The clinical dilemma of using medications in substance-abusing adolescents and adults with attention-deficit/hyperactivity disorder: what does the literature tell us?

Substance-use disorders in adolescents and adults with ADHD: focus on treatment

A high prevalence of comorbidity of ADHD and substance-use disorders (SUDs) has been shown in the literature. In this article, the literature for the treatment of adolescents and adults with co-occurring ADHD and SUD is examined. Findings from pharmacotherapy suggest mild improvement in ADHD without demonstrable changes in SUD unless the addiction was stabilized prior to treating the ADHD. No unique adverse effects, worsening of SUD, misuse or diversion of stimulants are reported in the included studies. Treating ADHD pharmacologically in individuals with ADHD plus SUD only has a modest impact on ADHD and SUD that is not observed in controlled trials. Limited data in adults with ADHD and brief abstinence of their SUD showed improvements in both ADHD and SUD with treatment. Further studies of cognitive behavioral therapy, sequencing of therapies and longer term treatment outcomes for groups with ADHD and active SUD are necessary.

Attention deficit hyperactivity disorder and substance use disorders

During the past two decades, there has been an increased recognition that Attention Deficit Hyperactivity Disorder (ADHD) is overrepresented in treatment and community populations of both adolescents and adults with substance use disorders (SUDs). This chapter explores this relationship, including a review of the prevalence of this comorbidity, ADHD and the risk for the development of SUDs. Possible neurobiological underpinnings of the relationship are also discussed. Because of the salience of the association between smoking (tobacco) and ADHD, this topic is included in the discussion of substance use and SUDs.

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.

METHODS

The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.

RESULTS

Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?

CONCLUSIONS

ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Psychotropic medications and substances of abuse interactions in youth

The majority of youth with substance use disorders (SUDs) manifest one or more co-occurring psychiatric disorders. Consequently, many of these youths are being prescribed with psychotropic medications. As prescribing rates continue to increase for early-onset psychiatric disorders, potential risk for substance of abuse-psychiatric medication interactions may be enhanced. Because this type of drug-drug interaction has received little attention in the scientific literature, the authors conducted a systematic literature search examining the potential interactive adverse effects between psychotropic medications and substances of abuse in youth. Regardless of the scarcity of psychotropic medications-substance of abuse interactions found, it is important to stay vigilant due to the continued introduction of new classes of medications as well as the ever-changing map of street drugs.

Treating adult attention deficit hyperactivity disorder in hospitalized psychiatric patients

OBJECTIVES

We intend to review the importance of appropriately recognizing and managing attention deficit/attention deficit hyperactivity disorder (ADD/ADHD) in the acute psychiatric hospital setting.

METHODS

We demonstrate the management of three patients with associated ADD/ADHD diagnosis in the hospital setting. This case series is followed by a review of the literature on the treatment of ADD/ADHD with particular focus on inpatient treatment.

RESULTS

Given that the core symptoms of ADD/ADHD are inattention, hyperactivity, poor concentration, impulsivity, poor organization and emotional instability, it follows that a comprehensive inpatient treatment plan should address these issues in order to obtain sustained, focused participation on the part of the patient. Suppression of ADD/ADHD symptoms with stimulants greatly enhanced our patients' ability to more productively and actively participate in the treatment of the acute psychiatric problems which led to their admission.

CONCLUSIONS

Currently, no published data exist on prevalence of ADD/ADHD in psychiatric hospitals, rates of treatment and outcome of treatment with regard to recovery and quality of aftercare. Nonetheless, the benefits of treating ADD/ADHD among psychiatric inpatients may be seen in case examples and are also apparent in the data concerning treatment of ADD/ADHD in the dually diagnosed.

Pharmacological management of attention-deficit hyperactivity disorder in adolescents: special considerations

Approximately one-half of children medicated for attention-deficit hyperactivity disorder (ADHD) will continue to experience sufficient impairment during adolescence to warrant the continuation of their treatment; a smaller number of people with ADHD may require treatment for the first time during adolescence. The academic and social demands of adolescence can exaggerate the impairment caused by attentional problems, as adolescents, more so than children, have activities in the afternoon and evening that will tax their attentional abilities. Stimulant and nonstimulant medications are likely to be as effective for adolescent patients as they are for younger children, provided treatment adherence is satisfactory. Long-acting medications are preferred over immediate-release compounds as they provide better coverage of symptoms throughout the day. Patterns of comorbidity with ADHD change from childhood to adolescence and may require a shift in treatment strategy. The choice of time to discontinue treatment should be a decision shared by the clinician and the patient. A negotiated trial of time off treatment followed by a review of the patient's symptoms can avert premature discontinuation of treatment.

Combination pharmacotherapy for adult ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent neuropsychiatric disorders of adulthood. Although clinical guidelines recommend monotherapy with stimulants or atomoxetine, combination pharmacotherapy is a common practice among clinicians. There are four main situations in which combination medications may be necessary: partial response, dose-limiting side effects, associated disorders, and comorbid diagnoses. We present data from two chart reviews that support existing research on combination pharmacotherapy. Adjunct treatment of d-methylphenidate to stimulant medications extended the duration of therapeutic effect. Adjunct treatment of mirtazapine to stimulant medications reduced associated insomnia. These data support previous research that validates the use of combination pharmacotherapy for adults with ADHD.

Therapeutic challenges of attention-deficit hyperactivity disorder with substance use disorders

Attention-deficit hyperactivity disorder (ADHD), a common neuropsychiatric disorder of childhood, adolescence and adulthood, is frequently comorbid with substance use disorders (SUDs) in both adolescents and adults. This paper will provide an overview of the relationship between ADHD and SUDs and discuss the primary areas of therapeutic challenge in the treatment of individuals with comorbid ADHD and SUDs, including the diagnosis of ADHD in populations with SUDs, selecting appropriate agents for use and prevention of abuse and/or diversion of the therapeutic pharmacological agents used in ADHD treatment. The authors will also provide a discussion on the future of research and treatment in this area and key issues for clinicians.