Prescribing stimulants for patients on Suboxone or methadone

In this occasional feature, members of the Psych Congress Steering Committee and faculty answer questions asked by attendees at Psych Congress meetings.

QUESTION: Should we treat patients who are on Suboxone or methadone with stimulants?

PSYCH CONGRESS CO-CHAIR RAKESH JAIN, MD, MPH: Complex question. But you pose a question that while complex, truly deserves to be addressed and thought out carefully. Suboxone is of course used for the treatment of chronic opioid addiction and has proven to be a helpful, lifesaving treatment for many patients.

Such patients often do have a high risk of attention-deficit/hyperactivity disorder (ADHD) as a comorbid condition. Treatment with Suboxone will not treat the ADHD. And ADHD in many adults, if not treated, leads to significant life impairment. But, at the same time, use of stimulants in patients with well-established history of addictions is also fraught with abuse and diversion risk. What is a clinician to do?

Here are a few suggestions I offer you for your consideration as you work your way through this complex issue:

1. Is the diagnosis of ADHD substantiated by more than the patient’s current report? For example, are there clinical notes from before, perhaps even preceding the opioid addiction that substantiate a diagnosis? Are there old school records available? Is there a reliable family member you can talk to in order to obtain reliable historical collaborative data? Any or all of these would be hugely helpful.
2. Currently, is there a presence of both DSM-5 diagnostic symptoms and impairment arising from ADHD? Use of rating scales such as the ADHD-RS might be very helpful. 
3. Is the patient fairly stable, with sustained abstinence from illegal opioid and other substances/medications?
4. Are they deemed reliable? Do they have a history of diversion?
5. If you do decide to offer a patient a trial of a stimulant, please ensure that the patient’s cardiovascular system is stable and there are no contraindications to their use.
6. Make sure no obvious drug-drug interactions are an issue in that individual patient.
7. Consider use of nonstimulants first. If you do decide to use stimulants, consider using long-acting stimulant formulations. Avoid short-acting formulations.
8. Offer a limited number of capsules/tablets of the stimulants. If possible, ask a reliable family member to be the custodian of the medication.
9. Repeat scales to measure improvement after treatment.
10. Stay vigilant about abuse/diversion.

While all this may sound like “a lot of work,” stimulants can be hugely helpful even in such complex patients. Hence, this extra effort may really help you further improve the quality of the patient’s life.

Psych Congress co-chair Rakesh Jain, MD, MPH, is a clinical professor in the Department of Psychiatry, Texas Tech Health Sciences Center School of Medicine, Midland.

This story originally was published by Psych Congress Network, a sister publication of Addiction Professional.