When ADHD Presents as Substance Use Disorder
Brian Johnson, MD; Stephen V. Faraone, PhD
CME Released: 10/07/2010; Valid for credit through 10/07/2011
The following test-and-teach case is an educational activity modeled on the interactive grand rounds approach.
The questions within the activity are designed to test your current knowledge. After each question, you will be
able to see whether you answered correctly and will then read evidence-based information that supports the
most appropriate answer choice. Please note that these questions are designed to challenge you; you will not
be penalized for answering the questions incorrectly. At the end of the case, there will be a short post-test
assessment based on material covered in the activity.
Case Presentation
Cody, an 18-year-old man, presents for an initial evaluation with complaints
of "depression and drug use."
Prompted by his mother, Cody is seeking addiction treatment after being
administratively discharged from a therapeutic school for troubled/drugabusing teenagers. The reason for the administrative discharge was that he
was discovered intoxicated on
dextromethorphan/acetaminophen/antihistamine (Coricidin® HBP™), a cold
remedy abused by many teenagers because of its dextromethorphan
content. He attended many meetings of Alcoholics Anonymous (AA) for
nearly 1 year at the school that he attended. Nonetheless, he admitted that
he had taken cold preparations with dextromethorphan many times while at
the school. No one noticed until the day when he became grossly intoxicated.
Psychiatric history: Cody had been given a diagnosis of borderline
personality disorder by a psychiatrist affiliated with the recovery school. His
sister was diagnosed with rapid-cycling bipolar disorder. Two years earlier,
Cody had a week of grandiosity accompanied by the conviction that people
are robots, but he was on LSD (lysergic acid) at the time. He had never been
prescribed psychotropic medications.
Social history: Cody endorses risk-taking behaviors, such as jumping off buildings at the cemetery (about 12 ft
high). He understands that other people see this as poor judgment. He says that he becomes aggressive when
other people get in the way of him accomplishing his activities. His mother is the chief offender. He has
experienced these symptoms both when intoxicated and during the period of time at the school when he was
chemical free. He also has had trouble in school: not paying attention; talking out of turn; and getting poor
grades despite being obviously intelligent. He was a rambunctious child even before he started in kindergarten,
and has always avoided activities that required an investment of time or concentration.
In addition to the aforementioned drugs, he has been drinking alcohol since he was 14 years old. He also has
experimented with alprazolam, oxycodone, and ecstasy. He regularly smokes cigarettes and marijuana, and
reports that he last smoked marijuana the previous night. He has gone back to drinking frequently since his
discharge from the school.
Mental status: Cody is wearing a Ninja Turtles T-shirt, baggy jeans, and mismatched flip-flops. He is likable,
related, articulate, and in constant motion. He rocks in his chair, jiggles his legs, and moves his head while
talking. His overall score on the Hamilton Rating Scale for Depression is 17, indicating dysthymia. His
symptoms include depressed mood, guilt, belief that life is not worth living but without being frankly suicidal,
insomnia, loss of interest in activities, anxiety, and diurnal mood variation -- which is worst when he wakes up
in the morning.
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The baseline rate of alcohol use disorders (AUDs) in the US population is 8.5% and 2% for drug use
disorders. How common are AUDs in patients with attention-deficit/hyperactivity disorder (ADHD)?
RADIOBUTTON
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< 8.5%
Approximately 8.5%
17%-45%
52%-65%
73%-90%
Save and Proceed
According to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), [1] the baseline
rate of AUDs in the US population is 8.5% and 2% for drug use disorders; about half of drug-dependent
individuals also have AUDs.[1] Various studies have found the single-year prevalence of AUDs in persons with
ADHD to be 17%-45%,[2] with an incidence of drug use disorders of 9%-30%.[2]
Conversely, among patients with AUDs, the prevalence of ADHD is estimated to be between 35% and 71%,
and the prevalence of ADHD among adults with either alcohol or drug use disorders is estimated to be 15%25%.[2] The course of alcohol and substance use disorders is worsened by ADHD; onset is earlier and severity
is greater.[3] Among patients with ADHD, the risk for substance use disorders is highest among patients with
additional psychiatric disorders that are commonly seen in conjunction with ADHD (eg, mood, antisocial, and
anxiety disorders).
Patients with ADHD are distractible, impulsive, and disorganized. They also have difficulties planning,
managing time, and regulating their emotions. The emotional dysregulation associated with ADHD leads to low
frustration tolerance, impatience, quickness to anger, and easy excitability. Such symptoms make it difficult for
these patients to benefit from treatment experiences such as those provided in a residential recovery school.
Cody's response to addiction treatment in the context of his undiagnosed ADHD is typical. The treatment may
have been effective for many of the school's students, but Cody was not able to use it. Given that ADHD is
common among substance-abusing patients, clinicians working in addiction treatment settings should expect to
diagnose and treat ADHD every day.
The initial diagnoses for Cody are ADHD, dysthymia, AUD, and cannabis and nicotine dependence.
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What approximate percentage of patients with ADHD and comorbid substance use disorders (SUDs)
have an additional psychiatric disorder?
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20%
40%
60%
80%
100%
Save and Proceed
In a study of 120 referred adults with childhood-onset ADHD, Biederman and colleagues found that
approximately 80% of patients with ADHD and SUDs have at least 1 additional comorbidity; the most common
third disorder was an anxiety or mood disorder.[4] With careful evaluation, all active disorders should be possible
to diagnose.
Cody has ADHD, addiction, and a mood disorder, and has just failed a major effort at addiction treatment;
indeed, he is actively using 3 substances. Thus, the clinician is faced with deciding which condition to address
first.
For practitioners who take a cognitive-behavioral approach to addiction treatment, the general wisdom is to
take up the SUD first, and to follow with treatment for comorbid disorders as soon as a stable remission is
achieved.[5] Cognitive-behavioral therapy has also been shown to be effective for the treatment of ADHD in
adults when used as an adjunct to stimulant treatment.[6,7]
Psychoanalytic/psychodynamic clinicians tend to begin immediately with an engagement that interprets drug
use as self-medication for underlying issues, assuming that the patient can participate in and use the
psychotherapy.[8-11] This means that interventions may be necessary to ensure that the patient will arrive for the
treatment and will remember the strategies and information discussed during the psychotherapy.
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Which of the following substances is most likely to compromise the patient cognitively and impair the
effectiveness of psychotherapy?
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Alcohol
Marijuana
Dextromethorphan
Nicotine
Save and Proceed
Marijuana interacts with the cannabinoid/anandamide receptor system. This system has the apparent function
of helping us forget nonessential memories, such as what we ate for breakfast a week ago. When patients who
are actively using marijuana are in psychotherapy, the therapist may perceive emotional immediacy,
engagement, and progress on the patient's part. Unfortunately, when patients are intoxicated on marijuana,
they remember little of what went on during these intense engagements. Therefore, therapists must understand
some of the pharmacologic effects of addictive drugs in order to provide good psychotherapy. The effects of
marijuana on memory prevent the emotional experience of the patient from matching that of the therapist. If the
therapist depends on empathy alone, and does not understand the neurobiology of the substance, the patient
who is under the influence of marijuana is unlikely to benefit from the therapy.[9]
Case Continued
For Cody, referral to another substance abuse program that cannot address his concurrent ADHD and mood
disorder issues will simply lead to more treatment without effect. Therefore, he begins psychotherapy with a
specific focus on denial, specifically the rationalizations that enable him to continue to drink and smoke
cigarettes and marijuana, despite knowing that he is addicted to alcohol, nicotine, and marijuana. However,
there are specific cognitive barriers to Cody benefiting from psychotherapy: his use of marijuana and his
current ADHD.
Cody is trying to balance a number of conflicting wishes. He wants to function better. Cody wants the love and
approval of his girlfriend and his mother who object to his drinking and drug use. He also urgently wants to
drink and to smoke cigarettes and marijuana. Although he has warm feelings about his experience at AA, the
one requirement for membership is the sincere wish to stop drinking. Therefore, he doesn't want to go to AA
precisely because it would disrupt his drinking. In addition, he is impaired in his ability to pay attention and
impaired in his ability to inhibit his urges -- common features of ADHD. His drinking and smoking are addictive,
driven activities.
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For patients with active addictions, ADHD, and mood disorders, which of the following are
appropriate interventions? (choose all that apply)
CHECKBOX
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Suggested attendance at a 12-step recovery group
Mandatory daily attendance at a 12-step recovery group
Family therapy
Stimulant medication for ADHD
Nonstimulant medication for ADHD
Antidepressant medication with efficacy for ADHD
Medication that increases sensitivity to alcohol
Save and Proceed
Case Continued
To treat Cody's alcohol abuse, his mother is given a prescription -- with Cody's name on it -- for disulfiram, a
medication that causes unpleasant sensations (flushing, tachycardia, nausea, and vomiting) when alcohol is
ingested. Disulfiram has been found to be ineffective when given to patients, but is quite effective when it is
given to a family member to give to the patient.[12,13] The family member is asked to meet with the patient as
often as possible, ideally every day. They have a conversation about recovery followed by the support person
saying, "I love you" and asking the patient to take the disulfiram in front of the support person. They have no
further discussion of addiction issues until the next morning when the pair again discuss recovery and
disulfiram is administered by the sober support person.
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For patients with ADHD and active SUDs, which of the following choices is most supported by the
literature?
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Start treatment of ADHD with a short-acting stimulant, and move to a long-acting agent if there
is a good response
Start treatment of ADHD with a long-acting stimulant to improve the patient's ability to participate
in addiction treatment
Delay starting any medications until the patient is reliably sober
Start treatment with a stimulating antidepressant, such as bupropion or desipramine, which are
known to have efficacy for ADHD
Start treatment of ADHD with the nonstimulant atomoxetine
Save and Proceed
Cody is started on bupropion XL, and the drug dose is rapidly titrated to 450 mg/day. Bupropion is effective for
the commonly seen triad of ADHD, depression, and nicotine dependence.[14-21] The side-effect profile of
bupropion is especially propitious: dry mouth further discourages smoking; minor weight loss; and sometimes
increased libido. Seizures were an early complication when physicians did not understand that dosing must be
limited to no more than 450 mg/day. Since then, bupropion has been underused, considering its good
outcomes for depression and anxiety symptoms.[14] The tricyclic antidepressant desipramine has also been
found to be effective in reducing symptoms of ADHD in adults.[22] Stimulants are generally not considered firstline drugs for patients with SUDs and ADHD because of the risk for misuse. [5,23,24]
Case Continued
The motor and attentional symptoms of Cody's ADHD improve as the bupropion gradually takes effect over the
first month of treatment. Cody is increasingly able to make good use of his psychotherapy because he is better
able to listen and respond, rather than going on endlessly without any interest in his psychotherapist's
feedback.
Cody also has the chance to balance his warm relationship with the therapist against the therapist's explicit
statement that continuing with marijuana would make it impossible for Cody to benefit from psychotherapy.
Cody also has the emotional space and a supportive relationship in which to consider his enduring interest in
drinking and smoking against his memories of how nice it had been to be a member of the AA fellowship.
Cody decides to get sober, to actively participate in AA, and to get closer to both his mother and his girlfriend.
The practitioner does not repeat the Hamilton Rating Scale for Depression because Cody reports that his
depression is gone. His use of nicotine has diminished, but he has not decided to stop smoking. His
psychotherapist, a psychiatry resident, transfers him from the (short-term treatment) addiction service to the
outpatient psychiatry clinic for continued psychotherapy.
The treatment team did not choose atomoxetine to treat Cody's ADHD. In a 3-month study of atomoxetine in
patients with ADHD and comorbid AUDs, ADHD was improved, but clear effects on alcoholic drinking were not
shown.[25] In a study of patients comparable to Cody, atomoxetine had no effect on either ADHD or substance
use outcomes in adolescents also treated with cognitive-behavioral therapy.[26]
The treatment team on the Addiction Service did not choose a stimulant to treat Cody's ADHD. In Cody's case,
the potential that he might divert or abuse a prescribed stimulant outweighs the efficacy of stimulants for
treating ADHD symptoms.
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According to some recent research, how commonly are stimulants misused or abused; that is, either
taken in larger amounts than prescribed or sniffed to intensify the activating effects?
RADIOBUTTON
0
In a recent survey, less than 15% of college students said that they sold, shared, or misused
their ADHD stimulants
In a recent survey, only patients with cluster B personality disorders, such as antisocial or
borderline, said that they sold, shared, or misused their ADHD stimulants
In a recent survey, 62% of college students said that they sold, shared, or misused their ADHD
stimulants
In a recent survey, 95% of college students said that they sold, shared, or misused their ADHD
stimulants, stating that they use them as party drugs
Save and Proceed
In a Web-based survey of college students, 27% of those who were taking prescription medications had been
approached to sell, trade, or give away their medications; however, 54% of students taking stimulants had been
asked to divert these medications.[27] In a study of first-year college students (ages 17-19 years), 36% of
students overall had diverted prescribed medications; 62% of these had diverted ADHD medications; and 35%
had diverted narcotic analgesics.[27] Prescription medications with abuse potential have now exceeded
marijuana as the drug with which children are most likely to begin experimenting.[28]
A systematic review of misuse and diversion of stimulants[29] by Wilens and colleagues found that
methylphenidate-related adverse experiences reported to a poison control center had increased 3-fold from
1993 to 1999. For high school students with ADHD, 15% gave away their stimulants; 7% sold them; and 4%
had them stolen during a 30-day period.[29] In a survey of 545 patients in an ADHD treatment center, 14% stated
that they abused their stimulant medications. The most frequent method of abuse was by crushing the pills and
snorting them.[30] Patients who abused stimulants also commonly abused other drugs, most often cocaine
(62%), methamphetamine (5%), or both (31%).[30]
Although these studies all show evidence for the misuse and diversion of stimulants, clinicians should be aware
that not all stimulant-treated patients divert or misuse their medications. Risk factors for stimulant misuse and
diversion include having an SUD, having conduct disorder, using an immediate-release stimulant, white race,
male gender, and belonging to a fraternity or sorority.[31] Clinicians should discuss the potential for misuse and
diversion of stimulants with parents or, for adolescents and adults, with the patients themselves, particularly
when working with high-risk patients. Clinicians need to be especially vigilant in discussing and monitoring
adolescents and young adults with ADHD and conduct disorders or SUDs for the appropriate use of their
medications. Such monitoring may include questioning, specifically about appropriate use or misuse of the
medication, as well as the potential for diversion of the medicine and observing that pill counts are accurate.
For patients who have many risk factors, particularly conduct disorder or SUDs, use of a nonstimulant
alternative should be considered.
Given the risks associated with stimulants in substance-abusing patients, is it sensible to consider prescribing
stimulants for ADHD in this difficult population? Clearly, immediate-release stimulants should not be used,
given that they are more likely to be misused, diverted, or abused than long-acting stimulants. Kollins and
colleagues[32] compared the acute behavioral effects of orally administered sustained-release methylphenidate,
immediate-release methylphenidate, and placebo in 10 healthy volunteers. The immediate-release formulation
produced dose-dependent stimulant-like drug effects, such as higher ratings of "good effects." By contrast, the
sustained-release formulation produced only transient effects on these measures. Wilens and colleagues [33]
found that all misused or diverted stimulant medications were immediate-release preparations. Likewise,
Jaffe[34] found that long-acting stimulants were not successfully misused in a group of adolescents with ADHD
and SUDs, probably because of the difficulty of transforming the long-acting stimulants into a form that could be
intravenously or intranasally administered.
The argument in favor of using long-acting stimulants vs nonstimulants (eg, atomoxetine, bupropion, and
extended-release guanfacine) in substance-abusing patients with ADHD is that stimulants are more effective
than the nonstimulant alternatives for treating ADHD.[35] In considering this possibility, clinicians need to balance
the potential for abuse, misuse, and diversion with the greater efficacy afforded by stimulants, which could lead
to better ADHD treatment outcomes that could make the patient more amenable to addiction therapies.
When a stimulant is indicated, novel formulations, such as the stimulant prodrug lisdexamfetamine dimesylate
(LDX), may be considered. LDX has significant efficacy for treating ADHD, an extended duration of action, and
a safety profile consistent with other once-daily stimulants.[36-39] In addition, abuse liability studies have shown
that LDX has lower abuse-related liking scores compared with equipotent doses of immediate-release damphetamine.[40] LDX contains d-amphetamine covalently bonded to l-lysine, rendering it pharmacologically
inactive before oral ingestion. After ingestion, the bond is hydrolyzed, releasing pharmacologically active damphetamine, which is responsible for the drug's activity, and l-lysine, a naturally occurring amino acid. Thus,
compared with other stimulants, LDX is less susceptible to misuse by other delivery routes, such as injection or
inhalation, which should limit its abuse potential. The LDX formulation also leads to lower toxicity and overdose
potential.[41] With regard to abuse, Jasinksi and colleagues[40] found that, at an equivalent amount of
amphetamine base taken orally, 100 mg of LDX led to lower abuse liability scores compared with 40 mg of
immediate-release d-amphetamine.
Case Continued
When Cody presented initially he was disorganized, impulsive, and inattentive, and having an alliance with his
mother helped assure that Cody would show up for his psychotherapy. He developed a therapeutic alliance
with his young, male psychotherapist. As Cody improved cognitively and motorically with the gradual onset of
action of the bupropion, and as his psychotherapist worked on denial, he began to be sober. Three weeks into
his treatment, he reflects that he hasn't had a drink since an alcoholic blackout 12 days ago. He hasn't smoked
marijuana for 5 days; he has not had any suicidal thoughts; and he has begun going to AA. His mother stops
coming to treatment with him.
A week later, Cody tells the therapist that he used a drug called "spike," a cannabinoid that can be bought on
the Internet. Intoxicated on spike, Cody pulled a gun on his roommate. His roommate moved out the next day.
This event and its discussion in psychotherapy leads him to a greater resolve to be sober. In his next
psychotherapy hour, Cody tells his psychotherapist that he called an AA friend when he had an urge to buy
cough syrup containing dextromethorphan. Over the next few weeks, the psychotherapy deepens, although
Cody is often late for his sessions. The therapist and Cody explore the reasons for this lateness, an
unconscious expression of anger toward his therapist, which leads to associations about how abandoned he
had felt by an abusive father and a difficult, preoccupied mother.
Six weeks into his treatment, Cody observes that it has been a long time since he expressed himself in a clear,
organized fashion. He feels anxious about being sober because he has no idea how his life will develop.
Despite his anxiety he begins a "fourth step," examining character flaws in preparation for discussing his
shortcomings with a sponsor in AA -- the "fifth step."
At this point, Cody stops his bupropion, initially claiming that he lost his prescription bottle. However, with
psychotherapy it becomes clear that the anxiety of being sober and facing his issues made him reluctant to
stay sober. Using alcohol and drugs was easy, automatic, and required no thought. Sobriety and the constant
self-examination; the use of relationships; and taking the bupropion, which he needed to think clearly, required
an enormous effort. The psychotherapist notes that when Cody felt entirely free, not trapped by any
responsibilities or relationships and in a euphoric state of unrelatedness, he was likely to relapse to drug use.
The therapist posits that Cody had stopped his bupropion with the unconscious intention of using drugs and
alcohol again.
Cody resumes his medication. Nicotine dependence continues as an unresolved active addiction, and both the
patient and the psychotherapist are aware that it will be addressed at some point in the treatment. Nicotine
dependence is common among patients with ADHD, and having ADHD makes it more difficult to quit
smoking,[42] which is partly due to the fact that nicotine reduces ADHD symptoms.[43-45] Thus, Cody's treatment is
ongoing.
Conclusions
ADHD has been reported in 40%-75% of clinically referred adolescents with SUDs.[31,33] The treatment of ADHD
in patients with SUDs is, at best, complex. Commonly co-occurring psychiatric disorders, such as ADHD and
depression, often go untreated in community drug treatment programs, which may contribute to poorer
substance abuse treatment outcomes when compared with patients who do not have comorbidities. [46]
Moreover, addicted patients with comorbid ADHD are more likely to drop out of treatment compared with those
without ADHD.[46]
In regard to treatment of ADHD in patients with comorbid SUDs, stimulants are more effective than
nonstimulants,[35] but they can be misused, diverted, or abused. These risks are lower for long-acting
stimulants, particularly a prodrug formulation of amphetamine. On the other hand, nonstimulant treatments -such as bupropion, extended-release guanfacine, or atomoxetine -- carry no abuse liability and are not
scheduled substances. Bupropion has the advantage of efficacy against mood and anxiety symptoms that so
commonly accompany ADHD and SUDs.
Correctly diagnosing ADHD and other disorders in substance-abusing patients is essential for effective
treatment. For Cody, the initial diagnosis of borderline personality disorder prevented effective intervention, and
led to the limited efficacy of nearly a year of residential schooling/addiction treatment. When the diagnosis of
ADHD and a significant mood disorder were made, a specific pharmacologic intervention enabled the
psychotherapy to help the patient make significant changes through insight and relatedness. AA is an
outstanding resource that helps people maintain high functioning despite addiction. Outcomes of addiction
treatment are significantly improved by attendance at AA; in the NESARC study, the chance of recovery
doubled with 12-step attendance.[47] Psychotherapy and medication facilitated the patient's new-found ability to
be engaged in this important organization for recovery.
Supported by an independent educational grant from Shire.
References
1.
2.
Stinson FS, Grant BF, Dawson DA, et al. Comorbidity between DSM-IV alcohol and specific drug use
disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related
Conditions. Drug Alcohol Depend. 2005;80:105-116. Abstract
Wilens TE. The nature of the relationship between attention-deficit/hyperactivity disorder and
substance use. J Clin Psychiatry. 2007;68(suppl11):4-8.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Faraone SV, Biederman J, Wilens TE, Adamson J. A naturalistic study of the effects of
pharmacotherapy on substance use disorders among ADHD adults. Psychol Med. 2007;37:1743-1752.
Abstract
Biederman J, Wilens T, Mick E, Milberger S, Spencer TJ, Faraone FV. Psychoactive substance use
disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric
comorbidity. Am J Psychiatry. 1995;152:1652-1658. Abstract
Riggs PD, Wilens TE, Fusillo S. When ADHD and substance use disorders intersect: relationship and
treatment implications. Curr Psychiatry Rep. 2007;9:408-414. Abstract
Safren SA. Cognitive behavioral approaches to ADHD treatment in adulthood. J Clin Psychiatry.
2006;67(suppl8):46-50.
Safren SA, Otto MW, Sprich S, et al. Cognitive behavioral therapy for ADHD in medication-treated
adults with continued symptoms. Behav Res Ther. 2005;43:831-842. Abstract
Johnson B. Psychoanalysis of a man with active alcoholism. J Subst Abuse Treat. 1992;9:111-123.
Abstract
Jones DS, Krotick S, Johnson B, Morrison AP. Clinical challenge: waiting for rescue, an attorney who
will not advocate for himself. Harvard Rev Psychiatry. 2005;13:344-356.
Dodes LM. Addiction and psychoanalysis. Can J Psychoanal. 2003;11:123-134.
Dodes LM. Addiction as a psychological symptom. Psychodynamic Pract. 2009;15;381-393.
O'Farrell TJ, Fals-Stewart W. Behavioral couples and family therapy for substance abusers. Curr
Psychiatry Rep. 2002;4:371-376. Abstract
Fals-Stewart W, O'Farrell TJ, Birchler GR. Behavioral couples therapy for substance abuse: rationale,
methods, and findings. Sci Pract Perspect. 2004;2:30-41. Abstract
Solhkhah R, Wilens TE, Daly J, Prince JB, Van Patten SL, Biederman J. Bupropion SR for the
treatment of substance-abusing outpatient adolescents with attention-deficit/hyperactivity disorder and
mood disorders. J Child Adolesc Psychopharmacol. 2005;15:777-786. Abstract
Kratochvil CJ, Wilens TE, Upadhyaya H. Pharmacological management of a youth with ADHD,
marijuana use, and mood symptoms. J Am Acad Child Adolesc Psychiatry. 2006;45:1138-1141.
Abstract
Reimherr FW, Hedges DW, Strong RE, Marchant BK, Williams ED. Bupropion SR in adults with
ADHD: a short-term, placebo-controlled trial. Neuropsychiatr Dis Treat. 2005;3:245-251.
Szobot CM, Bukstein O. Attention deficit hyperactivity disorder and substance use disorders. Child
Adolesc Psychiatr Clin North Am. 2008;17:309-323.
Papakostas GI, Trivedi MH, Alpert JE, et al. Efficacy of bupropion and the selective serotonin reuptake
inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of
individual patient data from 10 double-blind, randomized clinical trials. J Psychiatr Res. 2008;42:134140. Abstract
Monuteaux MC, Spencer TJ, Faraone SV, Wilson AM, Biederman J. A randomized, placebo-controlled
clinical trial of bupropion for the prevention of smoking in children and adolescents with attentiondeficit/hyperactivity disorder. J Clin Psychiatry. 2007;68:1094-1101. Abstract
Wilens TE, Haight BR, Horrigan JP, et al. Bupropion XL in adults with attention-deficit/hyperactivity
disorder: a randomized, placebo-controlled study. Biol Psychiatry. 2005;57:793-801. Abstract
Riggs PD, Leon SL, Mikulich SK, Pottle LC. An open trial of bupropion for ADHD in adolescents with
substance use disorders and conduct disorder. J Am Acad Child Adolesc Psychiatry. 1998;37:12711278. Abstract
Wilens TE, Biederman J, Prince J, et al. Six-week, double-blind, placebo-controlled study of
desipramine for adult attention deficit hyperactivity disorder. Am J Psychiatry. 1996;153:1147-1153.
Abstract
Verbeeck W, Tuinier S, Bekkering GE. Antidepressants in the treatment of adult attention-deficit
hyperactivity disorder: a systematic review. Adv Ther. 2009;26:170-184. Abstract
Pliszka S; AACAP Work Group on Quality Issues. Practice parameters for the assessment and
treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child
Adolesc Psychiatry. 2007;46:894-921. Abstract
Wilens TE, Adler LA, Weiss MD, et al. Atomoxetine treatment of adults with ADHD and comorbid
alcohol use disorders. Drug Alcohol Depend. 2008;96:145-154. Abstract
Thurstone C, Riggs PD, Salomonsen-Sautel S, Mikulich-Gilbertson SK. Randomized, controlled trial of
atomoxetine for attention-deficit/hyperactivity disorder in adolescents with substance use disorder. J
Am Acad Child Adolesc Psychiatry. 2010;49:573-582. Abstract
Garnier LM, Arria AM, Caldeira KM, Vincent KB, O'Grady KE, Wish ED. Sharing and selling of
prescription medications in a college student sample. J Clin Psychiatry. 2010;71:262-269. Abstract
28. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and
complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician.
2008;11(suppl):S63-S88.
29. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: a
systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47:21-31. Abstract
30. Bright GM. Abuse of medications employed for the treatment of ADHD: results from a large-scale
community survey. Medscape J Med. 2008;10:111.
31. Faraone SV, Wilens TE. Effect of stimulant medications for attention-deficit/hyperactivity disorder on
later substance use and the potential for stimulant misuse, abuse, and diversion. J Clin Psychiatry.
2007;68(suppl11):15-22.
32. Kollins SH, Rush CR, Pazzaglia PJ, Ali JA. Comparison of acute behavioral effects of sustainedrelease and immediate-release methylphenidate. Exp Clin Psychopharmacol. 1998;6:367-374. Abstract
33. Wilens TE, Gignac M, Swezey A, Monuteaux MC, Biederman J. Characteristics of adolescents and
young adults with ADHD who divert or misuse their prescribed medications. J Am Acad Child Adolesc
Psychiatry. 2006;45:408-414. Abstract
34. Jaffe SL. Failed attempts at intranasal abuse of Concerta. J Am Acad Child Adolesc Psychiatry.
2002;41:5.
35. Faraone SV, Glatt SJ. A comparison of the efficacy of medications for adult attentiondeficit/hyperactivity disorder using meta-analysis of effect sizes. J Clin Psychiatry. 2010;71:754-763.
Abstract
36. Wigal SB, Kollins SH, Childress AC, Squires L; 311 Study Group. A 13-hour laboratory school study of
lisdexamfetamine dimesylate in school-aged children with attention-deficit/hyperactivity disorder. Child
Adolesc Psychiatry Ment Health. 2009;3:17.
37. Faraone SV. Lisdexamfetamine dimesylate: the first long-acting prodrug stimulant treatment for
attention deficit/hyperactivity disorder. Expert Opin Pharmacother. 2008;9:1565-1574. Abstract
38. Adler LA, Goodman DW, Kollins SH, et al. Double-blind, placebo-controlled study of the efficacy and
safety of lisdexamfetamine dimesylate in adults with attention-deficit/hyperactivity disorder. J Clin
Psychiatry. 2008;69:1364-1373. Abstract
39. Biederman J, Krishnan S, Zhang Y, McGough JJ, Findling RL. Efficacy and tolerability of
lisdexamfetamine dimesylate (NRP-104) in children with attention-deficit/hyperactivity disorder: a
phase III, multicenter, randomized, double-blind, forced-dose, parallel-group study. Clin Ther.
2007;29:450-463. Abstract
40. Jasinski DR, Krishnan S. Abuse liability and safety of oral lisdexamfetamine dimesylate in individuals
with a history of stimulant abuse. J Psychopharmacol. 2009;23:419-427. Abstract
41. Krishnan S, Moncrief S. An evaluation of the cytochrome p450 inhibition potential of lisdexamfetamine
in human liver microsomes. Drug Metab Dispos. 2007;35:180-184. Abstract
42. Pomerleau CS, Kurth CL. Willingness of female smokers to tolerate postcessation weight gain. J Subst
Abuse. 1996;8:371-378. Abstract
43. Levin ED, Conners CK, Sparrow E, et al. Nicotine effects on adults with attention-deficit/hyperactivity
disorder. Psychopharmacology (Berl). 1996;123:55-63. Abstract
44. Levin ED, Conners CK, Silva D, et al. Transdermal nicotine effects on attention. Psychopharmacology
(Berl). 1998;140:135-141. Abstract
45. Levin ED, Conners CK, Silva D, Canu W, March J. Effects of chronic nicotine and methylphenidate in
adults with attention deficit/hyperactivity disorder. Exp Clin Psychopharmacol. 2001;9:83-90. Abstract
46. Riggs P, Levin F, Green AI, Vocci F. Comorbid psychiatric and substance abuse disorders: recent
treatment research. Subst Abus. 2008;29:51-63.
47. Dawson DA, Grant BF, Stinson FS, Chou PS. Estimating the effect of help-seeking on achieving
recovery from alcohol dependence. Addiction. 2006;101:824-834. Abstract