How to manage a patient with methamphetamine use disorder and Attention Deficit Hyperactivity Disorder (ADHD)?

Managing Patients with Methamphetamine Use Disorder and ADHD

For patients with comorbid methamphetamine use disorder and ADHD, non-stimulant medications such as atomoxetine should be used as first-line pharmacotherapy, combined with behavioral interventions including contingency management and cognitive behavioral therapy. 1, 2, 3

Assessment Considerations

When evaluating a patient with both methamphetamine use disorder and ADHD:

• Confirm ADHD diagnosis through comprehensive clinical interview assessing:

  • Childhood history of symptoms
  • Current symptoms across multiple settings
  • Functional impairment in academic, occupational, and social domains
  • Family history of ADHD (high heritability)
  • Executive function deficits

• Assess severity of methamphetamine use disorder:

  • Frequency and amount of use
  • Duration of use
  • Previous treatment attempts
  • Triggers for use
  • Current withdrawal symptoms

Treatment Algorithm

Step 1: Pharmacotherapy Selection

First-line options:

• Atomoxetine (Strattera) 1

  • Starting dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day
  • Advantages: No abuse potential, does not exacerbate substance use

• Alternative non-stimulants:

  • Bupropion (100-150 mg daily, sustained-release)
  • Guanfacine (Intuniv) (0.1 mg/kg once daily)

CAUTION: Avoid prescribing methylphenidate or amphetamine-based medications initially due to high risk of misuse and diversion in patients with active methamphetamine use disorder 4

Step 2: Behavioral Interventions (Concurrent with Pharmacotherapy)

• Contingency Management 2, 3

  • Provide tangible rewards for drug-negative urine samples
  • Research shows significantly more negative samples and longer abstinence periods (5 vs 3 weeks)

• Cognitive Behavioral Therapy 1, 3

  • Target both ADHD symptoms and substance use behaviors
  • Focus on:
    • Developing coping skills for ADHD symptoms
    • Identifying triggers for methamphetamine use
    • Building relapse prevention strategies

Step 3: Monitoring and Follow-up

• Weekly visits initially, then biweekly as stability improves
• Regular urine drug screens (3 times weekly initially)
• Monitor vital signs at each visit (blood pressure, heart rate)
• Assess ADHD symptoms using standardized scales
• Evaluate for psychiatric comorbidities (depression, anxiety)

Special Considerations

For Patients with Sustained Abstinence (≥3 months)

In patients who have demonstrated sustained abstinence from methamphetamine and continue to have significant ADHD symptoms despite non-stimulant treatment, cautious consideration of lisdexamfetamine may be warranted:

• Lisdexamfetamine has lower abuse potential compared to other stimulants due to its prodrug formulation 5
• Case evidence suggests it may reduce stimulant cravings in some patients 5
• Requires:
  • Close supervision
  • Frequent urine drug screens
  • Dispensing limited quantities
  • Clear boundaries and treatment agreement

Common Pitfalls to Avoid

1. Prescribing stimulants too early - Stimulant medications have high abuse potential and can trigger relapse in patients with methamphetamine use disorder 4

2. Ignoring comorbid psychiatric conditions - ADHD often co-exists with other psychiatric illnesses that require simultaneous treatment 1

3. Inadequate monitoring - These patients require more frequent follow-up and drug testing than typical ADHD patients

4. Dismissing ADHD symptoms as drug effects - Untreated ADHD may contribute to continued substance use as a form of self-medication 6

5. Focusing only on substance use - Treating both conditions concurrently yields better outcomes than addressing only the substance use disorder

By following this structured approach that prioritizes non-stimulant medications and evidence-based behavioral interventions, clinicians can effectively manage the challenging combination of methamphetamine use disorder and ADHD.