ADHD—Focus on Adults

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Attention Deficit Hyperactivity Disorder (ADHD) is a condition characterized by inattention, disorganization, and/or hyperactivity-impulsivity that consistently disrupt a person’s activities and relationships. According to DSM-5 (p 32), “Inattention and disorganization entail inabil­ity to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, in­ability to stay seated, intruding into other people’s activities, and inability to wait—symptoms that are excessive for age or developmental level.”

This conception of ADHD is relatively new, although literature of the past 200 years depicts individuals who might meet current criteria for ADHD. In 1844, for example, German psychiatrist Heinrich Hoffman created a children’s story about Fidgety Phil (“Zappelphilipp”). In 1902, English pediatrician George Still described children with an “exaggeration of excitability” whose behavior was so disruptive that he considered them to have a defect of moral control. In 1937, Rhode Island physician Charles Bradley, while attempting to treat headaches that followed pneumoencephalograms, discovered that the stimulant benzedrine improved learning and behavior in hyperactive children. The modern understanding of ADHD began to emerge with descriptions of “minimal brain dysfunction” in the 1960s and 1970s. (Lange et al. 2010)

Estimates vary, but about 10 percent of children and 4 percent of adults may meet criteria for ADHD. ADHD in childhood is a risk factor for early substance use and adult substance use disorder. Up to 30 percent of adults with ADHD are estimated to have a substance use disorder. The common comorbidity of ADHD and addiction makes it important for clinicians who treat ADHD in adults to assess patients comprehensively—even though their patients don’t like to wait.

When assessing adults for ADHD, symptoms may be misleading and accurate diagnoses elusive. Family histories of ADHD, other mental illnesses, and addiction are relevant. So is evidence of when patients’ ADHD symptoms began, since rigorous diagnosis of adult ADHD requires that several symptoms were present before age 12. Old report cards help, or talking with individuals who were adults when they knew the patient as a child.

ADHD, bipolar disorder, and addiction mimic one another, yet any two—or all three—conditions may co-occur in one individual. Hyperactivity and impulsivity, for example, suggest both ADHD and bipolar disorder. (Bipolar disorder is favored when the behaviors are episodic and accompanied by elevated mood.) Inability to wait (“I want what I want when I want it”) can be a manifestation of any of the three conditions.

Clinicians are frequently secure when they diagnose addiction (substance use disorder severe), sometimes aided by objective evidence of excessive substance use and supporting history from third parties. But when addiction is present, to then establish a clear diagnosis of ADHD or bipolar disorder can be difficult. It has been said that clinicians both overdiagnose and underdiagnose ADHD and bipolar disorder in patients with addiction.

Many question all diagnosis and medication of ADHD. Some argue that, at least in the United States, the diagnosis is a fad and medications are prescribed too freely. Others argue that reluctance to diagnose and treat ADHD hinders affected individuals from functioning at their best. Prescribers and the public are wary in part because some medications used to treat ADHD are diverted for misuse and addictive use.

Stimulant medications used to treat ADHD, such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine), are thought to increase activity of norepinephrine and dopamine in the brain by blocking their reuptake. Increases in these neurotransmitters can cause restlessness and confusion in people without ADHD, but have paradoxical effects such as reducing hyperactivity and increasing attention in the majority of those with ADHD. Stimulants enhance concentration even in the absence of ADHD, which makes them popular substances of misuse among high school and college students.

Addiction to stimulants may develop in individuals whether or not they have symptoms of ADHD. Increases in dopamine activity are associated with pleasure and euphoria, which are more intense when dopamine activity rises quickly. Individuals who consume stimulant medications in higher doses than usually prescribed—or by routes such as sniffing or injecting that get substances to the brain more efficiently than swallowing—can become addicted. Stimulant medications are, after all, in the same pharmacologic family as cocaine and methamphetamine.

When ADHD is diagnosed in adults and treatment is considered necessary, stimulant medications are often the first intervention. Stimulants have the advantage that, if they work, they work either right away or after a short period of dose adjustment. Their drawbacks—especially potential for abuse and, because of that, street value—are good reasons not to prescribe them to anyone with active addiction. Some prescribers also avoid prescribing stimulants to individuals with a past history of addiction, particularly if the patient abused stimulants. Stimulants are classified as controlled substances and, whether or not patients on them have histories of addiction, regular (preferably not predictable) urine drug tests are indicated.

Fortunately, stimulant medications are not the only means of treating ADHD. (Kolar et al. 2008) Psychosocial treatment and cognitive-behavioral therapy can improve symptoms in areas such as time management, organization, anger, and self-esteem. Non-stimulant medications for ADHD are usually less effective than stimulants, but are options for patients who have already misused or become addicted to stimulants or are at high risk for doing so. Non-stimulants are also options for the 10-30 percent of patients with ADHD whose symptoms do not respond to stimulants. Non-stimulant medications with potential to help ADHD include atomoxetine (Strattera), bupropion (Wellbutrin), tricyclic antidepressants such as desipramine (Norpramin), clonidine (Catapres), guanfacine (Estulic, Tenex, and the extended release Intuniv), and modafinil (Provigil).

Within the stimulant category, extended release or longer-acting preparations are considered to have lower potential for abuse and diversion. These include extended release or long-acting methylphenidate (Concerta, Biphentin, Ritalin LA), mixed amphetamine salts XR (Adderall XR), and lisdexamfetamine (Vyvanse), a newer medicine that discourages intranasal and intravenous use because it becomes a stimulant (dextroamphetamine) only after the body removes an amino acid (L-lysine) from the original molecule.

Individuals, especially those in recovery, seeking help for possible ADHD are wise to insist that their clinician proceed with caution. Patients and providers alike best remain mindful that some patients in this situation are more driven to increase the dopamine activity in their brain than to increase the balance in their lives.