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ADHD Stimulant Treatment Plan Should Include Monitoring for Substance Abuse
When treating individuals with attention-deficit hyperactivity disorder (ADHD) with stimulants, clinicians should make a treatment plan that includes monitoring for any emergent substance abuse, says ADHD Section Editor and Psych Congress Steering Committee member Vladimir Maletic, MD, MS.
In this video, Dr. Maletic discusses the complex relationship between ADHD and substance use disorder (SUD) and expands on updates from the “World Federation of ADHD International Consensus Statement”.
In the upcoming part 2, Dr Maletic who is also Clinical Professor of Psychiatry at the University of South Carolina School of Medicine, Greenville, answers the question: “Does the information you presented mean clinicians should not prescribe stimulants to patients with ADHD who have a history of SUD?"
Read the transcript:
Hello, my name is Vladimir Maletic. I'm a clinical professor of psychiatry at the USC School of Medicine in Greenville, South Carolina. I have been a member of the Psych Congress steering committee for the last 12 years. Currently, I serve as section editor for Psych Congress Network for ADHD section.
Q: What do we know about the relationship between ADHD and substance use disorder?
Dr. Maletic: The question about the relationship between ADHD and substance use disorder has been a very complex one and very important from the clinical perspective to debate and understand.
For the first time now, we have access to large genome-wide association studies. These studies included over 20,000 individuals with ADHD, but also in excess of 35,000 typically developing controls.
We have found that individuals who have ADHD carry a certain polygenic risk to also later on in their life develop substance use or tobacco use. These conditions are linked at the root, so to say.
Epidemiologic studies confirm this risk. It is an approximately 2 to 3 times greater risk for tobacco use if somebody has a diagnosis of ADHD. It is anywhere between 50% to a threefold increased risk of lifetime alcohol use if somebody has an associated ADHD diagnosis.
In terms of what comes first, epidemiologic studies are pretty clear-cut. Over 98% ADHD will precede substance use. Therefore, in a clinical context, data suggests that this is something that we should always be thinking about.
Whenever we are evaluating a patient with ADHD, risk is slightly greater in adolescence and growth towards adulthood. We need to be thinking about a treatment plan that would include monitoring for any kind of emergent substance use because it can greatly intervene with a person's functioning. It can increase their suffering and our ability to deal with ADHD symptoms would be compromised.
Q: What do we know about the misuse of stimulants among patients with ADHD? What tips do you have for clinicians that are working in the field treating these patients?
A: A very important question imposes itself. That is, stimulants are conventional and sometimes considered first-line treatment for ADHD. Yet, there may be some reason for concern about misuse or diversion of these substances.
What do we really know about that? There are a couple of interesting facts that have emerged. There is a suggestion that if there is going to be diversion and misuse of stimulants, it is mostly for the sake of enhancing either academic or work performance in non-ADHD affected individuals.
While the misuse and diversion is there, the question is, does it really benefit these individuals who don't have ADHD? The answer might surprise you. It is no. There is actually no evidence that individuals who have ADHD and are using stimulants to enhance their performance that it will benefit them.
As a matter of fact, there are data suggesting that if there is a non-medical use of stimulants to help individuals study, they're 17% less likely to attain a bachelor's degree. Indeed, it is something that unfortunately doesn't make sense but is a common occurrence.
It is a completely different question if individuals who have ADHD are more likely to misuse stimulants. This question has been addressed at several different levels. One particularly large study compared 2 populations. One is for a population of individuals who had ADHD and the other one's who have asthma.
Authors of this study were interested in so-called shopping behaviors. This is how they defined it. A likelihood of having multiple healthcare providers writing prescriptions for stimulants or using multiple pharmacies to fill stimulant prescriptions.
The finding is that, compared to individuals who have asthma, individuals who have ADHD were four times more likely to engage in these shopping behaviors. The risk does exist.
In terms of comparison of, again, the emergence of these shopping behaviors in ADHD individuals who are prescribed stimulants versus non-stimulants, there is no comparison. If they are prescribed stimulants, they are eight times more likely to engage in these shopping behaviors versus individuals who are treated with non-stimulants for their ADHD symptoms.
How often does this really occur? According to a recent study, it is about 1 in 250 patients prescribed stimulants who are likely to seek prescriptions from multiple providers or have prescriptions filled at multiple pharmacies. It's relatively rare. One in 250.
Where should we be most concerned? Unfortunately, past behavior is still the best predictor of future behavior. Our focus needs to be on individuals who have had past history of misuse of controlled substances or misuse and abuse of illicit substances. They are the ones who are twice as likely to abuse stimulants versus the ones who did not have that type of history.
As a matter of fact, 75% of the time misuse of stimulants is preceded by past prescription-drug misuse. Again, we need to be worried about the ones who have a history of alcohol use, misuse of prescription medications, and drug abuse. They are the ones who are most likely to also misuse or divert stimulants.
Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr. Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University.
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