Diagnosis and Management of Comorbid ADHD in Patients with Substance Use Disorders

Adult attention-deficit/hyperactivity disorder (ADHD) is a common precursor and comorbidity in those seeking treatment for substance use disorders (SUDs). Up to one in four patients with SUD may have comorbid ADHD. ADHD and SUD have common neurobiological features. Both ADHD and SUD have a chronic course, with severe functional impairments in educational, employment, interpersonal, and quality-of-life outcomes. Untreated childhood ADHD may lead to younger patient presentation with comorbid SUD+ADHD. The presence of ADHD increases the duration, severity, chronicity, and complexity of SUDs. Because treatment of comorbid ADHD can improve the ultimate outcomes for patients with SUD+ADHD, prompt screening and diagnosis of ADHD is important. Therefore, it is now recommended that SUD treatment programs: (1) include routine screening for ADHD in every initial SUD evaluation; and (2) perform a full diagnostic evaluation of ADHD, for those screening positive for ADHD. SUD treatment programs can increase their effectiveness by enhancing traditional care with 1) pharmacological treatment for ADHD, added to the SUD treatments already in use; and 2) cognitive-behavioral psychotherapy (CBT) specifically adapted to include ADHD-specific skills training (“integrated CBT”). Treatment for both conditions in those with SUD+ADHD is strongly recommended, with ADHD treatment starting as soon as the patient’s SUD is stabilized. Many excellent ADHD treatment options have demonstrated benefit to patients with SUD+ADHD. Abuse-resistant, extended-release stimulant medications demonstrate the best outcomes, and nonstimulant options have also shown success. Prescribers can do much to prevent stimulant medication misuse and diversion, while still offering first-line pharmacological treatment for ADHD. Recognition and treatment of comorbid SUD+ADHD ultimately improves SUD treatment retention and outcomes.