Along with anxiety and depression, attention deficit hyperactivity disorder (ADHD) is a common comorbidity among patients with chronic pain. Although most commonly diagnosed in childhood, ADHD is seen in approximately 4.8% of adults.
ADHD has become a well-recognized and validated syndrome, known for the havoc it can create in patients’ lives.
Because more patients carry the diagnosis and are on ADHD medications (primarily stimulants), it is important for pain physicians to be aware of the consequences of the disorder. In addition, it is helpful to be aware of interactions between ADHD and pain medications.
Diagnosis of ADHD in Adults
In my experience, most patients who carry the diagnosis of ADHD from childhood have been correctly diagnosed; although there is occasional overdiagnosis of ADHD, underdiagnosis remains more prevalent.
Mood disorders may cause an attention/concentration problem in adults, leading to an inappropriate diagnosis of ADHD. However, most patients with ADHD do have associated psychiatric comorbidities, such as anxiety or depression.
Many individuals who fit on the bipolar spectrum can have concurrent ADHD. It is important to assess patients for all of these conditions.
ADHD and Impairment
The severity of childhood/adolescent ADHD is an accurate predictor of impairment as an adult.
The associated psychiatric comorbidities add to impairment, particularly if they are not treated. These include anxiety, depression, bipolar depression, and substance abuse.
The evidence is strong for treating ADHD. Compared with treated patients, those who remain untreated are at greater risk, at age 20 to 25, for drug abuse, accidents, joblessness, and jail.
The clinical stakes for underrecognizing and undertreating ADHD are enormous. If impulsivity does not improve by the early 20s, it is a poor prognostic indicator for how the patient will do over time.
ADHD and the Patient With Pain
ADHD complicates the lives of patients with pain. The patient struggles with functional impairment due to pain, and ADHD adds to this dysfunction.
Chronic pain often leads to performance issues at work or joblessness; ADHD only accentuates this problem. It is not uncommon for patients with chronic pain and ADHD, in combination with anxiety and depression, to be underfunctioning in a number of areas.
“First-line” medications for ADHD are stimulants. The most commonly used stimulants include
- methylphenidate (Concerta, Ritalin, others),
- dextroamphetamine (Dexedrine, others),
- amphetamine and dextroamphetamine (Adderall), and
- lisdexamfetamine (Vyvanse).
The longer-acting forms are Adderall XR, Vyvanse, Ritalin LA, Focalin XR, Daytrana, and Concerta.
The stimulants have mild analgesic effects and in some patients may be an adjunct for the pain. In addition, some patients with depression find that the stimulants act as an adjunct for the depression, whereas in others they may actually exacerbate depression
Fatigue is a common comorbidity encountered in patients with pain, and stimulants may help their energy level during the day. In addition, the anorexiant effects are beneficial for some patients with pain, as obesity and weight gain are commonly encountered among this population.
The stimulants may improve attention, energy level, pain, and depression, as well as decrease appetite. However, many patients cannot tolerate the adverse effects of stimulants. In addition, patients with pain are usually on various medications, with possible interactions
Fortunately, addiction to stimulants among adults with ADHD is uncommon.
When stimulants are not appropriate or are not tolerated, various “second-line” medications can be tried for ADHD.
- The α2-adrenergic agonists (guanfacine ER [Intuniv], clonidine [Kapvay]) are primarily used in children and adolescents.
- Various antidepressants have been successfully used for ADHD. These include the older tricyclics (desipramine, nortriptyline), as well as bupropion. These may be appropriate with concurrent anxiety or depression.
- Atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor, is used as a second-line medication for ADHD and is very similar to the tricyclic desipramine, which also increases norepinephrine.
Although these medications are not as effective as the stimulants, they offer several benefits, including the advantage of being nonaddictive, and, when used as once-daily medications, being long acting.
In addition to medications, we often refer patients to psychotherapy. Although therapy does not improve attention itself, the patient benefits in a number of ways. These include receiving help with associated anxiety/depression, family life, relationships, organization, and work life.
A good therapist who is acquainted with pain and ADHD can play a crucial role in improving a patient’s functioning and quality of life.
ADHD is commonly encountered, and is seen in 4.8% of adults. The various symptoms complicate the lives of patients with pain.
The clinical stakes for not recognizing ADHD are enormous; patients often underperform at work, have poor family relationships, and are at increased risk for substance abuse.
Treatment with medications, primarily stimulants, improves quality of life and functioning.
In addition, psychotherapy plays a role, as does stressing the role of sleep, nutrition, and exercise.
Here are other links to this association of ADHD with Pain:
- Attention Deficit Disorder Linked to Chronic Pain | National Pain Report
- Chronic Pain Linked to Attention-Deficit Disorder | Medscape