This is the first in a regular series of posts about ADHD and comorbidity with other common psychiatric or neuropsychological conditions, which is defined as the occurrence of two or more conditions in a person. If a person has ADHD and anxiety, the conditions are considered comorbid.
Comorbidity can be tough! It makes diagnosis difficult, especially when those two or more conditions present with similar manifestations. Then it can be difficult to say “what’s the ADHD” and “what’s the other condition”.
Today we’re talking ADHD and Substance Use Disorder.
Defining Each Condition
Attention Deficit Hyperactivity Disorder (ADHD) is a neuropsychological disorder characterized by difficulty with paying attention, hyperactivity, impulsivity, and/or difficulty controlling or regulating emotions. ADHD is broken into three categories (or presentations): Primarily Inattentive, Primarily Hyperactive-Impulsive, and Combined.
Substance Use Disorder (SUD), which may be colloquially referred to as addiction, is a psychiatric condition in which a person uses illicit or prescription drugs, alcohol and/or cigarettes in a harmful manner, to the degree that their use has a significant impact on their personal life, work, and/or schooling. People with SUD often may experience mental and/or physical health problems due to long-term use.
The Facts about ADHD and SUD
I don’t often like to cite statistics here because they are ever-changing from one study to the next, and I hate the idea of throwing down numbers and the next week a new study comes out and moves the goalpost.
But here I’ll make an exception because I think the numbers are really critical in helping you recognize that if you have ADHD and have also experienced any period of substance use in your life, you’re very much not alone:
- ADHD affects approximately 4-5% of adults and 6-9% of adolescents worldwide
- Anywhere from 15-25% of adults with SUD also have comorbid ADHD
- 9% of all adolescents have a drug use disorder, and 6% have an alcohol use disorder
- It’s estimated that people with any lifelong psychiatric or neuropsychological conditions are at least 2x more likely to also have a comorbid SUD
- Weed, alcohol and cigarettes are the three most cited substances used by adolescents with ADHD
- Adolescents with ADHD are more likely to develop SUD and typically have a shorter path from first-use to SUD, when compared to their non-ADHD peers
Where Does it Start?
Most people with SUD begin using their drink or drug of choice between the ages of 15 and 21. Studies have shown that of those who have their first-use experience after age 21, the likelihood of developing SUD drops significantly.
For reference: I started smoking weed when I was 16 years old, using alcohol when I was 17, and I picked up my first cigarette at 19.
We all may know the typical root causes of addiction: as a way to deal with stress or traumatic events in childhood; peer or societal pressure; and genetic predispositions.
But for those with ADHD, there may be other reasons why they turn to drinking or drugs or cigarettes.
Trouble Fitting In
ADHD can bring with it a certain level of social awkwardness, and persistent difficulties maintaining interpersonal relationships, because many of the manifestations come off as rude, cold, or uncaring.
- People with ADHD are often impulsive, and often interrupt because they’ve had a thought that they simply can’t contain
- People with ADHD also may experience thought jumping – rapidly cycling through topics – and it’s difficult for others to keep up
- People with ADHD also often experience time blindness, meaning they miscalculate how long it takes to complete tasks, or they easily lose track of time, making them late for appointments and events
Imagine you have a friend who constantly interrupts you, can’t tell a story to save their life, and has been late for every plan you’ve ever made. Fairly annoying and maybe reasons to end the friendship.
So, many with ADHD turn to drugs and alcohol and cigarettes as a way to fit in.
Maybe they find cigarettes calm their racing thoughts, or alcohol slows their hyperactivity, making it easier to hold a conversation.
Maybe the other smokers/drinkers/drug users seem less judgmental.
Maybe whatever they’re taking helps them to sit calmly for a few hours, in a way they’ve never experienced before – and the calmness feels good because they finally feel “normal”.
ADHD makes it easy to stand out, and drugs/alcohol/cigarettes might seem to make it easier to fit in.
Boredom and Stimulation
For many, ADHD brings with it a sense of restlessness and need to always be doing, often multiple things at once. As I sit here typing this sentence, I’m simultaneously reading through my source material; tweeting; glancing at my work email; writing down other blog post ideas; and chatting in a discord.
I find it difficult to do just one thing because my brain likes to hop around, but allowing it to happen can actually make me more efficient and focused.
Not having known this about myself at a young age meant I was frequently bored, because I was often put in situations that were under-stimulating – like sitting in class, or worship services, studying – and I had no clue how to handle it. (If I’d only had a fidget!)
So, I turned to alcohol and weed because when I drank and smoked, suddenly everything was interesting. They dulled my hyperactive mind to the point that I didn’t require that extra stimulation as much, and I could better manage myself through anything that required sitting still.
Boredom is a commonly cited reason for turning to any kind of substance – many with ADHD say it gives them something to do with all their extra energy, and the (short-term) changes in brain chemistry may make them feel more stimulated or dim the chaos of their mind.
Difficulty with Emotions
Emotional dysregulation, an inability to control or regulate emotional responses to stimuli, is a very common manifestation of ADHD. People with ADHD may become irrationally angry, irritable, or upset at the drop of a hat due to real or perceived injustices, and the emotional response can last for hours.
As an adult, I can recognize that I’m overreacting. As an adolescent, I had no concept of emotional regulation, and I labelled myself a crybaby and overly sensitive. I assumed it was a personal problem that I had to overcome, not something being triggered by an actual condition!
Handling difficult emotions is often noted as the reason people turn to alcohol and drugs in adolescence, because they are perceived to help calm one’s emotional state. If you’re smoking weed, you’re too chill to get angry. If you’re drunk, you’re too happy to care about minor inconveniences. If you’re taking opiates, you may find a sense of inner peace that keeps you from lashing out.
For many with SUD, they find that their substance of choice has been helping them regulate their emotions, by doing the work that a properly prescribed medication should be doing instead.
IT’S SO IMPORTANT TO NOTE: The negative side effects of alcohol and irresponsible drug use greatly outweigh the one perceived positive effect, and I would never recommend it for emotional regulation. I would only recommend prescribed, properly managed medications and therapy.
ADHD, SUD, and Stigma
There’s a stigma surrounding people who have both ADHD and SUD, which is that their occurrence of SUD means they’re at such a high risk for stimulant abuse that they can never be prescribed ADHD medication.
Though someone with SUD may inherently be at a higher risk for stimulant abuse (not all, but some), it does not categorically define them as untreatable.
In fact, more recent studies have shown the favorable effects of both extended-release stimulants and nonstimulants in treating those with comorbid ADHD and SUD, which both have historically lower rates of abuse overall (in populations with and without ADHD).
One such study specifically put current cocaine users on Adderall XR 60mg and 80mg, and found for participants in both dosage categories that their cocaine usage decreased significantly, and there was no evidence of abuse of the prescribed Adderall.
This way of thinking also tends to lump all substance users together as having the same motivations for their substance use, to get high, when many people with undiagnosed SUD and ADHD together may be using their substance(s) of choice to unknowingly manage their manifestations. In this kind of scenario, ADHD treatment could specifically be helpful in treatment of SUD.
We can’t pretend that people with ADHD who are prescribed stimulants never abuse them. It’s just critical to distinguish that people with SUD and ADHD can be treated through medication, though the situation may need to be more tightly monitored (but let’s not infantilize addicts, please – we deserve to be treated like adults).
Most professionals will recommend treating SUD first, then ADHD. This is because for many people, if their SUD has been long-term, it can be difficult for a doctor to pick apart which of their manifestations are from the substance use and which are from the ADHD. There can be some manifestations in common depending on the substance in question and length of term of use.
Some doctors treating ADHD may request a period of sobriety anywhere from six weeks to six months before they will prescribe any ADHD medications.
However, if there have been repeated attempts to treat SUD and they have proven ineffective, doctors can (and should!) turn to treating the ADHD and SUD concurrently.
The benefit of treating ADHD and SUD together is that it’s possible each condition exacerbates the other – substance use decreases the effectiveness of ADHD medications, and ADHD manifestations, like difficulty sustaining attention and impulsivity, can interfere with SUD treatment.
There is no medication alone that can “cure” SUD. The most effective known treatment is a combination of therapy (typically Cognitive Behavioral Therapy), treatment of other underlying psychiatric conditions, and support groups.
Treatment of ADHD typically involves a combination of medication, Cognitive Behavioral Therapy, and coaching (either one-on-one or in a group setting).
If you know someone with a Substance Use Disorder, or if you suspect you may have one, it’s important to seek help from a trusted source. In the United States, the Substance Abuse and Mental Health Services Administration, or SAMHSA, offers information and resources on SUD, including statistics and facts on substance use, treatment facilities, and other resources.
References, in no particular order or citation style:
- “Understanding Drug Use and Addiction DrugFacts”, National Institute on Drug Abuse, https://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction
- “The Truth About ADHD and Addiction”, Carl Sherman, PH.D., ADDitude Magazine, https://www.additudemag.com/the-truth-about-adhd-and-addiction/
- “Substance Abuse and ADHD”, CHADD, https://chadd.org/for-parents/substance-abuse-and-adhd/
- “The Complicated Relationship Between Attention Deficit/Hyperactivity Disorder and Substance Use Disorders”, Courtney A. Zulauf, Susan E. Sprich, Steven A. Safren, and Timothy E. Wilens, Current Psychiatry Reports, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414493/
- “Drug addiction (substance use disorder)”, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112
- “ADHD and Substance Use Disorders: How to Recognize and Manage Addiction in Adults and Adolescents”, webinar presented by Timothy Wilens, M.D., ADDitude Magzine, https://www.additudemag.com/webinar/substance-abuse-disorder-addiction
- “Treatment Strategies for Co-Occurring ADHD and Substance Use Disorders”, John J. Mariani, MD and Frances R. Levin, MD, The American Journal on Addictions, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676785/