SUMMarySubstance use disorders are a frequent co morbidity in adult attentiondeficit hyperactivity disorder (ADHD). This review discusses the relationship between adult ADHD and substance use disorder, including use of licit and illicit substances such as nicotine, alcohol, cocaine and cannabis. We discuss treatment studies in this area and provide a treatment algorithm to guide clinicians in the management of adult ADHD comorbid with different forms and severities of substance use disorder. Declaration of intereStU.M. has received research grant support from JanssenCilag and honoraria and/or travel expenses for conference presentations from BristolMyers Squibb, Eli Lilly, JanssenCilag, PharmaciaUpjohn, and UCB Pharma. Box 1 Main clinical issues of ADHD comorbid with substance misuse• Substance use disorders are a frequent comorbidity in ADHD• Significant challenges exist in assessing and treating ADHD in the context of substance use disorder comorbidity• No clear treatment guidelines and care pathways exist to guide clinicians to manage ADHD with comorbid substance use disorder• Issues in relation to exacerbation of substance use disorder, future risk of substance misuse and diversion of psychostimulants complicate treatment Patients with ADHD and substance use disorders tend to commence early and experiment more freely with substance misuse compared with patients with substance use disorder without ADHD (Krause 2002a). Two recent studies, the UMASS project and Milwaukee study (Barkley 2008) demonstrate important findings. Compared with matched controls, adults with ADHD were more likely to be past or current users of substances and used these substances in greater amounts. They were also more likely to receive treatment for previous alcohol and drug use disorders. The UMASS project and the Milwaukee study further demonstrate that children growing up with ADHD may carry a greater risk for using alcohol and tobacco, while clinic-referred adults with ADHD seem more likely to use marijuana, cocaine and lysergic acid diethylamide (LSD). Substances most commonly used by adults with aDHD (Box 3)Nicotine Studies in both adults and adolescents have found ADHD to be associated with earlier initiation of regular cigarette smoking and higher rates of lifetime smoking (41-42% v. 26% for ADHD and non-ADHD respectively) (Pomerleau 1995). Significant associations between ADHD symptoms and cigarette smoking have been found in both general population (Kollins 2005) and longitudinal studies (Milberger 1997;Molina 2003). Attention-deficit hyperactivity disorder has been shown to be an independent risk factor for tobacco use specifically in clinical and highrisk samples, even after controlling for comorbid conduct disorder (Milberger 1997;Molina 2003). Milberger et al (1997) followed 6-to 17-year-olds with and without ADHD for 4 years and found that ADHD was specifically associated with a higher risk of initiating cigarette smoking even when controlling for social class, psychiatric comorbidity and intelligence.Factors such as i...

Aims and method To measure compliance with National Institute for Health and Care Excellence (NICE) recommendations in two adult attention-deficit hyperactivity disorder (ADHD) clinics and to guide further service development. We audited the case notes of 150 patients referred to adult ADHD clinics in East Anglia in 2010-2011 against NICE standards using an adapted version of the ADHD audit support tool.Results We found good compliance with NICE standards for diagnosis, assessment and pharmacological treatment of adult ADHD. There was a failure in smooth transitional arrangements from child and adolescent mental health to adult ADHD services. Comprehensive treatment programmes addressing psychological, behavioural, educational and occupational needs were not well developed. Deficiencies were observed in conducting recommended physical examinations. Substance use was prevalent in almost half of ADHD patients.Clinical implications Greater attention is needed in delivering better transitional arrangements and comprehensive treatment programmes for adult ADHD. More structured training with emphasis on ADHD-specific psychological interventions, physical examination and treatment of complex cases, especially with comorbid substance misuse, should be offered to clinicians.

Objective: To evaluate an enhanced physical health clinic led by physician associates (PAs) for patients with severe mental illness. Methods: A guidance and data collection tool was developed to support and document the outcomes of the PA-led enhanced physical health clinic. Results: The clinic led to diagnoses of diabetes, hyperlipidemia, and hematologic abnormalities. One patient was started on metformin, two patients started a prediabetes program with their general practitioner, one patient started simvastatin, one patient switched from cigarettes to e-cigarettes, and one patient switched from olanzapine to aripiprazole because of metabolic adverse reactions. Three patients intended to contact the National Health Service for cancer screening for which they were eligible but they had not taken up. Conclusions: PAs can be integrated into a community mental health multidisciplinary team and support the physical health of people with severe mental illness. Mental health trusts should consider roles for PAs in their workforce planning.

Aims and methodTo evaluate the quality of services offered by community drug and alcohol teams (CDATs) to pregnant women in substitution treatment. A full audit of the practice across all local CDATs against national standards was undertaken in 2008 and 2010.ResultsQuality of services improved and met three standards in 100% and the fourth standard in 96% of cases. There was good implementation of the recommendations arising out of the action plan of the first cycle, which resulted in significant improvements in interagency liaison and risk-benefit analysis documentation within the CDATs.Clinical implicationsManagement of pregnant women in substitution treatment can be improved by adhering to a multipronged approach as identified by this audit.

A ttention-deficit hyperactivity disorder (ADHD) is one of the most-common psychiatric disorders; it is highly comorbid with many other psychiatric disorders and associated with substantial role impairment. Untreated ADHD results in psychiatric comorbidity, relationship and parenting problems, underachievement, frequent job losses, and opportunistic delinquency. Nevertheless, ADHD remains the most under-recognised and undertreated mental health condition in adults. This article discusses the clinical presentation of ADHD in adulthood with a particular focus on recognition, assessment and management of ADHD in adults in primary care.