Attention-Deficit/Hyperactivity Disorder and Substance Abuse
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
Guidance for the Clinician in
Rendering Pediatric Care
CLINICAL REPORT
Attention-Deficit/Hyperactivity Disorder and Substance
Abuse
Elizabeth Harstad, MD, MPH, FAAP, Sharon Levy, MD, MPH,
FAAP, and COMMITTEE ON SUBSTANCE ABUSE abstract
KEY WORDS Attention-deficit/hyperactivity disorder (ADHD) and substance use dis-
ADHD, attention-deficit/hyperactivity disorder, nonstimulant
medication, safe prescribing, stimulant medication, substance
orders are inextricably intertwined. Children with ADHD are more
abuse likely than peers to develop substance use disorders. Treatment with
stimulants may reduce the risk of substance use disorders, but
ABBREVIATIONS
AAP—American Academy of Pediatrics
stimulants are a class of medication with significant abuse and di-
ADHD—attention-deficit/hyperactivity disorder version potential. The objectives of this clinical report were to present
DSM-5—Diagnostic and Statistical Manual of Mental Disorders, practical strategies for reducing the risk of substance use disorders
Fifth Edition
in patients with ADHD and suggestions for safe stimulant prescribing.
OR—odds ratio
SUD—substance use disorder Pediatrics 2014;134:e293–e301
This document is copyrighted and is the property of the
American Academy of Pediatrics and its Board of Directors. All
authors have filed conflict of interest statements with the
INTRODUCTION
American Academy of Pediatrics. Any conflicts have been
resolved through a process approved by the Board of Directors. Attention-deficit/hyperactivity disorder (ADHD) is the most common
The American Academy of Pediatrics has neither solicited nor
accepted any commercial involvement in the development of the
neurobehavioral disorder of childhood and occurs in approximately 8%
content of this publication. of children and youth.1,2 It is characterized by deficits in attention in
The guidance in this report does not indicate an exclusive addition to hyperactivity and impulsivity that cause functional im-
course of treatment or serve as a standard of medical care. pairment in at least 2 settings.3 ADHD is considered a chronic con-
Variations, taking into account individual circumstances, may be dition.4 Stimulant medication is recommended as first-line therapy for
appropriate.
school-aged children with ADHD, with implementation of behavioral
therapy also recommended. Children with ADHD are at high risk of
having co-occurring mental health and behavioral problems, including
substance use disorders (SUDs).5,6 It is not clear whether stimulant
treatment reduces the risk of SUDs in adolescents with ADHD. Some
epidemiologic studies have found an inverse association between
stimulant treatment and SUDs,7,8 although this association was not
found in a study that examined the relationship between ADHD,
stimulant medication, and conduct disorder.9,10 Stimulant medication
can also have significant potential for misuse,11 abuse, and di-
www.pediatrics.org/cgi/doi/10.1542/peds.2014-0992
version12,13 (ie, giving away, trading, or selling of prescription medi-
doi:10.1542/peds.2014-0992
cation), which complicates care. Although the potential for misuse
All clinical reports from the American Academy of Pediatrics
and diversion of stimulants has been studied,11,12 there is a paucity of
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time. recent research on the abuse potential of stimulants among children
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). and adolescents. The objectives of the present clinical report were to
Copyright © 2014 by the American Academy of Pediatrics
review the literature and provide practical suggestions for optimizing
ADHD care while minimizing misuse, abuse, and diversion of stimulant
medication.
PEDIATRICS Volume 134, Number 1, July 2014 e293
Downloaded from www.aappublications.org/news by guest on September 14, 2021EPIDEMIOLOGY OF SUDS AMONG meeting criteria for a diagnosis of ADHD Stimulant medications manage ADHD
INDIVIDUALS WITH ADHD in adolescence is associated with de- symptoms by increasing synaptic do-
veloping SUDs in a subject’s 20s and 30s. pamine concentrations in the striatum
Children and adolescents with ADHD
Among individuals with ADHD, the num- (which includes the nucleus accumbens)
are more likely to misuse alcohol, to-
ber of inattention and hyperactivity/ via presynaptic transporters.35 Theo-
bacco, and other illicit substances com-
impulsivity symptoms exhibited is posi- retically, some individuals with ADHD
pared with children without ADHD.14,15
tively correlated with risk of substance may use substances to increase syn-
In a 2011 meta-analytic review of the
use.21 Debate exists regarding whether aptic dopamine concentrations as
prospective association of childhood
the inattentive versus hyperactive/ a form of self-medication.36 Another
ADHD and substance use, Lee et al14 impulsive subtypes of ADHD confer theory proposes a common genetic
included 27 longitudinal studies that different risk.22–26 factor underlying both ADHD and
followed up children with and without risk of SUDs, although more studies
ADHD into adolescence or adulthood. are needed to further evaluate this
The following demographic/methodologic EXPLORING THE BIOLOGICAL AND
ENVIRONMENTAL BASIS OF THE association.37,38
factors did not significantly moderate
RELATIONSHIP BETWEEN ADHD Children and adolescents with ADHD
the associations between childhood
AND SUD have higher rates of grade retention
ADHD and substance outcomes: gen-
and school dropout than those without
der, age, race, publication year, sample To date, the mechanisms underlying
ADHD.39,40 These academic failures
source, version of the Diagnostic and the association between ADHD and
may increase an individual’s likelihood
Statistical Manual of Mental Disorders SUDs are not completely understood,
to use drugs as a means to escape
used to diagnose ADHD, family history although several theories have been
anxiety about school.41 Academic fail-
of SUD, cognitive impairment, executive proposed. Impulsivity is associated
ures may also cause changes in peer
dysfunction, and family environment.16 with an increased risk of substance
groups, placing the individual with
Lee et al reported that, compared with use,27 a prerequisite for developing an
ADHD in social settings with others
control subjects without ADHD, chil- SUD. It is also possible that impulsivity
who have experienced school prob-
dren with ADHD were: and poor judgment associated with
lems and are at a higher risk of al-
ADHD contribute to the development
twice as likely to have a lifetime of SUDs.28 However, executive func-
cohol and drug use.42,43
history of nicotine use (odds ratio
tioning deficits and increased sub-
[OR]: 2.08, P < .001); TREATING ADHD AND
stance use seem to be only one piece
nearly 3 times more likely to report of the puzzle.29 In addition to difficulty CO-OCCURRING MENTAL HEALTH
nicotine dependence in adolescence/ with executive functioning and poor DISORDERS TO REDUCE THE RISK
adulthood (OR: 2.82, P < .001); judgment, which may lead to trying OF SUDS
almost 2 times more likely to meet substances, individuals with ADHD Treatment of ADHD May Reduce the
diagnostic criteria for alcohol abuse may also be biologically more vul- Risk of SUDs
or dependence (OR: 1.74, P < .001); nerable to developing addiction than Treatment of ADHD symptoms with
approximately 1.5 times more likely their peers without ADHD. stimulant medication may reduce the
to meet criteria for marijuana use Dopamine transmission is central to risk of developing SUDs.7,44 Biederman
disorder (OR: 1.58, P = .003); current models of both ADHD and et al45 determined that pharmaco-
twice as likely to develop cocaine SUDs.30–32 Compared with unaffected therapy was associated with an 85%
abuse or dependence (OR: 2.05, control subjects, individuals with reduction in risk of SUDs in youth with
P < .001); and ADHD have greater dopamine trans- ADHD. Timing of treatment matters:
porter density, which may result in children with ADHD who are treated
more than 2.5 times more likely to rapid clearance and low levels of with stimulant medication at a youn-
develop an SUD overall. synaptic dopamine.33 Drugs of abuse, ger age are less likely to use sub-
ADHD is associated with an earlier age including cocaine, amphetamine, stances than those who have delayed
at onset of substance use and a higher methamphetamine, Ecstasy, nicotine, onset of treatment.46 Behavioral ther-
likelihood of use of a variety of sub- alcohol, opiates, and marijuana, all apy may also confer some protection
stances.17–19 Brook et al20 reported increase synaptic dopamine concen- against substance use. Findings from
that the diagnosis of ADHD poses an trations, most notably in the brain’s re- the Multimodal Treatment Study of
increased risk of SUD into adulthood; ward center, the nucleus accumbens.34 Children with ADHD revealed that
e294 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on September 14, 2021FROM THE AMERICAN ACADEMY OF PEDIATRICS
behavioral interventions afforded pro- risk. Brook at el20 determined that used medications for ADHD and their
tection from SUDs at 24 months’ post- conduct disorder mediated the associ- suspected relative abuse potential.
intervention but not at 36 months.47 The ation of ADHD and SUDs. Other studies The terms “misuse,” “diversion,” and
optimal age at which to begin treatment have revealed that, even after control- “abuse” are all associated with im-
of ADHD to decrease the risk of sub- ling for conduct disorder, ADHD symp- proper use of medication, but they
stance use has not been established. toms are associated with increased risk
are different phenomena with dif-
The American Academy of Pediatrics of both substance use and development
ferent definitions. The term misuse
(AAP), in its clinical practice guidelines of SUDs.18,25 Comorbid conditions, in-
includes the use of medications not
for ADHD,4 recommends treating ADHD cluding depression, anxiety, and low
symptoms in children 6 years and older self-esteem, have each been noted to prescribed to the individual and using
by using both behavioral interventions confer increased risk of substance use medications in ways other than pre-
and medications approved by the US in individuals with ADHD.5,17,25,50,51 These scribed. Examples of misuse include
Food and Drug Administration. The AAP findings suggest that diagnosing and taking larger or more frequent doses
recommends that ADHD symptoms in treating co-occurring conditions in than prescribed or using someone
children as young as 4 years be treated individuals with ADHD may help to re- else’s medication to enhance perfor-
with behavioral interventions and duce the risk of developing SUDs. mance.13 The most common reasons
possibly medications. In this context, reported for stimulant misuse are to
treatment of ADHD symptoms is rec- STIMULANT MEDICATIONS concentrate, study, and improve
ommended as soon as the diagnosis grades; “to party” and “get high”; and
of ADHD is made. Symptoms of ADHD Stimulant medications are highly effec-
to experiment.54–57 Most individuals who
often persist into adulthood,48,49 al- tive for children and adolescents in re-
misuse stimulant medications do so via
though optimal duration of medication ducing the core symptoms of ADHD.52
oral administration, with intranasal in-
treatment has not been established. The most commonly used preparations
of stimulant medication are methyl- sufflation (“snorting”) less common.43,46
Maintaining children on medication
phenidate and amphetamine. Atom- Adolescents who report snorting medi-
while symptoms persist and monitor-
oxetine, a selective norepinephrine cations or using stimulants to “get high”
ing for adverse effects seems to be
reuptake inhibitor, and long-acting may be at highest risk of stimulant
a reasonable approach.
guanfacine and clonidine, which abuse and dependence.58 The term di-
As noted in the AAP clinical practice
are selective α2-adrenergic ago- version means the transfer of medica-
guidelines for ADHD,4 at any point at
nists, are also recommended for tion from the person to whom it is
which a clinician believes that he or she
the management of some ADHD prescribed to a person for whom it is
is not adequately trained or is uncertain
symptoms.4 However, the effect sizes not prescribed.13 The term substance
about making a diagnosis or continuing
(meaning likelihood of reducing ADHD abuse was used in the Diagnostic and
with treatment, a referral to a pediatric
symptoms compared with placebo) are Statistical Manual of Mental Dis-
or mental health subspecialist should be
lower for atomoxetine and long-acting orders, Fourth Edition, to refer to use
made. If a diagnosis of ADHD or other
guanfacine and clonidine than they are associated with problems or risk that
condition is made by a subspecialist, the
for the stimulant medications.
primary care clinician should develop interfere with functioning. The term
a management strategy with the sub- Stimulant medications are both more addiction refers to loss of control or
specialist which ensures that the child effective at treating ADHD symptoms53 compulsive use of a substance. In the
will continue to receive appropriate care and much more commonly misused Diagnostic and Statistical Manual of
consistent with a medical home model than nonstimulant medications. Pedia-
Mental Disorders, Fifth Edition (DSM-
wherein the primary care clinician part- tricians are thus in a position to pre-
5), diagnostic terms were changed to
ners with parents so that both health and scribe a medication that can reduce
SUD, mild/moderate/severe, depend-
mental health needs are integrated. both ADHD symptoms and the risk of
developing an SUD and simulta- ing on the number of positive crite-
neously pose a risk for abuse and ria.3 Even though they are not formal
Treating Co-occurring Mental diversion. An understanding of the diagnoses, the terms substance abuse
Health Disorders factors associated with misuse, and addiction will likely remain in the
Co-occurring mental health conditions abuse, and diversion of stimulant lexicon and retain their meaning for
are common in individuals with ADHD medication may help to guide safe some time, particularly in reference
and are associated with increased SUD use. Table 1 lists the most commonly to prescription medications.
PEDIATRICS Volume 134, Number 1, July 2014 e295
Downloaded from www.aappublications.org/news by guest on September 14, 2021TABLE 1 List of Most Commonly Used Medications for ADHD With Suspected Relative Abuse disorders are more likely to both
Potential
misuse and divert their stimulant
Stimulant Status Medication Type US Trade Namea Suspected Relative medication,64 as are white individuals,
Abuse Potentialb
members of fraternities and sorori-
Stimulants
Short-acting/immediate Methylphenidate Ritalina High
ties, and students with lower grade-
release Methylina High point averages.54,65
Dexmethylphenidate Focalina High
Amphetamine- Adderalla High
Abuse of Stimulant Medications
dextroamphetamine
Dextroamphetamine Dexedrine High Methylphenidate and amphetamine
DextroStata High
ProCentra High
both have known abuse potential, al-
LA/ER Methylphenidate Metadate CD Medium though there is little evidence that
Metadate ERa Medium these drugs are widely abused by the
Ritalin LAa Medium
patients to whom they are pre-
Ritalin SRa Medium
Methylin ER Medium scribed,59 and evidence for abuse po-
Daytrana patch Low tential among children and adolescents
Concertaa Low
is limited. “Subjective effect” (ie, how
Quillivant XR Low
Dexmethylphenidate Focalin XR Low much a person likes a drug, achieves
Dextroamphetamine Dexedrine Spansulea Medium euphoria, experiences reinforcement
Amphetamine- Adderall XRa Medium with use) is an important factor con-
dextroamphetamine
Lisdexamfetamine Vyvanse Low sidered in determining abuse potential
Nonstimulants of a substance. Among individuals with-
α2-adrenergic agonists Guanfacine Intuniv Low out ADHD, both methylphenidate and
Clonidine Kapvay Low
Selective norepinephrine Atomoxetine Strattera Low amphetamine produce significant sub-
reuptake inhibitor jective effects; amphetamine is nearly
CR, controlled release; ER, extended release; LA, long acting; XR, extended release; SR, sustained release. twice as potent as methylphenidate at
a
Indicates that generic formulation is available.
b
Relative abuse potential is suspected based on length of action and formulation of medication.
equivalent doses.66 Research performed
in the 1970s revealed that stimulants
do not reliably produce these subjec-
Misuse of Stimulant Medications prescription stimulants in their life- tive effects in individuals with ADHD.67
Misuse and diversion of stimulant time. Nonmedical use of prescription Fredericks and Kollins68 found that
medications are more widespread stimulants was associated with pre- individuals with ADHD displayed a high-
problems than abuse or addiction.59 vious use of illicit substances as well er preference for methylphenidate com-
Wilens et al54 conducted a systematic as alcohol and marijuana dependence. pared with placebo, although other
review of the literature examining measures of abuse potential, specifically
misuse and diversion of prescription Diversion of Stimulant Medications participant-rated effects of methylpheni-
ADHD medications. Of the 21 studies Diversion of stimulant medication is date on mood, were not elevated. Thus,
reviewed, rates of past-year non- common. Between 16% and 23% of the preference for methylphenidate may
prescribed stimulant use ranged from school-aged children reported that they reflect its therapeutic efficacy rather
5% to 9% in grade school and high have been approached to sell, give, or than abuse potential. Most of the studies
school children and from 5% to 35% trade their prescription stimulant evaluating abuse potential of stimulant
in college-aged individuals. In a large medication.60,61 Boys are more likely medications used short-acting prepara-
public university in the mid-Atlantic to divert their stimulant medications tions, and there is evidence that
region, Arria et al55 found that 18% of than girls.62 The most common source sustained-release and longer acting
students who were not prescribed of diverted medications is friends preparations have decreased abuse po-
stimulants engaged in nonmedical and family members.63 More than one- tential.59,69 Indeed, short-acting medi-
stimulant use, more than one-quarter quarter of university students reported cations are more likely to be misused or
(26.7%) of students with diagnosed that diverted stimulant medications are abused, and amphetamine preparations
ADHD reported having used more easy or somewhat easy to obtain.56 are misused and abused more fre-
medications than prescribed, and Individuals with ADHD who have co- quently than methylphenidate prepa-
15.6% reported using someone else’s occurring SUDs and/or conduct rations.53,70,71
e296 FROM THE AMERICAN ACADEMY OF PEDIATRICS
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SAFE STIMULANT-PRESCRIBING Screen Older Children and Provide Anticipatory Guidance
PRACTICES Adolescents for Use of Alcohol, Anticipatory guidance regarding
Marijuana, and Other Drugs proper use of stimulant medications
In light of the high risk of SUDs among
individuals with ADHD, pediatricians The AAP recommends screening, brief should be part of every patient en-
should seek to accurately diagnose intervention, and referral to treat- counter in which medications for
ADHD and treat symptoms appropriately. ment as part of routine health care ADHD are discussed. Table 2 lists
Several precautions may help to reduce for older children and adolescents.74 points that should be included in this
stimulant misuse, abuse, and diversion. This recommendation is particularly discussion. The pediatrician should
important for adolescents with ADHD, discuss that medications should only
who are more likely to use sub- be taken as prescribed by the phy-
Before Prescribing, Confirm
a Diagnosis of ADHD stances and to develop an SUD than sician, even with very young children,
their peers. Adolescents with ADHD in a developmentally appropriate
Inattention is multifactorial. Many who use alcohol, marijuana, or other manner. As children enter the upper
children or adolescents who are de- substances are also more likely to elementary school years, the con-
pressed, anxious, neglected, or having divert stimulant medication and thus versation should evolve to include
academic difficulty because of require increased attention and discussion about the proper use of
a learning disorder may present as monitoring by their prescriber. medication. Children and parents
inattentive. ADHD is a primary dis- should be aware of the risk for mis-
The AAP policy statement titled
order of attention. According to the use, diversion, and abuse. Children
diagnostic criteria for ADHD in the “Substance Use: Screening, Brief In-
tervention, and Referral to Treatment should understand that trading or
DSM-5,3 ADHD symptoms must be selling stimulant medication is ille-
present during childhood; thus, par- for Pediatricians”74 provides a com-
plete review of recommended screen- gal. Children who live in areas of
ticular caution is warranted before high-crime rates should have a con-
making a new diagnosis of ADHD, es- ing tools and brief interventions for
adolescent substance use. The AAP crete, realistic safety plan for man-
pecially in an adolescent. Although it aging their medication. For children
is possible that symptoms in child- currently recommends the 3 “open-
ing questions” associated with the who are 12 years and older, the dis-
hood were unnoticed, adolescents cussion should also include in-
sometimes attempt to get a stimulant CRAFFT tool (see the following text) to
detect past-year substance use. Al- formation about careful transitioning
prescription by feigning symptoms of of administration of medication. Al-
ADHD.72 The diagnosis of ADHD is though currently an active area of
though the child should not be
made clinically in an individual who National Institutes of Health–funded
pushed to start self-administering
fulfills the criteria for ADHD listed in research,75,76 these questions have
medication, having this discussion
the DSM-5.3 Standardized tools, such not been validated to date, and it is
earlier with the family can alert them
as parent- and teacher-completed not known whether the “other drugs”
that transition of medication man-
ADHD rating scales, assist in making question is sensitive enough for
agement from caregiver to child
a diagnosis and should be used in the identifying misuse or abuse of pre-
should be a gradual and carefully
assessment.73 A thorough history, re- scription medications. An additional
monitored one so that when the child
view of medical and school records, question (eg, “Have you ever used
is developmentally ready to assume
and a collateral parent interview may someone else’s prescribed medica-
more responsibility of medication
all help confirm a correct diagnosis. tion?”) may be warranted to identify
management, there is a plan in place
The criteria used for diagnosing ADHD misuse, particularly before pre-
to ensure that the transition is safe.
and any history or evaluations that scribing a stimulant medication for
were made to rule out other con- the first time.
ditions that might be confused with “Opening questions” to identify past- Document Prescription Records
ADHD (eg, sleep disturbances, other year substance use: Stimulant medication is a Drug En-
learning disabilities, thyroid dysfunc- In the past year, have you: forcement Administration Class II
tion) should be recorded in the controlled substance. Every prescriber
1. Had a drink with alcohol in it?
patient’s medical record. The AAP’s must document and monitor the pre-
Clinical Practice Guideline for ADHD 2. Used marijuana? scribing of stimulant medications.
provides specific guidance about di- 3. Used any other substance to get Requests for early refills should be
agnosis and management.4 high? explored and carefully documented to
PEDIATRICS Volume 134, Number 1, July 2014 e297
Downloaded from www.aappublications.org/news by guest on September 14, 2021TABLE 2 Discussion Points for Anticipatory Guidance Regarding Stimulants and Substance Use medication, it may be best to start with
Proper administration a long-acting stimulant medication
At each clinic visit, review with the patient how he or she is taking his or her stimulant medication. with low risk of misuse or diversion.
• Only take the amount of medicine prescribed. Do not take extra medication. Long-acting preparations, especially
• Take your stimulant medication exactly as prescribed. Do not change the dose or timing. Speak to your
doctor if you do not think your medication is working as it should or if you are experiencing adverse
those with an osmotic controlled-
effects. release oral delivery system such as
• Do not use alcohol, tobacco, marijuana, or other illicit substances. Drug use worsens problems with Concerta, have lesser likelihood of
attention, leads to medication noncompliance, and can interact with stimulant medication. misuse or diversion.77 It is also rea-
• If stimulant medication is administered at school, it should be dispensed at school nurse’s office or
other safe location with adult supervision. sonable to consider use of a non-
Risk of misuse, diversion, and abuse stimulant preparation,78 even though
For people who do have ADHD, when stimulant medications are taken as prescribed, there is no nonstimulant medications are less
increased risk of abuse; rather, stimulant medication appears to decrease the risk of developing an
SUD. efficacious than stimulants.79 The
• Explain that some people who do not have ADHD may take stimulant medications inappropriately. prodrug formulation of dextroam-
• Inform patient and parent that children and adolescents may be asked to give away or sell their phetamine, lisdexamfetamine, has
stimulant medications but should never do so. Parents may role play appropriate responses so that
the child will be prepared if asked. Have the patient and parents keep medication in a safe location
a lower abuse potential than other
(either at home or in a locked office at school). Medications should never be carried in a backpack or stimulants and thus may be consid-
purse. ered.80,81 However, physicians should
Transition of care
be aware that any psychoactive med-
Transitioning of administration of stimulant medication from caregiver to child/adolescent should be
done incrementally. Parents and patients should be counseled that ADHD generally persists into ication can be misused. As for all
adulthood. patients, it is important to carefully
• To start a transition, the child/adolescent must be able to remember to take medication as prescribed. monitor medication adherence.
Signs suggesting readiness should include the ability to name the medication, dose, and timing of
administration as well as emerging signs of independence in other areas, such as being home alone, A special circumstance occurs when
carrying a key, completing homework independently, or participating in care for a pet. a pediatrician prescribes stimulant
• The caregiver should continue to periodically supervise medication administration and monitor the
child’s/adolescent’s overall school, social, and family functioning. Weekly pill dispensers can allow
medications for college students and
burgeoning autonomy for the child/adolescent while allowing the caregiver to monitor doses and older patients living away from home.
control the supply. A treatment plan should document
• If concerns develop regarding medication misuse or diversion or use of other drugs, the parent
how medication will be prescribed and
should resume control of the medication, dispense each dose, and monitor carefully.
how frequently the patient is expected
to return for follow-up visits with the
detect a pattern of frequent early symptoms of substance use may be
pediatrician. Medication administra-
requests. Similarly, it is important to indistinguishable from ADHD symp-
tion by a student health staff member
document communications between toms. In general, an active SUD should
or keeping medications in a small
multiple providers who share re- be treated (usually via referral to
medication safe may reduce diversion
sponsibilities for prescribing medi- a mental health counselor or addiction
or theft. Follow-up visits should include
cations or altering treatment regimens specialist) before beginning medica-
self-report of medication efficacy, ad-
for the same patient. tion to treat ADHD. However, for
verse effects (appetite, abdominal
patients with well-documented ADHD
symptoms, headaches, and sleep dis-
that predates the onset of substance
Prescribing Medications for ADHD turbance) and screening for medica-
use, it may be reasonable to treat both
in Context of Active SUD tion misuse, abuse, or diversion.
disorders concurrently. Consultation
The patient’s responses should be
Illicit substance use often results with a psychiatrist or addiction spe-
documented in the medical record.
in attention difficulties, hyperactivity, cialist when managing complex patients
Reports or suggestions of new physi-
and/or impulsivity, making a new di- is suggested.
cal or mental health symptoms re-
agnosis of ADHD difficult or impossible When considering which ADHD medi- quire reevaluation.
to distinguish from symptoms related cation to prescribe to a patient with
to ongoing substance use. In these a co-occurring SUD, a careful risk/
cases, reevaluation after a period of benefit assessment must be con- SUMMARY
abstinence may be warranted. ducted. If the patient is currently ADHD is a common neurobehavioral
Adolescents who have both previously abusing prescription stimulants or disorder of childhood, and individuals
diagnosed ADHD and an active SUD there is a clear indication that the with ADHD are more likely to misuse
may be difficult to monitor because patient would sell or divert stimulant alcohol, tobacco, and other illicit
e298 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on September 14, 2021FROM THE AMERICAN ACADEMY OF PEDIATRICS
substances compared with children includes screening for SUDs and LEAD AUTHORS
and adolescents without ADHD. Indi- providing anticipatory guidance Elizabeth Harstad, MD, MPH, FAAP
Sharon Levy, MD, MPH, FAAP
viduals with ADHD and co-occurring around the appropriate and safe use
mental health conditions, such as of stimulant medications. Individu-
disruptive behavior disorders or als with co-occurring ADHD and COMMITTEE ON SUBSTANCE ABUSE,
2013–2014
depression, are at even higher risk active SUDs require a careful, in- Sharon Levy, MD, MPH, FAAP, Chairperson
of developing SUDs. Appropriate dividual risk/benefit assessment Seth D. Ammerman, MD, FAAP
treatment of ADHD symptoms with regarding the safety of prescribing Pamela K. Gonzalez, MD, FAAP
medication and behavior therapy a stimulant medication. Longer act- Sheryl A. Ryan, MD, FAAP
Lorena M. Siqueira, MD, MSPH, FAAP
may reduce the risk of development ing preparations of stimulant med- Vincent C. Smith, MD, MPH, FAAP
of SUDs. Primary care providers ication, the prodrug formulation
should seek to identify and treat of dextroamphetamine, and non- LIAISONS
ADHD to prevent the development of stimulant medications for ADHD all Vivian B. Faden, PhD – National Institute of
SUDs. However, the recommended have lower abuse potential than Alcohol Abuse and Alcoholism
first-line medication therapy for ADHD short-acting preparations of stimu- Gregory Tau, MD, PhD – American Academy of
Child and Adolescent Psychiatry
is stimulant medications, which lant medication and, thus, their use
themselves pose a risk of misuse, di- should be strongly considered if
STAFF
version, and abuse. Therefore, an im- there is a high risk of misuse, di- Renee Jarrett, MPH
portant part of ADHD treatment and version, or abuse of stimulant James Baumberger, MPP
stimulant medication management medications. Katie Crumley, MPP
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disorder? Towards resolution of the con- vice use for US children with ADHD, 2007. col. 2011;21(4):331–339
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