# Presentation: 016106

## 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 

**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 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)

**Substance**
**Abuse/Dep**

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

**Overlap Between ADHD****and Substance Use Disorders (SUD)**

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

## Smoking in ADHD Adolescents (Mean 15 years) 

**%**
**Smoking**

**p<0.003**
**vs cntrls**

**24**

**11**

**(Millberger et al., JAACAP 1997)**

**(Conduct Disorder accounting for differences)**

## Onset of Substance Abuse in ADHD Adults(Retrospectively Derived)

**ADHD**

**Control**

**Age of Onset**

**Probability**

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

*****

***p<.05 vs control**

## 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

- 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 ADHD

**SUD Monitoring**
**Subjective measures**
**Drug use severity index****1**
**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

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

**(Wilens et al., APA 2004)**

***p=0.039**

**ADHD**

**Control**

## 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)**

## 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

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

**(Wilens et al., APA 2004)**

**p=0.04**

**ADHD**

**Controls**

## 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)**

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

***p=0.801**

***p=0.012**

**(Wilens et al., APA 2004)**

## 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

**OR=2.8**
***p=0.058**

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

**(Wilens et al., APA 2004)**

## 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

**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

**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

**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

## MGH Longitudinal Study of ADHDMedication 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 Questionnaire

** ****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?**

**(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?**

## Sold Prescribed Medication

**p=0.025**

**11%**

**0%**

## Misused Medication

**p=0.006**

**22%**

**2%**

## Used More Medication

**p=0.018**

**22%**

**5%**

## Gotten High From Medication

**p=0.414**

**9%**

**5%**

## Skipped Medication to UseAlcohol or Drugs

**p=0.027**

**16%**

**2%**

## Used Medication with Alcohol or Drugs

**p=0.6**

**31%**

**26%**

## Reaction to Alcohol or Drugs with Medication

**p=0.125**

**5%**

**0%**

## Diverting medication... Who is at risk?

**11%**

**10%**

**14%**

## Diversion of Medications and ADHD Comorbidity

**83%**

**83%**

**100%**

## Misuse of Medication... Who is at risk?

**22%**

**21%**

**14%**

## Misuse of Medication and ADHD Comorbidity

**75%**

**59%**

**83%**

## 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

**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

**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**

## QUESTIONS?