Susan Carruthers

Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an international multi-center study exploring DSM-IV and DSM-5 criteria

Background Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. Methods A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. Results Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: 2.4–8.3) for Hungary to 31.3% (CI 95%:25.2–37.5) for Norway and for DSM-5 from 7.6% (CI 95%: 4.1–11.1) for Hungary to 32.6% (CI 95%: 26.4–38.8) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2–83%→ 5.4–31.3%). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. Conclusions Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD.

Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients

BACKGROUND To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed. OBJECTIVES To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder). METHODS In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard. RESULTS The prevalence of adult ADHD was 13.0% (95% CI: 11.0-15.0%). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: 0.22-0.30), the negative predictive value (NPV) was 0.97 (95% CI: 0.96-0.98). The sensitivity (0.84, 95% CI: 0.76-0.88) and specificity (0.66, 95% CI: 0.63-0.69) measured at admission were similar to the sensitivity (0.88, 95% CI: 0.83-0.93) and specificity (0.67, 95% CI: 0.64-0.70) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD. CONCLUSIONS The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population.

The International ADHD in Substance Use Disorders Prevalence (IASP) study: Background, methods and study population

Attention deficit/hyperactivity disorder (ADHD) is an increasingly recognized comorbid condition in subjects with substance use disorders (SUDs).

Pharmaceutical opioid analgesic and heroin dependence: how do treatment-seeking clients differ in Australia?

INTRODUCTION AND AIMS Non-prescribed use of pharmaceutical opioid analgesics (POA) has been escalating internationally. In Australia, few studies have examined if POA users have similar characteristics and treatment needs to heroin users. The aim of this study was to compare those presenting for treatment where heroin versus POA were the primary drugs of concern. DESIGN AND METHODS A convenience sample of 192 treatment entrants were recruited from alcohol and drug treatment services in four Australian jurisdictions. A structured interview collected data on demographic characteristics, substance use, self-perceived mental and physical health, crime and harms resulting from drug use. Multivariate analyses were performed to identify characteristics which may differentiate those seeking treatment for heroin compared with POA. RESULTS Most treatment entrants sampled reported a history of injection drug use and use of both heroin and POA. However, those with primary POA problems were less likely to report an overdose history (adjusted odds ratio 0.90, 95% confidence interval 0.81-0.99) and more likely to initiate opioid use for pain (adjusted odds ratio 2.52, 95% confidence interval 1.04-6.12) than those with primary heroin problems. Latent Class Analysis found that, while most of the POA group were similar to heroin users in demographics, health and injecting drug use, there was a small, distinct group of primary POA problem users that did not typically inject and who commonly initiated opioid use for pain and also experienced elevated physical and mental health disability. DISCUSSION AND CONCLUSIONS While some differences existed, this study of Australian treatment seekers found many similar characteristics between those with primary problems with heroin and POA. Few non-injecting POA were recruited in this sample. This finding contrasts with reports of a growing population of opioid-dependent people with characteristics that are distinct from traditional opioid-dependent populations, which may reflect the orientation of current treatment systems in Australia towards injection drug users.

The sources of pharmaceuticals for problematic users of benzodiazepines and prescription opioids.

Objectives: To describe benzodiazepine and prescription opioid use by clients of drug treatment services and the sources of pharmaceuticals they use.

The Australian Study of HIV and Injecting Drug Use. Part I: Prevalence for HIV, hepatitis B and hepatitis C among injecting drug users in four Australian cities

The objective of this study was to assess differences in HIV, hepatitis B and hepatitis C seroprevalence among injecting drug users (IDU) in four Australian cities. Eight hundred and seventh-two current IDU were recruited in approximately equal numbers from each of Adelaide, Melbourne, Perth and Sydney, and interviewed individually using a structured questionnaire. Fingerprick blood samples were taken from the majority of respondents, and tested for past exposure to the three viruses. HIV and hepatitis B and C raw seroprevalences were compared across cities, and comparisons were made of age-standardized seroprevalences for hepatitis B and C. Three percent of all respondents were HIV seropositive; 19% (23% age-standardized) were hepatitis B seropositive and 55% (60% age-standarized) were hepatitis C seropositive. There were general city differences and gender, sexual preference and treatment status group differences between the cities. Sydney respondents had the highest risk of infection for all three viruses in all comparisons. This was particularly striking for HIV among non-heterosexual men. Various explanations for the findings were considered, including city differences in demographic and drug use variables, underlying patterns of risk behaviour, and period/cohort effects. It was concluded that none of these explanations appeared to fit the pattern of findings, and that these probably represented true underlying differences in size of pools of infection. The reasons for this, however, cannot be ascertained from this study.

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

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 ones 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.

Preventing hepatitis C: what do positive injectors do?

The majority of hepatitis C prevention research among injectors is concerned with preventing initial exposure to the virus. Given that the prevalence of hepatitis C among injectors is between 50 and 60 per cent, one aim should be to prevent further transmission of the virus from infected to non-infected injectors. The major aim of this study was to investigate the risk management strategies hepatitis C positive injectors might take to prevent further transmission of the virus. A total of 111 hepatitis C positive injectors were recruited and interviewed with a questionnaire designed to gather information regarding current and past injecting behaviours and risk reduction options outlined in response to a series of injecting vignettes. The responses indicated that the majority of respondents recognised the risks associated with the various injecting scenarios and could describe actions by which they could reduce those risks. However, the examination of reported options revealed that while some of these would indeed eliminate the risk of further transmission others would be less effective because they either relied on unproven methods of removing viral material from used needle and syringes or the user assumed that other injectors had knowledge equivalent to that of the respondent.

Sex, gender, drugs and risk: The Australian study of HIV and injecting drug use1

Abstract The Australian Study of HIV and Injecting Drug Use (ASHIDU) is a multi-city study of 872 injecting drug users (IDUs), recruited from treatment and non-treatment sources. Questionnaire data and seroprevalence for HIV, hepatitis B and hepatitis C were collected during 1994. This paper investigates Very Risky Sexual Behaviour (VRSB), which is defined as having had penetrative sex with more than one partner, and inconsistent use of barrier protection, during the month prior to interview. Predictors of risk for women and men were analysed separately. It was found that VRSB in women was independently predicted by using tranquillisers before the last sexual encounter (O.R.=5.7), being single (O.R.=2.9), being non-heterosexual (O.R.=2.7), not being in drug treatment (O.R.=2.3) and being employed (O.R.=1.9). VRSB in men was predicted by having a non-regular last sexual partner (O.R.=5.5), being HIV positive (O.R.=4.4), using tranquillisers during the month prior to the interview (O.R.=2.5), the last sexual partner being an IDU (O.R.=2.5) and being younger. These gender differences are discussed in the light of harm reduction strategies to minimise the spread of sexually transmissible diseases in IDU. It is concluded that different strategies will be needed for different sub-categories of IDU.

The Australian study of HIV and injecting Drug Use. Part II: Predicting exposure to hepatitis C and hepatitis B

Researchers agree that while hepatitis B maybe in control, hepatitis C is present in epidemic proportions among injecting drug users and that current HIV prevention strategies have not been sufficient to halt the spread of this hepatitis virus, although there is some evidence to suggest that incidence rates are stabilizing. Since there is no effective cure and it is unlikely that a vaccine will become available in the foreseeable future all efforts to control the spread of hepatitis C must rely on education and prevention strategies. The Australian Study of HIV and Injecting Drug Use is a cross-sectional national study designed to investigate exposure to and risks for infection with bloodborne viruses. Of those volunteering a usable blood sample for hepatitis C antibody and hepatitis B core antibody testing 55% and 19%, respectively, returned reactive test results. Logistic regression statistical models were used to identify risk factors for hepatitis C and hepatitis B. Risk factors for hepatitis C were identified as duration of use, use of opiates on last injecting occasion, education level, treatment status and having a history of sexually transmissible diseases. Risk factors associated with hepatitis B were duration of use, and use of opiates on last injecting occasion. The lack of identifiable risk factors for hepatitis B suggest that past rather than current injecting and sexual behaviour patterns are required to predict accurately risk of exposure to hepatitis B. In addition to this, one-third of respondents reported being vaccinated against hepatitis B. Respondents perceived themselves to be at greater risk from hepatitis C than from hepatitis B or HIV. A discussion of strategies needed to prevent the spread of the hepatitis viruses will be presented along with recommendations for further research.