ADHD Meds May Boost Treatment Retention in Comorbid Addiction

Fran Lowry

December 15, 2020

Judicious use of stimulants may help patients with attention deficit hyperactivity disorder (ADHD) and comorbid substance use disorder (SUD) stay in addiction treatment programs, new research shows.

Results of a 5-year retrospective cohort study showed adult patients with ADHD attending an addiction recovery program were five times less likely to drop out of care if they were receiving stimulant medication within the first 90 days compared with their peers who received no medication.

"When considering the risks and benefits of ADHD pharmacotherapy and particularly stimulant therapy in the addiction clinic, we should really be thinking about the risk of treatment dropout and poor retention if we do not treat the ADHD syndrome," study investigator Kristopher A. Kast, MD, Vanderbilt University School of Medicine, Nashville, Tennessee, told Medscape Medical News.

The findings were presented at the American Academy of Addiction Psychiatry (AAAP) 31st Annual Meeting, which was held online this year.

Comorbidity Common

"This study matters because this clinical situation comes up a lot, where you have patients who are presenting in the substance use disorder clinic who are experiencing symptoms of ADHD and who have been on stimulant therapy either as a child or young adult in the past," said Kast, who conducted this study while he was at Massachusetts General Hospital in Boston.

About 25% of patients presenting to outpatient substance use care meet criteria for an ADHD diagnosis, and having both conditions worsens ADHD and SUD outcomes, he noted.

"ADHD treatment would be helpful to these people, but often clinicians are reluctant to prescribe stimulant medication because it's a controlled substance. Especially early on in treatment, we're often worried that such a medication could destabilize the patient," said Kast.  

To examine the relationship between ADHD pharmacotherapy and retention in SUD treatment participants, the investigators assessed electronic medical record data from Mass General over a period of 5.5 years, from July 2014 to January 2020.

The data included information on 2163 patients (63% men; mean age, 44 years) admitted to the addiction clinic. A total of 203 had a clinical diagnosis of ADHD (9.4%). Of these 203 participants, 171 were receiving ADHD pharmacotherapy and 32 were untreated.

Among all participants, the group with ADHD was significantly younger than the non-ADHD group (mean age, 38 vs 45 years, respectively) and more likely to use cocaine (31% vs 12%) and have private insurance (64% vs 44%) (P < .001 for all comparisons).

Results showed ADHD stimulant therapy within the first 90 days of SUD treatment was a robust indication of retention. After adjusting for several variables, only ADHD pharmacotherapy was significantly associated with retention (hazard ratio, 0.59; 95% CI, 0.4 - 0.9; P = .008).

"It was the only variable in a multivariate regression analysis that predicted longer-term retention. It was an even stronger predictor than Suboxone [buprenorphine and naloxone] therapy, with is traditionally strongly associated with retention," Kast noted.

He added that because this was a retrospective, nonrandomized study, it limited the ability to address confounding and unmeasured covariates.

"Our findings may not generalize to the undiagnosed group of patients who would be identified by standardized diagnostic instruments," Kast said. "Future studies should address risk and number-needed-to-harm associated with ADHD pharmacotherapy."

High Dropout Rate

Dr Frances Levin

Commenting on the findings for Medscape Medical News, Frances Levin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York City, noted that previous research has shown that patients with ADHD tend to do less well in addiction treatment and drop out of programs more frequently.

What has not been shown as effectively, at least in substance use treatment settings, is that treating ADHD makes a difference in terms of retention, she said.

Although Levin wasn't involved in this study, she is currently part of a European study that is assessing SUD treatment-retention outcomes in patients with ADHD who have been randomly assigned to receive either stimulant or nonstimulant medication.

Clinicians are too often focused on risks for overtreatment, diversion, and misuse but what is underappreciated is the risk for undertreatment, Levin noted.

"This study reminds us of the dangers of undertreatment. Not using the right drugs may make people less likely to stay in treatment and continue their drug use," she said.

"Misuse and diversion are much higher with immediate release preparations, and for this reason it's important to use the long-acting stimulants in this population. Often people do not make that distinction," Levin added.

As an expert in the field for more than two decades, Levin said she has learned a lot about treating this type of patient. "You have to monitor them very closely, and never prescribe in a cavalier way," she said.

"I have the same discussion with these patients that I have when I talk about buprenorphine for opioid use disorder. It is a tremendously powerful medication, saves many lives and prevents overdose, but there is a risk of misuse and diversion, albeit pretty low. It's there, and you have to use it carefully, but I think being careful vs never prescribing are two different things," Levin said.  

"Guidance and Reassurance"

Dr Cornel Stanciu

The traditional belief among the general medical community that controlled substances should always be avoided in patients with SUD has hindered treatment for many with comorbid ADHD, said Cornel Stanciu, MD, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, when asked for comment.

"I have encountered many nonaddiction-trained physicians who provide buprenorphine treatment for OUD and they hesitate not only to assess for ADHD but also to implement standard of care treatment when such a diagnosis is made," Stanciu told Medscape Medical News.

He added that this practice often stems from fear of "being under the radar" of the US Drug Enforcement Administration for what it might consider an aberrant prescribing pattern involving two controlled substances.

"Hopefully, studies such as Dr Kast's will continue to shine light on this issue and offer guidance and reassurance to those treating addictive disorders," Stanciu said. 

Kast, Levin, and Stanciu have disclosed no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 31st Annual Meeting: Presented December 12, 2020.

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