Teens and young adults with ADHD and substance use disorder face treatment gap

(Press-News.org) HERSHEY, Pa. — Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, affecting 12%–13% of adolescents in the United States, according to some studies. The pattern of inattention, hyperactivity and impulsivity can interfere with daily life, raising problems at home, work or school. At the same time, individuals diagnosed with ADHD are at a higher risk of developing substance use disorder.

But treating the combination of these two conditions can be complicated. A team, led by researchers from Penn State College of Medicine, identified a treatment gap among adolescents and young adults diagnosed with both ADHD and substance use disorder.

In a study published in the Journal of the American Academy of Child and Adolescent Psychiatry, the researchers found that despite having an ADHD diagnosis, young people who also have a substance use disorder were significantly less likely to be prescribed central nervous system (CNS) stimulants, which is the first-line medication-based treatment for ADHD symptoms. Yet, among individuals receiving this type of ADHD medication, better health outcomes were observed and serious complications were reduced, including fewer emergency visits, hospitalizations and thoughts of suicide. Over five years, ADHD treatment was linked to approximately a 30% reduction in risk of death.

“For young adults with ADHD and substance use disorder, appropriate treatment for ADHD could potentially save lives,” said Raman Baweja, professor of psychiatry and behavioral health and of public health sciences at Penn State College of Medicine and the first author on the study. “Clinicians shouldn’t hesitate to provide evidence-based ADHD treatment when it is indicated.”

According to the research team, up to 50% of individuals diagnosed with ADHD develop a substance use disorder, and these individuals face worse outcomes than if they had one of the conditions alone. They are more likely to be hospitalized or have thoughts of suicide as well as have higher rates of suicide attempts.

ADHD symptoms can be treated with both CNS stimulant and non-stimulant medications. CNS stimulant medications typically have higher response rates. Yet, clinicians often have concerns about prescribing medication, particularly stimulants, due to their controlled substance nature and Food and Drug Administration warnings about misuse, the researchers explained. There’s a fear that the medication could be misused or could make substance use symptoms worse, especially among young adults who have already struggled with a substance use disorder. As a result, clinicians may steer patients away from stimulants, which are an evidence-based treatment for ADHD symptoms.

Understanding how individuals with ADHD and substance use disorder are currently treated and the health outcomes people experience could help better guide clinicians when making treatment decisions and improve outcomes for patients, Baweja said.

In this study, the research team examined a national sample of de-identified health records of adolescents and young adults between the ages of 15 and 25. Over 1.2 million of the individuals were diagnosed with ADHD and of these, approximately 288,000 were diagnosed with both ADHD and substance use disorder, ranging from nicotine use disorder to alcohol, cocaine and opioid use disorders. The team then analyzed ADHD treatment patterns and clinical outcomes over one year and mortality over five years.

Among the young people diagnosed with both ADHD and substance use disorder, the researchers found that receiving ADHD treatment — either stimulants or non-stimulants — was associated with fewer hospitalizations, emergency room visits, and accidental overdoses; fewer suicidal thoughts; lower risk of suicide attempts; and more consistent use of psychiatric services compared to those who did not receive ADHD medication. Overall, young people had a 30% lower risk of dying over five years.

In particular, patients receiving stimulants experienced even greater reductions in risk compared to those on non-stimulant alternatives. For example, thoughts of suicide and suicide attempts were 4% lower among those treated with stimulants.

However, the researchers identified that young people were less likely to be prescribed ADHD medication after a substance use disorder diagnosis. Prescriptions for ongoing stimulant treatment dropped by approximately 15% and the number of new stimulant prescriptions decreased by more than 17% after a young person with ADHD was also diagnosed with substance use disorder.

“Although CNS stimulants are first-line, evidence-based treatments for ADHD, some clinicians appear hesitant to prescribe them in patients with substance use disorder based on these findings. We theorize that it is because of concerns about misuse, which we agree are a real risk,” Baweja said. “Our findings suggest that, when used appropriately, treating ADHD — including with stimulants — can be associated with significantly better outcomes.”

The research team is building on this work by examining a broader age range — ages 16 to 65 — of individuals with ADHD and substance use disorders. This analysis will explore how demographic factors — such as age, sex, and race/ethnicity — and clinical factors, including the type of substance use disorder and co-occurring psychiatric conditions, influence both the likelihood of receiving ADHD treatment and the type of medication prescribed.

Other Penn State College of Medicine authors include senior author James Waxmonsky, professor of psychiatry and behavioral health and University Chair in child psychiatry; Daniel Waschbusch, professor of psychiatry and behavioral health and vice chair for research; Felix Padilla, assistant professor of psychiatry and behavioral health; and Ritika Baweja, associate professor of psychiatry and behavioral health and of obstetrics and gynecology.

Other authors on the paper include Balwinder Singh, assistant professor at Mayo Clinic; William Pelham III, assistant adjunct professor of psychiatry at the University of California, San Diego; Brooke Molina, professor of psychiatry, psychology, pediatrics, clinical and translational science at the University of Pittsburgh; and Timothy Wilens, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School.

Funding from the National Center for Advancing Translational Sciences of the National Institutes of Health supported this work.

At Penn State, researchers are solving real problems that impact the health, safety and quality of life of people across the commonwealth, the nation and around the world.

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Learn more about the implications of federal funding cuts to our future at Research or Regress.

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