What are the recommended medications for Attention Deficit Hyperactivity Disorder (ADHD) in individuals with a history of substance use disorder?

ADHD Medications for Individuals with Substance Use History

For patients with ADHD and a history of substance use disorder, begin with atomoxetine or extended-release guanfacine/clonidine as first-line treatment, reserving long-acting stimulant formulations for cases where non-stimulants prove inadequate. 1, 2

Initial Assessment and Risk Stratification

Before initiating any ADHD medication in patients with substance use history, assess the following critical factors:

• Current substance use status - If active substance use is identified, refer to a subspecialist for consultative support before beginning ADHD pharmacotherapy 1
• Severity of ADHD symptoms - Determine if symptoms cause moderate to severe impairment in at least two different settings 2
• Comorbid psychiatric conditions - Screen for depression, anxiety, bipolar disorder, and antisocial personality disorder, as these increase SUD risk 3, 4
• Implement urine drug screening to ensure compliance and detect any return to substance use 2

Medication Selection Algorithm

First-Line: Non-Stimulant Medications

Atomoxetine is the preferred initial choice for patients with substance use history due to its uncontrolled substance status and lack of abuse potential 2, 5, 3:

• Start at 60-100 mg daily 2
• Requires 2-4 weeks to achieve full therapeutic effect 2
• Monitor for suicidality and clinical worsening, particularly in adolescents 5
• FDA-approved as the only non-stimulant for adult ADHD 2

Alpha-2 agonists as alternative first-line options 1, 2:

• Extended-release guanfacine: 1-4 mg daily 2
• Extended-release clonidine: dosing per guidelines 1
• Particularly useful if sleep disturbances or tics are present 2
• Administer in the evening due to somnolence/fatigue side effects 2
• Require 2-4 weeks until effects are observed 2

Bupropion as an additional option 3, 4:

• Consider when comorbid depression is present 2
• Lower abuse liability compared to stimulants 3
• Start with 100-150 mg daily (SR) or 150 mg daily (XL) 2
• Can titrate to maintenance doses of 100-150 mg twice daily (SR) or 150-300 mg daily (XL) 2
• Maximum dose 450 mg per day 2

Second-Line: Long-Acting Stimulant Formulations

If non-stimulants prove inadequate after adequate trial, consider long-acting stimulants with lower abuse potential 1, 2:

• Long-acting formulations (e.g., Concerta methylphenidate) are resistant to diversion and have lower abuse potential 2
• Provide "around-the-clock" effects and reduce rebound symptoms 2
• When used at recommended doses and frequencies, oral stimulants are unlikely to yield abuse effects in patients with ADHD 4, 6
• Evidence suggests stimulant treatment may actually reduce the risk of developing SUD 3, 4

Avoid stimulants entirely if 2:

• Uncontrolled hypertension or symptomatic cardiovascular disease is present 2
• Active substance abuse is ongoing 2
• Active psychosis or mania is present 2

Critical Monitoring Requirements

Schedule monthly follow-up visits to assess 2:

• Response to medication changes
• Potential substance use relapse
• Signs of misuse or diversion of ADHD medication 1
• Prescription refill requests for patterns suggesting diversion 1

Monitor cardiovascular parameters 2:

• Blood pressure and pulse at baseline and regularly during treatment 2
• Particularly important with stimulant medications 2

Monitor psychiatric symptoms 2, 5:

• Suicidality and clinical worsening, especially with atomoxetine 2, 5
• Development of new psychiatric comorbidities 2
• Sleep disturbances and appetite changes 2

Utilize prescription drug monitoring programs 1:

• Most states now require prescriber participation 1
• Helpful in identifying and preventing diversion activities 1

Combination with Behavioral Interventions

Always implement psychosocial interventions alongside medication 2, 3:

• Cognitive-behavioral therapy and skills training 2
• Addiction treatment/psychotherapy for those with active or recent SUD 3
• Treatment plans should include behavioral interventions and careful monitoring 4

Common Pitfalls to Avoid

• Do not assume a single medication will treat both ADHD and comorbid conditions - No single antidepressant is proven for dual ADHD/depression treatment 2
• Do not use MAO inhibitors concurrently with stimulants or bupropion due to hypertensive crisis risk 2
• Do not prescribe short-acting stimulant formulations as first-line in this population - they have higher potential for abuse, misuse, and diversion 6
• Do not delay treatment of severe substance abuse - Stabilizing substance abuse should be the first priority when treating adults with both conditions 3
• Exercise particular caution with adolescents - Treatment initiation during adolescence or young adulthood has been linked to increased risk of polydrug use and non-medical stimulant use 4