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ADHD, Substance Use and Addiction

Categories: 2010, February

When the Solution Becomes a Problem

troubled woman at computer

by Ari Tuckman, PsyD, MBA

RESEARCH CLEARLY SHOWS THAT PEOPLE WITH AD/HD are more likely to run into trouble with drinking, drugs, or other addictive behaviors.* Most of them don’t qualify as alcoholics or addicts, but they still engage in these behaviors more than do their peers who are not affected by AD/HD, and they pay a price for it. Not surprisingly, those with other mental health conditions, such as anxiety, depression, or bipolar disorder, are also at an increased risk for substance use and addictive behaviors. However, those with AD/HD are a little bit more likely to run into trouble here. They are more likely to start drinking or doing drugs earlier, to try more drugs, and to drink or do drugs more often.

Perhaps also not surprising is that those who had a history of defiant and law-breaking behavior in childhood and adolescence (technically speaking, those who have oppositional defiant disorder, conduct disorder, or antisocial personality disorder) are at the greatest risk for alcohol and drug abuse. Having the hyperactive/impulsive subtype of AD/HD makes someone more likely to qualify for one of these other diagnoses, so AD/HD indirectly leads to substance abuse. This speaks to the importance of treating AD/HD early so that things don’t go from bad to worse.

Research has also found that those who were treated with stimulant medication as children were less likely to get into drinking and drugs as teens and young adults, so there is some protective effect there.** Each person is different, but there are several reasons why someone with AD/HD may be more likely to drink or use drugs to excess, including the following:
• Self-medication. Those with undiagnosed and untreated AD/HD have probably had a harder life, so they may have more reason to seek out opportunities to drown those sorrows.
• Impulsivity. Some may drink or do drugs without thinking through the potential consequences, either for later that day or over a longer time. Eventually, it can become a habit, and they keep going with it.
• Thrill seeking and avoiding boredom. Some may drink or do drugs because they’re bored or want to make a good time even better.
• Peer group. Many teens with AD/HD deal with their difficulties at school by disengaging and finding other kids who aren’t into school. This makes them more likely to hang out with kids who are more likely to drink and do drugs.

Although smoking cigarettes is less immediately problematic than drinking and doing drugs, its effects can easily add up over time. Those with AD/HD are at a much greater risk to become regular smokers,* which can produce drastic health and financial detriments over time.

Drinking, drugs, smoking, and other addictive behavior can all have negative effects on various parts of a person’s life, including family peace, romantic relationships, friends, school, work, and finances. It’s hard to be at your best if you’re doing too much of this stuff. It’s also hard to get the most from therapy or coaching, which tend to work best with a clear mind. It can also reduce the effectiveness of medication. So, for those who are drinking or doing drugs too much or too often, it is probably worth addressing that behavior directly.

Manage excessive substance use

Perhaps because of their greater need to self-medicate or perhaps because they tend to be more impulsive, adults with AD/HD are more likely than those without AD/HD to have trouble with addictive behavior. This includes people who drink too much but wouldn’t be called alcoholics, as well as people who have tendencies towards compulsive behaviors like overspending, overeating, overuse of sex, and gambling. The desire to feel better is understandable, and a few drinks or whatever may help some people to do that, but unfortunately, the solution can become its own problem if it becomes excessive.

So if you have more than two drinks a night, use other drugs, or engage in other addictive behaviors, you need to be honest with yourself about the effect the behaviors are having on you. Keep in mind who your comparison group is. For example, you may not feel that you drink too much since many of your friends drink the same amount. However, that may not be a good measure, since we tend to choose friends who are similar to us—if you drink too much, they probably also drink too much.


WARNING SIGNS

Potential warning signs of excessive substance use can be:

• You do things that you wouldn’t do sober, such as spending money, arguing or fighting, engaging in sexual activities, or other high-risk behaviors.
• You get into arguments about your drinking or drug use.
• You spend too much money or time on it.
• You’re not as sharp the next day.

If you feel that too many of these apply to you, you may want to think seriously about cutting back or stopping the use altogether.


If you feel that you don’t have a true addiction, but that you would be better off if you used less, you may be able to kill two birds with one stone by treating your AD/HD. I’ve found that many of my clients simply have less desire to overuse once they get some control over their AD/HD and life. Without even really thinking about it, they just don’t engage in that problematic behavior as much. It makes sense—as they feel more on top of their lives and their overall mood improves, the escape offered by drinking too much, or whatever, may become less necessary or appealing.

If you aren’t able to keep it reined in and you wind up getting into trouble again, then you may want to think about stopping completely. If you can do this on your own, then that’s great. If you can’t, you may want to consider getting some help with it. It’s hard to make progress on your AD/HD, or much of anything else, if your addictive behavior is making a mess of things. In this case, you may need to get that under control first by seeking treatment for the addictive behavior.

Unfortunately, many prescribers are hesitant to prescribe stimulants, the most effective medication for AD/HD, to people with a strong history of addiction. This is especially unfortunate because untreated AD/HD can make it harder for some people to stay clean. Therefore, you may need to settle for one of the nonstimulants, at least until you get enough clean time under your belt that the prescriber feels more comfortable. Meanwhile, you can work with a therapist on other ways of coping with the urge to use.

Some people find Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other twelve-step groups helpful, whereas others find them kind of culty. Some people are also turned off by the religious overtones. It depends a lot on the specific group you attend and also on what you make of it. If you don’t like the first group you attend, then try another one and see if the chemistry is better there. As with many things in life, you may need to ignore the negatives and focus on the positives if there are some helpful things about attending.

However, if you’re taking medication, especially one of the stimulants, you may find that there are some attendees who will take issue with that. They may see it as cheating on your sobriety and no different than taking street drugs, even though you have a valid prescription and legitimate reason for it. Although presumably well intentioned, this rigid attitude is usually counterproductive and underinformed. These people probably don’t understand AD/HD and how it can affect your sobriety when untreated, and that there is no high from normally prescribed doses. So you may want to think about whether you want to disclose at meetings that you’re taking medication. If you do disclose, you may want to have some prepared thoughts about how to respond to these comments. You certainly don’t have to justify yourself to anyone, but it may minimize a conversation that you don’t want to get into.

Medicating substance abusers: Balancing the risks
Because prescription stimulants can be abused by those who choose to do so, many prescribing professionals are leery of giving them to patients with a history of substance abuse—and especially to those who are currently using. This is sometimes due to a fear of intentional misuse, but prescribing doctors may also be concerned that the stimulant will give the patient a craving for illegal drugs again.

The patient may have the same fear, as one of my clients did after several years of being clean. It was a real dilemma for her whether she wanted to try stimulants, even though her AD/HD was really making a mess of her life. Although the stimulants are abusable when taken at excessive doses, they will not create a high when taken at the dosage prescribed. Additionally, the longer-acting formulations tend to give a slower onset and therefore very little rush.

Unfortunately, there is a pretty big overlap between AD/HD and substance abuse, so there are a lot of people out there who may potentially be denied access to the most effective medication treatment. Some prescribers like to see the patient stay clean for a certain length of time before starting the stimulant. While understandable, the untreated AD/HD can undermine that sobriety. Conversely, medicating the AD/HD may better enable the person to stay clean. This is a judgment call for both the prescriber and the patient.

One option is to have a reliable family member dispense the medication, thus ensuring that it’s only taken as prescribed. This family member would then be authorized to communicate with the prescriber. While not ideal, it may be better than nothing. If substance abuse is an issue for you or a loved one, it may be worth treating it directly, either through a twelve-step group or more formal treatment, in addition to whatever is done for the AD/HD.


Some formulations are better options

All stimulants are not created equal. In increasing order, here are the options for those with a history of substance abuse:
 
• Long-acting formulations are less abusable than short-acting ones. All three of my clients who admitted to abusing their prescription stimulants were taking one of the short-acting formulations. However, where there is a will there is a way, so even the long-acting ones may not be totally safe.
• Methylphenidate transdermal patch. Because the methylphenidate needs to absorb through the skin, it has a gradual onset, even if someone were to use several patches, so it gives very little rush.
• Lisdexamfetemine dimesylate. This formulation needs to be activated by enzymes in the stomach and bloodstream, so it doesn’t give a high when snorted or injected because that enzymatic conversion regulates how quickly the active medication is created.
• Atomoxetine. Atomoxetine is a nonstimulant AD/HD medication and therefore completely nonabusable (i.e., not worth abusing) although tends to not work as well. But it can be just the right thing for someone who is locked out of taking stimulants.

So there are some options to consider and discuss with your prescriber. It really comes down to being completely honest with yourself about whether you are ready to handle the responsibility of managing a medication like this. If you aren’t sure that you are, that’s OK. Work on your AD/HD in other ways and maybe you’ll be more ready later.

ImageFOR MORE INFO: CHADD's National Resource Center on AD/HD has a helpful chart on medications used to treat AD/HD.



NOTES

*Barkley, R.A., Murphy, K., & Fischer, M. (2007) AD/HD in Adults: What the Science Says. New York: Guilford Press.
** Wilens, T. (2004). Impact of AD/HD and its treatment on substance abuse in adults. Journal of Clinical Psychiatry, 65, 38-45.

Ari Tuckman, PsyD, MBA, is a clinical psychologist based in West Chester, Pennsylvania, who specializes in diagnosing and treating children, teens, and adults with AD/HD. He is the author of Integrative Treatment for Adult AD/HD: A Practical, Easy-to-Use Guide for Clinicians (New Harbinger, 2007) and the vice president of the Attention Deficit Disorder Association.
Adapted from More Attention, Less Deficit: Success Strategies for Adults with AD/HD by Ari Tuckman (© 2009: Specialty Press, Inc.).

From the February 2010 issue of Attention magazine. Copyright © 2010 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). Reproduction in whole or in part without written permission from CHADD is prohibited.