MENTAL HEALTH & ADDICTION
Attention Deficit Hyperactivity Disorder is a common diagnosis amongst those struggling with addiction. The patterns of impulsivity, distractibility, and childhood development seem to play into the hands of alcoholism and drug abuse quite well (or poorly, depending on your point of view). ADHD involves a constellation of symptoms including inattentive and hyperactive subtypes. For the diagnosis, there must be 6 symptoms in a category present for at least the past 6 months. It is possible for a person to meet the diagnosis of ADHD – inattentive type, ADHD – hyperactive type, or ADHD – combined type.
ADHD develops in childhood, Not adulthood
Treatment options may be lifelong as this can be a chronic condition. There is some data that childhood symptoms will improve simply based on the brain growing and the front part of the brain developing more, but we also have many adults with clinically significant ADHD. Of note, there is no such thing as adult-onset ADHD. ADHD is a brain-structure disease that has to be present from childhood years. If you are getting diagnosed with this as a ‘new’ condition, something is wrong with the analysis.
Medication management of ADHD is broken into stimulant approaches and non-stimulant approaches. The stimulant meds are further subdivided into amphetamine and methylphenidate products (Adderall and Ritalin, respectively). Of the stimulants, there are long and short-acting versions of each form. For instance, Vyvanse is a long-acting amphetamine product and Concerta is a long-acting methylphenidate product.
The nonstimulant medications used include atomoxetine (Strattera), guanfacine (Tenex), and bupropion (Wellbutrin). Both Strattera and Wellbutrin affect dopamine and lead to increased levels within the brain. Dopamine dysfunction, in the prefrontal cortex, is the primary cause of ADHD symptoms. Tenex acts more through blood pressure calming. In this way, the Tenex is commonly used more in children and to treat the hyperactivity and restlessness connected to ADHD.
We can compare stimulant and nonstimulant approaches for ADHD treatment through a concept of effect size. This is a statistical calculation which describes the overall impact of the medication as compared to a placebo impact. It also accounts for variance and chance in the studies. To put this into play, the effect size of stimulant medication ranges around 0.95. For comparison, the effect size for selective serotonin reuptake inhibitors (SSRIs) for depression is about 0.5. The effect size for nonstimulant medication in the treatment of ADHD is about 0.62. So there is a marked difference between using a stimulant medication over a nonstimulant.
There has been a fair amount of research looking into psychotherapy options to improve ADHD symptoms. For moderate or severe ADHD, the psychotherapy did not show significant benefit. For more mild cases of distractibility and attentional issues, courses of cognitive behavioral therapy seemed the most useful. These programs focused on basic organizational routines to help someone with this condition manage their life as efficiently as possible. Overall, our emphasis at CeDAR has been a therapy approach over the use of many medications, but this condition seems to respond ideally to the right med approach.
ADHD is an extremely common psychiatric condition amongst those struggling with addiction. Why does it create so much controversy in the addiction world? The simple answer to this is that the most common (and effective) treatment for ADHD involves stimulant medication. These meds show an incredibly strong response and work well, but have severe abuse potential. Student data shows that about 3/4 of the stimulant addiction is for Adderall products and 1/4 for Ritalin products. The interplay between ADHD managed well and addiction stabilized is also complex. Some data shows that taking stimulant medication will improve ADHD symptoms, but not necessarily affect recovery rates. There is also a severe problem if the patient has a history of a methamphetamine addiction, setting the stage for a ‘pharmaceutical relapse’ of sorts by abusing the prescription stimulant. There also is some issue in urine drug screens becoming invalid if the patient takes a prescription stimulant. I have had people actively seek out stimulant prescriptions to avoid accountability for their illegal stimulant abuse.
The other interesting issue with ADHD treatment is what I have seen from my own experience in treatment. It is common to have a person come into addiction care and demand their Vyvanse or Adderall. This is a fascinating issue, in that children will often resent stimulant medication for ADHD. This is because the medication does show a marked change in their activity level and organization. For children, the medication often makes them ‘less fun’ but better performers at school. My personal opinion about this is that the people seeking stimulants quite assertively (or aggressively at times) do not seek the organizational component of the medication. They are receiving a form of socially-sanctioned speed and it gives them a significant boost in energy and mood.
Our clinical approach in these circumstances is to conduct structured performance testing for these people. Our preliminary data shows that about 3/4 of the people requesting stimulant medication while in rehab based on prior diagnoses of ADHD, do not, in fact, have bona fide ADHD.
I do prescribe stimulant medications to some people with addictive disorders and concurrent ADHD. My checklist for this is as follows:
If you have a current or past diagnosis of ADHD, it may be worthwhile having a detailed discussion about management decisions with your doctor. By using safe approaches, we can help you improve organizational ability and functioning. Most importantly, we need to remember that medical care treats disease instead of simply improves performance. If you took a sample of baseline college students and gave them all stimulant medication, study performance and grades would improve. Just because someone does functionally ‘better’ on a medication, does not mean they should necessarily receive it. The side effects of stimulants include weight issues, cardiac risk, and blood pressure problems. Taking this medication without clinically significant ADHD disability is drug abuse. We call it abusing Speed.