ADHD in Substance Use Disorders Prevalence and Pharmacotherapy Maija Konstenius, PhD, Licensed psychologist Karolinska Institutet Department of Clinical Neuroscience Handledare: Prof. Johan Franck, Nitya Jayaram-Lindström, Björn Philips
Attention Deficit/Hyperactivity Disorder ADHD DSM-IV diagnostic criteria A. Six out of nine age inappropriate symptoms of inattention and/or hyperactivity/impulsivity B. Symptoms lead to functional impairment in C. several settings D. Symptoms started in childhood before age of 7 - ADHD NOS and DSM5; before age of 12 E. The symptoms are not better explained by any other disorder (APA, 1996)
Studier Studie I - Prevalence of DSM-IV and DSM-5 ADHD in Treatment Seeking Substance Users; Results from an International Multi- Center Study Studie II - An Epidemiological Study of ADHD, Substance Use, and Comorbid Problems in Incarcerated Women in Sweden Studie III - Sustained Release Methylphenidate for the Treatment of ADHD in Amphetamine Abusers: a Pilot Study Studie IV - Methylphenidate in Adults with ADHD and Substance Dependence: A 24-week Randomized Placebo-controlled Trial
Prevalens Namn Efternamn 2013-12-17 4
Studie I Prevalence of DSM-IV and DSM-5 ADHD in Treatment Seeking Substance Users; Results from an International Multi-Center Study Geurt Van de Glind*, Maija Konstenius*, Frances R Levin, Maarten W J Koeter, Katelijne van Emmerik-van Oortmerssen, Pieter-Jan Carpentier, Sharlene Kaye, Louisa Degenhardt, Arvid Skutle, Johan Franck, Eli-Torild Bu, Franz Moggi, Geert Dom, Sofie Verspreet, Zsolt Demetrovics, Máté Kapitány-Fövény, Melina Fatseas, Marc Auriacombe, Arild Schillinger, Brian Johnson, Stephen V Faraone, J Antoni Ramos-Quiroga, Miguel Casas, Steve Allsop, Susan Carruthers, Robert A Schoevers, Sara Wallhed, Csaba Barta, Peter Allemann, IASP research group, Wim van den Brink Drug and alcohol dependence, 2013 accepted
Prevalence of ADHD in Substance Use Disorders IASP Study Ett nätverk med kliniska forskare från 10 länder Australien, Belgien, Frankrike, Nederländerna, Norge, Schweiz, Spanien, Sverige, Ungern, USA
All patients referred to participating site Selection Random sample, related to patient flow and availability of staff Stage 1: Screening Demographics, ASRS, Substance use quesonnaire Selection All subjects from stage 1 were asked to parcipate in Stage 2. Stage 2: Full assessment ADHD screen: ASRS SUD diagnosis: MINI-plus ADHD diagnosis: CAADID/ MINI plus MD/BD/ASP/: MINI plus BPD: SCID II module Stage 2: Full assessment - dropout group, control for biases
IASP population - Fas 2 (n=1276) Ålder M 40 years (SD 10; range 37 to 43) Kvinnor 27% (range 18 to 34) Primär substans - alkohol 55% - CS 15.1% - cannabis 10.8% - opiater 10.8% - andra droger 8.6% Skillnader mellan länderna - slutenvård/öppenvård - primär substans - demografi
Huvuddrog France (n=157) Hungary (n=226) Netherlands (n=129) Norway (n=220) Spain (n=222) Sweden (n=168) Switzerland (n=154) Total (N=1276) % % % % % % % % - Alcohol 50.3 74.8 61.2 31.8 25.8 55.8 96.1 54.6 - Stimulants - Opiates - Cannabis - Other drugs 6.4 5.8 9.3 26.6 36.7 9.7 1.3 9.6 3.5 0.8 17.3 17.6 21.2 1.3 20.4 1.8 24.0 14.0 13.6 6.1 0 13.4 14.2 4.7 10.3 6.3 7.3 1.3 15.1 (191) 10.8 (137) 10.8 (137) 8.6 (109)
ADH D Frankrike n=157 Ungern n=226 Nederländerna n=129 Norge n=220 Spanien n=222 Sverige n=168 Schweizn =154 Adult DSM-IV 11.2 (6.3-16.2) 5.4 (2.4-8.3) 10.1 (4.9-15.3) 31.3 (25.2-37.5) 9.2 (4-13.0) 19.7 (13.7-25.7) 6.1 (2.3-9.9) Adult DSM-5 16.2 (10.5-22.0) 7.6 (4.1-11.1) 11.8 (6.2-17.3) 32.6 (26.4-38.8) 10.6 (6.6-14.7) 22.4 (16.1-28.7) 7.7 (3.5-12.0) Adult DSM-IV ADHD- NOS 16.9 (11.0-22.7) 8.9 (5.2-12.7) 12.3 (6.7-18.0) 34.5 (28.2-40.7) 10.6 (6.6-14.7) 22.4 (16.1-28.7) 8.2 (3.9-12.5) ADHD prevalens i olika länder
ADHD prevalens varierar Beroende på - Land - Substans - alkohol/illegala droger - Vårdform - sluten/öppenvård - Ålder
A relationship between the prevalence of ADHD and solar intensity (SI) (kilowatt hours/square meters/day) Specific for ADHD Arns et al. Biol. Psychiatry, 2013
Psykiatrisk komorbiditet hos personer med SUD och ADHD Aktuell depression Aktuell (hypo)mani EJ ADHD (n=1098) ADHD (n=168) n (%) n (%) OR (95% CI) 191 (18.4) 49 (29.2) 1.82 (1.26-2.64) ** 42 (4.1) 25 (14.9) 3.96 (2.33-6.73) *** Antisocial 176 (17.0) 87 (51.8) 5.25 (3.73-7.41) *** Borderline 121 (11.7) 51 (30.4) 3.30 (2.26-4.82) *** Van Emmerik - van Oortmerssen et al. Addiction 2013 (accepted)
ASRS fungerar bra som screening Sensitivitet 0.84 Specificitet 0.66 NPV 0.97
STUDIE II - Prevalens 29% - ASRS sensitivitet 1.0, specificitet 0.66, NPV 1.0, PPV 0.57
Farmakoterapi
STUDIE III RCT 72 mg Concerta/placebo 12 veckor N= 24 Amfetaminberoende+ADHD Primärt utfallsmått - förändring av ADHDsymptom Resultat ingen skillnad mellan grupperna CAARS score 90 80 70 60 50 40 30 20 10 0 PL MPH 1 2 3 4 5 6 7 8 9 10 11 12 Week in treatment
STUDIE IV Primärt utfallsmått negativa urinprover alla droger (ITT) RCT 18-180 mg Concerta/placebo 24 veckor N=54 Amfetaminberoende+ADHD Rekryterades från anstalt * Konstenius et al. Addicition 2013(accepted)
Sekundärt utfallsmått negativa urinprover för amfetamin (ITT) ** Konstenius et al. Addicition 2013(accepted)
Methylfenidat förbättrade ADHD Symptomen (ITT) ** Konstenius et al. Addicition 2013 (accepted)
Studierna finansierades av Socialstyrelsen Kriminalvårdsverket Stockholms läns landsting Vetenskapsrådet Psykiatrifonden Milan Valverius Studie I: läkemedel donerades av Jansen Cilag