Evidence-Based Reviews

Benzodiazepines and stimulants for patients with substance use disorders

Current Psychiatry. 2011 May;10(5):58-62,64-67

References

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Case discussion/suggestions. As Mr. C’s case illustrates, there are alternatives to stimulants for ADHD. For example, atomoxetine, a selective norepinephrine reuptake inhibitor, may be considered a first-line agent in patients with mostly inattentive ADHD symptoms and comorbid stimulant abuse, or for those in whom stimulants cause adverse effects such as mood lability or tics.³⁴ Other alternatives to stimulants are listed in Table 3.³⁵

Because Mr. C did not respond to bupropion, which presumably was tried first because of his ongoing substance use, he asked about atomoxetine. This agent is not addictive and there is no evidence that it leads to or exacerbates substance use. Depending on Mr. C’s symptom profile, atomoxetine might be a good choice. Continued monitoring of his marijuana use and frequent assessment of his motivation to quit are necessary. Psychoeducation about the cognitive effects of marijuana, including inattention and poor concentration, is important.

Clinical Point

Short-acting stimulants are abused 4 times more often than extended-release formulations

If Mr. C does not respond to atomoxetine, his psychiatrist will face a difficult decision. Setting Mr. C’s marijuana use aside, symptoms that do not respond to atomoxetine or a second-line agent are likely to respond to a stimulant. However, several issues must be addressed. If Mr. C’s motivation to stop using marijuana is low, how motivated is he to improve his ADHD symptoms? Next, would marijuana’s depressive/blunting effects counteract the anticipated benefit of a stimulant? Also, what is the risk that Mr. C might sell or exchange his stimulants to obtain marijuana? Assessing these complicated questions is key. Another important factor in Mr. C’s case is his wife’s involvement. Does she monitor his marijuana use? Would she be willing to supervise Mr. C’s stimulant use, and would he allow it?

Past or present SUDs are not an absolute contraindication to stimulant use. You should affirm the diagnosis and identify target symptoms. Consider nonstimulant alternatives if appropriate.

Table 3

Alternatives to stimulants for ADHD

Treatment option	Comments
Atomoxetine	Effectiveness may be limited to inattentive type
Modafinil	Well-tolerated but expensive, limited evidence, no FDA indication; may be a consideration in ADHD + SUD
α2-adrenergic agonist (eg, clonidine or guanfacine)	Useful when hyperactivity/impulsivity symptoms predominate, or when stimulant-induced insomnia occurs
Bupropion	Some evidence of mild efficacy, especially useful if nicotine dependence also is a target for treatment
Psychotherapy	Can be useful as adjunctive treatment, but as monotherapy it is of little benefit in ADHD
ADHD: attention-deficit/hyperactivity disorder; SUD: substance abuse disorder Source: Reference 35

Legal liabilities

Being aware of the medicolegal issues of benzodiazepine and/or stimulant prescribing is crucial because a court may find a psychiatrist liable for negative outcomes (eg, suicide) when controlled substances are prescribed to a patient with a history of addiction.³⁶ The most prudent course is to weigh the pros and cons for each patient individually, taking into consideration the factors described above.⁸ This is consistent with guidelines from the American Psychiatric Association and the British Association for Psychopharmacology,³⁷ both of which call for extreme caution in these cases.

Clinical Point

Provide and document explicit instructions that the patient will receive stimulants from only a single provider

Educate patients and caregivers about the risks of taking a controlled substance, including misuse, diversion, and theft. Provide and document explicit instructions that the patient will receive stimulants from only a single provider. Remind patients that state and federal authorities closely track controlled medications. Finally, a “stimulant contract” or “benzodiazepine contract,” similar to a pain or narcotic contact, may be useful to formally document discussions about appropriate medication use.

Related Resources

National Institute on Drug Abuse. Prescription drugs: abuse and addiction. Research Report Series, 2005. http://drugabuse.gov/ResearchReports/Prescription/Prescription.html.
Galanter M, Kleber HD. The American Psychiatric Publishing textbook of substance abuse treatment. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc; 2008.

Drug Brand Names

Alprazolam • Xanax
Atomoxetine • Strattera
Bupropion • Wellbutrin, others
Chlordiazepoxide • Librium
Clonazepam • Klonopin
Clonidine • Catapres
Clorazepate • Tranxene
Dextroamphetamine • Dexedrine
Diazepam • Valium
Diphenhydramine • Benadryl, others
Doxepin • Silenor
Estazolam • ProSom
Gabapentin • Neurontin
Guanfacine • Tenex, Intuniv
Lisdexamfetamine • Vyvanse
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Methylphenidate • Ritalin, Concerta, others
Mirtazapine • Remeron
Mixed amphetamine salts • Adderall
Modafinil • Provigil
Oxazepam • Serax
Pemoline • Cylert
Propranolol • Inderal
Trazodone • Desyrel, Oleptro
Triazolam • Halcion

Disclosures

Dr. Casher is a speaker for AstraZeneca and Pfizer Inc.

Drs. Gih and Bess report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.