ADHD and Substance Abuse

adhdBetween four and five percent of the general population have severe attention-deficit/hyperactivity disorder (ADHD), and half have a comorbid substance use disorder.[1] Unfortunately, few physicians feel comfortable diagnosing and managing ADHD in adults, and even fewer are comfortable treating comorbid addiction.1

ADHD affects a person’s academic, social, and vocational aspects of life, and to establish a diagnosis, asking the patient why they think they may have ADHD will elicit a clear history of lifelong impairments in these aspects.1 However, assuming that success in elementary and high school rules out the disorder is a common mistake.1 In fact, ADHD may not manifest clinically until college-age, as the unstructured environment, lack of parental guidance, and need for time management brings the dysfunction to the forefront.1

Also, the lack of hyperactivity does not preclude ADHD.1 It is just as common for a person to be in their own world, not paying attention as it is for someone who cannot sit still.1 It is common for people with ADHD to focus on things that they enjoy and be totally disorganized, scattered, chronically late, impatient, and always on the go.1 Overall, ADHD diagnosis requires patients to have at least six symptoms of distractibility/executive dysfunction or hyperactivity/impulsivity—but not always both.1

Many of today’s street drugs began as naturally occurring substances that our ancestors found by accident.1 Refining those substances created illicit drugs.1 They all stimulate dopamine neurotransmission; therefore, stimulating the reward circuit, as well as learning, memory, and behavioral circuits.1 Those who are vulnerable to addiction, such as those with ADHD, will experience these drugs as highly pleasurable.1

Therefore, when adolescents with ADHD experiment with drugs or alcohol, they may find that the substance is so rewarding as it effectively reverses their dysphoria.1 This can lead to recurrent use, misuse, abuse, and addiction.1

The more powerfully a drug stimulates dopamine neurotransmission, the more reward it creates and the more addictive it is.1 Crystal methamphetamine and cocaine are common, extremely addictive drugs that multiply dopamine transmission by 150 times and 35 times, respectively.1

With ADHD, genetic, environment, and drug-induced insults combine to create impaired dopamine neurotransmission, and diminished perception of reward, worsening cognition, and impaired behavioral inhibition.1 Life seems boring, and drugs are enticing.1

Without a comorbid substance use disorder, ADHD is treated effectively with psychostimulant medicines.1 These medicines reduce the speed and degree of dopamine neurotransmission, creating a steady mood and attention.1 Stimulants may even improve retention in addiction treatment and decrease the harm from substance abuse.1

Unfortunately, studies have shown that individuals with ADHD are more likely to have an earlier onset of substance use, more severe addiction, and more difficulty maintaining abstinence.1 It is especially difficult to treat ADHD users who use illicit drugs that are stimulants.1 Mood dysregulation can occur.1 Using non-stimulant medicines for ADHD in the first four months of recovery before prescribing extended-release stimulants has been shown to be effective.1 Also, pretreating the patient with a mood stabilizer before the addition of a psychostimulant will increase the safety of this intervention and improve positive outcomes.1

[1] Ocana, A. (2010, April 7). ADHD and Comorbid Substance Use Disorder. Psychiatric Times. Retrieved November 15, 2013, from http://www.psychiatrictimes.com/adhd/adhd-and-comorbid-substance-use-disorder/page/0/1

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