Why do people with ADHD get addicted?

Navigating the Chaos, PART I:

Constant Mouton

by Constant Mouton, Psychiatrist and Head of Department, Triora Netherlands

 

“Picture a room with a thousand TVs, each TV showing something different. Now try and concentrate on just one TV without getting distracted,” Damian DaViking Aird.

This article is the first in a series of articles aiming to explore the link between ADHD and addiction. It focuses on the risk factors for developing addiction in association with (often undiagnosed) ADHD. Subsequent articles will take a look at the clinical presentation of ADHD in adults, diagnosing ADHD in addiction and how to treat these co-occurring disorders. This article was first published on LinkedIn.

Increased risk of addiction

People with ADHD have a two to three times higher risk of developing substance use disorder. Twenty to forty percent of adults with ADHD have a history of substance use disorders. In a group of patients admitted for addiction treatment, 15%-25% will have ADHD, often still undiagnosed.

Why do people with ADHD get addicted?

Risk factors

If undiagnosed or undertreated, people with ADHD will often use drugs, alcohol or medication to self-medicate. Often unaware that they have ADHD, sufferers will use medication, alcohol or drugs to try to sleep or relax in order to function better at school or work.

Failure to treat adults with ADHD creates a number of complications that put sufferers at risk of developing an addiction. Some risk factors associated with an increased risk of developing addiction in ADHD are:

  1. Associated disorders
    ADHD is associated with higher rates of depression, anxiety, post-traumatic stress disorder, sleep disorders and conduct disorder. Each of these disorders is associated with a higher risk of developing an addiction if left untreated.
     
  2. Genetic risk
    Genetic factors also play a role. Genes associated with risk-taking, and novelty seeking behaviour may predispose an individual to both ADHD and substance abuse.
     
  3. Impulsivity
    A core symptom of both ADHD and addiction is impulsivity. Due to increased impulsivity at a young age, there seems to be a higher rate of experimental drug and alcohol use at a younger age in ADHD. Studies of alcoholism show that the earlier the first exposure to alcohol, the higher the risk of becoming addicted later in life. Early onset of substance abuse has also been associated with more severe forms of ADHD and poorer treatment results for both ADHD as well as addiction.
     
  4. Early aggressive behaviour
    The risk of addiction increases with early aggressive behaviour. Knowing that ADHD in childhood is associated with conduct disorder, the aggression seen in conduct disorder might prognosticate a higher risk of addiction later in life if left untreated.
     
  5. Stress
    If a person’s stress levels are high, there is a greater chance that a substance such as alcohol may be used in an attempt to alleviate the stress. Some stress hormones are linked to alcoholism. Having ADHD can lead to an increase in stress due to chronic underachievement and feelings of worthlessness. Poor functioning in the workplace and difficulty managing relationships can also result in high stress levels, increasing the risk of addiction.
     
  6. Personal adversity and loneliness
    For several reasons, for example due to failed relationships, people with ADHD often experience personal adversity, leaving them lonely and feeling insecure. Being alone and feeling lonely can lead to the consumption of substances as a way of coping, resulting in a higher risk of addiction.
     
  7. Unemployment
    ADHD is strongly linked to high rates of absenteeism from work due to sickness, and unemployment. These factors are not only stressful but can also lead to poverty, which increases the risk of addiction.
     
  8. Relationship problems
    ADHD is associated with high rates of family and marital conflicts. A stable family system and network acts as a basis for recovery. Without this, the risk of addiction as well as relapse will increase.

Self-medicating in ADHD

It is said that people use drugs and alcohol to feel better, or to do better. This is even more so for people with ADHD. As explained above, people with ADHD will often unknowingly start using alcohol or drugs to relieve symptoms of depression, anxiety or low self-esteem, and help them feel better. Others might realise that taking drugs or alcohol will improve concentration and focus, [1] helping them to do better. Often patients will struggle with the idea of being labelled an addict, because for them they (temporarily) functioned better while abusing a substance.

Not all substance abuse in ADHD is associated with self-medication. A study conducted by Harvard medical school showed that 70% of students with ADHD use drugs to relieve symptoms, while 30% use drugs to get high (recreational use).

Which addictions are most common in ADHD?

Patients self-medicate with both stimulants and sedatives, as both classes of drugs partially relieve the symptoms of ADHD. The most commonly abused substances in ADHD are alcohol and cannabis (commonly known as “downers”) because they slow down all neuronal activity and relieve the symptoms of ADHD. The reason why this is the most common addiction in ADHD is unknown. It most likely has to do with availability and easy access to alcohol and cannabis.

On the other hand “uppers” such as cocaine, caffeine and amphetamines are also abused because of their pharmacological effect in ADHD. For ADHD sufferers, the increased dopamine levels in the prefrontal cortex, lead to a better ability to filter input from the environment, which results in a calming effect. This is also the main effect of the medication used to treat ADHD. Of course using unprescribed and unmonitored stimulants leads to a worsening of symptoms and negative outcomes for people with ADHD over the longer term.

Questions around the use of prescribed stimulants in the treatment of ADHD, and the concern that they may increase the risk of developing an addiction, seem to finally have been answered. The latest evidence shows that children diagnosed with ADHD who were prescribed stimulants under careful professional supervision, have a 50% lower risk of developing addiction later in life.

Research not only studies substance addictions in ADHD sufferers. There is growing evidence linking ADHD to process addictions. Evidence soon to be released, links ADHD symptoms to internet gaming disorder and addictive use of social media.

What can be done?

By treating both the ADHD and the addiction, higher rates of recovery from addiction can be expected. Diagnosing ADHD in a person struggling with addiction can be challenging. A comprehensive psychiatric assessment should be done to also examine other possible diagnoses such as depression, anxiety and trauma. IDDT (integrated dual diagnosis treatment) is key to the initial diagnosis and treatment of this frequently occurring, yet underdiagnosed and undertreated condition. Counselling, cognitive behavioural therapy, family therapy, self-help groups and holistic treatments are core elements of a successful treatment programme.

A multidimensional treatment plan not only focusing on biological treatment, but also addressing any associated social and psychological factors, will improve outcomes and lead to more sustainable recovery for both ADHD as well as addiction.

This multidimensional approach is the most effective way in turning down the unnecessary distraction caused by the thousand TVs competing for attention.
 

Navigating the Chaos, Part II: Recognising ADHD throughout the lifespan

Navigating the Chaos, Part III: Assessing ADHD in addiction


References

  1. Bolea-Alamañac B, Nutt DJ , Adamou M, et.al. (2014) Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology, Journal of psychopharmacology. 28(3): 179-203.
  2. McGough JJ, Smalley SL, McCracken JT, et.al. (2005) Psychiatric comorbidity in adult attention defecit hyperactivity disorder: findings from multiplex families. Am J Psychiatry 162(9): 1621-7.
  3. Clure C, Brady KT, Saladin ME, et.al (1999) Attention-deficit/hyperactivity disorder and substance use: symptom pattern and drug choice. Am. J. Drug Alcohol Abuse. 25(3):441-8.
  4. 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(11): 1652-8.
  5. Lee SS, Humphreys KL, Flory K, et.al. (2011) Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev. 31(3):328-41.
  6. Yen J-Y, Liu T-L, Wang P-W et al. (2017) Association between internet gaming disorder and adult attention deficit and hyperactivity disorder and their correlates: Impulsivity and hostility. Addictive behaviours, Vol 64:308-313.
  7. Wilens,T, Zulauf C, Martelon M. (2016) Nonmedical Stimulant Use in College Students: Assiciation with Attention-Deficit/Hyperactivity Disorder and Other Disorders. J Clin. Psychiatry 77(7):940-7.
  8. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

 



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