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ADHD - Drug Addiction and Misuse

 

The relationship between Attention Deficit Hyperactivity Disorder (ADHD) and risky drug is controversial.  Proponents argue that if it goes undiagnosed and untreated, later in life children with ADHD will disproportionately misuse alcohol and other drugs.[1][2]  Critics counter that the 'medications' used to treat ADHD are frequently misused and that far from preventing drug abuse their use facilitates it.[3]

The most commonly prescribed medications for ADHD are Amphetamine-Type Stimulants (ATS).  Stimulant medications are pharmacologically similar to illicitly produced stimulants including methamphetamine and cocaine.[4]  In the USA methamphetamine (brand name Desoxyn) is approved for the treatment of ADHD in patients aged 6 and older.[5]   All prescription stimulants carry similar addiction and abuse warnings to that for Dexedrine (a brand of dexamphetamine):

Amphetamines have a high potential for abuse. Administration of amphetamines for prolonged periods of time may lead to dependence and must be avoided. Particular attention should be paid to the possibility of subjects obtaining amphetamines for non-therapeutic use or distribution to others and the drugs should be prescribed and dispensed sparingly.[6]

Despite these warnings, a number of studies conclude that treating childhood ADHD with amphetamines reduces the probability of future drug use.[7][8][9]  Typically the methodology of these studies involves retrospectively diagnosing ADHD in adults with drug use disorders, and then attributing the problematic drug use to ADHD.  There are two obvious problems with this approach.

  1. It is a requirement of the DSM5 diagnostic criteria that the behavioural criteria of ADHD should be displayed before age twelve. So how do researchers deal with the retrospectivity of the diagnosis? 

  2. How do the researchers distinguish between dysfunctional, impulsive and inattentive adult behaviour caused by drug use and that caused by ADHD?

The simple answer to both questions is that researchers can't either; find evidence of behaviours of adults as children, and more significantly there is no way of distinguishing between dysfunctional behaviour caused by problematic drug use, and that caused by ADHD.  These concerns align with broader criticisms that the process of diagnosing ADHD using reports of dysfunctional behaviour, and then attributing the dysfunctional behaviour to ADHD, is a circular absurdity.[10]

It is widely acknowledged that rates of substance use disorders are significantly higher in adults who were diagnosed and medicated as children than the general population.[11]  Proponents attribute the higher rate of substance use disorders to ADHD and contend that the rate of substance use would have been higher if the ADHD was not recognised and treated in childhood.[12]  Critics assert that substance use is a logical consequence of administering amphetamine-type stimulants, with the potential for dependence, drugs to children, adolescents and adults.[13]

For those without time to examine the evidence supporting the conflicting views, it is worth remembering, that proponents claim that the best way to prevent children diagnosed ADHD becoming drug abusers, is to give them a daily amphetamine habit.

References

[1]    Dave Coghill (2005), ‘Attention-deficit hyperactivity disorder: should we believe the mass media or peer-reviewed literature?’, The Psychiatrist, 29, pp.288–91 https://www.cambridge.org/core/services/aop-cambridge-core/content/view/6D5A11FF87F92ABC62ED710F467830D0/S0955603600028713a.pdf/attentiondeficit_hyperactivity_disorder_should_we_believe_the_mass_media_or_peerreviewed_literature.pdf

[2]    David Hay, ‘Why is ADHD so under-diagnosed and treated?’, ABC News: The Drum, 4 September 2008.  Available at http://www.abc.net.au/news/2008-08-29/why-is-adhd-so-under-diagnosed-and-treated/491866 (accessed 8 January 2013)

[3]    Peter R. Breggin M.D. Testimony September 29, 2000 Before the Subcommittee on Oversight and Investigations Committee on Education and the Workforce U.S. House of Representatives available at http://breggin.com/breggin-testifies-before-congress-re-ritalin-and-adhd/

[4]    DrugRehab.com Website, Is Cocaine a Stimulant. https://www.drugrehab.com/addiction/drugs/cocaine/stimulant/

[5]    Desoxyn Prescribing Information https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/005378s026lbl.pdf

[6]    GlaxoSmithKline, Prescribing Information – Dexedrine (dextroamphetamine sulphate). Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017078s042lbl.pdf  (accessed 29 November 2017)

[7]    Young, J.T., Carruthers, S.J., Kaye, S., Allsop, S., Gilsenan, J., Degenhardt, L., van de Glind, G., van den Brink, W. and Preen, D. (2015). Comorbid attention deficit hyperactivity disorder and substance use disorder complexity and chronicity in treatment-seeking adults. Drug and Alcohol Review. DOI: http://dx.doi.org/10.1111/dar.12249

[8]    GlaxoSmithKline, Prescribing Information – Dexedrine (dextroamphetamine sulphate). Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017078s042lbl.pdf  (accessed 29 November 2017)

[9]    Timothy E. Wilens, Stephen V. Faraone, Joseph Biederman, Samantha Gunawardene. Does Stimulant Therapy of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse? A Meta-analytic Review of the Literature. Pediatrics January 2003, Vol 111 / Issue 1 http://pediatrics.aappublications.org/content/111/1/179.short

[10]    Pérez-Álvarez M, The Four Causes of ADHD: Aristotle in the Classroom. Front. Psychol., 09 June 2017. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465299/ Accessed 17 July2017

[11]    Berit Bihlar Muld (et al) Attention deficit/hyperactivity disorders with co-existing substance use disorder is characterized by early antisocial behaviour and poor cognitive skills BMC Psychiatry 201313:336 https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-13-336

[12]    David Hay, ‘Why is ADHD so under-diagnosed and treated?’, ABC News: The Drum, 4 September 2008.  Available at http://www.abc.net.au/news/2008-08-29/why-is-adhd-so-under-diagnosed-and-treated/491866 (accessed 8 January 2013)

[13]    Breggin, P. Talking Back to Ritalin : What Doctors Aren't Telling You about Stimulants and ADHD. Cambridge, Mass. :Perseus Pub., 2001.