What steps can be taken to improve symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in patients with a history of substance abuse with dexamphetamine (Dextroamphetamine) who are no longer responding to bupropion (Bupropion hydrochloride)?

Managing ADHD Symptoms When Bupropion Loses Effectiveness in Patients with History of Substance Abuse

For patients with ADHD and a history of substance abuse with dexamphetamine who are no longer responding to bupropion, consider switching to long-acting stimulant formulations with lower abuse potential, such as lisdexamfetamine (Vyvanse) or OROS methylphenidate (Concerta), which are more difficult to divert or misuse. 1

Medication Management Options

First-line Approaches

• Consider long-acting stimulant formulations that have lower abuse potential, such as:
  • Lisdexamfetamine (Vyvanse) - contains dextroamphetamine with a lysine molecule that is only activated after ingestion, making extraction difficult 2
  • OROS methylphenidate (Concerta) - has a delivery system that makes extraction of the stimulant more difficult 2
  • Dermal methylphenidate (Daytrana) - transdermal delivery system reduces abuse potential 2

Non-stimulant Alternatives

• If concerns about stimulant misuse are high, consider other non-stimulant options:
  • Atomoxetine (Strattera) - a norepinephrine reuptake inhibitor with no abuse potential 2, 1
  • Extended-release guanfacine (Intuniv) or extended-release clonidine (Kapvay) - alpha-2 adrenergic agonists with no abuse potential 2
  • Increase bupropion dosage if not at maximum (up to 200 mg SR twice daily) before switching medications 3

Monitoring and Assessment

• Implement regular urine drug screening to ensure compliance and detect any return to substance use 1
• Schedule monthly follow-up visits to assess response to medication changes 1
• Assess for development of new psychiatric comorbidities that might be contributing to worsening ADHD symptoms 1
• Monitor for side effects of new medications, particularly if stimulants are introduced 1

Adjunctive Approaches

• Add psychosocial interventions to medication management:
  • Cognitive-behavioral therapy to address both ADHD symptoms and substance use patterns 1
  • Skills training for ADHD symptom management 1
• Implement lifestyle modifications that can enhance medication effectiveness:
  • Regular sleep schedule 1
  • Stress management techniques 1
  • Regular exercise regimen 1

Important Considerations and Cautions

• A history of substance abuse is not an absolute contraindication to stimulant use, but requires careful monitoring 2
• Avoid concomitant use of MAO inhibitors with stimulants or bupropion due to risk of severe hypertension and potential cerebrovascular accidents 2, 1
• Be aware that patients with ADHD may respond to either amphetamine or methylphenidate with an overall very high response rate when both types are tried 2
• Treatment for adults with ADHD and substance abuse should include a combination of addiction treatment/psychotherapy and pharmacotherapy 4
• When treating adults with both conditions, generally stabilizing or addressing the substance abuse should be the first priority 4

Clinical Pitfalls to Avoid

• Don't assume a single antidepressant will effectively treat both ADHD and any comorbid depression 1
• Don't overlook the potential for bupropion to cause headache, insomnia, and anxiety as side effects, which might be mistaken for returning ADHD symptoms 1
• Avoid using mixed agonist-antagonist medications as they may precipitate withdrawal in patients with a history of substance dependence 1
• Don't continue ineffective treatments without periodic reassessment - guidelines recommend that patients with ADHD should be periodically assessed to determine continued need for treatment 2

By implementing these evidence-based approaches, clinicians can effectively manage ADHD symptoms in patients with a history of substance abuse who are no longer responding to bupropion treatment.