Treatment of Cocaine Use Disorder and ADHD
For patients with comorbid cocaine use disorder and ADHD, initiate extended-release mixed amphetamine salts (60-80 mg daily) or sustained-release methylphenidate (40-80 mg daily) combined with cognitive behavioral therapy, as this dual approach effectively treats both ADHD symptoms and reduces cocaine use. 1
Pharmacological Treatment Strategy
First-Line Medication Approach
Extended-release mixed amphetamine salts at robust doses (60-80 mg daily) are the most effective pharmacological intervention, demonstrating both significant ADHD symptom reduction (75% of patients at 60 mg achieved ≥30% symptom reduction) and superior cocaine abstinence outcomes (30.2% continuous abstinence in final 3 weeks at 80 mg vs 7.0% with placebo). 1
Sustained-release methylphenidate (40-80 mg daily in divided doses) represents an alternative first-line stimulant option, showing significant reductions in both ADHD symptoms and cocaine-positive urine toxicologies under close supervision. 2
Long-acting stimulant formulations are specifically preferred over immediate-release preparations to minimize abuse potential and provide sustained therapeutic coverage throughout the day. 3
Alternative Pharmacological Options
Atomoxetine can be considered when stimulants are contraindicated or refused, though evidence specifically for cocaine use disorder comorbidity is limited, with weak recommendations for ADHD symptom improvement but not for reducing cocaine use. 4
Methylphenidate is not recommended as monotherapy specifically for cocaine use disorder with ADHD based on recent guideline synthesis, which found insufficient evidence for reducing cocaine use. 4
Critical Medication Considerations
Stimulant medications appear safe in patients with cocaine use disorder and do not increase substance use when properly monitored, contradicting historical concerns about prescribing controlled substances to individuals with active addiction. 4, 1
The self-medication hypothesis is strongly supported in this population—many patients report therapeutic effects from cocaine during initial addiction phases, suggesting they were unknowingly treating undiagnosed ADHD symptoms. 3, 5
Cocaine use improvement correlates closely with ADHD symptom improvement, reinforcing the importance of adequately treating the underlying ADHD to address the substance use disorder. 5
Psychosocial Treatment Integration
Essential Behavioral Component
Cognitive behavioral therapy (CBT) must be delivered concurrently with pharmacotherapy, as combined treatment shows superior outcomes compared to usual care (effect sizes g=0.18-0.28). 6
Weekly individual relapse prevention therapy sessions should be standard practice alongside medication management to address both ADHD-specific coping skills and substance use triggers. 2, 1
Optimal Psychosocial Approach for Cocaine Use Disorder
Contingency Management (CM) plus Community Reinforcement Approach (CRA) represents the most effective psychosocial intervention for cocaine use disorder (NNT=3.7), though this should be integrated with ADHD-specific pharmacotherapy rather than used as monotherapy when ADHD is present. 7, 8
CM involves providing tangible rewards (vouchers/prizes) contingent upon drug-free urine samples, creating immediate positive reinforcement for abstinence. 7
CRA addresses underlying psychological and social factors through functional analysis, coping-skills training, and social/familial/recreational/vocational reinforcements. 7
The combination addresses both immediate behavioral reinforcement (CM) and long-term recovery factors (CRA), which is critical since CM alone shows efficacy during treatment but effects are not sustained at long-term follow-up. 7
Monitoring and Implementation Protocol
Essential Monitoring Components
Obtain urine toxicology screens three times weekly during initial treatment phases to provide objective evidence of abstinence and enable effective CM implementation. 2, 1
Monitor vital signs at each visit, as both cocaine use and stimulant medications can affect cardiovascular parameters including heart rate and blood pressure. 2
Assess ADHD symptoms weekly using standardized rating scales (such as the Adult ADHD Investigator Symptom Rating Scale) to guide dose optimization. 1
Treatment Duration and Titration
Plan for a minimum 13-week initial treatment trial to adequately assess response to both pharmacotherapy and behavioral interventions. 1
Titrate stimulant doses to robust therapeutic levels (not subtherapeutic doses) to achieve adequate ADHD symptom control, which directly correlates with cocaine use reduction. 1, 5
Long-term maintenance treatment is necessary, as ADHD is a chronic condition and discontinuation may lead to relapse of both ADHD symptoms and cocaine use. 3
Common Pitfalls to Avoid
Avoiding stimulant medications due to unfounded fears about prescribing to patients with substance use disorders—evidence clearly demonstrates safety and efficacy when properly monitored. 4, 1
Using subtherapeutic doses of ADHD medications out of excessive caution, which fails to adequately treat ADHD symptoms and leaves patients vulnerable to continued self-medication with cocaine. 1
Relying solely on pharmacotherapy without integrated behavioral interventions, as combined treatment is superior to medication alone. 6, 1
Failing to screen for ADHD in adults presenting with cocaine use disorder, missing a critical treatment opportunity. 1
Implementing CM without addressing underlying psychological and social factors through CRA or similar comprehensive approaches, leading to relapse after treatment completion. 7
Inadequate long-term follow-up and support after initial treatment stabilization, which is critical for sustained recovery. 7, 8