Attention deficit hyperactivity disorder (ADHD) and substance use disorders

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder that often continues to manifest symptoms into adulthood. In children and adults, this condition may contribute to addictive vulnerability. Several factors are common to the developmental psychopathology of these conditions, suggesting an underlying deficit in behavioral regulation as an explanation for this comorbidity. Developmentally, faulty learning processes or attempts to self-medicate dysfunctional behavior may contribute to the pathogenesis of substance use disorders. Substance abuse itself also may contribute to the development of attentional deficits and behavioral dysregulation through direct (eg, prenatal or self-inflicted exposures to neurotoxic substances) and indirect (eg, poverty, neglect, abuse) mechanisms. Because ADHD can be identified prior to the peak onset of substance use, effective treatment of this common disorder may reduce the development of substance use disorders. Adult ADHD may also contribute to the development and maintenance of substance use disorders Substance abuse patients may particularly benefit from treatment of this comorbidity.     

Compulsory treatment of substance use disorders

Substance use disorders are the cause of significant suffering for individuals and impose a tremendous burden on society in terms of related social costs. Current drug policy in the USA has failed to have a significant impact on the prevalence or the deleterious effects of this group of illnesses. Crime, violence, family disruption and economic displacement are felt most acutely by already impoverished and disadvantaged communities. The need for a public health approach to these problems rather than a law enforcement solution, is discussed with special attention to compulsory drug use treatment approaches. These approaches are considered in the context of their history and effectiveness through a review of current literature. The positive and negative aspects of compulsory treatment approaches are summarised and recommendations for expanded use of treatment options for clients involved with the criminal justice system are elaborated.     

Impact of substance use disorder on ADHD and its treatment

Attention deficit/hyperactivity disorder (ADHD) is associated with a high rate of psychiatric comorbidity. Substance use disorder (SUD) is common, affecting 1 in 5 adults with ADHD. Adolescents with ADHD are twice as likely to become cigarette smokers as those without ADHD, and cigarette smoking is a significant risk factor for the development of subsequent SUD in adulthood. Patients with SUD and ADHD have been shown to have lower retention in SUD treatment programs, lower rates of SUD remission, and longer courses of SUD. SUD also complicates the diagnosis of adult ADHD. Fortunately, pharmacologic treatment of ADHD does not appear to increase the risk for development of SUD in ADHD patients.     

When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders

Substances such as alcohol, cocaine, amphetamine, and cannabis can produce psychotic reactions in individuals who are otherwise free of serious mental illness. However, persons with primary psychotic disorders, such as schizophrenia and bipolar disorder, who use these substances often present for treatment with signs and symptoms similar to those whose psychosis resulted from the use of drugs alone. While it is often difficult to distinguish substance-induced from primary psychoses, especially early in the course of treatment, this differential diagnosis has important implications for treatment planning. To help clinicians distinguish these two types of presentations, the authors first review the types of psychotic symptoms that can co-occur with substance use. They discuss the prevalence and patterns of substance use that have been found in patients with schizophrenia and other primary psychotic disorders and review the negative outcomes associated with substance use in this population. The prevalence of and types of symptoms and problems associated with psychotic symptoms that occur as a result of substance use alone are also reviewed. The authors describe assessment procedures for differentiating substance-induced and primary psychotic disorders. They stress the importance of accurately establishing the temporal relationship between the substance use and the onset and continuation of psychotic symptoms in making a differential diagnosis, as well as the importance of being familiar with the types of psychological symptoms that can occur with specific substances. The authors review the utility and limitations of a number of diagnostic instruments for assessing patients with co-occurring psychosis and substance use problems, including The Addiction Severity Index, The Michigan Alcohol Screening Test, and diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM. They then discuss the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), an instrument that has been developed to address the lack of a diagnostic interview that is suitable for assessing the comorbidity of substance use and psychiatric disorders. The article concludes with a discussion of the importance of an appropriate match between diagnosis and treatment and the current state of our knowledge concerning the most appropriate types of treatment interventions for patients with substance-induced psychosis and those with dual diagnoses.     

Comparisons of patients with comorbid psychiatric and substance use disorders: implications for treatment and service delivery

OBJECTIVE: Individuals with co-occurring psychiatric and substance use disorders are treated in mental health and substance abuse treatment systems, yet research on comorbid disorders rarely includes comparisons across systems. Knowledge about patients who share the label "comorbid" but are found in different treatment sectors should illuminate service issues and inform policy development. Differences across systems should provide support for separate treatments; similarities should indicate the value of the integration of services. The hypothesis that there are meaningful clinical differences between patients with comorbid mental health disorders and patients in drug treatment was tested. METHOD: As part of a larger longitudinal study, 106 patients with comorbid illness from mental health (N=106) and drug treatment (N=120) settings were compared regarding diagnosis, drug use, and problem severity. Data were obtained by using the Diagnostic Interview Schedule for DSM-IV and the Addiction Severity Index. RESULTS: Few differences between groups emerged. There were no diagnostic differences except that schizophrenia spectrum disorders were more common among mental health (43%) than drug treatment (31%) patients. Although more drug abuse than mental health subjects reported drug use in the 30 days before treatment entry, the average number of days of drug use in this period was not different. CONCLUSIONS: These findings document the high prevalence of severe mental illness in drug treatment clients and of serious drug problems in mental health patients. Only minimal differences emerged between the groups and none that indicated need for specialized treatments in separate systems of care.     

Diagnosis and treatment of co-occurring affective disorders and substance use disorders.

There is growing interest in the co-occurrence of mood and substance use disorders. It is clear that co-occurrence of these disorders is common and has an impact on prognosis and course of both disorders. The diagnostic issues at the interface of substance or alcohol use disorders and affective illnesses are particularly difficult because of the substantial symptom overlap between substance intoxication and withdrawal and symptoms of affective disorders. Over the past few years, advances have been made in the treatment of co-occurring disorders. Further investigation of specifically tailored treatments for patients with co-occurring substance use and other mood disorders is underway. Because many advances have been made in pharmacotherapy of mood disorders in the past 10 years, this progress will impact individuals with co-occurring disorders, because newer agents with less toxicity and fewer adverse effects and interactions with substances of abuse will be evaluated for treating the comorbid condition. Specific considerations in choosing a pharmacologic agent for use in patients with substance use disorders include safety, toxicity, and abuse liability. Although there are few studies specifically targeting pharmacotherapy for co-occurring disorders, those that have been conducted indicate that similar pharmacotherapeutic agents work for mood disorders with or without substance use disorders. In conclusion, although the co-occurrence of substance abuse and mood disorders is an important area in which recent developments provide cause for considerable optimism, much work remains to be done.     

Heroin use among adolescents in treatment for substance use disorders

OBJECTIVE: To clarify prevalence rates and describe patterns of adolescent heroin users who are in treatment for substance use disorders. METHOD: The Treatment Episode Data Set (TEDS) was examined for trends in the number of adolescents admitted to substance abuse treatment centers and for changes in the routes of heroin administration. Thirteen adolescents who used heroin from one treatment program were compared with 536 adolescents who did not. RESULTS: Between 1992 and 1996, heroin-using youths represented 2.0% of youths in treatment and in 1997 they represented 2.6%. Heroin-using youths represented 56% of those using injection drugs. Heroin-using youths from one treatment program had significantly more polysubstance dependence in comparison with adolescents who did not use heroin. CONCLUSIONS: Nationally, there has been an increasing number, but not percentage, of heroin-using youths in treatment between 1992 and 1996. In 1997 there was an increase in both the number and percentage of heroin-using youths in treatment. Heroin-using adolescents have the highest rate of injection drug use when compared with youths using other substances. Because of their greater risk of contracting human immunodeficiency virus through injection drug use, treatment trials for these adolescents are needed.     

Dual diagnosis psychosis and substance use disorders: theoretical foundations and treatment

Dual Diagnosis (DD) patients with psychosis and substance use disorders (SUD) represent a large core group among patients with schizophrenia. Cannabis use disorders are most prevalent among DD patients, particularly in adolescent and young adult populations. There are different models to explain the high rates of comorbidity between psychosis and SUD. Currently, evidence is best for the model of cannabis use being a component cause of psychosis in individuals who are highly vulnerable to psychosis. There is also some evidence for the model of common vulnerability factors for psychosis and SUD. DD patients are difficult to treat as they comply poorly, their long-term outcomes are unfavourable and they suffer frequent psychotic relapses and hospitalisations. Successful treatment models integrate traditional psychiatric therapy for psychosis and therapy for addiction in one setting, modifying and adjusting the two components to the special needs of the DD patients. Integrated programmes focus mostly on long-term outpatient treatment and offer pharmacotherapy, motivational enhancement, psychoeducation, cognitive-behavioural therapy and family interventions. Current clinical research demonstrates that integrated treatment programmes can achieve significant improvements with regard to the social adjustment of, as well as decreased substance use by DD patients.     

Integrated treatment of comorbid depression and substance use disorders.

OBJECTIVE: The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. METHOD: On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. RESULTS: Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. CONCLUSION: Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.     

ADHD and manic symptoms: Diagnostic and treatment implications

Introduction: Reports document children with attention deficit hyperactivity disorder (ADHD) and irritability, aggression or mood lability. Whether these additional symptoms represent severe ADHD, juvenile bipolar disorder, or other comorbidities is often unclear and has both diagnostic and treatment implications. We use the Cantwell modifications of the Robins and Guze diagnostic construct to examine the diagnostic validity and treatment implications of children with ADHD and some manic symptoms. Methods: We examined 579 children with ADHD from the multimodal treatment study of children with ADHD (MTA) and compared those with manic symptoms to those without manic symptoms in the domains of clinical phenomenology, demographic factors, psychosocial factors, biological factors, family genetic factors, family environmental factors, natural history, and intervention response. Results: Children with manic symptoms were more symptomatic at baseline and had more comorbidities and psychosocial and family environmental stressors. There were few differences in parental psychopathology and no biological differences. While ADHD children with manic symptoms were more symptomatic at 14 months, most differences were not significant when controlling for baseline symptoms. They were not more likely to have manic-like side effects except for moderate or severe worries. Discussion: Children with ADHD and manic symptoms compared to ADHD children without manic symptoms were more symptomatic and had more comorbidities at baseline. They nonetheless showed no systematic pattern of differences according to the Robins/Guze/Cantwell criteria. Moreover, they improved over time with standard ADHD treatments and were generally not found to have more adverse effects from stimulants.     

Chronic pain and comorbid mood and substance use disorders: A biopsychosocial treatment approach

Chronic pain is a colossal heath care problem that is devastating to the individual afflicted with unremitting pain and frustrating to the beleaguered health care provider attempting to adequately manage this multifaceted disease. The biopsychosocial model of pain management is a promising approach that emphasizes evidence-based medication management in conjunction with cognitive-behavioral therapy and a graded exercise program. The patient with chronic pain and concomitant mood and/or substance use disorders is exceptionally challenging. Effective pharmacologic management of pain and comorbid mood disorders, including the thoughtful use of opioids, can have a dramatic effect in improving the quality of life in patients with chronic pain. The high prevalence of chronic pain in our society and the scarcity of experienced pain medicine physicians necessitate the development of a community-based systems approach to this complex patient population.     

Neuropathology of substance use disorders

Addictions to licit and illicit drugs are chronic relapsing brain disorders that affect circuits that regulate reward, motivation, memory, and decision-making. Drug-induced pathological changes in these brain regions are associated with characteristic enduring behaviors that continue despite adverse biopsychosocial consequences. Repeated exposure to these substances leads to egocentric behaviors that focus on obtaining the drug by any means and on taking the drug under adverse psychosocial and medical conditions. Addiction also includes craving for the substances and, in some cases, involvement in risky behaviors that can cause death. These patterns of behaviors are associated with specific cognitive disturbances and neuroimaging evidence for brain dysfunctions in a diverse population of drug addicts. Postmortem studies have also revealed significant biochemical and/or structural abnormalities in some addicted individuals. The present review provides a summary of the evidence that has accumulated over the past few years to implicate brain dysfunctions in the varied manifestations of drug addiction. We thus review data on cerebrovascular alterations, brain structural abnormalities, and postmortem studies of patients who abuse cannabis, cocaine, amphetamines, heroin, and “bath salts”. We also discuss potential molecular, biochemical, and cellular bases for the varied clinical presentations of these patients. Elucidation of the biological bases of addiction will help to develop better therapeutic approaches to these patient populations.     

The effect of comorbid substance use disorders on treatment outcome for anxiety disorders

This study examined the impact of concurrent substance use disorders (SUDs) on outcomes for psychotherapy targeting anxiety disorders. Study 1 (N=484) sought to determine the prevalence of SUDs in a sample referred to a community anxiety disorders clinic, as well as the impact of comorbid SUDs on outcomes for a subsample (n=200) completing cognitive behavior therapy (CBT). Around one-quarter (22-29%) of patients with one or two anxiety disorders met criteria for at least one SUD, but this rate was substantially higher (46%) for patients with three anxiety disorders. Concurrent SUDs were associated with higher levels of anxiety but not depression or stress, compared to those without a SUD. However, concurrent SUDs did not moderate treatment outcomes. Study 2 (N=103) focused on the impact of alcohol use on diagnosis-specific symptom measures and generic measures of distress and disability, following a course of CBT for panic disorder or social phobia. Pre-treatment alcohol use did not predict changes in panic symptoms, performance anxiety, distress, or disability, but it did predict changes in social interaction anxiety. Problem drinking per se did not have any predictive utility in terms of treatment outcome. These findings suggest that clinicians treating patients for a primary anxiety disorder and concurrent SUD can be relatively optimistic about treatment outcomes.     

Anxiety disorders and substance use disorders: different associations by anxiety disorder

Anxiety disorders (ADs) and substance use disorders (SUDs) often occur together, but the strength of this association and their apparent order of onset differ across studies. The goals of this study were to examine: (1) which ADs were associated with which SUDs, and (2) among people who experienced both an AD and a SUD, which disorder had an earlier onset. Lifetime diagnoses from the National Comorbidity Survey-Replication (n=9282) were used. Social phobia, generalized anxiety disorder, panic disorder, and agoraphobia were positively associated with all SUDs. Among people with both an AD and a SUD, the order of onset differed by anxiety type: social phobia nearly always had an onset prior to any SUD; panic disorder and agoraphobia tended to occur prior to some SUDs; and generalized anxiety disorder tended to occur after the onset of at least one SUD. Therefore, all ADs are positively associated with SUDs, but ADs differ in the timing of their onset relative to comorbid SUDs.