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Bangladesh Journal of Medical Science Vol. 13 No. 02 April’14

128

Original article

Association of Attention Deficit Hyperactivity Disorder with Heroin Addiction

Salman S1, Idrees M2, Anees M3, Idrees J4, Idrees F5, Badshah S6

Introduction:
The attention deficit hyperactivity disorder (ADHD)
is one of the most common neuropsychiatric child-
hood onset disorders that affect 3% to 6%1 and
almost 5% of adults2 and personality characteristics
and diseases, such as novelty-seeking personality,
substance abuse, and heroin addiction, whose fea-
tures are similar to ADHD or are associated with
ADHD3.

Its prevalence in school children is approximately
6% to 9% and etiology of this disorder is unknown4.
There was a myth for many years that the disorder
remits during adolescence, but it is now well estab-
lished that it can be experienced by a patient in
adulthood as well. There is a bidirectional overlap
between ADHD and drug abuse and dependence5
and affect 27% of adult population6.

Corresponds to: Saad Salman, Department of Pharmacy, University of Peshawar, Pakistan.
Email: saadirph@gmail.com 

Abstract:
Objectives: To study the association of attention-deficit hyperactivity disorder (ADHD) with
heroin addiction. Study design: A cross-sectional, hospital based study. Place and duration of
study: The study was carried out at Lady Reading Hospital and Khyber Teaching Hospital,
Peshawar, Pakistan from 4th April 2012 to 13th September 2012. Subjects and Methods: A sam-
ple of 137 adult heroin addicts were analyzed that whether they were ADHD and that child-
hood problem continues to manifest symptoms in adults. For retrospective assessment of child-
hood ADHD, the Wender Utah Rating Scale (WURS) as well as the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) symptom checklist for ADHD was used. The Conners’
Adult ADHD Rating Scales (CAARS) was used to assess the persisting symptoms of ADHD
in adults. Inclusion criteria: Patient diagnosed with heroin addiction according to ICD-9 and
DSM-IV. Exclusion criteria: Patient has co-morbid with any other mental illnesses. Results:
The difference between the mean score of WURS and CAARS of ADHD patients were signif-
icantly greater than the normal patients. Heroin addicts showed 41.6% (WURS) and 38.6%
(DSM-IV diagnostic criteria) that indicated evidence of retrospective ADHD affliction in child-
hood. 22.6% were IV users. CAARS was presented in 37.9% heroin addicts who exhibited a
substantiation of ADHD persistent in adulthood. The difference between the mean score of
WURS and CAARS of ADHD patients were significantly greater (P = 0.003), than the normal
patients. Conclusions: These results revealed that addiction is associated with co-morbidity
with ADHD, expressed in the form of heroin addiction.

Key words: Attention-deficit hyperactivity disorder, heroin addiction, Wender Utah Rating
Scale, Conners’ Adult ADHD Rating Scale.

1. Saad Salman, Department of Pharmacy, University of Peshawar, Pakistan
2. Muhammad Idrees, Department of Chemistry, Islamia College University Peshawar, Pakistan
3. Muhammad Anees, Khyber Medical College, Peshawar, Pakistan
4. Jawaria Idrees, Department of Zoology, Islamia College University Peshawar, Pakistan
5. Fariha idrees, Department of Chemistry, Islamia College University Peshawar, Pakistan
6. Sareer Badshah, Department of Statistics, Islamia College University Peshawar, Pakistan

DOI: http://dx.doi.org/10.3329/bjms.v13i2.18294
Bangladesh Journal of Medical Science Vol.13(2) 2014 p.128-134



The co-occurrence of ADHD and addiction is very
common. Previous studies have shown that adults
with ADHD are a risk for substance use disorder
(SUD) and almost 52% of adult had a lifetime histo-
ry of SUD2, 4. The co-morbidity between ADHD and
SU shows relativity and relevant to research and
clinical development in psychiatry, pediatrics and
psychology6. The diagnosing and specific risk factor
associated with SU within ADHD may lead to a bet-
ter targeted pharmacotherapy and psychotherapeutic
treatments for both the disorders upon expression at
early stage of their lives8, 9. Higher rates of ADHD
have been reported in patients having SUD relative
to controls10, 11. 15% to 25% adults with SUD history
have been estimated to have ADHD12. 

Studies have conducted in juvenile adolescents for
assessing ADHD and other disorders in substance
abusing groups had overrepresentation of ADHD11,12.
ADHD predominates from 15% to 25% in individu-
als with SUD13,14. Two studies showed that the 24%
of 201 inpatients15 and 10% cocaine abusers for drug
detoxification treatment had ADHD16. The treatment
of ADHD is usually done with stimulants like
methylphenidate, amphetamine etc., with the behav-
ioral therapy of the patient and family counseling.
Biederman and colleagues demonstrated that
untreated ADHD is a risk factor for the development
of an SUD5. Wilens14 drew the conclusion that a
pharmacological treatment had no negative influ-
ence on SUDs in ADHD patients. 

Various studies have shown that a treatment of
addicted ADHD patients with stimulants reduces
drug consumption16,17. Adolescents medicated with
stimulants showed a lower risk of developing an
addiction (cocaine, alcohol and other drugs). In our
previous study, we demonstrated that many sub-
stance-dependent patients like THC (tetra-hydro-
cannabinol), poly drug, alcohol and opium abuse
were suffered because of ADHD or were adult
ADHD17.

Material and Methods:
One hundred and thirty seven consecutive patients
admitted in Psychiatry ward of LRH for drug detox-
ification were included in the study. All the patients
were analyzed through an extended clinical semi-
structured interview to collect socio-demographic,
drug use related, clinical data and also the non-
ADHD psychiatric diagnoses were assessed in both
the hospitals by the use of a semi structured diagnos-

tic interview previously validated against the
Structured Clinical Interview for DSM-IV-TR13-15.
Patients evaluated in the hospitals were also assessed
for ADHD, using DSM-IV criteria and a structured
interview provided by J. Biederman, M.D.2,5. 

Adult patients with various drug and alcohol
dependence gave their consent to participate in this
study as in-patients at the Department for Addiction
Lady Reading Hospital. At a clinical interview, all
137patients (all males) met the diagnostic criteria
required for heroine according to Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV),
and were permitted to participate in this investiga-
tion. The examination was performed only after a
10-day detoxification therapy as it was imperative
that the patients were no longer suffering from any
withdrawal symptoms. Exclusion criteria included
other illnesses. Approval for this study was given by
the Ethics Committee of Lady Reading Hospital.

The Wender Utah Rating Scale (WURS) and the
DSM-IV symptom checklist for ADHD served as
investigating instruments for the retrospective
assessment of the presence of ADHD in childhood.
Furthermore, the DSM-IV criteria were used to
divide the patients into diagnostic sub-groups (inat-
tentive type, impulsive type, combined type). The
Conners’ Adult ADHD Rating Scales (CAARS,
Short Version) (Conners et al., 1999) were used to
assess persisting ADHD symptoms in adulthood as a
part of a comprehensive intake valuation battery.

Statistical Analyses:
We analyzed demographic differences between
groups, using chi-square tests for categorical vari-
ables and comparisons of proportion and for the
comparison of proportions. The unpaired t-test was
used to compare means between two groups. The
unpaired t-test was used to compare means between
two groups; 61.3%, patients with ADHD showed a
marked tendency towards substance abuse when
compared to those patients without ADHD (38.7%)
(P = 0.003).A principal components analysis using
varimax rotation was performed on the 25 test items
of WURS and 25 items of CAARS-S. The number of
factors retained was determined by examination of
the screen plot and use of the Kaiser-Guttman rule
(i.e., eigenvalues greater than 1.0). Cronbach's alpha
was calculated as a measure of internal consistency
on all the items of WURS and CAARS-S resulting
from the factor analysis in Wender Utah and Conners
rating scales.

Attention Deficit Hyperactivity Disorder and Heroin Addiction

129



Results:
The total sample comprised of 137 male patients
with an average age groups of 37.5 ± 9.8 years. The
socio-demographic data have been presented (Table
1).The mean score of 61-items of WURS and 26-
items of CAARS-S were calculated but we arbitrar-
ily chose 25-items of WURS and 25-items of
CAARS-S showing the greatest mean difference
between the patients of ADHD and normal.

Table 1: Socio-demographic data of the patients.

Total IV-users in the sample were 31 and affected
were 21 (67.7): HBV 5 (23.8%), HCV 13 (61.9%),
and HIV 3 (14.2%) respectively. Their distribution
in different addiction is shown. (Table 2)

Table 2: Total IV users in the sample (n=31,
affected n=21).

Heroin addicts showed 41.6% (WURS) and 38.6%
(DSM-IV diagnostic criteria) indicated evidence of
retrospective ADHD affliction in childhood.
CAARS was presented in 37.9% heroin addicts.
Scree-test and eigenvalues greater than one, exclu-
sion of factor loadings less than 0.30, factors loading
greater than 0.30 not on more than one factor. A vari-
max rotation yielded the four factors:(1) inatten-

tion/memory problems, (2) hyperactivity/restless-
ness, (3) impulsivity/emotional liability, and (4)
problems with self-concept29 Additionally, an ADHD
index and indices for DSM-IV subscales (DSM-IV:
predominantly inattentive, predominantly hyperac-
tive-impulsive, combined sub-type) can be
obtained11. Test-retest correlations range between
0.81 (impulsivity/emotional lability) and 0.88 (prob-
lems with self-concept). Construct-validity with
WURS reached moderate to satisfying correlations
of 0.31 (inattention problems) to 0.68

(impulsivity/emotional lability). Criterion
validity with a semi-structured interview
for adult ADHD yielded a sensitivity of
81% and a specificity of 83% 33.52
(47.2%) of the patients achieved the cut-
off 50 in the WURS-k and, therefore,
fulfilled the criteria for ADHD symptoms
in childhood.

The correlation matrix was subjected to
principal axis factoring, yielding 11 fac-
tors with eigenvalues greater than 1.0.
Conners et al. decided on an orthogonal

rotation to obtain independent factors of inattention,
hyperactivity, and impulsivity. Since it is unlikely
that these three dimensions are totally unrelated, we
did not limited our analyses to varimax rotation, but
also used oblique rotations. Items were eliminated
from further analyses if they failed to load above
0.30 on any one factor, or if they loaded greater than
0.30 on more than one factor.

The first factor accounted for 12.91% of the total
variance. The eight items that loaded on this factor
were related to inattention/distractability ( =0.82).
The second factor explained 8.12% of the total vari-
ance. The five items loading on that factor tapped on
problems with self-concept ( =0.75). The third fac-
tor accounted for 4.82% of the variance and the four
items loading on it are related to emotional instabil-
ity ( =0.77). The fourth factor explained 4.27% of
the total variance with six items related to impulsiv-
ity ( =0.71). Five items loaded on the fifth factor
that explained 2.25% of the total variance, tapping
on hyperactivity ( =0.87). The sixth factor account-
ed for 2.36% of the total variance and the six items
loading on it are related to sensation seeking (
=0.67).

Salman S, Idrees M, Anees M, Idrees J, Idrees F, Badshah S

130

Socio-demographics ADHD 

Number of Patients, n 137 

Males/Females, n 137/Nil 

Age (Mean ± SD) 37.5 ± 9.8 

Employed n (%) 61 (44.5) 

Married n (%) 37 (27) 

Divorced n (%) 11 (8.02) 

Types of 
Indications 

No. %age Heroin 
users 

HBV 5 23.8% Present 
N=3

HCV 13 61.9% Present
N=7

HIV 3 14.2% Present 
N=1

Total N (%) 21 100% 
approx. 

11(52.3) 



Table 3: Attention deficit hyperactivity disorder
diagnosed with Wender Utah Rating Scale
(WURS), DSM-IV symptom check-list for ADHD
and Conners’ Adult ADHD Rating Scales
(CAARS).

*WURS = The Wender Utah Rating Scale (WURS)
indicates ADHD with a score of more than 30.
**CAARS = Conners Adult ADHD Rating Scales
(the analysis is conducted to indicate subject’s cur-
rent state).
***DSM-IV = Diagnostic and Statistical Manual of
Mental Disorders (a score higher than six in the first
nine items indicates attention problems: a score
higher than six in the last nine items indicates hyper-
activity).

Discussion:
This study comprised of sample of adults admitted in
psychiatry ward seeking detoxification treatment
for heroin addiction were studied that whether they
were ADHD in childhood and this disorder is per-
sisting in adulthood or not. Results of this study sug-
gest that the four factors: inattention/memory prob-
lems, hyperactivity/restlessness, impulsivity/emo-
tional liability, and problems with self-concept char-
acterize the WURS and CAARS-S. These four fac-
tors are found in both the retrospective childhood
and the adult assessment in the corresponding instru-
ments. These factors helped: in distinguishing
ADHD from non-ADHD, associate patients with a
clinical diagnosis of drug and alcohol addiction co-
morbid with ADHD, and do better to identify adults
who do not have ADHD. In addition to poor speci-

ficity of WURS, 31 the underlying factor structure
suggests that WURS can measures depression and
conduct problems, which are not specific to the
DSM-IV ADHD classification. Another possible
reason for the low specificity of the WURS may be
a response bias on the part of patients evaluated in an
ADHD specialty clinic; this is more probable in
adult patients, who are unlikely to have parents
available as informants regarding childhood behav-
ior. Other studies of symptom clusters in children
with ADHD support two factors: inattention and
hyperactivity-impulsivity32,33.
The finding that these four factors are the best dis-
criminator in adults is consistent with the evolution
of ADHD over the lifespan from mixed to more pre-
dominantly inattentive and hyperactive. This finding
also highlights that the cognitive symptom domain is
perhaps the most important to consider when evalu-
ating a general psychiatric population for presence
of ADHD. Our investigations showed significantly
high values for the hyperactive and the combined
types. The isolated inattentive type was under-repre-
sented. The over-representation of the hyperactive
type in this group reflects those individuals willing
to take on a higher risk. Patients categorized under
the inattentive type most likely use the substance pri-
marily for recreational purposes and later on became
dependent.
The results of this study confirm that a high percent-
age of the drug and alcohol-dependent patients
admitted in psychiatry fulfilled the diagnostic crite-
ria of DSM-IV for the presence of ADHD.
The highest rate of ADHD was in children born to
mothers with heroin dependency raised at home,
being twice that observed in the other groups.
Mothers of these groups of children also had a high
rate of ADHD34.
One study suggests that cyclothymic, and to a lesser
extent irritable traits could represent the tempera-
mental profile of heroin addicts, largely irrespective
of co-morbidity, and tend to cohere with previous
conceptualizations hypothesizing sensation-seeking
as the main personality characteristics of addic-
tion35.
Kessler et al. (2006) found quite a high prevalence of
ADHD in alcohol addicts of 4.4%. Our study found
a rather moderate rate of persisting ADHD in the
entire examined group of alcohol-dependent
patients. However, according to our data concerning
the prevalence in childhood, ADHD can represent a
considerable risk factor for the onset and develop-

Attention Deficit Hyperactivity Disorder and Heroin Addiction

131

Heroin addicts n=137 Frequency Percent 

DSM-IV-TR* 53 38.6 

Inattentive type 6 11.3 

Hyperactive-impulsive type 27 50.9 

Combined type 20 37.7 

WURS** 57 41.6 

CAARS*** 52 37.9 

Inattentive type, 5 9.6 

Hyperactive-impulsive type 25 48.07 

Combined type 19 36.5 

Indistinct type 3 5.7 



ment of heroin and other drug dependence as well.
Furthermore, those patients with ADHD were much
more likely to commence with drugs at an early age,
so ADHD can be considered to be a risk factor for
‘early introduction’ to drug addiction. Pre-clinical
investigators (Fung and Lau, 1989) hypothesized
that early exposure to nicotine may result in neu-
ronal sensitization and initiation, pre-disposing to
later behaviors linked to SUD. From a preventive
standpoint, reducing the manifest psychiatric symp-
toms, such as in ADHD, may result in a decrease in
cigarette consumption as well. Findings also indicate
that ADHD accelerates the transition from substance
abuse to substance dependence (Biederman et al.,
1998). There is also evidence that ADHD increases
the risk of drug use disorders in those individuals
with alcohol abuse or dependence (Biederman et al.,
1998). ADHD is also known to affect remission from
SUD. A study was carried out with 130 adults with
ADHD and SUD and 71 non-ADHD adults with
SUD, and the results showed that the average time to
SUD remission was more than twice as long in
ADHD patients than in the control subjects (144 vs.
60 months, respectively) (Wilens et al., 1998).
Studies performed on ADHD patients suggest that
persisting ADHD can lead to continued misuse and
abuse of substances following dependence, a longer
duration of SUD and a lower rate of remission
(Biederman et al., 1998; Wilens et al., 1998). In sum-
mary, these findings indicate that ADHD influences
the initiation, transition and recovery from SUD. 
The high coincidence of ADHD and addiction ill-
nesses may also be due to a number of other causes.
In particular, ADHD patients suffering from hyper-
activity and disturbed control impulses and patients
of the combined type are known to derive a higher
level of pleasure from experimentation and risk-tak-
ing concerning drugs and alcohol. It was found that
hyperactive ADHD patients with drug dependence

were more likely to have an additional other addic-
tions compared to those patients with just attention
disorders (Saules et al., 2003).

Conclusion:
It was confirmed that ADHD forms an association
with heroin addiction and that many patients suffer-
ing from an addiction may also have co-morbid
ADHD. With the help of CAARS, it could be
demonstrated that a significant number of patients
who fulfilled the diagnostic criteria of ADHD,
according to DSM-IV, had persisting ADHD in
adulthood. An ADHD patient poses a marked risk
for the development of different types of addictions.

Limitations:
Some limitations have to be taken into account that
when doing psychometrics on a scale, generally the
sample of subjects chosen to complete the scale
should be similar to the population; the scale was
written for. In this case, the intended population in
adults with ADHD, but this study sampled from a
normal distribution, thus psychometric statistics
generated are biased by properties of the sample.
Even though we assessed a large sample, this is not
normative for the whole Pakistani population due to
convenience and consecutive sampling. Another
limitation of this study was that there were only male
participants.

There should also be comparison of self-ratings on
the CAARS with performance on the Conners
Continuous Performance Test (CPT-II) for further
validation. Although we cross checked the informa-
tion told by the patients but still the responses on the
CAARS-S should also be cross-validated with rat-
ings from close associates, friends or family mem-
bers (CAARS-O).

Salman S, Idrees M, Anees M, Idrees J, Idrees F, Badshah S

132



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