Stimulant substitution in methamphetamine dependence from the perspective of adult ADHD

To the Editor

Doctors Dobry and Sher (2012) argue that in the context of harm reduction it makes sense to prescribe psychostimulants, such as methylphenidate and dexamphetamine, to prevent relapse in patients who have been using methamphetamine. I agree, but suggest an alternative perspective. I treat many adult attention deficit hyperactivity disorder (ADHD) patients with psychostimulants. In adult ADHD, comorbidity is more often the rule than the exception (Barkley, 2006; Barkley et al., 2008). Drug abuse is one of the most common comorbidities. A significant minority of patients have used illicit drugs in the past or are ongoing drug users. Many use marijuana and alcohol. Quite a few have used methamphetamine in the past, sometimes for prolonged periods. In the diagnostic phase I ask patients how they reacted to illegal amphetamines. Often the answers are: ‘It made my friends high, but it made me feel calm. I could get things done. It made me feel normal.’ Over time I have learned that these kinds of answers are highly predictive of a positive reaction to methylphenidate or dexamphetamine. Psychostimulants help patients organise their lives, allow them to work or study, and assist them to improve their relationships. Stimulants put them in control of their lives. The former ‘abuse’ of illegal drugs can easily be recast as a form of self medication.

Doctors Dobry and Sher mention that a foreseeable problem with prescribing stimulants to former users of methamphetamine is that they can become addicted to the prescribed stimulants. This may be the case, but is, in my experience, unlikely. I have failed to find cases of methylphenidate or dexamphetamine addiction and could not find any colleagues who had diagnosed or treated such cases. So, if addiction occurs, the risk of addiction can’t be very high. Addiction to psychostimulants should not be confused with being dependent on them, in the sense that patients with ADHD can depend on psychostimulants to live their lives in an acceptable way, like other patients may not be able to get on with life without antidepressants.

With the successful treatment of adult ADHD, stimulants generally also lower the urge to use alcohol or marijuana. One of the main features of adult ADHD is a lifelong feeling of stress and unrest. Alcohol, marijuana and sometimes methamphetamine are used to dampen these ongoing unpleasant feelings. In sum, patients with a history of methamphetamine addiction are, in my experience, more likely than others to suffer from ADHD, and are likely to react positively to treatment with stimulants.