Does a patient with a history of alcohol use disorder (AUD) who relapses after 4 months of improvement on long-acting stimulants for attention deficit hyperactivity disorder (ADHD) require a change in medication treatment?

Management of ADHD Medication in a Patient with Alcohol Use Disorder Relapse

Yes, long-acting stimulants are contraindicated in patients with acute alcohol use disorder, and treatment should be changed to a nonstimulant medication. 1, 2, 3

Rationale for Medication Change

When a patient with ADHD relapses into active alcohol use disorder (AUD), the medication management strategy needs to be adjusted for several important reasons:

1. Safety concerns: Long-acting stimulants combined with alcohol can:

   • Increase risk of cardiovascular complications
   • Mask signs of alcohol intoxication, potentially leading to excessive consumption
   • Create unpredictable drug interactions 3

2. Efficacy considerations:

   • Active substance use can reduce the effectiveness of ADHD treatment
   • The patient's relapse indicates a need to reassess the overall treatment approach 2

3. Guideline recommendations:

   • Non-stimulants are specifically identified as "possible first-line options in comorbid substance use disorders" 1
   • Clinical practice parameters recommend prioritizing stabilization of substance use before continuing stimulant therapy 3

Recommended Medication Alternatives

First-line option:

• Atomoxetine (norepinephrine reuptake inhibitor):
  • Demonstrated efficacy in adults with ADHD and comorbid alcohol use disorders 4
  • Showed significant improvement in ADHD symptoms in patients with alcohol use disorder 4
  • Has no abuse potential or controlled substance status 1
  • Dosing: Start at 40mg daily, titrate to 80-100mg daily as tolerated

Alternative options:

• Alpha-2 adrenergic agonists (clonidine, guanfacine):
  • Specifically noted as appropriate for patients with substance use disorders 1
  • Lower abuse potential than stimulants
  • May help with impulse control issues that contribute to substance use

Treatment Algorithm

1. Immediate action: Discontinue long-acting stimulant medication
2. Initiate non-stimulant therapy: Start atomoxetine or alpha-2 agonist
3. Address alcohol use disorder: Implement appropriate AUD treatment
   • Consider FDA-approved medications for AUD (naltrexone, acamprosate) 5
   • Refer to psychosocial interventions (CBT, support groups) 5
4. Monitor closely:
   • Assess for withdrawal symptoms from both alcohol and stimulants
   • Monitor liver function tests, as both AUD and some ADHD medications can affect hepatic function
   • Track ADHD symptom control with standardized measures

Important Considerations and Pitfalls

• Timing: The non-stimulant medications take longer to reach full effectiveness (6-12 weeks for atomoxetine, 2-4 weeks for alpha-2 agonists) 1
• Withdrawal: Abrupt discontinuation of stimulants may lead to temporary worsening of ADHD symptoms
• Compliance: Patients with active AUD may have difficulty adhering to medication regimens
• Diagnostic reassessment: Consider whether ADHD symptoms are being exacerbated by alcohol use or withdrawal

Future Considerations

If the patient achieves sustained sobriety (typically 3-6 months), reassessment for possible return to stimulant medication could be considered, but only with:

• Regular monitoring for relapse
• Structured dispensing to prevent misuse
• Continued psychosocial support for both conditions

The primary goal should be stabilization of both conditions, with priority given to addressing the substance use disorder while maintaining adequate treatment for ADHD symptoms through safer pharmacological options.