USPSYCH: Concurrent Treatment Works for ComorbidADHD and Substance Abuse

SAN FRANCISCO, April 25 -- Given the high prevalence of substance abuse in patients with attention deficit hyperactivity disorder (ADHD), psychiatrists need to consider comorbidity in assessment of both conditions. Despite concerns over the role that stimulant drug treatment has in increasing the risk for substance abuse disorders among individuals with ADHD, treating early seems to serve a protective role, said Scott H. Kollins, Ph.D., of Duke University.

He presented clinical recommendations for assessing and treating such patients at the U.S. Psychiatric & Mental Health Congress regional extension meeting here.

In assessment of ADHD, Dr. Kollins suggested collecting a detailed substance abuse history, particularly for high-risk patients -- adolescents, those with a family history of substance abuse, and those with comorbid conduct disorder or antisocial personality disorder. Collection of detailed information about ADHD in childhood, using objective data sources when possible, is critical though challenging, he said.

In assessment of substance abuse, consider how withdrawal will affect existing ADHD symptoms and that "co-occurring ADHD can interfere with most treatment programs," he suggested.

When considering whether to attack the substance abuse or the ADHD first, the answer is almost always that substance abuse poses the most immediate risk to the patient but concurrent treatment is possible, Dr. Kollins said.

Patients at low risk for comorbid substance abuse should receive stimulant medications as first-line therapy and, like all patients receiving these medications, should be warned against diversion of the drugs and monitored for ADHD response and use or abuse patterns.

First-line therapy for those at moderate risk because active alcohol or marijuana substance abuse disorder or recreational use of other illegal drugs may substitute atomoxetine (Strattera) or bupropion (Wellbutrin) in place of stimulants. They should also receive more frequent monitoring of use or abuse patterns, substance abuse counseling, and urine toxicology testing and family treatment as indicated.

In addition to these precautions, higher-risk patients with current or prior cocaine, opiate, stimulant, or prescription drug abuse disorder should receive atomoxetine or bupropion as first-line agents with use of stimulants only under strict supervision. ADHD treatment may also be delayed until patients have been in substance abuse remission for weeks or months, Dr. Kollins said.

In February, the FDA approved a stimulant medication that may have less abuse potential, the d-amphetamine pro-drug lisdexamfetamine (Vyvanse), for treating pediatric ADHD. However, it is controlled as a Schedule II drug like all the other stimulant medications because of the potential for abuse.

"We've known about this comorbidity for many, many years," Dr. Kollins said.

In one study, substance abuse prevalence among adults with ADHD was double that of the general population (55% versus 27%).

While comorbid conduct disorder was initially blamed, ADHD by itself in adults makes alcohol, tobacco and other addictions 70% more likely, he said. ADHD patients have also been shown to start smoking earlier, to smoke more, and to have a harder time quitting than individuals without ADHD, he added.

The emerging evidence indicates "medications alone for ADHD do not appear to affect substance abuse disorders, but it doesn't appear to make it worse," he said.