What are suitable medications for a 15-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD), complicated by a history of Substance Use Disorder (SUD)?

From the Guidelines

For a 15-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD) and a history of Substance Use Disorder (SUD), non-stimulant medications such as atomoxetine, guanfacine extended-release, or clonidine extended-release are typically recommended as first-line treatment options. These medications are preferred due to their lower abuse potential compared to stimulants like methylphenidate or amphetamine-based medications, which could exacerbate substance use issues in vulnerable adolescents 1.

Key Considerations

• Atomoxetine (Strattera) can be started at a dose of 40mg daily, gradually increasing to 80mg daily as needed, with monitoring for side effects like nausea or fatigue 1.
• Guanfacine extended-release (Intuniv) is another option, usually started at 1mg daily and potentially increased to 4mg daily, taken consistently at the same time 1.
• Clonidine extended-release (Kapvay) may also be considered at 0.1mg daily, potentially increasing to 0.4mg daily 1.
• Treatment should be combined with behavioral therapy, substance use counseling, and regular monitoring by healthcare providers to ensure comprehensive care and minimize the risk of medication diversion or misuse 1.
• Family involvement is crucial for medication adherence and supporting overall treatment, as it can significantly impact the patient's quality of life and treatment outcomes 1.

Monitoring and Follow-Up

• Regular assessment of medication adherence and potential issues in adherence is essential to ensure the effectiveness of the treatment plan and to make necessary adjustments 1.
• The medication choice should be reassessed regularly based on symptom improvement, side effects, and continued substance use status to optimize treatment outcomes and minimize potential harms 1.
• Clinicians should be aware of the potential side effects of these medications, including somnolence, dry mouth, dizziness, irritability, headache, bradycardia, hypotension, and abdominal pain, and monitor patients accordingly 1.

By prioritizing non-stimulant medications and incorporating comprehensive treatment approaches, healthcare providers can effectively manage ADHD symptoms in adolescents with a history of substance use while minimizing the risk of exacerbating substance use issues 1.

From the FDA Drug Label

Table 6: Summary of Primary Efficacy Results from Short-term Studies of Lisdexamfetamine Dimesylate Capsules in Pediatric Patients (Ages 6 to 17) and Adults with ADHD Study Number (Age range)Primary EndpointTreatment GroupMean Baseline Score (SD)LS Mean Change from Baseline (SE)Placebo-subtracted Difference* (95% CI) Study 1(6 to 12 years)ADHD-RS-IVLisdexamfetamine dimesylate capsules (30 mg/day)†43.2 (6.7)-21.8 (1.6)-15.6 (-19.9, -11.2) Study 4(13 to 17 years)ADHD-RS-IVLisdexamfetamine dimesylate capsules (30 mg/day)†38.3 (6.7)-18.3 (1.2)-5.5 (-9.0, -2.0)

Suitable medications for a 15-year-old patient with ADHD

• Lisdexamfetamine dimesylate capsules are approved for use in pediatric patients aged 6 to 17 years with ADHD.
• The medication has been shown to be effective in reducing symptoms of ADHD in pediatric patients, including those in the 13 to 17 age range.
• However, there is no direct information in the label regarding the use of lisdexamfetamine dimesylate capsules in patients with a history of Substance Use Disorder (SUD).
• Therefore, the use of lisdexamfetamine dimesylate capsules in a 15-year-old patient with ADHD and a history of SUD should be approached with caution.
• It is essential to weigh the potential benefits and risks of treatment and consider alternative options or close monitoring. 2

From the Research

Suitable Medications for ADHD with SUD

• For a 15-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD) complicated by a history of Substance Use Disorder (SUD), suitable medications may include non-stimulant and stimulant options 3, 4, 5.
• Non-stimulant medications such as atomoxetine and guanfacine extended release may be considered, as they have been shown to be effective in treating ADHD symptoms with potentially lower risk of misuse compared to stimulants 3, 6.
• Stimulant medications like dexmethylphenidate, lisdexamfetamine, and methylphenidate may also be effective, but their use requires careful monitoring due to the risk of misuse and diversion, particularly in patients with a history of SUD 3, 4, 5.
• Combination therapy, such as combining stimulants with non-stimulants like atomoxetine, may be considered for patients who do not respond to monotherapy, but more research is needed to determine the efficacy and safety of such combinations 7.

Considerations for Pharmacotherapy

• When selecting a medication, it is essential to consider the patient's medical history, including their history of SUD, and to monitor their response to treatment closely 4, 5.
• Prescribers should address the risks of stimulant misuse and diversion through patient and family education, medication monitoring, and other risk-reducing practices 4.
• The choice of medication should be based on the individual patient's needs and circumstances, and treatment should be tailored to their specific symptoms and response to therapy 3, 6.