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Subtypes of ADHD Related to Substance Use Disorders (SUD): Results from the MGH Longitudinal Study of Boys with ADHD. Timothy E. Wilens, MD Massachusetts General Hospital Harvard Medical School. Funding: NIDA RO1 DA1441 & DA 11929 (TW). Disclosures.

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slide1

Subtypes of ADHD Related to Substance Use Disorders (SUD): Results from the MGH Longitudinal Study of Boys with ADHD

Timothy E. Wilens, MD

Massachusetts General Hospital

Harvard Medical School

Funding: NIDA RO1 DA1441 & DA 11929 (TW)

slide2

Disclosures

Dr. Wilens has served as a consultant, speaker, or has received grant support from the following

  • NIH (NIDA, NICMH, NIMH)
  • Abbott, Celltech, Glaxo/SKB, Lilly, McNeil, Neurosearch, Novartis, Pfizer, Shire
  • Some of the products discussed are not FDA approved for ADHD or other psychopathology; others may not be FDA approved in the manner discussed (e.g. dosing, patient groups, combination therapy)
adhd overview
ADHD Overview
  • ADHD is the most common neurobehavioral disorder presenting for treatment in youth
  • Prevalence: 6-8% youth worldwide; 4% of adults
  • Associated with impairment in multiple domains
  • Majority with comorbid learning disabilities & psychiatric comorbidity including conduct disorder
  • Treatment includes educational, psychotherapeutic, and psychopharmacological interventions

(Goldman, JAMA:1998; Wilens et al Ann Rev Med, 2002;

Faraone et al., World Psych; 2003; Kessler et al, APA 04)

overlap between adhd and substance use disorders sud
Overlap Between ADHDand Substance Use Disorders (SUD)

Substance

Abuse/Dep

ADHD

  • Excessive overlap of ADHD in SA
  • ADHD±comorbidity is a risk factor for SA

(Wilens et al., Psych Clin N Am: 2004)

smoking in adhd adolescents mean 15 years
Smoking in ADHD Adolescents (Mean 15 years)

(Conduct Disorder accounting for differences)

p<0.003

vs cntrls

%

Smoking

11

24

(Millberger et al., JAACAP 1997)

onset of substance abuse in adhd adults retrospectively derived

1.0

0.8

0.6

0.4

0.2

0.0

0

10

20

30

40

50

60

Onset of Substance Abuse in ADHD Adults(Retrospectively Derived)

ADHD

Control

*

*p<.05 vs control

Probability

Age of Onset

Wilens TE, et al. J Nerv Ment Dis. 1997;185(8):475-482.

lifetime rates of sud in controlled longitudinal studies of adhd adults
Lifetime Rates of SUD in Controlled Longitudinal Studies of ADHD Adults

Mean age range at follow-up: 18-26 years

Total ADHD N=845, total Control N=1085

% with SUD

( from Wilens et al., Psych Clin N Am: 2004)

sud in young adults with adhd
SUD in Young Adults with ADHD

Methods

  • Male subjects ascertained from an ongoing longitudinal family study of ADHD.
  • Case matched controls (at baseline)
  • Data obtained from year 10
  • Diagnosis(es) by KSADS/SCID
  • Raters blinded to ascertainment

(Wilens et al., APA 2004)

sud in young adults with adhd1
SUD in Young Adults with ADHD

SUD Monitoring

  • Subjective measures
    • Drug use severity index1
      • Self-report measure
      • Items including frequency and severity (problem)
      • Items relative to initiation and continuation
    • Module from DSM on SA
      • Semi-structured interview
      • Direct report of proband to interviewer
      • Indirect report of parent to interviewer
      • Best estimate diagnosis
  • Objective measures
    • Urine by radioimmunoassay (RIA)-hospital analysis including osmolality

1. Tarter RE, Hegedus AM. Alcohol Health Res World. 1991;15:65-73.

nicotine use in male probands at 10 year follow up age 21 yrs any use
Nicotine Use in Male Probands at 10 year Follow-up (Age 21 yrs), Any Use

*p=0.039

Control

ADHD

(Wilens et al., APA 2004)

*p=0.039 vs. No Use, controlling for SES and Conduct Disorder

nicotine use in male probands at 10 year follow up age 21 yrs stratified by frequency of use
Nicotine Use in Male Probands at 10 year Follow-up (Age 21 yrs), Stratified by Frequency of Use

OR=3.2

*p=0.04

(Wilens et al., APA 2004)

slide12
Nicotine Use in Male Probands at 10 year Follow-up (Age 21yrs), Stratified by Comorbidity with Conduct Disorder (CD)

*p=0.359

*p=0.141

(Wilens et al., APA 2004)

marijuana use in male probands at 10 year follow up any use
Marijuana Use in Male Probands at 10 year Follow-up, Any Use

p=0.04

Controls

ADHD

(Wilens et al., APA 2004)

*p=0.04 vs. No Use, controlling for age, SES and Conduct Disorder

marijuana use in male probands at 10 year follow up stratified by frequency of use
Marijuana Use in Male Probands at 10 year Follow-up, Stratified by Frequency of Use

OR=2.7

*p=0.114

(Wilens et al., APA 2004)

slide15
Marijuana Use in Male Probands at 10 year Follow-up, Stratified by Comorbidity with Conduct Disorder (CD)

(Wilens et al., APA 2004)

*p=0.012

*p=0.801

reason for first use of preferred drug to get high
Reason for First Use of Preferred Drug:To Get High

OR=2.0

*p=0.1

*p=0.1 controlling for age, SES and Conduct Disorder

(Wilens et al., APA 2004)

reason for first use of preferred drug to change mood
Reason for First Use of Preferred Drug:To Change Mood

OR=2.8

*p=0.058

(Wilens et al., APA 2004)

*p=0.058 controlling for age, SES and Conduct Disorder

reason for first use of preferred drug to sleep better
Reason for First Use of Preferred Drug:To Sleep Better

OR=5.4

*p=0.061

*p=0.061 controlling for age, SES and Conduct Disorder

(Wilens et al., APA 2004)

continued use of preferred drug to get high
Continued Use of Preferred Drug:To Get High

OR=1.7

*p=0.316

*p=0.316 controlling for age, SES and Conduct Disorder

(Wilens et al., APA 2004)

continued use of preferred drug to change mood
Continued Use of Preferred Drug:To Change Mood

OR=2.4

*p=0.121

*p=0.121 controlling for age, SES and Conduct Disorder

(Wilens et al., APA 2004)

continued use of preferred drug to sleep better
Continued Use of Preferred Drug:To Sleep Better

OR=5.7

*p=0.03

*p=0.03 controlling for age, SES and Conduct Disorder

(Wilens et al., APA 2004)

apparent ages of risk for sud related to adhd and adhd comorbidity bpd cd bpd cd
Apparent ages of risk for SUD related to ADHD and ADHD comorbidity (BPD, CD, BPD+CD)
  • Age of SA onset
    • Comorbid ADHD: 12-16 years
    • Noncomorbid ADHD: 17-22 years
      • Females earlier onset than males
      • ADHD impact starts approximating comorbidity
    • “Start talking about it in 10-12 year olds”
  • Cigarette use
    • 50% of stable cigarette users with ADHD manifest SUD

(Wilens TE. Psych Clin N Am: 2004).

mgh longitudinal study of adhd medication questionnaire
MGH Longitudinal Study of ADHDMedication Questionnaire
  • Query of medication use
    • Pilot data
    • Seven questions regarding appropriate use of prescribed medications
    • Self-report on those who were taking meds
    • Not psychometrically validated
  • Longitudinal study of ADHD (and controls)
    • 10 year follow-up data (mean age 19 years)
    • Data available on 55 ADHD and 43 controls
    • Psychopathology by KSADS (baseline)
mgh longitudinal study of adhd medication questionnaire1
MGH Longitudinal Study of ADHDMedication Questionnaire

(continued)

  • Have you sold the medication prescribed by your doctor?
  • Have you used more of your medication than you were supposed to?
  • Have you gotten high on your medication?
  • Have you misused your medication?
mgh longitudinal study of adhd medication questionnaire continued
MGH Longitudinal Study of ADHD Medication Questionnaire(continued)
  • Have you not taken your medication so that you could use drugs or alcohol?
  • Have you used alcohol or drugs on the days you take your medication?
  • Have you had a reaction to drugs or alcohol while taking your medication?
misused medication
Misused Medication

p=0.006

22%

2%

diversion and misuse of medications in adhd
Diversion and Misuse of Medications in ADHD
  • All cases receiving immediate-release stimulants
    • Methylphenidate
    • Amphetamine
  • No evidence of diversion or misuse of
    • Extended-release stimulants (e.g. OROS MPH)
    • Nonstimulants (TCA, bupropion, clonidine)
limitations
Limitations
  • Relatively small sample size
    • Especially for med questionnaire
  • Data generalize to males only
  • Data from “middle class” sample
  • Data presented today based on self report
  • Medication questionnaire not psychometrically validated
  • Other comorbidities and mediators of SUD not examined for these analyses
summary adhd substance abuse
Summary: ADHD+Substance Abuse
  • ADHD is a risk factor for Cigarette Smoking
  • ADHD is a risk factor for any and heavy substance use
    • Adolescent-onset clearly linked to conduct disorder (and Bipolar disorder)
    • Later onset probably more linked to ADHD
  • Evidence of self medication
    • Attenuation of mood
    • Soporiphic effects of medication
  • Evidence of diversion and misuse of immediate release stimulant medication in ADHD
    • High risk groups (those with ADHD+SUD+Conduct)
    • Need to discuss proper storage and use of medications