ADHD and SUDs
taken from
TIP 42 Substance Use Disorder Treatment for People With Co-Occurring Disorders
a Samhsa Document This updated (March 2020) TIP is intended to provide addiction counselors and other providers, supervisors, and administrators with the latest science in the screening, assessment, diagnosis, and management of co-occurring disorders (CODs).
Publication ID
PEP20-02-01-004
Publication Date
March 2020
link to full pdf tip sheet
ADHD and SUDs SUDs are among the most common comorbidities of ADHD (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017), and data from clinical and epidemiological studies support this linkage (Martinez-Raga, Szerman, Knecht, & de Alvaro, 2013). Among adults with substance misuse, the prevalence of ADHD is approximately 23 percent, although this estimate is dependent on substance of misuse and assessment instrument used (van Emmerik-van Oortmerssen et al., 2012). Among a sample of more than 500 children with and without ADHD who were followed throughout adolescence and early adulthood (Molina et al., 2018), early substance use in adolescence was greater and escalated more quickly in the children with ADHD. Further, weekly and daily cannabis use and daily smoking in adulthood were signifcantly more prevalent in the ADHD group than the non-ADHD
group. Adults with ADHD have been found primarily to use alcohol, nicotine, cannabis, and cocaine (Lee, Humphreys, Flory, Liu, & Glass, 2011; Luo & Levin, 2017). People with addiction who have co-occurring ADHD have a heightened risk for suicide attempts, hospitalizations, earlier onset of addiction, impulsivity, more severe disease course (for both ADHD and the SUD) and polysubstance use as well as lower rates of abstinence and treatment adherence (Egan, Dawson, & Wymbs, 2017; Katzman et al., 2017). ADHD and SUDs carry an enhanced risk of comorbidity with depression, conduct disorder, bipolar disorders, anxiety disorders, and PDs (Luo & Levin, 2017; MartinezRaga et al., 2013; Regnart, Truter, & Meyer, 2017; Young & Sedgwick, 2015; Zulauf, Sprich, Safren, & Wilens, 2014). Symptoms of ADHD hyperactivity and impulsivity are more strongly seen with substance misuse and SUDs than ADHD symptoms of inattention (De Alwis, Lynskey, Reiersen, & Agrawal, 2014). Although it is important to rule out other causes of inattention or hyperactivity, including substance misuse, misattribution of ADHD symptoms to SUDs increases the likelihood of underdiagnosis (Crunelle et al., 2018). People with SUDs who are newly abstinent or those in active or protracted withdrawal may experience some impairments similar to ADHD. Many of the behavioral symptoms of ADHD also appear during substance intoxication and withdrawal, and functional consequences of ADHD, such as poor job performance or job loss, are also evident in people with addiction. Both alcohol and cannabis can produce symptoms that mimic ADHD. This underscores the importance of conducting a thorough assessment (see Chapter 3) to fully investigate symptoms in childhood, family history of addiction and psychiatric illness, and other biopsychosocial factors that can inform whether a diagnosis of ADHD, SUD, or both are warranted. Treatment of ADHD and SUDs ADHD complicates SUD treatment because clients with these CODs may have more diffculty engaging in treatment and learning abstinence skills, be at greater risk for relapse, and have poorer substance use outcomes. The most common attention problems in SUD treatment populations are secondary to short-term toxic effects of substances, and these should be substantially better with each month of sobriety. Only a limited number of studies explore treatment of ADHD with comorbid SUDs (De Crescenzo, Cortese, Adamo, & Janiri, 2017). Treatment of adults with ADHD often involves use of stimulant or nonstimulant medication; although effcacious in reducing psychiatric symptoms, these medications generally do not alleviate SUD symptoms (Cunill, Castells, Tobias, & Capella, 2015; De Crescenzo et al., 2017; Luo & Levin, 2017). Thus, ADHD medication alone is an insuffcient treatment approach for clients with these CODs (Crunelle etal., 2018; Zulauf et al., 2014). Stimulant medications have misuse potential, and counselors should be vigilant for signs of diversion. Use of longacting or extended-release medication or use of antidepressants instead of stimulants can attenuate diversion and misuse liability. The advised approach to treatment involves a combination of psychoeducation, behavioral coaching, CBT, and nonstimulant or extended-release stimulant medication (De Crescenzo et al., 2017). Little research supports concurrent treatment of these conditions. Some researchers recommend frst addressing whichever condition is most debilitating to the client (Katzman et al., 2017; Klassen, Bilkey, Katzman, & Chokka, 2012). Others suggest that, to stabilize the client, treating the SUD should be prioritized (Crunelle et al., 2018). A systematic literature review and meta-analysis of pharmacotherapy for ADHD and SUD (Cunill et al., 2015) found no effect of timing of initiation of treatment but warns that treatment of ADHD symptoms may need to be delayed until after abstinence is achieved, given possible harmful interactions that can occur between ADHD medications and substances of misuse.
CASE STUDY: COUNSELING AN SUD TREATMENT CLIENT WITH ADHD
John R., a 29-year-old White man, is seeking treatment. He has been in several treatment programs but always dropped out after the frst 4 weeks. He tells the counselor he dropped out because he would get cravings and that he just could not concentrate in the treatment sessions. He mentions the diffculty of staying focused during 3-hour intensive group sessions. A contributing factor in his quitting treatment was that group leaders always seemed to scold him for talking to others. The clinician evaluating him asks how John R. did in school and fnds that he had diffculty in his classwork years before he started using alcohol and drugs; he was restless and easily distracted. He had been evaluated for a learning disability and ADHD and took Ritalin for about 2 years (in the 5th and 6th grades), then stopped. He was not sure why, but he did terribly in school, eventually dropping out about the time he started using drugs regularly in the 8th grade. Discussion: The SUD treatment provider reviewed John R.’s learning history and asked about anxiety or depressive disorders. The provider referred him to the team’s psychiatrist, who uncovered more history about the ADHD and also contacted John R.’s mother. When the provider reviewed a list of features commonly associated with ADHD, she agreed that John R. had many of these features and that she had noticed them in childhood. John R. was started on bupropion and moved to a less intensive level of care (1 hour of group therapy, 30 minutes of individual counseling, and AA meetings 3 times weekly). Over the next 2 months, John R.’s ability to tolerate a more intensive treatment improved. Although he was still somewhat intrusive to others, he was able to beneft from more intensive group treatment.
The Power of Perceptions and Understanding: Changing How We Deliver Treatment and Recovery Services
Millions of people in the U.S. live with a substance use disorder. In 2016, there were 20.1 million people, or 7.5 percent, aged 12 or older in 2016 who had a substance use disorder in the past year. In addition, an estimated 8.2 million U.S. adults 18 or older reported having co-occurring disorders. This means that within the previous year, they experienced both a mental illness and a substance use disorder.
Health care providers are often the first contact for addressing their patient’s substance use disorder. There is ample evidence that those who have a substance use disorder often have feelings of shame that impede treatment-seeking. Therefore, it is essential health care providers understand that negative attitudes, beliefs and language can be barriers that prevent those in need from seeking services, or even sharing information, including being in recovery.
About the Webcast Series: The Power of Perceptions and Understanding
SAMHSA, in partnership with Massachusetts General Hospital, Recovery Research Institute, produced a four-part webinar series was developed to educate healthcare professionals about the challenges of discriminatory practices and inaccurate perceptions in treating individuals with substance use disorders (SUDs) and related conditions, as well as those living in recovery. The series emphasized the harm caused by negative perceptions and prejudicial behaviors and highlighted the importance of adopting non-discriminatory approaches to improve care and outcomes for these individuals.
Webinars
The webinars aired live in March 2018. Participants could earn free CME/CE credits for attending the one-hour webinars.They are available on SAMHSA’s YouTube Channel.
March 28, 2018: “Overcoming stigma, ending discrimination”
April 26, 2018: “Why addiction is a 'disease' and why it’s important”
May 22, 2018: “Reducing discriminatory practices in clinical settings”
June 19, 2018: "A future without discrimination and discriminatory practices"
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