A Guide for Clinicians on Treating Substance Abuse in Patients with Comorbid ADHD

Attention deficit hyperactivity disorder (ADHD) and substance use disorders (SUDs) frequently co-occur, a cause of concern to researchers, clinicians, and patients. Individuals with untreated ADHD are twice as likely to develop a SUD compared to those without ADHD, and around half of adolescents and a quarter of adults with SUDs have comorbid ADHD.1 2 3 The trajectory of SUD is often more severe, complex, chronic and harder to treat among those with ADHD compared to those without ADHD.4 5 6 7 8 9

However, even with comorbid ADHD, SUDs are treatable and patients' retention in substance use treatment is essential to recovery. Retention is likelier when ADHD symptoms are treated. Sadly, many patients with an active SUD (or a past history of substance use issues) are either not diagnosed with ADHD or denied medication and appropriate treatment for their co-occurring ADHD due to biases, misinformation, and unfounded fears. Many clinicians, with these attitudes, discriminate against people with comorbid ADHD and SUDs.

Structured therapies that combine psychotherapy and pharmacotherapy are most effective in treating adolescents and young adults with ADHD and SUDs.10 Results from numerous studies on patients with ADHD and comorbid SUDs indicate that cognitive behavioral therapy (CBT) can mitigate ADHD and SUD. Moreover, ADHD medication yields improved outcomes for SUD treatment retention, ADHD symptoms, and recovery outcomes.

A study led by Frances Levin, M.D., examined adults with ADHD and cocaine use disorder. Participants treated with extended-release mixed amphetamine salts experienced more significant ADHD symptom improvement and a substantial reduction in cocaine use compared to those treated with a placebo over the 13-week study period.11 Patients who took higher doses of the medication (80 mg versus 60 mg) witnessed further reductions in cocaine use. By the end of the study, nearly 90% of participants in the placebo group tested positive for cocaine use, while about 65% in the 60 mg medication group and around 50% in the 80 mg group had tested positive.

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

Our 2021 study of patients with SUD and ADHD indicates that treating ADHD through active substance use also improves SUD treatment retention.13 Among patients admitted to an addiction psychiatry clinic who were receiving ADHD medication as part of their treatment, only 5% dropped out within 90 days of admission. By contrast, among patients who were not taking ADHD medication, 35% discontinued treatment by the 90-day mark. These findings underscore the importance of diagnosing ADHD and initiating early treatment for co-occurring ADHD in patients with SUDs.

Medications for ADHD - both stimulants and non-stimulants - can treat patients with comorbid substance use disorder. 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.

However, stimulant misuse, including diversion, non-medical use, and use other than prescribed, remains a concern regarding patients with SUD and those in other high-risk groups like young adults and college students.14 Guidelines recommend best practices for treating patients with SUD and comorbid ADHD, including steps to curtail prescription misuse.15 16

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., broadcast on January 31, 2023.

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