Substance Abuse in Pediatric ADHD

Theresa R. Cerulli, MD: The question around stimulants and substance abuse is in the front of all our minds. These are real risks. Obviously, the stimulants carry black-box warnings regarding risk of abuse and dependence. As much as would like to say that this is just an issue with our adult patients, it’s an issue with our kids and adolescents as well. It’s unbelievable, the number of stories I hear. I say adolescence because it’s not just our college-age children. These are our middle schoolers and our high schoolers as well, so that’s very concerning.

We need to do significant screening in our patients, mostly because the statistics I’ve given you on comorbidities is so high with ADHD [attention-deficit/hyperactivity disorder]. Substance abuse and anxiety are some of the highest comorbidities. It depends on the patient’s age, but those comorbidities are especially true in adults. The possibility of a substance abuse comorbidity means that a risk with giving a patient stimulants goes up. There are cases right now looking at health care prescribers’ patterns in terms of stimulants and nonstimulants. The nonstimulants are prescribed for kids about 23% of the time. For adults, nonstimulants are prescribed 8% of the time. In this discussion of stimulants vs nonstimulants, the nonstimulants come into play more in the pediatric. That’s probably based on our own histories, as our psychoeducation on the condition of ADHD, but also our experience. Their prescribers are more comfortable or concerned and using nonstimulants more in the children and adolescents than in our adult patients.

I’m hoping there’s greater understanding of the important the role of comorbidities, that we’ll see some shift even in the adults in the use of nonstimulants. I’ll give you an example of some indications that we’re moving in that direction of understanding this aspect diagnostically. The American Academy of Pediatrics and the Society for Developmental [and Behavioral] Pediatrics have started to recognize what I’ll call comorbid complex ADHD, that 75% of patients that have comorbidities. The diagnostic guidelines have been updated by both entities in the last year and a half to include the importance of diagnosing not only the ADHD but also the comorbidity. If the health care provider isn’t comfortable doing so, then it’s part of the guidelines for that health care provider to refer to someone who can make the diagnosis of the comorbidity. Along with the diagnostic guidelines shifting, so is the treatment paradigm. You need to address both the ADHD and the comorbid conditions and not just assume that the comorbid condition is going to get better on its own.

What does that mean for substance abuse? If we’re trying to treat simultaneously the ADHD and a comorbid substance abuse, there’s a reason to look at a nonstimulant over a stimulant, whether for an adolescent or an adult patient. The comorbidity of substance abuse and knowing the black-box warning, in my professional opinion, moves the nonstimulants higher on the tier of intervention compared with the stimulants. There are other reasons that someone may reach for a nonstimulant. Comorbid anxiety was another 1 with extremely elevated with rates with our patients with ADHD. Stimulants can worsen anxiety. If that’s the case, a nonstimulant may be the first-line treatment in those patients, including with our children.

Transcript edited for clarity.