Evidence-Based Reviews

Do stimulants for ADHD increase the risk of substance use disorders?

Current Psychiatry. 2011 August;10(8):20-24

References

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Clinical Point

Nonstimulant medications may be an option for a patient with comorbid ADHD and SUDs

Table 2 offers clinical recommendations to minimize the risk of SUDs when treating ADHD patients with stimulants. Long-acting stimulant formulations are preferred over short-acting medications because they are less likely to be abused. Psychosocial interventions for treating ADHD and co-occurring SUD disorder include cognitive-behavioral therapy with emphasis on structured skills training and cognitive remediation.

Table 2

Minimizing SUD risk when treating ADHD patients with stimulants

Assess symptom burden and psychosocial impairment
Establish a treatment contract and boundaries at the onset of treatment, including your right to terminate treatment if you suspect stimulant misuse
Assess for comorbidities that may increase your patient’s SUD risk (see Table 1)
Emphasize strict adherence to treatment recommendations
Involve the patient’s family as much as possible
Obtain collateral information on the patient’s history of ADHD-related symptoms from parents, siblings, significant others, etc.
Distinguish between patients with substance use vs an SUD or a history of an SUD
Obtain urine toxicology screening as appropriate
Carefully document dispensed stimulants– strength of medication, number of capsules, pills, patches, etc. Note date of dispensation and refill dates
Select delayed- or extended-release stimulant formulations
Consider prescribing nonstimulants if appropriate
Use rating scales such as Conners Adult ADHD Rating Scale to monitor ADHD symptom severity and response to treatment
Schedule frequent, face-to-face clinical monitoring visits
ADHD: attention-deficit/hyperactivity disorder; SUD: substance use disorder

Related Resource

Clinical Point

Extended-release stimulant formulations are less likely to be abused

Faraone SV, Wilens T. Does stimulant treatment lead to substance use disorders? J Clin Psychiatry. 2003;64(suppl 11):9-13.
Upadhyaya HP, Rose K, Wang W, et al. Attention deficit hyperactivity disorder medication and substance use patterns among adolescents and young adults. J Child Adolesc Psychopharmacol. 2005;15:799-809.
Mariani JJ, Levin FR. Treatment strategies for co-occurring ADHD and substance use disorders. Am J Addict. 2007;16(suppl 1):45-56.

Drug Brand Names

Atomoxetine • Strattera
Bupropion • Wellbutrin, Zyban
Guanfacine • Tenex, Intuniv
Methylphenidate • Ritalin
Modafinil • Provigil
Venlafaxine • Effexor

Disclosures

Dr. Shailesh Jain and Dr. Islam report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Rakesh Jain has received research support from, is a consultant to, and/or is a speaker for Addrenex Pharmaceuticals, AstraZeneca, Eli Lilly and Company, Forest Pharmaceuticals, Merck, Pamlab, Pfizer Inc., Shionogi Inc., Shire, and Sunovion Pharmaceuticals.