Reassuring Data on Stimulants for ADHD and Substance Abuse

There is no increased risk of substance abuse later in life among children treated with stimulants for attention-deficit/hyperactivity disorder (ADHD), results of a large study show.

“Throughout rigorous analyses, and after accounting for more than 70 variables in this longitudinal sample of children with ADHD taking stimulants, we did not find an association with later substance use,” lead investigator Brooke Molina, PhD, told Medscape Medical News.

The findings were published online July 5 in JAMA Psychiatry.

Protective Effect?

Owing to symptoms of impulsivity inherent to ADHD, the disorder itself carries a risk for elevated substance use, the investigators note.

They speculate that this may be why some previous research suggests prescription stimulants reduce the risk of subsequent substance use disorder. However, other studies have found no such protective link.

To shed more light on the issue, the investigators used data from the Multimodal Treatment Study of ADHD, a multicenter, 14-month randomized clinical trial of medication and behavioral therapy for children with ADHD. However, for the purposes of the present study, investigators only focused on stimulant use in children.

At the time of recruitment, the children were aged 7 to 9 and had been diagnosed with ADHD between 1994 and 1996.

Investigators assessed the participants prior to randomization at months 3 and 9 and at the end of treatment. They were then followed for 16 years and were assessed at years 2, 3, 6, 8, 10, 12, 14, and 16 until a mean age of 25.

During 12-, 14-, and 16-year follow-up, participants completed a questionnaire on their use of alcohol, marijuana, cigarettes, and several illicit and prescription drugs.

Investigators collected information on participants’ stimulant treatment via the Services for Children and Adolescents Parent Interview until they reached age 18. After that, participants reported their own stimulant treatment.

A total of 579 participants were included in the analysis. Of these, 61% were White, 20% were Black, and 8% were Hispanic.

Decline in Stimulant Use Over Time

The analysis showed that stimulant use declined “precipitously” over time ― from 60% at the 2- and 3-year assessments to an average of 7% during early adulthood.

The investigators also found that for some participants, substance use increased steadily through adolescence and remained stable through early adulthood. For instance, 36.5% of the adolescents in the total cohort reported smoking tobacco daily, and 29.6% reported using marijuana every week.

In addition, approximately 21% of the participants indulged in heavy drinking at least once a week, and 6% reported “other” substance use, which included sedative misuse, heroin, inhalants, hallucinogens, or other substances taken to “get high.”

After accounting for developmental trends in substance use in the sample through adolescence into early adulthood with several rigorous statistical models, the researchers found no association between current or prior stimulant treatment and cigarette, marijuana, alcohol, or other substance use, with one exception.

While cumulative stimulant treatment was associated with increased heavy drinking, the effect size of this association was small. Each additional year of cumulative stimulant use was estimated to increase participants’ likelihood of any binge drinking/drunkenness vs none in the past year by 4% (95% CI, 0.01 – 0.08; P =.03).

When the investigators used a causal analytic method to account for age and other time-varying characteristics, including household income, behavior problems, and parental support, there was no evidence that current (B range, -0.62 to 0.34) or prior stimulant treatment (B range, -0.06 to 0.70) or their interaction (B range, -0.49 to 0.86) was associated with substance use in adulthood.

Molina noted that although participants were recruited from multiple sites, the sample may not be generalizable because children and parents who present for an intensive treatment study such as this are not necessarily representative of the general ADHD population.

Reassuring Findings

Commenting for Medscape Medical News, Julie Schweitzer, PhD, professor of psychiatry and behavioral sciences at the University of California, Davis, School of Medicine, said she hopes the study findings will quell the stigma surrounding stimulant use by children with ADHD.

“Parents’ fears that stimulant use will lead to a substance use disorder inhibits them from bringing their children for an ADHD evaluation, thus reducing the likelihood that they will receive timely treatment,” Schweitzer said.

“While stimulant medication is the first-line treatment most often recommended for most persons with ADHD, by not following through on evaluations, parents also miss the opportunity to learn about nonpharmacological strategies that might also be helpful to help cope with ADHD symptoms and its potential co-occurring challenges,” she added.

Schweitzer also noted that many parents hope their children will outgrow the symptoms without realizing that by not obtaining an evaluation and treatment for their child, there is an associated cost, including less than optimal academic performance, social relationships, and emotional health.

The Multimodal Treatment Study of Children with ADHD (MTA) was a National Institute of Mental Health (NIMH) cooperative agreement randomized clinical trial, continued under an NIMH contract as a follow-up study and under a National Institute on Drug Abuse contract followed by a data analysis grant. Molina reported grants from the NIMH and the National Institute on Drug Abuse during the conduct of the study.

JAMA Psych. Published online July 5, 2023. Abstract

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