An analysis of all available studies that examine the possible impact of stimulant treatment for attention-deficit hyperactivity disorder (ADHD) on future substance abuse supports the safety of stimulant treatment. Using a statistical technique called meta-analysis, the researchers from Massachusetts General Hospital (MGH) found that medication treatment for children with ADHD resulted in an almost two-fold reduction in the risk of future substance abuse. The report appears in the January 2003 issue of Pediatrics.
"We know that untreated individuals with ADHD are at a significantly increased risk for substance abuse. And we understand why parents often ask whether stimulant medications might lead to future substance abuse among their children," says Timothy Wilens, MD, MGH director of Substance Abuse Services in Pediatric Psychopharmacology, the paper?s lead author. "Now we can reassure parents and other practitioners that treating ADHD actually protects children against alcohol and drug abuse as well as other future problems."
Wilens and his MGH colleagues have conducted previous studies that found a protective effect in stimulant treatment. However, at least one report from another research center asserted that stimulant treatment increased the risk of later substance abuse. In order to resolve the question, Wilens' group searched the medical literature for studies of children, adolescents and adults with ADHD that included followup information on later substance abuse. They identified six such studies conducted in the U.S. and Germany, which provided information on more than a thousand participants with ADHD -- 674 who received stimulant treatment and 360 who were non-medicated -- followed for four years or more. These studies included both the previous MGH research and the study suggesting increased risk.
After application of standard meta-analysis techniques, the researchers found a significant overall reduction in the risk of subsequent substance abuse among those receiving stimulant treatment. They note that four of the six studies showed "striking protective effects of stimulant medications."
Of the other two studies, one did not find significant differences in substance abuse between the treated and untreated groups. Regarding the study that suggested an increased risk, the MGH researchers noted that participants who received stimulant treatment in that study had more problems before they began treatment, particularly a greater incidence of conduct disorder (juvenile delinquency). Since conduct disorder is a recognized and very strong risk factor for substance abuse, it is unclear whether the conduct disorder or the medication actually resulted in the increased substance abuse risk.
The MGH team also noted that the protective effect of stimulant treatment for ADHD in childhood was not as strong in young adults as it was in adolescents. While some of this could relate to the fact that adolescents are still subject to parental supervision, the researchers also suggest that past recommendations that stimulant treatment be discontinued in adolescence could cause the protective effect to disappear in subsequent years.
"From a public health level," Wilens says, "these results finding protection against later substance abuse -- which is one of the most malevolent problems facing adolescents and young adults -- are among the strongest in child psychiatry. Moreover, these findings add to the growing literature supporting the long-term safety of stimulants and other medications for treatment of ADHD."
Wilens and colleagues are continuing to study the biological and psychological mechanisms by which ADHD increases the risk for substance abuse in young people and why treatment decreases the ultimate risk.
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Wilens' coauthors are Stephen Farone, PhD; Joseph Biederman, MD, and Samantha Gunawardene, all of the MGH Pediatric Psychopharmacology Unit. The study was entirely supported by grants from the National Institute on Drug Abuse.
The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of almost 0 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, transplantation biology and photomedicine. In 1994, the MGH joined with Brigham and Women's Hospital to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups and nonacute and home health services.
Source: Massachusetts General Hospital
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ADHD Drugs Not Tied to Later Substance Abuse
Researchers say Ritalin and kin may actually protect
By Amanda Gardner
HealthScoutNews Reporter
MONDAY, Jan. 6 (HealthScoutNews) -- Stimulants
used to treat children with attention deficit hyperactivity disorder (ADHD) do
not put them at greater risk of drug abuse later in life, new studies find.
Researchers further say these stimulants, such as Ritalin, may actually have
a protective effect when it comes to substance addiction. The researchers "found absolutely no evidence" for later substance
abuse, says Mariellen Fischer, a professor of neurology at the Medical College
of Wisconsin in Milwaukee and second author of a 13-year prospective study that
appears in the January issue of Pediatrics. "Stimulants are the
first-line medications. They work the best and we know the most about them and
they're the safest. I think we'll feel more comfortable using them now." "We asked, 'Does treating younger children predispose them to becoming
substance abusers?' The very straightforward answer to that is 'no,'" adds
Dr. Timothy Wilens, a child psychiatrist at Massachusetts General Hospital in
Boston and lead author of a second study, also appearing in Pediatrics.
"As for the second question -- 'Does it help?' -- we think that the answer
to that is, 'Yes, it does help.'" ADHD is on the rise among American schoolchildren, with some 4 percent to 9
percent of youths affected, according to information in the Wilens study. The
preferred treatment for the disorder, which usually manifests with restlessness,
lack of focus and impulsivity, is stimulants such as Ritalin. These medications have had great success with ADHD, with some 74 percent to
97 percent of children responding positively. Although 10 previous studies
failed to find evidence that the stimulants made children more prone to drug
abuse, parents remain wary. "A lot of our parents are very concerned about the use of stimulant
medication leading to substance abuse, and that's a complex concern," says
Patricia Saunders, a clinical psychologist and director of Graham Windham's
Manhattan Mental Health Center in New York City, the oldest child welfare agency
in the country. "I doubt that any psychiatrist prescribing medication or
psychologist or clinical social worker working with children shares the concern
to that degree." Addiction, Saunders says, involves many complex factors. In addition to a
biological component, there are also socioeconomic and cultural vectors. It was
a biological factor that raised a red flag regarding future addictive behavior.
The stimulants used to treat ADHD affect the same neurotransmitters as some
drugs of abuse. The 13-year prospective study followed 147 hyperactive children, 98 of whom
received stimulant medication. The children were aged four to 12 at the
beginning of the study and were checked again at adolescence (mean age 15) and
in early adulthood (mean age 21). "Thirteen years is enough time," Fischer says. "We're talking
about a period of time that's the highest risk of substance abuse, too." With one small exception, the researchers found that children diagnosed with
ADHD and taking stimulants had no greater risk than those not taking stimulants
for turning towards illegal drugs when they were older. As for the exception (a
small increased risk for trying cocaine one time in high school), "we
really think that had to do more with the individuals the children were
associating with," Fischer says. The second study was a meta-analysis that assessed six existing studies, and
it concluded that stimulant therapy in childhood actually resulted in a 1.9-fold
reduction in the risk for substance abuse later on. No one is sure why stimulants have these effects, but experts have an idea as
to why it might be so.
"My gut feeling from a research standpoint and clinical standpoint is
that when you reduce the demoralization, when you improve self-esteem and
academic performance, these are three very bad risks for substance abuse,"
Wilens says. Successfully treating ADHD also reduces a child's social isolation
and lessens the likelihood that they'll end up in the wrong crowd. "What we know from ADHD kids is that they will aggregate to other kids
eventually but a tougher peer group," he says. What To Do For more on ADHD, visit the National
Institute of Mental Health or the American
Academy of Pediatrics.
SOURCES: Mariellen Fischer, Ph.D., professor, neurology, Medical College of Wisconsin, Milwaukee; Patricia Saunders, Ph.D., director, Graham Windham's Manhattan Mental Health Center, New York City; Timothy Wilens, M.D., child psychiatrist, Massachusetts General Hospital, Boston; January 2003 Pediatrics
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Medicine for childhood attention disorder not linked to later abuse, say experts