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Figure 1. from Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med. 2012 Sep 4 10:99 (see ref 6 below).
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One of the main concerns in the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) is whether treatment improves outcomes. The outcomes measure of interest may depend on the clinical population that you are focused on treating. In primary care settings, my impression is that a lot of the adults treated by internists are relatively stable and that they do not have a lot of problems with other mental illnesses or addictions. That is my speculation based on some of the numbers of adults I have heard are seeing primary care physicians and the fact that seeing those numbers with even a fraction of patients who have additional psychiatric problems or addictions would be unsustainable. I have also directly observed the pattern that many patients who are discharged from primary care for stimulant overuse or psychiatric complications like mania end up seeing psychiatrists. As a psychiatrist working in a residential setting that treats substance use problems - trends in overprescribing, misdiagnosis and confusion about the concept of addiction and ADHD treatment are readily observed. It is very clear that people with clear ADHD can misuse stimulants and continue to insist on using stimulants. It is clear than many of these people develop insight into this and can say at one point that they can no longer take stimulants even though they have a bona fide ADHD diagnosis. It is also clear that there is a lot of confusion among treating professionals about the issue of whether or not a stimulant should be prescribed to a person with an addiction.
There is a lot of overlap between the diagnosis and treatment of Attention-Deficit/Hyperactivity Disorder and addiction or substance use disorders. Discovering this overlap depends on clinical experience, training and exposure to patients with addictions. It is fairly common to read studies about ADHD outcomes that may not look at addictions as outcomes. Like many areas in medicine, some of the early studies in this area have not been borne out by subsequent studies. The study of this problem has only been a relatively recent endeavor. The original AHRQ report in 1999 (1) looked at 77 randomized controlled clinical trials included in the time period from 1971 to 1999. Half of the studies were published since 1990. At that time there were only 13 adult studies. The outcome variables were generally improvement on symptomatic rating scales, neuropsychological tests or educational achievement tests.
Connor's review (2) looks at the studies prior to 2006. At the time he states that there were a total of 14 studies that looked at potential abuse issues. One of the studies supported the idea of behavioral sensitization or stimulant administration leading to craving and eventual self administration. That study did not control for Conduct Disorder, a comorbid condition that increase the risk of substance use disorders. The other studies found no increased risk, and in some cases a decreased risk of substance use disorders. There were no review elements that looked at addictions or substance use disorders. A meta-analysis of 6 studies by Wilens, et al showed a 1.9 fold reduction in risk in the stimulant treated patients. Connor's conclusion is that "...in uncontrolled environments, active substance abuse is a relative contraindication to prescribing stimulant medications." the use of atomoxetine or antidepressants with a known efficacy for ADHD was encouraged (p. 626).
Connor's review (2) looks at the studies prior to 2006. At the time he states that there were a total of 14 studies that looked at potential abuse issues. One of the studies supported the idea of behavioral sensitization or stimulant administration leading to craving and eventual self administration. That study did not control for Conduct Disorder, a comorbid condition that increase the risk of substance use disorders. The other studies found no increased risk, and in some cases a decreased risk of substance use disorders. There were no review elements that looked at addictions or substance use disorders. A meta-analysis of 6 studies by Wilens, et al showed a 1.9 fold reduction in risk in the stimulant treated patients. Connor's conclusion is that "...in uncontrolled environments, active substance abuse is a relative contraindication to prescribing stimulant medications." the use of atomoxetine or antidepressants with a known efficacy for ADHD was encouraged (p. 626).
A more recent review by Shaw, et al from 2012 takes a different approach. The authors looked at studies between 1980 and 2010 with a minimum follow-up period of two years or more (prospective or retrospective) or cross sectional studies that compared two ages differing by two years of more. Nine separate outcome measures were examined as indicated in Figure 1 at the top of this page. Since some studies reported more than one outcome measure, a total of 636 outcomes were examined from the 351 studies reviewed for this paper. Drug use or addictive behavior was one of the most frequently examined outcomes with a total of 160 results. The next most frequent result was academic functioning with 119 results. The data is represented as percentage comparisons as improved, similar, or poorer than the comparators. As an example in Figure 1, the last 4 categories show that treatment was beneficial in 67% of the drug/addictive, 50% of the antisocial, 50% of the service use outcomes, and 33% of the occupational outcomes. The authors conclude that in these four treatment groups there was no benefit conferred by treatment. They looked at the issue of treatment of these four groups in the rest of the world and found that there was substantially better outcomes for this subgroup. There were significant methodological problems noted in the studies including the need to control for Conduct Disorder, Oppositional Defiant Disorder, and a number of other comorbid psychiatric disorders. Other potential comparison issues between the American and non-American studies included the fact that the American studies were largely prospective, the non-American studies used more stringent ICD-10 codes. One of the main variables that addiction psychiatrists are focused on clinically is when the addiction is established. Did it occur before, during, of after the ADHD diagnosis in childhood? What does that spectrum suggest for the impact of stimulant treatment on an addiction outcome?
Where does all of this leave clinicians today? It is possible to find clinicians who believe that they are treating addiction with stimulants because they are reducing impulsivity associated with ADHD. There are also clinicians who believe that stimulants must be avoided at all costs, even in people with a diagnosis of ADHD. Is there a rational approach to discuss what is known about the diagnosis and treatment with the patient as part of their overall treatment program that might optimize treatment outcomes? I think that there is and have written it down in this worksheet entitled 28 Discussion Points for Stimulant Treatment of ADHD. The worksheet is intended to address problematic diagnosis as the first point of variance. It discusses the relevant addiction and safety considerations. There is also a framework for exploring the decision to use a stimulant in the broader context of a treatment plan that may include non-medical therapists and treatment programs and housing programs that may limit or prohibit the patient from using stimulants. It does not incorporate the therapeutic alliance and overprescribing considerations. One of the most difficult tasks for physicians is not prescribing a medication with addictive potential when a person believes it is necessary for their life or they are demanding it.
Remembering that people with addictions are compelled to take stimulants whether they improve outcomes or not is an important part of providing quality care to this population.
George Dawson, MD, DFAPA
References:
1: Jadad AR, Boyle M, Cunningham C, et al. Treatment of Attention-Deficit/Hyperactivity Disorder. Evidence Report/Technology Assessment No. 11 (Prepared by McMaster University under Contract No. 290-97-0017). AHRQ Publication No. 00-E005. Rockville, MD: Agency for Healthcare Research and Quality. November 1999.
2: Connor DF. Stimulants. In: Barkley DF. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York, NY. The Guilford Press, 2006: 608-647.
3: Barkley RA, Fischer M, Smallish L, Fletcher K. Does the treatment of attention deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13-year prospective study. Pediatrics. 2003 Jan;111(1):97-109. PubMed PMID: 12509561.
Attribution:
The graphic at the top of this post is from reference 6 above and is posted per the open access license at that site.
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