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Learning Objectives

Learning Objectives

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Learning Objectives

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  1. Learning Objectives • Review common symptoms, epidemiology, etiology and costs of ADHD • Review the overlap between SUD and ADHD • How does treating ADHD benefit SUD? • Issues when treating ADHD in SUD NorthShore ADHD Clinic

  2. ADHD and Addiction NorthShore ADHD Clinic

  3. ADHD Sx at school • Behavioural Symptoms • Fidgets • Leaves Seat • Disrupts Class • Restless • Acts impulsively • Can’t wait turn • Blurts things out • Interrupts Cognitive Symptoms • Not paying attention • Forgets/ Loses • Careless/ Clumsy • Difficulty reading • Seems not to listen • Messy desk/ work • Avoids/ procrastinates • Can’t stick to task NorthShore ADHD Clinic

  4. ADHD Sx in relationships • Oppositionality • Marital discord • Social miscues • Forgotten dates • Unfinished projects • Broken promises • Money/ Time mismanagement • Impatient parenting style • Substance misuse NorthShore ADHD Clinic

  5. ADHD Sx at work • Distracted from priorities • Good ideas, poor execution • Incomplete Work • Accidents • Poor Sleep/ Fatigue • Frequently Late/ Absent • Workplace conflict • Time lost due to illness • Substance misuse NorthShore ADHD Clinic

  6. Reward and Addiction E Gardner, NIH Getty Images Survival is determined by paying attention to salient information Aversion • pain, noxious stimuli Novelty • travel, adventure, socialization Pleasure • sex, work, passion, exercise Survival • threats, risk, danger, chaos, competition Sustenance • glucose, fat, salt NorthShore Adult ADHD Clinic

  7. Reward and Addiction E Gardner, NIH Getty Images Certain plants also stimulate dopamine and noradrenaline: Opium, alcohol, cannabis, coca, cacao, coffee, tobaco, tea, betel. Refining those substances created the first drugs. All addictive substances stimulate dopamine. Euphoria is proportional to dopamine peak NorthShore Adult ADHD Clinic

  8. Addiction Substance Use Disorder • Nicotine • Alcohol • Cannabis • Opioids • Methamphetamine Impulse Control Disorder • Eating • Gambling • Spending • Internet • Sex NorthShore ADHD Clinic

  9. Epidemiology SUD • 5-10% of the adult population ADHD • 4-5% of the adult population NorthShore ADHD Clinic

  10. Chronic Disease in BC NorthShore ADHD Clinic

  11. Addiction in BC NorthShore ADHD Clinic

  12. Treatment Gap Less than 50% of youth with ADHD receive either an accurate diagnosis or regular medical treatment NorthShore ADHD Clinic

  13. The Treatment Gap • few physicians feel comfortable diagnosing ADHD • fewer are comfortable managing ADHD • even fewer would contemplate treating an adult with ADHD and an addiction NorthShore ADHD Clinic

  14. The Standard of Care Do not diagnose Do not treat NorthShore ADHD Clinic

  15. Social and Economic Consequences of ADHD • Crime • Substance abuse • earlier onset, worse course, increased recidivism • Teen pregnancy/ STDs • Delinquency • Traffic accidents • More than $500 million each year in BC • for direct health, education and justice-related costs NorthShore ADHD Clinic

  16. Social and Economic Consequences of SUD SUD has a direct impact on health care and criminal justice costs and indirect costs on productivity due to disability and premature death. estimated to be $40 billion annually. not including gambling or other addictions. NorthShore ADHD Clinic

  17. Functional Impairment 1. Barkley. Attention-deficit hyperactivity disorder, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al. JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995. NorthShore ADHD Clinic

  18. Key Learning Points ADHD is commonly co-morbid with SUD • increases functional impairment • associated with huge socio-economic costs • standard of care is non-diagnosis/ non treatment NorthShore ADHD Clinic

  19. SUD and ADHD ADHD SUD Distractibility Executive Dysfunction Reward deficit Impulsivity NorthShore ADHD Clinic

  20. Common Pathways • ADHD and addiction are distinct disorders. • They share the dysregulation of one or more of the dopaminergic circuits. • They are both associated with decreased impulse control NorthShore ADHD Clinic

  21. Etiology In both ADHD and Addiction • Genetics • Environment • Drug-induced insults combine to create areas of impaired dopamine neurotransmission NorthShore ADHD Clinic

  22. Dopamine Dopamine Dopamine Dopamine Neurotransmission NorthShore ADHD Clinic

  23. Neurotransmitter Functions Dopamine - stimulus acquisition • Fixes / Filters / Focuses • saliency Noradrenaline - stimulus modulation • energy/ motivation/ interest/ arousal NorthShore ADHD Clinic

  24. Dopamine Circuits Attention - optimizes signal, filters noise Impulse Control - don’t do what you’re not supposed to do Executive Function - do what you are supposed to do Motor Control - keep doing it until you are finished Reward - regulate emotions required to complete the task NorthShore ADHD Clinic

  25. Attention Circuit Dysfunction • Difficulty establishing signal vs. noise • poor attention to detail, careless mistakes • difficulty with verbal / visual memory • forgetting, losing things NorthShore ADHD Clinic

  26. Impulse Control Circuit Dysfunction • distractibility, impulsivity, being impatient • difficulty choosing between competing priorities • excessive talking, blurting things out, interrupting NorthShore ADHD Clinic

  27. Executive Circuit Dysfunction • Difficulty with commitment, difficulty sticking to task • Poor planning/ organization/ problem solving • Difficulty with self monitoring NorthShore ADHD Clinic

  28. Motor Control Circuit Anatomy PFC motor cortex-lateral striatum-thalamus loop. Dysfunction • fidgeting, inner restlessness • difficulty sitting through meals/ meetings/ movies. NorthShore ADHD Clinic

  29. Reward Circuit Dysfunction • being easily bored • diminished pleasure/ reward/ satisfaction NorthShore ADHD Clinic

  30. ADDICTION IS A DISEASE OF THE BRAIN Dopamine D2 Receptors are Lower in Addiction DA DA Cocaine DA DA DA DA DA DA DA DA DA DA Reward Circuits Non-Drug Abuser Meth DA D2 Receptor Availability DA DA DA Alcohol DA DA DA Reward Circuits Drug Abuser Heroin Volkow et al., Neurobiology of Learning and Memory 78:610-624, 2002. control addicted

  31. Control Control CG Saliency Saliency Drive Drive Saliency NAc Drive OFC Memory Memory Memory Amygdala Non-Addicted Brain Addicted Brain Volkow et al., J Clin Invest 2003.

  32. Circuits to Symptoms Impaired dopaminergic neurotransmission • diminished perception of reward - bored • worsening cognition – repeat mistakes • impaired behavioral inhibition – can’t stop NorthShore ADHD Clinic

  33. ADHD and SUD Redux • ADHD results from dysfunctional Dopamine Circuits • Drugs stimulate Dopamine • Dopamine stimulates learning/ memory circuits (not just reward) • Dopaminergic activity temporarily improves ADHD • Drug seeking becomes learned and reinforced • Drugs are obtained at the expense of other rewards NorthShore ADHD Clinic

  34. ADHD and Associated Disorders Prevalence (%) Biederman. Am J Psychiatry. 1993;150(12):1792. Biederman Psychiatry Research 1994;53:13 Shekim. Compr Psychiatry. 1990;31(5):416. NorthShore ADHD Clinic

  35. Depression/ Anxiety ADHD SubstanceUse Psychosis BipolarDisorder ImpulseControlDisorder EatingDisorder ASPD ConductDisorder Addiction and Co-morbid Disorders NorthShore ADHD Clinic

  36. ADHD Diagnosis in SUDSchubiner H. J Clin Psychiatry (2000) 61:244-251 • ADHD symptoms that preceded drug use and persist into periods of prolonged abstinence • Family history of ADHD or SUD • History and pattern of impulsivity • Attention seeking, risk-taking, antisocial traits • Age of substance initiation, current substance use NorthShore ADHD Clinic

  37. Hierarchy of Intervention • Treat psychosis if present • Stabilize Mood / impulsivity • Treat Mood Disorder • Treat SUD • Then Treat ADHD with non-stimulants if < 4 mo with LA stimulants > 4 mo avoid IR stimulants NorthShore ADHD Clinic

  38. Talk Therapy for SUD • behavioral therapy • cognitive-behavioral therapy • Interpersonal therapy • contingency management • 12-step self-support groups • motivational interviewing • family therapy NorthShore ADHD Clinic

  39. Re-introduce non-drug rewards - Dopamine AddictedBrain Control Strengthen inhibitory control - GABA Decrease stress/ anxiety Drive Saliency GO STOP Memory Saliency Drive Control Decrease prefrontal-stimulation - Glutamate Avoid conditioned memories Memory SUD Treatment

  40. Stimulant Treatment Risks • over-stimulation/ mania/ psychosis • misuse, abuse and/ or diversion • increased drug use NorthShore ADHD Clinic

  41. Stimulant Risk ManagementMariani JJ, Levin FR. Am J Addict. 2007;16 Suppl 1:45-54. • Assess patients for co-morbidity with family • Start low, go slow, follow often • Educate patients re side effects • Ensure that patients avoid caffeine/ other stimulants • Use non-stimulants in the first 3 months • Prescribing XR stimulants whenever possible NorthShore ADHD Clinic

  42. Glutamate: the new frontier Glutamatergic System is involved in relapse to cocaine-seeking: • Glutamate levels in the nucleus accumbens increase during reinstatement • Glutamate receptor activation is necessary for reinstatement to drug-seeking. • Full antagonists block the increased glutamate release, but produce undesirable side effects. • modulation of glutamatergic transmission with anticonvulsants, such as topiramate or lamotrigine has shown efficacy in treating cocaine dependence or reducing relapse in humans CNS Neurol Disord Drug Targets 2008 Nov; 7(5):482-91 NorthShore ADHD Clinic

  43. Glutamate and GABA modulate Dopamine PFC Glutamate excites VTA Nucleus Accumbens GABA inhibits NorthShore ADHD Clinic

  44. Effect of Mood Stabilizerin Cocaine/ ADHD Poster Presented at 2nd International Congress on ADHD: Vienna, May 2009

  45. Key Learning Points Both ADHD and SUD/ ICD are associated with dysfunctional dopamine circuits Dysfunctional Dopamine Circuits explain the common symptom complex: • Easily Bored • Doesn’t think through consequences • Impulsive NorthShore ADHD Clinic

  46. Key Learning Points • Treating co-morbidity increases remission • Both stimulation of dopamine circuits (with stimulants) and modulation (with mood stabilizers) has benefits • Return to full function requires integrated treatment NorthShore ADHD Clinic

  47. Key Learning Points • CBT / therapy is an important part of overall Tx • Stimulant doses change and often > than guidelines • Lamictal works • Treat psychosis first; SUD/ ICD next Then decide between mood and cognition • Stratify SUD into low/med/high risk to determine Tx NorthShore ADHD Clinic