The Relevance of Attention Deficit Disorder in Addiction Treatment

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How many times has the addict wished that they had more self-control and could resist the cravings for the drug?  I have stressed that the existence of a craving is the basic abnormality in addiction.  The patient is still responsible for their behavior; they are responsible for whether they give in to their cravings.  When cravings are extremely intense, almost anyone will give in.  Yet, what happens when the cravings are not as intense?   The ability to resist cravings in general becomes a factor.  

Attention Deficit disorder (ADD), with or without a component of hyperactivity, is a common and often misunderstood problem.  I have seen some estimates that 25% of boys can be diagnosed as such.  Many girls are similarly affected even if they are less like to exhibit hyperactivity.  The majority of people will have their disease last into adulthood.  Although many adults have learned to accommodate their weaknesses and tendencies, they are still affected by them.

I say “disease” with some degree of caution.  It is not clear to me that ADD is a disease but rather a trait.  Some people are faster and some are taller.  Some people focus more on a task and some people have their attention all over the place.  A million years ago, one of our ancestors who was focused on a task may not have noticed the lion nearby.  Therefore, some degree of a wandering attention is healthy.  Unfortunately, in our present society, the wandering attention is more of a hindrance then a benefit.  It may still need to be treated.

One of the things we learn when we are young (as pre-schoolers and younger) is how to focus our attention on what we are doing and tune out other things.  We all have our attention torn away from the task at hand, but we learn to tune out distractions and come back to it.  We resist the impulse to focus on other stimuli in the environment.  Therefore, at its’ core, ADD is an impulse control disorder.  How can the addict with ADD ignore their drug using impulses if their ability to ignore any impulse is diminished?

Not only that, the inability to filter out and ignore the plentitude of environmental stimuli results in an overwhelming environment for the ADD patient.  This creates stress that in turn increases the impulse to use drugs.

ADD does not create the addiction.  However, since both problems are common, there are many people who have both.  These are the people that are most disabled by their addiction.  They are also more like to participate in impulsive, inappropriate behavior to get drugs.  They may act out more and be more violent.  Such behavior may have legal consequences. 

I assume any young person coming to my office has the problem especially if their drug use has been continuous since high school or before.   Many times I can get a history that the use of cocaine allows them to focus better.

ADD needs to be differentiated from other psychiatric problems.  I often have difficulty distinguishing it from mild forms of manic-depression.  Frequently, I refer patients out for objective psychological testing to determine what is going on.

As you can imagine, persons with ADD have a much higher incidence of substance abuse.  When they are treated for ADD, the incidence of substance abuse goes down to a level on par with the rest of the population.  It is unfair to look at stimulant use since Ritalin is a stimulant.  However, the use of alcohol, opiates and other categories of abused substances will decrease.  

The treatment has traditionally been Ritalin, Adderall or other types of stimulants.  The ADD patient typically becomes quieter and more focused.  It’s as if we have stimulated their ability to inhibit themselves.

These drugs are Category Two drugs and do carry a risk of abuse.  I am always hesitant to use them in people who have demonstrated themselves to be unreliable.  Yet, if the disease is well documented, and no other interventions have worked, it is reasonable to use these medications with caution.

In the past few years, a non-controlled medication named Strattera has become available.  It works well and is safer to use.  I do prescribe it first line to many patients.  

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