|Year : 2017 | Volume
| Issue : 1 | Page : 35-40
An observational study of the characteristics of different substance-use disorder subtypes combined with adult attention deficit hyperactivity disorder
Khaled S Sherra MD 1, Dalia M Khalil2, Ahmed M El Melegy3
1 Psychiatry Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Psychiatry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Clinical Pathology Department, Zagazig University Hospitals, Zagazig, Egypt
|Date of Submission||29-Aug-2016|
|Date of Acceptance||26-Sep-2016|
|Date of Web Publication||22-Feb-2017|
Khaled S Sherra
Psychiatry Department, Faculty of Medicine, Mansoura University
Source of Support: None, Conflict of Interest: None
The aim of this study was to examine the characteristics and intensity of the association between various subtypes of substance-use disorders (SUD) with adult attention deficit hyperactivity disorder (ADHD) and compare this with the progression of substance use in those without ADHD.
Participants and methods
The study was conducted at the Psychiatric Department, Mansoura University Hospital. Both inpatients and outpatients who screened positive for any one of the substances such as alcohol, opioids, amphetamine, or cannabis were approached to enter the study. Out of these, patients who gave informed consent, satisfied the inclusion and exclusion criteria, and met the DSM-IV-TR diagnosis for SUD for dependence or abuse entered the study and completed the patient intake form. A total of 100 such consecutive patients were screened for symptoms of adult ADHD by administering the first six questions of part A of the Arabic version of the adult ADHD self-report scale-VI.I (ASRS-VI.I) symptom checklist. Only the first six questions that are found to be the most predictive of symptoms were included for screening. Patients who answered positive for four or more questions were further interviewed using the Diagnostic Interview of Adult ADHD to make a diagnosis of adult ADHD in these patients. A total of 97 patients completed all parts of study questionnaire. The patients were divided and grouped depending on the type of substance abused, alcohol, opioid, cannabis, amphetamine, or polysubstance, and whether or not they had comorbid adult ADHD. The results obtained were statistically analyzed using SPSS software.
The prevalence and course of SUD combined with adult ADHD differed depending on the primary substance of abuse. Cannabis and alcohol users had a higher percentage of adult ADHD (36.4 and 33.3%, respectively) compared with other drug users. Cannabis had the earliest age of onset of SUD at 15 years of age. Cannabis and amphetamine had a prolonged duration of abuse: 14.87 and 14.7 years, respectively. Similarly, they had a greater number of hospitalizations (3.82 and 3.88 times, respectively) and an increased duration of stay in the hospital (166.67 and 110 days, respectively) as compared with other drugs. Polysubstance, cannabis, and amphetamine abusers had more relapses: 3.27, 3.36, and 3.38 times, respectively.
The percentage of ADHD differs among different subgroups of SUD depending on the primary substance of abuse. Cannabis and amphetamine have a higher comorbidity, an earlier age of onset, and a more protracted course of SUD in ADHD patients compared with other drugs.
Keywords: ADHD, ASRS, DIVA, SUD
|How to cite this article:|
Sherra KS, Khalil DM, El Melegy AM. An observational study of the characteristics of different substance-use disorder subtypes combined with adult attention deficit hyperactivity disorder. Egypt J Psychiatr 2017;38:35-40
|How to cite this URL:|
Sherra KS, Khalil DM, El Melegy AM. An observational study of the characteristics of different substance-use disorder subtypes combined with adult attention deficit hyperactivity disorder. Egypt J Psychiatr [serial online] 2017 [cited 2017 Jun 26];38:35-40. Available from: http://new.ejpsy.eg.net/text.asp?2017/38/1/35/200717
| Introduction|| |
Studies show a higher prevalence of adult attention deficit hyperactivity disorder (ADHD) in adults with substance-use disorders (SUD) compared with the general population (Rounsaville and Carroll, 1991; Levin et al., 1998; King et al., 1999; Wilens, 2007; Arias et al., 2008; Ohlmeier et al., 2008; Huntley et al., 2012). This is an important observation because research suggests that co-occurring ADHD and SUD is associated with a more severe course of substance use and a poorer treatment outcome (Carroll and Rounsaville, 1993; Wilens and Fusillo, 2007).
Prevalence rates of ADHD in SUD patients show an enormous variation ranging from 2% in substance-abusing Icelandic adolescents (Hannesdottir et al., 2001) to 83% in Japanese methamphetamine and inhalant abusers. In a recent meta-analysis by Van Emmerik-van Oortmerssen et al. (2014) of 12 studies on adult seeking SUD patients, the pooled ADHD prevalence rate was 23.3%, ranging from 10.0 to 54.1% in individual studies. The possible explanations for this huge variability include differences in diagnostic criteria, the primary drug of abuse, country-specific factors, the treatment setting, clinical biases, and demographic factors. However, the relative effect of each of these factors has not been studied (Van de Glind et al., 2014).
Also, there are conflicting data on the kind of primary substance of abuse that was more prevalent and had more impact on the course of progression of SUD combined with adult ADHD. According to one study, the prevalence is lower among treatment-seeking SUD patients whose primary substance of abuse was alcohol, compared with those whose primary substance of abuse was illicit drugs (Van de Glind et al., 2014). Another study states that there is a lower prevalence of adult ADHD in treatment-seeking cocaine-dependent patients compared with treatment-seeking alcohol-dependent and opioid-dependent patients (Van Emmerik-van Oortmerssen et al., 2012). As there was little information about these issues, we decided to conduct a preliminary analysis of the relationship between the primary drug of abuse in SUD and their course when they were comorbid with adult ADHD.
Furthermore, we decided to test our hypothesis that the prevalence and course of SUD combined with adult ADHD did not vary depending on the primary substance of abuse.
| Participants and methods|| |
The study was conducted from February to August 2015 and was approved by the Ethical Committee. Patients attending the outpatient and inpatient unit at the Psychiatric Department, Mansoura University Hospital, who screened positive for one or more of the substances such as alcohol, opioids, amphetamine, and cannabis were approached to participate in the study. Written informed consent was obtained from all participants. The patients were interviewed by a trained professional, and those who satisfied the inclusion and exclusion criteria, aged between 18 and 65 years, with a current DSM-IV-TR diagnosis of SUD entered the study. Exclusion criteria included any severe mental or neurological disorders such as psychosis, affective disorders, dementia, or Parkinson’s disease. A total of 100 consecutive patients were enrolled in the study and were requested to complete all parts of the patient intake form, which consisted of demographic data, details regarding their substance use, and screening questions for adult ADHD from the Arabic version of the adult ADHD self-report scale (Kessler et al., 2005b).The patients were further subjected to a Diagnostic Interview for Adult ADHD (DIVA) to make a final diagnosis. Out of 100, 97 patients completed all parts of the study. Three patients dropped out due to the nonavailability of an informant to complete DIVA and due to physical health reasons.
Screening for substance abuse
Alcohol was measured by the enzymatic method by oxidation to acetaldehyde with NADH+, a reaction catalyzed by alcohol dehydrogenase (Dubowski and Caplan, 1996).
To assess opiate, cocaine (benzoylecgonine), and amphetamine qualitatively in urine, an initial immunoassay screening test was carried out, with cutoff values of 300, 300, and 500 ng/ml, respectively, and a confirmatory test of gas chromatography-mass spectroscopy was performed if needed (Kwong et al., 1988).
For opiates, urine is treated first with acid to hydrolyze the glucuronides and then with hydroxylamine, and then extracted with a solid-phase extraction column. For cocaine, derivatives of benzoylecgonine after extraction from urine were analyzed with a deuterated internal standard in the selected ion-monitoring mode.
Screening for adult ADHD was performed by the Arabic version of the adult ADHD self-report scale-VI.I (ASRS-VI.I) symptom checklist. Only the first six questions, which are found to be the most predictive of symptoms, were included for screening (Fayyad et al., 2007; Kessler et al., 2007).
DIVA 2.0 is a structured interview for ADHD in adults (Kooij et al., 2005, 2008). It is divided into three parts that are each applied to both childhood and adulthood: the criteria for attention deficit (A1), the criteria for hyperactivity–impulsivity (A2), and the age of onset and impairment accounted for by ADHD symptoms. The patients were diagnosed as having adult ADHD if they scored 6 or more in each of the symptom domains of attention deficit (A) and hyperactivity–impulsivity in childhood and during adult life with evidence of a lifelong persistent course with impairment in at least two situations, given that these symptoms are not explained by another psychiatric disorder.
Statistical analyses were performed using the IBMSPSS (United States- 2004) 23 program and methods according to Landau and Everitt (2004).
| Results|| |
Description of the studied patients
Out of the 97 patients who completed the study, 27 had adult ADHD. These 27 patients were separated and grouped depending on the primary substance of abuse and compared with their non-ADHD counterparts and also among themselves.
On comparison with non-ADHD patients, patients abusing cannabis and alcohol had a higher percentage of adult ADHD at around 36.4–33.3%. In contrast, the percentage of opioid users was 25%. The percentage of amphetamine and polysubstance abusers were 21.4% each.
The age of onset of all subtypes of SUD was much earlier if they had a dual diagnosis, that is, adult ADHD compared with those who did not have ADHD. The adult ADHD group started drug abuse about 10 years earlier and during the adolescent years of their life. Among the drugs, cannabis had the earliest age of onset, approximately at 15 years of age ([Table 1]).
All patients with ADHD had a longer duration of abuse than non-ADHD patients, irrespective of their primary drug of abuse. Cannabis and amphetamine had a prolonged duration compared with opioid and alcohol: 14.87 and 14.7 years, respectively ([Table 2]).
Except for alcohol, all other drugs had on average more number of hospitalizations when they were comorbid with adult ADHD. Cannabis and amphetamine abusers had 3.82 and 3.88 times the number of hospital admissions compared with 2.81, 2, and 1.5 in polysubstance, opioid, and alcohol abusers ([Table 3]).
All primary drugs of abuse except alcohol, when combined with ADHD, had a longer duration of stay in hospitals. The stay was the longest for cannabis users (about 166.67 days) and amphetamine users (around 110 days) compared with other drug abusers ([Table 4]).
Similarly, all drug abusers had a greater number of relapses except for alcohol users in patients with adult ADHD. Cannabis, amphetamine, and polysubstance abusers had 3.36, 3.38, and 3.27 times the number of relapses, which is greater than that with opioids ([Table 5] and [Table 6]).
| Discussion|| |
Our study showed that among SUD patients with ADHD, 36.4% abused cannabis, which was the highest among ADHD patients. This was followed by alcohol and amphetamine. This is consistent with the study conducted by Biederman et al. (1995), who reported that the drug most commonly used by ADHD patients was cannabis, at a frequency much greater than that of amphetamine, cocaine, and hallucinogens, only then followed by opioids, which does not appear to be the preferred drug of ADHD sufferers.
It was noticed that 33.3% of the ADHD patients abused alcohol in our study, which is comparable to the study by Downey et al. (1997), who investigated 78 adult ADHD patients and determined an incidence of 33.3% for alcohol abuse or dependence.
The age of onset of all substances of abuse was earlier when comorbid with ADHD as compared with non-ADHD abusers. This is comparable to the research by Umut Mert et al. (2012) who stated that individuals with ADHD begin using substances at an earlier age with rapid transformation from substance abuse to dependence and substance use becoming more intense. The study also explains our findings that cannabis had the earliest age of onset of about 15 years of age, which could be due to the recent trends of increase in cannabis use by young people in the USA and European countries (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2005).
The duration of drug abuse was longer in SUD patients with ADHD compared with those without ADHD. Among the drugs, cannabis and amphetamine had more chronic usage when compared with opioid and alcohol, which could be probably due to the earlier age at which the drug use starts or due to self-medications for symptoms of inattention and hyperactivity (Biederman et al., 1995; Upadhyaya and Carpenter, 2008).
It is interesting to note that in our study all drugs except alcohol had a greater number of hospitalizations, a longer duration of stay in hospitals, and a greater number of relapses when they coexisted with ADHD. Also, cannabis and amphetamine had a greater number of hospital admissions and longer stays in hospital admissions compared with other drugs. They also have an increase in relapse rate. These findings need further research to find out the probable cause for which this could be hypothesized due to the longer time taken by alcohol to cause considerable damage to the human body as compared with other drugs such as amphetamine, opioid, and cannabis, which lead to gross damage to the body in a short duration of their use. Moreover, patients find it increasingly difficult to come out of their addictive behaviors while using cannabis and amphetamine because of the self-medicating properties. It could also be due the early onset of these substances, which increases the severity of SUD, decreases the effects of treatment, and prolongs the duration of SUD (Brook et al., 1995; Johnson et al., 2000). Hence, we disproved our hypothesis and there are differences in patients with SUD and ADHD depending on their substance of abuse. Further studies are needed in this area to examine these effects in more detail.
| Conclusion|| |
Our study is an indication that the onset, course, and response to treatment of patients with SUD and ADHD vary according to the primary substance of abuse. It points that cannabis and amphetamine contribute to the earlier onset of SUD, prolonged course, and more relapses in these groups of patients, and hence, further research is needed to study the effects of the primary drug of abuse in SUD patients who have comorbid ADHD for better awareness of treatment and prevention of relapses.
The findings of this study need to be viewed in light of some of the methodological limitations. Details regarding the primary substance of abuse were obtained in relation to the current primary substance of abuse and this may have an effect on the course, as patients may have used other substances during their lifetime. Because of the small sample size, the study prevents us from making causal inferences on the associations that we found. The diagnosis obtained by a structured interview were based on the retrospective recall of illness such as the age of onset and duration of illness, which are subject to recall bias.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arias AJ, Gelernter J, Chan G, Weiss RD, Brady KT, Farrer L, Kranzler HR (2008). Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders. Addict Behav 33:1199–1207.
Biederman J, Wilens T, Mick E et al.
(1995). Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. Am J Psychiatry 152:1652–1658.
Brook JS et al.
(1995). Longitudinally predicting late adolescent and young adult drug use: childhood and adolescent precursors. J Am Acad Child Adolesc Psychiatry 34:1230–1238.
Carroll KM, Rounsaville BJ (1993). History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers. Compr Psychiatry 34:75–82.
Downey KK, Stelson FW, Pomerleau OF et al.
(1997). Adult ADHD: psychological test profiles in a clinical population. J Nerv Ment Dis 185:32–38.
Dubowski KM, Caplan YH (1996). Alcohol testing in the workplace. In: Garriott JC, editor. Medicolegal aspects of alcohol. Tucson, AZ: Lawyers & Judges Publishing Co; 439–475.
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2005). The state of drugs problem in Europe. Annual report (2005)
Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyher M, Demyttenaere K et al.
(2007). Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. BJP 190:402–409.
Hannesdottir H, Tyrfingsson T, Piha J (2001). Psychosocial functioning and psychiatric comorbidity among substance-abusing Icelandic adolescents. Nord J Psychiatry 55:43–48.
Huntley Z, Maltezos S, Williams C, Morinan A, Hammon A, Ball D et al.
(2012). Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units. BMC Psychiatry 12:223.
Johnson BA et al.
(2000). Age of onset as a discriminator between alcoholic subtypes in a treatment-seeking outpatient population. Am J Addict 9:17–27.
Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E et al.
(2005b). The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med 35:245–256.
Kessler RC, Adler LA, Gruber MJ et al.
(2007). Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members. Int J Methods Psychiatr Res 16:52–65.
King VL, Brooner RK, Kidorf MS, Stoller KB, Mirsky AF (1999). Attention deficit hyperactivity disorder and treatment outcome in opioid abusers entering treatment. J Nerv Ment Dis 187:487–495.
Kooij JJS, Buitelaar JK, Van den Oord EJ, Furer JW, Rijnders CATH, Hodiamont PPG (2005). Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults. Psychol Med 35:817–827.
Kooij JJS, Boonstra AM, Willemsen-Swinkels SHN, Bekker EM, de Noord I, Buitelaar JK (2008). Reliability, validity, and utility of instruments for self-report and informant report regarding symptoms of attention-deficit/hyperactivity disorder (ADHD) in adult patients. J Atten Disord 11:445–458
Kwong TC, Chamberlain RT, Frederick DL, Kapur B, Sunshine I (1988). Critical issue in urinanalysis of abused substances: report of the substance-abuse testing committee. Clin Chem 34:605–632.
Landau S, Everitt BS (2004). A handbook of statistical analysis using SPSS. Chapter 3. London, New York, Washington, D.C: Chapman and Hall/CRC Press LLC, a CRC Press Company Boca Raton. 71–98.
Levin FR, Evans SM, Kleber HD (1998). Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment. Drug Alcohol Depend 52:15–25.
Ohlmeier MD, Peters K, Te Wildt BT, Zedler M, Ziegenbein M, Wiese B et al.
(2008). Comorbidity of alcohol and substance dependence with attention-deficit/hyperactivity disorder (ADHD). Alcohol Alcohol 43:300–304.
Rounsaville B, Carroll K (1991). Psychiatric disorders in treatment-entering cocaine abusers. NIDA Res Monogr 110:227–251.
Umut Mert A, Sennur Gunay A, Abdullah A, Fulya M (2012). Attention deficit hyperactivity disorder (ADHD) symptoms and adult ADHD diagnosis in adult men with cannabis dependence. J Soc Dev New Net Environ B&H 6:1930–1934.
Upadhyaya HP, Carpenter MJ (2008). Is attention deficit hyperactivity symptom severity associated with tobacco use? Am J Addict 17:195–198.
Van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, Schroevers RA (2012). Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend 122:11–19.
Van Emmerik-van Oortmerssen K, van de Glind G, Koeter MWJ, Allsop S, Auri-acombe M, Barta C et al.
(2014). Psychiatric comorbidity in treatment seeking substance use disorder patients with and without ADHD; results of the IASP study. Addiction 109(2):262–272. doi: 10.1111/add.12370. Epub 2013 Nov 20.
Van de Glind G, Konsteniusc M, Koeterb MWJ, van Emmerik-van Oortmerssenb K, Carpentierf P-J, Kayeg S et al.
IASP Research Group (2014) Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria. Drug Alcohol Depend 134:158–166.
Wilens TE (2007). ADHD: prevalence, diagnosis, and issues of comorbidity. CNS Spectrosc 12:1–5.
Wilens TE, Fusillo S (2007). When ADHD and substance use disorders intersect: relationship and treatment implications. Curr Psychiatry Rep 9:408–414.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]