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.