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.High dosescan result in paranoid psychosis, depression, anxiety and suicidal ideas.Ecstasy isalso associated with a rapid development of tolerance.LSD is another hallucinogen.This drug creates the effect of visual distortion, distur-bance in sense of time and increased sensitivities to colours and sound.These sensa-tions may be attractive to people with ADHD, who are experimental in nature andnot afraid to take risks.However, users are particularly sensitive to their environ-ment and a threatening atmosphere can create a bad trip.Adverse effects includelater flashbacks and panic attacks.Opiates (heroin, methadone, codeine, etc.)Some adults with ADHD have experimented with harder drugs such as heroin.Reg-ular use of such drugs results in a higher tolerance to opiates leading to dependencyand addiction.Dependence withdrawal occurs 8 12 hours after the last dose, lead-ing to symptoms of intense craving for the drug, restlessness, irritability, increasedbowel activity, nausea and vomiting.Withdrawal and craving, combined with an238 ADHD IN ADULTSimpulsive temperament, may increase the likelihood of individuals committing op-portunistic theft and violence to fund their habit.The prescription of oral methadoneis the commonest approach to the management of opiate withdrawal.If individualspresent with this level of dependency, then it is strongly recommended that the per-son is referred for detoxification.Only after this has been successfully completedand the person has been drug free for a period of at least six months should psycho-logical treatment for ADHD be commenced.Prior to this, it would be difficult todetermine whether symptoms relate to drug misuse or ADHD.PSYCHOEDUCATIONPsychoeducation is a vital component of the process of change.It is importantthat clients make informed decisions and are empowered to make choices.This isachieved by the therapist outlining the model of the stages of substance misuse.Itapplies techniques to assess the position of the client within the model, and evaluatesthe risk of their behaviour.The Five Stages of Substance UseSubstance use can usually be categorised into one of five different stages of use.Indi-viduals may use several substances, each in different stages.Table 13.1 shows the dif-ferent stages and describes the function or motivation each stage serves to an individualwith ADHD (this is also included on the Companion Website in handout format).A characteristic of ADHD is sensation-seeking behaviour and a need for stimu-lation.The first stage of experimenting with drugs can fulfill these needs as theyprovide personal gratification in the form of thrills and excitement.For example,a client, Craig, described how he first began abusing solvents when truanting fromschool.This arose partly because, by not attending school, he had more unstructuredtime on his hands; he became bored and wanted thrills and excitement.He thoughthe could achieve this by trying new experiences.He made friends with a group ofTable 13.1 The fi ve stages of substance useStage of use Motivation for use1.Experimental Curiosity; pleasure seeking; risk taking; sensation seeking; poorimpulse control2.Social Need to be liked; affected by peer group social influence; socialattitude; depends on availability3.Instrumental Used purposefully to create certain behaviours such as seeking highs or using to cope with stress and negative feelings4.Habitual The need to use becomes more regular and frequent5.Dependent The substance is constantly needed and misuse is regarded as normal despite negative consequencesSUBSTANCE MISUSE 239adolescents who spent time at the local park, drinking alcohol and sniffing glue.Healso started to steal items from shops.People with ADHD are unlikely to considerthe risks attached to taking a mind-altering substance because they do not thinkabout the potential consequences.Aside from damaging his health, Craig ran therisk of being caught and prosecuted, but he did not consider this possibility.The second stage of substance use, the social stage, may be particularly relevant forpeople with ADHD as they may perceive this to be a way of making friends andincreasing their popularity.Drug misuse may be a means of integration with peers,as opposed to being an outsider.The ADHD individual may believe that if they takedrugs, they will be accepted by their peer group (even if this is a deviant peer group),which is a position to which they have long aspired.For example, Craig looked olderthan his friends and got away with buying alcohol when he was 15 years old.For abrief period he found he was very popular with his new friends who requested him topurchase drink on their behalf.He believed he was accepted socially and spent timewith these friends in the park drinking to excess.When his new friends became oldenough to buy their own alcohol, they were no longer interested in Craig.Once the individual enters the instrumental stage, the drug provides positive rein-forcement.This means the individual feels rewarded by their experience of takingthe drug itself and this increases the likelihood that they will take it again.For ex-ample, many young people take ecstasy to stay up and dance all night.They have agreat time and do not feel tired, so the next time they go out late, they take ecstasyagain.This begins to become a problem when the person believes that they cannothave a good time or enjoy themselves without taking the drug.Ironically, for indi-viduals with ADHD, the positive reinforcement may be that they are better able toconcentrate and complete tasks.Their social skills may improve as they engage betterin social situations by resisting the urge to flit about in company or frequently changethe topic of conversation
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