Attention-deficit/hyperactivity disorder (ADHD) is frequently missed in patients with alcohol use disorder (AUD), despite strong evidence that the two conditions often co-occur and that treating both concurrently can significantly improve outcomes. A new review study by clinicians and researchers at New York-Presbyterian, Columbia, and the New York State Psychiatric Institute published in CNS Drugs offers guidance for managing these coexisting conditions, challenging longstanding treatment silos and emphasizing the benefits of integrated care.
“In treating substance use disorders, there’s a tendency to minimize ADHD or overlook its clinical impact,” says Frances Levin, M.D., an addiction psychiatrist at New York-Presbyterian and Columbia and chief of the Division on Substance Use Disorders at the New York State Psychiatric Institute, and a coauthor of the review. “Clinicians are trained to recognize conditions like depression or psychosis, but ADHD frequently goes undetected, despite its significant morbidity and mortality. Left untreated, ADHD can significantly interfere with a patient’s ability to engage in and sustain recovery.”
The Role of ADHD Medications in Treating Substance Use Disorders
Research shows that nearly one in four individuals in substance use treatment meet the criteria for ADHD, yet routine screening is uncommon. One reason for that is that many clinicians remain hesitant to treat ADHD in patients with active substance use, fearing that stimulant medications could lead to misuse or worsen addiction.
But mounting evidence challenges that concern. A large Swedish study found that individuals with substance use disorder who were prescribed ADHD medication had lower rates of hospitalization and mortality than those who went untreated.
We need to shift from fear-based thinking to evidence-based care. Treating both conditions together isn’t just possible — it’s the best path forward for patients.
— Dr. Frances Levin
Dr. Levin and her Columbia colleagues Mariely Hernández, Ph.D., a clinical psychologist and postdoctoral research fellow, and Aimee Campbell, Ph.D., professor of clinical psychiatric social work, outline multiple treatment approaches in the paper, including long-acting stimulants with lower abuse potential, nonstimulants like atomoxetine or guanfacine, and psychosocial therapies such as cognitive behavioral therapy (CBT) and motivational interviewing. These strategies, when paired with regular follow-up and coordinated care, can improve focus and increase treatment retention.
“We need to shift from fear-based thinking to evidence-based care,” says Dr. Levin. “Treating both conditions together isn’t just possible — it’s the best path forward for patients.”
The authors emphasize that abstinence is not a prerequisite for screening or diagnosing ADHD. Delaying treatment until a patient is fully abstinent can, in fact, undermine recovery. When individuals are engaged in care and treatment is closely monitored, ADHD medications can be safely introduced, even while substance use is ongoing.
How ADHD Can Increase Risk of Alcohol Use Disorder
ADHD symptoms, including impulsivity, poor decision-making, and the need for stimulation, can increase both the risk and severity of alcohol misuse. Many individuals use alcohol to self-regulate symptoms that began in childhood, often without recognizing the underlying disorder.
“People with ADHD are more likely to experience serious consequences when they drink, even if they consume the same amount as their peers,” says Dr. Hernández, who is first author of the review. “Alcohol lowers inhibition, which can amplify the cognitive vulnerabilities already present with ADHD.”
ADHD is one of the most manageable psychiatric conditions we see, and the costs of ignoring it — especially in this population — are significant.
— Dr. Frances Levin
These risks are often compounded by the broader clinical profile of individuals with both ADHD and substance use disorders. They tend to have more severe psychiatric symptoms and are more likely to carry additional diagnoses, such as anxiety or mood disorders. They also have higher dropout rates from treatment programs. Addressing the underlying ADHD can help reverse these patterns.
“If a patient goes from using every day to three days a week, that’s a meaningful change,” Dr. Hernández said. “That’s more days when they can function, show up for their family, and engage in treatment.”
Balancing Risk, Reducing Harm
Clinicians often focus on the risks of prescribing medication, particularly around diversion or misuse, while underestimating the consequences of leaving ADHD untreated. While caution is warranted, the review emphasizes that ADHD can be safely and effectively treated in patients with AUD, provided that care is closely monitored and individualized.
“There’s always anxiety around overprescribing,” says Dr. Levin. “But what often gets ignored is how much harm can come from undertreating. ADHD is one of the most manageable psychiatric conditions we see, and the costs of ignoring it — especially in this population — are significant.”
You don’t have to wait for someone to hit rock bottom to start ADHD treatment. Meet patients where they are, track progress together, and make the process collaborative.
— Dr. Mariely Hernández
A delayed diagnosis can have lifelong effects. Many patients come to understand past academic failures or unstable work histories through the lens of unrecognized ADHD and wonder how differently things might have gone with earlier intervention.
To mitigate risk, the authors recommend strategies such as issuing shorter prescriptions, prioritizing long-acting medications with lower abuse potential, and ensuring regular follow-up. Integrating care across addiction and mental health services is also key.
“You don’t have to wait for someone to hit rock bottom to start ADHD treatment,” says Dr. Hernandez. “Meet patients where they are, track progress together, and make the process collaborative.”
