A Dangerous Relationship: ADHD and Substance Use Disorders 

The connection between Attention Deficit-Hyperactivity Disorder (ADHD) and Substance Use Disorders (SUD) is, quite honestly, terrifying. Between 50 and 70 percent of people with ADHD have struggled with some form of substance abuse (Didier, 2022). That’s a huge chunk of the ADHD population. To put it in perspective, a large-scale study from the National Comorbidity Survey Replication found that 15.2 percent of adults with ADHD met the criteria for SUD, compared to just 5.6 percent of adults without ADHD. 

What’s even scarier? Treating individuals who have both ADHD and SUD is extra challenging due to the nature of these co-occurring disorders (Didier, 2022). With overdose rates rising, it's crucial to understand how these two conditions are linked, how they’re treated together, and what can be done to prevent this growing issue. We need to pay attention—literally—to how we handle these diagnoses before things get even worse.

A bit about ADHD 

ADHD is one of those mental disorders that doesn’t just affect how you focus—it impacts nearly every part of your life. It's characterized by patterns of inattention, impulsivity, and hyperactivity that don’t quite match a person’s age or developmental stage. ADHD is actually the most common mental disorder in childhood, affecting about 5-10% of kids in the U.S. and 2-5% of adults who experience clinically significant symptoms.

According to the American Psychiatric Association (2022), signs of inattention include things like wandering off task, being disorganized, and lacking persistence. On the hyperactivity side, you’ve got fidgeting, excessive talking, and even tapping or other restless behaviors. Diagnosing ADHD isn’t as simple as running a lab test; it’s a clinical process, meaning doctors rely heavily on interviews and observations. There’s no single neuropsychiatric test that can definitively say, “Yep, that’s 100% ADHD.”

At its core, ADHD is a disorder of executive functioning—basically, it messes with the part of your brain that helps you stay aware of what you’re doing (Barkley, 2022). Without treatment, this lack of consciousness can put people at risk of engaging in risky behaviors, potentially cutting up to 13 years off their lifespan compared to those without ADHD.

The big connection

People with ADHD are more likely to develop substance use disorders. For example, they’re twice as likely to have smoked cigarettes and three times more likely to be addicted to nicotine. They’re also twice as likely to struggle with alcohol or cocaine use, 1.5 times more likely to develop a cannabis use disorder, and 2.5 times more likely to have any kind of substance abuse issue. On top of that, adults with ADHD often face more lifestyle challenges, like lower educational attainment, frequent job loss, more traffic accidents, higher divorce rates, and social issues. All of these factors can make it even harder for people with ADHD to avoid turning to substances as a way to cope.

Researchers think this link has a lot to do with the feelings of failure and demoralization that people with untreated ADHD and SUDs often face. For some, alcohol and marijuana might become a way to escape those negative feelings or self-perceptions. It’s like they’re self-medicating. Research suggests that people with ADHD sometimes turn to substances like these to manage their symptoms. Some even use cocaine because it boosts their attention span and calms their motor restlessness—both classic ADHD traits. Others might lean on marijuana to ease hyperactivity and impulsivity.

Then there’s the issue of poor executive functioning. People with ADHD often struggle with impulse control, which doesn’t help when they’re exposed to substances like alcohol or drugs. This lack of self-restraint can lead to early experimentation with substances. Mariani and Levin back this up, explaining that people with both ADHD and SUDs tend to start using substances earlier than those without ADHD. It also turns out that kids with ADHD are more likely to try a wider variety of substances throughout their lives compared to those without the disorder. And once they develop a SUD, they tend to have a tougher time getting clean, taking longer to reach remission, and facing more continuous problems.

ADHD plays a significant role in the development of addictive behaviors. Mariani and Levin argue that the impulsivity, emotional dysregulation, and potential academic struggles often seen in people with ADHD create more opportunities for substance use to take hold. It might even be related to an impaired reward system in the brain, where drugs like nicotine and cocaine activate similar pathways to the stimulants used to treat ADHD. 

At the core of this is dopamine dysfunction. Dopamine is the neurotransmitter that regulates reward and pleasure in the brain, and researchers believe that issues with dopamine transmission are a major cause of ADHD symptoms. Studies show that stimulant medications, which increase dopamine levels, effectively manage ADHD symptoms. Genetic studies have also linked dopamine-related genes to ADHD, and imaging research shows abnormalities in dopamine-producing areas of the brain in people with ADHD. Since SUDs are also connected to dopamine issues, researchers think there might be some common factors that make ADHD and SUDs more likely to occur together.

What this means for treatment 

When it comes to treating co-occurring ADHD and substance use disorder, the key is recognizing that tackling both conditions simultaneously is the best way forward. This makes sense because the symptoms of untreated ADHD—like impulsivity and poor planning—can actually interfere with substance use disorder treatment. They can also reduce the effectiveness of ADHD treatment in the first place. Didier agrees, pointing out that ADHD treatment should be fully integrated into SUD treatment, and vice versa, since the symptoms of one can easily disrupt the treatment of the other (2022).

Fortunately, research shows that using ADHD medications in people with both ADHD and SUD can not only improve their ADHD symptoms but also have a positive impact on their substance use outcomes. Treating the ADHD symptoms first can stabilize patients enough to make them more receptive to SUD treatment. Plus, ADHD medications could help them stay abstinent by boosting their cognitive control and reducing their restlessness and impulsivity. Although there’s always some concern about the risk of abusing these medications, they might actually serve as a form of substitution therapy in cases of stimulant dependence.

And these aren't just theories. Studies have shown that people with co-occurring ADHD and SUD are more likely to maintain sobriety for longer when they take stimulant medications (Didier, 2022). More recent trials have confirmed that pharmacotherapy is highly effective for patients dealing with both disorders, giving them the tools they need to overcome their addictions.

Typically, ADHD is treated with medication, which can be divided into two main categories: stimulants and nonstimulants, with stimulants being more effective. These stimulants include familiar names like Ritalin, Adderall, Vyvanse, and Concerta. They’re available in both immediate-release and extended-release versions. For those with both ADHD and SUD, extended-release formulations are often the safest choice because they reduce the potential for abuse (Didier, 2022). However, it’s important that doctors weigh the risks and benefits before starting stimulant therapy, especially in patients with a history of substance use.

For some people, nonstimulant medications can be a good alternative, especially if there’s concern about the potential for drug abuse. A conservative approach might involve starting with nonstimulants and only turning to stimulants if necessary. While extended-release stimulants are usually the go-to, nonstimulants can be a solid middle ground.

But let’s be clear—medication alone isn’t enough. People with both ADHD and SUD need a well-rounded treatment plan that addresses both issues. This means combining medication with psychotherapy, psychoeducation, cognitive behavioral therapy (CBT), peer support, and motivational interviewing (Didier, 2022). Martínez-Raga emphasizes that psychotherapy should always be part of the treatment alongside medication. It’s essential to consider not only the severity of both disorders but also the patient’s substance use history, any withdrawal symptoms, and the presence of other mental health conditions.

Ultimately, the best outcomes are achieved when both ADHD and SUD are diagnosed and treated together. It’s a challenging road, but addressing both conditions at the same time is the key to long-term success.

References

American Psychiatric Association. (2022). Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). 

Barkley, R. (2022, November 10-11). ADHD, Executive functioning, and health outcomes: Implications for life expectancy and clinical management [Conference presentation]. ADHD Summit: What’s New, What’s Next in Supporting Neurodiverse Clients, online.

Didier, J. (2022, November 10-11). The critical intersection of ADHD and addiction: Why treating both matters [Conference presentation]. ADHD Summit: What’s New, What’s Next in Supporting Neurodiverse Clients, online.