHD & Substance Abuse", for the Kolmac School on May 15, 2015 in the Kolmac Clinic - Silver Spring office. It was rated one of the best Kolmac School presentations.

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The Complex Relationship Between ADHD & Substance Abuse

  1. 1. ADHD and Substance Abuse Alan Zametkin MD* Kristen Moulton Kathleen Nadeau PhD* *Chesapeake ADHD Center of MD
  2. 2. The Complicated Relationship between ADHD and SUD
  3. 3. Prevalence of ADHD in SUD • 23% * • Which Substances? • What diagnostic instrument? • *Van Emmerick-van OortmerssenK, van de Glind G, van den Brink W, et al Prevalence of attention deficit disorder in substance abuse disorder patients: a meta analysis and meta regression analysis. Drug Alcohol Depend 2012, 122: 11—9
  4. 4. 1) What causes ADHD? 2) What sort of diagnostic mistakes should we be careful to avoid? 3) What sort of questions are helpful to establish a diagnosis of adult ADHD? (assuming parental information is not available or not reliable)
  5. 5. 4) How to use stimulants 5) What to do with patients who cannot take stimulants? 6) Can drugs of abuse cause something similar to ADHD? 7) Can they treat ADHD?
  6. 6. 8) How to deal with the combination of ADHD and anxiety? 9) How to treat ADHD without medications? What are the non-pharmacological interventions that actually have an impact KIDS VS ADULTS 10) Which books to read? (considering that most people treat adults and some late adolescents) for the professional? for patients? What about autobiographies of people with ADHD?
  7. 7. Attention-Deficit / Hyperactivity Disorder • Neurodevelopmental disorder that affects both children and adults • Persistent pattern of inattention and/or hyperactivity-impulsivity that impairs daily functioning Inattention Hyperactivity Impulsivity -Difficulty following instructions and completing tasks -Easily distracted -Forgetfulness -Organizational problems -Difficulty remaining still -Fidgets or bounces when seated -Always seems to be moving -Excessive talking -Difficulty awaiting turn in group situations -Interrupts others -Blurts out answers before questions are completed
  8. 8. Subsyndromal ADHD • According to the DSM-5, children diagnosed with ADHD display at least 6 IA or HI symptoms of disorder, and adults display 5 or more symptoms • Some individuals display fewer symptoms than required for diagnosis, yet show comparable impairment in neuropsychological function • Subclinical symptoms, particularly inattention, may still correlate with executive dysfunction Lin, Chen, & Gau, 2014
  9. 9. Potential Confound: Fetal Alcohol Syndrome • Children with FAS present with similar symptoms to ADHD and are often misdiagnosed • Individuals with FAS show slower development and function at a younger mental age • However, maternal alcohol use during pregnancy is also associated with increased risk of ADHD • Some children suffer from both FAS and ADHD Nauert, Raldiris, Bowers, & Towsey, 2014
  10. 10. Causes of ADHD • No single causal risk factor, but appears to be a combination of genetics and environment • Family and twin studies consistently show higher heritability in those with shared genes ▫ Heritability estimate: ~79% • Often presents with other neurodevelopmental and psychiatric problems • Environmental risks: ▫ Maternal smoking, alcohol, or substance abuse ▫ Family adversity and low income ▫ Nutritional deficiencies, low birth weight and prematurity Thapar, Cooper, Jefferies, & Stergiakouli, 2012
  11. 11. Diagnosing Adults without Prior Diagnosis • Skepticism, Skepticism, and more Skepticism • Mistake #1: Assume previous dx is correct • Mistake #2: Disregard DSM 5 rules “not better accounted for another Dx.” (page 60, DSM-5) • Structured Interview or Rating Scales: ▫ WURS*, Murphy Depaul and Barkley ▫ Wender Utah Rating Scale : see References
  12. 12. DEPRESSION •Sadness •Fatigue •Sleep •Suicidal Ideation ANXIETY DISORDER •Excessive worry •Fears •Avoidance •Separation/Social Symptom Overlap •Poor concentration •Restlessness •Distractibility ADHD •Fidgeting •Impulsive •Organizational problems
  13. 13. Adult Recall of Childhood Sx • Findings are INCONSISTENT: • Barkley et al: only 47 % of adults could recall that a childhood diagnosis existed. • Only 20 % concordance between parents and adults diagnosed as children with ADHD • Manuzza et al: good recall in adulthood (but this was a clinically referred sample) • HOWEVER HIGH RATES OF FALSE POSITIVES IN CONTROLS
  14. 14. Assessment of Adults 1. Developmental Hx 2 Clinical Interview R/O all DSM- 5 disorders 3 Outside sources: spouse, parents 4 Previous reports (report cards best) 5 Teen school ratings parent ratings 6 Neuropsych Reports 7 Outside sources
  15. 15. Effects of Chronic Marijuana Use • Greater attention deficits • Reduced verbal or overall IQ • Executive dysfunction • Slower processing speeds • Poor emotional control, increased impulsivity **particularly severe cognitive consequences for early-onset marijuana use (before 16 years old)
  16. 16. Effects of other drugs… • Chronic opiate users show impairments in executive function and memory ▫ Also show brain structure abnormalities: non-specific ventricular and cortical volume losses • Cocaine and other psychostimulant users show impaired working memory, in addition to attentional deficits, impaired executive function and slower response speeds ▫ More specific structural abnormalities, including losses in the prefrontal and medial temporal lobes • These drug effects can lead to what appears to be symptoms of ADHD…
  17. 17. What % SUD need Tx for ADHD 20 %** **2 Kooij SJ, Bejerot S, Blackwell A et al European consensus statement on diagnosis and treatment of adult ADHD: the European Network Adult ADHD. BMC Psychiatry 2010; 10: 67. doi: 10.1186/1471-244X-10-67.
  18. 18. ADHD leads to SUD 1. Twice as likely to smoke 2. Twice as likely for OH dependence 3. 1.5 as likely to have marijuana dependence 4. Twice as likely to have cocaine dependence 5. 2.5 times as likely to have a SUD
  19. 19. Why? 1. ADHD: Impulsivity and Risk Taking 2. ADHD has DAT density/rapid clearance of DA 3. Hence lower DA in synapses 4. Drugs of Abuse: All* increase DA in reward centers (Nucleus Accumbens) 5. *cocaine stimulants, Ecstasy, nicotine , OH, opiates, marijuana
  20. 20. To Treat ADHD or Not • Is there evidence to support pharmacological treatment? • Is there an argument not to treat?
  21. 21. Major Questions? •Is it safe and effective in treating ADHD? •Does it work to treat SUD?
  22. 22. Risk of ADHD to Develop SUD ▫Risk is twice normal rates ▫Risk is four times if CONDUCT DISORDER develops
  23. 23. What explains the link? 1. Nicotine improves attention/Exec Fct 2. FUNCTIONAL IMAGING shows both disorders have Deficits in Ant. Cingulate and Frontocortical systems 3. DOPAMINE involved in BOTH Disorders
  24. 24. Effects of Early ADHD Tx on SUD • Clearcut: Stimulant Tx does NOT INCREASE later SUD • HOWEVER…
  25. 25. DOES EARLY TX PREVENT OR REDUCE LATER SUD • META-ANALYSIS (Wilens) SHOWED REDUCED LATER SUD BUT… • Later META-ANALYSIS #2 SHOWED NO EFFECT!
  26. 26. IN ADOLESCENTS • STIMULANT TREATMENT REDUCES SUD WHILE TREATED • LESS CRIMINAL ACTIVITY WHILE TREATED • CD IS A GATEWAY TO SUD
  27. 27. IS it safe to Treat ADHD in SUD • MPD and Cocaine well tolerated • No EKG findings in interaction between MPD and Cocaine • MPD reduced some positive effects of cocaine • BUT. . . . • Earlier Literature suggests MPD may INCREASE CRAVING
  28. 28. Actions of MP vs Cocaine • MPD blocks DA REUPTAKE TRANSPORTER • Cocaine blocks DA REUPTAKE Transporter • PICTURE HERE
  29. 29. Pharmacotherapy: Receptors Synapse Dopamine Norepinephrine Nerve Impulse Transporter Tyrosine Hydroxylase Courtesy of T. Wilens. Mechanism of Action
  30. 30. What does MPD treat in SUD • Clearly Reduces SX of ADHD (impulsivity) • Clearly Rarely Reduces SUBSTANCE ABUSE • WHY????? Anybody’s Guess !!!!!!! • Treatment for ADHD does not exacerbate SUD
  31. 31. Wait for SUD Control Before Treating ADHD? • YES: Cannot diagnose ADHD while USING SUD will prevent response: (Not True) • Diagnostic uncertainty • Short acting tx can be abused ! • Exacerbation of non ADHD co morbidity • Remember: If ADHD exists only during SUD, IT IS NOT ADHD!!
  32. 32. Wait for SUD Control Before Treating ADHD? • NO: ADHD treatment will reduce SA (not been show in research but there are individual exceptions) • ADHD is a “causal” factor in SUD (True) • BUT LONGITUDINAL RESEARCH has NOT show ADHD Tx to alter the development of SUD • Pt care is NOT LONGITUDINAL/ Individual
  33. 33. 9 Studies of MPD (Ritalin) • NOT EFFECTIVE IN TREATING COCAINE /Nicotine • Atomoxatine (1 study) reduced Nicotine Abstinence (non ADHD sample)
  34. 34. Treating ADHD in Active SUD 1. Be certain of childhood onset and Dx certainty 2. Use Concerta or Vyvanse (pro drug) or atomoxatine 3. Careful nursing or significant other participation 4. Avoid drug seeking or previous stimulant abusers
  35. 35. CONCERTA™: Proof of Product Develop OROS® Technology
  36. 36. CONCERTA™: Proof of Product Pharmacokinetics CONCERTA™ provides –Immediate release followed by extended release of methylphenidate –Minimized fluctuations in peak and trough plasma concentrations compared to methylphenidate tid N = 36 healthy adults
  37. 37. Comprehensive Tx of ADHD/SUD 1. Extended release Ritalin mixed results 2. Buproprion in adults (mixed) 3. CBT: results are not clear cut 4. Contingency mgmt. moderate effect 30 studies
  38. 38. Abuse Potential of Tx of ADHD • High: Dexedrine, Adderall, short-acting Ritalin • Medium: Ritalin LA, SR, Metadate ,Methylin Adderall XR • Low: Vyvance, Intunive, Strattera, Concerta Buproprion, Daytrana Patch
  39. 39. Bottom Line: To Treat or Not 1. Case by case decision-making 2. Degree of diagnostic certainty 3. Risk of diversion or destabilization of other comorbidity 4. Presence of reliable support and monitoring 5. Previous and current substances abused
  40. 40. Discussion Points for TX 1. Proper administration (SUPERVISION) 2. Education about diversion and misuse 3. Transition of care* 4. other administration to self-administration
  41. 41. Role of Psychotherapy • 8 studies show CBT effective for ADHD symptom reduction when SUD is comorbid • Since most studies include psychotherapies alone, UNLCEAR the role of CBT on SUD in ADHD but 3/10 studies DID show an effect
  42. 42. Books for Professionals Tx of Adult ADHD 1) Ari Tuckman - More Attention, Less Deficit 2) Kathleen Nadeau- ADD-friendly Ways to Organize your Life 3) Safren - Mastering your Adult ADHD 4) Zylowska - The Mindfulness Prescription for Adult ADHD
  43. 43. Non Medication Tx of ADHD 1) Lydia Zylowska's mindfulness meditation -shows very positive benefit : book : The Mindfulness Prescription 2) Julia Rucklidge, Ph.D. micronutrients in British Journal of Psychiatry High doses of a complex combination of vitamins, minerals and supplements. 3) Steve Safren at MGH: Benefits of Cognitive Behavioral Therapy in Adult ADHD 4) Mary Solanto Book on CBT for adult ADHD - and group CBT methods.
  44. 44. References: • Ersche, K. D., Clark, L., London, M., Robbins, T. W., & Sahakian, B. J. (2006). Profile of executive and memory function associated with amphetamine and opiate dependence. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 31(5), 1036–1047. http://doi.org/10.1038/sj.npp.1300889 • Jovanovski, D., Erb, S., & Zakzanis, K. K. (2005). Neurocognitive deficits in cocaine users: a quantitative review of the evidence. Journal of Clinical and Experimental Neuropsychology, 27(2), 189–204. http://doi.org/10.1080/13803390490515694 • Lin, Y. J., Chen, W. J., & Gau, S. S. (2014). Neuropsychological functions among adolescents with persistent, subsyndromal and remitted attention deficit hyperactivity disorder. Psychological Medicine, 44(8), 1765–1777. http://doi.org/10.1017/S0033291713002390 • Raldiris, T. L., Bowers, T. G., & Towsey, C. (2014). Comparisons of Intelligence and Behavior in Children With Fetal Alcohol Spectrum Disorder and ADHD. Journal of Attention Disorders. http://doi.org/10.1177/1087054714563792 • Thapar, A., Cooper, M., Jefferies, R., & Stergiakouli, E. (2012). What causes attention deficit hyperactivity disorder? Archives of Disease in Childhood, 97(3), 260–265. http://doi.org/10.1136/archdischild-2011-300482
  45. 45. THE END
  46. 46. DSM-IV ADHD Diagnostic Criteria A: List of symptoms must be present for past 6 months B: Some symptoms present before 7 years of age C: Some impairment from symptoms must be present in 2 or more settings (eg, school and home) D: Significant impairment: social, academic, or occupational E: Exclude other mental disorders American Psychiatric Association. 1994:83-85.
  47. 47. DSM-IV Symptoms of Hyperactivity- Impulsivity Hyperactivity • Squirms and fidgets • Can’t stay seated • Runs/climbs excessively • Can’t play/work quietly • “On the go” / “Driven by a motor” • Talks excessively Impulsivity • Blurts out answers • Can’t wait turn • Intrudes/interrupts others *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. Manifestations of the following symptoms must occur OFTEN*
  48. 48. DSM-IV Symptoms of Inattention Inattention • Careless • Difficulty sustaining attention in activity • Doesn’t listen • No follow through • Avoids/dislikes tasks requiring sustained mental effort • Can’t organize • Loses important items • Easily distractible • Forgetful in daily activities *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. Manifestations of the following symptoms must occur OFTEN*

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