Attention Deficit Hyperactivity Disorder and Substance Use Disorder: A Narrative Review

Attention deficit hyperactivity disorder (ADHD) has a growing incidence and prevalence in the United States and throughout the world, much of which is contributed to increased awareness of the condition and solidified diagnostic criteria. Substance use disorder (SUD) similarly has seen a sharp increase, particularly with the rising cases of opioid abuse. Management of ADHD is done primarily with pharmacologic therapy, often stimulants and with psychosocial interventions (i.e., exercise, meditation, peer-to-peer intervention, etc.) for adjunctive management. Management of SUD involves cessation and treatment based on the underlying drug of abuse. Many clinicians are uncomfortable treating ADHD in patients with SUD based on concerns the intervention may lead to an adverse event, including drug relapse, and the development of other psychiatric comorbidities. Concerns also arise about stimulants acting as a gateway drug in adolescents leading to the onset of SUD. Thus, in this narrative review, we aim to shed light on ADHD in relation to SUD and to provide clinical insight based on the current scientific literature on the topic. ADHD causes lesions in subcortical structures in the basal ganglia and limbic system. Treatment of ADHD with stimulants has been shown to normalize malformed neuroanatomical variations and lead to improved long-term outcomes compared to non-treatment of ADHD. Based on current scientific literature, it is recommended to treat ADHD with guideline-directed pharmacologic agents including stimulants along with non-pharmacologic interventions primarily exercise. There may be some improvement in reducing risky behavior, such as substance abuse, and may even help prevent the development of SUD.

Opioid Use Disorder: Treatments and Barriers

Over the last decade, opioid use around the world has risen considerably and is projected to continue to rise at an alarming rate. As opioid use rises, so too does the number of people who suffer from opioid use disorder (OUD) and opioid overdose-related deaths. As science and medicine progresses, new medications and therapies have arisen in order to help treat patients suffering from addiction. Treatment can be split into two main domains: pharmacological and non-pharmacological. Buprenorphine and methadone, currently the most prescribed medications for patients suffering from OUD, have been shown to be extremely effective in clinical trials but have significant real-world limitations. Geographical disparities between various locations, physician stigma with prescribing these medications, and training required to prescribe medication can make access to these treatments difficult for patients. Non-pharmacological interventions have also been shown to help with limited efficacy when combined with pharmacological interventions. However, the time and resources required to implement these strategies may be a difficult barrier to overcome. In this review, we assess pharmacological interventions, non-pharmacological treatments, examine barriers to treatment for patients, and propose solutions to bypass these barriers.

High Prevalence of Misuse of Prescribed Opioid Analgesics in Patients with Chronic Non-Cancer Pain

Opioid analgesic misuse by patients with chronic non-cancer pain is increasing in Western countries. To determine the extent of opioid misuse by patients with chronic non-cancer pain followed at a French pain management clinic. A questionnaire on pain (severity, causes and management) and opioid misuse (based on the 11 DSM-V criteria for substance abuse disorders) was administered by a health professional to patients during a short hospitalization. During the study period (September 1, 2015 to March 31, 2016), 52 patients (73.1% women; median age = 50 years [IQR_25-75: 43-57]) responded to the questionnaire. Chronic pain was caused by fibromyalgia in 55.6% of patients, and was mainly classified as neurogenic (32.6%), nociceptive (30.4%), and psychosomatic (15.2%). At hospitalization, the median pain visual analog scale score was 7/10 [IQR_25-75: 6-8], despite the ongoing treatment. The opioid misuse evaluation suggested the presence of misuse in 76.9% of patients (≥2 DSM-V criteria) that was severe in 52% of patients (≥6 DSM-V criteria). Our data highlight the high prevalence of misuse of prescribed opioids by adults with chronic non-cancer pain. A consultation with an addiction specialist should be included in the management of such patients.