Posts Tagged ‘Dominic Ferro’

ADHD and Substance Abuse

Summarized by Dominic Ferro, M.D.

Daniel Pimstone, M.D. and Itai Danovich, M.D. spoke about the dilemma of treating adolescents with both Attention Deficit Hyperactivity Disorder (ADHD) and Substance Use Disorders: the most effective treatment for ADHD is with stimulants, which are themselves substances of abuse.

Having both ADHD and substance abuse affects the outcome of both conditions.  30-65% of ADHD patients have impairing symptoms that persist into adulthood, most often symptoms of inattention.  These patients have higher rates of divorce, arrest, and speeding.  They have higher rates of tobacco dependence as well.  In addition, ADHD predicts worse substance abuse outcomes as ADHD patients develop substance abuse disorders at a younger age.  They progress more rapidly from experimentation to dependence and quickly move from one drug to others.  They are less responsive to treatment and relapse more quickly.

Pertinent to the treatment dilemma is the fact that stimulants are not the most commonly abused substances by adolescents with ADHD.  Surveys have shown that 67% used cannabis and 40% used alcohol as their drug of choice.  Only 21% abused stimulants. While adolescents with ADHD have similar rates of substance use disorders as other adolescents, they progress to adult chemical dependency disorders at a substantially higher rate.

Looking at populations of adolescent substance abusers, ADHD is an independent risk factor for substance abuse.  10% of adolescent substance users have comorbid ADHD and 25% had ADHD and took medication during earlier childhood.  Adolescents with alcohol dependency had the highest rate of comorbid ADHD; those with opiate or cocaine dependence had lower rates.

Dr. Pimstone discussed different theories to explain the correlation between ADHD and substance abuse.  One possibility is that children with ADHD have a developmental vulnerability to substance abuse.  For instance, there are higher rates of substance abuse disorders among first degree relatives of children with ADHD.  Also, children with ADHD have higher rates of social problems and school difficulties, both of which are known risk factors for substance abuse disorders.  Similarly, the impulsivity and sensation seeking which are common in ADHD increase the risk of substance abuse.

Another possible explanation is that substance abuse and ADHD share common endophenotypes, genetic predispositions to both disorders.  The best evidence for such endophenotypes is found in the dopamine system that results in a theorized hypodopaminergic state.  Other possible shared endophenotypes include cognitive processing deficits and selective attention, excessive arousal with consequent aggression and impulsivity, impaired behavioral disinhibition, and impaired affective regulation that results in insensitivity to aversive conditioning and rewards.

A third possible explanation is that adolescents with ADHD use substances to modulate psychiatric symptoms, in other words the “self medication” theory.  Surveys of patients indicate that they believe that this is the best explanation for their experience.  Attentional dysfunction is a predictor of initiation and maintenance of tobacco use, which patients describe as helpful with focus.  Alcohol and cannabis may ameliorate the commonly reported subjective symptoms of anxiety and dysphoria or they may help with disordered sleep.  Adolescents with ADHD more often reported using substances to alter mood instead of trying to get high.  Illicit substance use also reportedly improved the self image of ADHD adolescents.

A final explanation is that early exposure to stimulants results in substance abuse, the so-called “priming phenomenon”.  Dr. Danovich described some of the factors that support this theory, in particular the cases of later stimulant abuse. The pharmacokinetics of stimulants, especially their rapid rate of onset, does seem to play a role. For instance, the subjective effect is less evident when stimulants are taken orally vs. intravenously, the latter of which had linear dose response of “liking” the drug.  Compared to extended release preparations, short acting stimulants have a greater likelihood of developing a reinforced pattern of use was in animal models.  Animal models also demonstrate patterns of sensitizing and dependence on stimulants.

However, in humans, early stimulant initiation has not led to measurable negative outcomes.  In fact, the rate of substance use disorders was decreased among ADHD adolescents taking prescribed stimulants than those who do not. On further analysis, a comorbid conduct disorder was more predictive of the observed substance abuse into adulthood.  However, Dr. Danovich concluded that there is no good evidence that substance abusing teens could be safely treated with stimulants, and it is known that some patients will divert or abuse prescribed medication.

Dr. Pimstone opined that neuropsychological evaluation is not helpful when an adolescent is actively using, and that the best tool is a thorough clinical assessment with an eye toward the timing of symptoms.  He recommended establishing separate timelines for the symptoms of ADHD and of the substance abuse disorder.  He also recommended performing the neuropsychological assessment after several weeks of abstinence.

With regard to treatment, these adolescents should be engaged with enhanced psychosocial interventions in integrated and structured care with frequent re-evaluation.  Dr. Danovich recommended minimizing the use of reinforcing medications, for instance starting with long acting stimulant preparations, or considering Strattera and other non-stimulant medications.  He also recommended involving the adolescent’s support network to assist in close monitoring. Since there are separate treatment systems and funding sources for mental health, substance use, and medical care, treatment is even more challenging since contact between providers in different systems is needed to effectively manage these cases.

From the 2010 Annual Meeting….

BY Dominic Ferro, M.D.

In his address, Dr. Koplewicz displayed the erudition and eloquence that made him a most deserving recipient of ASAP’s Schonfeld Award.  His address was entitled “More than Moody: Adolescent Angst, Depression and Suicide Risk”.

The concept of adolescent angst dates back to Anna Freud’s assertion that an adolescent not experiencing angst is missing an important stage of development.  Adolescence is a period of dramatic change.  The adolescent must adapt to the physical changes of puberty, to the demands of individuation from parents or guardians, to the development of complex social networks, to begin to conceive vocational goals and to define their sexual orientation.  Modern neuroscience validates and clarifies the challenges faced by the adolescent.

In the human frontal cortex, the seat of executive functions, adolescents undergo an intense pruning of synaptic connections. An astounding peak of synaptic connectivity occurs during the second year of life, and it is during adolescence that connectivity declines to the modest levels of adults.

These neurological findings are consistent with the findings of cognitive scientists regarding executive functioning during adolescence.  They have demonstrated that adolescents are about as capable as adults at discerning the risks and benefits of behavioral choices.  However, they are not as adept at conforming their behavior.  For instance, adolescents demonstrate awareness of the risks of driving while intoxicated, yet teen driving is the number one killer of adolescents.  Similarly, adolescents understand the risks involved, but also have high rates of unprotected sex, smoking, vandalism and stealing.

Other findings indicate that adolescents do not process the facial expressions of others as well as adults.  This correlates with imaging evidence that during tests of facial expression recognition, adolescents have greater activity in the amygdala than adults, whereas adults evidence greater activity in the prefrontal cortex.  The amygdala is associated with emotional reactivity, particularly fear response, where as the prefrontal cortex is more involved in pattern recognition.

Adolescents are subject to intense passions, which contribute to increased risk behavior.  They are also subject to high reward sensitivity, and as a result they tend to seek high levels of stimulation.  So, it is not surprising that adolescents are more subject to peer influence and emotional arousal than adults.

Dr. Koplewicz reflected on the role of this constellation of changes in the adolescent brain and the resulting increase in risky behavior.  In order to elucidate what adaptive function this might serve, he drew a parallel with the behavior of adolescent monkeys.  He noted that in many species, the adolescent male takes a tremendous risk by leaving the safety of family and of familiar environs.  Singly and in small groups, adolescent males seek to join and mate in other troops, thus increasing genetic diversity.  Yet, in so doing they may be rejected or attacked by the troop members.  The individual must become insensible to the individual risks and press on in service of improved survival as a species.

Dr. Koplewicz clarified the emerging picture of adolescent development and pathogenesis.  He noted that 75% of serious mental illness starts during adolescence.  He noted that, given all these changes, it is not surprising that suicidal ideation is a common phenomenon during this time of life.  The roots of suicide contagions can be seen in light of the frequency of suicidal ideation, coupled with the increased vulnerability to peer influence.  Impulsivity increases the risk of substance use disorders, which complicates treatment for depression and increase the risk of suicidal behaviors.

With regard to treatment, it is important to increase the adolescent’s future orientation, as their increased impulsivity and affective intensity tend to narrow their focus to the immediate term.  Evidence suggests that more active treatments which engage the adolescent with greater interaction and which challenge latent cognitive abilities, such as CBT and DBT, are more effective for adolescents.  The immediacy of the adolescent brain may necessitate more frequent sessions, perhaps even more frequent that once per week.

Dr. Koplewicz also spoke about incorporating what we know about adolescent strengths in our interventions.  For instance, he noted that data reflect that adolescent males tend to use their seatbelt when they drive with adolescent females, but not when they drive with other adolescent males.  He coupled this with data indicating that increased use of condoms can be attributed to increased demands made by female adolescents.  Public health interventions are therefore more likely to be effective if they are directed at the female adolescents.

Our profession is fortunate to have a leader like Dr. Koplewicz working to apply clinical and basic sciences to aid in the formulating and intervening in the lives of our adolescent patients.  The opportunity to honor him was one of the special moments of the 2010 Annual Meeting.