Myles* was an appealing young man: good-looking, engaging, mild-mannered, with a self-deprecating sense of humor. He was also one of my sicker patients, using cocaine, alcohol and the antianxiety drug Xanax in large quantities. He was on a temporary leave of absence from work at a high-profile financial services company. When he was still working, on a typical Friday night, he would go out with colleagues, call his dealer at 8 P.M. and begin drinking at 10 P.M. By midnight, when the cocktails led to stupor, he would start snorting lines of cocaine. The ebb and flow of the high floated him for the rest of the night. Occasionally he got into a fight. Sometimes he had reckless sex. The next morning he would feel profoundly guilty and sad, and he often took a few tabs of Xanax to “sleep it off.” The next night he would resume the cycle. These binges would last two to three days, costing him $500 or more a day in cocaine alone. During the workweek he would get intense cocaine cravings, and he would do more lines at home by himself. He knew he needed sleep—on sleepless nights he would ply himself with alcohol before crashing, sometimes still in his suit. People at work started to notice. Cocaine withdrawal symptoms—anxiety, irritation and fatigue—plagued him on business trips and in the office. Feeling nervous, he took Xanax before his performance review and nodded off in front of the boss. It was obvious that he needed help, and his employer told him to take some time off. “I can’t control myself,” he admitted when he showed up in my office in New York City. “A couple of nights ago after another cocaine binge, I had the thought that I’d be better off dead than alive, and that’s when I called you.”
Credit: Matt Harrison Clough
Myles did not land in this dire place in one day. When he started his job a few years earlier, he was excited by the big paycheck and titillating world of high finance. But the 80- to 100-hour workweek crushed him: he found it increasingly difficult to focus on the details of a presentation, especially at 2 A.M., when he was working to meet an 8 A.M. deadline set by someone in another time zone. He had trouble wrapping up projects—he would dive in enthusiastically, working on a spreadsheet or PowerPoint deck, only to procrastinate when the details got too tedious. His work was littered with neglectful errors, and he began to worry about being fired. It was around this time that he was first exposed to cocaine. One of his colleagues tempted him to use it one late night at the office. Initially he did not notice the high but only felt calmer and carried on work duties effortlessly into the night. He had a hunch that cocaine could help him stay up longer and be more productive, and he attributed his escalating use to the hours that piled on that winter. He was still coping comfortably on the surface, and his performance was deemed to be rapidly improving at his midyear evaluation. But things fell apart and his cocaine use surged when his longtime girlfriend, who lived in California, decided to break up with him. Since he started his leave from work—a few weeks before I saw him—Myles had tried to cut back. He managed to give up drinking and Xanax, but the cocaine cravings ceaselessly pulled at his mind, until he capitulated. Dopamine Drive We understand substance use disorders today as a condition in which drugs essentially hijack the brain. Patients are often fully aware of the risks, but craving and withdrawal symptoms override their efforts to take control. The intense craving, the sensation of a “high,” the compulsion to procure and use drugs, and the dysphoric state of withdrawal are all associated with a critical neurotransmitter released in the brain: dopamine [see “The Currency of Desire”]. Dopamine signals the presence of rewarding and reinforcing stimuli, and cocaine prevents the brain from reabsorbing dopamine. The excess dopamine throws the brain into a state of imbalance: a circle of use, dopamine release and depletion, then craving, withdrawal and relapse.
SOURCES: CDC (ADHD in children); National Institute of Mental Health (ADHD in adults); Howard Schubiner in CNS Drugs, Vol. 19, No. 8; August 2005 (ADHD in substance misusers)
A less well-known part of the story is that dopamine not only mediates reward, it also has important functions in maintaining focus and motivation. Dopamine is released not only in the limbic system, the part of the brain that evaluates and predicts reward, it is also released in the frontal cortex, which oversees attention and other executive functions. When the brain does not respond to dopamine optimally or does not release dopamine at the right time and place, people will experience cognitive difficulties such as poor concentration, listlessness, lack of patience and a tendency to make careless mistakes. When these symptoms are present early in childhood, they are recognized as signs of attention-deficit/hyperactivity disorder (ADHD). People with ADHD often develop substance use disorders, perhaps in an attempt to self-medicate. Conversely, an estimated 20 to 30 percent of substance misusers have underlying ADHD (versus about 4 percent of adults in the general population). The exact reasons for this overlap are still unknown and probably vary by individual but most likely trace back to common problems in the dopamine system. Even so, patients with substance use disorders are often underdiagnosed for ADHD because clinicians do not routinely think of connecting the two conditions. And yet not recognizing and treating ADHD in such patients can make it more difficult for them to achieve abstinence and avoid relapse. A Root Cause To accurately diagnose Myles’s possible ADHD symptoms, I called his parents and used the diagnostic interview for ADHD in adults. Evaluating when and what symptoms started early is an important consideration in consolidating the ADHD diagnosis. Myles’s parents told me he was “absent-minded” and “fidgety” as a youngster. Because he was so bright and did well in school, though, they never had any concerns. My in-depth review revealed that Myles’s ADHD symptoms and substance use problems both started early. In adolescence, he often felt distracted and irritable at school; for a while, he smoked marijuana daily, which helped to lessen these symptoms. He was able to “coast” because his schoolwork did not require his sustained attention. In college, he would occasionally “borrow” an Adderall—a psychostimulant drug used to treat ADHD—from friends to help him push through more challenging assignments. “It always made me feel calmer,” he said, “which should’ve given me a clue.” Nevertheless, when I finally made the diagnosis of ADHD and suggested a course of prescription medication, Myles was hesitant. “Doc, I’m trying so hard to come off of cocaine,” he petitioned. “Are you really going to put me on something that may be addictive?” He echoed a common concern among clinicians and patients that psychostimulants, such as Adderall and Ritalin, while excellent treatments for ADHD, can themselves be addicting. In fact, evidence suggests that newer long-acting versions of these medications are safe and effective for ADHD and only rarely habit-forming. In addition, recent studies, including a 2015 investigation by Frances R. Levin of Columbia University and her colleagues, suggest that robust doses of a psychostimulant can not only improve ADHD symptoms but also help people quit addictive substances and prevent relapse, especially for cocaine. After we thoroughly discussed the pros and cons, Myles agreed to a course of extended-release Adderall capsules. We combined it with a standard cognitive-behavioral therapy (CBT) program, targeting cocaine use disorder. Because he is so motivated, Myles was a pleasure to work with—diligent with his CBT homework assignments, conscientious in his effort to cut ties with his dealer, and he always took his medications on time. We also treated his withdrawal symptoms with safer alternatives than alcohol and Xanax, such as clonidine and gabapentin. After one month of this treatment, Myles was drug-free but still had occasional cravings. We decided to continue with ongoing psychotherapy sessions, and we were optimistic that he could stave off relapses when work pressure resumed again, as it soon did. Myles’s treatment success is not atypical. Contrary to popular belief, a large proportion of patients with even the most severe substance use disorders can achieve abstinence. Relapse is common and part of the recovery process and, though serious, is not a sign of hopeless addiction. For Myles and many others, recognizing ADHD symptoms and successfully treating them can be crucial steps in breaking the cycle. *Not the patient’s real name.
He was on a temporary leave of absence from work at a high-profile financial services company. When he was still working, on a typical Friday night, he would go out with colleagues, call his dealer at 8 P.M. and begin drinking at 10 P.M. By midnight, when the cocktails led to stupor, he would start snorting lines of cocaine. The ebb and flow of the high floated him for the rest of the night. Occasionally he got into a fight. Sometimes he had reckless sex. The next morning he would feel profoundly guilty and sad, and he often took a few tabs of Xanax to “sleep it off.” The next night he would resume the cycle. These binges would last two to three days, costing him $500 or more a day in cocaine alone. During the workweek he would get intense cocaine cravings, and he would do more lines at home by himself. He knew he needed sleep—on sleepless nights he would ply himself with alcohol before crashing, sometimes still in his suit.
People at work started to notice. Cocaine withdrawal symptoms—anxiety, irritation and fatigue—plagued him on business trips and in the office. Feeling nervous, he took Xanax before his performance review and nodded off in front of the boss. It was obvious that he needed help, and his employer told him to take some time off.
“I can’t control myself,” he admitted when he showed up in my office in New York City. “A couple of nights ago after another cocaine binge, I had the thought that I’d be better off dead than alive, and that’s when I called you.”
Myles did not land in this dire place in one day. When he started his job a few years earlier, he was excited by the big paycheck and titillating world of high finance. But the 80- to 100-hour workweek crushed him: he found it increasingly difficult to focus on the details of a presentation, especially at 2 A.M., when he was working to meet an 8 A.M. deadline set by someone in another time zone. He had trouble wrapping up projects—he would dive in enthusiastically, working on a spreadsheet or PowerPoint deck, only to procrastinate when the details got too tedious. His work was littered with neglectful errors, and he began to worry about being fired.
It was around this time that he was first exposed to cocaine. One of his colleagues tempted him to use it one late night at the office. Initially he did not notice the high but only felt calmer and carried on work duties effortlessly into the night. He had a hunch that cocaine could help him stay up longer and be more productive, and he attributed his escalating use to the hours that piled on that winter. He was still coping comfortably on the surface, and his performance was deemed to be rapidly improving at his midyear evaluation.
But things fell apart and his cocaine use surged when his longtime girlfriend, who lived in California, decided to break up with him. Since he started his leave from work—a few weeks before I saw him—Myles had tried to cut back. He managed to give up drinking and Xanax, but the cocaine cravings ceaselessly pulled at his mind, until he capitulated.
Dopamine Drive
We understand substance use disorders today as a condition in which drugs essentially hijack the brain. Patients are often fully aware of the risks, but craving and withdrawal symptoms override their efforts to take control. The intense craving, the sensation of a “high,” the compulsion to procure and use drugs, and the dysphoric state of withdrawal are all associated with a critical neurotransmitter released in the brain: dopamine [see “The Currency of Desire”]. Dopamine signals the presence of rewarding and reinforcing stimuli, and cocaine prevents the brain from reabsorbing dopamine. The excess dopamine throws the brain into a state of imbalance: a circle of use, dopamine release and depletion, then craving, withdrawal and relapse.
A less well-known part of the story is that dopamine not only mediates reward, it also has important functions in maintaining focus and motivation. Dopamine is released not only in the limbic system, the part of the brain that evaluates and predicts reward, it is also released in the frontal cortex, which oversees attention and other executive functions. When the brain does not respond to dopamine optimally or does not release dopamine at the right time and place, people will experience cognitive difficulties such as poor concentration, listlessness, lack of patience and a tendency to make careless mistakes. When these symptoms are present early in childhood, they are recognized as signs of attention-deficit/hyperactivity disorder (ADHD).
People with ADHD often develop substance use disorders, perhaps in an attempt to self-medicate. Conversely, an estimated 20 to 30 percent of substance misusers have underlying ADHD (versus about 4 percent of adults in the general population). The exact reasons for this overlap are still unknown and probably vary by individual but most likely trace back to common problems in the dopamine system. Even so, patients with substance use disorders are often underdiagnosed for ADHD because clinicians do not routinely think of connecting the two conditions. And yet not recognizing and treating ADHD in such patients can make it more difficult for them to achieve abstinence and avoid relapse.
A Root Cause
To accurately diagnose Myles’s possible ADHD symptoms, I called his parents and used the diagnostic interview for ADHD in adults. Evaluating when and what symptoms started early is an important consideration in consolidating the ADHD diagnosis. Myles’s parents told me he was “absent-minded” and “fidgety” as a youngster. Because he was so bright and did well in school, though, they never had any concerns.
My in-depth review revealed that Myles’s ADHD symptoms and substance use problems both started early. In adolescence, he often felt distracted and irritable at school; for a while, he smoked marijuana daily, which helped to lessen these symptoms. He was able to “coast” because his schoolwork did not require his sustained attention. In college, he would occasionally “borrow” an Adderall—a psychostimulant drug used to treat ADHD—from friends to help him push through more challenging assignments. “It always made me feel calmer,” he said, “which should’ve given me a clue.”
Nevertheless, when I finally made the diagnosis of ADHD and suggested a course of prescription medication, Myles was hesitant. “Doc, I’m trying so hard to come off of cocaine,” he petitioned. “Are you really going to put me on something that may be addictive?”
He echoed a common concern among clinicians and patients that psychostimulants, such as Adderall and Ritalin, while excellent treatments for ADHD, can themselves be addicting. In fact, evidence suggests that newer long-acting versions of these medications are safe and effective for ADHD and only rarely habit-forming. In addition, recent studies, including a 2015 investigation by Frances R. Levin of Columbia University and her colleagues, suggest that robust doses of a psychostimulant can not only improve ADHD symptoms but also help people quit addictive substances and prevent relapse, especially for cocaine.
After we thoroughly discussed the pros and cons, Myles agreed to a course of extended-release Adderall capsules. We combined it with a standard cognitive-behavioral therapy (CBT) program, targeting cocaine use disorder. Because he is so motivated, Myles was a pleasure to work with—diligent with his CBT homework assignments, conscientious in his effort to cut ties with his dealer, and he always took his medications on time. We also treated his withdrawal symptoms with safer alternatives than alcohol and Xanax, such as clonidine and gabapentin. After one month of this treatment, Myles was drug-free but still had occasional cravings. We decided to continue with ongoing psychotherapy sessions, and we were optimistic that he could stave off relapses when work pressure resumed again, as it soon did.
Myles’s treatment success is not atypical. Contrary to popular belief, a large proportion of patients with even the most severe substance use disorders can achieve abstinence. Relapse is common and part of the recovery process and, though serious, is not a sign of hopeless addiction. For Myles and many others, recognizing ADHD symptoms and successfully treating them can be crucial steps in breaking the cycle.
*Not the patient’s real name.
