(Part 3 of 5)
In this video, Psych Congress 2020 presenter Timothy Wilens, MD, provides strategies clinicians can use when treating a patient with both attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD).
Dr. Wilens is Chief, Division of Child and Adolescent Psychiatry, and Co-Director, Center for Addiction Medicine, at Harvard Medical School, Boston, Massachusetts. He spoke at Psych Congress 2020 on "Stimulants in ADHD: Friend or Foe?"
Read the transcript:
One of the most common presentations of ADHD is that which is associated with substance use disorder. It's often referred to as SUD. A common question by clinicians, and parents of kids who may have this, or individuals themselves is, how do you approach this?
First of all, you have to realize that in the untreated state, ADHD increases the likelihood for substance use. Even in treated ADHD kids, they sometimes will develop substance use disorders.
In addition, if you work in an addiction setting, you're going to find that if you're working with younger people, about 50 percent have ADHD in addition to their addiction. If you work with adults, about a quarter of them have ADHD in addition to their addiction.
So what are some strategies we can think about? Number one is ensure that the kid or the adult actually has ADHD. There's a lot of complicating factors. If somebody's going through withdrawal or detox, you want to be sure that they actually have ADHD. Ensure the diagnosis.
Number two is you're going to have to have a strategy that addresses both disorders. In terms of sequencing, if it's lower‑level substance use, for example, somebody's smoking too much marijuana or drinking a little bit too much, you probably are going to continue the treatment for the ADHD and you're going to try to treat the addiction.
If there is somebody who comes in and you're working with them through an addiction standpoint and they have severe addiction such as opioid use disorder, they're using cocaine, methamphetamine, you're probably going to try to stabilize that addiction first either in an inpatient or higher level of care, really trying to go after that addiction.
Pretty soon thereafter, you're going to think about, "What can I do to treat the ADHD?" There is evidence that if you don't treat the ADHD, people aren't retained in treatment, and they don't do as well even if they're in treatment.
We have evidence from the Mass General, for example, that starting, let's say, stimulants early in the treatment during addiction really improves retention for those individuals to stay through treatment. You have a lot of motivation to think about getting the ADHD treatment started relatively rapidly.
What are some of those treatments? Some of the things we think about are cognitive‑behavioral therapies, structured therapies. Cognitive‑behavioral therapy has been demonstrated to be effective for addiction. It's also effective for ADHD. There's some pilot combined substance use‑ADHD CBTs now that seem to be effective for this population.
When we think about treating pharmacologically, you may want to treat with a nonstimulant. If you're going to be using a stimulant, because stimulants continue to be most effective agents for ADHD, we're thinking at this point to use the extended‑release forms of these medications. They appear to have lower abuse liability than the immediate‑release preparations of these medications.
Clearly, these are patients that you're going to follow more carefully with more frequent follow‑up visits. Again, you're going to be addressing both the ADHD and the substance use disorders in your follow‑up visits.
Having said that, I've treated a number of individuals personally. I find it very rewarding to help identify the ADHD, treat it, and treat the substance use disorder. These individuals can do very, very well in life.