Managing Adult Attention-deficit/Hyperactivity Disorder With Comorbid Substance Use Disorder

Objectives:Attention-deficit/hyperactivity disorder (ADHD) has its onset before 12 years but often persists into adulthood. Adult ADHD is overrepresented in persons with substance use disorders (SUD). Yet, diagnosis is challenging due to proneness to overdiagnosis, where substance use and other etiologies of attentional symptoms are misattributed to ADHD, and underdiagnosis, where symptoms are attributed to substance use alone. Untreated adult ADHD in persons with SUD can lead to worse overall treatment outcomes. Therefore correct diagnosis and the appropriate treatment are essential. Methods:A clinically focused narrative review was conducted to highlight means to identify, diagnose and manage adult ADHD in persons with comorbid SUD. Results:Screening for adult ADHD should start with interview questions and the use of 2 standardized screening instruments. If screening is suggestive, a thorough diagnostic review is required to ensure adult ADHD is diagnosed correctly, addressing aspects of substance intoxication/withdrawal and potential psychiatric comorbidity. Treatment primarily involves pharmacotherapy, but there is significant controversy in persons with comorbid adult ADHD and SUD regarding whether to prescribe nonstimulants versus long-acting stimulants, even though the best evidence supports the long-acting stimulants. Conclusions:Adult ADHD often goes undetected in persons with SUD, necessitating standardized screening in all adults with SUD. After an affirmative diagnostic review, treatment should be initiated with either a long-acting stimulant or a nonstimulant depending on patient characteristics. Follow-up should use screening instruments to measure symptom improvement beyond subjective reports and clinically monitor for any potential substance cravings or relapse.