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ADHD is not often recognized among drug addicts

ADHD is not often recognized among drug addicts

According to a British study, there may be many undetected cases of ADHD among drug addicts. The high consumption of cannabis and stimulants could be a kind of self-medication in these people.

Attention Deficit Hyperactivity Disorder (ADHD) is mostly diagnosed in children and adolescents, but it can persist into adulthood. According to the Robert Koch Institute, the diagnosis of ADHD is made in just under five percent of children and adolescents in Germany. It is estimated that 30 to 50 percent of ADHD symptoms persist into adulthood, with the symptoms of hyperactivity diminishing while attention-getting issues are highlighted.

According to studies, up to 58 percent of people with ADHD would be drug abusers or drug addicts. However, a British research team suspects that some people with ADHD go undetected. Study leader Philip Asherson and his team have therefore searched for ADHD in a sample of 226 drug-addicted men and women.

The research team has carried out a two-stage diagnostic procedure as part of a detoxification treatment. The first survey took place during the hospital stay, the second one a week later. This was to avoid that the withdrawal and its concomitants distort the result of the diagnosis.

In 12 percent of the drug addicts studied, the research team was finally able to make an ADHD diagnosis that was previously unknown to those affected. In particular, the high prevalence of cocaine and amphetamine use was noted. Since the drug treatment for ADHD also uses stimulants such as metylphenidate (trade name Ritalin®), the research team suspects that stimulant use is a form of self-medication. Those affected also suffered more than other drug addicts from depression and had committed more suicide attempts in the past.

Their study would thus show how important it is to recognize ADHD in good time and treat it appropriately, the research team writes in its journal article. Although the treatment with drugs such as methylphenidate is problematic in view of the drug abuse, but there are now other drugs without stimulating effect. In addition, it must be examined whether certain psychotherapeutic procedures can help here.

Methylphenidate in ADHD does not prevent the drug career

            Children with an attention deficit / hyperactivity disorder (ADHD) are at higher risk of becoming addicted to adolescence as young adults. That is known. But controversial is the question of whether drugs for ADHD can protect against drug abuse or even promote it. New results from a long-term study show that methylphenidate appears to have less influence on the drug behavior of adolescents with ADHD than previously thought.

            Also Prof. Dr. Martin Ohlmeier, Director of the Clinic for Psychiatry and Psychotherapy at Kassel Hospital, talks to Medscape Germany that young people with ADHD have a high addictive potential. The greater risk is also due to the fact that adolescents and adults suffering from ADHD are more willing to take risks and use the drugs as a kind of "self-therapy". Therefore, the specialist in psychiatry, psychotherapy and neurology warns caution: "The new data also show that prescribing medicines for children with ADHD cannot definitely prevent a later addiction development. So far, it has not been clearly decided whether ADHD sufferers who have also developed an addiction disorder should be treated with methylphenidate. The data on this is so far unclear and there is still considerable need for research. "

            The more than 15-year-old American "Multimodal Treatment Study on Children with Attention Deficit Hyperactivity Disorder - MTA" is the largest randomized-controlled comparative study to date for the treatment of ADHD [1]. Researchers from the University Of Pittsburgh School Of Medicine and the Western Psychiatric Institute and Clinic of UPMC, as well as 6 other health care centers in the United States, are also monitoring the drug use of 579 children with ADHD until adolescence in this multimodal long-term study.

            The more than 15-year-old American "Multimodal Treatment Study on Children with Attention Deficit Hyperactivity Disorder - MTA" is the largest randomized-controlled comparative study to date for the treatment of ADHD [1]. Researchers from the University Of Pittsburgh School Of Medicine and the Western Psychiatric Institute and Clinic of UPMC, as well as 6 other health care centers in the United States, are also monitoring the drug use of 579 children with ADHD until adolescence in this multimodal long-term study.

Tobacco, cannabis and alcohol are especially popular

            Some results of this multi-center study have recently been published in the Journal of the American Academy of Child and Adolescent Psychiatry [2]:

            At the age of 15, 35% of children with ADHD consume one or more drugs, compared to 20% of those without ADHD.

            Criteria for drug abuse and drug dependence were 10% of the ADHD group, compared to only 3% in the others.

            At the age of 17, 13% of children in the ADHD group had problems with heavy marijuana use, compared to 7% in the comparison group.

            At 17%, the rate of smokers in ADHD children was much higher than would normally be expected at that age. In the control group, 8% of 17-year-olds smoked.

            Alcohol consumption was high in both groups - this underlines the usual behavior in this age group.

            Adolescents who were still on medication for ADHD had no lower or higher rates of drug abuse than those ADHD teens who stopped taking medicine.

            This study highlights the significant risk of drug abuse for boys and girls with childhood ADHD, says lead author of the study, Prof. Dr. med. Brooke Molina, who teaches psychiatry and psychology at the University of Pittsburgh.

            For Ohlmeier, the earlier observations confirm: "We know from existing epidemiological studies and from clinical practice that ADHD patients have a high coincidence in the development of an addiction." There are also neurobiological causes for this. Dopamine deficiency in ADHD patients accounts for increased impulsivity, risk behavior, and possible substance dependence, as drug use in certain centers of the central nervous system increases dopamine levels and, as a result, ADHD symptoms.

            Ohlmeier: "Many young adults with ADHD report consuming cannabis because they then feel calmer inside and can thus improve their sleep disorders that are common in this condition. Even in patients considered to be primarily amphetamine-dependent, ADHD is not uncommon as an underlying disease. Amphetamines such as e.g. Speed has a paradoxical effect in these patients. They are not turned up after consumption like other consumers, but on the contrary quiet. "

Self-medication through drugs

            This makes the addictive behavior of ADHD sufferers somewhat plausible for Ohlmeier: "In this way, the affected patients themselves treat themselves. Cocaine, on the other hand, tries out the ADHD adolescents relatively often, because they are willing to take risks, but they mostly listen to it quickly, because the actually desired effect, namely to be intoxicated, stays with them: cocaine does not stimulate them, but makes them rather tired ".

            As drugs for ADHD appear to have no effect on addictive behavior, more attention is now needed to find alternative ways to prevent substance abuse in adolescents with ADHD, Molina admits.

            "We are working hard to understand the reasons why children with ADHD are at a higher risk for substance abuse. Our hypothesis, supported by our research and that of others, is that many things are involved in it: Impulsive decisions, bad school success, and the difficulties of finding good friends, "says Molina.

            Much is also biological, "because we know that ADHD is hereditary". The psychiatrist hopes that it will succeed - similar to high blood pressure or obesity - to find non-drug options to reduce the risk of drug abuse [3].

Children with ADHD are at an increased risk of becoming addicted to adulthood.

With cigarettes, cannabis, cocaine or alcohol, those affected apparently treat themselves. Whether the frequently used for therapy methylphenidate can protect against addiction is still unclear.

Some children and teenagers do not come to rest. They are constantly on the move, touching everything and climbing over walls and fences. In addition to this motor hyperactivity, it is difficult for young people to be attentive and focused on a cause. Often they lose control on minor occasions, impulse control is inadequate. These young people suffer from Attention Deficit Hyperactivity Disorder (ADHD). ADHD affects about 3 to 5 percent of all children and adolescents, making it one of the most common child and adolescent psychiatric disorders (1). More than half of those affected continue to have the disease in adulthood (2).

Although the exact diagnostic criteria in the American disease catalog under DSM-IV, in Germany listed under ICD-10, but there is still no simple test that measures the typical behavioral problems accurately and provides a clear result. Nevertheless, ADHD can be determined relatively reliably and distinguished from age-appropriate behavior. This is of great importance because the disease should be recognized and treated as early as possible, partly because there seems to be a link between ADHD and other diseases. In addition to anxiety disorders, depression and the development of an antisocial personality that disregards social rules, this includes the addiction.

For example, ADHD is at high risk of developing substance abuse in adulthood. It is estimated to be four times higher than healthy people (3). A literature review found high rates of alcohol abuse (17 to 45 percent) and drug abuse (9 to 30 percent) in adults with ADHD (4). In adolescence, the frequencies of a substance abuse do not differ at first. However, ADHD-ill adolescents start drinking alcohol or consuming drugs earlier, do so more often and get worse off the drugs. There are several reasons for this (5). An ADHD sufferer is impulsive and therefore easy to influence. Always on the lookout for new sensations ("sensation seeking"), he is relatively daring and therefore also careless in dealing with drugs. Since he does not plan far ahead, he is particularly susceptible to the short-term euphoric effects of substance abuse.

Environmental factors also play a major role. Thus diminished attention and uncontrolled behavior give the impression that the adolescent is disinterested, forgetful and chaotic. Despite normal talent, he gets bad grades and becomes a social outsider. The increased impulsivity and the attention deficit reduce the chances of success of psych educational treatment measures or long-term therapeutic concepts. In this difficult situation, the patient often receives little support from his parents because they are mentally ill themselves. For example, it has been shown that the parents of ADHD sufferers are much more dependent on alcohol and stimulants, suffer from anxiety disorders, mood swings and show social behavioral problems than the average population (5).

Genetic changes

This indicates that genetic factors play an important role in the development of ADHD. Of particular importance are genes for various proteins that affect the circulation of the neurotransmitter dopamine at the synapse. Dopamine transporters remove the dopamine from the synaptic cleft so that it can no longer attach to the dopamine receptors of the downstream nerve cell and the transmission of the nerve signal is interrupted. In ADHD patients, researchers mainly found deviations in the genes for the dopamine transporter DAT1 and the dopamine receptor DRD4. For example, it has been shown that the 7-repeat allele of DRD4 is more common in children with ADHD (6). Because of these genetic changes, the dopamine is transported back faster compared to the healthy and the dopamine signal mediated weaker via the receptors. Stimulants lead to the release of dopamine and thus relieve the symptoms of ADHD.

This could be one reason that stimulant abuse occurs relatively frequently in adult ADHD sufferers. The substance abuse can be regarded as a kind of self-medication. Apparently, the improvement of the mental state after stimulants taking is noticed at a young age. In a survey on the motivation for their persistent substance abuse, most adolescents with ADHD answered that they have an effect on mood stabilization. Adolescents without ADHD mainly explained it with the euphoric effects (7). Similarly psychoactive as the stimulant methylphenidate is cocaine (8).

Which genes are responsible for the fact that adult ADHD sufferers suffer alcohol abuse or dependency far more than healthy people is not yet known. Genes may play a role in DRD4 and serotonin transporters (9).

Imaging procedures

ADHD seems to be accompanied by a deregulation of the dopamine metabolism, which then derails the neuronal information processing. According to the results of different imaging techniques such as positron emission tomography (PET) or functional magnetic resonance tomography (fMRI), the following brain regions are affected: the frontal brow (frontal lobe), the parietal lobe of the cerebrum (parietal lobe), which are responsible for the movements areas of the cerebral cortex (the motor cortex), the striatum (consisting of the caudate nucleus and putamen) and the cerebellum (cerebellum).

In ADHD-ill children, the volume of gray and white brain substance is 3 to 5 percent lower than in healthy ones. In particular, in the dorsolateral prefrontal cortex (DLPFC), which is responsible for executive functions such as action planning, working memory, and attention, there is a slight volume reduction (10). Volume reduction in the caudate nucleus has been associated with impulse control disorders (11).

In the caudate nucleus, volume reductions decrease with age (12). It could be shown that there is no overall volume reduction in adulthood. However, a significant decrease in volume was also found in the frontal cerebral cortex immediately above the orbit, the orbitofrontal cortex, which is associated with reward processes (13). Reward systems in the brain are important for feelings of joy and positive reinforcement - a sense of well-being for a "good" act that is responsible for learning a behavior. When a person feels such a feeling, dopamine is released in his brain. In the brain stem, there are about half a million dopamine cells on each side, which, in response to certain stimuli, direct this substance into the centers of the reward system, in particular into the striatum and the orbitofrontal cortex. In these regions, the brain controls and processes the information that controls behavior.

Why ADHD patients are more prone to addictive behavior
Research has shown that about 25 percent of adults who are being treated for alcohol or substance abuse also have ADHD.

On every testimony of Niall Greene was the same. He was a good boy, very talented, but over and over again his teachers added the same note: "He is quickly distracted."

"I had unbelievable difficulty finding myself," recalls Greene, who grew up in a small village in Northern Ireland about 30 kilometers from where he lives now. "I did not work very well in groups ... and today I know why."

But it took him more than ten years to figure that out-ten years of drug use, booze, doctors, therapists, detox, and a suicide attempt. As an adult, he was eventually diagnosed with attention deficit hyperactivity disorder (ADHD).

About 25 percent of adults who are being treated for alcohol and substance abuse also have ADHD, according to WebMD. Both often go hand in hand: the easy distractibility and impulsivity-both signs of ADHD-promote addictive behavior, as well as the personal stress that ADHD brings, which can even torment the simplest tasks.

"I am dealing with many young women who tell me that they have managed to deal with and arrange. But steps that others might take an hour or two cost these people four hours - they only manage them because they come to work early and stay longer than the others, "says Dr. Timothy Wilens, head of the Child Psychiatry at the Massachusetts General Hospital.

Wilens is the author of a 2010 study titled "A Sobering Fact: ADHD Leads to Substance Abuse," which concludes that 15 to 25 percent of adults with addiction problems have ADHD at the same time, Wilens says People with ADHD are "two to three times higher" than people without ADHD.

But of course you can also ask yourself what came first: the chicken or the egg? Do the symptoms of ADHD promote addictive behavior, or is it the way ADHD is treated - usually with stimulants like Ritalin that favors addictive behaviors?

"ADHD is like this: you wake up, everything is fine. But until 17 o'clock your life is a disaster. When things go wrong everything goes awry. "- Niall Greene

As a teenager, Niall's behavior was not attributed to ADHD. "If I do not get enough stimuli, then I'll make my own stimuli," he explains, for him these stimuli were alcohol and drugs, and from the age of fifteen, he drank until he broke film, and by the age of 20, his cocaine use had become compulsive and sometimes he swallowed up to five ecstasy pills at once, emphasizing that he was never joking - he did it in despair.

When he was 18, he moved from Northern Ireland to New York, where he spent "every penny for alcohol." Then it went from city to city: Liverpool, Galway, Dublin, he could not keep a job for long periods, everything was unstable, if he was not drank, he threw his money in slot machines.

"ADHD is like that," he says: "You wake up, everything is fine, but your life is a disaster until 5 pm you have to look for a new job, they throw you out of the apartment everything is going wrong.”

After visiting a detox clinic, Greene went to a psychiatrist who suggested that Niall probably has ADHD. It was the first time someone had considered this diagnosis. Greene found a book about the disruption in the only bookstore in his town, but it said nothing about how adults handle it.

That's probably because Dr. Howard Schubiner, who has carried out several studies on the disorder until recently, the existence of ADHD in adults was not thought possible. "It has always been assumed that it is a disorder that affects only children and settles on its own as soon as the children enter puberty."

The US Centers for Disease Control and Prevention estimates that in the US alone, 6.4 million children between the ages of 4 and 17 have been diagnosed with ADHD, but these children will become older and doctors will find that ADHD increases with age has not disappeared. Approximately 4.4 percent of all adult Americans are affected by ADHD, which, according to an estimate from the year 2000, costs the health care system and the economy through lost working time around 31.6 billion US dollars.

The problem, however, is that ADHD manifests itself in adulthood in different ways. The hyperactivity seems to decrease somewhat as the child grows older, but the attention deficits remain. "They are still there, but they are in some ways internalized," says Schubiner, and one of the forms that shows up in adults is addictive behavior: In a 2005 study, Schubiner stated that 20 to 40 percent all adults with ADHD had to deal with drug problems at some point in their lives.

Some research suggests that people with ADHD sometimes use drugs to counteract the dopamine deficit in their brains. But Dr. Schubiner and other researchers have also looked at whether it is not the commonly used treatments for ADHD stimulants, such as the amphetamine derivative Ritalin, that are leading patients to patterns of abusive drug use.

So far, however, this assumption could not be confirmed. "There is virtually no evidence that ADHD treatments increase the risk of quitting smoking or other drugs-in fact, they reduce the risk," Wilens says, pointing to a study of 25,000 ADHD patients who had a marked incidence Reduction in criminal behavior (including drug-related crime) among those who treat the disorder with medication. "There is every indication that the risk of [drug abuse] continues to be reduced as long as you take your medication," Wilens says. "In any case, they do not increase the risk."

"I think everyone in this area agrees that once a connection to addictive behaviors can be made, you should seriously consider getting ADHD treatment as soon as possible," he says. "When treating ADHD aggressively and at the same time controlling addictive behavior, it reduces [the risk of delinquency]. “

After being diagnosed with ADHD at Greene and completing a treatment based on it, he finally found stability in his life. But even today, he says, adult ADHD would still be accompanied by a stigma. "It's something like the black sheep of mental disorders," he says. Last year, the Daily Mail published an article by a doctor who completely denied the existence of ADHD.

"After 50 years as a practicing physician and thousands of patients with ADHD symptoms, I conclude that something like ADHD does not exist," he wrote, adding that the ADHD diagnosis and subsequent treatment of teenagers with Stimulants would ignore "the true cause of their problems" - in his opinion, these are things like marijuana or alcohol.

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For Greene, the opposite seems to apply. The treatment of his alcohol and drug addiction opened the possibility for him to be diagnosed, and finally he has the feeling of being in control of himself. Three years ago, Greene launched Adult ADHD NI, a nonprofit organization that helps other adults with this disorder in Northern Ireland. Above all, he has set himself the task of helping children and adults who are feeling the same way as he used to, although some doctors still believe that ADHD does not exist. "I like to face this challenge," he says.

Greene still remembers that feeling of being lost. He sees the relief in the faces of his clients when they realize that they are not the only ones who feel that way. Together it's easier.

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