Professor Wim van den Brink will be giving the Society Lecture at the SSA’s 2023 Annual Conference. In this special episode of the Addictions Edited podcast, he talks to Rob Calder about attention deficit hyperactivity disorder (ADHD) and addiction.

“If we want to prevent substance use disorders in patients with ADHD, we have to start early.”

Professor Wim van den Brink has had a storied career. He completed his medical degree in 1981, followed by training in psychiatric epidemiology, and a PhD. He was appointed Professor of Addiction Psychiatry in 1992, and has gone on to receive several awards for his work, including the lifetime achievement award from the Netherlands Association of Psychiatry in 2014, and the European Addiction Research Award from the European Federation of Addiction Societies (EUFAS) in 2017. He has (co)authored more than 600 international peer-reviewed scientific papers and has been a thesis advisor to more than 75 PhD students. Wim was invited to give the Society Lecture at the SSA’s 2023 Annual Conference – an honour previously extended to eminent academics such as Professor John Kelly and Dr Nora Volkow.

In an exclusive interview for the Addictions Edited podcast, Wim says that he hopes to use his talk at the SSA conference to deliver a few key messages: firstly, that ADHD is very common in patients with addiction – perhaps one in four will have adult ADHD; secondly, that the overlap or comorbidity could be attributed to a number of things – from neurobiological and psychological factors, to genetics and the environment; and thirdly, that establishing the respective weight of these contributing factors is important for prevention and treatment – for example, in determining whether pharmacological treatments and neuromodulation could offer more promise than, say, psychotherapies.

Rob is interested in the overlap between ADHD and addiction, and intuits that greater awareness of ADHD today than a few decades ago might be causing some people with substance use problems to question whether they also have ADHD. Rob asks Wim whether it can be difficult to diagnose someone with ADHD if they are currently using drugs. Wim says that, yes, some drugs can make it difficult to form a diagnosis of ADHD. Stimulants, for example, produce many of the same symptoms as ADHD, such as hyperactivity and increased reward sensitivity.

“In terms of alcohol and tobacco, if that’s the only drugs that are being used, the overlap of symptoms of these addictions and ADHD are not so big, and I think it’s not so difficult to make the distinction between the two. It becomes more complicated when it’s about using, or addiction to, stimulants, where some of the behaviours of stimulant use look very similar to ADHD symptoms. Sometimes the problems with attention, many times the hyperactivity, the oversensitivity to reward, you can see a lot of the same symptoms. And so that will be more difficult.”

In childhood, one of the barriers to diagnosing and treating ADHD can be doubt among caregivers that “ADHD is an existing, bona fide mental disorder”. In Wim’s experience, this can lead to more hesitance to treat childhood ADHD than other long-term conditions such as epilepsy. And Wim says he understands this as a parent himself; any kind of medication is a big decision for parents. However, effective treatment for ADHD can be life-changing and even life-saving.

Wim explains that most studies of ADHD treatments have examined the effects of medication, and of all the types of treatment, medication has so far shown the most promise. One purported benefit in adults from roughly 15 randomised controlled trials, is that ADHD medication can improve retention in addiction treatment.

“What we see is, as soon as people that come for treatment in addiction centres and they also have ADHD, if you start to give them medication, treatment retention is much better. So, they stay in treatment for a longer period of time. And the difference is very big.”

Retention is important. Without people staying in treatment for the recommended course, they might not be able to extract the full benefits. Wim acknowledges, however, that the ultimate goal often isn’t for people to stay in treatment; the goal is to see improvements in their lives and overall wellbeing, including relief from the symptoms of their substance use problems.

Unfortunately, Wim says, there is little evidence to date that medication will reduce drug use or symptoms of ADHD. While “very disappointing”, this is far from the end of the road for treatment. Wim describes studies where people have experienced an improvement in ADHD symptoms and drug use when prescribed higher doses (or more ‘robust’ doses, as some people prefer to say) than usual for their ADHD.

Two of the most commonly used and studied medications for ADHD are the stimulants methylphenidate and dexamphetamine. Wim acknowledges the irony that some patients will be addicted to stimulants, yet may be offered medications with stimulant effects for treatment of their ADHD. Wim says it could be argued that this is replacing a stimulant addiction with stimulant treatment – something he is not personally opposed to, but that would need to be discussed with and explained to the patient. He also says, however, that there is evidence to counter the argument that this would just be a substitution. A US study, for example, suggested that stimulant medications first and foremost treat the ADHD, which may then have an impact on the person’s substance use behaviour, including their use of non-stimulant drugs (e.g. alcohol).

Treating the symptoms of ADHD may also have preventive benefits. Specifically, providing timely treatment to children with ADHD may help prevent them from developing substance use problems later in life.

“There have been quite some studies now that show if you start to treat ADHD in children, at an early age, between 7 and 9, with medication – stimulant medication – the probability that they develop an addiction is reduced by more than 50%.”

Rob and Wim end the podcast on this encouraging note. Wim advocates for psychiatry to move towards prevention – not necessarily preventing ADHD, which can be very difficult to do given its strong genetic components, but preventing addiction by effectively treating ADHD in young people. He says, “We have to start to think about other types of prevention and spending our money in other ways. Not a little bit to every kid in the world. But perhaps a little bit more to kids that are more likely to develop an addiction.”

by Natalie Davies

Editor’s note: Quotes have been condensed and edited for clarity.

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