9/14/15

Adult ADHD Prevalence

ADHD and
Substance Use Disorders

John Roberts, MD

US Current prevalence -2.5- 4.4%(Kesler, et al,

2006,NCSR)/5%(Barkley 2012)
Lifetime prevalence in SUD 23.1%(van Emmens et
al,2012)
Adults with ADHD more likely than general
population to have SUD, OR=1.5-7.9(Kessler, Barkley,
2006)
33% of Adult ADHD patients have AUD, 20% have
SUD(Waid,1998)
Hx of childhood ADHD found in 17-50% of those
with SUD(Waid,1998)
Adult ADHD patients have higher rates of mood
disorder, anxiety disorders, intermittent explosive
disorder, antisocial personality disorder

Childhood ADHD

Impairments

Childhood

Higher

40-60%

Occupational

ADHD and Relationships

Pathogenesis

Marital

Brain

prevalence 5-7%
continue to have significant
ADHD-elated problems in adulthood

discord related to:

listening skills
Distractibility
Emotional outbursts
Isolation and hyperfocus
Forgetfulness
Disorganization/clutter
Impulsive spending/difficulty with finances
Poor

rates of:
difficulties
Criminal behavior
Traffic accidents and citations
Divorce
Bankruptcy
Mortality

imaging indicates dysfunction in

right fronto-subcortical and parietal
circuits
Most prominently in prefontal cortex
Smaller volumes in frontal cortex,
cerebellum and subcortical structures
Hypoactivity of dopamine and
norepinephrine in these circuits underlies
the brain dysfunction

9/14/15

Genetics

Is Adult ADHD a Distinct Disorder?

Risk

of ADHD in parents and siblings of

children with ADHD increased 2-8 times
Heritability estimated at 76%
10-35% of immediate family members of
children with ADHD are likely to have
ADHD
If parent has ADHD, risk to the offspring
is 57%

Recent

Adult ADD Distinct Disorder?

DSM 5 Diagnosis

Adults

showed almost none of hallmark

deficiencies found in childhood
Brains worked fine when taking IQ or
working memory tests
More trouble with forgetfulness and word
finding
Adults had much higher rates of
SUD(48%) than those diagnosed as
children
Moffitt, et al, 2015

Hyperactive-impulsive
presentation:

Fidgets with hands or feet or squirms in chair.

Has difficulty remaining seated.
Runs about or climbs excessively in children;
extreme restlessness in adults.
Difficulty engaging in activities quietly.
Acts as if driven by a motor; adults will often
feel inside like they were driven by a motor.
Talks excessively.
Blurts out answers before questions have been
completed.
Difficulty waiting or taking turns.
Interrupts or intrudes upon others.

study suggests Adults presenting

with ADHD may not have childhoodonset neurodevelopment disorder
1,037 people followed for 4 decades in
New Zealand
Childhood prevalence-6%
Adult prevalence-3% but only 3 of these
had childhood ADHD diagnosis

In making the diagnosis, children still should have six or more

symptoms of the disorder. In people 17 and older the DSM-5 states
they should have at least five symptoms.
The criteria of symptoms for a diagnosis of ADHD:
INATTENTIVE PRESENTATION
Fails to give close attention to details or makes careless
mistakes.
Has difficulty sustaining attention.
Does not appear to listen.
Struggles to follow through on instructions.
Has difficulty with organization.
Avoids or dislikes tasks requiring a lot of thinking.
Loses things.
Is easily distracted.
Is forgetful in daily activities.

Combined inattentive &

hyperactive-impulsive
presentation:
Has

symptoms from both of the

above presentations. Reference:
American Psychiatric Association
(2013). Diagnostic and statistical
manual of mental disorders (DSM-5),
Washington, D.C.: American Psychiatric
Association

9/14/15

Specify
Several

symptoms present before age 12

Several impairments are present in 2 or
more settings
Sxs interfere with functioning
Sxs do not occur during course of
psychotic disorder and not better
accounted for by another mental disorder
(e.g., mood, anxiety, dissociative or
personality disorder)

Combined

presentation
Predominately inattentive presentation
Predominately hyperactive-impulsive
presentation
Partial remission
Mild
Moderate
Severe

Proposed Diagnostic criteria for

ADHD in Adults
6

of 9 sxs or 4 of the first 7 for 6 months

easily distracted by extraneous
stimuli.
2.Often make decisions impulsively.
3.Often have difficulty stopping activities
when they should do so.
4.Often start projects without reading or
listening to directions
5.Often show poor follow through on
promises pr commitments made to others.
1. Often

6. Often

have trouble doing things in their

proper order or sequence
7. More likely to drive faster or have
difficulty in leisure activities or doing fun
things quietly
8.Often has difficulty sustaining attention
in tasks and leisure activities.
9.Often has difficulty organizing tasks and
activities

Inattention Examples
Easily

Daydreamer, gets

Problems

distracted by sounds, movements

resuming tasks after distraction
Poor concentration in conversations,
meetings
Difficulty getting started on and following
through on tasks, procrastination
Forgetfulness, lose items, late for deadlines
Difficulties with focus and comprehension
when reading

Disorganization

lost in thought

Run

out of steam, low attention vigilance

Require longer than average to complete
projects
Underperformance relative to abilities

9/14/15

Hyperactive-Impulsive Examples
Fidgety, frequent

shifting
fingers, pen wagging foot, playing
with items
Discomfort with sedentary, confining tasks
Mental restlessness, juggling several ideas but
not following through on any
Starting projects but not finishing them
Saying things without thinking or
inappropriate to setting, impulsive

Making

Sluggish Cognitive Tempo

Executive Function (EF)

Lethargic, slow

moving
energy
Difficulty getting engaged in a setting
mind wandering, daydreaming
Problems staying awake, alert if bored
Slow mental processing
Easily confused or mentally overwhelmed
Likely to shut down
Anxiety

Those

Executive function (EF)

Executive Function

These

Regarded

Tapping

Underactive, low

difficulties contribute to failure to

achieve goals, - personally, academically,
and occupationally which can in turn lead
to high rates of anxiety and depression
ADHD now understood as
neurodevelopmental disorder of EF and
motivational deficits (Volkow et al., 2009)

promises but then becoming

overcommitted, impulsive compliance
Impulsive spending, substance abuse
Difficulties managing discomfort, boredom
Problems turning off brain

self-directed actions needed to

choose goals and to create, enact and sustain
actions towards those goals
Difficulty with self-management, including
organization, planning, initiating and
completing tasks on a timely basis
Results in reduced productivity, inefficiency,
missed deadlines, poor planning, careless
errors and losing and forgetting things as a
result of disorganization

by many as the defining

characteristic of ADHD in children and
adults
Response inhibition
Working memory
Set shifting
Planning and executing for the future:
temporal discounting

9/14/15

EF Neuropsychological Testing vs.

Rating Scales

Neuropsychological testing

Question

Not

Self-Rating Scales of EF

Brown Attention Deficit Disorder

Scale (BADDS; Brown,1996)

Brown Attention

40

whether these tests capture the

cope of EF in ADHD and other disorders
Neuropsychological testing identified only
14% of 194 adults with ADHD
Few false positives for boys but higher rates
of false negative in identifying ADHD
Only 33% of 259 children with ADHD had
EF deficits based on neuropsychological test
battery
Biederman and colleagues 2004
&2008

Deficit Disorder Scale

(BADDS; Brown,1996)
Behavior Rating Inventory of Executive
Function Adult Version (BRIEF-A; Roth,
Isquith, & Gioia,2005)
Barkley Deficits in Executive Functioning
Scale -BEDEFS (Barkley, 2011)

BEDEFS (Barkley, 2011)

89

item

Self-Management

to Time-prepared on
time for tasks, time estimation, planning
Self-Organization/Problem Solving
Self-Restraint
Self-Motivation
Self-Regulation of Emotions
(Barkley, 2011)

appropriate to rule in or rule out a

diagnosis of ADHD
May be useful in for assessing cognitive
strengths, reading and learning deficits for
educational and occupational purposes
May be required to document need for
academic accommodations
Barkley 2014

items divided into 5 subscales

of task, time estimation
Attention-focused, sustained and shifting
Memory-working and short term
Effort-regulation of alertness, sustaining
effort
Affect-modulating emotions
142 adults- significant difference between
controls and ADHD groups
Activation-initiation

EF Tests vs. EF Scales

EF

scales accounted for > half of the

variation in impairment
EF Tests explained < 10%
These two approaches are not measuring
the same construct

al.; 2013)

(Toplak et

9/14/15

Psychological Assessment Of Adults

with ADHD

ADULT ADHD Evaluation

Clinical

interview- Family, Educational,

Occupational, Social History
Structured Diagnostic interview
Review of clinical Inventories- past and
current ADHD Sx checklist (self and other
report)
Adult ADHD inventories (self and other
report)
EF inventory (self and other report)
Other mood, anxiety and psychiatric Sx
inventories

ADHD Symptom Checklists

Adult ADHD Inventories

ADHD

Screening brief telephone screen to rule out

contraindications
The World Health Organizations Adult ADHD
Self-Report Scale (ASRS; ADLER,et al 2003)
18 item scale
First six items provide a reliable stand-alone
screening measure- each item rated on 5-point
Likert scale from 0 rarely to 4 very often
Total scores of 11 or more highly predict ADHD
< 11 raise question about motive

Rating Scale-IV
Self-Report Scale
Barkley Adult ADHD Rating Scales-IV
Wender Utah Rating Scale (for childhood
symptoms)

Brown Attentive-Deficit

Adult

Disorder ScalesAdult Version

Conners Adult ADHD Rating Scale

EF Inventories

Functional Impairment Inventories

Barkley

Adult ADHD

Deficits in Executive Functioning

Scale (BEDEFS)
Behavior Rating Inventory of Executive
Function Adult Version (BRIEF-A)

Quality of Life Scale

Functional Impairment Scale
Weiss Functional Impairment Scale
Barkley

9/14/15

Comorbidity Inventories

Imaging or Laboratory Testing

Beck

Depression Inventory-II (BDI-II)

Hamilton Depression Scale (HAM-D)
Hamilton Anxiety Scale (HAM-A)
Beck Anxiety Inventory (BAI)
The Penn State Worry Questionnaire
(PSWQ)
Symptom Checklist -90
Revised )SCL-90-R)

NEBA

Neuroimaging

NEBA

The

SPECT

SPECT

The

Few ADD

is the first of a new kind of medical

device cleared by the FDA that uses
brainwaves (EEG) to help clinicians more
accurately diagnose ADHD in children
and adolescents (ages 6 17.99 years).
FDA created an entirely new category of
medical device to regulate NEBA. These
devices are called Neuropsychiatric
Interpretive EEG-based Assessment Aids
or NIEAs for short.

procedure entails an injection of a

radioactive isotope that is then picked up
by the brain. This means exposure to a
small amount of radiation - about the
equivalent of an X ray. The patient lies
motionless as a camera rotates around his
head. Several scans may be required, at a
cost that can top $1,000.
Daniel Amen, MD Amen Clinics (6
ADHD subtypes)

NEBA (Neuropsychiatric Interpretive

Electroencephalograph Assessment Aid)
NEBA is a 15 minute test that integrates an EEG
biomarker for ADHD into the clinical setting. NEBA
can help the clinician verify when ADHD is present
When applying NEBA, clinicians still conduct their
regular evaluation. NEBA provides additional
information by using EEG to separate ADHD patients
into biomarker-based groups with clinical differences
that allow validated recommendations to be offered
to the clinicians. NEBA is the only ADHD biomarker
that is FDA cleared, CE marked, Health Canada
licensed, and USPTO patented.

neuroimaging technique that has

aroused the most interest among those
suspected of having ADD is SPECT. This
20-minute test measures blood flow
within the brain; it shows which brain
regions are metabolically active ("hot")
and which are quiescent ("cold") when an
individual completes various tasks.

experts consider SPECT a

particularly useful tool in diagnosing or
treating ADD. The work of people like Dr.
Amen, many experts say, has not been
available for the scrutiny of the scientific
community, and his findings haven't been
duplicated by the research of others - a
basic criterion of scientific validity.

9/14/15

What if Patient Does Not have

ADHD

American Psychiatric Association and the

American Neurological Association, maintain that
information obtained through EEG isn't reliable
enough to detect the more subtle changes of
psychiatric disorders.
More generally, the American Academy of
Pediatrics doesn't recommend any lab tests for
ADD - making specific reference to neuroimaging
techniques, including SPECT, and qEEG. The
American Academy of Child and Adolescent
Psychiatry is similarly skeptical: ADD is "a clinical
diagnosis," and brain imaging and the like provide
"insufficient data."

40%

Malingering

Malingering

Particularly

relevant for high school and

college students who are motivated to
obtain academic accommodations or
prescriptions for stimulants for
performance, misuse and/or diversion
22% misrepresented symptoms or
performance on cognitive testing
15% estimated baseline rate of
malingering

Comprehensive

Malingering

Differential Diagnosis

Easy

GAD

to fake symptoms on ADHD scale

but more difficult to give specific
examples of functional impairment across
time in a coherent fashion
Corroborative information report cards
or observer reports
Extreme exaggeration on behavior scales
(> 2 standard deviations)
Symptom validity tests (SVTs)

of referrals to an Adult ADHD were

found NOT to met full DSM-IV criteria
although all suspected they might have
ADHD
Explain many factors can contribute to
inattention
All inattention is not ADHD and ADHD is
far more than being inattentive

assessment and multiple

steps involved may protect against
individuals looking for quick diagnosis
More likely to seek out all-in-one
appointments (PCP or psychiatrists)
Excessive focus on and agitation about
obtaining medications, especially at the
start of the evaluation
Circumventing typical assessment
procedures

BPAD
MDD
ODD/ASP
PAWS
SUD/SIMD

9/14/15

ADHD and SUD

Strategies for ADHD

Alcohol

is most commonly abused substance

followed by cannabis
May self medicate with stimulants
Poorer outcomes and greater risk for
relapse
Difficulty focusing in groups
Disruptive
Procrastinate or fail to complete
assignments
Emotional lability
Forgetfulness/missed appointments

Engagement-

Strategies for ADHD

ADHD/SUD Workbooks

Usual

3 hours, three times weekly in IOPs

will be difficult for many with ADHD
Frequent brief sessions preferable to a few
long intense ones
Standard Substance abuse treatment
modalities such as AA meetings(60 minutes
versus all day, videos vs. textbooks, short
group check-ins
Help with organization and set deadlines
(Substance Abuse Treatment for Persons
with COD, TIP 42)

The Twelve

CBT

Neurofeedback (NF)

Integrated

Based

cognitive behavioral
therapy for patients with Substance
Use Disorder and Comorbid ADHD:
(van-Emmerik-van Oortmerssen et
al.)
2 case studies
RCT in progress

motivational techniques for

invasive, talkative , hyperactive client
Gentle redirection
Increase use of visual aids- modalities
other than auditory/verbal (diagrams,
pictographs, videos)
Structured and goal-directed sessions
Avoid long verbal exchanges, extended
group therapies, over stimulating
environments

Steps- A key To Living With

Attention Deficit Disorder
Friends in Recovery/RPI Publishing, Inc.
San Diego

on findings of increased theta band

activity and higher beta-to-theta ratio on
EEG
Early studies claimed as effective as
medication and produced long lasting
improvement in 80% of children (none
used sham, placebo, comparison groups or
blinded assessments)
More recent better controlled studies
have led to mixed results

9/14/15

Neurofeedback (NF) Review

NF Review

studies that used sham or placebo and

kept parents blinded and therapist blinded
founded improvement in both groups but no
difference between groups (no treatment
effect)
No changes in in the EEG and no difference
in neuropsychological testing
The very mechanism by which NF is argued
to work did not change

(Loo and
Makieg, 2012)

Strongly

NR Review

CBT

studies

herein do not support NF

treatment as a first-line, stand alone
treatment for ADHD (Loo and Makieg,
2012)
Other reviews found similar
conclusions(Moriyama et al, 2012) and
Lofthouse et al, 2012)
Recent sham-placebo treatment with blinded
evaluations found significant improvement
with no difference between groups (van
Dongen-Boomsma et al, 2013)

Objections:

CBT

CBT

Behavioral

Individual

Medicine Service at
Massachusetts General Hospital(Boston,
MA)
Mount Sinai Adult ADHD Program at the
Center of Excellence in ADHD and
Related Disorders, Icahn School of
Medicine at Mount Sinai (New York, NY)
Penn Adult ADHD Treatment and
Research Program (Philadelphia, PA)

suggest improvement is non-specific

(therapist contact, parental expectancy
effects, participant motivation, etc.)
5 studies comparing NF to another active
treatment found ADHD inattention
significantly improved with each treatment
rated by parents( one-tailed test biased to
finding an effect)
None found improvement in teacher rated
Sxs and found no change in EF

Neurobiological

disorder so nonmedical
treatment wont work
Medications are already effective
ADHD in children with ADHD in the
1980s did not work well

approach:
for medication-treated adults with
ADHD and residual symptoms (Safren etal.,
2005)
3 core skills modules
Organization and planning skills
Distractibility reduction skills
Dysfunctional thought patterns
Support significant other
procrastination
CBT

10

9/14/15

CBT

CBT and Medication

Group

No

approach: Cognitive Behavioral

Therapy for Adult ADHD (Solanto etal.,
2008)
Designed to help develop executive selfmanagement skills
train clients in time management,
organization and planning of long term
projects
Weekly 2 hour group sessions

head to head medication vs. CBT

medication helps to
control the core symptoms of
distractibility, short attention span,
and impulsivity, CBT is more
effective at increasing the habits and
skills needed for executive selfmanagement, and may also serve to
improve emotional and
interpersonal self-regulation.

Whereas

Adult ADHD Books

Taking

Charge of Adult ADHD (Barkley,

2011)
Work, finances, relationships, organization,
etc.
ADD-Friendly Ways to Organize
Your Life Paperback November 7,
2002
by Judith Kolberg (Author),
Kathleen Nadeau (Author)

ADD-Friendly Ways to Organize Your Life

Also available in audio format
Authors: Judith Kolberg and Kathleen
Nadeau
Understand Your Brain, Get More Done:
The ADHD Executive Functions Workbook
Author: Ari Tuckman
The Disorganized Mind: Coaching Your
ADHD Brain to Take Control of Your Time,
Tasks, and Talents Author: Nancy Ratey

CBT
You

Mean I'm Not Lazy, Stupid or

Crazy !:The Classic Self-Help Book
for Adults with Attention Deficit
Disorder
Also available in audio format
Authors: Kate Kelly and Peggy Ramundo

Safren, S.A., Sprich, S., Perlman, C. and

Otto, M., Mastering Your Adult ADHD: A
Cognitive-Behavioral Treatment Program
(Client Workbook ), Oxford University
Press, New York, 2005. 7.
Solanto, M.V., Cognitive-Behavioral Therapy
for Adult ADHD: Targeting Executive
Dysfunction, Guilford Press, New York,
N.Y., 2011.

11

9/14/15

CBT

Useful Apps for ADHD

Solanto, M.V., Marks, D.J., Wasserstein, J., Mitchell,

K., Abikoff, H., Alvir, J.M. and Kofman, M.D., Efficacy
of meta-cognitive therapy (MCT) for adult ADHD,
American Journal of Psychiatry., 167 (2010) 958-968.
Zylowska, L., The Mindfulness Prescription for Adult
ADHD: An 8-Step Program for Strengthening
Attention, Managing Emotions, and Achieving Your
Goals, Shambhala Press, 2012.
Zylowska, L., Ackerman, D.L., Yang, M.H., Futrell,
J.L., Horton, N.L., Hale, T.S., Pataki, C. and Smalley,
S.L., Mindfulness meditation training in adults and
adolescents with ADHD: a feasibility study, Journal
of Attention Disorders., 11 (2008) 737-746.

Useful Apps for ADHD

Useful Apps for ADHD

2. 30/30
30/30 is a time management app that can help
patients finish a task or a project within an allotted
time. A common struggle in adult ADHD is how to
budget, pace, and manage time effectively. Once
the allotted time for a task has been set (Eg. couple of
hours), 30/30 takes over. The user sets up
a list of tasks and a length of time for each of them.
When the timer starts, it will tell the user when to
move on to the next task. One can add a 5 or
10minute mini-break to allow mental rest, check a
text message, or score and return to finish remainder
of the task when prompted

Useful Apps for ADHD

4.
Sleepio
Sleep difficulties are extremely common among adult
ADHD individuals for several reasons. For one, there
are changes in sleep architecture due to ADHD itself.
In addition, medications, including
Psychostimulants may have adverse effects.
Sleepio is a virtual sleep therapist, a 6week cognitive
behavioral therapy
based program. The app trains people to use
techniques that address the cognitive factors associated
with insomnia, such as the racing mind, and to
overcome anxiety and other negative emotions that
accompany the experience of being unable to sleep

1. Awesome Note
Awesome note is an all in one life organizer app
designed to integrate a patients phone, calendar,
and to do list in one place. For someone with
adult ADHD, the app provides a snapshot of all
activities in folders that can be customized as
personal, work, travel, to do list, etc. This helps to
ensure that all commitments are fully completed
and work life balance is not disrupted. A folder
can be password protected to store private
information.
The contents of the app back up automatically to
Google Drive or Evernote

3.You Need A Budget (YNAB)

Financial Discipline maintaining a home budget, setting aside
savings, and paying bills on time can be a challenging task for
any adult. Adults with ADHD face these challenges and
subsequent negative consequences at a much higher rate due
to symptoms of impulsivity, disorganization, procrastination,
and inattentiveness
YNAB can be an invaluable tool that allows budget keeping,
personal financial planning, and bill reminder all in one mobile
app and desktop companion. The app is user friendly and
takes a team approach by allowing a person to add his or her
spouse in this important process. Practical tutorials are
available for support. All relevant data is backed up in
dropbox

Useful Apps for ADHD

5.
Medisafe
Like other chronic conditions, adult ADHD is often
accompanied by the challenge on the part of the patient to
comply with treatment recommendations, such as medication
adherence. Deficits in attention, disorganization, and
procrastination all negatively impact quality of life. Missed
doses and medication taken at incorrect times (especially in
the case of a stimulant) can cause more harm than benefit.
Medisafe is a virtual pill organizer that is easy to use and
has an attractive user interface. What sets this app apart from
others?
MedFriendhas a feature that allows family or friends to
remind patients to take their medication on time

12

9/14/15

Useful Apps for ADHD

1. Awesome Note
(bridworks.com; iOS; Free)
2. 30/30
(3030.binaryhammer.com; iOS; free)
3.You Need A Budget (YNAB)
(youneedabudget.com; iOS, Android, PC; 30 day trial
then one time $60)
4. Sleepio
(sleepio.com; iOS, Android, PC; Free trial, Paid
monthly plans)
5. Medisafe
(medisafe.com; iOS, Android; Free)
- See more at: http://www.psychiatrictimes.com/adhd/
5-useful-apps-adult-adhd#sthash.WFRZ4Luu.dpuf

Video games
Project

EVO
Train to ignore distractions and stay
focused
Networks that control multitasking
overlap networks that control working
memory, and attention span

Psychopharmacology

Strattera

Stimulants

Atomoxetine

(Atomoxetine)
(buproprion)
Desipramine
SNRIs
Tenex (guafenasine)/ Intunive
Clonidine/Kapvay
Nuvigil/Provigil

norepinephrine reuptake
inhibitor increases norepinephrine and
Dopamine
FDA approved
No abuse potential
Delayed onset
Meta-analysis of 12 clinical studies found
it to be modestly more effective than
placebo in reducing inattention and
hyperactivity

Strattera

Wellbutrin

Greater

Antidepressant

Strattera

Wellbutrin

reduction of symptoms than

placebo (30 vs. 20%)
Expensive
Side effects N/V, dry mouth, decreased
appetite, insomnia, sexual side effects,
sweating
May help anxiety
Dose 80-100mg

that increases
norepinephrine and dopamine
No direct comparisons to stimulants
Low abuse potential but multiple case
reports of abuse
53 vs. 31 percent experienced a 30%
decrease in symptoms
1st line if depression or nicotine
dependence

13

9/14/15

TCAs

Alpha-2 agonists

Desipramine

Guanfacine

Higher

Clonidine

Other Options Lacking Robust

Evidence

Medications used in ADHD

proportion of treatment
responders (68 vs. 0%)
Dose 100-300mg q day
Lethal in overdose
Helpful with depression and anxiety

Venlafaxine

(Effexor)

SSRIs
MAOIs
Selegeline

(l-deprenyl)
Modafonil (Provigil)/ Armodafonil(Nuvigil)
Cholinesterase inhibitors (Aricept)
Dopamine agonists (Amantadine)
Micronutrients

(Tenex/Intuniv) 1-2mg BID -TID

(Kapvay) .1mg -.2mg TID
More helpful with impulsive, aggressive boys
May help with anxiety/agitation
Sedation
Hypotension
1-2 week onset
Considered 4th line treatment

Stimulants
Atomoxetine(Strattera) 30 Vs. 20%
Buproprione- mixed results
Desipramine/SNRIs
Modafinil
Clonidine/Guanfacine
Dopamine agonists
Donepezil (Aricept)
Selegeline/Pargyline

Stimulants
Stimulants

show greater effect size than

non-stimulants

Mariani, JJ, Levine

FR Stimulant
Pharmacotherapy in ADHD in
Patients with Co-occurring
Substance Use Disorders. Advances
in ADHD 2006;1(2):47-52.

14

9/14/15

Stimulants
Methylphenidate(Ritalin) improved ADHD and
decreased cocaine use
Methylphenidate improved ADHD, but showed no
change in drug use
SR methylphenidate showed improvement in
ADHD, but no change from placebo/ decreased
probability for (+) cocaine UDS/responders had a
better outcome than non responders
Mariani, JJ, Levine FR Stimulant
Pharmacotherapy in ADHD in Patients
with Co-occurring Substance Use
Disorders. Advances in ADHD 2006;1(2):
47-52.

Extended-Release

Mixed
Amphetamine Salts vs Placebo for
Comorbid Adult Attention-Deficit/
Hyperactivity Disorder and Cocaine
Use Disorder
A Randomized Clinical Trial
JAMA Psychiatry. 2015 Jun 1; 72(6): 593
602.
doi: 10.1001/jamapsychiatry.2015.41
Levine and Mariani et al., 2015

Similar to other clinical trials of extendedrelease formulations of stimulants, there was no

reported medication diversion or abuse.
A recent laboratory study of individuals who
regularly used cocaine reported dose-related
increases of liking for higher cocaine doses, but
low and high doses of amphetamine produced
only minimal drug liking.49 This critical finding
suggests that oral amphetamine doses in the
therapeutic range have lower reinforcing efficacy
in individuals with stimulant use disorders,
plausibly due to history, tolerance, or lower abuse
potential of oral doses.

More patients achieved at least a 30% reduction in ADHD

symptom severity in the medication groups (60 mg: 30 of 40
participants [75.0%]; odds ratio [OR] = 5.23; 95% CI, 1.98
13.85; P < .001; and 80 mg: 25 of 43 participants [58.1%]; OR
= 2.27; 95% CI, 0.945.49; P = .07) compared with placebo
(17 of 43 participants [39.5%]). The odds of a cocainenegative week were higher in the 80-mg group (OR = 5.46;
95% CI, 2.2513.27; P < .001) and 60-mg group (OR = 2.92;
95% CI, 1.157.42; P = .02) compared with placebo. Rates of
continuous abstinence in the last 3 weeks were greater for
the medication groups than the placebo group: 30.2% for the
80-mg group (OR = 11.87; 95% CI, 2.2562.62; P = .004) and
17.5% for the 60-mg group (OR = 5.85; 95% CI, 1.0433.04; P
= .04) vs 7.0% for placebo.

In summary, this trial finds that (1) patients with

ADHD and CUD benefit from treatment with
extended-release mixed amphetamine salts combined
with CBT; (2) exposure to extended-release mixed
amphetamine salts produces a reduction in cocaine
use; and (3) extended-release mixed amphetamine
salts can be given safely to patients with CUD. Often,
stimulants are withheld from individuals with cooccurring substance use disorders because of
concern of diversion and clinical worsening. Instead,
this study found the opposite patients benefited
from treatment. Thus, under closely monitored
conditions, pharmacotherapy should be promoted,
not barred.

Use

of extended-release psychostimulants
to manage ADHD is not contraindicated
in patients with a past history of stimulant
abuse (eg, cocaine, methamphetamine,
MDMA) as long as they are 4 months
stimulant-free. Stimulants may improve
retention in addiction treatment, and in
some cases, may decrease harm from
substance use.

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Stimulant Replacement Therapy

Stimulants

Ann

Use

N Y Acad Sci. 2010 Feb;1187:76-100.

doi: 10.1111/j.1749-6632.2009.05145.x.
Agonist-like pharmacotherapy for
stimulant dependence: preclinical,
human laboratory, and clinical
studies.
Herin DV1, Rush CR, Grabowski J.

with caution ( delay for 4 months)

delayed release formulas
Lisdexamphetamine (Vyanse)
Adderall XR
Concerta
Daytrana
No abuse of stimulants or increase
cravings for cocaine were reported
Use

Summary
High

rate of ADHD in SUD

testing not
mandatory
CBT and 12 steps are effective
Mixed results regarding Imaging and
neurofeedback
Non-stimulants are first line
Stimulants not contraindicated
Neuropsychological

John Roberts, MD

Medical Director, Addiction Psychiatrist

241 Pavillon Place

Mill Spring, NC 28756
828-694-2300
www.pavillon.org

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