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03/08/2007 - Frequency of ADHD and Substance Use Disorders provides challenges for Physicians
Recent research has shown that a significant number children with Attention Deficit-Hyperactivity Disorder (ADHD) abuse substances when they become teenagers. Of course, substance abuse is of great concern for any teen, however those with persistent ADHD symptoms tend to be at a higher risk of future substance use disorder (SUD).
According to the 2005 Monitoring the Future survey, 47% of high school seniors say they have consumed alcohol within the past month, versus 23% reporting use of tobacco. 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 society at large.
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.
Several studies show that persistence of ADHD is a better predictor of alcohol abuse than the original ADHD status. Even after controlling conduct disorder, ongoing symptoms of ADHD have been associated with repetitive drunkenness and daily cigarette smoking.
ADHD may also serve as a predictor, of sorts, for future SUD among adults. Of the total number of adults who abuse substances, some 20% have ADHD. Studies show that 35% to 71% of adult alcoholics had childhood-onset ADHD that persisted into their adult years.
Screening for Adolescent Substance Abuse
Every primary care practice should screen adolescent patients for use of alcohol and drugs, especially those with ADHD or conduct disorder. For patients who don't use substances or whose use remains normal, delivering a cautionary message is sufficient. For patients whose substance use puts them at risk for abuse, a brief intervention should be offered, along with further evaluation.
According to the American Academy of Pediatrics, fewer than half of pediatricians screen their adolescent patients for alcohol/drug use. Lack of time and not knowing what to do next if a teen screens positive - or believing that no therapeutic interventions are available - are major reasons given for not screening.
Treating Comorbid 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. Conduct disorder is even more common in SUD patients, ranging from 60% to 80%, and pharmacotherapy is not first-line treatment.
It is important to treat both ADHD and SUD when they co-occur. When treating patients, it is best to first stabilize the SUD. Given that ADHD is characterized by low frustration tolerance, impulsivity, and the like, not treating these symptoms can make treating substance abuse more difficult.
If abstinence or low-level substance use is not feasible, 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.
The relationship between ADHD and SUD clearly is complex. 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 to a clinician with expertise in providing integrated treatment for both SUD and ADHD.