How do you approach the use of stimulants in patients with ADHD with previous or current substance use disorders?

I agree with Dr. @Dr. First Last about the use of non stimulants as an important intervention with these patients with the added caveat that Wellbutrin XL is highly abused by crushing it up and snorting it. Even this strategy has its limitations in addressing the issue of ADHD and Substance Use Disorders (SUDs). Additional some patient's ADHD is severe enough that only stimulants can help adress their symptoms. Therefore my answer will concentrate mainly on the clinical decision of whether or not to use stimulants in this situation.

The use of stimulants to treat ADHD in kids with SUDs is actually the most frequent question I get from parents of teenagers with ADHD and here in El Paso, as I'm sure occurs in a lot of the country, there is a clear divide in how psychiatrists (and to a larger extent) pediatricians, address this question. Most pediatricians and about half of the psychiatrists refuse to precribe stimulants to any kids with substance abuse issues. Even worse, Medicaid won't cover stimulants for anyone with a history of a positive UDS. All of this reluctance or outright refusal, to use stimulants with kids who have SUDs, is driven by the black box warning from the FDA and what a well meaning colleagues/friend called "common sense" convictions. But what is the evidence supporting our response to such an important question?

Unfortunately, for obvious ethical reasons, prospective double-blind placebo-controlled studies of the use of stimulants and SUDs cannot be conducted. Most studies have, therefore, concentrated on retrospective analysis of the relationship between ADHD stimulant treatment and SUDs and, more recently, a few more useful, prospective longitudinal observation studies on this issue. I included the latest published prospective study as a citation because they do a great job of reviewing the previous meta-analysis findings and the limitations and difficulties of these types of studies. Please read that study for greater insight on this issue. 

In short, they confirmed what an earlier metalysis (2013) concluded; they found "no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, Marijuana, nicotine or other substances". So where does that leave us? What should we advice our patients?

That's why I love this organization for giving us a chance to share how we incorporate the best data available into our everyday practice, where we take care of patients that rarely meet the inclusion criteria of our gold standard studies. I, like most of us, probably start of by educating our patients on the available data. With this issue, I think it is important to start of with the "common sense" ideas underlying this difficult decision.

I let them know that some poeple believe that the use of stimulants can cause changes in the brain that could predispose or make them more sensitive to substance use, a process known as "priming" or "sensitization". Most of the evidence for this idea comes from animal models of addiction and not from human studies. However, it is important to consider that when correctly diagnosed, kids with ADHD do not experience stimulants in the same way as other kids. They calm down and rarely describe any euphoric effects with stimulants and can even get sleepy on them. So any concern for "priming" our ADHD patients for SUDs should probably be reserved for our misdiagnosed patients and not the correctly diagnosed patients.

The other thing to consider with our patients is the idea that treatment of ADHD with stimulants can help decrease impulsive behavior, which is widely accepted as an important susceptibility factor for SUDs, especially in animal models. I let my patients know that treating their ADHD can help them think their decisions through a lot more often, and can help them decide not to use drugs, more often than if they were not on a stimulant. This concept has great construct validity and uses common sense to show our patients how stimulants could help them in their everyday decisions that can that can keep them from getting into trouble with drugs or other things like fighting.

It is also important to let them know that even though the data has been inconclusive overall, most of the early metaanalysis of retrospective studies, as well as more recent large epidimiological studies have shown a protective factor for the use of stimulants with SUDs. One final factor that I always bring up with my patients when making these decisions is my belief that adolescents use drugs to self medicate. I know that this is a controversial idea that is too simplistic to account for the totality of factors affecting SUDs but I really do believe that a lot of our patients are self medicating with drugs. If parents and patients believe this to be true for themselves then this can also play a huge role in deciding whether or not to use stimulants to treat their ADHD. Of treatment with the stimulant or non stimulant can make them feel better overall then they won't need to look for relief from recreational drugs as often, or at all.

After I educate them on all of this, then we decide together which way to go. As you can tell from my post, I am a big believer that treating ADHD is very helpful in getting my patient's SUDs under better control. One final thing to consider is the use of prodrugs as your drug of choice for kids with ADHD and SUDs since these formulations (Vyvanse, Astarys, Journey PM, etc.) cannot be abused through snorting them and that kids with ADHD and anxiety seem to do better with Straterra and Tenex than they do with stimulants.

Sorry for the long answer but I find this subject fascinating and I wanted to at least got the highlights of this important issue. I hope that some of you have found this helpful.

Molina et al., PMID 37405756

As a child/adolescent psychiatrist, I am less wary about prescribing stimulants than many general psychiatrists might be. However, even in teens who are eligible to drive, I would primarily recommend non-stimulants such as Strattera, Wellbutrin, or Cymbalta. These provide 24-hour efficacy, far superior to stimulants’ brief coverage.

But the core question is really diagnostic, right? Is this patient malingering, manipulating us to enable their addiction? Certainly, ADHD predisposes kids to develop addiction. Would appropriate treatment then be protective? Can we get reliable information about this patient’s childhood and the presence of ADHD symptoms early in life? Tough questions. If someone presents suggesting that they may have ADHD, I am likely to ask for core symptoms; distraction, impulsivity, lack of persistence, and organizational skills, but then ask for examples both current and historical to pin down the diagnosis to my satisfaction. Only then can we begin discussing treatment.

Working primarily in the addiction field, I will try to break down what can be a 30-minute lecture.

1. During your intake, ask an open-ended question about "What kind of student were you in elementary and middle school?" and you can then follow up with high school GPA, college, etc. If you ask a leading question; "Did you have trouble focusing and sitting still in childhood?" they are more likely to help you arrive at an ADHD diagnosis.
2. Still exploring their childhood, during intake explore any issues that might be related to a diagnosis of PTSD, MDD, Bipolar, or substance use disorders, that could better explain the issues with focusing and sitting still that they might have been experiencing.
3. Speak with parents, siblings, or spouses who have information about childhood functioning in school and current-day functioning. Make sure they are not currently using substances such as cannabis, alcohol, benzos, or other substances/medications that can cause symptoms that mimic ADHD.
4. Get psychological testing. Do not rely on poor quality testing or on a client's statement that "so and so doctor" has been treating them for ADHD for years. Speak with their prior treating doctor and ask what led them to a diagnosis of ADHD, how the patient has responded to treatment, etc.
5. Do not prescribe ADHD medications until mood and anxiety are stable. Often clients ask for ADHD medications because they have depression and low energy and stimulants give them energy and focus. By treating their "ADHD", you miss an opportunity to treat their underlying depression.
6. Make sure you have the right diagnosis. Are you treating bipolar or unipolar? There is a triad of early-onset substance use, mood disorder, and ADHD that co-occur. So if you have a client with a substance use and mood disorder, I am at high suspicion that they have ADHD.
7. The most common mistake I see doctors make is missing a bipolar diagnosis and not treating a patient's mood and anxiety adequately before initiating ADHD treatment.
8. Start with atomoxetine and then Qelbree as a first-line treatment for most patients. I have had great success with Qelbree. If adequate trials of these meds don't work, then move onto the stimulants. I usually start with Vyvanse which has an easier and less abrupt onset of action.
9. Don't be in a rush to treat ADHD. Do all of the above first. I have a handful of patients I treat in my small practice to prove that the above works. When it's done right, the benefits to the patient are immeasurable in giving them a fantastic life.