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Prescribing Stimulants to Patients With ADHD Who Have a History of SUD
(Part 2 of 2)
In this video, ADHD Section Editor and Psych Congress Steering Committee member Vladimir Maletic, MD, MS, answers the question, “does the information you presented [in part 1] mean clinicians should not prescribe stimulants to patients with attention-deficit/hyperactivity disorder (ADHD) who have a history of substance abuse disorder (SUD)?"
In part 1 of this video, Dr Maletic who is also Clinical Professor of Psychiatry at the University of South Carolina School of Medicine, Greenville, discusses the complex relationship between ADHD and substance use disorder (SUD) and expands on updates from the “World Federation of ADHD International Consensus Statement”.
Read the transcript:
Where does that leave us? There is clearly a risk, at least in a subgroup of ADHD patients, that they may be diverting or misusing stimulants, although again, that risk seems to be on a relatively low scale, 1 in 250.
Does that mean that we should not be prescribing stimulants to this category of patients? There are 2 things that we need to consider.
One is, is there current abuse of substances of any kind? If we do have strong suspicion that there is current misuse, if the patients are calling early for prescription renewals, if they are losing prescriptions, if we have indications that there are other prescribers prescribing stimulant medications, in those circumstances, we strongly need to consider replacing the stimulant with non-stimulant.
Let us say that there is a past history. Years ago, this individual has used substances or has misused prescription medications. In that case, it is not a contraindication to prescribing stimulants, but does deserve extra caution.
We need to make sure that, indeed, medications are taken appropriately. We need to watch for these telltale signs, as in calling in early or losing prescriptions or having a printout from the pharmacy where there are multiple prescribers. All of those will then warrant reexamining our strategy.
Finally, there is a scenario where there was no past history of substance use. Do stimulants confer a greater risk for the future? The answer is not really.
Actually, use of stimulants in individuals who have ADHD, based on a large Swedish cohort that included over 39,000 individuals followed for over four decades suggests that use of stimulant medication was associated with a 30% reduction in substance use. The longer stimulants were prescribed to treat ADHD, the greater reduction of the risk.
When it comes to a reduction in risk of tobacco use, appropriate treatment with stimulants is associated with about a 50% reduction in risk of tobacco use. Other studies have noted that individuals who are properly monitored and have ADHD treated with stimulants have no increased risk of use or misuse of alcohol, tobacco, cocaine, or marijuana.
Finally, there are some studies that are emerging now, including one that is from Mass General Hospital, looking at the number needed to treat. How many patients do we need to treat with stimulants in order to prevent one negative outcome? It suggests that the number needed to treat to prevent one future use of tobacco is six.
If we treat 6 patients with stimulants, we will prevent 1 nicotine dependence in the future. When it comes to alcohol, that number is 10. If we treat 10 patients who have ADHD with stimulants, we will prevent 1 future occurrence of alcohol use disorder.
Indeed, we should not be dismissive out of hand vis-a-vis use of stimulants in ADHD, but we have to keep in mind that there are always some inherent risks. By the way, there may be a surprise. If our patients are likely to divert or misuse stimulants, what age category will they be?
It is not what we would suspect. They're not individuals in their 20s and 30s. The patients most likely to divert or misuse stimulants are between ages 46 and 65. Indeed, caution, understanding current circumstances, and understanding the risk between ADHD and substance use.
Again, it's not an absolute rule out for using stimulant medications.
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