Benzodiazepines and stimulants for patients with substance use disorders
Careful assessment, close monitoring are essential when prescribing drugs with abuse potential
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.
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.
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. https://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.
