Transcript ASAM 2009 - NorthShore ADHD and Addiction Clinic

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
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ADHD and Addiction
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ADHD Sx at school
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
Behavioural Symptoms
 Fidgets
 Leaves Seat
 Disrupts Class
 Restless
 Acts impulsively
 Can’t wait turn
 Blurts things out
 Interrupts
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ADHD Sx in relationships
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Oppositionality
Marital discord
Social miscues
Forgotten dates
Unfinished projects
Broken promises
Money/ Time mismanagement
Impatient parenting style
Substance misuse
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ADHD Sx at work
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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
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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
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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
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Addiction
Substance Use Disorder
 Nicotine
 Alcohol
 Cannabis
 Opioids
 Methamphetamine
Impulse Control Disorder
 Eating
 Gambling
 Spending
 Internet
 Sex
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Epidemiology
SUD
 5-10% of the adult population
ADHD
 4-5% of the adult population
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Chronic Disease in BC
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Addiction in BC
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Treatment Gap
Less than 50% of youth with ADHD
receive either an accurate diagnosis
or regular medical treatment
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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
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The Standard of Care
Do not diagnose
Do not treat
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Social and Economic
Consequences of ADHD
Crime
 Substance abuse
earlier onset, worse course, increased recidivism
Teen pregnancy/ STDs
 Delinquency
 Traffic accidents
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More than $500 million each year in BC
for direct health, education and justice-related costs
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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.
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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
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1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.
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
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SUD and ADHD
ADHD
SUD
Distractibility
Reward deficit
Impulsivity
Executive Dysfunction
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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
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Etiology
In both ADHD and Addiction
 Genetics
 Environment
 Drug-induced insults
combine to create areas of impaired dopamine
neurotransmission
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Dopamine Neurotransmission
Dopamine
Dopamine
Dopamine
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Neurotransmitter Functions
Dopamine
- stimulus acquisition
 Fixes / Filters / Focuses
 saliency
Noradrenaline
- stimulus modulation
 energy/ motivation/ interest/ arousal
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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
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Attention Circuit
Dysfunction
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Difficulty establishing signal vs. noise
poor attention to detail, careless mistakes
difficulty with verbal / visual memory
forgetting, losing things
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Impulse Control
Circuit
Dysfunction
 distractibility, impulsivity, being impatient
 difficulty choosing between competing priorities
 excessive talking, blurting things out, interrupting
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Executive Circuit
Dysfunction
 Difficulty with commitment, difficulty sticking to task
 Poor planning/ organization/ problem solving
 Difficulty with self monitoring
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Motor Control
Circuit Anatomy
PFC motor cortex-lateral striatum-thalamus loop.
Dysfunction
 fidgeting, inner restlessness
 difficulty sitting through meals/ meetings/ movies.
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Reward Circuit
Dysfunction
 being easily bored
 diminished pleasure/ reward/ satisfaction
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ADDICTION IS A DISEASE OF THE BRAIN
Dopamine D2 Receptors are Lower in Addiction
DADA
Cocaine
DA
DA DA DA
DA
DA DA
DADA
DA
Reward Circuits
Non-Drug Abuser
Meth
DA
DA
DA
Alcohol
DA
DA
DA
Reward Circuits
Drug Abuser
Heroin
control
addicted
Volkow et al.,
Neurobiology of Learning and
Memory 78:610-624, 2002.
Non-Addicted Brain
Addicted Brain
Control
Control
CG
Saliency
NAc
Drive
OFC
Saliency
Saliency
Drive
Drive
Memory
Memory
Memory
Amygdala
Volkow et al., J Clin Invest 2003.
Circuits to Symptoms
Impaired dopaminergic neurotransmission
 diminished perception of reward - bored
 worsening cognition – repeat mistakes
 impaired behavioral inhibition – can’t stop
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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
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Prevalence (%)
ADHD and Associated Disorders
Biederman. Am J Psychiatry. 1993;150(12):1792. Biederman Psychiatry Research 1994;53:13 Shekim.
Compr Psychiatry. 1990;31(5):416.
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Addiction and Co-morbid Disorders
Depression/ Anxiety
ADHD
Substance Use
Bipolar Disorder
Impulse Control Disorder
Eating Disorder
Psychosis
ASPD
Conduct Disorder
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ADHD Diagnosis in SUD
Schubiner 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
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Hierarchy of Intervention
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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
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Talk Therapy for SUD
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behavioral therapy
cognitive-behavioral therapy
Interpersonal therapy
contingency management
12-step self-support groups
motivational interviewing
family therapy
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SUD Treatment
Addicted Brain
Control
Control
Re-introduce non-drug
rewards - Dopamine
Strengthen inhibitory
control - GABA
Saliency
Saliency
STOP
Drive GO
Drive
Memory
Memory
Decrease stress/ anxiety
Decrease prefrontalstimulation - Glutamate
Avoid conditioned
memories
Stimulant Treatment Risks
 over-stimulation/ mania/ psychosis
 misuse, abuse and/ or diversion
 increased drug use
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Stimulant Risk Management
Mariani 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
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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
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Glutamate and GABA
modulate Dopamine
PFC
Glutamate excites
Nucleus
Accumbens
VTA
GABA inhibits
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Effect of Mood Stabilizer
in Cocaine/ ADHD
Poster Presented at 2nd International Congress on ADHD: Vienna, May 2009
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
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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
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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
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