Treatment of ADHD in the face of addiction
In the absence of comorbidity, treatment of patients with ADHD is relatively straightforward and can be highly rewarding. The most effective medications (largest effect size) are the psychostimulants (methylphenidate, dexamphetamine, and variations thereof).22 Of the stimulants, the safest and least open to abuse are the long-acting stimulants.23 These medications reduce the speed and degree of dopamine(Drug information on dopamine) neurotransmission compared with shorter-acting stimulants; they therefore do not produce euphoria, drug liking, or withdrawal effects on discontinuation and, as such, are not considered to be addictive.24
Nonstimulants such as extended-release bupropion and atomoxetine(Drug information on atomoxetine) are second-line medications. They are less effective than stimulants (ie, have a smaller effect size), but they can be highly useful when stimulants are contraindicated.25 Older drugs such as desipramine can be effective in certain situations but are considered third-line agents because of the higher risk of adverse effects.26
Nonpharmacological treatments, while generally less effective than stimulant medication, nicely complement drug treatment and can increase the overall effectiveness of treatment significantly.27 In adults, psychosocial treatment includes lifestyle and workstyle coaching, parenting advice and coping strategies, organization skills building, counseling for non-ADHD comorbidity, exercise programs, nutritional supplements, diet management, and stress management techniques. All patients benefit from education and from having their physicians advocate on their behalf.
Studies have shown that ADHD is associated with earlier onset of substance use, more severe addiction, and more difficulty in maintaining abstinence.28 Treatment of ADHD in children and adolescents seems to decrease the risk of subsequent addic-tion, but a number of recent studies suggest that decreasing risk likely requires long-term treatment—at least long enough to cover the period of increased vulnerability into early adulthood.29-31
Managing ADHD with stimulants in patients who are active substance abusers is not contraindicated and in fact has shown some promise. Stimulants may improve retention in addiction treatment, and in some cases, they may decrease harm from substance use.32,33 However, stimulants have not been particularly effective in decreasing drug use per se; this may be because the prevalence of comorbidities is high in ADHD and because treating ADHD with stimulants (especially short-acting stimulants) has its own inherent risks.23,34
While it can be difficult to make the diagnosis of ADHD in persons with an active substance use disorder, the 2 disorders can be reliably separated if one obtains a clear history from family and school reports of ADHD symptoms that preceded drug use and/or that persisted through periods of prolonged abstinence.35,36 The use of psychostimulants to manage ADHD in active stimulant users is contraindicated. Because of the high incidence of comorbid mood and impulse control disorders, the primary risk associated with using stimulants in this population is mood dysregulation. A secondary risk is that stimulant medication, at least initially, may cause a high that triggers increased drug use. This is particularly true of short-acting stimulants, which also pose the added risk of being prone to misuse, abuse, and diversion.23,37
These risks can be mitigated by a combination of patient education, contracting, and due diligence38:
• Assessing patients for a full range of comorbidity in the presence of a family member
• Starting medication at low doses and titrating slowly up to symptom remission, with close follow-up
• Educating patients about possible adverse effects and how to manage them
• Ensuring that patients avoid stimulant-containing foods, drinks, and medications
• Using nonstimulants in the first 4 months of recovery and prescribing extended-release stimulants whenever possible
