What is the best treatment approach for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who uses methamphetamine?

Treatment of ADHD in Patients with Methamphetamine Use

For patients with ADHD who use methamphetamine, atomoxetine is the recommended first-line treatment to manage ADHD symptoms while minimizing risks associated with stimulant medications. 1, 2

Rationale for Non-Stimulant First Approach

When treating ADHD in the context of methamphetamine use, several key considerations guide medication selection:

1. Avoid stimulants initially:

   • Stimulant medications have high abuse potential 3
   • Risk of diversion is significant in patients with substance use disorders 4
   • Methamphetamine use creates concerns about cardiovascular safety with stimulants

2. Benefits of atomoxetine:

   • No abuse potential (not a controlled substance) 1
   • Recommended for ADHD patients with substance use disorders 2
   • Increases both noradrenaline and dopamine in the prefrontal cortex 4
   • Starting dose: 0.5 mg/kg/day; target dose: 1.2 mg/kg/day 1

Treatment Algorithm

Step 1: Stabilize Methamphetamine Use

• Address acute methamphetamine intoxication or withdrawal first
• Consider referral to addiction treatment services
• Implement contingency management strategies

Step 2: Initiate Non-Stimulant Medication

• First choice: Atomoxetine

  • Begin at 0.5 mg/kg/day
  • Titrate gradually to 1.2 mg/kg/day or maximum 100 mg/day 4
  • Monitor for side effects: drowsiness, GI upset, potential BP/HR increases 1
  • Screen for suicidal ideation, particularly in adolescents 1

• Alternative non-stimulants if atomoxetine is ineffective:

  • Extended-release guanfacine (Intuniv): Start at 1 mg daily
  • Extended-release clonidine (Kapvay): Start at 0.1 mg daily 1

Step 3: Add Behavioral Interventions

• Cognitive-Behavioral Therapy focusing on:
  • Time management and organizational skills
  • Substance use triggers and coping strategies
  • Emotional self-regulation 1
• Consider specialized dual-diagnosis treatment programs

Step 4: If Inadequate Response

• Optimize current non-stimulant medication (dose adjustment)
• If still inadequate after 6-8 weeks at optimal dose:
  • Consider switching to a different non-stimulant
  • Only consider stimulants if:
    1. Documented period of methamphetamine abstinence (minimum 3 months)
    2. Strong monitoring system in place
    3. No evidence of medication diversion
    4. Consider long-acting formulations with lower abuse potential like lisdexamfetamine 4, 1

Monitoring Requirements

• Weekly to biweekly visits initially to assess:

  • ADHD symptom response
  • Continued methamphetamine use (urine drug screens)
  • Medication side effects
  • Vital signs (BP, HR)
  • Weight and appetite changes

• Special monitoring for atomoxetine:

  • Baseline liver function tests and periodic monitoring
  • Assessment for suicidal ideation
  • Cardiovascular monitoring 1

Important Cautions

• Stimulant medications (methylphenidate, amphetamines) should be avoided initially due to:

  • High risk of misuse and diversion 3
  • Potential cardiovascular risks when combined with methamphetamine
  • Possible exacerbation of psychiatric symptoms 3

• Research indicates that patients with ADHD and substance use disorders:

  • Have more rapid transition from substance use to dependence 5
  • Experience longer duration of substance use disorders 5
  • May be self-medicating ADHD symptoms 5

The integrated treatment approach with non-stimulant medication and behavioral interventions offers the best chance for improving ADHD symptoms while minimizing risks associated with methamphetamine use 2, 6.