ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Faculty: Timothy E. Wilens, MD; Himanshu P. Upadhyaya, MBBS, MS; Oscar G. Bukstein, MD,
MPH; John Grabowski, PhD; Yifrah Kaminer, MD, MBA; Alessandra N. Kazura, MD, FAAP; John
R. Knight, MD; Frances R. Levin, MD; Paula D. Riggs, MD; Howard Schubiner, MD; Ramon
Solhkhah, MD; Steven J. Parker, MD
Needs Assessment
Many youngsters with ADHD abuse substances when they become teenagers. Pediatricians need
to know how they can help their ADHD patients circumvent this comorbidity by providing cautionary
guidance and identifying children most at risk, as recommended by the American Academy of
Pediatrics (AAP).[1] According to the AAP, fewer than half of pediatricians screen their adolescent
patients for drug use, an essential component of a prevention strategy that also calls for a
knowledge of screening instruments and how to use them. Confusion about the real and
misunderstood risks of prescribing standard stimulant pharmacotherapy for youngsters with ADHD
who abuse substances, or who are at risk for doing so, also needs to be addressed.
1. Kulig JW; American Academy of Pediatrics Committee on Substance Abuse. Tobacco, Alcohol,
and Other Drugs: the role of the pediatrician in prevention, identification, and management of
substance abuse. Pediatrics. 2005;115:816-821.
Learning Objectives
Upon completion of this activity, participants should be able to:
Describe the bidirectional overlap between ADHD and substance use disorders (SUDs) that has
been observed both statistically and clinically.
Discuss smoking and the "gateway hypothesis" in the context of ADHD and future substance
abuse.
List predictors of substance abuse in adolescents with ADHD.
Explain why it is important to screen all adolescents for substance abuse.
Summarize the evidence regarding pharmacologic treatment of ADHD and its effect on the risk for
the development of subsequent SUDs.
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Contents of This CME Activity
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Introduction
by Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Primary Care and Pediatric Substance Abuse
How Common Is Pediatric Substance Use?
Smoking Leads To Other Substance Abuse
Risk Factors For Alcohol Abuse In ADHD Patients
Risk Factors for Substance Use
Screening for Adolescent Substance Abuse
Treating ADHD and SUD
Provocative Findings in Adult Studies
Abuse Potential of Psychostimulants
Nonpharmacologic Therapy
Putting Theory Into Practice
Club Drugs—The List Keeps Changing
Motivational Interviewing: Mobilizing the Patient's Own Resources
Evaluating and Educating About ADHD
References
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ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Introduction
The link between attention-deficit hyperactivity disorder (ADHD), cigarette smoking, and substance
use disorders (SUDs) is strong. Research as well as clinical experience confirm that many
youngsters with 1 disorder also have the other. To help adolescents with ADHD avoid using
substances and effectively manage those teens who already have a problem, it is essential to
understand how substance abuse develops, which youngsters are at greatest risk, and the nature
of the ADHD/SUD overlap. Clinicians also need to know how to counsel, screen, and treat these
patients in a time-efficient manner.
ADHD is often a precursor to the full spectrum of substance use disorders. To help your patients
avoid this hazardous combination, it is important to provide cautionary guidance throughout
childhood, screen all adolescents for substance use, and treat ADHD symptoms as soon as they
appear.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Primary Care and Pediatric Substance Abuse
Substance abuse should concern pediatricians and other primary-care practitioners who care for
young patients because it affects children and caretakers across the developmental spectrum -beginning with the prenatal period (Figure 1).[1] The visit of a pregnant mother presents an
opportunity to make clear that addressing substance abuse will be part of well-child care in your
practice. You will want to take note of any in utero substance exposure and explain to the mother
the many ways such exposure endangers her unborn infant -- increasing the risk of spontaneous
abortion, placental abruption, postnatal withdrawal symptoms, neurobehavioral abnormalities, and
sudden infant death syndrome. Estimated in utero exposure rates are 11% for tobacco, 10% to
13% for alcohol, and 3% for illicit drugs; every year in this country, 40,000 babies are born with
fetal alcohol syndrome.[2,3] Also, some 40% to 50% of confirmed child abuse cases involve a
parent with substance abuse.[4]
Figure 1. The risk of SUD in individuals with ADHD extends across the developmental timeline.
Guidance on the importance of avoiding substance use should continue during middle childhood.
This may be a good time to begin talking directly to the child, to help him or her frame appropriate
attitudes about drugs, cigarettes, and alcohol. Adolescence calls for special vigilance; it is a time
when youngsters are more directly exposed to substance use and may start to experiment with
drugs. Keep in mind that in middle to late adolescence, peer influence becomes stronger. Try to
become familiar with substance-use trends in your area so you can tailor your advice and
screening appropriately.
Children first begin experiencing disorders of abuse and dependence, as defined by the Diagnostic
and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), during adolescence.[5] But many
teens who do not meet the DSM-IV criteria for a disorder nevertheless manifest clinically important
behaviors, such as involvement in motor vehicle accidents, violent and sexual risk-taking
behaviors, and academic and social difficulties. This is one reason all teenagers should be
screened for substance abuse, followed by appropriate intervention.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
How Common Is Pediatric Substance Use?
The Monitoring the Future study is an annual nationwide survey of behaviors, attitudes, and values
among 50,000 8th, 10th, and 12th graders in the United States. The 2005 survey found that the
rate of tobacco use -- daily, for the past month, and lifetime -- increased with age, with about one
quarter, more than one third, and one half of 8th, 10th, and 12th graders, respectively, reporting
"lifetime" use.[6] Even more teens drank alcohol than used tobacco; for example, 47% of high
school seniors say they have consumed alcohol within the past month, vs 23% reporting use of
tobacco.[6]
The survey also showed that 10% of 8th graders and 25% of 12th graders had used some illicit
drug within the past month. Marijuana was the most common. Abuse of prescription drugs among
high school students includes pain relievers (principally OxyContin and Vicodin) as well as
stimulants, sedatives, barbiturates, and inhalants (see "Club drugs -- the list keeps changing").
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Smoking Leads To Other Substance Abuse
Results of longitudinal and cross-sectional studies make clear that the teenager who smokes is at
increased risk for using other drugs, and that smoking is highly comorbid with SUD in
adolescence.[7,8]Further, early onset of smoking (by the age of 13) and frequent smoking appear
to be strong predictors of further progression along the path of substance use, according to results
of a 20-year longitudinal study of more than 1000 students.[9] Males appear to be more at risk than
females. Since early onset of cigarette smoking is associated with subsequent onset of other
substance use, some researchers consider smoking an SUD gateway.
A recent study showed that the association of smoking with subsequent onset of other substance
use applies even more strongly to youngsters with ADHD than to those without the disorder.[10]
The investigation involved 97 youngsters with ADHD and 297 controls, all of whom were at least 12
years old. The 15 youngsters with ADHD who smoked cigarettes were significantly more likely to
use alcohol and illicit drugs and to develop abuse and dependence in later years than the 76
youngsters with ADHD who did not smoke.
It may be that in youngsters with ADHD, smoking is a marker of elevated risk of SUD. In any case,
this study reinforces the importance of counseling teens with ADHD about not smoking. And since
parental smoking is a major risk factor for a child's initiating the habit, talking to parents about their
own cigarette use is also beneficial. Even if parents are unwilling to quit themselves, encouraging
their children not to take up the habit may be effective. Not only are youngsters who smoke and
have ADHD more likely to use other substances than youngsters who smoke and don't have
ADHD, but youngsters with ADHD are more likely than their peers to smoke in the first
place.[10,11]
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Risk Factors For Alcohol Abuse In ADHD Patients
The link between alcohol use and ADHD is of particular importance because alcohol is by far the
most commonly used substance among adolescents as well as in society at large. Although
studies of alcohol abuse and ADHD have certain limitations -- for example, they do not take into
account that alcohol use is normative behavior -- certain themes seem clear:
Conduct disorder greatly increases the risk of alcohol use disorder.
In an ongoing study of more than 350 individuals in the Pittsburgh area now in their mid-20s with
alcohol use disorders, investigators have found that between one quarter and one half of those
with ADHD also have conduct disorder, a comorbidity that raises the risk of drinking at an early
age. Individuals with comorbid ADHD and conduct disorder consumed alcohol more frequently and
in greater quantity and met the criteria for a nonalcoholic SUD.[12] This study and earlier ones
have shown that conduct disorder puts youth at high risk for alcohol abuse or dependence.
Conduct disorder is the most common psychiatric comorbidity of alcohol use disorders in
adolescents.
ADHD persistence is a predictor of alcohol abuse/SUD.
Several studies, including another investigation in Pittsburgh, show that persistence of ADHD is a
better predictor of alcohol abuse than the original ADHD status.[13] Even after controlling for
conduct disorder, ongoing symptoms of ADHD have been associated with repetitive drunkenness
and daily cigarette smoking.[13] The link between ADHD and alcohol abuse was most pronounced
in patients with behavior problems. It also appears that of the spectrum of ADHD symptoms, those
of impulsivity are most associated with greater alcohol use.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Risk Factors for Substance Use
Of the total number of adults who abuse substances, about 20% have ADHD (Figure 2).[1] Studies
show that 35%-71% of adult alcoholics had childhood-onset ADHD that persisted into their adult
years.[14,15]
Figure 2. ADHD/SUD overlap: Among adults who abuse substances, about 20% have ADHD,
studies show.
Several characteristics have been associated with this ADHD population:
Psychiatric comorbidities are common.
Approximately one third of adolescents with ADHD and a diagnosis of substance abuse have
psychiatric comorbidities, primarily conduct disorder but also major depressive disorder,
generalized anxiety disorder, and traumatic stress disorder.[16] And contrary to popular belief, girls
with ADHD and substance abuse or dependence are even more likely than their male counterparts
to have psychiatric comorbidities, and they begin abusing substances about a year and a half
earlier than boys do.[16]
Studies in cocaine abusers who sought treatment showed a high proportion with ADHD and a
history of conduct disorder or antisocial personality disorder. ADHD also was associated with a
longer course of substance abuse and less remission in these individuals.
Substance abuse is often associated with ADHD-related predictive factors.
Severe childhood inattentive symptoms appear to be an important risk factor for substance abuse,
as are oppositional defiant disorder/conduct disorder, persistence of ADHD, and adolescent
conduct disorder.[13]
Substance abuse may represent self-medication of ADHD symptoms.
A survey of 334 college students, of whom 84 had a diagnosis of ADHD, demonstrated a
relationship between substance abuse and ADHD symptoms. Those with ADHD symptoms were
more likely to report recent use of tobacco and other substances than those without symptoms,
suggesting self-medication.[17] In addition, smoking has been associated with improvement in
executive functions (planning ahead, setting priorities, controlling impulses, etc) that often are
impaired in ADHD, indicating the potential for self-medication.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Screening for Adolescent Substance Abuse
Every primary-care practice should screen adolescent patients for use of alcohol and drugs. For
patients who don't use substances or whose use remains minimal, delivering a cautionary
message is sufficient. For patients whose substance use puts them at risk for abuse, a brief
intervention, such as motivational interviewing, should be offered, along with further evaluation
(see "Motivational interviewing: mobilizing the patient's own resources"). Refer patients with
dependence on substances (as shown by a DSM-IV adolescent diagnostic interview) for treatment
to a psychiatrist or other appropriate behavioral-care specialist.
According to the American Academy of Pediatrics, fewer than half of pediatricians screen their
adolescent patients for alcohol/drug use. Feedback from a series of focus groups among
pediatricians and other primary-care practitioners who care for children revealed some of the
reasons why.[18] Lack of time and not knowing what to do next if a teen screens positive -- or
believing that no therapeutic interventions are available -- were major reasons for not screening.
Pediatricians also cited the need to triage competing medical problems during a short visit, parents'
unwillingness to leave the room to provide the necessary confidentiality, insufficient time to locate
treatment resources and to make referrals, and unfamiliarity with screening tools. Projects are
currently under way to help physicians overcome some of these barriers.
The CRAFFT screening instrument, which consists of 6 orally administered questions, is a widely
accepted, easy-to-administer, free tool that has been shown to have a sensitivity of 80% and a
specificity of 86% for abuse or dependence[19] (see "CRAFFT screening questions for problematic
drug/alcohol use"). To encourage the adolescent to answer the questions honestly, we suggest
asking, in a nonjudgmental manner, a few general questions first: "Have you ever tried alcohol?
What about marijuana? Any drug?"
Two or more "yes" answers to the CRAFFT questions are considered a positive result, indicating
that further evaluation is appropriate. Point out to the teen who has a positive result that, according
to the screening criteria, he has a serious problem, adding: "I'm really worried about you." Though
this brief intervention is in itself beneficial, it is not enough. A positive CRAFFT test calls for a
diagnostic interview, which generally means scheduling a 30-minute follow-up visit to discuss the
substance use (insurance generally covers this visit).
Can a physician rely on impressions instead of a DSM-IV diagnosis derived from a structured
interview? One investigation suggests not.[20] It found that adolescent-medicine specialists in an
adolescent clinic correctly identified only 18 of 101 teens whose use of alcohol and drugs was
problematic. Of 50 patients with an abuse diagnosis, these clinicians correctly identified 10. They
failed to identify any of the 36 with a diagnosis of dependence.
In a recent study of adolescents and young adults, screening questionnaires actually appeared to
be more reliable in identifying substance abuse than urine tests, even in the high-risk groups. But
urine toxicologies remain helpful in confirming suspected cases and monitoring patients with recent
addictions.[21]
CRAFFT screening questions for problematic drug/alcohol use
C Have you ever ridden in a CAR driven by someone (including you) who was "high" or had been
using alcohol or drugs?
R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol/drugs while you are by yourself, ALONE?
F Do you ever FORGET things you did while using alcohol or drugs?
F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug
use?
T Have you ever gotten into TROUBLE while you were using alcohol or drugs?
Two or more "yes" answers suggest a significant problem with using alcohol or drugs.
Free copies of the CRAFFT questionnaire can be found at www.crafft.org or www.ceasarboston.org/clinicians/crafft.php
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Treating ADHD and SUD
Choosing treatment for ADHD or SUD must take into account that both these conditions almost
always have additional psychiatric comorbidities. Half of adolescents with SUD have ADHD, the
most common comorbidity in adolescents with SUD for which pharmacotherapy is first-line
treatment. But conduct disorder is even more common in SUD patients -- ranging from 60% to 80%
-- and pharmacotherapy is not first-line treatment. For depression (comorbid with SUD in 15% to
25% of cases) and anxiety disorders (comorbid in 25% to 35% of cases), psychosocial
interventions, primary cognitive behavioral therapy, family-based intervention, and medication have
been shown effective.
It is important to treat both ADHD and SUD when they co-occur. It is best to strive for abstinence or
low-level substance use prior to initiating ADHD treatment, according, in part, to findings from
controlled trials treating ADHD in active SUD patients. For instance, in a 12-week, controlled trial,
69 adolescents with substance abuse, ADHD, and conduct disorder were treated for ADHD with
pemoline but were not treated concurrently for SUD. Pemoline had the expected effect on ADHD,
but in the absence of treatment for SUD, neither the pemoline group nor the placebo group showed
any change in substance abuse.[22]
Conversely, an unpublished study of adolescents who were treated for depression with fluoxetine
or placebo showed that in both groups, when depression remitted, substance use declined
significantly. About one third of the youngsters in the study also had ADHD, and those whose
ADHD was untreated had the same decrease in drug use as those who were treated.
Nevertheless, given that ADHD is characterized by low frustration tolerance, impulsivity, and the
like, not treating these symptoms can only make quitting substance use more difficult.
Pharmacotherapy for ADHD can be initiated early along with treatment for SUD. In selecting a
medication for ADHD in a patient with SUD, tricyclic antidepressants and the antihypertensive
clonidine are not recommended. Consider atomoxetine (Strattera) or the antidepressant bupropion
(Wellbutrin), though its use for ADHD is off label. When nonstimulants are ineffective, stimulants
can be considered in patients with a reasonable duration of stable sobriety. The most commonly
used stimulants are methylphenidate (Ritalin, Concerta, Daytrana, Focalin, Methylin, Metadate,
etc.) and amphetamine compounds (Adderall, Dexedrine, DextroStat). Stimulants have been
shown to be effective for about 70% of adolescents and seem to operate in a dose-dependent
manner in improving cognition and behavior.[23] The beneficial effects of stimulants are of similar
quality and magnitude for adolescents of both genders and for younger and older children.[23]
The newer extended-release formulations provide longer duration of action, resulting in the need
for fewer daily administrations, elimination of the need to take medication at school, and thus fewer
adherence issues. Longer-acting stimulants also appear to have less potential for diversion and
abuse than shorter-acting stimulants. (A new formulation of amphetamine called lisdexamfetamine
is designed to have less potential for abuse. The medication, which has demonstrated safety and
effectiveness for ADHD in clinical trials, has received an approvable letter from the FDA.)
Understandably, abuse of stimulants is a concern in adolescents and young adults with ADHD and
SUD. But ADHD pharmacotherapy does not appear to worsen drug use. In a meta-analysis, 5 of
the 6 studies reviewed did not support the notion that stimulants increase later substance
abuse.[24] In fact, 4 of the 6 studies indicated that the risk of substance abuse was actually
reduced in those who were treated for ADHD, with a greater reduction in adolescents than in
adults.
A recent study showed a gender difference in vulnerability to SUD among ADHD patients.[25]
Individuals identified as having ADHD were followed from birth for a mean of 17.2 years; 295 of the
ADHD subjects were treated with psychostimulant medication and 84 were not. Sixty (20.3%) of
those who were treated later developed substance abuse, compared with 23 (27.4%) of those not
treated, but the protective effect of treatment applied only to boys. In fact, untreated ADHD girls
had a lower rate of substance abuse than treated ADHD girls (10.3% vs. 15.2%).
When treating ADHD/SUD patients, it is best to first stabilize the SUD; if that is not feasible,
pharmacotherapy for ADHD can be initiated early along with an emphasis on treatment for SUD.
Data on the relative outcomes of integrated and sequential treatment are not available.
The principles of treating the SUD/ADHD combination
• Because youths with ADHD begin to use substances earlier than other children, they should be
educated about the risks of smoking, drinking, and illicit drug use before age 11. Parents should be
included in this discussion.[1,23]
• In patients with coexisting SUD and ADHD, the priority is to stabilize the addiction before treating
the ADHD.
• There are several options for treating ADHD. Pharmacologic management relies on agents that
affect dopaminergic and noradrenergic neurotransmitters -- the stimulants, antidepressants, and
antihypertensives. A noradrenergic reuptake inhibitor has also become available. Comorbidities
must be taken into account when considering treatment options. The most common comorbidities
are conduct disorder, depression, and anxiety.
• Stimulants have been shown to be effective for more than 70% of adolescents, but treatment with
stimulants should be undertaken cautiously and monitored closely. Extended-release formulations
have less potential for diversion and abuse.[23]
• Substance use should be monitored as the child ages into adolescence. Both the child and the
parent should be counseled regarding the risks associated with substance use, especially the
hazards of driving under the influence of alcohol or drugs.
• Depending on the age of the child and the consent laws in the state, the child's consent may be
needed to conduct screening. The American Academy of Pediatrics recommends that drug
screening not be performed without the child's consent except in cases of medical necessity. In
addition, parents need to know what to do if the test results are positive.
• For patients who don't use substances or whose use remains minimal, a "motivational interview"
might be helpful. Adolescents who are unable to stop using substances should be referred for
professional counseling or a drug-treatment program.
• College-bound adolescents should be advised to avoid binge drinking. They should know that
because of their ADHD, they have an increased long-term risk of alcohol and illicit-drug use.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Provocative Findings in Adult Studies
Trials with adults offer additional insight into how stimulant medications for ADHD affect illicit-drug
use in ADHD patients who abuse substances.
A recent investigation found that the response to cocaine did not differ between cocaine abusers
with ADHD and those without ADHD. However, maintenance on methylphenidate (sustainedrelease) decreased some of what patients perceived to be the "good" and reinforcing effects of
cocaine. Cocaine abusers with ADHD given methylphenidate also showed only slight elevations in
blood pressure and heart rate.[26]
Another investigation in 48 cocaine-dependent adults with ADHD showed that methylphenidate
(immediate-release) resulted in significantly more ADHD symptom relief than did placebo and did
not worsen cocaine use. The methylphenidate and placebo groups did not differ in cravings for
cocaine or rate of cocaine-positive urine samples.[27]
Finally, a comparison of the efficacy of methylphenidate, bupropion, and placebo in methadonemaintained adults with ADHD showed a reduction in ADHD symptoms in all 3 groups and no
significant differences in outcome among treatments. Nor did it appear that sustained-release
methylphenidate or sustained-release bupropion had an advantage over placebo for reducing
additional cocaine use.[28]
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Abuse Potential of Psychostimulants
A survey of more than 300 college students found that among those prescribed medications for
ADHD, 22% said they had used the medication to "get high" and almost 29% said they had given
or sold their medication to someone else.[29] Pharmacologic determinants of abuse potential
include the specific drug at issue and its dose, route of administration, time to onset of action and
to peak effect, and duration of action. Abuse potential is also determined by environmental, social,
and individual factors, such as the drug's availability and the individual's predisposition or
responsiveness. Studies of these determinants that are particularly relevant for ADHD include the
following:
• A comparison of the effects of cocaine administered intravenously or intranasally in subjects with
a history of cocaine use showed a positive relationship between peak plasma concentration,
physiologic and subjective responses, and size of dose.[30] Asked about drug effect, subjects who
received the slower intranasal infusion reported less of a "rush" than did those who received the
more rapid intravenous infusion. Similarly, a systematic evaluation of the effects of varying
intravenous infusion speeds of cocaine showed that subjective responses were significantly greater
when infusion was more rapid.[31] These findings suggest that immediate-release formulations of
psychostimulants prescribed for ADHD may have more potential for abuse than extended-release
preparations.
• Studies in pain management show that patients seek additional medications -- appropriately or
inappropriately -- when they have been undertreated, a phenomenon called pseudoaddiction. This
finding relates to pharmacotherapy for ADHD, because clinicians decide how much and how often
the patient should take the prescribed agent, although, of course, the patient ultimately decides
how much to take. Some patients may take additional medications when the prescribed dose does
not alleviate their symptoms.
• Studies in both animals and humans indicate that with administration route and dose equivalence,
methylphenidate and amphetamines have similar abuse potential. Clinicians should therefore
prescribe the agent with the greatest demonstrated efficacy for the patient. Noncompliance is more
likely to take the form of underuse rather than overuse of the prescribed medication.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Nonpharmacologic Therapy
It is becoming increasingly apparent that effective treatment for substance abuse when it occurs in
combination with ADHD includes psychosocial interventions. In part, this is because ADHD itself
responds best to a combination of psychopharmacologic and behavioral treatment. There is some
debate about how much improvement can be attributed to psychotherapy itself or to other,
nonspecific factors. Investigators have found, for example, that therapeutic techniques themselves
seem to account for only 15% of improvement. Expectancy accounts for another 15% of
improvement, the therapeutic relationship for 30%, and extratherapeutic factors, related to the
client or the environment, for example, for 40% -- all factors that can be changed or manipulated in
treatment.[32,33]
The 14-month Multimodal Treatment Study of Children with ADHD (MTA) of 579 children found
that either a combination of behavioral therapy and medical management or medical management
alone was substantially superior to behavioral therapy alone. Regarding social skills, academic
performance, and parental relations, results also suggested slight advantages of combination
therapy over single treatments.[34] Data from this large landmark investigation continue to be
interpreted and debated. In the meantime, combination therapy also proved superior to either
behavioral therapy or medical management alone in a study of 27 children with ADHD in an
intensive summer camp program, but the study was small and brief.[35] Further, as earlier studies
also showed, even low doses of methylphenidate enhanced outcomes when combined with
psychosocial interventions for coping with ADHD impairments.
As for effectively treating individuals who abuse substances, motivation and readiness to change
are key. Remaining in treatment and being engaged in the therapeutic process also are important.
The individual's belief that he or she can deal with certain behaviors (a feeling of self-efficacy) has
been found to be predictive of positive outcome, as has early response to treatment.
No single treatment approach to SUD appears to be superior to any other; promising short-term
strategies include behavioral modification, cognitive-behavioral therapy (training to restructure
thought patterns), contingency management (reinforcing desirable behavior), the 12-step program,
motivational interviewing, family therapies, integrative psychosocial programs, and medications
and psychosocial interventions. Some experienced clinicians strongly support an integrated
approach that comprises 3 components: drug urinalysis, addressing the individual patient's needs,
and involving the family. Group therapy is the most cost-effective approach for treating adolescents
with SUDs and should be used as long as it is effective.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Putting Theory Into Practice
The relationship between ADHD and SUD clearly is complex. Though we have learned how to
manage these disorders and prevent SUDs in the youngster with ADHD, much remains to be
discovered. The physician's challenge is to translate what we know now into a practical approach
for the primary-care setting.[36] The primary-care clinician who is not comfortable treating the
patient with a dual diagnosis of ADHD and an SUD may want to refer such patients, ideally, to a
clinician with expertise in providing integrated treatment for both SUD and ADHD. Alternatively,
ADHD should be treated, with close coordination of SUD management, by a clinician with expertise
in this area.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Club Drugs—The List Keeps Changing
Club drugs -- so named because of use at nightclubs and "raves" -- are drugs of opportunity. They
vary with the club's geographic location and current "flavor of the month" fads in illicit drug use.
Because clubs charge entry fees and the drugs themselves cost money, club drugs tend to turn up
mostly in affluent communities. Here are 4 currently popular ones:
• Ecstasy (3,4-methylenedioxy-n-methylamphetamine) is a cross between an amphetamine and the
hallucinogen mescaline. Ecstasy, which may be called XTC, X, E, Adam, Clarity, or Lover's Speed,
is taken orally in a tablet or capsule. Within 30-60 minutes, the user feels its effects, which can last
3-6 hours. There is often a hangover the next day. Adolescents describe strong feelings of
euphoria, comfort, and empathy, and a sense of connection to others. Ecstasy is linked to
significant increases in heart rate and blood pressure as well as to cognitive impairment.
• GHB (gamma-hydroxybutyrate) generally is taken as a clear liquid but also is available as a
powder, tablet, or capsule and is used in combination with alcohol. Two groups favor GHB: those
who like its intoxicating alcohol-like properties, and athletes, who like its purported growth
hormone-releasing effects, which users mistakenly believe will build muscle mass. Effects begin
within 20 minutes and last 3-4 hours. At high doses, GHB increases risk for seizure,
unconsciousness, and coma, though at low doses it can be anxiolytic.
• Ketamine, a human and veterinary injectable anesthetic, is used for its psychedelic and
dissociative effects. Referred to as K, Special K, Vitamin K, or cat valiums, ketamine is often
snorted or smoked with marijuana or tobacco products, though some people inject it
intramuscularly. At low doses, ketamine may impair attention, learning ability, and memory, and -at high doses -- it may cause delirium, amnesia, impaired motor function, and respiratory
depression, among other effects.
• 5-MeO-DiPT (5-methoxy-N,N-diisopropyltryptamine), a synthetic psychoactive tryptamine, is
similar to the hallucinogen psilocybin. It is available as a powder and as liquid. Onset of action is
20-60 minutes if ingested and less than 5 minutes if smoked or inhaled. The drug, called Foxy or
Foxy Methoxy, produces a strong feeling of energy, intensification of tactile experiences, a sense
of well-being, and visual/auditory hallucinations. Side effects include nausea, diarrhea, anxiety, and
insomnia.
Physicians can more effectively counsel their adolescent patients about club drugs by keeping up
with what is popular in their area via the Internet. Make sure the teen knows that using a
recreational drug even a single time can have lasting negative consequences. Advise parents to
make it clear to their children that they disapprove of drug use, and refer them to websites that can
support their efforts, such as www.theantidrug.com and www.DanceSafe.org.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Motivational Interviewing: Mobilizing the Patient's Own Resources
Motivational interviewing is a counseling style for eliciting behavioral change by helping patients
explore and resolve ambivalence about such change. Resolving this ambivalence is the basic
purpose of the intervention.[37] Motivational interviewing is intended to enhance the individual's
intrinsic motivation to change and is therefore totally unlike the confrontational 12-step program
and other such approaches, which may provoke resistance to change.
Expressing empathy is a major principle of motivational interviewing. Try to understand the
patient's frame of reference and listen carefully to what he or she has to say, with the aim of
creating forward momentum that will trigger change. Open-ended questions help sustain
conversational momentum, as do affirmations of the patient's strengths. Summarizing what the
patient has told you is an effective way to express your interest, build rapport, and emphasize
important parts of the discussion and direct it.
The spirit of the exchange between the clinician and the patient is more important than specific
clinician behaviors during the interview, however. You can foster the desired spirit by following
certain basic precepts:
• Elicit motivation to change from the patient; do not impose it.
• Direct the patient to articulate and resolve ambivalence about changing behavior. Your task is to
help him or her express both sides of the issue and offer guidance toward a resolution that will lead
to change.
• Use a quiet and eliciting style; do not be argumentative and confrontational. Don't give advice. If
the patient resists the idea of change, "rolling" with the resistance instead of opposing it may
actually bring him or her back to a more balanced position, particularly if he or she seems to reject
every alternative.
Comprehensive information about motivational interviewing is available at
www.motivationalinterview.org.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
Evaluating and Educating About ADHD
Recommended consecutive steps
Tips and comments
Develop a warm, trusting relationship with the patient
Enhance the patient's strengths by showing an interest in his or her interests; let the patient teach
you something
Practice motivational interviewing
Find out to what and whom patient is "connected," such as a parent, teacher, coach, specific
activity, and promote this connectedness
Research shows that connectedness is a crucial factor for adolescents in overall success
Take a medical and psychiatric history, including behavior and legal issues, school record, driving
performance. Take a family history of depression, suicide, anxiety disorders, bipolar, substance
abuse, alcoholism
Take a pointed and careful cardiac history as well as family history for sudden cardiac death, early
heart attacks, congenital heart disease, and significant arrhythmias
Evaluate any adolescent with a family history or personal history that is questionable for any kind of
cardiac disease before treating with pharmacotherapy for ADHD
Make a thorough evaluation of the patient's ADHD and comorbidities
The American Academy of Pediatrics practice guidelines on diagnosing and evaluating the child
with ADHD provide a framework for diagnostic decision making.[1]
Provide adolescent with general education about what ADHD is and is not
Make sure that patient understands that ADHD is a genetic disorder, is a mild disability and has no
relationship to intelligence, is invisible but may have significant consequences
Discuss medications for ADHD
Tell patient and parent that your major concern is that he does well—not that he takes medication
Clarify that rare cardiac deaths are in people with underlying cardiac abnormality (hence, cardiac
evaluatioin described above)
Stress that medication side effects indicate the wrong medication or wrong dose, which can be
changed
Let patient decide whether or not to take medication (while parent is out of the room)
Discuss other options, such as counseling, tutoring, parental help, consulting a social worker.
Screen for substance abuse. Take careful SUD and sexual histories
Adolescents find it difficult to disclose substance abuse to a health professional, so screen with a
questionnaire or on the computer
Based on findings, determine if patient might not be a candidate for stimulants (active stimulant
abuser?) and might be candidate instead for nonstimulant medication
Discuss medication options (if patient decides to take medication)
Discuss relative merits for individual patient of short-acting and long-acting formulations, dose
titration, evaluation of efficacy and side effects as dose is increased.
Address diversion issue and possible effects of using caffeine, OTC decongestants, club drugs
with prescribed medications
Keep in mind that combined pharmacologic and psychotherapeutic treatment may be best
Develop a treatment plan and goals
Be aware that parent and adolescent may not have the same goals and different definitions of
"success"
Parents need a lot of reassurance and help in reducing conflict with the adolescent
Help parent and patient understand the importance of applying established skills to areas where
less successful
Monitor the patient closely
Evaluate progress towards goals, how well patient is dealing with the tasks of adolescence, and
alleviation of the most troubling ADHD symptoms
Adjust medications and other aspects of treatment plan as appropriate
Monitor drug use, smoking, sexual activitiy, and substance abuse
[1] Adapted from American Academy of Pediatrics. Clinical practice guideline: diagnosis and
evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000:105:1158-1170.
ADHD and Substance Abuse: A Frequent -- and Risky -- Combination
Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MS
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Authors and Disclosures
Boston University School of Medicine asks all individuals involved in the development and
presentation of Continuing Medical Education (CME) activities to disclose all relationships with
commercial interests. This information is disclosed to CME activity participants. Boston University
School of Medicine has procedures to resolve any apparent conflicts of interest. In addition, faculty
members are asked to disclose when any discussion of unapproved use of pharmaceuticals and
devices is being discussed.
Author
Timothy E. Wilens, MD
Academic Chair
Associate Professor of Psychiatry, Harvard Medical School; Director, Substance Abuse Program,
Pediatric Psychopharmacology Clinic, Massachusetts General Hospital, Boston, Massachusetts
Disclosure: Grant/Research Support: Abbott Pharmaceuticals, Alza/Ortho-McNeil, Cephalon,
GlaxoSmithKline, Janssen Pharmaceutica, Eli Lilly and Company, NIDA, NIMH, NICMH,
Neurosearch, Novartis, Pfizer Pharmaceuticals, Saegis Pharmaceuticals, Sanofi-Synthelabo, Shire
Pharmaceuticals Inc; Consultant: Abbott Pharmaceuticals, Alza/Ortho-McNeil, Cephalon,
GlaxoSmithKline, Janssen Pharmaceutica, Eli Lilly and Company, NIDA, NIMH, NICMH,
Neurosearch, Novartis, Pfizer Pharmaceuticals, Saegis Pharmaceuticals, Sanofi-Synthelabo, Shire
Pharmaceuticals Inc.; Speaker's Bureau: Abbott Pharmaceuticals, Alza/Ortho-McNeil, Cephalon,
GlaxoSmithKline, Janssen Pharmaceutica, Eli Lilly and Company, NIDA, NIMH, NICMH,
Neurosearch, Novartis, Pfizer Pharmaceuticals, Saegis Pharmaceuticals, Sanofi-Synthelabo, Shire
Pharmaceuticals Inc.
Himanshu P. Upadhyaya, MBBS, MS
Associate Professor, Department of Psychiatry and Behavioral Sciences, Medical University of
South Carolina, Charleston, South Carolina
Disclosure: Grant/Research Support: Eli Lilly and Company, Cephalon, Inc.; Consultant: Shire
Pharmaceuticals Inc.; Advisory Board: Janssen Pharmaceutica, Shire Pharmaceuticals Inc.
Oscar G Bukstein, MD, MPH
Planning Committee
University of Pittsburgh School of Medicine
Disclosure: Grant/Research Support: McNeil Consumer & Specialty Pharmaceuticals, Shire
Pharmaceuticals Inc., Forest Laboratories; Consultant: Cephalon, Shire Pharmaceuticals Inc.,
Forest Laboratories; Speaker's Bureau: McNeil Consumer & Specialty Pharmaceuticals, Shire
Pharmaceuticals Inc., Novartis
John Grabowski, PhD
Planning Committee
University of Texas Health Science Center
Disclosure: Grant/Research Support: NIH, NIDA; Consultant: GlaxoSmithKline; Honorarium: Shire
Pharmaceuticals Inc.; Common Stock of Negligible Proportion: Eli Lilly and Company, Merck,
Pfizer Inc., New River Pharmaceuticals, Aventis
Yifrah Kaminer, MD, MBA
Planning Committee
University of Connecticut Health Center
Disclosure: Dr Kaminer has nothing to disclose with regard to commercial support
Alessandra N. Kazura, MD, FAAP
Planning Committee
Brown University Medical School
Disclosure: Dr Kazura has nothing to disclose with regard to commercial support
John R. Knight, MD
Planning Committee
Harvard Medical School
Disclosure: Dr Knight has nothing to disclose with regard to commercial support
Frances R. Levin, MD
Planning Committee
Columbia University College of Physicians and Surgeons
Disclosure: Research Support: Ortho-McNeil Pharmaceutical, UCB Pharmaceuticals, Eli Lilly and
Company, Shire Pharmaceuticals Inc., AstraZeneca; Consultant: Ortho-McNeil Pharmaceutical, Eli
Lilly and Company, Shire Pharmaceuticals Inc., AstraZeneca
Steven J. Parker, MD
Course Director
Boston University School of Medicine
Disclosure: Consultant: WebMD
Paula D. Riggs, MD
Planning Committee
University of Colorado at Denver Health Sciences Center
Disclosure: Grant/Research Support: NIDA, McNeil Pharmaceuticals
Howard Schubiner, MD
Planning Committee
Wayne State University
Disclosure: Speaker's Bureau: Shire Pharmaceuticals Inc.
Ramon Solhkhah, MD
Planning Committee
Columbia University College of Physicians and Surgeons
Disclosure: Speaker's Bureau: Eli Lilly and Company, GlaxoSmithKline, Bristol-Myers Squibb,
Pfizer, Inc
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Copyright © 2007 Haymarket Medical.
This CME activity is based on a monograph that was developed by the Substance Use Disorders
and ADHD Academic Leadership Council, November 2006.
This activity was developed for pediatricians, psychiatrists, and other physicians who have
pediatric patients.
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