The forest and trees of addiction

It’s unfortunate that some people look at substance abuse problems from their vantage point only – Everyone seems like them whether normal users, light abusers, abstainers, or hard-core alcoholics (recovered, recovering, or not).

The world is full of individuals arranged in loosely associated groups. Unless one can acknowledge that real, important, and consequential differences exist, all you’re seeing is a tiny little bit of the beauty.

ADHD and neurocognition – Knowing what to remember

Kate Humphreys

ADHD In children and adults – Symptoms and tests

Children with attention deficit hyperactivity disorder (ADHD, formerly known also as ADD) are classically seen as the kids in class who have trouble staying in their seats and paying attention during long lessons. Underlying these problematic behaviors is a confluence of factors, with evidence pointing to genetics, neural function, and environmental factors (including parenting and lead exposure) that can all affect ADHD behavior. Many children diagnosed with ADHD seem to simply “grow out” of their symptoms. They may learn particularly effective strategies for managing inattention and disorganization (I myself am a notorious list maker), or learn to control some of the fidgeting and restlessness or channel that energy into sports or other activities. Continue reading “ADHD and neurocognition – Knowing what to remember”

A new candidate for ADHD medication: Amantadine and the rise of non-stimulants

It is well known that ADHD diagnoses and substance abuse problems are closely associated. It is estimated that substance abuse problems including dependence are up to twice as common among individuals with ADHD, which is not surprising given the impulsivity factor involved in ADHD. The problem is that until recently, most medications for ADHD have belonged to the stimulant category and as many, including us, have written before it is probably not the best idea ever to give drugs that have a relatively large abuse probability to people who are relatively likely to develop substance abuse problems. Right?

We’ve already written about atomoxetine and bupropion, two drugs with relatively low abuse potential (since patients don’t actually feel “high” from them) that are being successfully used in treating ADHD. But there is little doubt that the type of effect seen among patients who are using stimulants (like adderall, ritalin, etc.) isn’t being observed among patients taking non-stimulant medications. All of this means that patients on non-stimulants are getting less bang but with less risk. A dopamine agonist by the name of amantadine might change all of that according to a recent study.

Amantadine versus stimulants for ADHD treatment

Fourty children between the ages of 6 and 14 were enrolled in the study conducted in a psychiatric hospital in Iran. The kids were randomized into two groups a methylphenidate (ritalin) and amantadine group. Over a six week period the kids were assessed four times – at intake and then every two weeks -using an instrument that parents and teachers (who didn’t know what medication the kids were getting) would use to rate the child’s behavior on the 18 ADHD symptoms listed in the DSM-IV.

Amantadine may soon offer a new non-stimulant medication option for ADHD treatmentThe final findings were very encouraging (see picture): The kids in both conditions improved greatly over the 6 weeks of the study and no difference was found between the two medications. the children in the amantadine condition actually suffered less side effects and significantly so when looking at side effects common to stimulant medication such as decrease in appetite and restlessness. While more studies are obviously needed, this randomized trial shows that amantadine is not only safe, but it may be safer than at least some stimulant medications while also providing the same effect on ADHD symptoms. Given that approximately 30% of patients don’t respond well to stimulants and that some families are afraid of giving stimulant medications to their children, at least partially because of the risk of substance abuse issues, non-stimulant medications can be an attractive alternative, and it seems like amantadine can deliver.

Final thoughts from Dr. Jaffe on ADHD medications and amantadine

One of the main reservations I have about the notion of using this medication for ADHD is that NMDA receptors are very important in learning, so it may be that we’re helping to resolve attention problems but making it more difficult to actually create memories that are crucial for learning. More research is necessary to see if these decreases in impulsivity are accompannied by improvements, and not reductions, in learning ability.

So, if you’re considering medicating a child who has been diagnosed with ADHD, I strongly support the notion given the difference that medication has made in my own life. However, I urge you to be educated and to consider non-stimulant options, especially as more are researched and as that treatment option becomes more available, less costly, and less likely to lead to abuse of the drug. With prescription drug abuse one of the fastest growing problems in the U.S., being careful is just sound advice.

Citation:

Mohammad-Reza Mohammadi, Mohammad-Reza Kazemi, Ebtehal Zia, Shams-Ali Rezazadeh, Mina Tabrizi, Shahin Akhondzadeh (2010) Amantadine versus methylphenidate in children and adolescents with attention deficit/hyperactivity disorder: a randomized, double-blind trial. Human Psychopharmacology.

Some parkinson work showing effect of amantadine: http://www.springerlink.com/content/76r5wxux8wn52rq5/fulltext.pdf

Biology versus Choice: Is a simple explanation of addiction enough?

At the recent Addictions conference, held in D.C. and sponsored by Elsevier, a well known academic publishing house, I got myself into one of those long debates with a fellow addiction researcher. The question we were debating was whether addiction is primarily biological or if it is mostly a matter of personal choice. We ran through research evidence, the notion of stigma, and more, making us late for the afternoon session of talks – but it was worth it.

My take on it was that one can’t separate biology from choice, a point I have made over and over (see my choice Vs. control talk), and that ignoring the biology of addiction is therefore impossible. My opponent across the stage (or lunch table as it were) was Christopher Russell, a graduate student at the University of Strathclyde in the United Kingdom who is a bigger believer in the choice view of addiction, along with people like Dr. Bruce Alexander of Rat Park fame and Dr. Gene Heyman who wrote “Addiction is a disorder of choice.”

I like good debates and at as far as I understand it Christopher and I ended-up agreeing that as usual neither biology, nor choice, do a good enough job of explaining a complex disorder like substance abuse and addiction. I’ve been making that point for a while, so I’m pretty comfortable with the final conclusion – Biology, environment, and choice (cravings) all factor into addiction as I understand it. Without understanding the machinery and how genetics and behavior affect it, I think the rest of the discussion is moot, but it is pretty much as pointless without addressing environmental influences and the role of choice.

I liked debating with Christopher so much that we’re going to be bringing him on a writer on A3. He’ll help us keep on top of the most recent addiction research and news while bringing in another voice on the topic that I think will help move our discussion forward. So please help me welcome Christoper Russell from the U.K., and look ahead for his contribution as well as a likely ongoing debate about the importance of biology versus personal choice.

Drug abuse and teens – The adolescent addiction challenge.

Guest author: Clint Stonebraker

teen-smokingRecovery from any addiction is a difficult process. It involves an individual’s willingness to take responsibility for his or her actions, a concrete decision to make significant lifestyle changes, and the courage to repair damaged relationships. The level of emotional maturity involved in taking these steps is usually somewhat foreign to an addict.

What about a person who is suffering from addiction and is, developmentally speaking, still a child? How does this person muster the emotional maturity needed to begin the recovery process?

I had the opportunity to work with a seventeen year old whose father had recently been treated for alcoholism. The father had suffered numerous consequences related to his alcohol problem including multiple D.U.I.’s and a divorce. By the time he sought treatment, the father was motivated to make a life change. He understood the root of his life problems revolved around alcohol abuse and had a desire to take responsibility for his actions.

When it came to the son, things weren’t that simple…

The seventeen year old had also suffered numerous consequences related to his drug abuse. He had already been arrested twice and had left home four months prior to seeing me. In fact, he clearly stated the only reason he agreed to the appointment was because his father had made it a part of the criteria for the boy to come home. He still believed the problems in his life were due to others not “leaving him alone.”

teensFor decades the adolescent substance abuse problem has gotten progressively worse. There have been prevention programs which have had some success, but adolescents continue to abuse drugs and alcohol at an alarming rate.

Because of this, it is important for anyone who works with adolescents to understand this unique population:

  • The conscious motivation for most adolescents to abuse drugs and alcohol is different than that of an adult. An adolescent who engages in substance abuse is seeking fun and peer acceptance, whereas the adult is seeking pain relief.
  • In most cases adolescents have yet to face the same level of physical or emotional consequences most adult addicts have faced
  • The adult addict is responsible for all aspects of his or her life, the adolescent isn’t

These are just a few of the differences between adults and adolescents with substance abuse issues. Some of the challenges in treatment include:

  • Creating an environment in which the adolescent has fun and gains peer acceptance. Developmentally these are needs which must be addressed
  • Helping an emotionally immature child take enough internal responsibility for his or her actions to be motivated to change
  • Showing an adolescent how to maintain healthy balance in his or her emotional life, in other words, limiting the emotional extremes

The biggest mistake clinicians make in treating adolescent substance abuse is assuming the adolescent is capable of dealing with life like an adult. In most cases, an adolescent must be able to see recovery as an attractive lifestyle. An adolescent substance abuser already has a general lack of trust with adults or any other “authority” figures. It is critical to maintain patience in order to gain the trust of an adolescent. Once trust is established, it is possible to reach an adolescent at their level.

When it came to this seventeen-year-old son, I knew that in order for this young man to begin the recovery process, he would need to see sobriety as an attractive lifestyle choice. I was aware of a group that held regular support group meetings specifically for young people. They also facilitated social events on the weekend.

As a part of the therapeutic process, I included his involvement with this group. The combination of counseling and a peer support system gave this young man a comprehensive plan of action.

As a result of beginning to associate sobriety with feeling good, he became more responsive to counseling. Over time he began to take more responsibility for his actions. He had a group of peers with whom he was accountable, could have fun, and network.

His father was involved in this process through his own counseling and involvement in a parent support group. Over time this young man was able to stay sober and reacclimatize himself into society.


This story illustrates key components of a process of recovery for adolescents. Over time an adolescent can begin to see the consequences of his or her actions. It is important to keep in mind what adolescents respond to. It is not one element that provides the key to adolescent recovery. It is the combination of therapy, peer support, and family involvement which provides the best opportunity for an adolescent to recover from addiction.

If we want to weaken the connection between teens and drugs, we have to start using what works.

How does it all start? My thoughts on addiction causes and substance abuse

I was talking with a friend the other night, and he asked me my opinion about the line between addiction and normal behavior. He was wondering whether I think that everyone who looks at porn is a sex addict.

I don’t. (see some of our posts on sex addiction here)

Still, the conversation made me feel like writing something about my views on addiction causes. So here goes:

For the addicts who are still unaware, the line between normal- and addictive-behavior tends to blur again and again until it seems like more of faded smudge on their life. For those looking at addicts from the outside, the line normally seems so clear and so far away that they rarely believe it can be crossed back again.

I don’t personally believe that addiction per se is where things started for most people. By this I mean that no matter how hard we look, I believe that we will never find the elusive “addiction gene“, genes, or trigger.

Having been in the thick of it, I think that substance abuse is nothing but one possible outcome of set of circumstances, both biological and environmental, that lead some individuals down a particular path.

Impulsivity and other addiction causes

As I mentioned in earlier posts, addiction, at least to drugs (and I believe other addictions as well) is very closely related to a set of psychological conditions that have to do with impulse control problems.

I believe that individuals with increased impulsivity are simply more prone to putting themselves in situations that are inherently dangerous to their well-being. A simple example from non-drug related behavior might be one-night stands.

A typical person with no impulse control issues may hold off on sex if the only option was to have it unprotected. They may think to themselves “I need to stop, this could seriously affect the rest of my life.”

A person who has a reduced ability to control initial impulses may have the exact same thought and yet go through with the action, leaving them feeling remorseful and anxious the next day, but still having put themselves at risk.

This is a very common occurrence among sex-addicts. The thoughts are there, the knowledge is there, the ability to connect those to actions is seriously lacking. While some people make moral judgments about this fact, I’ve seen enough research that connects this problem to biological processes and genetics that I’m now resigned to the fact that at least on some level, the issue is physical and neurochemical.

Addiction help – Cures, treatment, and solutions

Still, I think the battle is far from lost. I strongly believe that education, informed by actual knowledge rather than misguided mythology, can put people in a better position to deal with the issues even if their source is outside of their control.

Even aside from pharmacological treatments (as in medications) that can help, there are endless ways to help people learn to be in better control of their actions once they are aware of their initial deficit. That is how AA and many other support groups function. People within them ask others about decisions they’re making BEFORE they act on them.

We know already that when it comes to drugs, the equation changes once the person starts using regularly and for long periods of time.

Chronic substance abuse further breaks down the brain’s ability to control impulses by reducing functioning specifically in the prefrontal-cortex; the part of the brain right behind your forehead which is thouught to be the center of the brain’s control tower.

The cycle seems too obvious: Impulse control difficulties leading to dangerous behavior which leads to further impulsivity issues and so on…

The treatment, like the progression of the condition itself, needs to be long. I don’t believe that any 30 day treatment program will be able to resolve a condition that took years to develop. Still, the issue of treatment will come up again here. This is enough for now…

Question of the day:
Do you have any insights from your own experiences as to how addiction develops?

Drug abuse statistics: American drug abuse and addiction

In looking up some numbers for a recent post I put up on TakePart, I uncovered some amazing addiction and drug abuse statistics (most from 2007, so they’re probably higher by now).

StatisticsAddiction statistics highlights:

  • Slightly more than half of Americans surveyed indicated that they are current drinkers (I thought it’d be higher) – Meaning there were about 126 million drinkers in the country. About 57.8 million had consumed more than 5 drinks in one sitting in the month prior to the survey.
  • It is estimated that more than 30 million people in the US meet criteria for some addictive disorder including drug addiction, sex addiction, gambling addiction, and food addiction (added from SAMHSA statistics about individual addictions)!!
  • More than 15 million of those are only dependent on alcohol!!
  • The next drug on the list is, you guessed it, marijuana with 3.9 million dependent individuals!!!
  • Of the more than 23 million individuals who needed drug treatment, only 10% sought help (2.4 million).
  • The most  staggering of all numbers – The cumulative estimated cost of addictive behavior (including overeating) in the United States = $500 Billion!!! Almost half of our current budget deficit!!!

I don’t know about you, but these numbers leave me a little in awe of just how big this problem really is. Given some of the other treatment-cost posts I’ve written (see here), I once again reiterate the notion that if we shifted our focus to drug-treatment, we’d save lives and money all at the same time.