What treatment approach is recommended for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who is also taking cocaine?

Treatment of ADHD in Patients with Active Cocaine Use

For a patient with ADHD who is actively using cocaine, initiate combined treatment with extended-release mixed amphetamine salts (60-80 mg daily) or sustained-release methylphenidate (40-80 mg daily) alongside contingency management plus community reinforcement approach and weekly cognitive behavioral therapy. 1, 2

Pharmacological Treatment Approach

First-Line Stimulant Therapy

• Extended-release mixed amphetamine salts at 60-80 mg daily is the preferred pharmacological intervention, as it has demonstrated both significant ADHD symptom reduction (75% of patients achieving ≥30% symptom reduction at 60 mg dose) and substantial cocaine use reduction (5.46 times higher odds of cocaine-negative weeks at 80 mg dose compared to placebo). 2

• Sustained-release methylphenidate at 40-80 mg daily in divided doses represents an effective alternative, showing significant reductions in both ADHD symptoms and cocaine-positive urine toxicologies under close supervision. 3

• Do NOT delay ADHD treatment until sobriety is achieved, as patients with comorbid ADHD and active substance use disorder have more severe addiction patterns and worse prognosis, making them likely to relapse before obtaining ADHD treatment if you wait. 4, 5

Safety Considerations with Stimulants

• Stimulant medications are safe when combined with cocaine in this population under close supervision, though cardiovascular effects may be increased (this has not warranted session termination in clinical trials). 6

• Methylphenidate maintenance actually decreases some positive subjective effects of cocaine and reduces cocaine choice behavior in patients with ADHD. 6

• Long-acting stimulant formulations are preferred over short-acting preparations as they provide better medication adherence and lower abuse potential. 7, 4

Mandatory Psychosocial Interventions

Combined Behavioral Therapy (Non-Negotiable)

• Contingency management (CM) plus community reinforcement approach (CRA) must be implemented concurrently with pharmacotherapy (NNT=3.7 for abstinence at longest follow-up), as this combination addresses both immediate behavioral reinforcement and underlying psychological/social factors. 7, 1

• CM involves providing tangible rewards (vouchers/prizes) contingent upon drug-free urine samples, creating immediate positive reinforcement for abstinence. 7, 8

• CRA is a multi-layered intervention involving functional analysis, coping-skills training, and social/familial/recreational/vocational reinforcements that address long-term recovery factors. 7, 9

• Weekly individual cognitive behavioral therapy is essential, as combined CBT with pharmacotherapy shows superior outcomes compared to usual care (effect sizes g=0.18-0.28). 1, 2

Why This Combination is Critical

• CM alone shows efficacy during active treatment but effects are NOT sustained at long-term follow-up, making it insufficient as monotherapy. 7, 9

• The addition of CRA to CM potentiates the purely behavioral intervention with psychological and social components that enhance long-term effectiveness. 7

• Combined treatment (medication + CM + CRA + CBT) addresses the chronic neurodevelopmental disorder (ADHD) while simultaneously treating the behavioral, psychological, and social factors underlying cocaine addiction. 1, 9

Monitoring Requirements

• Obtain urine toxicology screens 3 times weekly to provide objective evidence of abstinence and implement CM effectively. 3, 8

• Monitor vital signs at each visit given potential additive cardiovascular effects of stimulants and cocaine. 3

• Assess ADHD symptoms weekly using structured rating scales (e.g., Adult ADHD Investigator Symptom Rating Scale). 2

• Continue long-term follow-up beyond initial treatment stabilization, as sustained recovery requires ongoing support. 1, 9

Critical Pitfalls to Avoid

• Never rely solely on pharmacotherapy without integrated behavioral interventions, as combined treatment is demonstrably superior to medication alone. 1

• Never implement CM without addressing underlying psychological and social factors through CRA, as this leads to relapse after treatment completion. 7, 1

• Never use non-contingent rewards (providing rewards regardless of drug use status), as these have proven completely ineffective. 7, 8, 9

• Never delay ADHD treatment waiting for sobriety, as this approach fails many patients who relapse before obtaining ADHD treatment, and untreated ADHD is associated with more severe cocaine consumption patterns (3-fold higher spending on cocaine). 4, 5

• Never prescribe short-acting stimulant formulations when long-acting preparations are available, as they have higher abuse potential and worse adherence. 7, 4

Clinical Context

• ADHD prevalence in cocaine-dependent adults seeking treatment ranges from 20-30%, making screening essential in this population. 4, 2

• Patients with comorbid ADHD and cocaine use disorder demonstrate more severe addiction patterns, including higher cocaine doses and more dangerous routes of administration. 5

• Psychostimulants for ADHD work by enhancing dopamine and norepinephrine activity, increasing prefrontal cortex efficiency and optimizing executive and attentional function. 7