Adult attention deficit/hyperactivity disorder (ADHD) often co-occurs with substance use disorders (SUD) and is associated with early onset and more severe development of SUD and with reduced treatment effectiveness. Screening tools allow for a good recognition of possible ADHD in adults with SUD and should be used routinely, followed by an ADHD diagnostic process initiated as soon as possible. Simultaneous and integrated treatment of ADHD and SUD, using a combination of pharmaco- and psychotherapy, is recommended. Long-acting methylphenidate, extended-release amphetamines, and atomoxetine with up-titration to higher dosages may be considered in patients unresponsive to standard doses. This paper includes evidence- and consensus-based recommendations developed to provide guidance in the screening, diagnosis and treatment of patients with ADHD-SUD comorbidity.

1.
Kaye S, Ramos-Quiroga JA, van de Glind G, Levin FR, Faraone SV, Allsop S, Degenhardt L, Moggi F, Barta C, Konstenius M, Franck J, Skutle A, Bu ET, Koeter MW, Demetrovics Z, Kapitány-Fövény M, Schoevers RA, van Emmerik-van Oortmerssen K, Carpentier PJ, Dom G, Verspreet S, Crunelle CL, Young JT, Carruthers S, Cassar J, Fatséas M, Auriacombe M, Johnson B, Dunn M, Slobodin O, van den Brink W: Persistence and dubtype stability of ADHD among substance use disorder treatment seekers. J Atten Disord 2016;pii:1087054716629217.
2.
Fatséas M, Hurmic H, Serre F, Debrabant R, Daulouède JP, Denis C, Auriacombe M: Addiction severity pattern associated with adult and childhood attention deficit hyperactivity disorder (ADHD) in patients with addictions. Psychiatry Res 2016; 246: 656–662.
3.
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; 34: 683–693.
4.
van Emmerik-van Oortmerssen K, van de Glind G, Koeter MW, Allsop S, Auriacombe M, Barta C, Bu ET, Burren Y, Carpentier PJ, Carruthers S, Casas M, Demetrovics Z, Dom G, Faraone SV, Fatseas M, Franck J, Johnson B, Kapitány-Fövény M, Kaye S, Konstenius M, Levin FR, Moggi F, Møller M, Ramos-Quiroga JA, Schillinger A, Skutle A, Verspreet S; IASP research group, van den Brink W, Schoevers RA: Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. Addiction 2014; 109: 262–272.
5.
Levin FR, Evans SM, Vosburg SK, Horton T, Brooks D, Ng J: Impact of attention-deficit hyperactivity disorder and other psychopathology on treatment retention among cocaine abusers in a therapeutic community. Addict Behav 2004; 29: 1875–1882.
6.
Kronenberg LM, Goossens PJ, van Etten DM, van Achterberg T, van den Brink W: Need for care and life satisfaction in adult substance use disorder patients with and without attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). Perspect Psychiatr Care 2015; 51: 4–15.
7.
Cunill R, Castells X, Tobias A, Capellà D: Pharmacological treatment of attention deficit hyperactivity disorder with co-morbid drug dependence. J Psychopharmacol 2015; 29: 15–23.
8.
Charach A, Yeung E, Climans T, Lillie E: Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. J Am Acad Child Adolesc Psychiatry 2011; 50: 9–21.
9.
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; 122: 11–9.
10.
van de Glind G, Konstenius M, Koeter MWJ, van Emmerik-van Oortmerssen K, Carpentier PJ, Kaye S, Degenhardt L, Skutle A, Franck J, Bu ET, Moggi F, Dom G, Verspreet S, Demetrovics Z, Kapitány-Fövény M, Fatséas M, Auriacombe M, Schillinger A, Møller M, Johnson B, Faraone SV, Ramos-Quiroga JA, Casas M, Allsop S, Carruthers S, Schoevers RA, Wallhed S, Barta C, Alleman P; IASP Research Group, Levin FR, van den Brink W: Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria. Drug Alcohol Depend 2014; 134: 158–166.
11.
Matthys F, Möbius D, Stes S, et al: Good Clinical Practice in de Herkenning en Behandeling van ADHD bij (jong)volwassenen met verslavingsproblemen. Richtlijnen voor de klinische praktijk. Brussel, VAD, 2010.
12.
Matthys F, Soyez V, van den Brink W, Joostens P, Tremmery S, Sabbe B: Barriers to implementation of treatment guidelines for ADHD in adults with substance use disorder. J Dual Diagn 2014; 10: 130–138.
14.
Hendriks V, de Jong C: Richtlijn ADHD en middelengebruik bij adolescenten: screening, diagnostiek en behandeling in de jeugd-GGZ en jeugdverslavingszorg. Perspectief Uitgevers, 2014;ISBN:9789492121134.
15.
Levin FR, Upadhyaya HP: Diagnosing ADHD in adults with substance use disorder: DSM-IV criteria and differential diagnosis. J Clin Psychiatry 2007; 68:e18.
16.
Dakwar E, Levin FR, Olfson M, Wang S, Kerridge B, Blanco C: First treatment contact for ADHD: predictors of and gender differences in treatment seeking. Psychiatr Serv 2014; 65: 1465–1473.
17.
Barkley RA, Brown TE: Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr 2008; 13: 977–984.
18.
Fatseas M, Debrabant R, Auriacombe M: The diagnostic accuracy of attention-deficit/hyperactivity disorder in adults with substance use disorders. Curr Opin Psychiatry 2012; 25: 219–225.
19.
Adler L, Cohen J: Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004; 27: 187–201.
20.
Martinez-Raga J, Szerman N, Knecht C, de Alvaro R: Attention deficit hyperactivity disorder and dual disorders. Educational needs for an underdiagnosed condition. Int J Adolesc Med Health 2013; 25: 231–243.
21.
Moffitt TE, Houts R, Asherson P, Belsky DW, Corcoran DL, Hammerle M, Harrington H, Hogan S, Meier MH, Polanczyk GV, Poulton R, Ramrakha S, Sugden K, Williams B, Rohde LA, Caspi A: Is adult ADHD a childhood-onset neurodevelopmental disorder? evidence from a four-decade longitudinal cohort study. Am J Psychiatry 2015; 172: 967–977.
22.
Ramos-Quiroga JA, Díaz-Digon L, Comín M, Bosch R, Palomar G, Chalita JP, Roncero C, Nogueira M, Torrens M, Casas M: Criteria and concurrent validity of adult ADHD section of the psychiatry research interview for substance and mental disorders. J Atten Disord 2015; 19: 999–1006.
23.
McCann BS, Simpson TL, Ries R, Roy-Byrne P: Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder. Am J Addict 2000; 9: 1–9.
24.
Goossensen MA, van de Glind G, Carpentier PJ, Wijsen RM, van Duin D, Kooij JJ: An intervention program for ADHD in patients with substance use disorders: preliminary results of a field trial. J Subst Abuse Treat 2006; 30: 253–259.
25.
Zulauf CA, Sprich SE, Safren SA, Wilens TE: The complicated relationship between attention deficit/hyperactivity disorder and substance use disorders. Curr Psychiatry Rep 2014; 16: 436.
26.
Torrens M, Rossi PC, Martinez-Riera R, Martinez-Sanvisens D, Bulbena A: Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system? Subst Use Misuse 2012; 47: 1005–1014.
27.
Wilens TE, Morrison NR: Substance-use disorders in adolescents and adults with ADHD: focus on treatment. Neuropsychiatry (London) 2012; 2: 301–312.
28.
Levin FR, Evans SM, Brooks DJ, Kalbag AS, Garawi F, Nunes EV: Treatment of methadone-maintained patients with adult ADHD: double-blind comparison of methylphenidate, bupropion and placebo. Drug Alcohol Depend 2006; 81: 137–148.
29.
Riggs PD, Winhusen T, Davies RD, Leimberger JD, Mikulich-Gilbertson S, Klein C, Macdonald M, Lohman M, Bailey GL, Haynes L, Jaffee WB, Haminton N, Hodgkins C, Whitmore E, Trello-Rishel K, Tamm L, Acosta MC, Royer-Malvestuto C, Subramaniam G, Fishman M, Holmes BW, Kaye ME, Vargo MA, Woody GE, Nunes EV, Liu D: Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders. J Am Acad Child Adolesc Psychiatry 2011; 50: 903–914.
30.
Schubiner H, Saules KK, Arfken CL, Johanson CE, Schuster CR, Lockhart N, Edwards A, Donlin J, Pihlgren E: Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. Exp Clin Psychopharmacol 2002; 10: 286–294.
31.
Winhusen TM, Somoza EC, Brigham GS, Liu DS, Green CA, Covey LS, Croghan IT, Adler LA, Weiss RD, Leimberger JD, Lewis DF, Dorer EM: Impact of attention-deficit/hyperactivity disorder (ADHD) treatment on smoking cessation intervention in ADHD smokers: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2010; 71: 1680–1688.
32.
Wilens TE, Adler LA, Weiss MD, Michelson D, Ramsey JL, Moore RJ, Renard D, Brady KT, Trzepacz PT, Schuh LM, Ahrbecker LM, Levine LR; Atomoxetine ADHD/SUD Study Group: Atomoxetine treatment of adults with ADHD and comorbid alcohol use disorders. Drug Alcohol Depend 2008; 96: 145–154.
33.
Riggs PD, Hall SK, Mikulich-Gilbertson SK, Lohman M, Kayser A: A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry 2004; 43: 420–429.
34.
Konstenius M, Jayaram-Lindström N, Guterstam J, Beck O, Philips B, Franck J: Methylphenidate for attention deficit hyperactivity disorder and drug relapse in criminal offenders with substance dependence: a 24-week randomized placebo-controlled trial. Addiction 2014; 109: 440–449.
35.
Levin FR, Mariani JJ, Specker S, Mooney M, Mahony A, Brooks DJ, Babb D, Bai Y, Eberly LE, Nunes EV, Grabowski J: Extended-release mixed amphetamine salts vs placebo for comorbid adult attention-deficit/hyperactivity disorder and cocaine use disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72: 593–602.
36.
Austic EA: Peak ages of risk for starting nonmedical use of prescription stimulants. Drug Alcohol Depend 2015; 152: 224–229.
37.
Cassidy TA, Varughese S, Russo L, Budman SH, Eaton TA, Butler SF: Nonmedical use and diversion of ADHD stimulants among U.S. Adults ages 18–49: a National internet survey. J Atten Disord 2015; 19: 630–640.
38.
Kollins SH, Youcha S, Lasser R, Thase ME: Lisdexamfetamine dimesylate for the treatment of attention deficit hyperactivity disorder in adults with a history of depression or history of substance use disorder. Innov Clin Neurosci 2011; 8: 28–32.
39.
Grau-López L, Roncero C, Navarro MC, Casas M: Psychosis induced by the interaction between disulfiram and methylphenidate may be dose dependent. Subst Abus 2012; 33: 186–188.
40.
Torgersen T, Gjervan B, Rasmussen K, Vaaler A, Nordahl HM: Prevalence of comorbid substance use disorder during long-term central stimulant treatment in adult ADHD. Atten Defic Hyperact Disord 2013; 5: 59–67.
41.
Klassen LJ, Bilkey TS, Katzman MA, Chokka P: Comorbid attention deficit/hyperactivity disorder and substance use disorder: treatment considerations. Curr Drug Abuse Rev 2012; 5: 190–198.
42.
Humphreys KL, Eng T, Lee SS: Stimulant medication and substance use outcomes: a meta-analysis. JAMA Psychiatry 2013; 70: 740–749.
43.
Tamm L, Trello-Rishel K, Riggs P, Nakonezny PA, Acosta M, Bailey G, Winhusen T: Predictors of treatment response in adolescents with comorbid substance use disorder and attention-deficit/hyperactivity disorder. J Subst Abuse Treat 2013; 44: 224–230.
44.
Kollins SH: Comparing the abuse potential of methylphenidate versus other stimulants: a review of available evidence and relevance to the ADHD patient. J Clin Psychiatry 2003; 64: 14–18.
45.
Skoglund C, Brandt L, Almqvist C, D’Onofrio BM, Konstenius M, Franck J, Larsson H: Factors associated with adherence to methylphenidate treatment in adult patients with attention-deficit/hyperactivity disorder and substance use disorders. J Clin Psychopharmacol 2016; 36: 222–228.
46.
Aviram RB, Rhum M, Levin FR: Psychotherapy of adults with comorbid attention-deficit/hyperactivity disorder and psychoactive substance use disorder. J Psychother Pract Res 2001; 10: 179–186.
47.
van Emmerik-van Oortmerssen K, Vedel E, van den Brink W, Schroevers RA: Integrated cognitive behavioral therapy for patients with substance use disorder and comorbid ADHD: two case presentations. Addict Behav 2015; 45: 214–217.
48.
Kronenberg LM, Verkerk-Tamminga R, Goossens PJ, van den Brink W, van Achterberg T: Personal recovery in individuals diagnosed with substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). Arch Psychiatr Nurs 2015; 29: 242–248.
49.
Bihlar Muld B, Jokinen J, Bölte S, Hirvikoski T: Skills training groups for men with ADHD in compulsory care due to substance use disorder: a feasibility study. Atten Defic Hyperact Disord 2016; 8: 159–172.
50.
Matthys F, Bronckaerts A, Crunelle CL: Managing ADHD in the presence of substance use disorders. Gompel & Svacina, 2018. ISBN 978 94 6371 023 7.
51.
van de Glind G, van den Brink W, Koeter MW, et al: Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend 2013; 132: 587–596.
52.
Chiasson JP, Stavro K, Rizkallah É, et al: Questioning the specificity of ASRS-v1.1 to accurately detect ADHD in substance abusing populations. J Atten Disord 2012; 16: 661–663.
53.
Reyes MM, Schneekloth TD, Hitschfeld MJ, et al: The Clinical Utility of ASRS-v1.1 for Identifying ADHD in Alcoholics Using PRISM as the Reference Standard. J Atten Disord 2016; pii: 1087054716646450.
54.
Konstenius M, Larsson H, Lundholm L, et al: An epidemiological study of ADHD, substance use, and comorbid problems in incarcerated women in Sweden. J Atten Disord 2015; 19: 44–52.
55.
Daigre C, Roncero C, Rodríguez-Cintas L, et al: Adult ADHD screening in alcohol-dependent patients using the Wender-Utah Rating Scale and the adult ADHD Self-Report Scale. J Atten Disord 2015; 19: 328–334.
56.
Dakwar E, Mahony A, Pavlicova M, et al: The utility of attention-deficit/hyperactivity disorder screening instruments in individuals seeking treatment for substance use disorders. J Clin Psychiatry 2012; 73: e1372–e1378.
57.
West SL, Mulsow M, Arredondo R: An examination of the psychometric properties of the attention deficit scales for adults with outpatient substance abusers. Am J Drug Alcohol Abuse 2007; 33: 755–764.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.