Substance Use Disorders: Signs, Symptoms, and Links to ADHD
Patterns of problematic, excessive drug and/or alcohol use may point to a substance use disorder, a complex but treatable condition that affects millions of Americans. Individuals with ADHD are at greater risk for developing SUDs. Learn about the signs and symptoms of SUDs, and what we know about the ADHD-SUD link.
What Are Substance Use Disorders?
Substance use disorders (SUDs) are chronic, complex conditions characterized by problematic patterns of substance use (single or multiple substances) that cause significant distress and impairment over time. Individuals with an SUD exhibit cognitive, behavioral, and/or physiological symptoms indicating that they continue to use the substance despite its negative effects and consequences. Individuals with substance use disorders lose control over their ability to cut back or stop substances. About 10% of teens and up to 30% of adults will have an SUD sometime in their lifetime.1
SUDs frequently co-occur with other disorders, including attention deficit hyperactivity disorder (ADHD).2 About one in two adolescents and one in four adults with an SUD has co-occurring ADHD; the risk for SUD is even higher among adolescents and adults with untreated ADHD.3 4
Substance Use Disorders: Symptoms, Features, and Diagnosis
Substance use disorders are categorized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) based on a patient’s use of the following classes of drugs and substances:5
- hallucinogens (including phencyclidine)
- sedatives (including hypnotics and anxiolytics)
The DSM-5 lists 11 symptoms, grouped into four categories, that characterize an SUD. Individuals may be diagnosed with an SUD based on the number of symptoms they exhibit within a 12-month period. Two to three symptoms indicate a diagnosis of mild SUD; four to five symptoms indicate moderate SUD; six or more symptoms indicate severe SUD.
Some of the following SUD symptoms may be more or less salient depending on the substance, or they may not apply at all. (Withdrawal symptoms, for example, are not specified for phencyclidine use disorder. Withdrawal symptoms also vary across the types of substances.)
SUD Symptom Category: Impaired Control Over Substance Use
- taking the substance in larger amounts or over a longer period of time than intended
- unsuccessful efforts or a persistent desire to cut down or control the substance use
- spending a great deal of time in activities to obtain, use, or recover from the substance’s effects
- experiencing cravings or strong urges to use
SUD Symptom Category: Social Impairment
- failing to fulfill major role obligations at work, school, or home as a result of recurrent substance use
- continuing to use the substance despite experiencing social or interpersonal problems caused or exacerbated by the effects of the substance
- giving up on or reducing time spent on important social, occupational, or recreational activities due to the substance use
SUD Symptom Category: Risky Substance Use
- recurring use of the substance in physically hazardous situations
- continuing to use the substance despite knowing that it likely caused or worsens a physical or psychological problem
SUD Symptom Category: Tolerance/Withdrawal
- needing more of the substance to achieve the desired effect (i.e., tolerance)
- experiencing withdrawal symptoms (sweating, nausea, vomiting, anxiety, etc.) and taking the substance to relieve or avoid those symptoms
What We Know About ADHD and Substance Use Disorder
Adults and teens with ADHD are more likely than individuals without ADHD to use nicotine, drink alcohol, and use other drugs.6 Teens (ADHD or not) may exhibit less inhibition around drug use at this developmental stage due to the fact that the frontal oversight (dampening) components of the brain develop later than the paralimbic areas, which are activated and sensitive to emotions and rewards (e.g., activated by stimuli like drug use).7 Still, teens and adults with ADHD are more likely than individuals without ADHD to start experimenting with drugs at earlier ages.8 For these reasons, teens and young adults with ADHD should be screened for potential problems related to substance use. (Established screeners such as S2BI, TAPS tool, or queries about SUD are recommended as opposed to toxicology testing.)
ADHD is associated with both an earlier onset of and a higher risk for SUDs.8 Untreated ADHD doubles the risk for developing an SUD, according to some estimates.3 9 SUD is often more severe, complex, and chronic when it co-occurs with ADHD. Remission rates are lower among individuals with SUD and ADHD, as are retention rates in SUD treatment — critical to patients for sustaining recovery.10 11 12 13 14 15
What Explains the ADHD-SUD Link?
Research on the mechanisms underlying the ADHD-addiction link is ongoing, but studies suggest that ADHD and SUD arise, in part, from differences in the brain’s reward system.16 ADHD and its associated symptoms, like impulsivity, may also increase vulnerability to substance use and later SUDs.17 Genetics may also play an important role in ADHD-SUD risk.18 Some researchers also hypothesize that the increased risk for SUD in ADHD stems from efforts to self-medicate, though studies on this theory remain inconclusive.19
ADHD and Marijuana Use
Marijuana use, as is well known, is associated with acute neuropsychosocial impairment. One study of young adults with and without ADHD found that individuals who started using before age 16 fared worse on measures of executive functioning (e.g. organization) and other cognitive outcomes than did those who started using marijuana later — an especially worrisome finding given that study participants with ADHD were more likely to report cannabis use before age 16.21 A large study called the Adolescent Brain and Cognitive Development (ABCD) study is currently underway to study the impact of cannabis on brain development.
While some individuals with ADHD self-report using marijuana to self-medicate, one study showed that cannabis use does not lead to improved cognitive performance or activity level, though more research is warranted to understand cannabis’ effect on ADHD symptoms.22 23
ADHD and Tobacco Use
- Children with ADHD are two to three times more likely than children without ADHD to smoke cigarettes and use nicotine when they age.8
- ADHD increases risk for e-cigarette use during adolescence and during the college transition.24 25
- Compared to neurotypical brains, ADHD brains appear to experience nicotine differently, which may explain higher rates of nicotine use in this group. In a study of young adults with and without ADHD who were exposed to varying doses of nicotine, those with ADHD reported greater dizziness and more pleasurable responses to nicotine exposure than did those without ADHD.26
- Nicotine also appears to enhance cognitive functioning in some individuals with ADHD — another possible reason behind tobacco’s appeal.27 28
Does Using Stimulants for ADHD Cause Future Drug Use, SUDs, or Addiction to Stimulants?
Unequivocally, no. In fact, the opposite appears to be true. Studies show that early treatment of ADHD and its continued treatment across the lifespan reduce risk for substance use and SUDs.29 Stimulant treatment for ADHD before age 9 seems to be associated with the biggest reduction in the risk for later SUD. One study showed that children who started stimulant treatment after this age were at greater risk for substance use during adolescence than were children who started earlier.30 The same study also showed that early onset stimulant treatment of ADHD does not increase risk for using cocaine or methamphetamine — both stimulants.
Substance Use Disorders and ADHD: Treatments
Treatments for SUDs include but are not limited to the following options (and are dependent on an individual’s circumstances and needs):
- hospitalization for medical withdrawal management
- residential/inpatient rehabilitation
- outpatient (or virtual) counseling and psychotherapy
- medications to control drug cravings and reduce symptoms of withdrawal
Given the known links between ADHD and SUD, adolescents and adults with SUDs or problematic substance use should be screened for ADHD. For individuals with both SUDs and ADHD, structured therapies such as cognitive behavioral therapy (CBT) and pharmacological approaches appear most effective.31 Treatment may start, for example, with CBT that focuses initially on SUD than on the ADHD. Throughout treatment, providers may alternate between focusing on the SUD and ADHD, helping patients understand and identify their thoughts and feelings around substance cravings and urges, and managing symptoms and other ADHD-related issues that may interfere with substance use treatment. Patients also learn how to keep themselves out of high-risk situations.
Treating ADHD with nonstimulant and/or stimulant medications during an active substance use disorder is important, as it helps individuals stay in treatment — and retention in substance use treatment is highly linked to successful outcomes.32
Substance Use Disorder and ADHD: Next Steps
- Read: 5 Key Facts About ADHD and SUDs
- Read: What Should My Teen Know About Marijuana and ADHD?
- Read: Does Stimulant Medication Cause Drug Dependence?
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Substance Use Disorder and ADHD: Safe, Effective Treatment Options” [Video Replay & Podcast #440] with Timothy Wilens, M.D., which was broadcast on January 31, 2023.
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