Is Adderall (amphetamine and dextroamphetamine) effective for treating stimulant use disorder?

Adderall for Stimulant Use Disorder: Not Recommended

Adderall (amphetamine/dextroamphetamine) should not be used to treat stimulant use disorder, as there is no evidence supporting pharmacotherapy for cocaine or amphetamine addiction, and psychosocial interventions—specifically the combination of contingency management plus community reinforcement approach—represent the only evidence-based first-line treatment. 1

Evidence Against Pharmacotherapy for Stimulant Use Disorder

• International clinical guidelines consistently recommend psychosocial interventions as first-line treatment for cocaine and amphetamine addiction, with little to no evidence supporting any pharmacotherapy or brain stimulation treatments 1

• The lack of validated pharmacological treatments for stimulant use disorders makes the provision of evidence-based psychosocial treatments all the more critical 1

• Using Adderall to treat stimulant addiction would be prescribing a controlled substance with abuse potential to someone with active substance use disorder—a practice that contradicts fundamental addiction medicine principles 2, 3

Recommended Treatment Approach

The combination of contingency management (CM) plus community reinforcement approach (CRA) is the most effective and acceptable intervention for both short-term and long-term treatment of individuals with stimulant addiction. 1

Specific Psychosocial Interventions

• Contingency management involves providing rewards (vouchers, prizes, or other incentives) to patients upon submission of drug-free urine samples, creating positive reinforcement for abstinence 1

• Community reinforcement approach is a multi-layered intervention that includes functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements 1

• The combination of CM plus CRA demonstrated superior efficacy and acceptability compared to 12 other psychosocial interventions in a network meta-analysis of 50 clinical studies involving 6,943 participants 1

Alternative Psychosocial Options

• Cognitive-behavioral therapy (CBT) alone shows moderate efficacy at the end of treatment but limited long-term benefit 1

• However, current evidence for CBT specifically targeting amphetamine-type stimulant use disorders is insufficient, with only low-quality evidence from small studies showing mixed results 4

Critical Pitfall: Adderall in Comorbid ADHD and Substance Use Disorder

When ADHD Coexists with Active Stimulant Use Disorder

• Do not initiate stimulant treatment (including Adderall) in patients with active, untreated substance use disorder 2, 3

• Substance use disorder must be stabilized first before considering ADHD pharmacotherapy 2

• Factors associated with highest risk of substance use disorder in ADHD patients include comorbid antisocial personality disorder, bipolar disorder, severe ADHD symptoms, and treatment initiation during adolescence or young adulthood 2

If ADHD Treatment Is Necessary in Stable Recovery

• Non-stimulant medications (atomoxetine, extended-release guanfacine, or extended-release clonidine) are strongly preferred over stimulants in patients with comorbid substance use disorder history 1, 5, 2, 3

• Atomoxetine provides "around-the-clock" effects without abuse potential and is uncontrolled, making it the safest option 1, 5

• If stimulants must be used in carefully selected stable patients, long-acting formulations have lower abuse potential than immediate-release preparations, though this remains controversial 2, 3

• Treatment plans must include intensive behavioral interventions, careful monitoring for diversion and misuse, and frequent urine drug screening 2, 3

Monitoring for Stimulant Misuse Red Flags

• Prescription refill requests that are early, frequent, or involve reports of "lost" medications suggest possible diversion or misuse 3

• Requests for dose escalation beyond therapeutic ranges warrant concern 3

• Evidence suggests that when oral stimulants are used at recommended doses and frequencies in patients with genuine ADHD, abuse is unlikely—but this does not apply to those with active substance use disorders 2, 3

Summary Algorithm

1. For active stimulant use disorder: Refer to evidence-based psychosocial treatment (CM plus CRA preferred) 1

2. For comorbid ADHD with substance use disorder history: Prioritize non-stimulant medications (atomoxetine first-line) 1, 5, 2

3. Never prescribe Adderall as treatment for stimulant addiction itself 1