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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.Credits Available

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Contents of This CME Activity

ADHD and Substance Abuse: A Frequent -- and Risky -- CombinationIntroductionby Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSPrimary Care and Pediatric Substance AbuseHow Common Is Pediatric Substance Use?Smoking Leads To Other Substance AbuseRisk Factors For Alcohol Abuse In ADHD PatientsRisk Factors for Substance UseScreening for Adolescent Substance AbuseTreating ADHD and SUDProvocative Findings in Adult StudiesAbuse Potential of PsychostimulantsNonpharmacologic TherapyPutting 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 -- CombinationADHD and Substance Abuse: A Frequent -- and Risky -- Combination

Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSIntroduction

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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSPrimary 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSHow 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").


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSSmoking 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]


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSRisk 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSRisk 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSScreening 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.ceasar-boston.org/clinicians/crafft.php


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSTreating 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSProvocative 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 (sustained-

release) 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 methadone-maintained 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]


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSAbuse 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSNonpharmacologic 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSPutting 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSClub 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSMotivational 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSEvaluating and Educating About ADHD

Recommended consecutive steps Tips and commentsDevelop 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 somethingPractice motivational interviewingFind out to what and whom patient is "connected," such as a parent, teacher, coach, specific activity, and promote this connectednessResearch shows that connectedness is a crucial factor for adolescents in overall successTake 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 arrhythmiasEvaluate any adolescent with a family history or personal history that is questionable for any kind of cardiac disease before treating with pharmacotherapy for ADHDMake a thorough evaluation of the patient's ADHD and comorbiditiesThe 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 notMake 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 consequencesDiscuss medications for ADHDTell patient and parent that your major concern is that he does well—not that he takes medicationClarify 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 changedLet 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 historiesAdolescents find it difficult to disclose substance abuse to a health professional, so screen with a questionnaire or on the computerBased on findings, determine if patient might not be a candidate for stimulants (active stimulant abuser?) and might be candidate instead for nonstimulant medicationDiscuss 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 medicationsKeep in mind that combined pharmacologic and psychotherapeutic treatment may be bestDevelop a treatment plan and goalsBe 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 adolescentHelp parent and patient understand the importance of applying established skills to areas where less successfulMonitor the patient closelyEvaluate progress towards goals, how well patient is dealing with the tasks of adolescence, and alleviation of the most troubling ADHD symptomsAdjust medications and other aspects of treatment plan as appropriateMonitor 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.


Timothy E. Wilens, MD and Himanshu P. Upadhyaya, MBBS, MSReferences

Wilens T. Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. Psychiatr Clin North Am. 2004;27:283-301.Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2003. Natl Vital Stat Rep. 2005;54:1-116.Bertrand J, Floyd LL, Weber MK, et al. Guidelines for identifying and referring persons with fetal alcohol syndrome. MMWR. 2005;54 (RR-11):1-14.3. Young NK, Gardner SL, Whitaker B, et al. A review of alcohol and other drug issues in the states' Child and Family Services reviews and program improvement plans. Available at: www.ncsacw.samhsa.gov/files/SummaryofCFSRs.pdf. Accessed September 6, 2006.Substance-related disorders, in American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Ed 4, rev. Washington, DC: American Psychiatric Press; 2000:191-212.Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the future: national results on adolescent drug use. Bethesda, Md; National Institute on Drug Abuse; 2006. Available at: www.monitoringthefuture.org. Accessed September 6, 2006.Lewinsohn PM, Rohde P, Brown RA. Level of current and past adolescent cigarette smoking as predictors of future substance use disorders in young adulthood. Addiction. 1999;94:913-921.Upadhyaya HP, Deas D, Brady KT, et al. Cigarette smoking and psychiatric comorbidity in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2002;41:1294-1305.Kandel DB, Yamaguchi K, Chen K. Stages of progression in drug involvement from adolescence to adulthood: further evidence for the gateway theory. J Stud Alcohol. 1992;53:447-457.Biederman J, Monuteaux MC, Mick E, et al. Is cigarette smoking a gateway to alcohol and illicit drug use disorders? A study of youths with and without attention deficit hyperactivity disorder. Biol Psychiatry. 2006;59:258-264.Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med. 2006;36:167-179.Molina BS, Pelham WE, Gnagy EM, et al. ADHD risk for heavy drinking and alcohol disorder are age-specific between adolescence and young adulthood. Alcoholism: Clinical and Experimental Research. In press.Molina BS, Pelham WE Jr. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol. 2003;112:497-507.Goodwin DW, Schulsinger P, Hermanson L, et al. Alcoholism and the hyperactive child syndrome. J Nerv Ment Dis. 1975;160:349-353.Wilens T, Spencer T, Biederman J. Are attention deficit-hyperactivity disorder and the psychoactive substance use disorders really related? Harv Rev Psychiatry. 1995;3:260-262.Shrier LA, Harris SK, Kurland M, et al. Substance use problems and associated psychiatric symptoms among adolescents in primary care. Pediatrics. 2003;111:e699-e705.Upadhyaya HP, Rose K, Wang W, et al. Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults. J Child Adolesc Psychopharmacol. 2005;15:799-809.

Knight JR, Van Hook S, Brooks T, et al. Barriers to screening teens for substance abuse in primary care. Poster presentation, Pediatric Academic Societies 2005 Annual Meeting; May 14-17, 2005; Washington, DC.Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156:607-614.Wilson CR, Sherritt L, Gates E, et al. Are clinical impressions of adolescent substance use accurate? Pediatrics. 2004;114:e536-e540.Gignac M, Wilens TE, Biederman J, et al. Assessing cannabis use in adolescents and young adults: what do urine screen and parental report tell you? J Child Adolesc Psychopharmacol. 2005;15:742-750.Riggs PD, Hall SK, Mikulich-Gilbertson SK, et al. A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43:420-429.Wolraich M, Wibbelsman C, Brown T, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005;115:1734-1746.Wilens TE, Faraone SV, Biederman J, et al. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. 2003;111:179-185.Katusic SK, Barbaresi WJ, Colligan RC, et al. Psychostimulant treatment and risk for substance abuse among young adults with a history of attention-deficit/hyperactivity disorder: a population-based, birth cohort study. J Child Adolesc Psychopharmacol. 2005;15:764-776.Collins SL, Levin FR, Foltin RW, et al. Response to cocaine, alone and in combination with methylphenidate, in cocaine abusers with ADHD. Drug Alcohol Depend. 2006;82:158-167.Schubiner H, Saules KK, Arfken CL, et al. Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. Exp Clin Psychopharmacol. 2002;10:286-294.Levin FR, Evans SM, Brooks DJ, et al. Treatment of methadone-maintained patients with adult ADHD: double-blind comparison of methylphenidate, bupropion and placebo. Drug Alcohol Depend. 2006;81:137-148.Upadhyaya HP, Rose K, Wang W, et al. Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults. J Child Adolesc Psychopharmacol. 2005;15:799-809.Javaid JI, Fischman MW, Schuster CR, et al. Cocaine plasma concentration: relation to physiological and subjective effects in humans. Science. 1978;202:227-228.Abreu ME, Bigelow GE, Fleisher L, et al. Effect of intravenous injection speed on responses to cocaine and hydromorphone in humans. Psychopharmacology (Berl). 2001;154:76-84.Morgenstern J, Blanchard KA, Morgan TJ, et al. Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting within treatment and posttreatment findings. J Consult Clin Psychol. 2001;69:1007-1017.Lambert MJ. Implications of outcome research for psychotherapy integration. In: Norocross JC, Goldstein MR, eds. Handbook of Psychotherapy Integration. New York: Basic Books; 1992:94-129.The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Multimodal treatment study of children with ADHD. Arch Gen Psychiatry. 1999;56:1073-1086.Pelham WE, Burrows-Maclean L, Gnagy EM, et al. Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD. Exp Clin Psychopharmacol. 2005;13:111-126.American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.

Rollnick S, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325-334.

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 supportAlessandra 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

These educational activities, certified by accredited providers, were not prepared by Medscape's editors, but are made available on our site as a service to our audience. Authors are routinely instructed by the provider to disclose significant financial relationships and mention of investigational drugs and unapproved indications. Medscape has received a fee for posting these activities. Direct questions or comments to: [email protected].

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.Goal

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