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Prescribing Stimulants for Patients on Suboxone or Methadone

October 16, 2018

In this occasional feature, members of the Psych Congress Steering Committee and faculty answer questions asked by attendees at Psych Congress meetings.

QUESTION: Should we treat patients who are on Suboxone or methadone with stimulants?

ANSWER: Complex question. But you pose a question that while complex, truly deserves to be addressed and thought out carefully. Suboxone is of course used for the treatment of chronic opioid addiction and has proven to be a helpful, lifesaving treatment for many patients.

Your Questions Answered logoSuch patients often do have a high risk of attention-deficit/hyperactivity disorder (ADHD) as a comorbid condition. Treatment with Suboxone will not treat the ADHD. And ADHD in many adults, if not treated, leads to significant life impairment. But, at the same time, use of stimulants in patients with well-established history of addictions is also fraught with abuse and diversion risk. What is a clinician to do?

Here are a few suggestions I offer you for your consideration as you work your way through this complex issue:

  1. Is the diagnosis of ADHD substantiated by more than the patient’s current report? For example, are there clinical notes from before, perhaps even preceding the opioid addiction that substantiate a diagnosis? Are there old school records available? Is there a reliable family member you can talk to in order to obtain reliable historical collaborative data? Any or all of these would be hugely helpful.

  2. Currently, is there a presence of both DSM-5 diagnostic symptoms and impairment arising from ADHD? Use of rating scales such as the ADHD-RS might be very helpful. 

  3. Is the patient fairly stable, with sustained abstinence from illegal opioid and other substances/medications?

  4. Are the deemed reliable? Do they have a history of diversion?

  5. If you do decide to offer a patient a trial of a stimulant, please ensure that the patient’s cardiovascular system is stable and there are no contraindications to their use.

  6. Make sure no obvious drug-drug interactions are an issue in that individual patient.

  7. Consider use of nonstimulants first. If you do decide to use stimulants, consider using long-acting stimulant formulations. Avoid short-acting formulations.

  8. Offer a limited number of capsules/tablets of the stimulants. If possible, ask a reliable family member to be the custodian of the medication.

  9. Repeat scales to measure improvement after treatment.

  10. Stay vigilant about abuse/diversion.

While all this may sound like “a lot of work,” stimulants can be hugely helpful even in such complex patients. Hence, this extra effort may really help you further improve the quality of the patient’s life.

— Psych Congress cochair Rakesh Jain, MD, MPHClinical Professor, Department of Psychiatry, Texas Tech Health Sciences Center School of Medicine, Midland


MORE QUESTIONS ANSWERED:

Can Mindfulness Be Used to Help Treat Children With ADHD?

Has Easy Access to Technology Increased the Rates of ADHD?

Is Nutrition Linked With ADHD Symptoms in Children?

Treating Patients Who Develop Tolerance Toward Stimulants

Comments

Submitted byrachela405 on September 27, 2019

Thank you doctor. Your words expressed neutrality—which is so refreshing.

I am prescribed buprenorphine and adderall. I am very stable on both. I don’t even like to think of life without them, especially the adderall. ADHD, I believe, had much to do with why I became dependent on powerful pain medication and eventually landed on MAT.

When I relocated to Oregon from the Bay Area over a year ago, I was and had been stable and productive on both medications for some time. Not long after moving, my new healthcare providers refused to prescribe adderall—ignoring my prior records and history. Unwilling to even speak to my former psychiatrists—I’d had three total over twenty years. I underwent lots of diagnostic procedures at some of the finest facilities on the West Coast and the results were that I indeed have ADHD.

It took time to find the medication that best worked for me. It was so upsetting to just have the ADHD medication ripped out of my brain. I spiraled downwards very quickly without it. I became terribly depressed and suicidal. In my 48-years, I had never before been suicidal. I was very frightened. So were my loved ones—for me. And I detested upsetting them.

There are literally (I’ve come to discover) no mental health professionals close by. Fortunately, amazingly, I found a Psychiatric Nurse Practitioner across the country who now sees me via telemedicine. For four months now, I’ve been on a regimen of psychiatric medications including buprenorphine and adderall that have completely turned my life around to the good. I’m back in school four days a week—and again painting and drawing—which, for the first time since I began ADHD treatment—I was not able to participate in without it. I hope that makes sense.

I do not abuse either of these medications—I take them as prescribed—and they are lifesaving. There is truly no “one size fits all.” Thank you again.

Submitted byStrych9 on October 05, 2019

I've had no luck with ADHD meds while on the subs. They do absolutely nothing. Adderall,Ritalin,and Vyvanse. I could take 200 mg and take a nap. Did nothing to help my focus or concentration.

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