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Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP—or Child and Adolescent Psychiatry—Smart Take, we will closely examine a clinical dilemma increasingly facing those of us treating children and especially adolescents—namely, what do we do when we see children and adolescents with ADHD and co-occurring cannabis use? This is a great piece, not a controlled study, that uses an informative, well-written case history to discuss this population’s medical, psychiatric, psychological, cognitive, societal, social, legal, and state-by-state problems. Moreover, the case report does an excellent job illustrating what is involved in these assessments and treatment decisions.
The recommendations and analyses provided by Dernbach and colleagues are timely and especially helpful for this increasingly common clinical dilemma facing all of us working with children and adolescents. ADHD is a severe, highly prevalent, often chronically disabling childhood-onset neuropsychiatric disorder that persists into adulthood. We also know that co-occurring cannabis use and cigarette smoking are far more common in adolescents with ADHD than in the general non-ADHD population. Conversely, chronic cannabis use that starts in childhood or adolescence is associated with long-term problems with attention, concentration, cognition, impulse control, executive planning, long-term planning, and even intellectual ability. There is a clear concern about cannabis use worsening preexisting attention and cognitive symptoms in youth with ADHD. Further complicating this already complicated picture is that untreated ADHD is associated with increased cannabis use. There is also growing evidence that effectively treating ADHD decreases the risk of youth developing substance use disorders. Stimulants are the most common and first-line treatment for ADHD in youth. However, stimulant misuse—selling or using stimulants for inappropriate indications—is common and appears to be increasing. I have been contacted frequently by parents, colleagues, and friends in many situations where they ask me if I can prescribe their child or teenager a stimulant medicine, even though they have no history of ADHD. Some are very direct about wanting it to improve their child’s performance on standardized testing like the SAT or ACT or their school performance. Moreover, I have never done that because these medicines can do enormous good when prescribed correctly, but when you start taking shortcuts—when you prescribe them when they are not indicated—you get into trouble. I always tell parents I would happily assess their child or teenager. If there is a medical or psychiatric condition, I would be happy to treat it and make treatment recommendations. However, in good conscience, I cannot prescribe a stimulant based on a parent’s request for improvement on standardized testing or other academic endeavors.
So, the bottom line is that there remains this uncertainty about how we treat and intervene for youth with ADHD and co-occurring cannabis use, which will only increase. And in some ways, you might argue that it gives us more latitude to go with our clinical intuition and experience because there are so few guidelines. However, we must also be cautious and cannot ignore the uncertainty and challenge in treating this population. It is also important that the physician consider local, state, and legal restrictions when adolescents use recreational or prescribed cannabis to someone else regarding disclosure of substance use and cannabis use to parents, guardians, and others. From my take, it often comes down to risk–benefit.
Moreover, breaking confidentiality may be necessary if there is a clear medical or psychiatric danger to self or others or other risks. However, there is a fine line, and there can be differences on a state-by-state basis in other local areas in terms of what the fine line is and how this can be done. So, do not try and guess this. There are resources and people to check with about this. Motivational enhancement interviewing can also be extraordinarily helpful in this population to help gauge the adolescent’s insight into how cannabis use could confound and complicate treating ADHD. Moreover, in adolescents, motivational interviewing approaches are preferable to confrontation and direct advice. There is no question that abstinence from cannabis should be considered. It is a reasonable goal, but not abstaining from cannabis does not necessarily preclude use in youth with ADHD. If there is cannabis use and a diagnosis of ADHD, the prescribing clinician might consider alternatives to stimulant treatment. To decrease the risk of nonmedical use, selling stimulants, and diversion of stimulants—particularly the immediate-release stimulants—the clinician can consider nonstimulant medicines. We know long-acting stimulants have a lower risk of abuse than immediate-release stimulants. Close monitoring for ongoing substance use/abuse and getting a urine drug screen is warranted. And sometimes, it is best to refer these patients to dual diagnosis programs, where ADHD and substance use concerns can be managed.
So, the bottom line is that this is a growing concern. It is only going to increase. All clinicians must have this on their radar, as significant clinical, prognostic, medical, psychiatric, psychological, legal, and state-by-state problems must be considered. Moreover, it is an area where more study and focus are urgently needed on this increasingly common clinical dilemma faced by all of us who work with adolescents.
Abstract
Prescribing Stimulants for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder and Co-occurring Cannabis Use: Considerations for Managing a Clinical Dilemma
Matthew Robert Dernbach, Kevin M Gray, Abbey Borich, Erin Seery, Sarah Brice Russo, E Thomas Lewis 3rd, McLeod Frampton Gwynette
Attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in the pediatric population, with 11% of children and adolescents having ever been diagnosed with the disorder.1 The management of ADHD in the setting of co-occurring cannabis use, which is more prevalent in adolescents with ADHD than in the general population, is an increasingly common dilemma facing clinicians, in part due to recent changes in social acceptability, access, usage, and state-level legal status of cannabis.2 Clinicians face several considerations, including the following: the confounding effects of cannabis use on assessment and management of ADHD symptoms; the potential reduction in risk of substance use when ADHD symptoms are well managed; and the increased risk of misuse and diversion of stimulants in patients with ongoing cannabis use.
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Reference
Dernbach, M. R., Gray, K. M., Borich, A., Seery, E., Russo, S. B., Lewis, E. T., & Gwynette, M. F. (2023). Prescribing stimulants for children and adolescents with attention-deficit/hyperactivity disorder and co-occurring cannabis use: Considerations for managing a clinical dilemma. Journal of the American Academy of Child & Adolescent Psychiatry.
