Children with ADHD are more likely than their peers without ADHD to develop substance abuse disorders. Stimulant medications, a common treatment for ADHD, have been found to not only reduce the primary symptoms of ADHD but to lower the risk of substance abuse. However, stimulant medications also have the potential for abuse. The American Academy of Pediatrics recently addressed this issue and provided strategies for reducing substance abuse in children with ADHD in areport published in the journal Pediatrics.
ADHD and Substance Abuse
Children with ADHD are more than 2.5 times more likely to develop a substance abuse disorder than those without ADHD. According to the report, children with ADHD are:
- Twice as likely to have a lifetime history of using tobacco
- Almost three times more likely to report nicotine dependence
- Almost two times more likely to meet the diagnostic criteria for alcohol use or dependence
- About 1.5 times more likely to meet the criteria for marijuana use disorder
- Twice as likely to develop cocaine abuse dependence
While it is not completely understood why children with ADHD are at a high risk for substance abuse, impulsivity and executive function deficits are thought to be contributing factors. In addition, the presence of comorbid conditions, such as depression or anxiety, increases the chances of substance abuse. People with ADHD also frequently have low self-esteem, which might also contribute to substance abuse.
Some studies have shown that treatment for ADHD can help reduce substance abuse, especially if treatment begins at a young age.
The AAP recommends that children between the ages of four and six years old be treated with behavioral interventions and, medication when necessary. Children over the age of six years old should be treated with a combination of behavioral interventions and medication.
Abuse and Misuse of Stimulant Medications
Stimulant medications have the potential for abuse, however, according to research dating back to the 1970's, these types of medications do not provide the euphoria or elevated mood in individuals with ADHD that is often associated with abuse. According to the recent report, "there is little evidence that stimulant medications are widely abused by the patients to whom they are prescribed."
Misuse and diversion are more common than abuse. Misuse is when prescription medication is used for a purpose other than why it was prescribed, using more medication than prescribed or using someone else's medication. This is considered a larger problem than abuse of medications. More than one-fourth of students diagnosed with ADHD report that they have taken more medication than prescribed and in one study 18 percent of college students reported having used stimulants even though they were not prescribed the medication.
Diversion is giving someone else your medication for a non-medical use. The report from the AAP states that between 16 and 23 percent of school age children with ADHD report that they have been approached to sell, give or trade their stimulant medications. More than one-fourth of college students state that diverted stimulant medications are easy to find.
Safe Prescribing Practices
Because of the high potential for abuse, misuse and diversion of stimulant medications and because of the high risk of substance abuse among those with ADHD, the AAP, has provided guidelines for safe prescribing practices:
Confirm the diagnosis of ADHD before prescribing stimulant medications. Physicians should complete a thorough medical history, review school records and conduct parent interviews when the initial diagnosis of ADHD occurs during adolescence. Although it is possible for ADHD to not be diagnosed until later, physicians should be aware that some teens might try to be diagnosed with ADHD in order to get a prescription for stimulant medications. Confirming the diagnosis before giving a prescription can help reduce diversion of stimulants.
Screen older children and adolescents for use of alcohol and drugs. Part of the routine monitoring for ADHD teens should include screening and, if necessary, intervention and referral for substance abuse treatment.
Provide anticipatory guidance. The AAP suggests that physicians should discuss the proper use of stimulant medications, including that they should only be taken as prescribed and should never be shared. These conversations should start at a young age and continue through adolescence, remaining age-appropriate.
Document prescription records. By maintaining proper records, physicians can keep track of any early requests for medication and question why it is needed.
In addition, doctors need to be aware of any comorbid conditions, such as depression or anxiety, and monitor treatment for these as well. This situation increases the risk of substance abuse. Making sure each person has an accurate diagnosis and a comprehensive treatment plan, some of that risk can diminish.