This article was first published on March 12, 2023. It was last reviewed/ updated on March 12, 2023.
Question from a Member:
Is it safe to prescribe stimulants for patients on buprenorphine (Suboxone®)?
Before we answer that question, let’s briefly look at why we need to look out for possible ADHD in all patients with a substance use disorder.
How common is ADHD along with a substance use disorder?
Our Member’s question is clinically important because two different meta-analyses of studies across different substance use disorders found that 20% (or more) of persons with a substance use disorder also have attention-deficit/ hyperactivity disorder (ADHD; Rohner et al., 2023a; van Emmerik-van Oortmerssen et al., 2012).
To repeat, the answer to remember is: 20%
Which substances?
The substances used by persons with ADHD include not only amphetamines and cocaine, but also (in no particular order) alcohol, cannabis, opioids, and so on (Cunill et al., 2022; Young et al., 2015).
For example, 20% to 25% of patients on oral opioid maintenance treatment were found to have comorbid ADHD (Rohner et al., 2023b; Carpentier et al., 2011).
ADHD makes substance use disorders worse
Patients with ADHD (Cunill et al., 2022):
– Are more likely to start using psychoactive substances at an early age
– Have more severe substance use disorders
– Are more likely to have poor outcomes of substance use disorder treatment (discontinuation of treatment, relapse into substance use).
– Are more likely to engage in criminal behavior (Mannuzza et al., 2010)
– Are at greater risk of fatal accidents (Dalsgaard et al., 2015).
We have to look for it
As an International Consensus Guideline noted, ADHD is not usually the reason why persons with substance use disorders seek treatment (Crunelle et al., 2018). So, the Guideline says, it is our task to recognize ADHD in these patients (Crunelle et al., 2018).
Be careful in diagnosing ADHD in persons with a substance use disorder
I shouldn’t have to say this but we have to be very careful in diagnosing ADHD in a person with a substance use disorder. This is not just because some people may falsely report or exaggerate symptoms of ADHD to get stimulant medications. It is also because there are many overlapping features in the clinical presentation of ADHD and substance use disorders.
For tips on how to evaluate any person for possible ADHD, please see the following article on this website:
Tips on history-taking in evaluating adults for possible ADHD
But, evaluating patients with a substance use disorder for possible ADHD presents some special challenges. In a separate article on this website, we’ll discuss tips for doing that.
Related Pages
ADHD with comorbid substance use disorder
We must identify ADHD in persons with substance use disorders
Stimulants for ADHD with a history of a substance use disorder?
Can stimulant medications be used along with buprenorphine or methadone?
How should ADHD be treated in persons with stimulant (including cocaine) use disorder
Tips for managing abuse potential of medications for ADHD
Does lisdexamfetamine really have lower abuse potential?
References
Carpentier PJ, van Gogh MT, Knapen LJ, Buitelaar JK, De Jong CA. Influence of attention deficit hyperactivity disorder and conduct disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients. Eur Addict Res. 2011;17(1):10-20. doi: 10.1159/000321259. Epub 2010 Sep 25. PMID: 20881401.
Cunill R, Castells X, González-Pinto A, Arrojo M, Bernardo M, Sáiz PA, Flórez G, Torrens M, Tirado-Muñoz J, Fonseca F, Arranz B, Garriga M, Goikolea JM, Zorrilla I, Becoña E, López A, San L. Clinical practice guideline on pharmacological and psychological management of adult patients with attention deficit and hyperactivity disorder and comorbid substance use. Adicciones. 2022 Apr 1;34(2):168-178. English, Spanish. doi: 10.20882/adicciones.1569. PMID: 34171106.
Fatseas M, Debrabant R, Auriacombe M. The diagnostic accuracy of attention-deficit/hyperactivity disorder in adults with substance use disorders. Curr Opin Psychiatry. 2012 May;25(3):219-25. doi: 10.1097/YCO.0b013e3283523d7c. PMID: 22449768.
Levin FR. Diagnosing attention-deficit/hyperactivity disorder in patients with substance use disorders. J Clin Psychiatry. 2007;68 Suppl 11:9-14. PMID: 18307376.
Levin FR, Upadhyaya HP. Diagnosing ADHD in adults with substance use disorder: DSM-IV criteria and differential diagnosis. J Clin Psychiatry. 2007 Jul;68(7):e18. doi: 10.4088/jcp.0707e18. PMID: 17685729.
Rohner H, Gaspar N, Philipsen A, Schulze M. Prevalence of Attention Deficit Hyperactivity Disorder (ADHD) among Substance Use Disorder (SUD) Populations: Meta-Analysis. Int J Environ Res Public Health. 2023a Jan 10;20(2):1275. doi: 10.3390/ijerph20021275. PMID: 36674031; PMCID: PMC9859173.
Rohner H, Gaspar N, Rosen H, Ebert T, Kilarski LL, Schrader F, Al Istwani M, Lenz AJ, Dilg C, Welskop A, Goldmann T, Schmidt U, Philipsen A. ADHD Prevalence among Outpatients with Severe Opioid Use Disorder on Daily Intravenous Diamorphine and/or Oral Opioid Maintenance Treatment. Int J Environ Res Public Health. 2023b Jan 31;20(3):2534. doi: 10.3390/ijerph20032534. PMID: 36767906; PMCID: PMC9915278.
van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, Schoevers RA. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend. 2012 Apr 1;122(1-2):11-9. doi: 10.1016/j.drugalcdep.2011.12.007. Epub 2011 Dec 30. PMID: 22209385.
Young JT, Carruthers S, Kaye S, Allsop S, Gilsenan J, Degenhardt L, van de Glind G, van den Brink W, Preen D. Comorbid attention deficit hyperactivity disorder and substance use disorder complexity and chronicity in treatment-seeking adults. Drug Alcohol Rev. 2015 Nov;34(6):683-93. doi: 10.1111/dar.12249. Epub 2015 Mar 18. PMID: 25790353.
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