DR ACHAL MISHRAASSISTANT PROFESSOR (DALHOUSIE UNIVERSITY), PSYCHIATRIST ANNAPOLIS VALLEY HEALTH

ADHD and Addictions

Agenda

• Diagnostic issues surrounding ADHD• Discussion mainly about adult population• Epidemiology of ADHD and substance misuse• Impact of the concurrent problems• Management issues• Case discussion• Questions

Disclosure: potential conflict of interest

• In the UK, I have received honoraria for acting as a speaker and participated in clinical trials organized by the following companies: Astra-Zeneca, Janssen-Cilag, Bristol Myers-Squibb, Lilly, Shire Pharmaceuticals, Wyeth.

• None in Canada.

ADHD: epidemiology

• Meta-analysis by Viktoria S., et al in BJPsych March 2009: pooled prevalence rate in adults was 2.5%. Prevalence declines with age in population

• Persistence of ADHD into adulthood was 5-9 times higher when based on parental report than self-report, and parental report showed higher potential to predict functional impairment. Barkley et al 2002; J Abnorm Psychol.

• Prevalence in children:3-5% (Ford et al 2003)

ADHD: etiology

• Genetic: heritability estimate of 0.7 to 0.8• Biological factors: maternal smoking, alcohol and

heroin use in pregnancy, foetal hypoxia, very low birth weight, brain injury, exposure to toxins such as Zinc and Lead

• Increased in developmental disorders• Dietary factors: additives, PUFA• Psychosocial factors: childhood adversity

ADHD: diagnosis - DSM-IV TR

• A1: Inattention- 6 or more symptoms for 6 mths to a degree maladaptive and inconsistent with developmental level

• A2: Hyperactivity- 6 or more symptoms for 6 months or more

• Symptoms causing impairment present before 7 yrs• Impairment in two or more settings• Impairment in social, academic and occupational

functioning

Diagnosis-problems for Adults

• DSM-IV-TR: Symptoms causing impairment present before 7 yrs of age

- No scientific rationale for age-of-onset- Field trials showed significant percentage of ADHD

children had no impairment before 7 yrs of age- Difficult to establish a retrospective diagnosis: poor

recall- only 47% of diagnosed adults recalled having ADHD (Barkley et al 2002)

Diagnosis-problems for Adults

• DSM-IV-TR: impairment from symptoms is present in two or more settings i.e. school/work/home-No mention of alternate domains of functioning for adults

• Clinically significant impairment in social, academic or occupational functioning- No recognition of adaptive lifestyles that minimize apparent dysfunction

ADHD: DSM-V

Inattention: Six (or more) of the following symptoms… Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (for example, overlooks or misses details, work is inaccurate).

(b) Often has difficulty sustaining attention in tasks or play activities (for example, has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

(c) Often does not seem to listen when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction).

(d) Frequently does not follow through on instructions (starts tasks but quickly loses focus and is easily side-tracked, fails to finish schoolwork, household chores, or tasks in the workplace).

(e) Often has difficulty organizing tasks and activities. (Has difficulty managing sequential tasks and keeping materials and belongings in order. Work is messy and disorganized. Has poor time management and tends to fail to meet deadlines.)

(f) Characteristically avoids, seems to dislike, and is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework or, for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

(g) Frequently loses objects necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

(h) Is often easily distracted by extraneous stimuli. (for older adolescents and adults may include unrelated thoughts.).

(i) Is often forgetful in daily activities, chores, and running errands (for older adolescents and adults, returning calls, paying bills, and keeping appointments).

ADHD: DSM-V

Hyperactivity and Impulsivity: (a) Often fidgets or taps hands or feet or squirms in seat. (b) Is often restless during activities when others are seated (may leave his or her place in the classroom, office

or other workplace, or in other situations that require remaining seated). (c) Often runs about or climbs on furniture and moves excessively in inappropriate situations. In adolescents or

adults, may be limited to feeling restless or confined. (d) Is often excessively loud or noisy during play, leisure, or social activities. (e) Is often “on the go,” acting as if “driven by a motor.” Is uncomfortable being still for an extended time, as in

restaurants, meetings, etc. Seen by others as being restless and difficult to keep up with. (f) Often talks excessively. (g) Often blurts out an answer before a question has been completed. Older adolescents or adults may

complete people’s sentences and “jump the gun” in conversations. (h) Has difficulty waiting his or her turn or waiting in line. (i) Often interrupts or intrudes on others (frequently butts into conversations, games, or activities; may start

using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

(j) Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

(k) Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

(l) Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks. (m) Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys

off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).

ADHD: DSM-V

Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12.

The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).

There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Specify Based on Current Presentation Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2

(Hyperactivity-Impulsivity) are met for the past 6 months. Predominately Inattentive Presentation: If Criterion A1 (Inattention) is met but

Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months.

Predominately Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months.

Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months.

Diagnosis-pitfalls

Mistaken for Personality Disorder esp. Cluster B due to chronic trait-like nature of the symptoms i.e. mood instability, impulsivity and anger outbursts.

Overlap with affective disorder- volatile and irritable mood reported by adults, both have over-activity, distractibility, mood changes and inattentiveness, euphoria and grandiosity uncommon in ADHD.

ADHD: screening instruments

• Conners Adult ADHD rating scale (Conners 1998)• Adult ADHD Self-Report Scale (ASRS) (Kessler 2005)• Barkley Adult ADHD Rating Scale (Barkley 1998)

What predicts persistence of ADHD?

• Severity of illness in childhood?• Presence of symptoms into late adolescence?• Which symptoms in children predict greater likelihood

of problems in adulthood?• Which symptom(s) cause maximum dysfunction in

adulthood?

Persistence of ADHD into adulthood

Childhood predictors of adult ADHD: Results from the WHO World Mental Health (WMH) Survey Initiative Biol Psychiatry. 2009 January 1; 65(1): 46–54

An average of 50% of children with ADHD (range: 32.8-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to childhood factors

ADHD symptom profile: (highest persistence associated with the attentional plus impulsive- hyperactive type, OR = 12.4, compared to the lowest associated with the impulsive-hyperactive type), severity of role impairment (OR = 2.0),

Comorbid major depressive disorder (OR = 2.2), high comorbidity (three or more child-adolescent disorders in addition to ADHD; OR = 1.7),

Paternal (but not maternal) anxiety-mood disorder (OR = 2.4), and parental antisocial personality disorder (OR = 2.2).

Adult ADHD- problems with ADL

• Education• Work• Cohabiting and relationships• Parenting: especially if children have ADHD• Organisational abilities• Violence and aggression

Impact on work in adults with ADHD

The prevalence and effects of Adult Attention-Deficit/Hyperactivity Disorder (ADHD) on the performance of workers: Results from the WHO World Mental Health Survey Initiative Occup Environ Med. 2008 December ; 65(12): 835–842.An average of 3.5% of workers in nationally representative surveys carried out in 10 countries met criteria for current DSM-IV adult ADHD.Workers with ADHD have an average 8.4 excess sickness absence days per year and even higher annualized average excess numbers of workdays associated with reduced work quantity (21.7 days) and quality (13.6 days).Only a small majority of these workers are treated for ADHD despite evidence that such treatment can be quite effective in improvingfunctioning.ADHD is a good candidate for targeted workplace screening and treatment programs.

Impact of the illness

• Untreated illness leads to negative outcomes in adulthood-

• Poor rates of employment• Harm to relationships with family & friends• Increased criminality and accidents• Co-morbid psychiatric illness including anxiety,

depression and substance misuseKessler et al, The prevalence and correlates of ADHD in the United States :results from the National

Comorbidity Survey replication. Am J Psychiatry 2006; 163:716-23

ADHD and Addiction: etiology

• Children and adolescents with ADHD have a greater risk of developing substance use disorders in later life compared to controls (Biederman 2006, Molina 2003)

• Earlier onset and wider range of substance use by young persons with ADHD as compared to controls (Krause 2002)

• Adults with ADHD more likely to be past users of substances and have received treatment (Barkley 2008)

ADHD and Addictions: etiology

• Comorbidity with Conduct disorder and bipolar disorder confers a higher risk for substance misuse.

• Substance misuse may be a form of self-medication• Independent risk factor for alcohol and tobacco use• Inattention & executive functioning deficits,

hyperactive/impulsive symptoms, novelty seeking traits, dopaminergic/nicotinic and acetylcholinergic dysfunction proposed as mechanisms.(Molina 2003, Fuemeler 2007, Tercyak 2003)

ADHD and Nicotine

• Earlier onset and higher lifetime prevalence of smoking in adolescents and adults with ADHD. (Pomerlau 1995)

• Earlier onset (smoking) independent of social class, intelligence or psychiatric comorbidity (Milberger 1997)

• Nicotine use improves attention, concentration and impulse control (Gehricke 2006)

• Higher rates of treatment failure in smoking cessation among people with history of childhood ADHD (Humfleet 2005)

ADHD and Alcohol

• High incidence of alcohol misuse and dependence in adults, 33-44%. (Biederman 1998, Rasmussen 2000).

• Alcohol dependent adults show increased prevalence of persistent symptoms of ADHD (Krause 2002)

• ADHD with comorbid Conduct disorder the strongest predictor of later alcohol dependence, each factor independently contributes to the risk (Knop 2009). Not been replicated.

ADHD and Stimulants

• Cocaine: earlier, frequent and intense use, greater intranasal and intravenous use (Caroll 1993)

• Cocaine use related to higher ADHD symptoms, lower IQ and greater criminal diversity scores (Barkley 2008)

• Self-treatment hypothesis: dopaminergic action of stimulants (Volkow 2003)

• Amphetamine used for similar reasons.

ADHD and Cannabis

• Significant association reported between cannabis use and self-reported symptoms of ADHD at age 25, study over 25 years from New Zealand (Ferguson 2008).

• Other studies have shown increased prevalence of Cannabis use among adolescents and adults who have ADHD.

• Animal models have shown improvement in symptoms of ADHD with cannabinoids.

ADHD and other substances

• Opioids: higher rates of ADHD have been noted in treatment seeking chronic opioid users (King 1999, Torgensen 2006).

• Caffeine: relationship unclear, clinical reports suggest increased consumption in this group.

ADHD: assessmentNICE (UK) 2008

Before starting drug treatment assessment should include:- full mental health and social assessment- full history and physical examination, including:• assessment of history of exercise syncope, undue

breathlessness and other cardiovascular symptoms• heart rate and blood pressure (plotted on a centile chart)• height and weight• family history of cardiac disease and examination of the

cardiovascular system• ECG if indicated: H/O sudden death or cardiac problems

in the family• risk assessment for substance misuse and diversion

ADHD: assessmentNICE (UK) 2008

Specific areas of competence:- Understanding of the normal patterns of child,

adolescent and adult development Be able to differentiate behaviours/symptoms of ADHD

from the normal patterns of cognitive function and behavioural features, as age appropriate

Be able to differentiate the behaviours/symptoms of ADHD from the patterns of cognitive function and behavioural features of other developmental disorders (such as global or specific learning disabilities, including specific reading difficulties, autism and related spectrum disorders).

ADHD: assessmentNICE (UK) 2008

Specific areas of competence- Be able to identify and assess the contribution of mental

health disorders, such as anxiety, depression, bipolar disorder and schizophrenia

Be able to identify and assess the contribution of coexisting conditions (such as epilepsy).

Be able to identify and assess the contribution of family and social factors.

Be able to identify and assess the contribution of the coexisting conditions and risk factors to the behavioural/symptom profile and level of impairment

ADHD: TreatmentNICE (UK) 2008

• Pharmacological:-Stimulants: Methylphenidate, Dexamfetamine,

Lysdexamphetamine-Atomoxetine-Others: Modafinil, TCAs, Bupropion, Atypical

antipsychotics, Clonidine • Psychological: support groups, coaching,

psycho-education, CBT, counselling

ADHD: Treatment

Methylphenidate: IR and XL versions Rapidly and completely absorbed in gut Bioavailability of 30% (11-51%) IR: effect evident in 30mins, peak plasma levels

1-2 hrs, duration of action of 1- 4 hrs XL: duration of action of 12 hrs Should be taken with food, spread through the

day

ADHD: Treatment

Methylphenidate: adverse effects Common: sleep problems, loss of appetite,

headaches, stomach aches, drowsiness, tearfulness, irritability, mild increase in pulse rate and blood pressure

Rare but serious: psychotic symptoms, sudden death and hypersensitivity reactions-may need discontinuation

ADHD: Treatment

Atomoxetine: non-stimulant drug Taken as once daily dose: 0.5mg/kg wt Rapidly absorbed, peak levels 1-2 hrs,

bioavailability of 63-94% Elimination half-life varies- 3.6 to 21 hrs

depending on speed of metabolism by CYP2D6 enzyme, 7% Caucasians poor metabolizers-higher risk of ADRs

ADHD: Treatment

Atomoxetine: ADRs Common- abdominal pain, nausea &

vomiting, reduced appetite and weight loss, dizziness, slight increases in pulse rate and blood pressure

Serious- hepatotoxicity (elevated liver enzymes), jaundice; seizures; increase in suicidal behaviour; sudden death-no previous H/O cardiac problems

ADHD: Treatment

Dexamfetamine in adults with ADHD: initial treatment with low doses (5 mg twice daily) the dose should be titrated against symptoms

and side effects over 4–6 weeks treatment should be given in divided doses the dose should be increased according to

response up to a maximum of 60 mg per day the dose should usually be given between two

and four times daily

ADHD: Treatment

Drug treatment should form part of a comprehensive treatment package addressing psychological, behavioural and educational/occupational issues

Methylphenidate should be the first-line treatment- 6 weeks followed by Atomoxetine or Dexamfetamine

Caution advised with Dexamfetamine where risk of diversion suspected

ADHD: Treatment

Monitoring - Methylphenidate, Atomoxetine or Dexamfetamine:

weight - measured at 3 and 6 months after starting treatment and 6 monthly thereafter

If evidence of weight loss, consider monitoring body mass index and changing the drug if weight loss persists

heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3 months.

ADHD: Treatment

For people taking Methylphenidate, Dexamfetamine and Atomoxetine, routine blood tests and ECGs are not recommended unless clinically indicated

Liver damage is a rare and idiosyncratic adverse effect of Atomoxetine and routine liver function tests are not recommended

I recommend ECG and LFTs annuallyI recommend ECG and LFTs annually

ADHD: Treatment

Atomoxetine : in young people and adults sexual dysfunction (erectile and ejaculatory) and dysmenorrhoea should be monitored as potential side effect

Methylphenidate, Dexamfetamine or Atomoxetine: sustained resting tachycardia, arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should have their dose reduced and be referred to a paediatrician or adult physician

ADHD: MonitoringNICE (UK) 2008

If psychotic symptoms emerge on starting Methylphenidate or Dexamfetamine the drug should be withdrawn and Atomoxetine considered

If seizures are exacerbated (child or young person) with epilepsy, or de novo seizures emerge following the trial of Methylphenidate or Atomoxetine, the drug should be discontinued immediately. Dexamfetamine may be considered as an alternative in consultation with a regional tertiary specialist treatment centre.

ADHD: Monitoring

Methylphenidate or Dexamfetamine: tics tics consider whether the tics are stimulant-related

(tics naturally wax and wane) if tic-related impairment outweighs the benefits

of ADHD treatment If tics are stimulant-related, reduce the dose of

Methylphenidate or Dexamfetamine, consider changing to Atomoxetine, or stop drug

treatment.

ADHD: TreatmentNICE (UK) 2008

Group CBT: (most cost-effective) for adults on medication with persistent impairment or with poor response

Pt. choice not to take medication Intolerance/partial response to medication Difficult accepting the diagnosis of ADHD and

adhering to drug treatment To target residual symptoms

Treatment issues in ADHD with substance misuse

• Stages: assessment, engagement, stabilization• Diversion of medication• Adherence to treatment • Urine/salivary drug testing• Setting of treatment: community versus inpatient

withdrawal management and stabilization• Use of structured treatment programs• Other therapeutic modalities useful in addictions

eg. AA, NA, other community support resources

Treatment issues in ADHD with substance misuse

• Interaction with other prescribed and non-prescribed medications/substances

• Involvement of Addictions services, agreement of goals/expectations

• Substitute prescribing: opioids, nicotine• Prescription of other medications to help combat

addictions i.e. Acamprosate, Naltrexone, Wellbutrin or Varinecline

• Addressing other psychiatric comorbidities

Useful internet resources

• CADDRA: www.caddra.ca• ADDITUDEMAG: www.additudemag.com• UKAAN: www.ukaan.org• www.russellbarkley.org

Case 1

• 37 year old male, unemployed, recently released from incarceration, Hepatitis C positive

• Alcohol misuse, Cannabis, Cocaine use.• H/o ADHD since childhood with conduct disorder• H/o poor schooling, truancy, delinquency, offending• Numerous offences ranging from theft, robbery,

domestic violence, drunk & disorderly, drug trafficking• Living with son and partner, finding it difficult to cope

with anger, children’s services involved

Case 1

• Wanting treatment for ADHD• Impaired liver function tests• Unwilling to take treatment for Hepatitis C, side-effects• Erratic consumption of alcohol, cannabis constant• Outbursts of aggression at home and in neighborhood• Reported one incident of ?seizure at home• Management: to treat ADHD or not, if so with what?• How to ensure safety?

Case 2

• 51 year old male, employed with local council as a middle level employee, married with two children

• Past diagnoses: Personality disorder, Depression, Dysthymia, Anxiety disorder, Cyclothymia

• Mood fluctuations superimposed on symptoms of ADHD, led to considerable problems at work

• History of alcohol and cannabis use, to cope with mood fluctuations and feeling of restlessness

• Two serious past suicide attempts when depressed

Case 2

• Medical history: myocardial infarction 2 years ago, hypertension, ex-tobacco smoker

• Wanting treatment for ADHD, had a friend who was diagnosed who suggested that he should get help

• Had researched on the internet about his problems• Diagnosed with ADHD and Bipolar disorder• Management: safe management of ADHD without

aggravating the bipolar disorder or cardiac problems

Case 3

• 23 year old male with current opioid dependence, cannabis use, unemployed and living alone

• Suspected to have ADHD by Addictions services• Prescribed methadone for opioid dependence,

adhering to the treatment regime, cannabis misuse• Wanting treatment to attend community college• Management: should he be prescribed another

psychoactive medication with this history of drug misuse, if so how?

Questions?