Why I Support Stimulants as First Line Treatment for ADHDers in Recovery

In my day job, I work closely with a program that provides treatment to individuals in recovery from substance abuse and mental illness. This small section of my caseload all share substance abuse disorder diagnoses, are all involuntarily assigned to me – and more than half of them have ADHD.

A quick overview of some stats:

• People with ADHD are almost three times more likely to develop an addiction than the general population.
• 25% of adults in treatment for substance abuse have ADHD (when I shared this with my clients, they insisted this percentage is too low).
• By age 14, 40% of kids with ADHD have started abusing substances compared to 22% of their neurotypical peers.

These are absurd numbers. It’s time to look closely for the threads that tie these two afflictions together: starting with 85%. This is how much the risk of developing a substance use disorder (SUD) can decrease in youth with ADHD if you treat them early and with stimulant medication.

In Part Two I explore more of why that is. Right now, I want to talk about a paradox in which health professionals and ADHDers alike find ourselves: The best medication for ADHD – and its accompanying substance abuse risks – carries substance misuse/diversion risk itself.

As a liaison between my clients and their psychiatrists, I frequently find myself advocating for their medication due to the hesitancy of doctors in prescribing stimulants once they see “history of substance abuse” on someone’s chart. To be clear: I’m not here to dispute the possibility that ADHDers with an SUD will abuse their stimulant medication, and I do not see psychiatrists and myself on opposing teams.

Prescribers have incredibly difficult jobs. They make constant judgment calls, weighing the risks of each medication against its benefits to honor the chances they are taking with their clients’ lives. I truly believe most doctors want to reduce their patients’ suffering, and I understand how they could worry that prescribing stimulants to those with a history of addiction may increase it.

But I have seen too many of my clients suffer from the shame and frustration of being reduced to their addiction – on top of the existing ADHD symptoms that contributed to their SUD in the first place – to not speak up when they are denied the most effective treatment for ADHD in comparison to literally everything else, including therapy and nonstimulant medications. Those with poorly or untreated ADHD are more likely to experience:

• Anxiety
• Depression
• Eating disorders
• Unplanned pregnancies
• STDs
• Traffic accidents
• Dropping out of high school
• Lower income
• Divorce
• Physical injuries
• Arrests
• Problematic gambling
• Self harm
• Suicide attempts

To me, these are the risks I cannot believe we in healthcare are taking. This is a disservice we are doing to those among us who are the most vulnerable. This is the harm we are imposing on those who trust us enough to seek us out for help.

Stimulants aren’t perfect, but they’re by far the best we’ve got. ADHDers in recovery seeking treatment have made a courageous move to surrender self-medication and choose sobriety every single day. I think we have a responsibility to start them off with whatever has the highest chance of success, instead of forcing them to prove their commitment by enduring meds and methods that produce more errors than trials.

If prescribers are still wary (and open to suggestions), I like to recommend the following safety measures when those in recovery choose stimulant medication:

1. Written contracts between doctor and patient. This can look like an explicit agreement to take medication as prescribed and a safety plan or consequences for abusing medication. It can be kept in a patient’s file to refer to when necessary.
2. Short term prescriptions. If insurance allows, writing prescriptions for one or two weeks’ supply at a time instead of a month lessens the chance of abuse.
3. Extended release medications in lieu of immediate release. ER/XR meds have a lower risk for abuse because there’s no instant “rush.” I.e., they’re much less fun.
4. Collaboration between a client’s doctor and their support system, such as other treatment providers or recovery supports.
5. Recommending medications be stored in a secure place and/or with a secure person, perhaps with this person administering/monitoring doses.

ADHDers with SUDs: How has your recovery impacted your ADHD treatment?

Professionals: Do you have any other recommendations for safely treating ADHD with stimulants?

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Next we will discuss the possible explanations for the ADHD and substance abuse overlap in The ADHD/Addiction Link: Part Two.