Individuals with AD/HD have several characteristics that make them more vulnerable to substance abuse: These may include self-medication, impulsivity, social skills problems and a tendency to associate with others who are not doing well in school.
Adult attention deficit disorder seems to be related to earlier onset of substance abuse, a longer period of active abuse, and a lower rate of recovery. (Wilens, Biederman and Mick, Am J Addict 1998) A study by Biederman et al Am J Psychiatry 1995 suggested found that 52% of adults with AD/HD(versus 27% of controls) had met criteria for substance abuse at some point in their lives. Other studies have found slightly lower rates but have still found that the rates are significantly higher than those of individuals without AD/HD.
Appropriately prescribed stimulant medication does not seem to increase the chance of later substance abuse. A recent study published in Pediatrics Vol. 104, No.2 1999 suggested that adolescents with AD/HD who were treated with stimulant medication, were less likely to develop drug problems than those who were not treated. It is possible that newly diagnosed adults have the higher rate of substance abuse because their AD/HD was not treated when they were children.
Prevention: Parents of a child with AD/HD should start talking about drug abuse and risky behavior early and maintain an open dialogue. Children and adolescents who are aggressive or who habitually break rules are at increased risk. If your child fits this profile, consider more intensive individual or family therapy. Teach your child the difference between legitimately prescribed drugs and illegal drugs. Look at your own pattern of drug or alcohol use. Try to model a conscientious approach to alcohol. If you the parent are is in recovery from drug or alcohol, consider taking your adolescent with you to a few Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings. If a child or adolescent has a AD/HD along with a strong family history of substance abuse, he or she should probably never drink. It is important to be honest with him about the family history so that he can understand the risks.
Treatment: If an individual seems to have both AD/HD and a substance abuse problem, how do we treat him or her? First, it is important to do an accurate diagnostic evaluation. Drug use can sometimes shorten attention span and thus mimic AD/HD. We get an in-depth history and often get information from family members. At some point, we like to see the individual when he or she is sober and is not in acute drug withdrawal. If this is not possible, we may need to make a tentative diagnosis and defer the definitive diagnosis until later.
It can be more difficult to treat substance abuse in an individual with AD/HD than in a non-AD/HD individual. We prefer not to treat an individual who has both AD/HD and substance abuse with medications alone.
We often encourage group therapy in a setting that encourages abstinence from drugs. Family therapy is also a good idea. The individual may benefit from 12-step groups. Family members may benefit from Alanon or Naranon. If impulsivity is part of the individuals AD/HD, recovery may be more difficult. It might be good to have a Narcotics Anonymous (or AA) sponsor who also has AD/HD. Such an individual may sometimes need more intensive treatment during the early and also the later phases of recovery. The substance abuse recovery program may, like many other aspects of the person’s life, get boring after a while. The individual and the treatment team need to watch out for this boredom factor.
Should we prescribe Schedule II medications (e.g. stimulants) to individuals who are actively abusing drugs? We prefer not to do so, especially if the individual refuses to participate in other forms of treatment. We may consider using a Schedule II stimulant if the individual is a minor, and the parents can tightly monitor the medication, and get regular drug screens. In other cases, we may start with non-Schedule II medications such as Wellbutrin. If active drug abuse is severe, or if close monitoring is not possible, it may not be safe to prescribe any medication at all. Once an individual is involved in treatment, actively working on sobriety, we can be more confident about prescribing medication. However regular drug screens, and close communication with other members of the person’s support system, are useful.
The individual who has AD/HD accompanied by persistent substance abuse may need intensive outpatient or even residential treatment to break through denial and start treatment in a safe environment. If the individual refuses treatment, we may start by bringing the family into treatment so that they can learn to understand the situation and set limits.