Patients at low risk for comorbid substance abuse should receive stimulant medications as first-line therapy and, like all patients receiving these medications, should be warned against diversion of the drugs and monitored for ADHD response and use or abuse patterns.

First-line therapy for those at moderate risk because active alcohol or marijuana substance abuse disorder or recreational use of other illegal drugs may substitute atomoxetine (Strattera) or bupropion (Wellbutrin) in place of stimulants. They should also receive more frequent monitoring of use or abuse patterns, substance abuse counseling, and urine toxicology testing and family treatment as indicated.

In addition to these precautions, higher-risk patients with current or prior cocaine, opiate, stimulant, or prescription drug abuse disorder should receive atomoxetine or bupropion as first-line agents with use of stimulants only under strict supervision. ADHD treatment may also be delayed until patients have been in substance abuse remission for weeks or months, Dr. Kollins said.

In February, the FDA approved a stimulant medication that may have less abuse potential, the d-amphetamine pro-drug lisdexamfetamine (Vyvanse), for treating pediatric ADHD. However, it is controlled as a Schedule II drug like all the other stimulant medications because of the potential for abuse.

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