How can psychopharmacologists effectively (and safely) prescribe stimulants to patients with ADHD who may be using psychoactive substances?
The assessment and treatment of patients with comorbid attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) can be straightforward, except when it is not. The real world of clinical practice is often not as cut-and-dry as the controlled world of clinical research that typically informs our decision-making processes. When does it make sense to prescribe an abusable medication to a patient who may also suffer from SUD? What clinical circumstances dictate prudence and, perhaps, limit-setting? In this case-based review, I will utilize a series of fictionalized clinical anecdotes to help psychopharmacologists determine how to approach prescribing stimulants to patients who may or may not be using psychoactive substances such as cannabis, alcohol, and cocaine.
ADHD in school-age children is known to be a risk factor for the subsequent emergence of SUDs in young adults,1 especially when the ADHD has not been effectively treated.2 Armed with knowledge that untreated ADHD affects children adversely, many pediatricians and child psychiatrists routinely prescribe stimulant medications for children diagnosed with ADHD—to an extent that now suggests the possibility that this condition is sometimes being overdiagnosed and, consequently, overtreated.3 In the following case, trusting parents and clinicians did not detect an emerging SUD in a high school freshman.
A well-spoken boy, aged 14 years, from a “good” family was referred to a child psychiatrist by his pediatrician after failing to respond to methylphenidate extended-release (ER) for “mild ADHD.” The child psychiatrist reviewed the electronic health record, where the social history indicated “no concerns about alcohol, pot, other drugs.” The boy’s history revealed declining school performance throughout eighth grade, and he appeared distracted and unkempt during the interview. Over the next several months, increasing doses of immediate-release (IR) amphetamine/dextroamphetamine were prescribed with an equivocal response. The patient’s mother called for an early refill, stating that her son’s gym locker had been broken into. The psychiatrist met with the patient and obtained a urine drug screen, which came back with a THC level of 584 ng/mL. When confronted, the young man broke down, begged the psychiatrist not to tell his parents, and eventually admitted that he was selling some of his stimulants to pay for weed, and that he himself had crushed and snorted his amphetamine pills on at least a few occasions.
Discussion of Anecdote 1
This situation is concordant with my experience in a variety of ambulatory psychiatric settings. In many real-world outpatient psychiatric settings, empirical stimulant trials to treat presumed ADHD are often undertaken, and urine drug screening may be underutilized at the outset of treatment, especially for younger patients.4 It may appear to the addiction psychiatrist that some patient-centered clinicians possess an alarmingly low index of suspicion that SUD either may be contributing to attentional difficulties or is perhaps the primary problem. Unfortunately, many child psychiatrists receive little to no training in child and adolescent addiction psychiatry,5 despite the fact that there may be much merit in conceptualizing addiction as a pediatric disease.6 Although clear-cut ADHD in a younger child may presage the emergence of SUD in teenagers and young adults, patients like this 14-year-old may appear, at first glance, to be more straightforward than they are. This boy’s primary diagnosis may be SUD, not ADHD.
Psychopharmacologists treating adult patients should routinely endeavor to enrich the fact pattern when they are called upon to prescribe controlled substances for individuals who carry a history of ADHD. Additional assessment strategies come to mind when considering Anecdote 2.
A new male clinic patient, aged 25 years, tells his psychiatrist that he suffers from ADHD. He shows the psychiatrist a prescription bottle of prescribed stimulants (IR amphetamine/dextroamphetamine) with 3 pills left. His previous psychiatrist is known to have retired from practice a few months back. The stimulant dose is average, and he assures his new psychiatrist that he takes his medication by mouth, as prescribed. He has a negative medical history, and other than ADHD diagnosed in elementary school, he has no known psychiatric history. When asked about alcohol consumption, he acknowledges drinking “a beer or two” on weekends, but he otherwise denies substance use. He is the father of an infant who is napping in a stroller in the waiting area, tended to by the patient’s girlfriend. The patient works as a manager in a call center, and he attributes his promotion to the medication’s efficacy.
A seemingly straightforward patient with known ADHD, he is continued on the medication he received from his previous psychiatrist, and a follow-up meeting in 1 month is scheduled. He fails to keep the follow-up appointment, and when called, his girlfriend answers his phone at his bedside in the hospital. She informs the psychiatrist that he had a grand mal seizure at work on Monday morning. Later on, it becomes known that he drank nearly a full 12-pack of beer at a bachelor party over the weekend. After a thorough workup, the consulting neurologist concludes that the seizure may have resulted from a combination of alcohol withdrawal and stimulant medication. The patient’s girlfriend confirmed that his weekend binge drinking has progressed since she gave birth to their son.
Discussion of Anecdote 2
Although this patient appeared “straightforward,” he did not reveal his history of binge drinking to his new psychiatrist. On the contrary, he minimized his alcohol use. This situation underscores the limitations of self-reported historical information. Denvir7 has described the not-uncommon circumstance of patients who put their best foot forward by minimizing their use of alcohol and drugs when interviewed by physicians, who often move forward quickly in taking the substance use history at face value without seeking details beyond the superficial information provided by the patient. In the case described, a recent binge, combined with a proconvulsant medication,8 had a serious and potentially catastrophic impact on the patient.
To what extent should the prescribing physician or clinician dig deep in such cases? One can readily speculate, in retrospect, about the measures the new psychiatrist might have taken. Records from the previous psychiatrist might have been obtained. Reviewing primary care records or speaking with the primary care provider often adds helpful data. In this case, information from the patient’s significant other could have been incorporated into the initial interview—she was right there in the waiting room and could have been artfully engaged in the initial evaluation session. When it comes to ruling out a current SUD, more information from multiple data sources is almost always clarifying. This takes time, but it is good medicine—good psychiatry. Because adults with ADHD are 3 times more likely to suffer from an SUD than those without ADHD,9 psychopharmacologists should routinely conduct a thorough substance use history, with multiple data inputs. This is a best practice that helps to protect patients, who may not be disclosing important information to the prescribing clinician.
A homeless female veteran, aged 30 years, was incarcerated after her fourth shoplifting arrest. She appeared unwell, with hypertension, tachycardia, diaphoresis, agitation, and confusion. Alcohol-withdrawal delirium was diagnosed, and she responded to benzodiazepines and supportive treatment. A toxic screen was positive for cocaine. During her 3 months of incarceration, she was seen by a mental health counselor with experience in the special education system. The inmate’s mental status and school history were consistent with a diagnosis of adult ADHD. The prison psychiatrist opted not to initiate pharmacotherapy, and the patient was discharged, while remaining on probation, to a halfway house for veterans with co-occurring disorders. An addiction psychiatrist affiliated with the Veterans Health Administration opted to treat her with methylphenidate hydrochloride ER tablets, provided she remained in the halfway house, which has daily 12-Step meetings and a robust urine drug screening program. Frequent drug random drug testing was also a condition of her probation. Within 6 months, the veteran was working gainfully and fully engaged in outpatient treatment, and she expressed a strong desire to stay on track and remain a productive member of society.
Discussion of Anecdote 3
Despite the severity of this homeless veteran’s co-occurring SUDs, this case is a success story that demonstrates the efficacy of an integrated treatment approach.10 This anecdote underscores “what good looks like” when it comes to treating an individual with significant ADHD and a severe psychoactive SUD. It is saddening, but not shocking, when patients receive excellent care as a byproduct of the severity of their disorders and the extreme consequences of untreated psychopathology. In this case, arrest and incarceration allowed for a careful longitudinal assessment, including urine drug screening, and this fostered the ability of a savvy clinician to make accurate diagnoses. The need for structured postincarceration treatment was extremely clear, and the patient’s veteran status afforded her access to an appropriate residential treatment program, along with specialized services to treat co-occurring disorders. Her impressive response to structure and accountability is further promoted by her enrollment in a tightly structured monitoring program that utilizes urine drug screening to support a robust abstinence-based recovery program.11
The anecdotes that have been presented and discussed demonstrate that when approaching the pharmacotherapy of ADHD in patients who may be misusing psychoactive substances, artful clinical decision-making should be evidence-based and informed by best practices that are routinely utilized by addiction professionals in the assessment and treatment of patients who suffer from SUDs. Because a history of ADHD is a risk factor for SUDs,12 it is clinically prudent to carefully assess all ADHD patients for current substance misuse. Gourlay’s13 universal precautions for treating pain (and minimizing addiction liability) have been utilized to develop “Universal Precautions for Psychiatrists” for safe, addiction-savvy treatment of anxiety disorders.14 This specific set of universal precautions is further adapted and generalized in the Table.
These universal precautions, initially developed by Gourlay13 to facilitate the addiction-informed treatment of chronic pain and then adapted to promote the addiction-informed treatment of anxiety disorders,14 are now presented in a format that can be utilized whenever a physician or other prescribing professional is considering whether or not to prescribe a potentially abusable psychoactive medication to any patient.
Bastiaens et al15 indicate that individuals with ADHD and co-occurring SUDs, with or without antisocial personality disorder, often respond positively to nonstimulant medications that are prescribed for ADHD. Some addiction psychiatrists make it a practice to begin the pharmacotherapy of ADHD with trials of nonaddictive medications. In fact, this practice may be particularly useful when a new patient presents with a sense of urgency in requesting a schedule II stimulant. When the use of stimulants clearly seems indicated, ER formulations and the prodrug lisdexamfetamine16 may be a safer first choice than IR stimulant compounds with greater abuse liability.
In conclusion, ADHD and SUDs are common conditions that frequently co-occur. A carefully conceived and executed integrated treatment plan that pays adequate attention to ADHD symptoms and also to possible psychoactive substance misuse is a universal best practice. When clinicians without addiction expertise notice problematic behaviors that may indicate that there is more going on than initially meets the eye, a subspecialty consultation may be useful in helping the patient while mitigating risk.
Dr Adelman is a coaching and consulting psychiatrist who is board certified in psychiatry, addiction medicine, and coaching (BCC). He launched www.AdelMED.com after 8 years directing Physician Health Services, Inc. He is on the faculty of the University of Massachusetts Medical School as well as a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.
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