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Categories: 2010, February
Tuckman, PsyD, MBA
RESEARCH CLEARLY SHOWS THAT PEOPLE WITH AD/HD are
more likely to run into trouble with drinking, drugs, or other addictive
behaviors.* Most of them don’t qualify as
alcoholics or addicts, but they still engage in these behaviors more
than do their peers who are not affected by AD/HD, and they pay a price
for it. Not surprisingly, those with other mental health conditions,
such as anxiety, depression, or bipolar disorder, are also at an
increased risk for substance use and addictive behaviors. However, those
with AD/HD are a little bit more likely to run into trouble here. They
are more likely to start drinking or doing drugs earlier, to try more
drugs, and to drink or do drugs more often.
Perhaps also not surprising is that those who had a history of
defiant and law-breaking behavior in childhood and adolescence
(technically speaking, those who have oppositional defiant disorder,
conduct disorder, or antisocial personality disorder) are at the
greatest risk for alcohol and drug abuse. Having the
hyperactive/impulsive subtype of AD/HD makes someone more likely to
qualify for one of these other diagnoses, so AD/HD indirectly leads to
substance abuse. This speaks to the importance of treating AD/HD early
so that things don’t go from bad to worse.
Research has also found that those who were treated with stimulant
medication as children were less likely to get into drinking and drugs
as teens and young adults, so there is some protective effect
there.** Each person is different, but there are
several reasons why someone with AD/HD may be more likely to drink or
use drugs to excess, including the following:
• Self-medication. Those with undiagnosed
and untreated AD/HD have probably had a harder life, so they may have
more reason to seek out opportunities to drown those sorrows.
• Impulsivity. Some may drink or do drugs
without thinking through the potential consequences, either for later
that day or over a longer time. Eventually, it can become a habit, and
they keep going with it.
• Thrill seeking and avoiding boredom. Some
may drink or do drugs because they’re bored or want to make a good
time even better.
• Peer group. Many teens with AD/HD deal
with their difficulties at school by disengaging and finding other kids
who aren’t into school. This makes them more likely to hang out
with kids who are more likely to drink and do drugs.
Although smoking cigarettes is less immediately problematic than
drinking and doing drugs, its effects can easily add up over time. Those
with AD/HD are at a much greater risk to become regular smokers,* which
can produce drastic health and financial detriments over time.
Drinking, drugs, smoking, and other addictive behavior can all have
negative effects on various parts of a person’s life, including
family peace, romantic relationships, friends, school, work, and
finances. It’s hard to be at your best if you’re doing too
much of this stuff. It’s also hard to get the most from therapy or
coaching, which tend to work best with a clear mind. It can also reduce
the effectiveness of medication. So, for those who are drinking or doing
drugs too much or too often, it is probably worth addressing that
Manage excessive substance use
Perhaps because of their greater need to self-medicate or perhaps
because they tend to be more impulsive, adults with AD/HD are more
likely than those without AD/HD to have trouble with addictive behavior.
This includes people who drink too much but wouldn’t be called
alcoholics, as well as people who have tendencies towards compulsive
behaviors like overspending, overeating, overuse of sex, and gambling.
The desire to feel better is understandable, and a few drinks or
whatever may help some people to do that, but unfortunately, the
solution can become its own problem if it becomes excessive.
So if you have more than two drinks a night, use other drugs, or
engage in other addictive behaviors, you need to be honest with yourself
about the effect the behaviors are having on you. Keep in mind who your
comparison group is. For example, you may not feel that you drink too
much since many of your friends drink the same amount. However, that may
not be a good measure, since we tend to choose friends who are similar
to us—if you drink too much, they probably also drink too
Potential warning signs of excessive substance use can
• You do things that you wouldn’t do sober,
such as spending money, arguing or fighting, engaging in sexual
activities, or other high-risk behaviors.
• You get into arguments about your drinking or drug use.
• You spend too much money or time on it.
• You’re not as sharp the next day.
If you feel that too many of these apply to you, you may want
to think seriously about cutting back or stopping the use
If you feel that you don’t have a true addiction, but that you
would be better off if you used less, you may be able to kill two birds
with one stone by treating your AD/HD. I’ve found that many of my
clients simply have less desire to overuse once they get some control
over their AD/HD and life. Without even really thinking about it, they
just don’t engage in that problematic behavior as much. It makes
sense—as they feel more on top of their lives and their overall
mood improves, the escape offered by drinking too much, or whatever, may
become less necessary or appealing.
If you aren’t able to keep it reined in and you wind up getting
into trouble again, then you may want to think about stopping
completely. If you can do this on your own, then that’s great. If
you can’t, you may want to consider getting some help with it.
It’s hard to make progress on your AD/HD, or much of anything
else, if your addictive behavior is making a mess of things. In this
case, you may need to get that under control first by seeking treatment
for the addictive behavior.
Unfortunately, many prescribers are hesitant to prescribe stimulants,
the most effective medication for AD/HD, to people with a strong history
of addiction. This is especially unfortunate because untreated AD/HD can
make it harder for some people to stay clean. Therefore, you may need to
settle for one of the nonstimulants, at least until you get enough clean
time under your belt that the prescriber feels more comfortable.
Meanwhile, you can work with a therapist on other ways of coping with
the urge to use.
Some people find Alcoholics Anonymous (AA), Narcotics Anonymous (NA),
or other twelve-step groups helpful, whereas others find them kind of
culty. Some people are also turned off by the religious overtones. It
depends a lot on the specific group you attend and also on what you make
of it. If you don’t like the first group you attend, then try
another one and see if the chemistry is better there. As with many
things in life, you may need to ignore the negatives and focus on the
positives if there are some helpful things about attending.
However, if you’re taking medication, especially one of the
stimulants, you may find that there are some attendees who will take
issue with that. They may see it as cheating on your sobriety and no
different than taking street drugs, even though you have a valid
prescription and legitimate reason for it. Although presumably well
intentioned, this rigid attitude is usually counterproductive and
underinformed. These people probably don’t understand AD/HD and
how it can affect your sobriety when untreated, and that there is no
high from normally prescribed doses. So you may want to think about
whether you want to disclose at meetings that you’re taking
medication. If you do disclose, you may want to have some prepared
thoughts about how to respond to these comments. You certainly
don’t have to justify yourself to anyone, but it may minimize a
conversation that you don’t want to get into.
Medicating substance abusers: Balancing the
Because prescription stimulants can be abused by those who choose to do
so, many prescribing professionals are leery of giving them to patients
with a history of substance abuse—and especially to those who are
currently using. This is sometimes due to a fear of intentional misuse,
but prescribing doctors may also be concerned that the stimulant will
give the patient a craving for illegal drugs again.
The patient may have the same fear, as one of my clients did after
several years of being clean. It was a real dilemma for her whether she
wanted to try stimulants, even though her AD/HD was really making a mess
of her life. Although the stimulants are abusable when taken at
excessive doses, they will not create a high when taken at the dosage
prescribed. Additionally, the longer-acting formulations tend to give a
slower onset and therefore very little rush.
Unfortunately, there is a pretty big overlap between AD/HD and substance
abuse, so there are a lot of people out there who may potentially be
denied access to the most effective medication treatment. Some
prescribers like to see the patient stay clean for a certain length of
time before starting the stimulant. While understandable, the untreated
AD/HD can undermine that sobriety. Conversely, medicating the AD/HD may
better enable the person to stay clean. This is a judgment call for both
the prescriber and the patient.
One option is to have a reliable family member dispense the
medication, thus ensuring that it’s only taken as prescribed. This
family member would then be authorized to communicate with the
prescriber. While not ideal, it may be better than nothing. If substance
abuse is an issue for you or a loved one, it may be worth treating it
directly, either through a twelve-step group or more formal treatment,
in addition to whatever is done for the AD/HD.
All stimulants are not created equal. In increasing order, here are
the options for those with a history of substance abuse:
• Long-acting formulations are less abusable than
short-acting ones. All three of my clients who admitted to
abusing their prescription stimulants were taking one of the
short-acting formulations. However, where there is a will there is a
way, so even the long-acting ones may not be totally safe.
• Methylphenidate transdermal patch. Because
the methylphenidate needs to absorb through the skin, it has a gradual
onset, even if someone were to use several patches, so it gives very
• Lisdexamfetemine dimesylate. This
formulation needs to be activated by enzymes in the stomach and
bloodstream, so it doesn’t give a high when snorted or injected
because that enzymatic conversion regulates how quickly the active
medication is created.
• Atomoxetine. Atomoxetine is a nonstimulant
AD/HD medication and therefore completely nonabusable (i.e., not worth
abusing) although tends to not work as well. But it can be just the
right thing for someone who is locked out of taking stimulants.
So there are some options to consider and discuss with your
prescriber. It really comes down to being completely honest with
yourself about whether you are ready to handle the responsibility of
managing a medication like this. If you aren’t sure that you are,
that’s OK. Work on your AD/HD in other ways and maybe you’ll
be more ready later.
FOR MORE INFO: CHADD's National Resource Center on
AD/HD has a helpful chart on medications used to treat AD/HD.
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