Management of attention deficit hyperactivity disorder in nonpregnant adults with a history of substance use disorder*^¶

ADHD: attention deficit hyperactivity disorder; SUD: substance use disorder; CBT: cognitive-behavioral therapy.

* This algorithm assumes that the individual does not have an active SUD. For individuals with an active SUD, we treat the SUD until stable prior to treating ADHD. For individuals with a history of an SUD who also have a co-occurring depression or anxiety disorder, we treat the ADHD using the steps in this algorithm. If clinically significant symptoms of depression or anxiety persist, we treat them using the preferred treatment for the disorder. Refer to UpToDate content for discussion of treatment of depression or anxiety in adults.

¶ We treat all adults who present for ADHD with combined modalities including pharmacologic management and CBT addressing executive dysfunction. However, for individuals with contraindications to medications, or in those who prefer not to take medication or engage in psychotherapy, we treat with the patient preferred modality. For individuals who begin with monotherapy, if symptoms persist, we encourage the addition of the other modality at any time during the treatment.

Δ Refer to UpToDate content for discussion of initiation, titration, and monitoring of atomoxetine in adults with ADHD.

◊ We work closely with the patient to establish what constitutes adequate treatment of symptoms of ADHD. Examples may include improvement in attention, decreased impulsivity, decreased hyperactivity, or improvement in overall functioning (eg, work, psychosocial). In all medication trials, unless limited by side effects, we allow sufficient time within the target dose range prior to making further medication decisions. This time period may vary between patients but generally ranges from four to six weeks.

§ Refer to UpToDate content for discussion of initiation, titration, and monitoring of bupropion in adults with ADHD.

¥ Some individuals may need stimulants for a limited period of time while others may need them indefinitely. For all decisions concerning length of treatment (ie, medication taper) we advocate shared decision making.

‡ Refer to UpToDate content for discussion of initiation, titration, and monitoring of tricyclic antidepressants in adults with ADHD.

† We use long-acting amphetamine in adults with a prior SUD if it does not include use of prior stimulants, cocaine, club drugs, or diversion/misuse of prescribed stimulants. Refer to UpToDate content for discussion of initiation, titration, and monitoring of long-acting amphetamine in adults with ADHD.