A qualitative review of issues arising in the use of psycho­stimulant medications in patients with ADHD and co‑morbid substance use disorders

Abstract

Objective: This review addresses the relationship between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs), with an emphasis on factors that determine the potential for psychostimulant abuse. Strategies for identification and treatment of patients with ADHD who are at risk for, or have, co-morbid SUD are also addressed.Research design and methods: The article was based on a qualitative review of current literature addressing co-morbid ADHD and SUD.Discussion: Adolescent and adult patients with ADHD are at increased risk for SUD, as well as a number of other psychiatric disorders. Psychostimulant agents like methyl phenidate (MPH) and mixed amphetamine salts (MAS) are effective first-line pharmacotherapies for ADHD; however, they are Schedule II controlled substances with a potential for abuse. Evidence suggests that treatment of ADHD during childhood with stimulant agents may reduce the risk of developing SUD later on. Factors associated with the highest risk of SUD in patients with ADHD include co-morbid antisocial personality disorder, bipolar disorder, an eating disorder, severe ADHD and/or antisocial behavior symptoms, and dropping out of school. Treatment initiation during adolescence or young adulthood also has been linked to increased risk of polydrug use and non-medical stimulant use, a pattern of behavior consistent with a risk of SUD development. Treatment plans for patients with ADHD and co-morbid SUD should include behavioral interventions, careful monitoring, and when appropriate, pharmacotherapy. When oral formulations of psychostimulants are used at recommended doses and frequencies, they are unlikely to yield effects consistent with abuse potential in patients with ADHD. Long-acting stimulant formulations and non-stimulants, like atomoxetine or bupropion, have a lower potential for abuse, and provide several safe and effective treatment options for the development of a comprehensive manage ment plan for patients with co-morbid ADHD and SUD.Conclusions: The present review is neither exhaustive nor systematic. Moreover, the reviewed studies vary wide ly with regards to methodology and patient populations. In light of these limitations, several conclusions are still warranted. Patients with ADHD are at increased risk for SUD. Under certain conditions, psychostimulants may be a pharmacologic option in the treatment of patients with co-morbid ADHD and SUD. However, clinicians should be mindful of the risks and benefits of this treatment approach in a high-risk population and should also bear in mind the labeling guidelines when working with this co-morbidity.

Pharmakologisches Neuroenhancement und „Hirndoping“

“…Dabei werden ihr Suchtrisiko und die Gefahr, als "Einstiegsdroge" zu wirken, kontrovers diskutiert. Auffallend hohe Komorbiditäten von Abhän-gigkeitserkrankungen und der ADHS-Diagnose sind bekannt, was auf ein erhöhtes Missbrauchs-und Abhängigkeitspotenzi-al auch bei Gesunden schließen lässt [10,11,12]. Die Einnahme in Tablettenform ist diesbezüglich allerdings erheblich sicherer als die Applikation durch Schnupfen oder die intravenöse Applikation, da es hier infolge eines sehr schnellen Anflutens der Substanzen im Gehirn zu einer…”

Differences in Methylphenidate Abuse Rates Among Methadone Maintenance Treatment Patients in Two Clinics

“…However, ADHD stimulants are classified as schedule II controlled substances in the United States based on their potential for abuse, dependence, and individual and public health harm, which is consistent with the Convention on Psychotropic Substances 1971 (Kollins, 2007). There is a high comorbidity between ADHD and substance dependence (Kollins, 2008;Schubiner, 2005). Prospective studies on ADHD patients found that the onset of substance dependence always follows ADHD onset (Elkins, McGue, & Iacono, 2007;Wilens, 2004), suggesting that ADHD children are more vulnerable to develop substance dependence (Elkins et al, 2007) and that treatment of ADHD may reduce their incidence of substance abuse when grown up (Wilens, Faraone, Biederman, & Gunawardene, 2003).…”

Attention Deficit Hyperactivity Disorder and Obsessive-Compulsive Disorder among Former Heroin Addicts Currently in Methadone Maintenance Treatment

“…There is a high rate of comorbidity between ADHD and substance dependence [8,9]. Prospective studies on ADHD patients found that the onset of substance dependence always follows ADHD onset [10,11], suggesting that ADHD children are more vulnerable to developing substance dependence [10].…”