For those with comorbid ADHD and AOD use, reviews of the evidence recommend an integrated, multimodal approach, incorporating psychotherapy focused on comorbid AOD use, as well as pharmacotherapy [477, 478]. The use of structured psychotherapies, including CBT with a focus on goals, with active AOD worker involvement, is likely to be the most beneficial , and, as with the treatment of other comorbid disorders, treating both conditions concurrently is more likely to produce a positive treatment outcome than treating either disorder alone .
Box 13 illustrates such a multimodal approach through the continuation of case study A, following Ali’s story after the identification of his ADHD disorder had been made.
Box 13: Case study A: Treating comorbid ADHD and AOD use: Ali’s story continued
Based on Ali’s symptoms, the AOD worker thought that it may be beneficial for Ali to see a psychiatrist who specialised in adult ADHD. The AOD worker asked Ali whether he would be open to seeing a psychiatrist who could assess him further and help him decide the best treatment plan. He told Ali that he would be pleased to continue seeing him, and would be happy to liaise with both his GP and the psychiatrist. Ali agreed and gave written consent for his AOD worker to contact his GP and the psychiatrist and for the sharing of information between these services.
After sending this form to the GP and psychiatrist, the AOD worker stayed with Ali while he called to make an appointment with both over the coming weeks. At the AOD worker’s suggestion, Ali put these appointments in his phone calendar and also arranged a follow-up appointment following these consultations. With Ali’s permission, the AOD worker also informed his family of the dates and times of these appointments so that they could remind him and help him get to the appointments. Ali also agreed to the AOD worker discussing his condition with his parents, as they would be able to provide further information about his condition and help him in his ongoing treatment.
The psychiatrist who assessed Ali made a diagnosis of ADHD, noting that Ali had a range of symptoms of inattention, hyperactivity and impulsivity. The psychiatrist told Ali that his earlier experiences with speed and the way he described feeling calmer after a small amount of the drug was significant. He explained that psychostimulants are one of the central treatments for ADHD, which are carefully prescribed and monitored. Following a medical assessment conducted by Ali’s GP, the psychiatrist prescribed psychostimulant medication, and advised Ali that it was very important for him to maintain abstinence from the use of any other drugs, due to possible interaction effects. The AOD worker advised Ali that he would be available for a phone call every day for the first week, to see how he was going.
Ali continued with his treatment. In addition to regular monitoring and minor adjustments to the dosage of the ADHD medication, Ali attended individual sessions with his AOD worker, where he was provided with a range of evidence-based interventions to help him with his speed and cannabis use. These began with psychoeducation and information about the substances Ali had been using, focusing on the way in which they affected his ADHD and how his ADHD symptoms impacted on his substance use. Ali was also given coping strategies for occasions when he became tense and he began to practice and enjoy the relaxation exercises he was taught.
One important component of the treatment plan was to help Ali organise activities in his daily life. The AOD worker helped him organise a daily timetable, and, using different functions on Ali’s smartphone, alarms for important events, reminders and appointments were set up. Ali’s parents helped Ali keep a schedule and maintain his reminders and appointments in his phone.
Before his first presentation to the AOD service, Ali had never been able to maintain employment for more than a few days, and had no meaningful educational qualifications because his school performance was so poor. After several months, the AOD worker was able to help Ali find a place in a community education course, and, because of the improvements in his concentration and attention, he was able to obtain part-time work in a local newsagency. Ali and the AOD worker had also begun talking about a plan for independent living.
- Treatment for ADHD and AOD use should be concurrent and multimodal.
- Education about the nature of the condition for the client and the family is essential.
- The treatment of comorbid ADHD and AOD use requires long-term follow-up and more general efforts at rehabilitation, including further education.