I Have ADHD and a Substance Use Problem. Can I Still Take a Stimulant?

“I know I have ADHD. But with my history, nobody’s going to give me a stimulant, right?”

A lot of the time, someone will. ADHD and substance use show up together often, and I understand why prescribers get nervous about giving a stimulant to someone with an addiction history. The problem is that when the answer becomes an automatic no, the people with the most to lose from untreated ADHD end up going without treatment. What I try to figure out is how to prescribe safely for the person in front of me. Sometimes that means a stimulant with tighter guardrails, sometimes a nonstimulant, and sometimes waiting until the substance use is more stable.

What a big study found

A study published in the Journal of the American Academy of Child and Adolescent Psychiatry (online in December 2025, in the October 2026 issue) looked at health records for about 1.24 million people aged 15 to 25 with ADHD. Roughly 288,000 of them also had a substance use disorder, ranging from nicotine and cannabis to alcohol, cocaine, and opioids.

In the year after the ADHD diagnosis, about 25% of the group with a substance use disorder received a stimulant, compared with about 41% of the group without one. The gap was wider for people starting a stimulant for the first time: about 17% compared with about 34%, so roughly half as likely. Among the young people who had both conditions, those who got ADHD medication had fewer hospitalizations, fewer emergency visits, and lower rates of suicidal thoughts and attempts than those who didn’t. ADHD medication was also associated with a 30% lower hazard of death during five years of follow-up (adjusted hazard ratio 0.70; 95% confidence interval 0.65 to 0.75). That is a relative comparison with no ADHD medication, not proof that medication prevented those deaths. Compared with nonstimulants, stimulants were tied to fewer hospitalizations, accidental overdoses, and suicidal thoughts or attempts.

Where I’d read it carefully

This was an observational study, so it shows an association and can’t prove the medication caused the better outcomes. People who get a prescription and keep coming back for refills may have been more stable to begin with, and the ones who get turned down may be the ones in the most chaos, which carries its own risk of death.

A couple of details caught my eye. Neither of the two drug classes was clearly better on five-year mortality, so the benefit may have more to do with treating ADHD at all than with picking a stimulant over a nonstimulant. The treated group also had fewer methadone prescriptions. The study can’t say why, and I wouldn’t assume that’s good news.

The randomized trials are smaller, but they lean the same way. In one 13-week trial in adults with ADHD and cocaine use disorder, extended-release amphetamine plus weekly therapy improved ADHD symptoms and was linked to more weeks without cocaine than placebo.

Misuse, diversion, and addiction are different problems

These three tend to get treated as one big risk, even though each one calls for a different response.

Misuse means taking your own medication in a way it wasn’t prescribed, like extra doses before an exam. Diversion means it leaves your hands, given or sold to someone else. A systematic review found that 16% to 29% of students with a stimulant prescription had been asked to give, sell, or trade it at some point. Addiction, or stimulant use disorder, is a pattern where someone loses control over their use and keeps using despite harm.

They overlap less than most people assume. In a national survey of US adults, about 8% of people taking only their own prescribed stimulant reported misusing it, and many adults who met criteria for stimulant use disorder said they had never misused at all. So some risk exists even when someone takes it as prescribed. When a patient tells me honestly about past drug use, that’s helpful information, but it doesn’t decide the question on its own.

How I approach it

I start by looking at how severe the substance use is and whether it’s active right now. An international consensus statement on ADHD with substance use recommends treating both conditions together, with medication and therapy, rather than waiting for perfect sobriety. If someone is in the middle of a severe, unstable addiction, I usually work on getting that steadier first.

When a stimulant makes sense, I use a long-acting form that’s harder to misuse, keep the fills small, see the person more often at the start, check the state prescription database, and talk through safe storage at home. I tell patients upfront that I’ll change the plan if things slip. Nonstimulants like atomoxetine, viloxazine, or guanfacine are real options too, and for some people I’d start there.

Being careful with stimulants makes sense to me. I’d just rather that caution change how we treat someone than become the reason they don’t get treated.

This is general information, not personalized medical advice. Please talk with your own prescriber before starting, stopping, or changing any medication. If you are thinking about suicide or are in crisis, call or text 988 in the US, any time.

This article was written in my own words with the help of Wispr Flow, a voice-to-text tool I use for drafting.

References

1. Baweja R, Waschbusch DA, Padilla FM, Baweja R, Singh B, Pelham WE, Molina BSG, Wilens TE, Waxmonsky JG. Attention-deficit/hyperactivity disorder treatment patterns and association with clinical outcomes in adolescents and young adults with co-occurring attention-deficit/hyperactivity disorder and substance use disorder: a retrospective analysis. Journal of the American Academy of Child and Adolescent Psychiatry. 2026;65(10):1273-1284. doi:10.1016/j.jaac.2025.12.003. New prescription rates from Supplement 1, Table S2. PubMed
2. Levin FR, Mariani JJ, Specker S, et al. Extended-release mixed amphetamine salts vs placebo for comorbid adult attention-deficit/hyperactivity disorder and cocaine use disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72(6):593-602. PubMed
3. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. Journal of the American Academy of Child and Adolescent Psychiatry. 2008;47(1):21-31. PubMed
4. Han B, Jones CM, Volkow ND, et al. Prescription stimulant use, misuse, and use disorder among US adults aged 18 to 64 years. JAMA Psychiatry. 2025;82(6):572-581. PubMed
5. Crunelle CL, van den Brink W, Moggi F, et al. International consensus statement on screening, diagnosis and treatment of substance use disorder patients with comorbid attention deficit/hyperactivity disorder. European Addiction Research. 2018;24(1):43-51. PubMed