uestion:
Does this patient have a history of substance abuse which would make the
use of stimulant drugs unwise? Characteristics of ADHD in adults, according to Wender, include: Motor hyperactivity; attention deficits in conversation, reading, remembering details; affective lability; hot temper; excessive emotional reaction to stress; disorganization with inability to complete tasks; and impulsivity and impatience.¹ Depression is present in a third of adult patients with ADHD.²
¹Wender PH. ADHD in Adults. New York, Oxford University Press, 1995.
²Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with ADHD. Am J Psychiatry 1993;150:1792-1798.
uestion:
Does this patient have a history of substance abuse which would make the
use of stimulant drugs unwise?
Help: Although there are no data from controlled studies to confirm or refute the proposal that patients with ADHD and a history of substance abuse are more likely to abuse prescribed stimulants, experts advise that stimulants should be used very cautiously or not at all in such patients.¹ Psychotherapeutic, expecially cognitive-behavioral treatments, have from clinical experience been reported to be particularly useful.²
¹Wender PH. ADHD in Adults. Psychiatric Times 1996;13(7):41-45.
²Wilens TE, Prince JB, Biederman J, et al. ADHD and comorbid substance abuse in adults. Psychiatric Services 1995;46(8):761-765.
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Wilens et al¹ reviewed controlled studies of medications in adults with ADHD, and concluded that stimulants were significantly effective. Other antidepressants and miscellaneous alternative drugs, although studied with less adequate methodology, appeared only moderately effective. However, in pediatric patients with comorbid depression and ADHD, the response of the ADHD to stimulants was not as good as when depression is not present (although the response of the depression was unclear).² Our best educated guess, now, is that if the adult patient with a treatment-resistant depression and comorbid ADHD has not had a trial with a stimulant to this point, it seems reasonable to try adding one. Tricyclics would also be a good if not better choice,² but they would have already been tried by the time you have reached this point in the algorithm.
This recommendation would appear to hold for both unipolar and bipolar patients who have come to this point in their sequential treatment history, barring contraindications such as a cardiac history precluding stimulant usage. For dosage considerations and considerations predicated on other kinds of comorbidity, see the references below.
Second line choices for this situation (other than tricyclics) include (if not already tried) bupropion¹ and venlafaxine.³
Recommendation #34
¹Wilens TE, Biederman J, Spencer TJ, and Prince J. Pharmacotherapy of adult ADHD: a review. J Clin Psychopharmacol 1995;15:270-279.
²Spencer T, Biederman J, Wilens T, Harding M, et al. Pharmacotherapy of ADHD across the life cycle. J Am Child Adolesc Psychiatry 1996;35(4):409-432.
³Findling RL, Schwartz MA, Flannery DJ, Manos MJ. Venlafaxine in adults with ADHD: an open clinical trial. J Clin Psychiatry 1996;57:184-189.
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The ADHD patient with substance abuse and treatment-resistant depression is a most challenging but unfortunately not uncommon problem that has received scant attention from the research establishment. There is some evidence that the combination of depression and ADHD gives you increased risk of substance abuse,¹ although the rate is fairly high among non-depressed ADHD patients (over 25%). Alcohol and marijuana seem to be the substances of choice. Cocaine abuse may clinically present similarly to ADHD, and the use of stimulants in such persons has been reported to escalate cocaine usage.¹
As the last question implies, stimulants are generally not recommended. Non-pharmacologic strategies focusing on the substance abuse and on the ADHD are advised.² Among the medications that could be considered, tricyclics have probably already been tried by this point in the algorithm. The possible efficacy of venlafaxine deserves consideration.³ Bupropion could also be offered, although in cocaine addiction there may be increased risk of seizures from synergistic effect with the cocaine.¹
There are a number of reports where clinicians have described successful experience using stimulants in cocaine-dependent patients.(4,5) With appropriate consent and caution regarding patient selection, and citation of these reports, the physician may elect to consider using a stimulant such as methylphenidate in conjunction with psychosocial treatment for the addictive disorder.
Recommendation #33
¹Levin FR, Kleber HD. ADHD and substance abuse: relationships and implications for treatment. Harvard Rev Psychiatry 1995;2(1):246-258.
²Wilens TE, Prince JB, Biederman J, et al. ADHD and comorbid substance abuse in adults. Psychiatric Services 1995;46(8):761-765.
³Findling RL, Schwartz MA, Flannery DJ, Manos MJ. Venlafaxine in adults with ADHD: an open clinical trial. J Clin Psychiatry 1996;57:184-189.
(4)Schubiner H, Tzelepis A, Isaacson JH, et al. The dual diagnosis of ADHD and substance abuse: case reports and literature review. J Clin Psychiatry 1995;56(4):146-150.
(5)Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult ADHD: a pilot study. J Clin Psychiatry 1998;59:300-305.
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