ADHD 'Inextricably' Linked to Substance Abuse

Megan Brooks

July 10, 2014

Attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) are "inextricably intertwined," and parents and patients should be made aware of this, according to a clinical report from the American Academy of Pediatrics (AAP).

The report, published online June 30 in Pediatrics, offers clinicians practical strategies for reducing the risk for SUDs in patients with ADHD and suggestions for safe prescribing of stimulant medication.

An "important part of ADHD treatment and stimulant medication management includes screening for SUDs and providing anticipatory guidance around the appropriate and safe use of stimulant medications," write Sheryl A. Ryan, MD, of Yale University in New Haven, Connecticut, and the AAP Committee on Substance Abuse.

Misuse, Diversion of Meds

The most common neurobehavioral disorder of childhood, ADHD affects about 8% of children and adolescents. Research has shown that children with ADHD are more apt to misuse alcohol, tobacco, and illicit substances compared with their peers without ADHD.

A meta-analytic review of relevant research published in 2011 found that children with ADHD were twice as likely to have a lifetime history of nicotine use; nearly 3 times more likely to report nicotine dependence in adolescence or adulthood; almost 2 times more likely to meet diagnostic criteria for alcohol abuse or dependence; approximately 1.5 times more likely to meet criteria for marijuana use disorder; twice as likely to develop cocaine abuse or dependence; and more than 2.5 times more likely to develop an SUD overall.

Stimulant medication may reduce the risk for trying drugs and developing an SUD, the report notes, and there is no evidence that stimulants increase the likelihood of developing an SUD.

However, stimulant medications have the potential for misuse, diversion, and addiction, the report notes. "Misuse and diversion of stimulant medications are more widespread problems than abuse or addiction," the report states.

Research suggests that between 16% and 23% of school-aged children are approached to sell, buy, or trade their stimulant medication. These findings highlight the need for careful diagnosis, anticipatory guidance for children prescribed stimulant medications, and careful monitoring to ensure appropriate use of stimulant medications, the report notes.

"Individuals with co-occurring ADHD and active SUDs require a careful, individual risk/benefit assessment regarding the safety of prescribing a stimulant medication. Longer acting preparations of stimulant medication, the prodrug formulation of dextroamphetamine, and nonstimulant medications for ADHD all have lower abuse potential than short-acting preparations of stimulant medication and, thus, their use should be strongly considered if there is a high risk of misuse, diversion, or abuse of stimulant medications," the report says.

Complex Relationships

"Although the information presented in the paper is not new, it is a very useful summary of the complex relationships among ADHD, substance use, ADHD medications, and comorbid disorders," Stephen V. Faraone, PhD, distinguished professor of psychiatry and of neuroscience and physiology, SUNY Upstate Medical University in Syracuse, New York, told Medscape Medical News.

"Parents and adolescent patients should be made aware of this risk, and doctors should monitor adolescent patients, as described in the article," said Dr. Faraone, who was not involved in developing the report.

"Substance abuse is extremely difficult to treat, so preventing it with appropriate ADHD treatments is essential. Although the most effective treatments are medications, emerging evidence suggests that, as an adjunct to treatment, cognitive-behavioral therapy (CBT) can help some adolescent patients. There is currently a need to develop CBT modules that teach adolescents with ADHD how to avoid trying drugs and, if they try them, how to stop using them," Dr. Faraone said.

Regarding the problem of diversion, Dr. Faraone noted that this is mainly an issue in colleges and some high schools. "It is not an epidemic, but clinicians need to be aware that it occurs."

Pediatrics. 2014;134:e293–e301. Full text

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