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ADHD AND ADDICTION
Things every addiction specialist should know about
ADHD
Dr Alberto Pertusa, PhD
Consultant Psychiatris...
• No conflicts of interest to disclose
• I have not received any Honoraria or fees from any
pharmaceutical companies over ...
• ADHD is one of my main areas of interest and clinical work
• Patients with both ADHD and addiction represent a significa...
What is ADHD?
The Dunning–Kruger effect
ADD = Attention Deficit Disorder
ADHD = Attention Deficit Hyperactivity Disorder
Three subtypes:
1. Predominantly inattent...
5 or more criteria from:
1. Lack of attention to details / careless mistakes
2. Difficulty sustaining attention
3. Does no...
5 or more criteria from:
1. Fidgetiness (hand or feet) / squirming in seat
2. Restless during activities (difficulty seati...
The list goes on…
ADHD is a continuum (spectrum)
Focused Distracted
Careful Risk taker
Patient Impatient
Relaxed Restless
...
• Neurodevelopmental condition
• Significant genetic component
• Brain abnormalities in neuroimaging studies
(delayed matu...
How frequent is ADHD
In the general
population?
How frequent is ADHD
in the general
population?
How frequent is ADHD
In the general
population?
How frequent is ADHD
in the general
population?
2 - 5% of general populati...
How frequent is ADHD
In the general
population?
How frequent is ADHD
in people with SUD?
How frequent is ADHD
In the general
population?
How frequent is ADHD
in people with SUD?
10 – 40% of people with SUD have ...
ADHD is associated with:
• Earlier age of onset of SUD
• Increased SUD in adulthood
• Poorer response to treatment
ADHD sy...
Attention-deficit/hyperactivity disorder and lifetime
cannabis use: genetic overlap and causality
Artigas et al, Molecular...
ADHD and comorbid conditions
• Lower academic achievement
• Higher risk for substance and process addictions
• Behaviour problems
• Increased risk of a...
• Dopamine is involved in reward and has 2 "firing modes”:
• tonic (background dopamine levels)  learning,
reinforcement ...
”Do you feel high”?
Methylphenidate (RITALIN) – IV vs Oral
Blood levels - Amphetamine vs Cocaine
STIMULANTS NON-STIMULANTS
Methylphenidate:
• Ritalin (short acting)
• Concerta, Medikinet (long acting)
Amphetamines:
• De...
To treat or not to treat…
Does treatment with
stimulant medication lead to
later substance use disorders?
Stimulant Medication and Substance Use Outcomes
A Meta-analysis
Humphreys et al, JAMA Psychiatry, 2013
Treatment of ADHD w...
• Randomized placebo-controlled trial, 24-weeks
• Chronic (20 years) IV amphetamine users
• Medication started whilst abst...
Pilot study of the effects of Lisdexamfetamine on cocaine use
Mooney et al, Drug Alcohol Dependence 2015
• Be aware that people people with a history of substance misuse may
have increased prevalence of ADHD
• No specific recom...
ICASA - International Collaboration on
ADHD and Substance Abuse
• Treat both SUD and ADHD together and in parallel
• Start medication as soon as possible as long as no
withdrawals or sym...
• Motivation, attitude and maturity
• Duration of SUD
• Type of substances
• Pattern of use vs misuse:
• Use: contained an...
Group 1 (RED)
Dependence (alcohol, opiates, benzodiazepines, regular cocaine use)
• address SUD initially
• start ADHD med...
• Patients may over-report symptoms of ADHD for secondary gain
(e.g. prescription of stimulants)
• Many addiction services...
ASRS – Adult ADHD self-report scale
• Takes a few minutes to complete
• Developed by the World Health Organisation
• Good ...
1. ADHD is an independent risk factor for SUD (based on a common
genetic predisposition i.e. dopamine dysregulation)
2. Ab...
Dr Alberto Pertusa, PhD
Consultant Psychiatrist
Thank you
Nightingale Hospital, London
nightingalehospital.co.uk
55 Harley...
iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and...
iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and...
iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and...
iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and...
iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and...
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iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and Addiction: things every Addiction specialist should know about ADHD.

In this presentation, Consultant Psychiatrist and international addictions specialist, Dr McPhillips, will provide an overview of emerging medical treatments for addiction and Dr Pertusa will discuss ADHD & addiction.

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iCAAD London 2019 - Dr Alberto Pertusa - Addiction treatment: What new medical treatments does the future hold? & ADHD and Addiction: things every Addiction specialist should know about ADHD.

  1. 1. ADHD AND ADDICTION Things every addiction specialist should know about ADHD Dr Alberto Pertusa, PhD Consultant Psychiatrist Nightingale Hospital, London nightingalehospital.co.uk 55 Harley Street, London (outpatients) psychiatristlondon.co.uk contact@psychiatristlondon.co.uk
  2. 2. • No conflicts of interest to disclose • I have not received any Honoraria or fees from any pharmaceutical companies over the last 10 years Disclosure
  3. 3. • ADHD is one of my main areas of interest and clinical work • Patients with both ADHD and addiction represent a significant proportion on my caseload • I am the founder of the London Adult ADHD Specialist Peer Group Clinical expertise in ADD/ADHD
  4. 4. What is ADHD?
  5. 5. The Dunning–Kruger effect
  6. 6. ADD = Attention Deficit Disorder ADHD = Attention Deficit Hyperactivity Disorder Three subtypes: 1. Predominantly inattentive type - ADD 2. Predominantly hyperactive/impulsive - ADHD 3. Combined presentation – ADHD (most frequent type) However both terms often used interchangeably ADD or ADHD? The three types of ADHD
  7. 7. 5 or more criteria from: 1. Lack of attention to details / careless mistakes 2. Difficulty sustaining attention 3. Does not seem to listen 4. Does not follow through on instructions (procrastination) 5. Difficulty organising tasks and activities 6. Avoids sustained mental effort 7. Loses and misplaces objects 8. Easily distracted 9. Forgetful in daily activities DSM-5 criteria for ADHD (APA 2013) INATTENTION
  8. 8. 5 or more criteria from: 1. Fidgetiness (hand or feet) / squirming in seat 2. Restless during activities (difficulty seating still) 3. Feeling restless inside, difficulty relaxing (mind-wandering, ceaseless mental activity) 4. Excessively loud or noisy 5. Always “on the go” 6. Talks excessively 7. Blurts out answers 8. Difficulty waiting his or her turn 9. Tends to act without thinking DSM-5 criteria for ADHD (APA 2013) HYPERACTIVITY/IMPULSIVITY
  9. 9. The list goes on… ADHD is a continuum (spectrum) Focused Distracted Careful Risk taker Patient Impatient Relaxed Restless Cautious Impulsive Quiet Active Diligent Procrastinator Organised Chaotic Predictable Spontaneous Systematic Creative, out of the box Content Seeks constant gratification
  10. 10. • Neurodevelopmental condition • Significant genetic component • Brain abnormalities in neuroimaging studies (delayed maturation in some areas of the brain) • Neuropsychological abnormalities • Dysregulation of • Noradrenaline  inattention or hyper-focus • Dopamine  issues with gratification, motivation, seeking ”highs" ADHD as a valid medical diagnosis
  11. 11. How frequent is ADHD In the general population? How frequent is ADHD in the general population?
  12. 12. How frequent is ADHD In the general population? How frequent is ADHD in the general population? 2 - 5% of general population (18+) have ADHD
  13. 13. How frequent is ADHD In the general population? How frequent is ADHD in people with SUD?
  14. 14. How frequent is ADHD In the general population? How frequent is ADHD in people with SUD? 10 – 40% of people with SUD have ADHD
  15. 15. ADHD is associated with: • Earlier age of onset of SUD • Increased SUD in adulthood • Poorer response to treatment ADHD symptoms that can lead to SUD: • Dysregulation of dopamine reward system: • reward deficiency • novelty seeking behaviour • Issues with executive functions, impulsivity • Attempts to self-medicate restless brain, insomnia • Response to negative life experiences caused by ADHD (e.g. academic/professional problems) ADHD is a significant risk factor for developing addictions
  16. 16. Attention-deficit/hyperactivity disorder and lifetime cannabis use: genetic overlap and causality Artigas et al, Molecular Psychiatry, 2019 • analysis of the complete genome of more than 85,000 subjects • Mendelian randomization techniques • The genes that increase the risk for cannabis use overlap with those which cause ADHD symptoms • 40-50% of cannabis use is explained by genetic factors ADHD and cannabis use
  17. 17. ADHD and comorbid conditions
  18. 18. • Lower academic achievement • Higher risk for substance and process addictions • Behaviour problems • Increased risk of accidents and injuries (more driving anger and mistakes) • Problems with peers (rejection, instable relationships) • Anxiety • Low self esteem, low mood • Higher rates of unemployment • More rates of divorce • Increased risk for arrests and convictions Consequences of ADHD
  19. 19. • Dopamine is involved in reward and has 2 "firing modes”: • tonic (background dopamine levels)  learning, reinforcement response to common stimuli • phasic (intermittent spikes)  ”high”  addiction • Studies support reward deficiency theories in ADHD: • Underactivity in Anterior Cingulate Cortex in ADHD • Nucleus accumbens and other subcortical areas are under- responsive in ADHD • Reduced dopamine transporters in regions associated with reward Dopamine & Reward deficiency in ADHD
  20. 20. ”Do you feel high”? Methylphenidate (RITALIN) – IV vs Oral
  21. 21. Blood levels - Amphetamine vs Cocaine
  22. 22. STIMULANTS NON-STIMULANTS Methylphenidate: • Ritalin (short acting) • Concerta, Medikinet (long acting) Amphetamines: • Dexamphetamine - short acting • UK: Elvanse (US: Vyvanse) - long acting Atomoxetine (Strattera) Guanfacine (Intuniv) Modafinil (Provigil) ↑ Noradrenaline ↑ Dopamine ↑ Noradrenaline No effect on Dopamine ↑ Attention (very effective) ↑ Attention (less effective) ↓ Hyperactivity - ↓ Impulsivity and aggression - Improved emotional control Immediate effect (within 20-60 minutes) Fast and long-acting formulations (4-14 hours) Does not need to be taken daily Full effect takes 2-4 weeks Needs to be taken daily Side effects: ↓ Appetite, insomnia, anxiety, dry mouth Atomoxetine: Irritability, nausea, ↓ Appetite, sexual dysfunction Work in about 70-80% of people with ADHD Work in about 50% of cases
  23. 23. To treat or not to treat…
  24. 24. Does treatment with stimulant medication lead to later substance use disorders?
  25. 25. Stimulant Medication and Substance Use Outcomes A Meta-analysis Humphreys et al, JAMA Psychiatry, 2013 Treatment of ADHD with stimulant medication neither protects nor increases the risk of later substance use disorders.
  26. 26. • Randomized placebo-controlled trial, 24-weeks • Chronic (20 years) IV amphetamine users • Medication started whilst abstinent (2 weeks prior to release from prison) • Relapse-prevention therapy part of protocol • Slow-release oral Methylphenidate/RITALIN (12 hours effect) • Very high doses of stimulant up to 180 mg/daily (rationale: long- term drug use can down-regulate brain dopamine systems) • Possible to detect amphetamine use in urine test • Group treated with Methylphenidate had significantly more negative urine tests: • amphetamines • other drugs Methylphenidate for ADHD and drug relapse in criminal offenders with substance dependence. Konstenius et al., Addiction 2014
  27. 27. Pilot study of the effects of Lisdexamfetamine on cocaine use Mooney et al, Drug Alcohol Dependence 2015
  28. 28. • Be aware that people people with a history of substance misuse may have increased prevalence of ADHD • No specific recommendations re medication choice in ADHD + SUD (Lisdexamfetamine or extended release Methylphenidate/Ritalin remain 1st line, similar to ADHD without SUD) • If SUD: • risk assessment for substance misuse and drug diversion • monitor patient more frequently • modified-release once-daily preparations NICE (National Institute of Clinical Excellence) ADHD Guidelines 2018
  29. 29. ICASA - International Collaboration on ADHD and Substance Abuse
  30. 30. • Treat both SUD and ADHD together and in parallel • Start medication as soon as possible as long as no withdrawals or symptoms of intoxication • Consider high doses of ADHD medication (+ therapy) • Favour long- acting agents as low potential for abuse: • Methylphenidate: CONCERTA, MEDIKINET • Lisdexamfetamine; ELVANSE XXX
  31. 31. • Motivation, attitude and maturity • Duration of SUD • Type of substances • Pattern of use vs misuse: • Use: contained and stable, ”self medication" • Misuse: looking for a high, escalating doses, potential dependence • Mental health comorbidities (e.g. history of psychosis) • Physical health risk (e.g. heart problems, interactions) • Feasibility to objectively monitor SUD (UDS, breathalyser) • Communication with family • Engagement and consent to closely liaise with • Feasibility to prescribe small supplies of medication (e.g. 1 week at a time) • Risk of diversion Factors to consider when prescribing stimulant medication
  32. 32. Group 1 (RED) Dependence (alcohol, opiates, benzodiazepines, regular cocaine use) • address SUD initially • start ADHD medication when abstinent • maintain close liaison with addiction services Group 2 (GREEN) Low grade cannabis or alcohol use (”self medication") • assess motivation to reduce intake • consider starting ADHD medication • Harm minimisation advice  never take substances at the same day or time as medication Group 3 (GREY)  clinical judgment required Occasional use of street stimulants (cocaine) or regular cannabis (skunk) use • Consider all clinical factors • If treatment, monbitor substance use • Low threshold for cessation of treatment UKAAN (UK Adult ADHD Network) Guidelines
  33. 33. • Patients may over-report symptoms of ADHD for secondary gain (e.g. prescription of stimulants) • Many addiction services do not routinely screen for ADHD • Professionals treating Addiction not be trained to recognise ADHD • Inattention and disturbed behaviour may be attributed to: • substance use or withdrawal • personality disorder • Some still question the validity of the diagnosis • Concerns about people with SUD being prescribed ADHD medications which can restrict assessment and diagnosis Challenges in diagnosing of ADHD in people with SUD
  34. 34. ASRS – Adult ADHD self-report scale • Takes a few minutes to complete • Developed by the World Health Organisation • Good sensitivity in patients with SUD (false positives common) DIVA - Diagnostic interview for ADHD in adults • Takes longer to complete • Includes questions regarding childhood • Very comprehensive – maps DSM diagnostic criteria for ADHD • Very didactic Screening questionnaires for ADHD (Available online for free)
  35. 35. 1. ADHD is an independent risk factor for SUD (based on a common genetic predisposition i.e. dopamine dysregulation) 2. About 1 in 4 or 1 in 5 people with SUD have ADHD 3. People with a diagnosis of SUD should be screened for ADHD 4. The ASRS is a reliable screening questionnaire that takes a few minutes to complete 5. Treatment of ADHD in patients with SUD is a complicated area and needs more research - currently informed by best practice 6. Large registry longitudinal studies support medication treatment for ADHD as protective against SUD (high dose stimulants started during abstinence and with close monitoring and therapy for SUD) Conclusions
  36. 36. Dr Alberto Pertusa, PhD Consultant Psychiatrist Thank you Nightingale Hospital, London nightingalehospital.co.uk 55 Harley Street, London (outpatients) psychiatristlondon.co.uk contact@psychiatristlondon.co.uk

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