What are the risks of using stimulants, such as amphetamines, methylphenidate (Ritalin), or modafinil (Provigil), in individuals with alcohol use disorder (AUD)?

From the Guidelines

Using stimulants in individuals with alcohol use disorder (AUD) is strongly discouraged due to the significant risks of increased stroke risk, cardiovascular complications, and potential for cross-addiction, as evidenced by recent studies 1. The combination of stimulants and alcohol can have devastating consequences, including:

• Increased risk of stroke, with a dose-dependent response, as heavy alcohol use is consistently associated with increased stroke risk (ischemic and hemorrhagic) 1
• Cardiovascular complications, such as irregular heartbeat, elevated blood pressure, and increased risk of heart attack, due to the dangerous stress placed on the cardiovascular system by the combination of stimulants and alcohol
• Potential for cross-addiction, as individuals with one addiction are more vulnerable to developing others, and stimulants may increase the risk of developing another substance use disorder
• Masking of sedative effects of alcohol, leading to increased consumption and risk of alcohol poisoning
• Exacerbation of underlying psychiatric conditions, such as anxiety or mood disorders, which are common in individuals with AUD
• Accelerated liver injury, as both alcohol and stimulants can cause liver damage If stimulant treatment is absolutely necessary for conditions like ADHD in a patient with AUD, it should only be initiated after the patient has established stable sobriety, preferably with non-stimulant alternatives considered first, and should include close monitoring, regular drug screening, and integration with addiction treatment 1.

From the FDA Drug Label

WARNINGS Serious Cardiovascular Events Sudden Death and Pre-Existing Structural Cardiac Abnormalities or Other Serious Heart Problems Patients should be advised to discontinue therapy and immediately report to their physician any signs or symptoms suggesting angioedema or anaphylaxis Psychiatric Adverse Events Pre-Existing Psychosis Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a pre-existing psychotic disorder 5. 5 Psychiatric Symptoms Psychiatric adverse reactions have been reported in patients treated with modafinil.

The use of stimulants, such as amphetamines or modafinil, in individuals with alcohol use disorder (AUD) may pose significant risks, including:

• Cardiovascular events: Stimulants can increase heart rate and blood pressure, which may be problematic for individuals with pre-existing cardiovascular conditions.
• Psychiatric adverse events: Stimulants may exacerbate symptoms of pre-existing psychotic disorders, bipolar illness, or other psychiatric conditions.
• Interactions with other substances: The use of stimulants in combination with alcohol or other substances may increase the risk of adverse reactions, including angioedema or anaphylaxis. It is essential to exercise caution when prescribing stimulants to individuals with AUD, and careful monitoring is necessary to minimize potential risks 2 3.

From the Research

Risks of Using Stimulants with Alcohol Use Disorder

• The use of stimulants, such as amphetamines, methylphenidate (Ritalin), or modafinil (Provigil), in individuals with alcohol use disorder (AUD) poses significant risks 4.
• There is limited research on the specific risks of using stimulants with AUD, but studies suggest that combining these substances can lead to increased harm and decreased treatment efficacy 5, 6.
• The use of stimulants, such as modafinil, has been explored as a potential treatment for amphetamine-type stimulant use disorder, but a systematic review and meta-analysis found no significant effect on efficacy outcomes and an increased risk of serious adverse events at higher doses 7.

Potential Consequences

• Combining stimulants with alcohol can lead to increased risk of:
  • Cardiovascular problems
  • Psychotic episodes
  • Seizures
  • Respiratory depression
• The use of stimulants with AUD can also lead to decreased treatment efficacy and increased risk of relapse 8, 5.
• It is essential to approach treatment for AUD and stimulant use disorder with caution and under the guidance of a healthcare professional 6, 4.

Treatment Considerations

• Current evidence-based treatments for AUD include medications such as disulfiram, naltrexone, and acamprosate, as well as behavioral therapies 8, 5.
• Treatment for stimulant use disorder may involve contingency management, pharmacotherapies, and behavioral therapies 4.
• A comprehensive treatment plan should consider the individual's specific needs and circumstances, and be developed in consultation with a healthcare professional 6, 4.