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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 4, No.8
January 2007
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- Until Next Time


Welcome to all the new readers who are joining TNT for the first time. Thanks to all the “old-timers” too as we start 2007.

SAVVY
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A psychiatric disorder that is often associated with substance-related disorders is Attention-Deficit/ Hyperactivity Disorder (ADHD). There are certainly children, adolescents and adults for whom ADHD is concurrent with a substance disorder. However, it is also easy to get “trigger happy” with the diagnostic gun and see any impulsivity, distractibility or restlessness as ADHD. So here are a few facts, figures and philosophical issues about ADHD.

Tips**

** Attention-Deficit/ Hyperactivity Disorder (ADHD)

FACTS

  • ADHD dates back to 1902 when Still, a British pediatrician, first describe symptoms of ADHD in children. (1, 2); modern psychopharmacology started in 1937 with a study of benzedrine in a mixed population of children with ADHD symptoms; methylphenidate was subsequently synthesized in 1955 with its formulations being the most commonly prescribed agents for ADHD (2)

FIGURES

  • In the USA, ADHD is the most common psychiatric disorder afflicting children and adolescents with approximately 5% (3, 4) or 6%-9% of juveniles affected; and 4%-5% of adults or about 7 million adults. (5)
  • ADHD can be a life-long disorder with 60% - 70% of children who have ADHD age into adulthood with impairing symptoms of the disorder, if not full- syndrome criteria of ADHD (2, 6)
  • Up to 71% of adult alcoholics had childhood-onset ADHD that was persistent; and 15%-25% of adult alcoholics and drug addicted people meet criteria for ADHD (7, 8, 4)
  • About one third of ADHD patients have co- occurring alcohol and other drug dependence; 60% of people with untreated ADHD have co-occurring substance use disorders. (9 )


WHAT ADHD LOOKS LIKE

  • Current diagnostic criteria for ADHD describe three subtypes: hyperactive-impulsive; inattentive; and combined. (10)
  • In adults, the hyperactivity can manifest adaptively as working long hours with two jobs; or in a very active job. May avoid situations requiring low activity e.g. going to the ballet. Constant activity can lead to family tension and often feel like they cannot play or work quietly. (2)
  • Impulsivity may manifest as low frustration tolerance – quitting a job; ending a relationship; losing temper; driving behaviors. Makes quick decisions; interrupts. (2)
  • Inattention may manifest as poor time management. Difficulty initiating or completing tasks or changing to another task when required; or difficulty with multitasking. Avoids tasks that demand attention; proscrastination. (2)


WHAT IS HAPPENING IN THE BRAIN (5)

  • Neuroimaging shows structural brain abnormalities – smaller volumes in the frontal cortex, cerebellum and subcortical structures.
  • Brain imaging to look at what areas are functioning normally or are too active or low activity, point to problems in the subcortical systems in the frontal area; and in the anterior cingulate activation. There is too low a level of activity in the Anterior Cingulate Cortex.
  • Three subcortical structures – the caudate, putamen, and globus pallidus – are part of the neural circuitry underlying motor control, executive function, inhibition of behavior, and modulation of reward pathways – these are all critical in substance use disorders too.
  • Executive functions are:
    Planning: foresight in devising multi-step strategies.
    Flexibility: capacity for quickly switching to the appropriate mental mode.
    Inhibition: the ability to withstand distraction, and internal urges.
    Anticipation: prediction based on pattern recognition.
    Critical evaluation: logical analysis.
    Working memory: capacity to hold and manipulate information in our minds in real time.
    Fuzzy logic: capacity to choose with incomplete information.
    Divided attention: ability to pay attention to more than one thing at a time.
    Decision-making: both quality and speed.
  • The subcortical circuits provide feedback to the cortex to regulate behavior. ADHD is thought to use neural systems involving neurotransmitters norepinephrine and dopamine. Dopamine is also involved in the reward pathway for substance use disorders.
  • Bottom line: In ADHD there is too low activity (hypoactivation) in the areas responsible for regulating behaviors and cognitive functioning like motor control, executive function, inhibition of behavior, and modulation of reward pathways.


WHAT TO DO ABOUT ADHD
Nonpharmacologic approaches (9)

  • ADHD coaches who help clients identify deficits and organize and prioritize their time; identify strengths and exploit them and identify weaknesses and avoid them. A qualified ADHD coach can be found through the ADD Coach Academy (www.addca.com)
  • Time management
  • Patient education and advocacy groups like Children and Adults with ADHD (CHADD, www.chadd.org); the Attention Deficit Disorders Association (ADDA, www.add.org). College students with ADHD can have accommodations such as un- timed tests in noise-free rooms.
  • Cognitive-behavioral therapy
  • Anger-control skills
  • Individual, group and family therapy
  • Coaching versus counseling


WHAT TO DO ABOUT ADHD
Pharmacologic approaches (9)

Stimulant medication has been used for over 70 years but should be used carefully in the presence of preexisting structural heart defects.

  • Short-acting (4-6 hours); moderate-acting (6-8 hours); long-acting (8-12 hours)
  • Amphetamines (Adderall, Adderall XR= extended release, dexedrine); methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA=long acting); D- methylphenidate (Focalin XR)
  • Stimulants act on the brain’s dopamine and norepinephrine neurotransmitter systems by enhancing the release of these neurotransmitters from storage vesicles in the presynaptic neurons. Stimulants also block the reuptake of the neurotransmitters which thus increases the available amount of dopamine and norepinephrine.(4) This increase in the available quantity of neurotransmitter makes up for the hypoactivity in the relevant areas of the brain. It is thought that this then restores the low activity to more normal levels. This corrects the signs and symptoms of ADHD.
  • Treating ADHD pharmacologically does not appear to exacerbate a substance use disorder e.g., stimulants have not been found to increase subjective or objective measures of cocaine use or cravings in ADHD or cocaine-substitution studies (11, 5)
  • Treatment of ADHD appears to protect against the development of substance use disorders.

Nonstimulant medications are more recent. (5, 9)

  • Atomoxetine (Strattera) – noradrenergic agent; two reports of liver toxicity in over 2 million exposures; and slight increase of suicidal ideation in children, but not adults.
  • Buproprion (Wellbutrin) – atypical antidepressant
  • Modafinil – arousal agent
  • Tricyclic antidepressants – desipramine, nortriptyline
  • Antihypertensives for adolescents – clonidine, guanfacine

Medications for co-occurring ADHD and Substance Use Disorders (5)

  • Untreated ADHD worsens the ADHD and the SUD
  • Atomoxetine, buproprion and extended-release stimulants are recommended for ADHD patients with very recent SUD i.e. within 3 months.
  • Alpha agonists and tricyclic antidepressants are often reserved as alternate agents for ADHD with SUD – lower potential for drug-drug interactions with substances of abuse.
  • Avoid amphetamines in patients with a history of amphetamine-related psychosis.

REFERENCES
1. Still GF (1902). Lancet 1:1008-1012, 1077-1082, 1163-1168.

2. Donnelly CL (2006): “History and Pathophysiology of ADHD” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

3. Faraone SV, Sergeant J, Gillberg C, Biederman J (2003): “The worldwide prevalence of ADHD: Is it an American condition?” World Psychiatry 2:104-113.

4. Donnelly CL (2006): “Treating Patients with ADHD and Coexisting Conditions”. Behavioral Healthcare Vol. 26, No. 9. pp. 40-44. September 2006.

5. Wilens TE (2006): “Attention Deficit Hyperactivity Disorder and Substance Use Disorders”. Am J Psychiatry 163(12): 2059-2063. December 2006.

6. Biederman J (2005): “Attention- deficit/hyperactivity disorder: a selective overview”. Biol Psychiatry 57(11):1215-1220.

7. Goodwin DW, Schulsinger F, Hermansen L, et al (1975): “Alcoholism and the hyperactive child syndrome”. JNerv Ment Dis 160:349-353.

8. Wilens TE (1998): “AOD use and Attention Deficit Hyperactivity Disorder” Alcohol Health Res World 22:127-130.

9. Young JL (2006): “Treatment of Adult ADHD and Comorbid Disorders” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

10. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.

11. Grabowski J, Shearer J, Merrill J, Negus SS (2004): “Agonist-like, replacement pharmacotherapy for stimulant abuse and dependence”. Addictive Behaviors 29:1439-1464.

SKILLS
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Last November I chaired a panel discussing how to improve services for teens in West Virginia. Phil Washington was telling us all about how he engages adolescents in educational but fun ways. He shared some of the tools he uses. With his permission, I am sharing a couple of exercises he uses which provokes good discussion within the group. Some are best used just with adolescents. Others can be used with any age group.



Tips**

** “Sounds Like Fun” are some thought- provoking questions to check whether using really is all fun.

Sounds Like Fun
These questions are to be asked in light of the fact that young people call getting high or drunk a good time. If it’s such a good time why do we not share it with everyone? Remind them of the times that they stuck their head in a toilet bowl to throw up. Remind them of promising God, “If you get me out of this I will never do it again.”

1. Do you ever call the police to let them know that you will be drunk and they can come pick you up at wherever?

2. Do you arrange for special lodgings at the jail in anticipation of being picked up for public intoxication?

3. Do you arrange for a special hairdo and clothing so you don’t get vomit on your good stuff?

4. Do you call your friends and family and tell them to watch the news to see you get into an altercation with the police on those special evenings?

5. Do you video yourself when you are drunk or high so you can show those special moments to your future children and grandchildren?

6. Do you let your potential boyfriend/girlfriend know that you sometimes have had unprotected sex while under the influence of drugs/alcohol?

7. Has anyone ever taken a picture of you while you were drunk or high, and you were so proud you made copies and sent them to the whole family?

8. Have you ever been with your boyfriend/girlfriend and offered them a big, wet, sloppy kiss after throwing up?

9. Have you ever checked your breath after drinking and smoking and thought, “Wow, my breath is enchanting. I think I'll kiss someone”?

10. If not, why not? Isn’t this what we call a good time? Shouldn’t good times be shared by all?

Reference for “Sounds Like Fun” and “Would You?”
Phil Washington - Daymark Inc.
1598 C Washington St., East
Charleston, WV 25311
(304) 340-3690
phil@daymark.org

** “Would You” helps young people and adults think through the situation and examine their values.

Would You?

1. Would you give the keys to your car to someone who was drunk or high?

2. Would you give the keys to your apartment to that same person?

3. Would you allow someone under the influence to baby-sit your children?

4. Would you allow a person who drinks and drives to take your children to an outing in their car?

5. Would you hand a person under the influence your check book?

6. Would you invite someone under the influence to fix your pipes, or electrical appliances, or your roof?

7. Would you take someone under the influence on vacation with you and your children, or family?

8. Would you take someone under the influence to meet your parents and family?

9. Would you take someone who you know will get drunk to your company picnic where there will be beer and liquor?

10. Would you recommend someone who gets high for a job at your company?

SOUL
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My New Year’s resolution was about achieving balance between work, love and play. Since you will get this month’s TNT while I am playing Down Under, here are a few lighthearted quotes and tidbits to help you play a little too. Most come from the vast cyberspace:

Zen for those who take life too seriously
--> Change is inevitable, except from vending machines
--> Plan to be spontaneous tomorrow
--> If you think nobody cares, try missing a couple of payments
--> When everything’s coming your way, you’re in the wrong lane
--> Depression is merely anger without the enthusiasm
--> Just remember – If the world did not suck, we would all fall off.

Quotes from George Carlin
--> “Ever notice that anyone going slower than you is an idiot, but anyone going faster than you is a maniac?”
--> “Isn’t making a smoking section in a restaurant like making a peeing section in the swimming pool?”

And to end with an Aussie flavor - What do you call a boomerang that doesn't work?
A stick.

G’day mate!

Until Next Time
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Thanks for joining us. See you in February.
David


Contact Information
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email: info@dmlmd.com
phone: 530-753-4300 PACIFIC
web: http://www.dmlmd.com
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