Medscape (free registration) has a new interview published about substance abuse and ADHD. Some high (and low) points:
I particularly want to comment on 2 studies. One is the study presented by Bright[5] recently at the APA [American Psychiatric Association meeting], showing that more than 1 out of 5 adolescents who have ADHD have misused their drugs. That’s a very high number. And of them, 80% used short-acting drugs, short-acting stimulants, in comparison to long-acting [stimulants]. So these kids are already finding a differentiation.
That sounds depressing. It also runs counter to what I’ve read in other studies, which is that people with ADHD, if treated properly, are less prone to substance abuse than non-ADHDers. As I read further into the interview, I found clarification:
Dr. Jain: Sometimes quite dramatically. And, again, let me offer you a particular review I read recently, again by Steve Faraone and Tim Wilens,[7] published in 2003 in the Journal of Clinical Psychiatry. They did a meta-analysis of the 6 studies that have been published and 1 that was halfway analyzed. So they put it together to see what are the rates of abuse with poorly treated ADHD vs very well treated. And here is the interesting fact: your rates [of abuse] are cut in half. So here we have a condition which, if you treat it well, [greatly reduces] your risk of turning to substance abuse — not only is your risk cut in half, it actually falls into the same category as for those who do not have ADHD in the first place.
I think that’s the tragedy of this condition, and this class of highly effective medications for a disorder that can be very impairing. Our goal is to find interventions so that you can have your cake and eat it, too.
and this:
The impact, interestingly, is not just at one point in time. If you have ADHD that’s poorly diagnosed, or poorly treated for that matter, your risk starts climbing up in your early teenage years, 13 or 14. But the interesting thing is we have studies showing that the risk never goes away.[8]
Even individuals in their twenties, thirties, forties, or fifties, if they have ADHD, their risk is high. So the take-home message for us clinicians is, every time you run into someone with substance abuse, look out for ADHD. And every time you run into an individual with ADHD, make sure you’re optimally treating this patient and also watching out for substance abuse issues.
Going back to the first quote, it was very significant to me that there was a differentiation between short-acting medications and long-acting medications; specifically, the medications most prone to misuse were the short-acting medications.
The insurance companies give preference to the short-acting medications because they are generic and cheap. But the risk for abuse appears to be much, much higher. It seems clear that the inference to “well-treated” in the quotes following are suggesting that proper treatment includes long-acting medication, proper diagnosis and ongoing monitoring and therapy.
I can attest to this. The problem with short-acting medication is that by the time they are absorbed into the blood stream and reach full efficacy, they’re wearing off. That creates the ‘roller-coaster’ effect which lends itself to abuse , simply as a means to avoid that up-and-down feeling. The long-acting stimulants are very different — they’re absorbed in just about the same amount of time, but last for 8-10 hours. The wearing-off effect is vastly reduced, so there’s not a sense of feeling fine one minute and out of it the next.
If the insurance companies are truly interested in the health of their insureds they will compromise with regard to the bottom line on this and loosen the hold on the longer-acting stimulant medications.
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