There has been much debate on the age of onset criteria currently used for diagnosing older adolescents and adults with ADHD. Barkley has proposed that requiring child-based symptoms for adults to meet the diagnosis of ADHD is too stringent [17
]. Studies have shed important light on establishing the diagnosis of ADHD in adults with ADHD and SUD who fail to have clear recollection of symptom onset in childhood. Faraone et al. [18
] have examined differences between groups of adults with ADHD based on age of onset of symptoms of ADHD. In this study, researchers investigated whether differences existed between 79 adults who met full current criteria for ADHD but did not have a clear track of symptoms prior to age 7 years and 127 adults who had their ADHD onset prior to age 7 years [18
]. Interestingly, no differences in rates of psychiatric comorbidity, SUD, family history of ADHD, or impairment were found between groups of adults with full criteria ADHD and those who had a longitudinal track of ADHD without clear onset in youth, supporting the growing contention of problems with using the current onset of symptoms prior to age 7 years stringently, particularly in adults with SUD. In a study examining symptom prevalence of ADHD in a residential substance abuse treatment program using contemporary methods, McAweeney et al. [19**
] found that the prevalence rate of ADHD from the program clinical records was 3%, while the prevalence rate from the study assessments was 44% suggesting that ADHD may be under diagnosed in addiction treatment programs.
The treatment needs of individuals with SUD and ADHD need to be considered simultaneously; however, if possible, the SUD should be addressed initially. If the SUD is active, immediate attention needs to be paid to stabilization of the addiction(s). Depending on the severity and duration of the SUD, individuals may require inpatient treatment. Self help groups offer a helpful treatment modality for many with SUD. In tandem with addiction treatment, SUD individuals with ADHD require intervention(s) for ADHD (and if applicable, comorbid psychiatric disorders).
The efficacy of various psychotherapeutic interventions for populations with ADHD and SUD remains to be established. However, data suggests efficacy of cognitive behavioral therapies for adults with ADHD in both individual [20*
] and group settings [21*
]—as well for SUD. It appears that effective psychotherapy for this comorbid group combines the following elements: structured and goal-directed sessions, proactive therapist involvement, and knowledge of SUD and ADHD.
Medication serves an important role in reducing the symptoms of ADHD and other concurrent psychiatric disorders. Effective agents for ADHD include the stimulants, noradrenergic agents, and catecholaminergic antidepressants. In general, while open studies are more encouraging, results from controlled trials with stimulants and/or bupropion suggest that ADHD pharmacotherapy used in adults with ADHD plus SUD has meager effects on the ADHD and substance use or cravings. Multiple recent studies shed light on this issue. A well conducted, pilot, placebo-controlled 12-week study of osmotic-release oral system methylphenidate (OROS MPH) (72 mg) in 24 adults with amphetamine abuse and ADHD indicated no significant differences in outcome for neither ADHD nor SUD [22*
]. A multisite, NIH funded placebo-controlled study of stimulants in adult smokers with ADHD was recently published [23**
]. In this 11-week study, OROS MPH/placebo was dosed to 72 mg/day in 255 adults with ADHD who were also treated with the nicotine patch to examine the effects on cigarette cessation and ADHD. The results of this trial showed improved ADHD but no effects on rates of cigarette cessation [23**
]. Of interest, there was no increased cigarette smoking in the medicated group and side effects in these adults were similar to those noted in previous stimulant trials. Data from another NIH multisite study of treatment of adolescents with ADHD and SUD was also recently reported [24
]. In this 16-week placebo-controlled study, 300 adolescents with mixed SUD received OROS MPH/placebo to 72 mg/day along with weekly individual cognitive behavioral therapy. Both treatment arms resulted in significant improvement compared to baseline; however, there was no significant improvement in ADHD (investigator/parent) or SUD (adolescent self report) between treatment groups. Side effects were reminiscent of adolescent studies and the medication was reported to be of low abuse liability.
In ADHD adults with recent SUD, the nonstimulant agents (atomoxetine), antidepressants (bupropion), and extended-release or longer acting stimulants with lower abuse liability and diversion potential are preferable [3*
]. The broad spectrum of activity in ADHD, lack of abuse liability, and recent work showing relative safety in the context of active SUD generate particular interest in studying atomoxetine in adults with alcohol use disorders [25
]. In a 12-week multisite study in recently abstinent alcoholics, atomoxetine (compared to placebo) was effective in treating ADHD, and reducing recurrent episodes of heavy drinking, but not relapse [25
]. In a separate analysis, atomoxetine administration in heavy relative to light or nondrinkers was associated with more side effects; yet, there were no serious adverse events nor evidence of impaired liver functioning in the heavy drinkers in these relatively short terms trials [26
]. In a similar 10-week, open-label study, atomoxetine was effective in treating ADHD symptoms as well as intensity, frequency, and length of cravings in recently abstinent adults with SUD and comorbid ADHD, and no serious adverse events were reported [27*
]. However, these promising data in abstinent alcoholics need to be tempered against recent work in currently using adolescents with SUD. Thurstone et al. [28*
] studied 70 adolescents with ADHD and at least one active non-nicotine SUD who received 12 weeks of atomoxetine or placebo in addition to motivational interviewing/cognitive behavioral therapy. There were no differences between ADHD scores or in use of substances between treatment groups that emerged during the study. The authors speculated that the therapy may have contributed to a larger than expected placebo response. The above findings linked with an older literature suggest that medications used in adolescents and adults with ADHD plus active SUD have only a meager effect on ADHD, and an even smaller effect on cigarette or substance use. It may be that some abstinence may result in improved outcomes for both ADHD and SUD. Regardless of the pharmacotherapy being administered, individuals with ADHD and SUD should be monitored frequently. Evaluation of compliance with treatment, questionnaires, random toxicology screens as indicated, and coordination of care with addiction counselors and other caregivers are integral components of effective treatment.