Causes of Substance Abuse & Addiction
Are stimulants considered drugs?
Parents have commented that using stimulants to treat ADHD with drugs is using one addictive medication to treat another addiction. On the contrary, studies have shown that the use of stimulants to treat ADHD decreases risk of subsequent drug abuse or if abuse has already occurred, that it decreases relapse. There are anecdotal reports of kids misusing and abusing their stimulant medications. In my practice, we consider using nonstimulant medications to treat ADHD comorbid with drug use to address these concerns. This includesatomoxetine (Strattera, a nonstimulant medication approved for ADHD) and bupropion (Wellbutrin, an antidepressant medication with some evidence of efficacy for ADHD). If stimulants have to be tried for lack of response to these medications, we consider Concerta (methylphenidate). Its preparation (in capsule OROS form) makes it difficult to pulverize and snort it.
There is a new medication called lisdexamfetamine, a prostimulant, that is converted to its active form, d-amphetamine, in the gut, and it has low abuse potential if taken intranasally or intravenously.
Stimulant misuse and diversion occurs in about 10–20% of college students surveyed. Stimulants are usually diverted from friends and used primarily to improve concentration and alertness in class rather than to get high.
I have heard that Subutex (buprenorphine) is used to treat heroin addiction. Does this method work?
Yes, and an additional benefit is that physicians with the proper training and authorization are now allowed to treat individuals with opioid addiction in an office setting. These individuals are usually able to keep their jobs and stay in school and can be seen monthly on a regular basis. We have treated youngsters with this medication. Buprenorphine, a partial agonist, can be used for detoxification (treatment of withdrawal symptoms), as an anticraving agent, and as a maintenance medication (to prevent relapse). Buprenorphine is also combined with naloxone (Suboxone) to decrease abuse and diversion.
These medications are administered by placing them under the tongue. Being on buprenorphine is similar to being on methadone (methadone maintenance treatment program), which also prevents relapse to drug use.
Is disulfiram (Antabuse) safe to use in adolescents?
Disulfiram has been used in adolescents and was found to be safe and effective. When someone takes disulfiram and then consumes alcohol, he or she experiences uncomfortable body reactions, thus encouraging one to abstain from the consumption of alcohol to avoid these effects. Disulfiram produces symptoms of headache, flushing, nausea or vomiting, diarrhea, and blood pressure changes after consuming alcohol. There has been one good study that established that disulfiram has few side effects and those who received active treatment had longer duration of sobriety. It is usually given at 250 mg daily orally. Disulfiram should not be taken by those with liver problems.
How long will my child stay on medication? How long should my child be in treatment?
This is based on a number of factors, including need for maintenance medication (for example, recurrent depression or chronic psychosis) and presence of a stable support system to effect longer-term sobriety, transition to school, or going back to school after a longer term treatment.
For those who have coexisting psychiatric conditions, it is best to continue on maintenance medications. In cases of depression, the following conditions favor use of medications for more than a year: recurrent depression (two depressive episodes or more), double depression (those with dysthymia and major depression, as reported by youngsters that they have been depressed “for as long as we can remember”), disordered thinking (psychosis), suicidal behavior, and ongoing family dysfunction. The goal of treatment is to gain full remission of symptoms and functioning and is no longer improvement of symptoms alone.
Parents should keep in mind that drug dependence is a chronic condition, so their child’s use of maintenance medications is akin to those one might take for diabetes, asthma, or psychiatric conditions like recurrent depression, ADHD, and bipolar disorder. Part of medication monitoring is looking for long-term side effects of prescribed medications. Of note, some medications used to maintain remission of psychosis and bipolar disorder can cause weight gain, difficulties in managing sugar in the body, or increase in fats. Parents, families, and treating physicians should continue to discuss the need for these medications. I always encourage people to look for answers and questions so that active discussion and collaboration will continue
What are the common side effects of medications?
The side effects are based on classes of medications such as those used for depression, psychosis, anxiety, and ADHD. The FDA has approved some medications for certain conditions in adults, and child psychiatrists use these medications to treat similar conditions in adolescents.
These medications have few side effects and are effective. These are acceptable practices known as off labeling. Premedication evaluations and workups are done to make sure that these medications are safe. Also, your child’s physician will closely monitor your child. Your child’s psychiatrist, who is preferably a child and adolescent psychiatrist with training in addiction, is best suited to answer your questions and concerns.
In order to ensure that medications are safe, the following are usually requested before trying a medication: a physical examination (usually done by the child’s own physician) to identify any problems, and a laboratory examination involving the kidneys, blood, and liver, and in cases where stimulants are being considered, heart tracing or electrocardiogram. Studies have shown that stimulant use is correlated with (but not established as causing) sudden cardiac death in children and adolescents.
The risk is increased if your child has structural heart abnormalities (enlarged or small heart, holes, or irregular heartbeat). Your child’s physician will ask you if any risk factors are present, such as family history of heart disease, rhythm abnormalities (irregular heartbeat), or sudden death from heart attacks.
Is my son at risk for suicide while taking antidepressants?
The FDA has mandated drug manufacturers to issue a black box warning on antidepressants to monitor for suicidal behavior. A black box warning appears on the prescription label of a medication, indicating the significant, serious, or even potentially life threatening side effect(s) of that medication. This is the most serious warning required by the FDA, and it has also been applied to medications other than antidepressants. Certain antibiotics, such as ciprofloxacin, had a black box warning for swelling of tendons and rupture as a side effect resulting in permanent disability; and the diabetes medication rosiglitazone can cause significant heart problems.
The black box warning for antidepressants has created considerable concern for parents, who do not want to give their child a medication that will worsen his or her depression. This warning was initially considered for antidepressants in 2004 after the FDA reviewed 23 studies involving more than 4300 children who received nine types of antidepressants and reported general characteristics of suicidal thinking and behavior. In 17 out of the 23 studies, asking about suicidal thoughts and behaviors was specifically included. In these data, medication did not worsen preexisting suicidal thoughts nor result in emergence of suicidal thoughts after treatment, and none of these individuals committed suicide (Parents Medguide for Depression). American studies have been done to further investigate this issue. One study (Simon, Savarino, Operskalski, & Wang, 2006) found that the risk for suicide was highest before medication treatment and significantly declined thereafter. Another study (Gibbons , Hur, Bhaumik, & Mann, 2006) found an association between higher SSRI prescription rates and lower suicide rates in children and adolescents.
Before the warning was given, there was an increasing trend in pediatric diagnosis of depression from 1993 to 2004. After that, there was a decrease in the diagnosis of depression, which deviated from what could have been predicted from the trend established in previous years. Pediatricians and nonpediatrician primary care doctors accounted for a reduction of these diagnoses. In 2002, 260 deaths from suicide occurred between the ages of 10 to 14 years, ranked third after accidents and malignancy as the leading cause of death in this age group.
From 1990 to 2003, the combined suicide rate among those aged 10 to 24 years declined 28.5%. However, from 2003 to 2004, the rate increased by 8.0%, the largest increase in a single year from 1990 to 2004 (CDC, 2007). Some believe this observation was correlated with a decrease in antidepressant prescription during that period. Treatment of pediatric depression with antidepressants declined significantly two years after this warning was given without any concomitant increase in the use of other treatments like counseling or use of other medication (Libby et al., 2007). In another follow-up study published two years later (Libby, Orton, & Valuck, 2009), under diagnosis of depression persisted for both pediatric and adult patients, suggesting that the effects were persistent, significant, and covered not only minors but adult patients as well.
It is important to be informed about these issues; to be involved with your child’s treatment; and to discuss these concerns with his or her psychiatrist, preferably a child and adolescent psychiatrist, who is best able to address these questions with you.
Terms:
Diversion – Occurs when prescribed medications with addictive potential are made available to individuals for the sole purpose of getting high.
Detoxification – Treatment of drug withdrawal symptoms, of which the level of medical supervision varies with the presence of life-threatening conditions or coexisting medical conditions
Off labeling – Use of medications under one of the following conditions:
1) Prescription of an FDA-approved medication outside of its recommended dosage (a physician prescribes higher doses that what is recommended for an approved antidepressant),
2) Prescription to an individual in a group for whom the drug was not studied (an approved antidepressant for adults being prescribed to adolescents), or
3) Prescription of an approved medication for something other than what is was originally intended for (use of antidepressants for anger control instead of depression). This is an acceptable medical practice that requires full disclosure from physicians to parents to ensure that informed consent is obtained.
Parents have commented that using stimulants to treat ADHD with drugs is using one addictive medication to treat another addiction.
