Identification and treatment of individuals with attention-deficit/hyperactivity disorder and substance use disorder: An expert consensus statement

Table 1 Pharmacology of commonly used recreational drugs that might be used by people with attention-deficit/hyperactivity disorder

Drug type	Primary target	Main effects/transmitters	Other actions	Antagonists/blockers
Opiates	Mu opiate receptors		Kappa and delta opiate receptors	Naltrexone
				Naloxone
				Nalmefene
Stimulants
Cocaine	DAT	Inc. Dopamine	Local anesthetic Inc. 5HT	[BP-897 partial agonist]
Amphetamines	DAT	Inc. Dopamine		Mecamylamine
Nicotine	Nicotinic ACH receptor	Inc. Dopamine		Varenicline
Sedatives
Ethanol	GABA/glut	Inc. GABA	1Inc. Dopamine	No
Benzos	GABA	Dec. glutamate		Flumazenil
GHB	GABA	Inc. GABA		No
Solvents	N/A			No
Cannabis	CB1 receptors	1Dopamine		Rimonabant
Ecstasy	5HT transporter	Inc. 5HT	Some DA release	1SSRIs
LSD	5HT 2 receptors	Stimulate 5HT		5HT2 receptor antagonists

¹Postulated but not proven.

Column 2 lists the primary molecular targets for the different pharmacological classes of drugs. Column 3 lists the neurotransmitters that are impacted by the interactions listed in column 2. Column 4 lists other molecular targets that these drugs can influence. Column 5 lists antagonists or blockers that can be used to stop or reverse the effects of the drugs. DAT: Dopamine transporter; GABA: Gamma-amino-butyric acid; inc: Increased; dec: decreased.

Table 2 Markers of potential concern for substance use/substance use disorder

Life domain	Markers
Physical	Declining physical health including nausea and abdominal pain
	Looks fatigued
	Disheveled
	Unexplained weight loss
	Dilated pupils, redness in eyes
	Muscle in-coordination
	Poor personal hygiene
	Sniffing
	Administration scars (needle entry marks)
Daily functioning	Unaccountable increase in expenditure
	Difficulty managing daily living tasks (including budgeting, staying on top of household tasks)
	Poor punctuality
	Possession of substances, hiding substances
	Accessing of prescription drugs in the home
	Difficulty managing underlying health conditions (e.g., epilepsy, diabetes)
Home life	Absconding from home (adolescents)
	Receiving packages in the post which they are eager to intercept
	Driving offences
	Accidental injuries, including road traffic accidents
	Increased risk of injury and assault (both to self and others)
	Difficulties fulfilling chores and/or parenting responsibilities
	Social services involvement
	Debts
	Gambling
	Housing problems and homelessness
Educationand work	Truancy/absence from school/college or work
	Deterioration in academic/work performance
	School detention, suspension, expulsion
	High turnover of short-term employment
	Official warnings and disciplinary procedures at work
Social	Social withdrawal
	Social exclusion
	Marginalized
	Sudden change in social groupings
	Part of a ‘bad crowd’ (gangs, friends much older than peers)
	Friendship and intimate relationship problems
	Domestic violence
Mental health	Apparent deterioration in mental state and health
	Signs of emotional or physical withdrawal from others
	Paranoia
	‘Unexplained’ onset and/or change of mood swings
	Presenting as exhilarated or with excessive confidence
	Low mood and depression
	Irritability, agitation
	Anxiety
	Paranoia
	Confusion, delusions and/or hallucinations
	Emotional lability
	A&E admissions due to mental health condition
Behaviour	Early use of experimentation with drugs including early onset vaping/smoking (e.g., under 12 yr)
	Excessive use of energy drinks
	‘Unexplained’ onset of behaviour that seems ‘out of character’
	Change in personality/demeanor
	Lack of constructive interests and activities
	Disengagement of ‘healthy’ leisure activities (change in interest)
	Increased energy, restlessness and disinhibition
	Conduct problems and/or oppositional behaviour
	Irritable, agitated, aggressive and/or violent behaviour
	Risk taking behaviour (shoplifting, theft from home and/or others)
	Risky/compulsive sexual behaviour (promiscuity, risk of pregnancy, sexually transmitted infections)
	Solitary drug use
	Missing appointments
	Parenting issues leading to safeguarding concerns
	Self-harming behaviors
Speech and cognition	Changes in cognitive functioning at different times of the day
	Difficulty sustaining concentration
	Increased alertness
	Confusion
	Memory problems and loss
	Change in usual speech presentation (e.g., slurred, rapid or rambling speech)
	Reference to ‘needing’ substances (e.g., to help sleep, improve confidence) rather than use for fun or enjoyment
	Unexplained improvements in functioning

Table 3 Potential increased risks from use of recreational drugs in people treated with attention-deficit/hyperactivity disorder medication

Substance	Risks	Risk level	Antidotes
Alcohol	Intoxication, dependence	++
Cannabis (d9THC)	Anxiety, paranoia	+	Benzodiazepines
Cocaine	Cardiac problems, seizures	+++	b-blockers – benzodiazepines
LSD/psychedelics	Paranoia	+	Risperidone/olanzapine
Ketamine	Dependence, bladder damage	++
MDMA	Cardiac problems	++	b-blockers
Methamphetamine	Dependence, paranoia	++	Risperidone/olanzapine
Nitrous oxide	Intoxication, neuropathy	+	Vitamin B12
Opioids	Respiratory depression, dependence	++	Naloxone naltrexone
Sedatives	Intoxication, ataxia	+	Flumazenil (for benzos)
Spice/synthetic cannabinoids	Cardiac problems, seizures	+++	Rimonabant

+: Moderate risk; ++: Considerable risk; +++: High risk; LSD: Lysergic acid diethylamide; MDMA: Methylenedioxymethamphetamine.

Table 4 Developmentally appropriate healthcare dimensions and examples of implementing them into practice

Dimensions of DAH	In practice
Biopsychosocial development and holistic care	Assess wider aspects of young person’s life using approaches such as HEEADSSS tool (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety)
	Consider stage young person is at in their development rather than chronological age
Acknowledgement of young people as a distinct group	Opportunity for young person to be seen independently (for some or all of the consultation)
	Flexible access to service (e.g., outside school/college hours)
	Dedicated clinics and space (e.g., age-banded clinics, appropriately sized seating, magazines/posters of relevance and interest)
	Consideration of different ways young person can contact the service (e.g., digital technologies rather than letters/phone calls)
	Explain confidentiality and rights; display confidentiality policy in waiting room
Adjustment of care as the young person develops	Communication to be adjusted in line with cognitive development
	Appointment letters addressed directly to young person in addition to parents/caregivers, when needed; language used is clear
	Use of simple self-assessment tools which may feel less awkward for young person
	Record contact details for both young person and parents/caregivers
Empowerment of the young person by embedding health education and promotion	Psychoeducation provided to young person and parents/caregivers
	Shifting emphasis and supporting family to move from shared-care to self-management as the young person gets older
	Check out with young person how they would like parents/caregivers to be involved
	Involve parents/caregivers in treatment decisions in ways that have been agreed with young person
	Sign-posting young person to local services, as appropriate
	Discuss with young person their confidence and independence in making appointments, managing medication, etc.
Working across teams and organizations	Workforce training in developmentally appropriate healthcare, including strength-based approaches such as solution-focused and motivational interviewing
	Adult service included in transitioning planning prior to transfer (e.g., multi-disciplinary team meetings with adult and child teams present, adult services copied into correspondence)
	Transition planning to start early (aged 13-14)
	Opportunity for young person to visit adult service prior to transfer; provide information leaflet about service to be transferred to
	Young people issues are considered in service policies and guidelines; consistency of policies in child and adult services
	Young people’s participation at all levels of delivery

DAH: Developmentally appropriate healthcare.

Table 5 Overlapping symptoms between attention-deficit/hyperactivity disorder, substance use/substance use disorder and other psychiatric disorders

Symptom	ADHD	SU/SUD	Other psychiatric comorbidity1
Agitation	√	√	√
Anxiety	√	√	√
Hyperactivity	√		√
Impulsivity	√	√	√
Inattention	√	√	√
Intolerance to frustrations	√	√	√
Mood instability	√	√	√
Poor concentration	√	√	√
Poor memory	√	√	√
Restlessness	√	√	√
Risk-taking behavior	√	√	√
Sleep difficulties	√		√

¹Anxiety, depression, bipolar disorder, personality disorders.

ADHD: Attention-deficit/hyperactivity disorder; SU: Substance use; SUD: Substance use disorder.

Table 6 Overview and practice recommendations

Recommendations
Identification and assessment
Due to the level of complexity, assessments should only be conducted by qualified healthcare professionals with appropriate training and expertise in assessing dual disorders. This may require foundation training in ADHD and SUD across the two services and/or assessments being made jointly by experts in different areas
It is critical to examine the temporal course of ADHD-like symptoms and SU/SUD. A focus on drug and alcohol-free periods may help with differential diagnosis
Symptoms of ADHD and SU/SUD may be masked for many reasons including overlapping of symptoms between disorders, other comorbid conditions (e.g., personality disorder, bipolar disorder, anxiety, depression), and the individual may have developed compensatory strategies
Substances may have a countereffect for individuals with ADHD. Where individuals appear to be functioning better under SU, this may indicate possible underlying ADHD
Assessors should be aware that for those in institutional settings, current presentation may be misleading due to structure and routine minimising deficits in functioning
A comprehensive assessment should include a full developmental history, mental health history and current mental state examination, medical history, educational/employment history, social history, cognitive executive functioning difficulties, family history of ADHD and SU/SUD, in addition to other psychiatric and neurological problems. Perceived sex differences in presentation should be considered which may result in missed or misdiagnosis
Rating scales are not diagnostic. If used to screen, services should not rigidly adhere to cut-offs as this is likely to lead to high proportion of false positives and negatives
Young people presenting with an initial diagnosis of ADHD should be continually monitored through development for SU/SUD, given high rates of ADHD and SU/SUD comorbidity
ADHD assessment should not be conducted when an individual is under the influence of substances at the time of the assessment and/or when in a stage of withdrawal. Ideally, ADHD clinical evaluations are best conducted during a period of sustained abstinence or following detoxification or stabilization
When conducting the assessment with young people, it is important to consider how parents/caregivers are involved commensurate with the wishes and needs of the young person
The assessment may need to address additional physical, criminogenic, and safeguarding risks associated with SU. The person should be informed of the confidentiality of information shared and circumstances in which this will be breached
There are high rates of comorbidity associated with both ADHD and SU/SUD; the assessment should look to exclude other conditions that could better explain presenting symptoms
Follow-up and continued monitoring of symptoms is advised to prevent misdiagnosis
Practitioners should be aware of the risk of diagnostic overshadowing, which may require improved training in mental health services
Whenever possible, collateral information should be obtained from independent sources. For those with SUD, this may be difficult due to poor/strained relationships; the absence of collateral information should not unduly delay or prevent assessment
Pharmacological treatment
A nihilistic attitude to pharmacological treatment is not appropriate; active users of substances should be offered ADHD medication, subject to appropriate risk assessment
Long-acting stimulant preparations are recommended as first line treatment. Generally non-stimulants should be reserved as a second line due to relative effectiveness and concerns regarding non-compliance
Short-acting stimulant preparations are advised for a very circumscribed group (e.g., in contexts where there is possibility for supervised consumption)
Abstinence of substance use is not necessary for individuals to benefit from ADHD medication, though SU should ideally be reduced/stabilized before initiating ADHD medication
For those with primary alcohol use, atomoxetine may be of specific consideration in light of research indicating effectiveness in reducing alcohol cravings
Prescribing needs to consider interactions between ADHD medication and other medications for comorbid conditions, where applicable
Practitioners should be aware of personal and family history of cardiovascular conditions. Where there are concerns regarding cardiovascular risk, a cardiologist should be consulted prior to prescribing stimulant medication
Heart rate, blood pressure and weight should be measured before initiating medications and routinely monitored during treatment; titration should be slow. Include height monitoring in CYP
Individuals with SU/SUD at time of stabilization should be considered for prioritization for assessment in ADHD services
Provision of developmentally appropriate healthcare (DAH) within services may be of benefit
Commissioning arrangements should permit prescribing beyond specialist services
In spite of lowered risk of misuse or diversion with long-acting stimulant preparations, practitioners should still be vigilant of signs including pattern of losing prescriptions, early re-ordering of prescriptions, demands for immediate release preparations or claims that long-acting prescriptions are not effective, and symptoms associated with heavier use or intoxication
Supervised consumption and interval dispensing should be considered as options to minimize risk. ADHD medication dispensing arrangements should correspond with prescribed methadone, where applicable
Psychoeducation on pharmacological treatment may help to improve adherence and engagement
Psychological treatment
Where neuropsychological testing has been conducted, the strengths and weaknesses profile should be used to inform adaptations to the treatment process
Email/text reminders from service should be used to reduce likelihood of non-attendance. Sessions may require increased frequency of sessions, with greater structure, being delivered at a slower pace in shorter duration and/or including mid-session breaks, with repetition and greater use of supplementary visual material
Individuals should be provided with a notebook which serves as a record of strategies learnt. This should be completed in the person’s own writing to facilitate ‘ownership’, responsibility, and action
Motivational interviewing (MI) is more suitable for older adolescents and adults and is particularly helpful in the initial motivational stages (precontemplation, contemplation, preparation)
Practitioners need to be aware of the individual’s current motivational stage and should monitor interest to engage in treatment throughout, adapting treatment interventions as necessary
Functional behavioral analysis should be used to help identify constructive or functional alternatives to substance use
Psychoeducation should be provided as an important part of the treatment process and should be returned to at regular intervals over the course of treatment, including key points of service and/or personal transition
Psychoeducational programs should differ for children, adolescents, and adult populations in relation to changing biopsychosocial needs and demands. They should be provided to both the young person and their family. Topics should include basic information about ADHD, the purpose and benefits of medication and non-pharmacological interventions, long-term consequences of SU (including legal consequences, misconceptions around medication increasing the likelihood of addiction, how and where to access local support
Societal connotations about SU can be disparaging; parent/carer group interventions provide a supportive environment where they can share experiences (common humanity) and assuage feelings of shame
Clear and realistic goals should be collaboratively identified and monitored using the SMART framework
Individuals should be invited to use self-reinforcement techniques (which hold personal meaning) as reminders of their goals
Reward systems should be incorporated into treatment to motivate new constructive behaviour
Cognitive behavioral therapy interventions should be adapted commensurate with cognitive and emotional functioning; there may need to be more of a focus on behavioral-oriented interventions when working with young people
Young people and adults may benefit from the R&R2ADHD program which adopts a transdiagnostic approach targeting difficulties common to both ADHD and SU/SUD
Psychological treatment should include a relapse and prevention action plan, with follow-up ‘booster’ sessions provided, as needed
Multiagency interventions
Signposting to services which provide routes into education, training, employment, can help to steer people away from a harmful trajectory and prevent relapse
Practitioners should be aware that individuals may lack support networks due to strained interpersonal relationships, requiring enhanced supportive scaffolding from healthcare and service-user services
Schools should have a drugs policy establishing clearly how schools will deal with SU, where appropriate, this may include a drugs contract. If deemed appropriate, schools should also screen and refer young people for assessment of ADHD
Educational and employment support services should be aware of potential challenges for individuals. Reasonable adjustments to education/workplace may be required to help individuals manage demands and prevent harmful trajectories
Healthcare services to make reasonable adjustments through offering combined appointments
Individuals to be sign-posted to alcoholics/drug addicts anonymous for support with treatment goals
Referral to social prescribing services may be helpful in connecting people with community groups and statutory services for practical and emotional support
Transition planning between child and adult services should commence early and be a primary focus
Services should not work in silos. Foundational awareness training in ADHD and SU/SUD (as individual and comorbid conditions) should be provided to key professionals across health and social care, education and justice services and third sector organizations

ADHD: Attention-deficit/hyperactivity disorder; SU: Substance use; SUD: Substance use disorder.