The Attraction Between ADHD & Recreational Cannabis Dr. David - - PDF document

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The Attraction Between ADHD & Recreational Cannabis

• Dr. David Teplin, C.Psych.

CADDAC Conference, Toronto October 20, 2019

What the Numbers Say

 Worldwide, cannabis is one of the most widely used

psychoactive substances, after tobacco and alcohol

 The latest 2019 Canadian figures show that about 16% of

the population age 15 and older report using cannabis

 3.3% use weekly, and 6.4% use daily/almost daily  Males use cannabis almost twice as much as females

What the Numbers Say

 In terms of age groups, those Canadians ages 15-24 use the

most cannabis (27.4%)

 US prevalence rates in the general population for lifetime DSM-5

cannabis use disorder is 6.27%; highest for those ages 18-29 (11%)

 Research shows that the risk for onset of cannabis use disorder

peaks in late adolescence and early 20s, and remission often

• ccurs within 3–4 years

 However, research suggest that those with ADHD may have

difficulty emulating their peers' developmentally normative declines in substance use

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What We Know

 The association between ADHD and both substance use

and substance use disorders is well-documented.

 Having ADHD has been shown to increase the risk of

developing a substance use disorder, including cannabis use disorder.

 Those with childhood ADHD are more likely to develop

disorders of abuse/dependence for nicotine, alcohol, marijuana, cocaine and other substances.

What We Know

 Those with childhood ADHD are more than twice as likely to

meet criteria for cannabis use disorder than those without ADHD

 ADHD youth are nearly three times as likely to report

cannabis use in later life compared to non-ADHD youth.

 Those with ADHD are at increased risk for early initiation of

cannabis use, heavy cannabis use and developing a cannabis use disorder, compared to those persons without ADHD.

What We Know

 Some research suggests that impulsivity and oppositional

problems during childhood, in particular, seem to predict increased risk of cannabis use in adulthood.

 Other research suggests that ADHD, alone, increases the

risk of a substance use disorder.

 Some research suggests that comorbid oppositional defiant

disorder and conduct disorder further increase the risk for a substance use disorder.

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10/16/2019 3 What We Know

 Other studies suggest that ADHD, independent of

comorbidity, increase the risk for substance use disorders across the lifespan.

 The combination of ADHD and having a substance use

disorder is also associated with a worse prognosis and quality of life.

What We Know

 Substance use often modifies ADHD, worsening both the clinical

picture, as well as the outcome.

 Comorbid ADHD and substance use produce significant and

unique treatment challenges

 This includes less likelihood of successful treatment completion,

a longer time to substance use recovery, and earlier substance use relapse.

 The National Epidemiological Survey on Alcohol & Related

Conditions in the US has shown that adults with ADHD use cannabis 2 to 3 times more than those adults without ADHD.

What We Know

 Other research suggests those with ADHD are almost

8 times more likely to use cannabis over their lifetime compared to those without ADHD.

 Studies have also shown that adults with ADHD are more

than 2 times likely to meet the criteria for cannabis use disorder than those adults without ADHD.

 Conversely, among those persons seeking treatment for

cannabis use disorder, the rates of ADHD are estimated to be 34% - 46%.

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Does Inattention or Hyperactivity/Impulsivity Matter?

 Some research shows that inattentive symptoms are more

predictive of substance use disorders.

 Other research shows that hyperactive/impulsive symptoms

are more predictive of substance use disorders.

 Research indicates that those with ADHD who use

cannabis, use all categories of substances more commonly than those with ADHD who do not use cannabis.

Does Inattention or Hyperactivity/Impulsivity Matter?

 More specifically, the rates of nicotine, alcohol and drug use

are significantly greater in those who use cannabis.

 Rates of alcohol use disorders, nicotine dependence, and

drug use disorders are significantly greater among people with ADHD who use cannabis, compared to those with ADHD who do not.

 The most common drug use disorders in adults with ADHD

who use cannabis involve cocaine, followed by opioids, and then amphetamines.

Does Inattention or Hyperactivity/Impulsivity Matter?

 Some research found no significant differences in the

prevalence of ADHD subtypes among those with ADHD who report cannabis use.

 Other research suggests that the average age of initiation

• f cannabis use is significantly younger among those with a

hyperactive/impulsive presentation, compared to those with an inattentive presentation.

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Does Inattention or Hyperactivity/Impulsivity Matter?

 Research also suggests that individuals with the

hyperactive/impulsive presentation tend to begin their most intensive period of cannabis use earlier than those with the inattentive presentation.

 The age of cannabis abuse tends to be younger among

those with the combined presentation of ADHD, compared to those with the inattentive presentation.

Does Inattention or Hyperactivity/Impulsivity Matter?

 An Ontario population survey found that hyperactive and

impulsive symptoms were associated with problematic cannabis use in men with adult ADHD, but not women.

 Conversely, inattentive symptoms predicted problems with

cannabis in women with ADHD, but not men.

Does Inattention or Hyperactivity/Impulsivity Matter?

 Research suggests that men with ADHD used marijuana

more frequently than women with ADHD.

 This is consistent with cannabis use in the general

population where males use almost twice as much as females.

 Other research suggests that men with ADHD may be using

cannabis to self-medicate inattentive symptoms, whereas women with ADHD may be using cannabis to self-medicate decreased sleep quality.

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What’s the Attraction?

 There are several possible explanations for substance use

and substance use disorders in adults with ADHD.

 The risk is particularly striking in people whose childhood

ADHD symptoms persist into adulthood, when substances are more readily available

What’s the Attraction?

 Recreational cannabis use among those with ADHD may

be associated with impulsivity, sensation-seeking, poor choices in peer groups, impaired occupational and social functioning, and the desire for intoxication.

 Both recreational substance use and substance use

disorders may be associated with efforts at self-medication

• f the various ADHD symptoms themselves.

What’s the Attraction?

 The co-occurrence may reflect efforts to self-medicate with

respect to negative emotionality, such as feelings of demoralization or failure, anger, sadness, anxiety, frustration, and inadequate emotional regulation.

 Self-medication may not necessarily be specific to ADHD

symptoms, but rather a way of relieving co-occurring mood and anxiety-related symptoms that are common in people with ADHD.

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What’s the Attraction?

 For some individuals, stimulant medication for the treatment

for ADHD may cause adverse effects such as excessive arousal and insomnia. Cannabis use may be an attempt to try and counter those adverse effects.

 Dopamine neurotransmission has been shown to be

involved in both ADHD and substance use. In the case of ADHD, this has to do with an underproduction of dopamine and norepinephrine.

What’s the Attraction?

 Studies show that acute use of THC (the psychoactive

component of cannabis) causes increased dopamine release, while long-term THC use is associated with blunting of the dopamine system.

 Thus, cannabis use may also be an attempt at

self-medicating, i.e., “chasing dopamine.”

What’s the Attraction?

 ADHD and cannabis use (in particular, early-onset and

• ngoing use) are both associated with deficits in

neurocognition, including attention, memory, reward networks, and executive functions.

 ADHD and regular cannabis use are both associated with

motivation.

 Familial and genetic contributions have also been shown to

potentially play a role in the association between ADHD and substance use disorders

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It Can Be Tricky

 Determining a diagnosis of ADHD in those who are actively

using cannabis, or in those who have recently been abstinent following active cannabis use, can be difficult.

 The clinician must tease out whether a person’s

presentation is primarily cannabis-induced, due to a true ADHD presentation, or perhaps a combination of both.

Is Recreational Cannabis Therapeutic for ADHD?

 Perceived risks associated with regular cannabis use has

decreased among adolescents and young adults in the general population.

 There is also an increasing perception that cannabis is

therapeutic for ADHD.

 Anecdotally, it is commonly reported that recreational

cannabis use reduces restlessness, improves focus and impulse control, and betters frustration tolerance.

Is Recreational Cannabis Therapeutic for ADHD?

 To date, though, clinical research in this realm remains

scarce.

 A relatively recent study looked at the content of online

(Internet) forum threads on ADHD and cannabis use

 That study found that 25% of posts indicated that cannabis

was therapeutic for ADHD, as opposed to 8% that it was harmful, 5% that it was both therapeutic and harmful, and 2% that it had no effect on ADHD

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Is Recreational Cannabis Therapeutic for ADHD?

 Such findings were specific to ADHD and did not generalize

to mood, non-ADHD psychiatric conditions or general quality of life.

 Interestingly, comments favoring the therapeutic effects of

cannabis for ADHD mostly had to do improving the inattentive symptoms of ADHD, not hyperactive-impulsive symptoms.

 There were relatively few comments on the forum threads

comparing cannabis to ADHD medications

What We Still Need to Know….

 Even though there is widespread belief that recreational

cannabis is considered therapeutic for ADHD, at the current time, there is no clinical recommendations or systematic research to support this.

 Hopefully the legalization of recreational cannabis will now

pave the way for such systematic clinical research, as well as increase funding and grants for such research.

Questions?

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References



Bidwell, L.C., Henry, E.A., Willcutt, E.G., Kinnear, M.K, Ito, T .A. (2014). Childhood and current ADHD symptom dimensions are associated with more severe cannabis outcomes in college students. Drug and Alcohol Dependence, 135:88–94.



Brandt, A., Rehm, J., Lev-Ran, S. (2018). Clinical correlates of cannabis use among individuals with attention deficit hyperactivity disorder. Journal of Nervous and Mental Disease, 206: 726–732.



Broyd, S.J, van Hell, H.H, Beale, C., Yucel, M., Solowidj, N. (2016). Acute and chronic effects of cannabinoids on human cognition-a systematic review. Biological Psychiatry, 79(7):557-67.



De Alwis, D., Lynskey, M.T ., Reiersen, A.M., Agrawal, A. (2014). Attention- deficit hyperactivity disorder subtypes and substance use and use disorders in

• NESARC. Addictive Behavior, 39(8):1278–1285.

References



Galan, C.A., & Humphreys, K.L. (2017). ADHD and substance use: current evidence and treatment considerations. Psychiatric Times, 34(8): 1-3.



Hasin, D.S., Kerridge, B.T ., Tulshi D. Saha, T .D., Huang, B., Pickering, R., Smith, S.M…(2016). Prevalence and correlates of DSM-5 cannabis use disorder, 2013: findings from the National Epidemiologic Survey on Alcohol and Related Conditions-III. American Journal of Psychiatry, 173:588–599.



Kennedy, T .M., Howard, A.L., Mitchell, J.T ., Hoza, B., Arnold, L.E….(2019). Adult substance use as a function of growth in peer use across adolescence and young adulthood in the context of ADHD: Findings from the MTA. Addictive Behaviors. https://doi.org/10.1016/j.addbeh.2019.106106



Kolla, N.J., van der Maas, M., Toplak, M.E., Erickson, P .G., Mann, R.E., Seeley, J., Vingilis, E. (2016). Adult attention deficit hyperactivity disorder symptom profiles and concurrent problems with alcohol and cannabis: sex differences in a representative, population survey. BMC Psychiatry, 16(1):50.

References



Lee, S.S., Humphreys, K.L., Flory, K., Liu, R., Glass, K. (2011). Prospective association of childhood attention-deficit/hyperactivity disorder and substance use and abuse/dependence: a meta-analytic review. Clinical Psychology Review, 31(3):328-41.



Lisdahl, K.M., Tamm, L., Epstein, J.N., Jernigan, T ., Molina, B.S.G., Hinshaw, S.P . Swanson, J.M…(2016). The impact of ADHD persistence, recent cannabis use, and age of regular cannabis use onset on subcortical volume and cortical thickness in young adults. Drug and Alcohol Dependence, 161: 135–146.



Loflin, M., Earleywine, M., De Leo, J., Hobkirk, A (2014). Subtypes of attention deficit hyperactivity disorder and cannabis use. Substance Use and Misuse, 49:427– 434.



Ly, C. & Gehricke, J.G. (2013). Marijuana use is associated with inattention in men and sleep quality in women with Attention-Deficit/Hyperactivity Disorder: A preliminary study. Psychiatry Research, 210(3): 1310-2.

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References



Miranda, A., Colomer, C., Berenguer, C., Roselló, R., Roselló, B. (2016). Substance use in young adults with ADHD: comorbidity and symptoms of inattention and hyperactivity/impulsivity. International Journal of Clinical Health Psychology, 16:157–165.



Mitchell, J.T ., Sweitzer, M.M., Tunno, A.M., Kollins, S.H., McClernon. F .J. (2016). “I use weed for my ADHD”: a qualitative analysis of online forum discussions on cannabis use and ADHD. PLoS ONE, 11(5): 1-13.



Notzon, D.P ., Pavlicova, M., Glass, A., Mariani, J.J., Mahony, A.L., Brooks, D.J., Levin, F .R. (2016). ADHD is highly prevalent in patients seeking treatment for cannabis use disorders. Journal of Attention Disorders, 1–6.



Soler Artigas, M., Sanchez-Mora, C., Rovira, P ., Richarte, V ., ….(2019). Attention- deficit/hyperactivity disorder and lifetime cannabis use: genetic overlap and

• causality. Molecular Psychiatry, 1-11.



Statistics Canada. (August 2019). National Cannabis Survey-2nd quarter.

References



Tamm, L., Epstein, J.N., Lisdahl, K.M., Molina, B., Tapert, S., Hinshaw, S.P ., …(2013). Impact of ADHD and cannabis use on executive functioning in young

• adults. Drug and Alcohol Dependence, 133(2):607–14.



Wilens, T .E., Kaminski, T .A. (2018). The co-occurrence of ADHD and substance use disorders. Psychiatric Annals, 48(7):328-332.



Wilens, T .E., Carrellas, N., Biederman, J. (2018). ADHD and substance misuse. In Banaschewski, T ., Coghill, D., Zuddas, A (Eds.), Oxford textbook of attention deficit hyperactivity disorder (pp. 215-227). Oxford University Press.



Wilens, T .E., Martelon, M., Joshi, G., Bateman, C….(2011). Does ADHD predict substance-use disorders? A 10-year follow-up study of young adults with ADHD. Journal of American Academy of Child and Adolescent Psychiatry, 50(6): 543– 553.

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