Thoughts on ADHD stimulant Rx with UDS positive/Cannabis Use?

[Blitz2006]

I've spoken to a lot of psychiatrists, and read a lot of papers online past few days.

Seems to be a lot of back and forth, whether or not reasonable to prescribe medications like Adderall or Ritalin for patients that use cannabis, particularly recreationally.

Some state no way, others state treatment of ADHD obviously helps with substance use.

Thoughts, or any good links for further reading?

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[littlefred]

Package insert for mixed amphetamine salts (Adderall):

Contraindications
Hypersensitivity (eg, angioedema, anaphylaxis) or idiosyncrasy to amphetamine, sympathomimetic amines or any component of the formulation; during or within 14 days following monoamine oxidase inhibitors.

Documentation of allergenic cross-reactivity for amphetamines is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Immediate release, Adderall XR: Additional contraindications: Advanced arteriosclerosis; symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism; glaucoma, agitated states; history of drug abuse.

I think the main issue that most experts confront is that you are prescribing a schedule II medication to a patient that is still misusing a schedule I medication (whether it should be a schedule I is up to debate, but my point still stands). It goes without saying that you can expand this thought process to any other substance, for example would you continue prescribing a stimulant if the patient was misusing any other schedule II (e.g. methamphetamine/cocaine)?

Another issue is diagnostically the following...

DSM-5 diagnostic criteria for ADHD states this line that a lot of people do not consider or just ignore.

The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

So if the patient has a cannabis intoxication or withdrawal can you with certainty state that they have ADHD?

Fair to say that I've seen a fair share of clinicians that draw the line in that if you want a schedule II medication, that should be the only drug in your UA. I think it's a fair demand and middle ground.

 

[wolfvgang22]

I discuss cannabis use with my patients and strongly encourage them to avoid cannabis use. With cannabis being available via medical marijuana, decriminalized, or even legal in my state and surrounding states, complete prohibition of cannabis isn't practical. So these days I treat cannabis use in the same way I do alcohol. Mild use once per week isn't usually a reason for me to avoid prescribing ADHD stimulants, as that person probably doesn't have a substance use disorder. Someone using cannabis recreationally every day likely has a substance use disorder and in those cases I generally do not prescribe stimulants due to risk of abuse of stimulants and the fact that they probably will not help ADHD much if the patient is intoxicated.

Like many of you, I have had patients who heavily use cannabis and this causes mood lability, paranoia, lack of motivation, weight gain, and poor self care. I had one particularly problematic patient who neglected his diabetes and died because he spent *all* his time and money using cannabis rather than work with his treatment team.

Personally I am strongly anti-cannabis (and anti-alcohol) but I am pragmatic about the culture patients are living in.

 

[calvnandhobbs68]

Yeah I don't have a hard and fast rule on this. For someone who comes in new and says "hey doc I think I have ADHD" and they smoke weed all day, I make it very clear they need to be off cannabis before we can accurately assess symptoms. For patients with a well established ADHD history who are now smoking cannabis, we absolutely discuss it every appointment and I make it very clear to them that I'm not going to fight cannabis use with a stimulant but I don't totally cut them off. I will do UDS generally a few times a year to make sure they aren't doing anything else. People who truly have ADHD when undertreated tend to have a higher rate of substance abuse.

 

[Merovinge]

I think the confusion for most is that psychostimulants in youth prior to SUD developing decrease SUD rates.

Psychostimulant use after the development of SUD often increase SU rates. They will have higher rates of diversion/misuse themselves but also potentiate the addiction reward circuitry.

Would agree with the heuristics above that if someone is using low amounts of THC 1-2x weekly would not impact my psychostimulant prescribing. If someone were using daily/multiple times per day and/or had utox quants in the several hundreds to thousands then I would not continue psychostimulant Rxing.

If someone went on to be in recovery, would need a lot of caution around the re-introduction of psychostimulants but could be reasonable in some cases.

 

[littlefred]

Agree with @Merovinge in regards to diminished SU/incarceration in adolescents treated with stimulants, I haven't seen studies on that for stimulants in adults (but there's plenty for OUD treatment outcomes with methadone/buprenorphine). I think the issue with THC is that you can't really tell how much they're using by UDS results. It is lipophilic and excretion can vary by many factors. So how do you really know they are using 1-2 times a week aside from self report?

 

[PikminOC]

I think the confusion for most is that psychostimulants in youth prior to SUD developing decrease SUD rates.

Psychostimulant use after the development of SUD often increase SU rates. They will have higher rates of diversion/misuse themselves but also potentiate the addiction reward circuitry.

Would agree with the heuristics above that if someone is using low amounts of THC 1-2x weekly would not impact my psychostimulant prescribing. If someone were using daily/multiple times per day and/or had utox quants in the several hundreds to thousands then I would not continue psychostimulant Rxing.

If someone went on to be in recovery, would need a lot of caution around the re-introduction of psychostimulants but could be reasonable in some cases.

So you are getting quantitative cannabis levels? People minimize all the time.

I use non controlled subs in people who abuse subs.

 

[Merovinge]

So you are getting quantitative cannabis levels? People minimize all the time.

I use non controlled subs in people who abuse subs.

Yes, but I do all PHP/IOP work so quants are done every week for any positive utox. It's trivially easy for me, I can understand the difficulty in people who are in private practice. The good PP folks I know who claim to have any experience in addiction do also send for quants or go your route of using Strattera/Qelbree/Wellbutrin/Intuniv combos.

 

[littlefred]

Yes, but I do all PHP/IOP work so quants are done every week for any positive utox. It's trivially easy for me, I can understand the difficulty in people who are in private practice. The good PP folks I know who claim to have any experience in addiction do also send for quants or go your route of using Strattera/Qelbree/Wellbutrin/Intuniv combos.

Quantitative THC can vary if for example the patient did strenuous exercise, also + THC can be seen well over 30 days for chronic users. I don't think it's the right tool to assess if patients have been using or not. You might see patients self reporting no use and do a quantitative today, you do one next week and the quantitative might be higher (I have seen this in inpatient settings where the patients are in fact institutionally sober). It is highly unreliable.

 

[FlowRate]

If I feel a patient is being honest about true mild use (once a week or less) then I have them get a UDS 7 days from our appointment because true rare users should have cleared by then. If negative for cannabis then I'm fine with treating and will do a UDS once a year and sooner if other reasons to want one. While I rarely actually get a random UDS, I do tell patients that they may be randomly tested and will again have only 7 days to get it done, for that same reason of verifying that use remains truly mild.

Our department policy (setting a baseline standard that's acceptable to everyone in the system) is a slight variation of that where a patient must be able to produce a negative UDS in order to get treatment (with stims, most of us will do nonstim options if patient unwilling/unable to stop cannabis.) In effect the idea is that you're less likely to have a cannabis UD if you're able to quit long enough to test negative. But this is less strict than the higher standard many of us keep because it's implicitly allowing patients to return to cannabis use.

 

[Sushirolls]

UDS clears, get the stimulant.
UDS is positive, no refill until clear.
UDS testing at appointments.

Pick one, cannabis or stimulant.

 

[clozareal]

If they do indeed have ADHD with clear full criteria evidence of impairment before age of 12 (a criteria that most adult ADHD patients coming to me do not have. "Things got harder when I got to college/a job/left home" really doesn't count even if they had parents who were extremely overprotective and did all their homework for them, that doesn't mean they didn't still have problems paying attention/being hyperactive in grade school class when their parents weren't there), then I would treat ADHD and substance use separately.

Lots of psychoeducation on substance use and impact on cognition and mental health, figuring out why they are using substances in the first place, doing motivation interviewing, for my teens teaching them assertiveness skills in social settings, setting goals with the patient on their mental/physical health, and working with their families on how to decrease use (not having privileges such as car, allowance, unrestricted access to credit card/money, etc).

In my private practice, those with both ADHD and substance use are seeing me more frequently as I am working with them in psychotherapy for both, probably around once every 1-2 weeks but sometimes even more frequently if they are really having a hard time but are motivated.

With that being said, if their substance use was so severe that they are abusing their medication, diverting it for money to obtain substances, not having a positive amphetamine/methylphenidate on UDS despite saying they are taking it, or their substance use is contributing to them using higher doses of stimulant because of the impairment in cognition or causing other psychiatric comorbidities (anxiety, paranoia, insomnia, appetite issues) that are hard to distinguish from the side effects of the stimulant, I would stop the stimulant. If they don't want to work collaboratively with me and have a difficult time with stopping use even after trialing several MAT off-label options, I would increase the number of sessions, and if they aren't able to do that, then I would recommend either a higher level of care for their use and/or fire them as a private practice patient.

 

[annoyedpsychiatrist]

You have to be practical. I live in a state where medical marijuana is insanely easy to get, basically anything qualifies for it. If the media, tiktok, reddit crams the idea that its safe/effective/miracle drug then people are going to believe all these influencers over people like us. Just is what it is. Also UDS is VERY hard to get in this area, because the local chain labs are absolute garbage, require appointment only, pick and choose which panel labs they do, and its so hit or miss. Getting a UDS is like pulling teeth most of the time. Even if I get a UDS, people arent stupid. They can specifically make the apt for a period of time where illicit drug use wouldnt show. Not super hard.

If i dont have a clear history of treatment for them as a child, i rely a lot on clinical interview. Give me two settings where they show significant issues and how the use of stimulants has objectively improved that. John smith who is on disability for depression, smokes weed everyday, etc I likely wont be giving him a stimulant. But Ms X who smokes medical marijuana a few times a week is working 50 hours a week/struggling to make it through the day, trying to do courses but cant stay on task/complete work/etc, im likely to be a lot more lenient towards. If we exclude treating ADHD in people who use medical marijuana, then a lot of patients will go untreated. I utilize any collateral I can find. Local arrest records, prior documentation, etc. Interesting how many people come to me for ADHD treatment and you see they were arrested for cocaine use/selling not too far back or something similiar.

The positive for long term stimulant use is there are clear benefits in ADHD compared with something like benzos where there are clear detriments.

 

[romanticscience]

I'm in private practice. What are you guys using for UDS? Reccommendations would be appreciated. Also, how would you bill for this, if at all?

 

[annoyedpsychiatrist]

I'm in private practice. What are you guys using for UDS? Reccommendations would be appreciated. Also, how would you bill for this, if at all?

it depends on the lab, some labs only do 6 panel, some 9, etc, etc, etc. I have that issue with quest and labcorp, where one does one particular uds, and the other one same deal and i have to remember which one they do. annoying process.

 

[Merovinge]

Quantitative THC can vary if for example the patient did strenuous exercise, also + THC can be seen well over 30 days for chronic users. I don't think it's the right tool to assess if patients have been using or not. You might see patients self reporting no use and do a quantitative today, you do one next week and the quantitative might be higher (I have seen this in inpatient settings where the patients are in fact institutionally sober). It is highly unreliable.

It absolutely can be positive for a long time, I have seen 6-7 weeks in residential patients, but that by no means diminishes the point I am making. The only patient's who have quants positive that long used heavy heavy amounts of THC and thus are bad candidates for psychostimulants. If someone tells you they last used 3 weeks ago and took 1 hit or 1 edible and their quant is positive, that story is not accurate.

The other time the situation you described where someone is institutionally sober and had elevated levels would occur at very low quants. This can be related to residual THC release from the fat cells and would not be at levels that would be concerning. If people have levels in the hundreds or thousands and they go up a week later, it's because they used THC as the expected decay in levels during that time is going to exceed the confidence band on the testing. Maybe there is some very very fringe scenario where someone can work out 5 hours/day in a residential setting, was using 10 + hits/day and is sober but the values go up after 1 week, but even this is easy to suss out with a follow-up quant the week following. We get serial quants all the time as do the other addictionologists I collaborate with and it's extremely useful information.

 

[Merovinge]

it depends on the lab, some labs only do 6 panel, some 9, etc, etc, etc. I have that issue with quest and labcorp, where one does one particular uds, and the other one same deal and i have to remember which one they do. annoying process.

Quest is able to setup a standing order that is customized to you so that when you send someone they always include exactly what you want with it (and the creatinine so you have a creatinine adjusted value). I'm sure it's a pain to initially setup the process but their support is actually pretty good for this stuff and then it's easy to log onto their portal to see the results. This is exactly what my organization does.

 

[romanticscience]

it depends on the lab, some labs only do 6 panel, some 9, etc, etc, etc. I have that issue with quest and labcorp, where one does one particular uds, and the other one same deal and i have to remember which one they do. annoying process.

Quest is able to setup a standing order that is customized to you so that when you send someone they always include exactly what you want with it (and the creatinine so you have a creatinine adjusted value). I'm sure it's a pain to initially setup the process but their support is actually pretty good for this stuff and then it's easy to log onto their portal to see the results. This is exactly what my organization does.

Thanks guys! I was wondering if they had to pee in a cup in my office. Not exactly the classy psychoanalytic vibe I hoped for lol.

 

[Merovinge]

I'm in private practice. What are you guys using for UDS? Reccommendations would be appreciated. Also, how would you bill for this, if at all?

Quest and dominion both do good quant services, I am sure there are many others.

One of my colleagues in PP just literally buys the tests from amazon and administers them herself to patients. For people that are screening positive you can have them then go do a quant at Quest or the like if the screening alone does not get them to be honest about use (and often times it does).

 

[littlefred]

It absolutely can be positive for a long time, I have seen 6-7 weeks in residential patients, but that by no means diminishes the point I am making. The only patient's who have quants positive that long used heavy heavy amounts of THC and thus are bad candidates for psychostimulants. If someone tells you they last used 3 weeks ago and took 1 hit or 1 edible and their quant is positive, that story is not accurate.

The other time the situation you described where someone is institutionally sober and had elevated levels would occur at very low quants. This can be related to residual THC release from the fat cells and would not be at levels that would be concerning. If people have levels in the hundreds or thousands and they go up a week later, it's because they used THC as the expected decay in levels during that time is going to exceed the confidence band on the testing. Maybe there is some very very fringe scenario where someone can work out 5 hours/day in a residential setting, was using 10 + hits/day and is sober but the values go up after 1 week, but even this is easy to suss out with a follow-up quant the week following. We get serial quants all the time as do the other addictionologists I collaborate with and it's extremely useful information.

Fair, I'm not trying to be difficult with you or anything. My opinion with the data presented is that you can't clearly tell how much someone is using given a quantitative test result, like ETS/ETG it gives you an idea but you can't extrapolate as well as you would with a blood alcohol concentration for example.

 

[annoyedpsychiatrist]

Quest is able to setup a standing order that is customized to you so that when you send someone they always include exactly what you want with it (and the creatinine so you have a creatinine adjusted value). I'm sure it's a pain to initially setup the process but their support is actually pretty good for this stuff and then it's easy to log onto their portal to see the results. This is exactly what my organization does.

interesting i have never heard of this before, if you establish it at one location does it apply to all the locations in the area or just the one?

the ones here are very much understaffed and its been a nightmare lately

 

[Merovinge]

interesting i have never heard of this before, if you establish it at one location does it apply to all the locations in the area or just the one?

the ones here are very much understaffed and its been a nightmare lately

Every quest, not location specific

 

[Merovinge]

Fair, I'm not trying to be difficult with you or anything. My opinion with the data presented is that you can't clearly tell how much someone is using given a quantitative test result, like ETS/ETG it gives you an idea but you can't extrapolate as well as you would with a blood alcohol concentration for example.

One data point is not a slam dunk thing beyond the presence of use and rough amount of use IF you know the last time of use. Recurrent data points are very compelling for knowing exactly what is going on, which is why we (and other programs around us) get weekly quants if the screens are positive.

This seems to be the standard from the big time addiction researchers I am in contact with through professional organizations, but I agree that it is not as cut/dry as a BAC test.

I do think you can get more information than ETS/ETG which I rarely see as more than present, minimally present (caught the end of use) or not present.

 

[calvnandhobbs68]

Thanks guys! I was wondering if they had to pee in a cup in my office. Not exactly the classy psychoanalytic vibe I hoped for lol.

Yeah I just have a lab order sheet I give them and tell them go pee for quest or labcorp down the street.

For the people saying they can find a way around this, sure people can always beat a UDS if they really want to try, I'm not the police....

 

[Merovinge]

Yeah I just have a lab order sheet I give them and tell them go pee for quest or labcorp down the street.

For the people saying they can find a way around this, sure people can always beat a UDS if they really want to try, I'm not the police....

Absolutely, people say that as an excuse to not test or make themselves feel better for not testing. The reality is that severe addicts cannot stop even if they know they have a drug test coming and even if those are the only ones you are finding, it will make a big difference to identify and get them treatment.

I just did an intake on an adolescent who was seeing a psychiatrist monthly and a therapist weekly who were aware of his initial substance use at time of intake being alcohol, THC, nicotine. They told him to stop using and left it at that. He failed to improve for the year and subsequently was found almost dead from accidental overdose, with the story coming to light that he was using IV heroin that entire time. They didn't drug screen him presumably for these same reasons, I can't imagine how different that story might have gone had people known sooner.

 

[annoyedpsychiatrist]

Absolutely, people say that as an excuse to not test or make themselves feel better for not testing. The reality is that severe addicts cannot stop even if they know they have a drug test coming and even if those are the only ones you are finding, it will make a big difference to identify and get them treatment.

I just did an intake on an adolescent who was seeing a psychiatrist monthly and a therapist weekly who were aware of his initial substance use at time of intake being alcohol, THC, nicotine. They told him to stop using and left it at that. He failed to improve for the year and subsequently was found almost dead from accidental overdose, with the story coming to light that he was using IV heroin that entire time. They didn't drug screen him presumably for these same reasons, I can't imagine how different that story might have gone had people known sooner.

Though I would counter with in the adult population usually there are abundant red flags in people with severe SUD: often criminal history, they're not working because they cant hold down a job/trying to get disability, they were previously on ridiculous doses (had a guy using adderall IR present to me using it 4x daily at a pretty high dose), during the interview they demonstrate questionable behavior/responses, etc. This doesnt apply to all severe SUD but a good bit.

But I would agree with you in that generally the ones with severe SUD dont have the insight to time the UDS.

Maybe my local quest sucks because i called them today and they were completely unhelpful, lol. But all the providers here have been having the same problem with labs, rather than just me. I generally try to obtain a baseline UDS on patients but i am also understanding if there are issues with the lab, because this has happened with many of my patients/other provider patients here so i tend to believe people in regards to this. If thats the case we usually just order a random UDS at some other point in time, unless i have strong suspicion of drug use (which I likely wouldnt start them on a stimulant anyways at that point)

 

[Dr.MONO]

I really don't get too excited about cannabis but if they are using a lot, that's bad.
I would continue adderall if I believe I am treating ADHD, and they are not abusing stimulants. I educated patients that cannabis can cause lack of motivation and may stop it in case of cannabis Amotivational syndrome.

 

[sloh]

I discuss cannabis use with my patients and strongly encourage them to avoid cannabis use. With cannabis being available via medical marijuana, decriminalized, or even legal in my state and surrounding states, complete prohibition of cannabis isn't practical. So these days I treat cannabis use in the same way I do alcohol. Mild use once per week isn't usually a reason for me to avoid prescribing ADHD stimulants, as that person probably doesn't have a substance use disorder. Someone using cannabis recreationally every day likely has a substance use disorder and in those cases I generally do not prescribe stimulants due to risk of abuse of stimulants and the fact that they probably will not help ADHD much if the patient is intoxicated.

Like many of you, I have had patients who heavily use cannabis and this causes mood lability, paranoia, lack of motivation, weight gain, and poor self care. I had one particularly problematic patient who neglected his diabetes and died because he spent *all* his time and money using cannabis rather than work with his treatment team.

Personally I am strongly anti-cannabis (and anti-alcohol) but I am pragmatic about the culture patients are living in.

Think he got the munchies?

 

[calvnandhobbs68]

Absolutely, people say that as an excuse to not test or make themselves feel better for not testing. The reality is that severe addicts cannot stop even if they know they have a drug test coming and even if those are the only ones you are finding, it will make a big difference to identify and get them treatment.

I just did an intake on an adolescent who was seeing a psychiatrist monthly and a therapist weekly who were aware of his initial substance use at time of intake being alcohol, THC, nicotine. They told him to stop using and left it at that. He failed to improve for the year and subsequently was found almost dead from accidental overdose, with the story coming to light that he was using IV heroin that entire time. They didn't drug screen him presumably for these same reasons, I can't imagine how different that story might have gone had people known sooner.

I mean I test when I feel like I need to but I also recognize the limitations of outpatient testing. I'm not a substance use disorder program and I don't have an onsite lab.

Also, nicotine and THC are so prevalent among adolescents that barely throws a red flag for me. I'm not getting UDS on every kid that vapes and smokes weed. On admission to an IOP/PHP or inpatient is different, you can just phrase it as part of "standard procedures" to get a UDS on everyone. If I get a UDS outpatient for a teen, parent is going to know about it and want to know what the results are, obviously is going to look fishy if I don't tell them what the results are (even if it pops positive for just cannabis) and if the kid doesn't want parent to know about the weed use after telling me about it, well now I've basically inadvertently disclosed it anyway and likely significantly damaged the probability that the kid is telling me much in confidence again. So I run the risk of damaging a lot of relationships with adolescents by trying to force outpatient drug testing for kids who are just reporting THC and nicotine to maybe possibly pick up the few who are doing harder stuff and not actually reporting it.

Alcohol, more concerning for me if they're using regularly and usually I'm recommending a SUD treatment program anyway with that. I mean, it's a stretch to say they'd catch even IV heroin use with a UDS 1x a month outpatient unless you made the kid go pee in a cup right in your office right there unannounced. Heroin/morphine clears in 48 hours, could they have caught it? Sure, maybe, but also quite likely they wouldn't have.

 

[claypigeon]

It’s legal recreationally in my state which has been interesting to work through.

I have plenty of adhd patients I’ve worked with pre legalization. Some of them use THC products. I wouldn’t change a long-standing effective treatment plan unless they were abusing it. And even then, perhaps the stimulant and/or better ADHD control is helping them abuse less THC / harm reduction.

The same goes with new patients post legalization. No reason to hold them to a different standard.

If I think it’s THC use, not ADHD, causing the inattention/hyperactivity/ impulsivity, I won’t rx new patients a stimulant or increase the dose of their maintenance med.

 

[annoyedpsychiatrist]

is there a real difference between medical marijuana and recreational marijuana? hahaha.

i mean what medical condition doesnt qualify for medical marijuana? has any patient ever been turned down for a medical marijuana card?

 

[Merovinge]

Alcohol, more concerning for me if they're using regularly and usually I'm recommending a SUD treatment program anyway with that. I mean, it's a stretch to say they'd catch even IV heroin use with a UDS 1x a month outpatient unless you made the kid go pee in a cup right in your office right there unannounced. Heroin/morphine clears in 48 hours, could they have caught it? Sure, maybe, but also quite likely they wouldn't have.

In this specific case, the patient was using it every day IV, it would have been very hard to not have caught it with any UDS done at any time.

We know so much about the pro depressive/anxiety effects of THC in adolescence as well as impact on both short-term and long-term cognitive functioning. The data is much worse for adolescent THC use than it is for adolescent alcohol use, although both portend significant negative outcomes in the future (as does vaping for the record, generally through it's 400-500% increase in THC use). There is nothing normative about vaping 90-100% pure THC on a daily to multiple times per day basis which is unfortunately a relatively common pattern for adolescents these days. Not asking questions about someone's use beyond some 5 second "I recommend you not use any substances" with no further discussion for a patient who is failing out of high school does not meet the standard of care in my opinion or based on what I can see from AACAP practice guidelines.

 

[calvnandhobbs68]

In this specific case, the patient was using it every day IV, it would have been very hard to not have caught it with any UDS done at any time.

We know so much about the pro depressive/anxiety effects of THC in adolescence as well as impact on both short-term and long-term cognitive functioning. The data is much worse for adolescent THC use than it is for adolescent alcohol use, although both portend significant negative outcomes in the future (as does vaping for the record, generally through it's 400-500% increase in THC use). There is nothing normative about vaping 90-100% pure THC on a daily to multiple times per day basis which is unfortunately a relatively common pattern for adolescents these days. Not asking questions about someone's use beyond some 5 second "I recommend you not use any substances" with no further discussion for a patient who is failing out of high school does not meet the standard of care in my opinion or based on what I can see from AACAP practice guidelines.

You're talking about two different things here, although there's multiple things to define including what you mean by "data is much worse" and even the term "use" ("use" can mean anything from intermittent cannabis/alcohol use with my friends to once weekly to daily use and everything in between). A pattern of persistent alcohol use or persistent binge drinking vs persistent cannabis use is, first of all, objectively more dangerous in terms of impact of actual intoxication during the period you are intoxicated. Second, alcohol use disorder in and of itself is obviously more dangerous than cannabis use disorder. So yeah, I'm not saying cannabis use is good and I'm not telling anyone they should keep doing it, but I'm less immediately concerned about that than persistent or frequent alcohol use.

I'm not saying the substance use was treated or followed properly in that case. I ask questions about substance use on nearly every single visit with anyone 12+. However, again on the regular outpatient side (outside of teens I could justify getting a UDS because I'm prescribing a controlled med), I'm balancing rapport and trying to make sure an adolescent can feel they can disclose things to me without me telling them I'm getting a UDS to see if they're up to anything else after they told me they smoke weed and vape multiple times a week.

It sounds like this case was more severe but overall kids who smoke cannabis and vape nicotine are a pretty decent chunk of a teen psychiatric referral population...which means I'm going to engage them in MI around this and offering/recommending SUD treatment referrals. I know guidelines all talk about getting UDS but in real life you're essentially disclosing the cannabis/nicotine use to parents by doing this, which is a real thing you have to balance around keeping this teenager engaged in seeing and being honest with you at all.

 

[Old&InTheWay]

Psychostimulant use after the development of SUD often increase SU rates. They will have higher rates of diversion/misuse themselves but also potentiate the addiction reward circuitry.

Is there actual data on this? I've been looking for a while and have come up empty handed.

 

[annoyedpsychiatrist]

i agree, that even without looking at the data, and using logic/personal experience, that using that prescribing stimulants after someone has developed SUD doesnt encourage the patient to stop using illicit substances; they usually just abuse both together. They already have an addiction at that point, adderall doesn't curb cravings for meth.

but it makes logical sense that treating ADHD BEFORE the developement of SUD likely leads to reduced chance- less desire to self medicate, less chance of experimenting, less chance of becoming addicted. Once they're at the addiction stage, its not just an active desire to self medicate, they are also addicted regardless, and desire the reinforcing effect.

 

[FlowRate]

i agree, that even without looking at the data, and using logic/personal experience, that using that prescribing stimulants after someone has developed SUD doesnt encourage the patient to stop using illicit substances; they usually just abuse both together. They already have an addiction at that point, adderall doesn't curb cravings for meth.

but it makes logical sense that treating ADHD BEFORE the developement of SUD likely leads to reduced chance- less desire to self medicate, less chance of experimenting, less chance of becoming addicted. Once they're at the addiction stage, its not just an active desire to self medicate, they are also addicted regardless, and desire the reinforcing effect.

It's basically the logic around why treating with concurrent heavy marijuana use doesn't make sense. Might as well just say you're treating known "adverse" effects of marijuana at that point rather than ADHD. I can't imagine how that would encourage someone to stop using THC since there are no longer any (perceived) downsides...

 

[annoyedpsychiatrist]

It's basically the logic around why treating with concurrent heavy marijuana use doesn't make sense. Might as well just say you're treating known "adverse" effects of marijuana at that point rather than ADHD. I can't imagine how that would encourage someone to stop using THC since there are no longer any (perceived) downsides...

oh i agree with that, if someone is using heavily throughout the day then im hesitant to aggressively throw on stimulants. If someone is a light user then its case by case and I look at all factors in that scenario.

Getting the younger generation/convincing them to stop using marijuana or even reduce use is typically an uphill battle, because theyve been told its "medical" and has "amazing benefits" and is now more normalized. In the same way that if you fill out a questionaire online you can be diagnosed with ADHD in the span of 5 minutes and be connected with a highly qualified devry university graduate who will prescribe you stupid doses of adderall.