Managing Treatment

The Truth About ADHD and Addiction

ADHD medication is not a gateway drug. In fact, teens and adults who seek treatment for their ADHD symptoms are much less likely to abuse drugs and alcohol than are their undiagnosed, untreated counterparts.

Row of whiskey shots ordered by someone with alcohol addiction and ADHD
A row of shots at a bar ordered by someone with ADHD and an addiction problem

Intoxicants are risky business if you have attention deficit hyperactivity disorder (ADHD). A recent survey found that more than 15 percent of adults with the disorder had abused or were dependent upon alcohol or drugs during the previous year. That’s nearly triple the rate for adults without ADHD. Alcohol and marijuana were the substances most commonly abused.

“Abuse isn’t about how much you’re doing or how often it happens. It’s about how your use affects your relationships, health, work, school, and your standing with the law,” says Wendy Richardson, a marriage and family therapist and certified addiction specialist in Soquel, California. “If you have difficulties in these areas and you keep on using, you definitely have a problem.”

Why are substance abuse and addiction such issues for adults with ADHD?

“In our study of young adults, only 30 percent said they used substances to get high,” says Timothy Wilens, M.D., associate professor of psychiatry at Harvard Medical School in Boston. “Seventy percent are doing it to improve their mood, to sleep better, or for other reasons.” This kind of “self-medication” seems especially common among individuals whose ADHD remains undiagnosed, or who have been diagnosed but have never gotten treatment. “When people with ADHD get older, the hyperactive component often diminishes,” says William Dodson, M.D., an ADHD specialist in Denver. “But inside, they’re just as hyper as ever. They need something to calm their brain enough to be productive.”

That was the case for Beth, 27, a special education teacher in Ft. Wayne, Indiana. In college, she recalls, “My mind was so out of control, and drinking would make that go away. I didn’t drink to get smashed, but to concentrate and get my homework done.” Drink eased other ADHD miseries, too. Says Beth, “The boredom was impossible. I could be sitting in an interesting lecture and be totally bored. When I drank, I didn’t care that I was bored.”

The impulsivity, poor judgment, and social awkwardness that often come with ADHD pave the way to overindulgence, regardless of the consequences. Jennifer, 29, of Fayetteville, Arkansas, felt that having ADHD made it hard for her to fit in — except with the crowd that smoked marijuana. “They accepted me,” she says. “I used to think, ‘They don’t care if I’m a little crazy, if I don’t finish sentences, and walk out of the room while they’re talking.'”

There are other ADHD-related factors that can raise the risk for substance-abuse problems. Compared to people without the disorder, those with ADHD are often less successful academically. Fewer graduate from high school and college, and they earn less money.

Biology is another factor. “There’s an increased rate of substance-use disorders in close relatives of people with ADHD,” says Dr. Wilens. Genes associated with risk-taking and novelty-seeking behavior may predispose an individual to both ADHD and substance abuse.

Whatever the explanation, trouble usually starts in adolescence; until age 15, people with ADHD are generally no more likely than people without ADHD to experiment with drugs. From this age on, rates of abuse and dependency skyrocket. Half of all adults with untreated ADHD will develop a substance use disorder at some point in their lives.

In adulthood, any major life change can mean increased risk. “Starting a new job, or having a child may activate a genetic vulnerability,” says Richardson.

Preventing the Problem

The medications most widely prescribed for ADHD, methylphenidate and amphetamine, are controlled substances — meaning they have the potential to lead to abuse and addiction. Because of this, some people assume that it’s risky to take these drugs. In truth, it’s the opposite: people with ADHD who take these medications as prescribed are less likely than their untreated counterparts to drink or abuse drugs. Put another way, treating ADHD effectively is powerful protection against substance abuse.

The implication is clear: If you or your child has ADHD, make sure to arrange for appropriate treatment (including, if necessary, ADHD medication).

Experts urge parents to start talking to their kids about the matter at an early age. If you wait until fifth or sixth grade, it may be too late. Let your child know that having ADHD raises his risk for trouble, that he is more vulnerable to addiction than his peers without ADHD. Make sure your child understands that the best way to avoid trouble is to avoid illicit drugs altogether, and to wait until adulthood to use alcohol (if at all).

The good news? According to the National Institute on Drug Abuse, an individual who hasn’t started abusing a substance by age 21 is unlikely to start later. This seems to be true for people with ADHD as well as those without.

What’s more, regular exercise seems to help people avoid the lure of self-medication. “It’s important for people with ADHD to exercise, and keep the brain stimulated,” says Richardson. “Boredom puts you at risk. You need to be moving, to challenge yourself physically.”

Double Trouble, Double Treatment

In her effort to break her dependency on marijuana and other drugs, Jennifer had been to countless 12-step meetings. She even attended a 28-day residential rehab program. But all was in vain, because her ADHD hadn’t yet been diagnosed or treated.

“I couldn’t stay focused on recovery,” Jennifer recalls. “In meetings, my mind was on anything but what they were talking about. How ugly the walls were. How annoying the speaker’s voice was. I’d think, ‘How long are they going to talk? The coffee is getting cold. I have to meet so-and-so at the mall.'”

The unfortunate truth is that ADHD makes substance abuse harder to treat — and vice versa. “I couldn’t deal with my ADHD until I got sober,” says 36-year-old David, a salesman in San Jose, California. “But it was hard to stay sober before my ADHD was under control.”

What’s the right way to get help? Recent studies suggest that it’s best to optimize the treatment for ADHD only after the individual has been sober for six weeks to a few months. “The results won’t be very dependable if you just try to blast through ADHD without waiting for abstinence,” explains Dr. Wilens. Adds Dr. Dodson, “You can’t really tell whether ADHD medication is working if someone is intoxicated on something else.”

From 12-step programs to psychotherapy, the same treatments that are effective for ending substance abuse in people without ADHD are also effective when ADHD is part of the picture. Be aware, however, that some 12-step programs continue to promote a mistrust of “mind-affecting” medication, and may advise participants against taking stimulants. The best defense against this misguided advice is education — for yourself, your sponsor, and other group members. “I sometimes have a sponsor come into a therapy session, to explain what ADHD is and how the medications work,” says Richardson.

Sometimes an ADHD diagnosis preempts treatment for substance abuse. Jim, of Greeley, Colorado, smoked marijuana for years without ever realizing he had a problem — until he was treated for ADHD.

“I could function and get by when I was high, but the drug blunted my curiosity and affected who I hung out with,” says the 41-year-old. “It stunted my emotional growth. Getting the right medication to treat my ADHD was an awakening. As I became familiar with what it was like to have a clear, stable mind, I came to value myself and my ability to interact with others intelligently. Pot wasn’t fun anymore.”

Which ADHD medication is best for someone who has already battled substance abuse? For many doctors, the first choice is a nonstimulant. These drugs may not be as effective as stimulants for treating certain symptoms, but they may be safer for individuals who have already exhibited a tendency toward addiction. Other doctors choose to prescribe a stimulant, perhaps initiating treatment with an extended-release formulation, like Concerta or the Daytrana skin patch; these slow-acting meds are less likely to be abused than immediate-release meds.

Staying Sober

For most people, stopping alcohol or drug use isn’t nearly as hard as staying sober. Maintaining effective ADHD treatment is key. “People who have ADHD are prone to impulsiveness and are less able to tolerate frustration,” says Richardson.

“I was able to get clean a number of times before I was diagnosed and treated, but I always relapsed,” says Jennifer. Recently, while visiting old friends with whom she used to abuse drugs, she felt tempted again. But this time, she could fight it off. “If I hadn’t been on ADHD meds, I probably would have relapsed right then.”

If a 12-step or another self-help program works, stay with it. If you feel you need more help to remain free of drugs and alcohol, ask your doctor about cognitive behavioral therapy. It has proven effective both to treat ADHD and to prevent substance abuse relapse. “Treatment shouldn’t be a one-shot thing,” says Dr. Dodson. “You really have to keep after ADHD” to maintain protection.

Experts also recommend adopting a sobriety-promoting lifestyle. For starters, this means doing what it takes to avoid becoming too hungry, too angry, too lonely, or too tired. The basic elements of this strategy, known by the acronym H.A.L.T., are as follows:

  • Avoid hunger: Eat three full meals a day, along with three healthy snacks. Limit sugar and caffeine intake.
  • Avoid anger: Learn to manage your emotions. Don’t bury your resentments. Talk about them. Consult a psychotherapist, if necessary.
  • Avoid loneliness: Reach out to supportive people to create a new social network to take the place of drug- and alcohol-using friends.
  • Avoid becoming overly tired: Get enough sleep, and bring any sleep problems to your doctor’s attention. “Among my patients, at least 90 percent of relapses happen between 11 p.m. and 7 a.m.,” says Dr. Dodson.

Experts emphasize that relapse isn’t an event so much as a process that unfolds over weeks or months. It’s essential to watch for worrisome signs — for example, feeling unusually restless or irritable, having trouble sleeping, or having an impulse to get in touch with an old drinking buddy. In such cases, it can be helpful to write about these feelings in a journal.

It’s also essential to have a well-established plan for dealing with temptations as they arise; such a plan might involve phoning a coach or a supportive friend, or perhaps attending a meeting. In some cases, an intense workout is all it takes to defuse a potentially explosive urge to start using again.

Perhaps the most powerful tool for preventing relapse is to enlist the support of friends and family members — to watch you and perhaps even to alert your doctor if you exhibit signs of trouble. “A lot of people with ADHD have zero ability for self-appraisal,” says Dr. Dodson. “It’s good to have lots of extra eyes on the ground.”


Don’t Fear ADHD Medication

Numerous studies have shown an inverse relationship between drug therapy for ADHD and drug abuse. Perhaps the most compelling was conducted recently by Dr. Wilens’s team at Harvard. They analyzed data from six studies and found that people with ADHD who received appropriate treatment in childhood (almost always with stimulants) were a remarkable 50 percent less likely than their untreated peers to abuse drugs or alcohol in adolescence or young adulthood.

Get Support

Twelve-step programs can be helpful for adults with ADHD. If problems with memory, attention, or organization make it hard to attend meetings on a regular basis, a friend or family member can be enlisted to issue reminders — and perhaps provide transportation to meetings.

Be on the Lookout

People with both ADHD and substance-use disorders are at heightened risk for depression and anxiety. Untreated, these coexisting conditions interfere with recovery. It’s essential for those with ADHD — and their doctors — to be on the lookout for mood problems, even after the ADHD has been successfully treated.