Sobering Advice: How to Treat ADHD Alongside SUD

Attention deficit hyperactivity disorder (ADHD) and substance use disorders (SUDs) are highly comorbid. They overlap — and their connection is of great concern to researchers, clinicians, and patients alike. Individuals with ADHD (especially when untreated) are twice as likely to develop a SUD as are individuals without ADHD, and about half of adolescents and one-quarter of adults with SUDs have comorbid ADHD.^{1 2 3} What’s more, ADHD complicates the trajectory of SUD; SUDs are often more severe, complex, chronic, and harder to treat among patients with ADHD compared to those without ADHD.^{4 5 6 7 8 9}

But SUDs, even with comorbid ADHD, are treatable. Retention in substance use treatment is key to recovery, and retention is far more likely when ADHD symptoms are treated. Unfortunately, many patients who have an active SUD (or even a past history of substance use issues) are either not diagnosed with ADHD or, even with a diagnosis, they are denied medication and appropriate treatment for their co-occurring ADHD due to overstated and misplaced fears, bias, and misinformation. In other words, far too many clinicians discriminate against patients with comorbid ADHD and SUDs.

The Role of ADHD Medications in SUD Treatment

Structured therapies comprising psychotherapy and pharmacotherapy are most effective in treating adolescents and young adults with ADHD and SUDs.¹⁰ Findings from various studies on patients with ADHD and comorbid SUDs show that cognitive behavioral therapy (CBT) can be very helpful to mitigate the ADHD and the SUD. Moreover, ADHD medication improves retention in treatment, ADHD symptoms, and recovery outcomes for SUD.

In one study led by Frances Levin, M.D., that looked at adults with ADHD and cocaine use disorder, those who were treated with extended-release mixed amphetamine salts saw greater ADHD symptom improvement and a significant reduction in cocaine use compared to those who were treated with placebo over the 13-week study period.¹¹  More than that, patients who took a higher dose of the medication (80 mg versus 60 mg) saw further reductions in cocaine use. By the end of the study, about 90% of participants in the placebo group tested positive for cocaine use, compared to about 65% of participants in the 60 mg medication group and about half of the 80 mg group.

Another study showed that atomoxetine improved ADHD symptoms and reduces episodes of heavy drinking in recently abstinent adults with ADHD and comorbid alcohol use disorder.¹² Relative to patients who were treated with placebo, those who were treated with the non-stimulant medication during the three-month study experienced a 26% reduction in cumulative heavy drinking days (more than 4 drinks for females or 5 drinks for males).

[Read: Substance Use Disorders — Signs, Symptoms, and Links to ADHD]

Treating ADHD through active substance use, most importantly, also improves SUD treatment retention, according to findings from our 2021 study of patients with co-occurring SUD and ADHD.¹³ Among patients admitted to an addiction psychiatry clinic who were receiving ADHD medication as part of their treatment, 5% dropped out within 90 days of admission. But among patients who were not taking ADHD medication, 35% discontinued treatment by the 90-day mark — a huge difference in treatment outcomes. These findings also indicate how important it is for clinicians to diagnose ADHD, and initiate early treatment for co-occurring ADHD in patients with SUDs.

Treating ADHD and SUD: Best Practices

ADHD medications — both stimulants and non-stimulants — may be used to treat patients with comorbid substance use disorder. In fact, addressing ADHD symptoms typically improves outcomes for patients with both conditions. For these patients, medication may actually mitigate the risk of dropping out of treatment.

This is not to say that stimulant misuse — including diversion, non-medical use, and use other than prescribed — isn’t a concern regarding patients with SUD and those in other high-risk groups (i.e., young adults and college students).¹⁴ The following guidelines outline best practices for treating patients with SUD and comorbid ADHD, including steps to curtail prescription misuse:^{15 16}

[Read: Treating a Child with ADHD Medication Diminishes His Future Risk of Substance Abuse]

• Treat ADHD concomitantly if the patient’s SUD is not severe (e.g., a patient with cannabis use disorder who intermittently smokes marijuana) and/or if misuse infrequently occurs. (Continuing to treat ADHD may arrest further substance use.)
• Focus on the SUD first if the patient’s substance use is severe, persistent, and causing dysfunction (such as for patients with an opioid use disorder who will need consideration of special medications to address the opioid use). Involve the patient in CBT adapted for SUD and ADHD.
• Consider non-stimulant medications initially (like atomoxetine, alpha agonists, off-label bupropion, tricyclic antidepressants, and more) to treat ADHD symptoms if there are concerns about stimulant misuse. Non-stimulants can also be used to treat symptoms of additional co-occurring conditions, such as depression and anxiety.
• If the patient does not respond well to non-stimulants, consider prescribing extended-release stimulants or prodrug stimulants rather than immediate-release, especially if there are concerns about misuse and diversion. Prodrug stimulants like serdexmethylphenidate/methylphenidate and lisdexamfetamine have lower abuse liability because they only activate once they are metabolized in the body. Many key opinion leaders in the field believe that stimulants may be considered as a first-line treatment if a patient has been off substances from one to three months. Other leaders believe that you can start stimulants safely during active substance use.
• While immediate-release stimulants have the most potential for misuse¹⁷, do not disregard these medications outright. Many SUD-ADHD patients take this type of stimulant and do well. For these patients, closer monitoring for signs of misuse and diversion may be necessary. Remind all patients not to sell, give away, or otherwise misuse their own medication. Prescribe the correct quantity of stimulants (don’t overprescribe), to decrease risk for diversion or misuse. Data suggests that creating excess supply (e.g. a reservoir) increases the likelihood of both misuse and diversion.¹⁸
• Keep open lines of communication with patients. Encourage patients to share if their ADHD medication is causing cravings for substances or otherwise making them more likely to use other substances. Some patients, for example, may experience substance cravings during a stimulant crash (i.e., the wear off of the medication) — an issue that can be resolved by prescribing a small dose of the same stimulant, to be taken about 30 minutes before the wear off symptoms typically emerge.
• Commit to ongoing education about SUDs, ADHD, and the medical, psychological, addictive, and legal issues tied to prescription drug misuse and diversion. Educate patients, especially adolescents and young adults, on these topics. Some patients may be unaware that the act of selling or giving away stimulants is a felony offense.
• Finally, enjoy working with your patients. There is a real sense of satisfaction in helping a patient (re)gain control of their ADHD and of their substance use, resulting in remissions of both their SUD and ADHD. Patients and their families will be highly appreciative of your efforts.

Substance Use Treatment with ADHD: Next Steps

• Take This Self-Test: Could You Have a Substance Use Disorder?
• Read:  The ADHD & Addiction Link — Addictive Behaviors in Adults Explained
• Read: Does Stimulant Medication Cause Drug Dependence?

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Substance Use Disorder and ADHD: Safe, Effective Treatment Options” [Video Replay & Podcast #440] with Timothy Wilens, M.D., which was broadcast on January 31, 2023.

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