EXPERT ANALYSIS AT THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE

SAN FRANCISCO – “If one is going to say ‘you need 6 months of abstinence from cannabis before I am going to treat your ADHD,’ that’s absurd. If [kids] are stoned all the time, no, but if it’s intermittent, it’s really not a factor,” according to James J. McGough, MD , director of the Attention Deficit Disorder Clinic at the University of California, Los Angeles.

There’s no evidence that ongoing stimulant treatment increases the risk of substance abuse, and “we must admit to ourselves that substance use among adolescents and young adults is normative. It happens,” even among well-adapted kids. “Think of your own past histories,” he said to an audience of psychiatrists and other medical professionals at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

With marijuana legalization rolling out across the United States, substance use in attention-deficit/hyperactivity disorder was on the minds of many in the audience, judging from their questions.

“You have” to deal with substance abuse that’s ruining lives, but otherwise, “I’m comfortable giving a prescription under some circumstances even if I know [patients] are using drugs. It’s the extent and type of [drug use] that informs if we should prescribe or not,” said Dr. McGough, also a professor of clinical psychiatry at the university, but be careful to “really document what you’re doing.”

Misuse and diversion is mostly related to performance enhancement, especially at competitive universities, or when grades head south. Children and young adults in those situations, as well as smokers, drinkers, and those with conduct disorders, “are the ones you worry about.” If a Stanford medical school student at age 27 suddenly develops a horrible problem focusing, with no past ADHD history, “I’m a little suspicious,” he said, noting that people who malinger “tend to go off the scale in terms of endorsing symptoms.”

If misuse and abuse are a concern, extended-release stimulants, as well as nonstimulants, are better options than immediate-release formulations.

Audience members also were curious about alternative approaches for ADHD, but the news wasn’t very good.

For now, there’s no brain scan, test, or lab measurement that reliably detects ADHD. Even with neuropsychiatric testing, only half of children and adolescents will have executive-functioning deficits. The problem with computerized tests, meanwhile, is that a lot of children and adolescents with ADHD have no problem focusing on computer games, so they aren’t helpful for diagnosis.

“The gold standard for ADHD assessment remains a good interview,” and documenting DSM-5 criteria, he said.

As for alternative treatments, “what studies have shown is that if you are highly invested in the treatment and not blinded” to it, “you tend to think you do better. In good studies where they look at teachers who don’t know what’s going on, it doesn’t pan out,” he said. Metanalysis of neurofeedback hasn’t shown effect, nor have computer games to train focus; kids will get better at them with practice, but they haven’t been shown to improve ADHD.

The only exception is omega-3, but the effect size is barely measurable. “If you can get the kid so swallow those fish oil things, go for it, or they can eat salmon,” Dr. McGough said.

In short, medications remain the best option for treating the core symptoms of ADHD, first with stimulants then, as needed, nonstimulants.

But “you are not meeting your patients’ needs if you are only prescribing medications,” he said. Psychosocial education, family behavioral therapy, and school interventions – even things as simple as sitting toward the front of the class and having a little more time on tests – are critical for overall improvement.

It’s also important to let patients and families know that “they don’t have to be ashamed of this,” and the patients need to know why they are taking their medication, he said.

Too often, children are started on a low dose of medication and told to come back in a month. “That’s a waste of time, because it’s a whole month when the person is probably inadequately treated,” Dr. McGough said.

Instead, he has patients titrate up at first, with advice to cut back or stop and call if there are problems. The patient returns after 3 weeks, and the most effective, best-tolerated dose is selected for treatment.

Dr. McGough disclosed relationships with Purdue, Shire, Tris, Sunovion, NeuroSigma, and Neurovance.

aotto@frontlinemedcom.com

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