What are the considerations for initiating Suboxone (buprenorphine/naloxone) in a patient with a history of alcohol and substance use, currently on Attention Deficit Hyperactivity Disorder (ADHD) medication?

Managing Suboxone Initiation in a Patient with Substance Use History on ADHD Medication

Continue both the ADHD medication and Suboxone concurrently, as treating opioid use disorder takes priority and ADHD treatment should not be interrupted when clinically stable. 1

Treatment Priority and Concurrent Management

Both ADHD and substance use disorders should be treated together whenever possible. 2 The severity and acuteness of the opioid dependence determines the treatment approach:

• When opioid dependence is less severe or the patient is stable on Suboxone, ADHD diagnostics and treatment can proceed simultaneously. 2
• Longer-term or maintenance treatment with buprenorphine is generally indicated for patients with opioid dependence, as brief treatment periods with rapid tapers are associated with high rates of relapse. 1
• Reductions in substance use frequency have important health correlates, and pharmacotherapy should not be restricted only to patients whose goal is complete abstinence. 1

ADHD Medication Considerations with Concurrent Suboxone

Stimulant Medications

Exercise caution when prescribing stimulants to patients with comorbid substance abuse disorders, but they remain a viable option with appropriate monitoring. 1, 3

• Long-acting stimulant formulations (such as Concerta) have lower abuse potential and are resistant to diversion, making them preferred in patients with substance use history. 3
• Stimulants have a 70-80% response rate for ADHD treatment and remain the gold standard first-line therapy. 3
• When oral formulations of psychostimulants are used at recommended doses and frequencies, they are unlikely to yield effects consistent with abuse potential in patients with ADHD. 4

Non-Stimulant Alternatives

If stimulants are contraindicated or not tolerated, atomoxetine (60-100 mg daily) is the preferred non-stimulant option as it is an uncontrolled substance with lower abuse potential. 3

• Atomoxetine requires 2-4 weeks to achieve full therapeutic effect, unlike stimulants which work within days. 3
• The FDA has issued a black box warning for atomoxetine due to increased risk of suicidal ideation, requiring close monitoring especially during the first few months or at dose changes. 3
• Alpha-2 agonists (guanfacine 1-4 mg daily or clonidine) are additional options with 2-4 weeks until effects are observed, particularly useful if sleep disturbances are present. 3

Critical Monitoring Parameters

Schedule monthly follow-up visits to assess response to both medications and monitor for potential substance use relapse. 3

Specific Monitoring Requirements:

• Implement urine drug screening to ensure compliance and detect any return to substance use. 3
• Monitor blood pressure and pulse at baseline and regularly during treatment, particularly with stimulant use. 3
• Assess for development of any new psychiatric comorbidities that might be contributing to worsening symptoms. 3
• Monitor for signs of misuse or diversion of ADHD medication, including prescription refill patterns and "doctor shopping" behaviors. 5
• Evaluate for sleep disturbances and appetite changes as common adverse effects of stimulants. 3

Alcohol Use History Considerations

The history of alcohol use requires additional vigilance but does not contraindicate either Suboxone or ADHD medication. 1

• Even small reductions in alcohol consumption translate into substantial decreases in risks of cancer, hypertension, and other conditions. 1
• Use motivational interviewing techniques to help the patient articulate advantages and disadvantages of continued substance use. 1
• Avoid benzodiazepines for any comorbid anxiety, as they may reduce self-control and have disinhibiting effects in this population. 3

Common Pitfalls to Avoid

Never use MAO inhibitors concurrently with stimulants or bupropion due to risk of hypertensive crisis; at least 14 days should elapse between discontinuation of an MAOI and initiation of these medications. 3

Do not withhold ADHD treatment simply because the patient is on Suboxone, as untreated ADHD can worsen substance use outcomes. 2, 6

Avoid abruptly discontinuing Suboxone in a physically-dependent patient, as this will precipitate withdrawal syndrome characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis. 5

Do not assume treatment of ADHD alone will resolve substance use issues; both conditions require specific, concurrent treatment. 2, 6

Pharmacotherapy Selection Algorithm

1. If patient is stable on current ADHD medication (stimulant or non-stimulant), continue it while initiating Suboxone. 2

2. If initiating ADHD treatment for the first time:

   • Consider long-acting stimulant formulations as first-line if no active substance use and patient is engaged in treatment. 3
   • Consider atomoxetine as first-line if concerns about diversion or active polysubstance use exist. 3

3. Monitor response over 4-6 weeks and adjust dosing as needed, with more frequent visits initially. 3

4. Address any comorbid depression or anxiety that may be contributing to functional impairment, as these can worsen both ADHD and substance use outcomes. 3