Monday, February 4, 2013

Substance Abuse, ADHD, and Medications: The Real Issues

by Ruth Hughes, PhD

The story of Richard Fee, as reported in the New York Times on Sunday, February 3, is as heart-wrenching as it is atypical in ADHD treatment. This was not a story about ADHD or about Adderall, but rather about substance abuse and our highly stressed and fragmented mental health system. As the mother of a young adult in college, my heart went out to this young man’s parents, who tried so valiantly to stop the downward spiral of his addiction.

Anyone who works in mental health or who has attempted to use mental health services can attest to the fact that there are multiple barriers to receiving effective treatment. There are simply not enough providers to address the many patients needing services in a timely way. The HIPAA privacy laws make it impossible for clinicians to speak with family members or with other providers, especially when a young adult refuses to sign a release of information request. Payment rates through insurance are so low for mental health services that many providers will no longer participate. And no one is willing to pay for the time needed for the outreach and collaboration that is so necessary for proper diagnosis and treatment. When the symptoms of mental illness (or addiction) interfere with good judgment or accurate reporting by the patient, the effects of these problems are multiplied many times over.

This is not an excuse for the careful evaluation and collaboration that appeared to be missing in the treatment of Richard Fee, but rather a statement of the disarray of our health care system. CHADD, along with many other mental health advocacy organizations, continues to fight for a better health care system, for parity in mental health services, and for better coverage of treatment for all mental health disorders. And we work with our professional counterparts to ensure training of mental health professionals in the diagnosis and treatment of ADHD is easily available and of high quality.

Unfortunately, the scary tone of this article misrepresents the danger of stimulant medications. Stimulant medications that are taken as prescribed are highly unlikely to lead to addiction. In fact, the director of the National Institute on Drug Abuse, Dr. Nora Volkow, states, “Methylphenidate treatment for children with ADHD does not increase their risk for later substance abuse,” in an article summarizing NIDA research on stimulants and abuse.

It is important to separate several related but different issues on substance abuse, ADHD, and medications:
  • Stimulant medications are often an integral part of treatment for ADHD, but the most effective treatment will include parent/family training, behavioral interventions, and school/work support as well as medications. Stimulants can help a person’s brain work more efficiently, but medication does not teach coping skills.

  • Anyone with ADHD has a higher risk of substance abuse. This is not because of the medication, but because the disorder itself is characterized by impulsivity and poor recognition of consequences. Few people with ADHD choose stimulants as the substance of abuse. Alcohol, cigarettes, and drugs will be more of a temptation for a person with ADHD. We must help anyone with ADHD be forewarned that there is a higher risk of substance abuse and we must be vigilant for early warning signs.

  • Misuse of stimulant medication as a study aid is unfortunately a regular occurrence on college campuses. CHADD is strongly opposed to the diversion of stimulants, which undermines the legitimate use of stimulants for the treatment of ADHD. We regularly warn parents and young people of both the criminal and health outcomes associated with diversion. The federal government’s most recent survey of substance abuse (page 15) indicated that misuse of stimulant medication is present in about 0.4% of the population, or 1.1 million people over the age of 12. Although the incidence of misuse has declined from 0.6% in 2003, it remains a serious problem that CHADD is very concerned about.

  • Misuse is not the same as addiction. Stimulant medications may become addictive when taken in very large dosages or when injected intravenously. Few addicts choose stimulants as their drug of choice. As the New York Times article reported, “Very few people who misuse stimulants devolve into psychotic or suicidal addicts.” That said, one person who becomes addicted is one too many. It is crucial that our health care systems do everything possible to prevent the misuse or addiction of any prescription drugs.

One final comment. A meeting of a local CHADD group was referenced at the end of the article. Unfortunately, comments made by CHADD board member Jeffrey Katz, PhD, were selectively reported, and crucial information that both CHADD and Dr. Katz always include was not reported. When asked about the safety of stimulant medications, Dr. Katz reminded the audience that he was not a physician and that an individual’s response to medication can vary dramatically. At all times, a person thinking about or taking any medication for ADHD should work closely with his or her physician. In general, the potential side effects of stimulant medications when taken as prescribed are relatively mild and can be safely managed.

The science of ADHD, investigating the causes, diagnosis, and treatment, has improved dramatically over the past decade. It is absolutely crucial that our clinical practice and our public policy be based on the most recent and most sound facts. It is for this reason that we need to continue and/or increase funding support for better research in mental health and improved treatment in our health care systems. CHADD is committed to ensuring that evidence-based information from research is at the forefront of any discussions about ADHD treatment.

CHADD will continue to fight for better health care services, better training of providers, and the elimination of diversion of prescription medications. We want to be certain that all our members and the general public have accurate, science-based information about ADHD and any of the related disorders that often accompany a diagnosis of ADHD.

Visit CHADD's web page on Medication Abuse and Diversion.

Ruth Hughes, PhD, is CEO of CHADD.


Unknown said...

I read that tragic article. thanks so much for writing this, Ruth. I am so proud to be a part of CHADD, and everything it stands for in order to advocate for best treatment for our kids and adults with ADHD!

Karen K Lowry,R.N.,M.S.N.
Parent2Parent ADHD Family Trainer

Sheila Siegel said...

I read the article and your response. While I agree it was about substance abuse, it was also about ADHD. As the psychologist at a private school I read test reports all the time and most are well documented, but there does exist a substrata of physicians who are quick to diagnose and perscribe. It is important for parents to be sure of the diagnosis and continue with well supervised follow-up when using medication.

Sheila J Siegel, Ph.D.

Anonymous said...

I can't agree more. Thank you for writing this... how about sending it to the NY Times!

Mother of a son with ADHD

Anonymous said...

Nice response! I actually responded to that article and felt the journalist was irresponsible because he reported a one-sided story and did not investigate the world of drug addiction as the cause of that boy's death.

This story is about the failure to recognize the root and primary cause of that boy's problems -- drug addiction. The parents recognized he was addicted. I felt so frustrated and sad for those poor parents that could not get the right help from bad practitioners. I was sober for 14 years before being diagnosed with ADHD, and I use a medication responsibly. That poor boy was drug addict -- he was addicted to speed. His parents knew it and tried to get help. The only thing that may have (and I stress may have) helped him was a 30-90 day rehab. He may have also been ADHD, but who could tell in the haze of all his drug addictions.

I do not understand why the psychiatric field is still so blind to drug addiction. Kids today are more apt to get addicted to Rx drugs than street drugs (and then turn to street drugs when their Rx runs out), and doctors just keep writing prescriptions. Check out the stats at Hazelden in Minnesota, and you will see the rise in Rx drug rehab in our kids. It's ruining this generation of kids.

I'm sorry, but this story is not about ADD/ADHD -- it was about drug addition.

John Samuels said...

Taking any psychiatric drug whether it be stimulants, any type of tranquilizer, sleeping pills, SSRIs always carries some risk that the drug will be abused by patients, or taken by persons for whom the drug was not prescribed.

Some have or develop a personality type that lends itself towards abusing prescription drugs, some have like a fatal attraction to pharmaceutical drugs that affect the mind. This might be the person for whom the drug is prescribed, or it can be someone else in the household.

Psychiatric drugs for all types of mental illness tend to be over-prescribed. The ideas presented in the NY Times articles of tightening up diagnoses on ADHD and on prescriptions on college campuses are totally valid.

Additionally, there are serious risks to taking meds for ADHD for a limited number of individuals who take them, perhaps 1% or less (see ADHD books from AYCNP for evidence). It is not a dramatic risk as some might try to make it, but perhaps a less than 1% risk to put a number on it based on evidence. Anyone who takes any type of psychiatric drug, including stimulants for ADHD should be fully aware of the benefits vs. risks.

The mental health system has serious breeches all the way around, the way medications are prescribed, over-diagnosis, doctors who are not as responsible as they should be, unscrupulous doctors who prescribe medications without even seeing the patient, and that is in the U.S. In other countries that are not as regulated in the U.S. there are even more serious breeches. No matter how much we would like it to, this is situation is unlikely to change, so extreme examples will always occur.

This quote in the CHADD blog, "Methylphenidate treatment for children with ADHD does not increase their risk for later substance abuse," is debatable. It depends which study you refer to. Other studies and researchers, authorities indicate that there might be some risk for increased addiction. If we cherry pick our quotes and studies, anything can be proved.