Preventing Substance Abuse in ADHD Takes Early Treatment, Harvard Expert Says

Treating children early and correctly for attention-deficit/hyperactivity disorder (ADHD) offers them protection against substance abuse and academic failure later in life, according to a Harvard psychiatrist who treats teenagers who struggle with both.

Timothy E. Wilens, MD, chief of the Division of Child and Adolescent Psychiatry and Director of the Center for Addiction Medicine at Massachusetts General Hospital, went through data showing that, compared with peers, youth with ADHD are twice as likely to develop a substance abuse disorder and three times as likely to smoke cigarettes.

“That’s huge,” he said.

Overall, 23% of all adults with a substance abuse disorder have ADHD, and the percentage rises to half of all adolescent patients in substance abuse treatment, Wilens said.

But Wilens, speaking at the 30th US Psychiatric and Mental Health Congress in New Orleans, Louisiana, said while there is an overlap between ADHD and substance abuse disorder, the data also show that the earlier a child begins treatment with stimulants, the less likely he or she is to use marijuana,¹ or have a substance abuse problem.²

Worldwide, 6% to 9% of children and adolescents have ADHD, and at least half will continue to present with the condition as adults, said Wilens, who is also an associate professor at Harvard Medical School.

“It isn’t just a cosmetic disorder,” he said, but a chronic condition of inattention, distraction, and impulsivity. And yet, “It’s actually a very rewarding group to treat, because treatment does help,” Wilens said. “People get better, and it really changes their life trajectory.”

When people with ADHD develop a substance abuse problem, they struggle more, have a harder time sticking with treatment, and suffer more psychiatric comorbidities than others. “It takes almost twice as long to get better,” he said.

Even smoking grips teenagers with ADHD more quickly, and it is linked with an early decline in executive functioning. Why might this be? Wilens has examined this, and it could be because of carbon monoxide, not the nicotine.

The idea that young people with ADHD gravitate toward stimulants is not supported by evidence, Wilens said. This group is using the same drugs and alcohol as their peers, but they are using the drugs to change their mood, he said.

How can substance abuse in ADHD be prevented? Large registry studies in Europe, especially in Scandinavia, show a 60% risk reduction if children begin treatment for ADHD before age 15.

“It’s better to start early,” Wilens said. There’s been concern about the long-term effects of treating a 6-year-old with stimulants, but the registry studies show failing to do so brings greater risk. “This shows start the medicines early; treat them chronically.”

Wilens said for many years, if a patient with ADHD was in treatment for substance abuse, the assumption was they had to get sober first. But a more recent study shows that in some cases, if that’s not happening, treating the ADHD with heavy doses of stimulants can reduce symptoms and help patients get clean.

“It’s best to get people clean and sober for a period of time; the likelihood that medicines will work is much higher,” Wilens said. “But if you can’t, you might want to consider stimulants. ... If you’re going to use stimulants—get brave and use higher doses.”

Also, patient retention in treatment improved, addressing a longtime problem with ADHD patients.

Wilens also addressed stimulant misuse, including the 40% of abusers who snort the drugs. Surveys and informal interviews reveal that students don’t always do this to get high—they want the drugs take effect quickly during peak study periods.

Having this knowledge, Wilens said, can help physicians ask better questions, stick with extended release formulations, monitor pill counts, or tell patients they will not renew prescriptions if they “lose” or run out of their drugs.

References

1. McCabe SE, Dickinson K, West BT, et al: Age of onset, duration, and type of medication therapy for attention-deficit/hyperactivity disorder and substance use during adolescence: a multi-cohort national study. J Am Acad Child Adolesc Psychiatry 2016;55(6):479-486.

Chang Z, Lichtenstein P, Halldner L, et al. Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry. 2014;55(8):878-885