Edited by Charles Ward
ADHD and Alcohol Use Disorder: Optimizing Screening and Treatment in Co-occurring Conditions
Hernández & Campbell, in CNS Drugs, 2025 May;39(5):457–72.
Key Messages
- There is a growing awareness regarding links between attention deficit hyperactivity disorder (ADHD) and predisposition to addiction;
- Many adults are first diagnosed with ADHD when they present to treatment centres with substance use disorder (SUD);
- Comorbid ADHD and alcohol use disorder should be treated concurrently with both pharmacologic and behavioural interventions;
- Abstinence from substance use provides benefits in ADHD symptom management;
- Screening for alcohol use disorder in ADHD patients (and vice versa) presents a positive opportunity for harm reduction in a high risk group.
Article Summary
This review explores the connection between ADHD and alcohol use disorder with a focus on optimisation of screening and treatment. The authors estimate that 23% of adult ADHD patients have co-occuring alcohol use disorder, explained by increased impulsivity and pre-existing deficits in inhibition control. Many patients are first diagnosed with ADHD when they present to clinicians for treatment with SUD. This can present a diagnostic challenge for clinicians treating substance using populations, who must assess whether symptoms of attention deficits, impulsivity and impaired inhibitory behaviours relate to the consequences of substance use or result from pre-existing ADHD, a neurodevelopmental disorder.
The authors find that treatment centres that implement concurrent, integrated or dual-diagnosis programmes for ADHD and SUD had superior outcomes when compared to programmes that only treat one disorder. The authors find that multimodal pharmaceutical and behavioural therapy provide the most effective outcomes, and they specifically note that combined pharmaceutical amphetamine treatment and cognitive-behavioural therapy for ADHD had a concurrent impact in reducing drug-positive urine screens. Meanwhile, patients who were successful in maintaining abstinence from substance use had better ADHD symptom control.
They conduct a thorough review of literature regarding risks of prescribing psychostimulant ADHD medication and find that the risk of adverse events is only marginally increased in concurrent use with alcohol. They propose that more emphasis on screening for SUD in ADHD patients and vice versa could provide a positive harm reduction measure, and they particularly recommend that clinicians adopt a combined or universal screening approach for both conditions in the adult population.
Commentary
2025 saw a flurry of research into the association between ADHD and addiction. Within the last ten years, the annual percentage change in ADHD incidence has been overwhelmingly positive in Europe and North America, especially in adolescent age groups, leading to an increase in prescribing patterns, especially regarding stimulants such as methylphenidate. Studies in Sweden (4) and Denmark (5) have highlighted increased disparities in diagnosis and prescribing between regions and socioeconomic groups with disadvantaged groups receiving a higher incidence of pharmaceutical treatment. It is estimated that persons with SUD are about four times more likely to have ADHD than baseline populations (6), and adults with ADHD have significantly higher risk of SUD involving alcohol, nicotine and benzodiazepines (2). Indeed, ADHD patients frequently exhibit comorbid psychiatric presentations including anxiety, depression, sleep disorders and predisposition to risky behaviour, all of which increases the likelihood of high-risk substance use. It is sobering to note that the prevalence of ADHD is ten times higher in incarcerated populations than the general public (3).
An Urgent Public Health Priority
While Hernández and Campbell provide a thorough review of adverse events in psychostimulant ADHD treatment in patients with SUD, their work is unlikely to allay an increasing controversy within the literature. Stimulant use is a growing public health concern and treatment programmes are characterised by failure to address psychiatric comorbidities, difficulties with polysubstance use, and ineffectiveness owing to the differing neurobiology of stimulant addiction when compared with other, better understood substances of abuse (7). Some physicians have referred to an epidemic of amphetamine use, a “present day opioid crisis”. Indeed, some commentators describe widespread overdiagnosis, overprescription, and high-risk daily use of amphetamines with the potential for addiction, diversion and iatrogenic harm in a population already predisposed to addiction (8). While there is no settled consensus, a narrative review produced by a team at Wrocław Medical University emphasised individualised, multimodality treatment for ADHD patients with SUD, with a focus on non-addictive pharmaceuticals and cognitive behavioural therapy as the best method of progression with this group (10).
What is clearly missing is an emphasis on harm reduction and joined-up thinking between medical, psychiatric and legal policymakers, who would do well to better understand the links between ADHD, predisposition to substance use and greater likelihood of these individuals coming into contact with elements of the criminal justice system. A key development would be better emphasis on screening for substance use disorders during ADHD diagnosis and vice versa, and better recognition and education regarding the propensity for high-risk behaviour in patients with ADHD.
References
1. Hernández M, Levin FR, Campbell ANC. ADHD and Alcohol Use Disorder: Optimizing Screening and Treatment in Co-occurring Conditions. CNS Drugs. 2025 May;39(5):457–72.
2. Zamboni L, Federico A, Casari R, Fusina F, Zandonai T, Zoccante L, et al. ADHD and the Risk of Benzodiazepine Misuse: A Systematic Review and Meta-Analysis. Subst Use Misuse. 2025 Dec 6;1–8.
3. Modesti MN, Gubbini S, De Rossi P, Manzi A, Nicolò G, Adriani B, et al. ADHD in adults and criminal behavior: The role of psychiatric comorbidities and clinical and sociodemographic factors in a clinical sample. Int J Law Psychiatry. 2025;101:102088.
4. Jablonska B, Kosidou K, Ponce de Leon A, Wettermark B, Magnusson C, Dal H, et al. Neighborhood Socioeconomic Characteristics and Utilization of ADHD Medication in Schoolchildren: A Population Multilevel Study in Stockholm County. J Atten Disord. 2020 Jan 1;24(2):265–76.
5. Wallach-Kildemoes H, Skovgaard AM, Thielen K, Pottegård A, Mortensen LH. Social Adversity and Regional Differences in Prescribing of ADHD Medication for School-Age Children. Journal of Developmental & Behavioral Pediatrics. 2015 June;36(5):330.
6. van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, et al. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: A meta-analysis and meta-regression analysis. Drug and Alcohol Dependence. 2012 Apr 1;122(1):11–9.
7. Bahji A. Limitations and Future Directions in Pharmacological Treatment for Amphetamine-Type Stimulant Use Disorder. Can J Psychiatry. 2025 Feb;70(2):136–7.
8. Miller N. Amphetamines: a current epidemic. Front Psychiatry [Internet]. 2025 Mar 25 [cited 2026 Jan 10];16. Available from: https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2025.1460341/full
9. Oliva HNP, Pulido-Saavedra A, Paredes-Naveda A, Forselius E, Potenza MN, Jegede OO, et al. Pharmacotherapies for stimulant use disorder and co-occurring attention deficit hyperactivity disorder: protocol for a systematic review and a meta-analysis. Front Psychiatry. 2025 Sept 4;16:1667614.
10. Żełabowski K, Petrov W, Ślebioda D, Rusinek M, Biedka K, Błaszczyk K, et al. Holistic Management of Adult ADHD with a History of Addiction: Emphasis on Low-Addiction-Risk Psychopharmacotherapy. Journal of Clinical Medicine. 2025 Jan;14(18):6470.
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