Symptoms of ADHD or Marijuana Use?

http://ajp.psychiatryonline.org/cgi/...full/164/6/973

Symptoms of ADHD or Marijuana Use?

NONI A. GRAHAM, M.P.H.
Gainesville, Fla., ROBERT L. DuPONT, M.D.
Rockville, Md. and MARK S. GOLD, M.D.
Gainesville, Fla.

To The Editor: We are grateful for the treatment in psychiatry article
"Attention Deficit Hyperactivity Disorder and Substance Use Disorders" (1),
by Timothy E. Wilens, M.D., published in the Dec. 2006 issue of the Journal.
The article provides sound scientific and practical steps for clinicians
encountering patients with co-occurring substance use and psychiatric
disorders, a rampant challenge for clinicians today. However, we feel that
the case presented is not a clear example of such encounters.

We have studied treatment-seeking students with "learning problems," or
attention deficit hyperactivity disorder (ADHD), who misuse
psychostimulants, such as methylphenidate, for academic performance
enhancement. A voluntary survey of 53 undergraduate stimulant abusers
revealed that 94.3% of participants had smoked marijuana within the past
month (32% smoking daily) (2). In the cases presented in this survey, as in
the case presented by Dr. Wilens, cannabis use was the most likely cause of
learning problems and psychostimulant-seeking behavior.

In the psychiatric evaluation in Dr. Wilens's case, it is assumed that ADHD
was present before (and independent of) the marijuana use during
childhood/adolescence. Although the patient admitted displaying personality
traits similar to those of his father (e.g., easily frustrated), these
traits do not confirm an ADHD diagnosis. No family history of ADHD or other
psychiatric disorders were mentioned in the case. Furthermore, all that
"wheezes" is not asthma. Depression can be undiagnosed hyperthyroidism,
cocaine dependence, or even mononucleosis (3). Every person with
inattention/hyperactivity does not suffer from ADHD.

The case presented does exhibit symptoms typical of marijuana users (4-6).
According to Fletcher et al. (7), long-term cannabis use is associated with
disruption of short-term memory, working memory, and attentional skills, all
of which are exemplified in the case presented in Dr. Wilens's article. If
symptoms of ADHD were present in this case, they are likely to be the result
of chronic substance abuse/dependence (in this case, marijuana). As
exemplified in the section on the overlap between ADHD and substance use
disorders, individuals with substance use disorders are more likely to be
diagnosed with a psychiatric disorder, such as ADHD, than are individuals
with a psychiatric disorder to be diagnosed with substance use disorders.
Furthermore, as Dr. Wilens confirmed, in those individuals with comorbid
substance use and psychiatric disorders, it is best practice to treat the
substance use disorder, followed by treatment of the psychiatric disorder
(if it persists).

In such cases, the primary clinical goal should not be "reduction," but
cessation of all nonmedical drug use, especially marijuana use, which is
likely to require referral to long-term participation in a 12-step program,
substance abuse treatment, and ongoing drug testing. Only prolonged
abstinence from nonmedical drug use can allow for a diagnosis of ADHD to be
made with confidence.


Footnotes

Dr. DuPont reports support from McNeil Pharmaceuticals for monitoring of
nonmedical use of prescription stimulants; he is also Chairman of the
Advisory Committee on Prescription Drug Abuse for the Institute for Behavior
and Health, Inc. Dr. Gold and Ms. Graham report no competing interests.

References


Wilens TE: Attention deficit hyperactivity disorder and substance use
disorders. Am J Psychiatry 2006; 163:2059-2063[Free Full Text]
Hall J, Frost-Pineda K, Gold MS: Marijuana use linked to prescription
stimulant abuse (abstract). Biol Psychiatry 2005; 5(suppl):159S
Extein I, Gold MS: The medical mimics of psychiatric disorders, in The
Progress in Psychiatry Series. Edited by Spiegel D. Washington, DC, American
Psychiatric Publishing, 1986
Copersino ML, Boyd SJ, Tashkin DP, Huestis MA, Heishman SJ, Dermand JC,
Simmons MS, Gorelick DA: Cannabis withdrawal among non-treatment-seeking
adult cannabis users. Am J Addict 2006; 15:8-14[CrossRef][Medline]
Lundqvist T: Cognitive consequences of cannabis use: comparison with abuse
of stimulants and heroin with regard to attention, memory and executive
functions. Pharmacol Biochem Behav 2005; 81:319-330[CrossRef][Medline]
Pope HG, Yurgelun-Todd D: The residual cognitive effects of heavy marijuana
use in college students. JAMA 1996; 275:521-527[Abstract]
Fletcher JM, Page JB, Francis DJ, Copeland K, Naus MJ, Davis CM, Morris R,
Krauskopf D, Satz P: Cognitive correlates of long-term cannabis use in Costa
Rican men. Arch Gen Psychiatry 1996; 53:1051-1057[Abstract]