ADHD and Substance Use

ADHD’s potential link to substance use disorder is a significant concern for those diagnosed with it. Understanding this link is key to getting appropriate help sooner.

Patterns of trouble paying attention, sitting still or controlling impulses are the core symptoms of Attention Deficit Hyperactivity Disorder (ADHD). While it’s common to think of children when it comes to ADHD, it can continue into teen, young adult and adult years, affecting various aspects of one’s life.

What is ADHD?

ADHD is a complex condition that affects the way individuals manage their attention, behavior and emotions.

The main symptoms of ADHD include:

1. Inattention: Imagine trying to focus on a task, but your mind keeps drifting off to other thoughts or distractions. Inattention can also lead to forgetting important details or tasks. It’s like having a cluttered desk where you struggle to find what you need because everything is scattered around. It can cause someone to be easily distracted as well.
2. Hyperactivity: This can include physical restlessness such as fidgeting, tapping the foot or having an urge to pace. It can also involve acting before thinking, like jumping into activities without considering the consequences. It’s like having a “go-go-go” mindset without pausing to assess the situation. It might be challenging to sit still or engage in quiet activities. It can feel like trying to contain a burst of energy within a small space—keeping it contained for too long is hard.
3. Impulsivity: People with ADHD may be impulsive; they might have a “just do it” button that’s easily triggered without much thought about consequences. Impulsivity can show up in various ways, such as acting without thinking and risk-taking without considering the dangers involved. They may also find it difficult to delay rewards.

Diagnosis and identification

Diagnosing ADHD involves an evaluation by a healthcare professional, typically a psychiatrist or psychologist. The diagnosis is based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including:

• the presence and severity of symptoms,
• impact on daily functioning (how a loved one manages at school, work, home or with friends), and
• the onset of symptoms before the age of 12

When evaluating a child, healthcare providers will also get input from parents and teachers. Additionally, they might use special tests or questionnaires (Connors 4) to see if ADHD symptoms are present.

In adults, healthcare professionals will ask about one’s childhood to see if there were ADHD symptoms at that time. Even if someone wasn’t diagnosed as a child, they might have shown signs that were missed. They will also be asked questions about how life is now and how ADHD symptoms affect them at work, with family, and in daily tasks.

Higher risk for substance use problems

Research suggests that individuals with ADHD are more at risk of using substances compared to those without the disorder.^[1]

Several factors may contribute to this:

• Self-medication: Some individuals with ADHD may use substances to address symptoms such as impulsivity, restlessness or difficulty focusing. They may find that substances like alcohol or other drugs temporarily relieve their symptoms.
• Impulsivity and risk-taking: The impulsivity, risk-taking and sensation-seeking linked to ADHD can lead loved ones to try substances more readily. Young people can quickly go from experimentation to habit.
• Inaccurate diagnosis: Loved ones who are improperly diagnosed with ADHD may be at greater risk of developing a substance use disorder.^[2]
• The American Academy of Pediatrics strongly recommends a complete examination before diagnosing ADHD and prescribing stimulant medications.^[3]
• Also, some individuals will “fake” symptoms either in visits with a healthcare provider or online prescribers to get medications. Likewise, some unethical prescribers may readily diagnose ADHD and medications to get repeat patients.^[4]
• Family risk factors: Although some research highlights a link between ADHD and depression, suicidality, and substance use disorder, there is evidence that this could be the result of family risk factors rather than any harmful effects related to ADHD medications.^[5]

It’s important to note that recent research from Kaiser Permanente indicates that if a child is effectively treated for ADHD before the age of 12, they are no more likely to develop a substance use problem than a child without ADHD.^[6]

There is no consistent evidence, across multiple studies of different types, that stimulants prescribed in childhood increase the risk for later substance use disorder (regardless of whether stimulants continue to be taken into adolescence).

Stimulants first prescribed at older ages do appear to have more of a possible association with increased risk, but more research is needed.  In a 2023 interview with Dr. Brooke Molina, Professor of Psychiatry, Psychology, & Pediatrics at the University of Pittsburgh, she states: “It’s entirely possible that those teens were already experimenting/using/misusing other substances beforehand or that they started using because of their ADHD and related characteristics and not because of the medication.”

Misuse of ADHD medications

There can be various reasons why some people misuse ADHD medications. Here are a few possible factors:

1. Non-medical use to improve thinking skills: Some individuals, particularly students or professionals, may misuse ADHD medications with the belief that they can enhance focus, concentration, and productivity even if they don’t have ADHD. They may view these medications as “study drugs” or “smart pills” and use them to try to gain a competitive edge. Research shows that while these medications may increase one’s motivation, they can actually increase the time and number of steps it takes to solve a problem.^[7]
2. Recreational purposes: ADHD medications, particularly stimulants like Adderall or Ritalin, can produce feelings of well-being and increase alertness. Some individuals may misuse these medications to experience a sense of bliss or to stay awake for longer periods.
3. Peer pressure or social influence: There might be social pressure to misuse prescription medications in certain settings. For example, in college or university environments, where sharing or selling ADHD medications to improve academic performance is not uncommon, some individuals may be influenced to misuse these medications to fit in or gain acceptance.

It is important to note that the intentional misuse of prescription medications, including ADHD medications, is illegal and can have serious consequences. Misuse can lead to physical and mental health risks, including increased heart rate, elevated blood pressure, anxiety, addiction and other harmful effects.

Recognizing Signs of Intentional Misuse

Families and loved ones can play a crucial role in recognizing signs of substance misuse in individuals with ADHD. Common signs may include:

• Changes in behavior or mood, such as increased irritability, agitation, or mood swings.
• Decline in academic or occupational performance.
• Social withdrawal or changes in peer groups.
• Physical signs including dilated pupils (large in size), changes in appetite or sleep patterns, or   unexplained changes in weight
• Missing pills from a script
• Seeing scripts from multiple prescribers
• Purchases from social media sites

Effective treatment approaches

Effective management of ADHD and co-occurring substance use disorders often involves a comprehensive approach that addresses both conditions at the same time. Treatment may include:

• Behavioral Therapy: Cognitive-behavioral therapy (CBT) can help loved ones develop coping strategies to manage ADHD symptoms. In addition, CBT can help them lessen unwanted behaviors associated with substance use.
• Neurofeedback: Neurofeedback is designed to help individuals regulate their brain function.^[8]
• It has been used as a treatment for ADHD (Attention-Deficit/Hyperactivity Disorder) to improve symptoms although it may not help with disruptive behaviors. For example, certain brainwave frequencies might be associated with calm and focused states, while others might be linked to distractibility and hyperactivity. When the individual produces the desired brainwave patterns, they receive positive feedback, such as making progress in a game.

Medication Management: Medications may be prescribed to manage ADHD symptoms.^[9]

• They include stimulant medications like methylphenidate (Ritalin, Concerta, Daytrana) and amphetamine-based medications (Adderall, Vyvanse, Dexedrine). If a loved one with ADHD also has a substance use disorder, caution will be used be prescribers when considering stimulant medications. There are non-stimulant medications that do not have the risks of misuse linked to stimulant medications. They include atomoxetine (Strattera) and guanfacine (Intuniv).
• Support Groups: Participation in support groups or peer-led programs can provide individuals with ADHD and substance use disorders with encouragement, understanding, and practical strategies for recovery. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) offer online support for parents, families and adults with ADHD.^[10]

Family support

Families can support a loved one with ADHD and substance use disorders by:

• Encouraging open communication and expressing non-judgmental support.
• Learning about ADHD and substance use disorders to better understand their loved one’s challenges.
• Working with healthcare professionals to develop and implement a treatment plan. Read more about suggesting treatment. Medications that are less likely to be misused may be recommended.[11]
• Monitoring medications (dispensing pills, keeping meds secured, filling scripts, watching for online purchases or mail deliveries of pills from social media sites) is helpful if possible.
• Providing a structured and supportive environment that promotes healthy habits and routines.
• Encouraging harm reduction measures if a loved one is unable or unready to connect with treatment.
• Engage in self-care. It can be challenging trying to help a loved one with either ADHD and substance use problems – and it can be even more difficult if they have both. Remember to take care of yourself so that you have the energy and the patience to help your loved one.

ADHD and substance use disorders often coexist, presenting unique problems for loved ones and their families. Understanding the link between ADHD and substance use, recognizing signs of misuse, and seeking quality treatment and support are important actions to take. With early intervention and ongoing support, loved ones with ADHD can learn to manage their symptoms effectively and lead fulfilling, substance-free lives.