Editor’s Note: Addiction research studies have repeatedly documented a high incidence of ADHD in patients with all types of substance use disorders. At a Kolmac School presentation last week, Dr. Zametkin said that evidence from two meta-analyses put this number at 23 percent. Having an ADHD expert of Dr. Zametkin’s stature focus on this disorder in addicted patients is a welcome development.
An internationally recognized clinician, clinical investigator and former academic child adolescent and adult psychiatrist, Dr. Alan Zametkin spent 30 years at the National Institute of Mental Health where he evaluated, studied and treated both children and adults with ADHD. He then spent three years as a civilian treating military families at Bethesda Naval Hospital and Fort Meade.
He has had his own private practice in Bethesda for 32 years. Dr. Zametkin’s major contribution while in the United States Public Health Service at NIH was the publication of four clinical research studies in The New England Journal of Medicine. The most widely cited work was on adult ADHD, which at the time was essentially an unknown entity.
Recently, he talked with Modern Addiction Recovery about some of the misconceptions about ADHD and its relationship to addiction.
What do you want clinicians to understand about ADHD?
Everybody that has inattentiveness does not have ADHD.
MAR: Some feel ADHD is over diagnosed; others think it’s under diagnosed. What’s your position?
AZ: My opinion is that it is greatly under diagnosed depending upon your zip code and country in which you live. For example, in rural Tennessee there are no providers whereas in suburban Bethesda we have many providers. Given these socioeconomic and geographic factors, ADHD still very much under diagnosed.
MAR: What are the primary goals of your private practice?
AZ: My most important goal has been to accurately distinguish the real
ADHD from pseudo ADHD so that patients get a correct diagnosis. Adults and teens have symptoms like depression and anxiety, which though associated with ADHD, are not necessarily indicators of the disorder. Conducting research requires having a really good diagnosis. Since I have that background, it enables me to give a more precise diagnosis. This is a happy circumstance.
At this point, do you think that the existing research dispels the original thinking that people grow out of ADHD?
AZ: There are at least six longitudinal studies that follow people with ADHD for 10 or 15 years. Instead of outgrowing it, most kids will still have two to three impairing symptoms in their twenties that may lead to problematic behavior such as driving arrests or difficulties in their relationships sometimes resulting in divorce. Their level of hyperactivity can decrease with age, but 80 percent are still impaired in their twenties, which can have a negative impact in many areas, including educational attainment.
MAR: If it’s a lifelong disorder, how can it best be managed? How should medication be used – initially, ongoing, or as needed?
AZ: When we use medication to treat ADHD, we never know how long it will be needed; there’s no way to predict that. Every year as their brains mature, a significant number of kids will outgrow it and no longer need medication. It’s not a life sentence. Every single kid won’t be on medicine forever.
The severity of symptoms and the impact on self-esteem are the main factors in deciding whether to medicate. Both behavior modification and psycho-social treatment are also used to manage ADHD. However, most studies report that
90 percent of improvement patients experience came from medication. I would
advocate for multi-modal treatment. Patients need medication to respond to behavior modification.
Do you have any sense of the possible relationship between ADHD and addiction?
Fifteen to twenty percent of addicted people have ADHD. There’s a huge overlap. Twenty-five to thirty of percent of people with ADHD have substance abuse disorders. It’s a huge risk factor. We know that treatment for ADHD does not increase the risk, but we don’t know that it’s preventive. That’s still an open question.
As the study of ADHD continues, what’s the greatest challenge? Opportunity?
Our greatest opportunity is to develop treatment that will treat both disorders at the same time; one medication for both. The greatest ongoing challenge is understanding the pathways to abuse.