Elsevier

Drug and Alcohol Dependence

Volume 144, 1 November 2014, Pages 70-77
Drug and Alcohol Dependence

Risk behaviours among substance use disorder treatment seekers with and without adult ADHD symptoms

https://doi.org/10.1016/j.drugalcdep.2014.08.008Get rights and content

Abstract

Background

Impulsivity and consequent risk-taking are features of both Attention Deficit Hyperactivity Disorder (ADHD) and substance use disorder (SUD). To date there are no data on the impact of comorbid ADHD on the likelihood and frequency of risk-taking behaviour among individuals with SUD. The current study aimed to examine drug-related, sexual and driving-related risk behaviours in people seeking treatment for SUD with co-occurring symptoms of Attention Deficit Hyperactivity Disorder (ADHD), taking into account potential confounders.

Methods

489 Australian adult SUD treatment seekers were administered a structured interview assessing demographics, drug use and SUD treatment history, psychiatric history, self-reported adult ADHD symptoms and self-reported drug-related, sexual and driving-related risk behaviours.

Results

Almost a third (32%) screened positive for adult ADHD symptoms with onset prior to age 12. Those screening positive were more likely to report early onset (<15 years) nicotine and illicit drug use and to have a prior diagnosis of childhood ADHD, anxiety, depression and personality disorder. ADHD symptom status was not independently associated with injecting drug use-related or sexual risk-taking in the preceding month, but was an independent predictor of a greater overall number of driving offences, a higher frequency of driving without a seatbelt, a greater likelihood of having driven without a valid licence, more at-fault accidents and having one's licence disqualified at the time of interview.

Conclusions

These findings suggest that the risk-taking behaviour that is common among people with SUD is further increased among those with comorbid ADHD symptoms, particularly with respect to dangerous driving practices.

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is consistently over-represented among substance use disorder (SUD) populations, particularly when symptoms persist through adolescence into adulthood (Kollins, 2007). Adult ADHD has been documented in 10–54% of SUD samples (van de Glind et al., 2014, van Emmerik-van Oortmerssen et al., 2012), with an estimated overall prevalence of 21% (van Emmerik-van Oortmerssen et al., 2012) (23% among SUD treatment seekers; van Emmerik-van Oortmerssen et al., 2012). ADHD is not only a risk factor for the development of SUDs, but is associated with an earlier onset and more severe course of SUD (Chilcoat and Breslau, 1999, Kaye et al., 2013, Sullivan and Rudnik-Levin, 2001, Wilens et al., 2011, Wilens and Upadhyaya, 2007), as well as poorer SUD treatment prognosis (McAweeney et al., 2010, Upadhyaya, 2007, Wilens, 2004, Wilens and Upadhyaya, 2007). Despite the well-documented association between ADHD and SUD, the public health burden associated with such comorbidity has received relatively little attention.

Impulsivity and consequent risk-taking are associated with both disorders. Impulsivity is a core diagnostic feature of the hyperactive-impulsive and combined presentations of ADHD and may be a determining factor in the initiation and maintenance of substance use (de Wit, 2009, Dick et al., 2010, Verdejo-Garcia et al., 2008), with increased levels of impulsivity consistently found among those with SUDs (Fernandez-Serrano et al., 2011, Verdejo-Garcia et al., 2008). Accordingly, increased risk-taking is observed among both SUD and ADHD populations (Abrantes et al., 2006).

SUDs are associated with a number of risk-taking behaviours, including unsafe sexual practices (Feldstein and Miller, 2006, Poulin and Graham, 2001, Santelli et al., 2001, Sly and Riehman, 1999), accidental injury (Darke et al., 2013, Gill and Catanese, 2002, Turk and Tsokos, 2004) and risky driving behaviours (Banks et al., 2004, Kelly et al., 2004, Landauer and Howat, 1983), with an increased risk of motor vehicle accident (MVA) mortality observed for all types of SUD (Callaghan et al., 2013). Among illicit drug users, mortality rates due to trauma far exceed those of the general population and MVAs are a major contributor to the excess mortality in this group (Darke et al., 2007). Moreover, particular concern has been expressed about the increased risk of blood-borne virus (BBV) transmission through unsafe drug injection (Degenhardt and Hall, 2012).

Similarly, ADHD is an independent predictor of an earlier initiation of sexual activity, more sexual partners and a higher frequency of casual, unprotected sex (Abrantes et al., 2006, Flory and Lynam, 2003). Children with ADHD also have higher rates of traumatic injury (Xiang et al., 2005) and are more likely to be involved in high-risk activities when injured (Badger et al., 2008). ADHD in late adolescence and adulthood, particularly when hyperactive-impulsive symptoms are present, is associated with high-risk and aggressive driving (Cox et al., 2011), more driving offences and licence violations, and a higher rate of MVAs (Barkley et al., 1996, Jerome et al., 2006).

Although impulsivity and risk-taking are well-recognised features of SUD, to date there are no data on the impact of comorbid adult ADHD on the likelihood and frequency of SUD-related risk-taking. Does ADHD compound the level of risk-taking associated with SUD per se, or is the increased risk propensity associated with ADHD overshadowed by the risky behaviour typically related to SUD? The current study aims to: (i) ascertain the presence of adult ADHD symptoms among SUD treatment seekers and (ii) investigate the association between co-occurring ADHD symptoms and the prevalence and severity of drug-related, sexual and driving-related risk behaviours.

Section snippets

Participants

Data were collected from the Australian sites of the International ADHD in Substance use disorders Prevalence (IASP) study (van de Glind et al., 2013a, van de Glind et al., 2013b) – a two phase study consisting of a screening and a diagnostic phase. Australian participation was limited to the screening phase only, with recruitment taking place between September, 2010 and August, 2011.

The sample comprised 489 adults attending drug and alcohol treatment centres (inpatient and outpatient) for a

Sample characteristics

Half (51%) the sample was male and the mean age was 34.6 years (SD 8.8; range 18–69). The mean length of school education was 10.6 years (SD 1.5; range 6–13) and the majority of participants (78%) were either unemployed or receiving a disability pension at the time of interview.

Participants were receiving treatment for alcohol (53%), meth/amphetamine (30%), cannabis (29%), heroin (26%), methadone (20%), other opioid (13%), benzodiazepine (18%), and/or cocaine (7%) dependence, with the majority

Discussion

This study is the first to investigate the association between co-occurring adult ADHD symptoms and the prevalence and severity of risk behaviours in SUD treatment seekers. In accordance with previous research, the current study found elevated levels of adult ADHD symptomatology. Using a conservative approach, which required evidence of a childhood onset of ADHD symptoms before age 12, about one third of participants screened positive for ADHD. In contrast, only 6% of a recent Australian

Role of the funding source

Funding for this study was provided by a Curtin University Strategic Research Faculty Grant. Curtin University had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The National Drug and Alcohol Research Centre at UNSW Australia and the National Drug Research Institute at Curtin University are supported by funding from the Australian Government under the Substance Misuse

Contributors

GvdG designed and coordinated the international IASP study. WvdB contributed to the design of the IASP study. SK, SA and LD designed the module on risk taking behaviour for use in the Australian sample. SK coordinated the Australian arm of the IASP study, drafted the manuscript and wrote the final version. SA oversaw conduct of the study in Western Australia. JG, SC and JY coordinated recruitment of study participants and undertook statistical analysis of the data. All authors contributed to

Conflict of interest

G. van de Glind was, on one occasion, consultant for Shire, for which he refused payment. In 2013 he received an unrestricted travel grant from Neurotech and he is a member (unpaid) of the advisory board of Neurotech. S. Kaye reports receiving an unrestricted travel grant for participation in the World ADHD Federation conference in Berlin (2011) from Shire, Janssen and Eli Lilly. W. van den Brink has received a fee from Eli Lilly for organising a symposium on the role of impulsivity in

Acknowledgements

The authors are grateful to the staff and clients of the participating treatment agencies for their assistance, and wish to thank Narelle Fordham, Michelle Torok and Katherine Tye for their help with data collection and entry. This research was funded by a Curtin University Strategic Research Faculty Grant. The National Drug and Alcohol Research Centre at UNSW Australia and the National Drug Research Institute at Curtin University are supported by funding from the Australian Government under

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