Although stimulants have been the most extensively studied treatment for adult attention-deficit/hyperactivity disorder (ADHD) (Levin, Evans, & Kleber, 1999), there are concerns that they may worsen the course of the SUDs or be subject to abuse themselves in dually diagnosed populations (Gawin, Riordan, & Kleber, 1985). At the same time, it has also been observed that a childhood history of ADHD worsens outcomes for cocaine dependence (Carroll & Rounsaville, 1993). Therefore, improving a patient's difficulties with inattention and hyperactivity may have beneficial effects on substance abuse as well (Levin et al., 1999). Consistent with this, prospective studies of children who received stimulant treatment for ADHD indicate that stimulants have a protective effect against future development of SUDs as an adult (Wilens, 2001).
Although not as well-studied as stimulants, nonstimulant medications that lack abuse potential are possible alternatives in the treatment of ADHD. In adult populations, only bupropion (Wilens et al., 2002), desipramine (Wilens et al., 1996), and atomoxetine (Michelson et al., 2003) have undergone double-blind, placebo-controlled study and demonstrated effectiveness in the treatment of hyperactivity and inattention. However, none of these trials included patients with active SUDs. To our knowledge, the only published trials of antidepressants as treatment for ADHD in populations with a current co-occurring SUD are a single-blind trial of bupropion for adult ADHD and cocaine abuse (Levin, Evans, McDowell, Brooks, & Nunes, 2002), and an open-label study of venlafaxine in patients with ADHD and alcohol use disorder (Upadhyaya, Brady, Sethuraman, Sonne, & Malcolm, 2001). Both showed improvements in hyperactivity and inattention, as well as improved substance use outcomes. However, these results need to be replicated in larger, more rigorous studies.
Clinical trials of methylphenidate in adults with ADHD and a history of cocaine use disorders have also shown promising results. Both open-label trials of long-acting methylphenidate (Castaneda et al., 2000; Levin, Evans, McDowell, & Kleber, 1998) and a double-blind, placebo-controlled study of regular methylphenidate (Schubiner et al., 2002) in adults with ADHD and cocaine dependence have all been consistent in that ADHD symptoms improved, and no escalation of the stimulant dose was observed. However, while the open trial by Levin and colleagues (1998) indicated reductions in cocaine craving and use, Schubiner and colleagues (2002) found no evidence of improved cocaine outcomes in their double-blind, placebo-controlled trial. Pemoline is a stimulant thought to have lower abuse potential than methyl-phenidate. However, there are no controlled trials of pemoline in this population, and its increased risk of hepatotoxicity, while small, makes its safety in this population unclear (Levin, Evans, & Kleber, 1999). Despite limited evidence that stimulants may be safely used in this population to treat ADHD without worsening SUD outcomes (and perhaps improving them), their use in these patients remains controversial.
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