Link Between ADHD and Substance Use Disorder: Symptoms and Treatments

Substance use disorders (SUDs) are chronic and complex conditions characterized by problematic patterns of substance use (single or multiple substances) causing significant distress and impairment over time. Individuals with SUD exhibit cognitive, behavioral, and/or physiological symptoms indicating that they continue to use the substance despite its negative effects and consequences. Individuals with substance use disorders lose control over their ability to cut back or stop substances. About 10% of teens and up to 30% of adults will have an SUD sometime in their lifetime.1

SUDs often co-occur with other disorders, including Attention Deficit Hyperactivity Disorder (ADHD).2 About one in two adolescents and one in four adults with SUD has co-occurring ADHD; the risk for SUD is higher among adolescents and adults with untreated ADHD.3 4

Substance use disorders are categorized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) based on a patient’s use of the following classes of drugs and substances:5

The DSM-5 lists 11 symptoms, grouped into four categories, that characterize SUD. Individuals may be diagnosed with SUD based on the number of symptoms they exhibit within a 12-month period. Two to three symptoms indicate a diagnosis of mild SUD; four to five symptoms indicate moderate SUD, and six or more symptoms indicate a severe SUD.

Some of the following SUD symptoms may be more or less salient depending on the substance, or they may not apply at all. (Withdrawal symptoms, for example, are not specified for phencyclidine use disorder. Withdrawal symptoms also vary across the types of substances.)

Adults and teens with ADHD are more likely than individuals without ADHD to use nicotine, drink alcohol, and use other drugs.6 Teens (ADHD or not) may exhibit less inhibition around drug use at this developmental stage due to the fact that the paralimbic areas, which are activated and sensitive to emotions and rewards (e.g., activated by stimuli like drug use), develop earlier than the frontal oversight (dampening) components of the brain.7 Still, teens and adults with ADHD are more likely than individuals without ADHD to start experimenting with drugs at earlier ages.8 Therefore, teens and young adults with ADHD should be screened for potential problems related to substance use. (Established screeners such as S2BI, TAPS tool, or queries about SUD are recommended as opposed to toxicology testing.)

ADHD is associated with both an earlier onset of and a higher risk for SUDs.8 Untreated ADHD doubles the risk for developing an SUD, according to some estimates.3 9 SUD is often more severe, complex, and chronic when it co-occurs with ADHD. Remission rates are lower among individuals with SUD and ADHD, as are retention rates in SUD treatment — critical to patients for sustaining recovery.10 11 12 13 14 15

Research on the mechanisms underlying the ADHD-addiction link is ongoing, but studies suggest that ADHD and SUD arise, in part, from differences in the brain’s reward system.16 ADHD and its associated symptoms, like impulsivity, may also increase vulnerability to substance use and later SUDs.17 Genetics may also play an important role in ADHD-SUD risk.18 Some researchers also hypothesize that the increased risk for SUD in ADHD stems from efforts to self-medicate, though studies on this theory remain inconclusive.19

Marijuana is the substance most commonly used and misused by individuals with ADHD, and ADHD is among the most common psychiatric comorbidities found in adolescents with cannabis use disorder.8 20

Marijuana use, as is well known, is associated with acute neuropsychosocial impairment. One study of young adults with and without ADHD found that those who started using before age 16 fared worse on measures of executive functioning (e.g. organization) and other cognitive outcomes than those who started using marijuana later — an especially worrisome finding given that study participants with ADHD were more likely to report cannabis use before age 16.21 A large study called the Adolescent Brain and Cognitive Development (ABCD) study is currently underway to study the impact of cannabis on brain development.

While some individuals with ADHD self-report using marijuana to self-medicate, one study showed that cannabis use does not lead to improved cognitive performance or activity level, although more research is warranted to understand cannabis’ effect on ADHD symptoms.22 23

No, early treatment of ADHD and its continuous treatment throughout life actually reduces the risk of substance use and substance use disorders (SUDs), according to studies. Stimulant treatment for ADHD before the age of 9 appears to be associated with the biggest reduction in the risk of later SUD. A study found that children who started stimulant treatment after this age were at greater risk for substance use during adolescence than those who started earlier. However, early onset stimulant treatment for ADHD does not increase the risk of using cocaine or methamphetamine – both stimulants.

Some treatment options for SUDs include: cognitive behavioral therapy (CBT), pharmacological approaches, and structured therapies, depending on an individual's circumstances and needs. Adolescents and adults with SUDs or problematic substance use should be screened for ADHD due to the known links between ADHD and SUD. Structured therapies such as CBT and pharmacological approaches appear to be the most effective for individuals with both SUDs and ADHD. Treatment may start with CBT focusing on SUD before ADHD, and then alternate between the two, helping individuals manage symptoms and other ADHD-related issues that may interfere with substance use treatment.

It is important to treat ADHD with non-stimulant and/or stimulant medications during an active substance use disorder, as it helps individuals stay in treatment, and retention in substance use treatment is highly linked to successful outcomes. 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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