Do Stimulant Medications Prevent Harmful Substance Use in ADHD?

How do you reassure parents who worry that, with a family history of substance use, their child will get used to taking a substance early in life?

A family history of substance use is not a mandate and not a contraindication to treating ADHD. Start with validation — it is an intuitive and reasonable concern, and it feels more acute in ADHD because the medications have direct, acute effects. Then frame medication as one part of a combined plan alongside tutoring, an IEP or 504, organisational support and therapy. Walk the family through what happens to people with ADHD when it is left untreated: not treating puts the child on a trajectory that actively adds risk factors for substance use.

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If someone presents for a first-time ADHD assessment with ongoing cannabis use, when is it appropriate to prescribe a stimulant, and what monitoring applies?

If the ADHD diagnosis is solid, active cannabis use alone is not a reason to withhold pharmacologic treatment. The work is in spending the time to be genuinely confident in the diagnosis. Dr. Sultan describes initiating treatment in young adults who were using heavily and seeing their cannabis use decrease. Monitoring is longitudinal and relationship-based: building trust, helping the patient see how regular use is not serving the concern they came in with, having them log what they buy and when, and shifting method away from vape pens, whose rapid blood levels create a tighter association than smoking.

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Should patients be required to stop using cannabis before they are given ADHD treatment?

No. In Dr. Sultan's experience that has never worked. Making abstinence a precondition ignores the patient's internal experience — if they were able to stop first, they would already be in a completely different situation.

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What role, if any, do urine drug screens have in an ADHD care workflow?

Not a routine one. Dr. Sultan does not use urine drug screens regularly, because they are of limited use and feel punitive, which does not get the work anywhere. Patient self-logging is more useful, since most people underestimate their own use and seeing the real number is itself therapeutic. Screens can have a place in high-structure situations with substantial support around the patient — close to an IOP level of structure — but that is hard to execute in ordinary outpatient care.

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These studies are univariate, but treating individuals is multivariate. What would it take to build multivariate models from large data sets?

Better per-patient data. EHRs were built out of billing rather than clinical care, so the clinical data they hold is poor. Dr. Sultan's own clinic built a research-forward assessment and EHR system that collects everything from open-ended questions to standardised measures over time. Clean, accurate longitudinal data is the precondition for the models the field wants.

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How can the field think more developmentally about ADHD and substance use, and why does that matter?

Because the brain is more plastic the younger you are, when you intervene matters as much as whether you intervene. Dr. Sultan is particularly focused on the under-25 range — which changes made in earlier periods put someone on the best trajectory available to them.

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Presentation

I think what we've done here is really nice, right? So we started off with really the I like to think of the most narrow scientific way to answer these questions which is randomized control trials. And then we moved on to my favorite way to do research which is large data sets which of course have their limitations but also have their strengths, right? And now I get to do the fun part, which I think is let's think about what we're doing with the people that we have in our offices. All right.

So, I just wanted to start what? There we go. Here we go. Okay. This is a paper I wrote a number of years ago, and I just wanted to emphasize this idea. You know, these are adolescence with ADHD. Look at their lifetime substance use. Look at the likelihoods that they have these lifetime substance uses. And even when you adjust, they're still very high numbers. This is another one looking at those individuals with ADHD and we actually compared those that end up getting antipsychotics and those that don't. You know the substance use rates are still very high and these are these complicated individuals that we were talking about earlier, right?

These are these really complicated individuals that probably wouldn't have been included in a randomized control trial. All right, so let's take a case. So we have this teenager 16 years old. They have ADHD. They've never been on a stimulant. They don't have any substance use, but there's a strong family history. They have this very attractive family. This is what AI came up for me. So, they have a father, they have a paternal uncle, and they have a cousin. All with all with issues with substance use. This is like a very loaded situation.

But they're having problems, right? They're disorganized. They're having lapses of their attention. You know this time blindness term which is not clinical but I think a good description. U maybe they're having some emotional dysregulation. What are we going to do about them? So you know concerns that might come you know risk of diversion is always a concern that we're thinking about. You know, treatment of their ADHD. That's something we want to be thinking about, right? Because we know that not treating their ADHD is has consequences as well, you know, and their own risk of addiction.

So, for me, I'm not super concerned about the diversion in this scenario. It's maybe more in a college scenario. Their risk of addiction, this individual's risk of addiction at this moment, I don't think is particularly high. Treat their ADHD. Well, there's a good risk benefit analysis that we want to be doing about that to make sure we're hitting their ADHD and their symptoms because we know not treating their ADHD is going to change their course. So, we've confirmed their ADHD diagnosis. We've assessed that they don't have any substance use. We've thought about them and stratifying risk.

Right? So, one of the things that has really helped me because I'm a clinician. I trained as a clinician and then I went on and I did psychiatric epidemiology and now substance use and that has really taught me to think in terms of probabilities and risk factors and I encourage all of you guys as clinicians to try to think that way too so thinking about what this person's risk factors are you know what's the genetic loading that they might have what might have been a protective factor for them so we've thought about that then we want to think about our formulations what are we going to maybe treat them with because we've decided we're going to treat them you know something changed for me like I was taught early on like use stimulants for ADHD.

They're so much more effective. The effect sizes are so good. You know, they're probably the some of the best effect sizes we have in psychiatry. But, you know, during the pandemic, it was really hard to find stimulants. So, I started using non-stimulants more. And I found that you can actually get a lot of mileage in terms of treatment. And you can then in include a stimulant with that. And then you have this really nice situation where it reminds me of for those of you guys that you know remember anything about diabetes you know like Lantus which is this long-acting insulin that you can take that covers you for 24 hours.

I think of the non-stimulants as being able to provide that and then you can add on our stimulant products as necessary. Okay. And then we're going to closely monitor for substance use. All right. So what does this actually mean? So ADHD treatment, you know, doesn't seem to increase the later substance use risk. The misuse that occurs is mostly linked to short-acting stimulants. And that's not surprising, right? Like the effect that you would have when you take a short-acting stimulant is going to be much more rapid. That association that reward system is going to be much more connected.

It's the same reason that like I hate Xanax. So family history alone is not a contraindication. So monitoring and our formulation to mitigate risk. So even in this person that has a high-risk family for substance use, you know, not treating their ADHD, that's probably a much greater concern than the any theoretical concern about their substance use. And so again, we have AI to thank for this. I tried to conceptualize how I might think about this. So on the left there, you know, you have two people. The top one blue doesn't have ADHD.

The bottom one is ADHD. And I'm imagining their index of well-being, which is the sort of made-up idea of how they're doing. And you know, the ADHD person's going up and down. It's probably more extreme than it is for the non-ADHD person. But now we introduced a substance use disorder. And the trajectory changes completely. And it changes for both individuals, the non-ADHD one and the ADHD one. But, you know, for me, look at the sort of like maybe that's calculus between the differences between the two lines, but the gap that we're seeing there that they're going to have a lot more problems, the ADHD folks, than the non-ADHD folks.

So, now we move on to the right and we think, okay, so we've got an ADHD person, they're up and down, and then we sort of split them up. Well, what happens if they had a substance use disorder with their ADHD treatment versus without their ADHD treatment? And the way I think of that is that, you know, this is this is hopefully going to be sort of mitigating or maybe even helping them improve, right? Versus if they had not had their ADHD treated. Okay. So, moving on, let's think about another case.

Now, we have a female. She's in college. She's coming in for evaluation of her ADHD. She's never been on medication. She has cannabis use daily and it's in the daytime, which is a little concerning, right? She also has anxiety and panic symptoms. She's having worsening academics. Her space is cluttered, time problems, task initiation. Okay, so we're thinking about her diagnosis. We're thinking about is her inattention from her cannabis? Are we adequately treating her anxiety? You know, from this, it doesn't look like she's getting anything for her anxiety other than maybe her cannabis.

And then will the stimulants make her cannabis use worse? All right. So, this is a paper that I put out a little while ago, and I had this here because I really want to drive home this point that like cannabis really affects your cognition. Slower thoughts, difficulty concentrating. Again, we even if we control for everything we can, you're still going to see that effect. And so when we're thinking about this individual who is using cannabis, I should have given her like a joint or something. That's an that's a really meaningful effect that's going on for her.

Does that mean that we're not going to treat her not treat her ADHD? And I also put this in here for her academics. So this is a another paper that I did a just came out a little while ago and then these are these are adolescence. This is monitoring the future which is one of the data sets we talked about earlier. And the main thing I want you guys to see here and I apologize the PDF conversion to JPEG didn't do so well with the resolution here. But this is dose sort of dependence or rather in terms of the how cannabis use is affecting them.

And you can see here as we're moving from left to right in each of these different domains from like not recent use, non-current use, monthly, weekly to near daily, like the odds ratios of these things occurring are getting worse. And if you look up at the top left there, her academic performance. So again, there's like a pretty strong association here. All right, so you know, we're establishing that she had ADHD. Okay, we've talked about her cannabis related cognitive effects. You know, we're for me when I have this scenario, I think of it as like a long game.

I start talking about the my concerns about how cannabis is affecting that individual's cognition from the first time that I meet them. I engage in motivational interviewing around that. I try to get them to maybe write down how often they're using the cannabis. Because you know you want them to have that sense that hey maybe the cannabis that is helping me I think in some ways like maybe with her anxiety that it's potentially making her cognition worse and subsequently giving a worse presentation of her ADHD. So we've evaluated her anxiety.

I really try to get people to give me a baseline abstinence. I'll be honest, I find that's very hard to get someone to do. Especially this scenario, which is someone that's a really, really heavy user. And then let's think about how we're going to treat her. There we go. So, her cannabis use is worsening her attention, but I don't think that explains her ADHD. She had an ADHD diagnosis earlier. Her anxiety might be making her dysfunction with her executive functioning worse. And you know she's we're trying to sort of do a staged treatment to clarify her which is challenging but we should still try to do you might want to use a lower misuse agent earlier on.

So but you know when you have ADHD when you have anxiety when you have cannabis overlapping you know let's not sort of fly through this. Let's move through it. Sequentially. Okay. So, now we've gone into the future. She's aged. She has not aged very much, by the way. So, she looks really good. Like, she's got Botox. She's got Renee. So, she's 35 now. She's a mom. Great. We know she has ADHD. You know, she we've got her on lisdexamfetamine, so we already thought about a compound that has a lower abuse potential.

But she had some kind of surgery and now she's using opioids. She's getting more impaired. And we're trying to figure out what to what to do for her. So, are the stimulants making her opioid use worse? Are we enabling her addiction by continuing the stimulants? Should we be stopping her ADHD meds because she now might have a new substance use disorder? So we've confirmed her ADHD. We identified the opioid issues. We when I say assess removing the structure, I mean like her ADHD treatment, right, that she's had for like a really long time.

You know, what's the consequence of removing that for her? We're going to continue her long-acting stimulant. And let's think about sort of an integrative way that we can we can give her some help in treatment. So, ADHD treatment, is going to improve her substance use treatment and her actually retention in her treatment program. Long- acting stimulants have a much lower misuse potential. Her untreated ADHDs would probably worsen the likelihood of like relapsing, assuming she's managing her opioid concerns now. So, what could we do? Let's think about what else we can do for contingency management.

We can do CBT with her around this. We can do motivational interviewing with her, but we don't want to remove her ADHD treatment, which by the way is something that some people do during this maybe emerging substance use disorder because it's probably more likely to make her situation worse. All right, that's why we're excited. I want to give us some time to talk and here are all of our collaborators.

Q&A — How do you reassure parents who worry that, with a family history of substance use, their child will get used to taking a substance early in life?

I think the first thing you start with in that situation is a lot of validation for this parent around this concern. I it's sort of an intuitive concern that we come up against in general I think around psychopharmarmacology which is this idea that like am I teaching my child that the solution to their problem is taking a pill and that feels even more acute in an ADHD setting where our medications have very direct one-to-one correlated acute effects. As opposed to something like an SSRI. And also in the context of a concern around substance use.

So, I want to make sure that they feel that I've heard that concern and that I think it's actually a reasonable thought process that they're having. I think the next step in that is having a discussion with the family around the idea that your suggestion around maybe a pharmacology intervention for their ADHD is just one of a number of things that you would like to be doing in this scenario. Getting back to the combined treatment. To this day I don't understand why we don't like bang home combined treatment across the board in psychiatry and mental health everywhere because I mean pretty much it's not surprising you know you do more things and people just sort of do better.

So I think really bringing home we're going to be doing other things right like oh your kid is struggling in school like you know can we get him a tutor to work with him on this kind of project you know do we want to consider a different learning environment for them? Does this kid need a individual educational plan or like a 504? Can we get them someone to sit down and help them organize themselves? That there's that this is multiple things coming together and bringing in the idea that the pharmacology is synergistic with these other things that we're doing.

And then I think the last part of it, for me comes down to thinking about with the parent and walking them through and there was no shortage of studies and numbers to support this. What happens to individuals with ADHD in an untreated scenario and the many consequences that come from that come with that and how many of those negative effects for them like you know which earlier studies would have shown like imprisonment right that is a major risk factor that many of these other things are major risk factors for that substance use disorder.

So, so, so you know, they're worried about the medication, but in fact, not treating, right? Not treating puts them on this different trajectory that actually starts adding other risk factors for substance use.

Q&A — If someone presents for a first-time ADHD assessment with ongoing cannabis use, when is it appropriate to prescribe a stimulant, and what monitoring applies?

Really hard situation depending on the age of the individual and how sort of how much reliability you think and validity there is to their ADHD diagnosis. So, I have I this can be very hard for you guys and so I know that we need it. We don't always have as much time to do this, but I spent a lot of time, really trying to feel comfortable that I feel that there is a an ADHD diagnosis there. And if I feel that there is an ADHD diagnosis there, as a as sort of a short answer, I'm very unlikely to sort of withhold pharmacologic treatment around that, even given active cannabis use.

In fact, I've initiated that with people that had an ADHD diagnosis as a child. They're now in their 20s. They're not doing well. They're basically high all the time. And initiating pharmacologic treatment with the non-stimulant and the stimulant, their substance use for their cannabis has actually started to decrease. They're still using, but it's gone down. So I would absolutely still consider doing that. But getting back to a little bit of what I talked about in my presentation, I think it's a it's a it's a longitudinal relationship that you want to have with this individual in terms of building trust with them and also helping them to start to see what you see, which is like how is your regular cannabis use like not serving you in this scenario?

And particularly around this thing that you're coming in with a complaint about which is your symptoms of ADHD. And so from a monitoring point of view, this is a question I get all the time. I don't do urine drug screens regularly. I just don't think it's I just don't think it's that useful. They're not they're and I think it feels too like you're about to punish them. And again, I just don't think that's that really gets us anywhere. I really try to get people to start to document what they're doing.

So, two ways that I do that is every time you buy cannabis, like just literally write it down and write down like what you bought and the date and then they come in with that log and we can sort of get a guesstimate of how much they're using and they're going to learn from that, right? Like they, you know, we all know, everyone in here who's ever diagnosed or interviewed someone with a substance use issue, we all actually underestimate our use. And if all you do is start to get them to realize that they're actually using a lot more than they thought, you've already made a dent in that.

So I like to do this sort of longitudinally. I like to try to document that with them and then make incremental changes around that. Something else that I do that is I try to think about what method they're using around their cannabis. There's so many options. The when I think of like a hierarchy of what I am trying to get them to stop is like vape pens. Besides the fact that the vape pens have so much garbage in them that are terrible for your lungs, the getting back to sort of the I guess pharmacokinetics of it, like they're the blood levels that they're going to be able to produce with the cannabis and the association that they're going to get through a vape pen is so connected and frankly worse than like smoking a joint.

So I try to move them away from that first and I and then considering moving towards limiting what they have available for themselves and how long they're about to use that. So they actually maybe have a supply of cannabis they're about to use, but they have to think about how much they're going to use it for and, you know, over what time period and challenging themselves to think about that. Can I just comment?

Q&A — Should patients be required to stop using cannabis before they are given ADHD treatment?

I've never had that work. I've never had I just want to reinforce that. And I just to sort of go off that for a second, I think that is so it's like you're not even thinking about the perspective of the patient and their internal experience of what's going on with them because if you did for a moment, it's quite obvious that's not going to work, right? Like if that was the situation, we would be they would be in a completely different situation, right? Exactly. And yesterday at the round

Q&A — What role, if any, do urine drug screens have in an ADHD care workflow?

So I'll tell you a situation I actually now that I think of it, I am using it. I got asked to consult on a case from another institution in New York. And this is like a high-profile family with a lot of resources. So they've been able to maybe pull this off a little bit better. And this kid was completely out of control and disregulated and was presenting to his psychiatrist looking like he might even be in some sort of mixed manic episode and it was difficult to understand him diagnostically. We actually shipped him to Mexico where he stayed with his mother's family and like a very stern aunt that was like on him like a drill sergeant.

And when he came back he actually had no cannabis. So he sort of gave him a little bit almost like a detox situation and it and he was going to go to a some kind of like therapeutic boarding school. And the mother like had a meltdown. Could not handle the idea of doing that to her son. And so we compromised that if he stayed negative on his on his urine drug screens that would not occur. And that has worked so far. We're like maybe three months into this. So I guess I should, you know, maybe edit my comment that I think there might be some scenarios that you can you can pull that off, but there is a lot of support and structure in this situation.

I mean, this kid has almost like a IOP level of structure that we're using to be able to achieve that. I think in a more casual outpatient situation, it's really hard to execute that.

Q&A — These studies are univariate, but treating individuals is multivariate. What would it take to build multivariate models from large data sets?

We have a little bit time. So, I want to connect a little bit. This a little bit of a sidebar on this. So I think that the way to do this, the problem that we have with this is the is the quality and the amount of data we have on every individual person and EHR data I thought was going to be the solution to that. You know like I grew up in the information age and you know when I was in medical school we were still writing things on paper. We were converting to EHR and I was so excited because it was going to be like Excel in business and like Word in school and like it was going to and that didn't happen because unfortunately EHRs were built out of billing and they are very big on billing and they are not big on the clinical side.

So because I am way too nerdy in my own clinic where I manage like 10 clinicians we actually built out our own assessment and EHR system that is research forward. And so we have a lot of everything from like a very psychoanalytic open-ended questions to standardized assessments and data that we're collecting over time. And I really hope that I'm not the only one that decides to do this because to me, if we had EHR data that was not garbage, right? I mean, like I don't know what else to describe it.

And that was actually, you know, clean and accurate. Imagine what we could do. Imagine the models that you could create of that. You know the imagine the information that you would have. And part of this is also it doesn't

Q&A — How can the field think more developmentally about ADHD and substance use, and why does that matter?

Very broad. You know, I've started thinking in like a I don't know, let's call it like a like a low-key basic neuroscience way around this in terms of like the connections that people are making and the links in their minds at different time periods. So for me, I'm really very concerned in the under 25 range around what we're doing how we're intervening and at what points because you know your brain is more plastic the younger you are. I mean when I was in high school we were taught you're it was just sort of stuck that way by 18.

And so you know what are the changes that we can make now in you know in earlier time periods to put people on the best trajectory that they can be.

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Columbia University Faculty | 440+ Citations | NIH-Funded Researcher