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ADD and Substance Abuse

The presence of ADHD is an important risk factor for the development of alcoholism and other disorders associated with the use of alcohol and other drugs. In addition, Substance Use Disorders tend to appear earlier and to progress more rapidly in persons with ADHD. Alcoholics with ADHD also are less likely than those without ADHD to remain in alcoholism treatment programs or to achieve moderation or abstinence. A recent survey found that more than 15 percent of adults with ADD had abused or were dependent upon alcohol or drugs during the previous year. That’s nearly triple the rate for adults without ADHD. Alcohol and marijuana were the substances most commonly abused. Substance Use Disorders appear at an earlier age among adults with, compared with those without, ADHD (19 vs. 22). In addition, adults with substance dependency exhibit increased severity of substance use problems when ADHD is also present. The presence of ADHD appears to accelerate the transition from substance abuse to dependence and increases the risk for developing a drug use disorder among subjects already abusing alcohol.

Why is substance abuse such an issue for adults with ADD? A study from Harvard suggests that only 30 percent of young adults said they used substances to get high. The remainder use illicit substances to improve their mood, to sleep better, or for other reasons. This kind of “self-medication” seems especially common among individuals whose ADHD remains undiagnosed, or who have been diagnosed but have never gotten treatment. Drugs, alcohol, and cigarettes are used to dull the effects of ADD and allow the person to concentrate.

Until age 15, youth with ADD are generally no more likely than their peers to experiment with drugs. From this age on, rates of abuse and dependency skyrocket. Half of all adults with untreated ADHD will develop a substance use disorder at some point in their lives.

Research has shown that children who have been treated with stimulants for ADHD/ADD are no more likely to use illegal drugs than their peers who have not received treatment. In fact, there is evidence that a child who is being treated for ADHD/ADD has a decreased chance of abusing drugs. Studies indicate that girls who are treated with stimulant drugs may have a significantly lower tendency to begin smoking cigarettes or using alcohol or drugs.

In a trial of one drug commonly used to treat ADD, scientists found clinically and statistically significant improvement in teacher-rated ADHD symptoms and standardized clinician ratings of ADHD in delinquent students with Substance Use Disorder who were put on medication. The subjects themselves generally noted that the treatment for ADD enhanced the treatment they were receiving for the Substance Use Disorder. Current clinical practices suggest the concurrently treating ADHD and the Substance Use Disorder offer the best chance for success in adolescents suffering from both.

Several decades of research have shown that childhood ADHD is associated with diminished academic, behavioral, and social functioning in adolescence. For example, longitudinal studies show that children diagnosed with ADHD are at higher risk for substance use and substance use disorders than are children without ADHD. Childhood ADHD is a predictor of adolescent heavy alcohol use and alcohol-related problems, daily cigarette smoking, and marijuana and illicit drug use. These findings indicated that ADHD in childhood is a risk factor for early substance use and abuse in adolescence; however, little is known about why children with ADHD might be at higher risk. It is also not clear which components of ADHD (i.e., inattention symptoms, hyperactivity–impulsivity symptoms, or both) put children at highest risk for substance use. One proposed theory suggests that children with ADHD are more likely to associate with a deviant peer group or a ‘bad crowd’ and are more susceptible to the peer pressure exerted upon them. This stems from the studies that show children with ADHD are less successful in the peer-group setting than are children without ADHDn peer rejection is a significant risk factor for affiliating with deviant (antisocial) peers, and deviant peer affiliation is one of the strongest predictors of adolescent substance use.

Children with high levels of hyperactivity–impulsivity might be vulnerable to a “social failure” pathway to deviancy because they are more likely to be rejected by their peers and as a result more likely to affiliate with peers out of the social mainstream in behavior and attitude. Moreover, children with high levels of hyperactivity–impulsivity often engage in impulsive, sensation-seeking behaviors and have difficulties regulating their behavior and emotion during social interactions with other children, both of which can serve as negative social catalysts in social arenas.

Children with high levels of inattention may also be vulnerable to the social failure pathway to adolescent deviancy. There is some evidence to suggest that deficits in social knowledge necessary to meet the high social and interpersonal demands of the peer environment may contribute to this effect. In addition, severe inattention can cause academic problems that lead to deviant peer affiliation. It is worth noting that levels of substance abuse are higher among youth with ADHD and a comorbid antisocial disorder such as Oppositional Defiant Disorder than among youth with ADHD alone.

Certainly, all adolescents are susceptible to the negative outcomes of peer pressure, however, Children with ADD, may be more vulnerable to their effects. However, several simple safeguards exist to mitigate the dangers of a deviant peer group including increased parent monitoring, a high quality of parent–child relationship, and the development of the child’s coping skills (to avoid peer pressure and find positive outlets for risk seeing behavior). Finally, it is important to recognize that risk for substance use may be driven largely by the negative academic and social consequences that children with ADHD face. Prevention and intervention programs that focus on remediation of impairment (i.e.,peer rejection, school failure) in childhood may ultimately prove to be the most successful in curbing long-term negative outcomes.

A common concern amongst parents and clinicians debating the appropriateness of ADD medication is the possibility for misuse. A vast majority of ADHD individuals, most of whom do not suffer from a Substance Use Disorder, appropriately use their medications. However, a minority of ADHD subjects have diverted or misused their immediate-release stimulant medications. Not surprisingly, given the properties of the medications used in ADHD, this rate is higher than that in non-ADHD controls. Subjects with ADHD who diverted or misused their medications also manifested a Substance Use Disorder. Our findings suggest that clinicians should closely monitor the appropriate use of medication in older adolescent and young adult ADHD patients with SUD.

Our finding of diversion in our sample of ADHD individuals is noteworthy at a public health level. Diversion of medications from ADHD individuals continues to be a concern in high school and college. Data from a self-reported medication questionnaire found in the survey of junior and senior high school students who were prescribed stimulants, 7% had sold (diverted) their medications.

Reports suggest that as high as 22% of adolescents and young adults with ADHD misuse their prescribed medication. The majority of misuse was in the escalation of the dose of the medication without proper authorization (22%). Although dose escalation may represent a therapeutic need for upward titration for ADHD control, it is noteworthy that 10% of subjects reported becoming euphoric from the medication presumably related to rapid upward escalation.

However, 80% of this group who misused their medication suffered from a Substance Use Disorder, indicating that it is possible to identify potential candidates for misuse or diversion of ADD medication. Clinicians need to be particularly vigilant in discussing and monitoring adolescents and young adults with ADHD and SUD for the appropriate use of their medications. Such monitoring may include questioning, specifically about appropriate use or misuse of the medication, as well as potential diversion of the medicine, and observing that pill counts are accurate.

Other actions can be taken to safeguard against misuse include the prescription of extended-release stimulants. Though not as common as immediate-release stimulants, they are less likely to be diverted or misused.

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