The shockingly strong connection between ADHD and addiction
Kids taking ADHD medication shouldn't make you worry about a "drug cascade" — the alternative is worse.
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Hi SL,
I’ve observed that many of my friends who struggle with substance use disorder or addictive tendencies also have ADHD. I’m not trying to stigmatize ADHD (especially as someone with the diagnosis), but I wonder what the research says about what the connection is, if indeed there is one. How might dealing with addiction be harder for ADHD brains? I ask so that A) those with the diagnosis can better understand themselves, and B) their friends and family without ADHD can learn how to support them better.
From, Seeking to Support
Hi STS,
This is a great question, and a timely one, considering the Wall Street Journal recently published a splashy story claiming that putting kids on ADHD medication can be the start of a “drug cascade” (more on that in a bit).
The short answer to your question is yes; the research is crystal clear that people with ADHD are significantly more likely to develop a substance use disorder than people without ADHD. You’ll find slightly different numbers depending on the study’s metrics, variables, and the substance in question, but the overall body of evidence is unequivocal about the connection.
A couple of examples for the number lovers: One meta-analysis found that a person with ADHD is more than two and a half times1 more likely to develop a substance use disorder than the general population. In a 2020 study, researchers estimated that the prevalence of alcohol use disorder among people with ADHD is 20.5 percent compared to 2.5 percent in people without ADHD2.
So it’s no coincidence that you’ve noticed that your friends who struggle with substance use often have ADHD. Substance use disorders and ADHD have overlapping genetic influences3, and impulsivity, risk-taking, and negative social and academic issues associated with ADHD are just a few of the factors that can increase the risk of developing substance use disorders. (This relationship can be bidirectional—substance use can elevate the risk of ADHD and vice versa, but the point is that the connection between the conditions is strong).
It’s easy to get lost in research and lose sight of how this affects actual human beings. Personally, I can draw a direct line from the symptoms of my undiagnosed ADHD to my alcohol use.
When I was in school, educators and clinicians alike considered hyperactivity to be the defining characteristic of ADHD. Many of us who had what’s now called the “inattentive” type of ADHD were thought of as...unmotivated students. Being a “space cadet”— as more than one teacher called me—was a matter of willpower. I was choosing to let my mind wander because I didn’t care enough about the subject matter. Teachers routinely engaged in the time-honored tradition of calling on me when it was clear I hadn’t been paying attention, in hopes of humiliating me enough to focus.
In one class, there was a day I was astonished to find that I finished a worksheet before the rest of the class. When the teacher—skepticism etched on her face—came over to my desk to review my work. She smirked as she held the paper up to the class, to a chorus of laughter. I hadn’t realized the worksheet was double-sided. The implication was clear: Not only was I only half done while the rest of the class was close to finishing, but I was the only moron who didn’t notice the little arrow at the bottom of the page signalling a second side.
Report card after report card came home with notes about not “living up to my full potential,” being “easily distracted by friends,” “disorganized,” being “underprepared” for tests and quizzes, and generally “smart but misses details.” Throughout grade school, the message was consistent: I was smart enough to be a good student, but clearly didn’t care enough to put in the work and be one. I was simply not trying hard enough.
Knowing that I was, in fact, trying as hard as I could left me with only one conclusion: I was painfully stupid. As you might imagine, this didn’t leave me brimming with self-confidence. By my first year in high school, I’d realized two things: 1) if I wanted to keep up, I needed to work 10 times harder than everyone else, and 2) if I couldn’t be good at anything related to academics, I had to be good at something else. That something else turned out to be finding and consuming alcohol.
This was made easier by the fact that alcohol gave me so much of what I wanted and was afraid I would never have: social clout, the thrill of being ‘bad’, and—most importantly—a sense that I was smart and funny and socially valuable, if not academically so.
I worked hard, I partied hard, and I never felt like I was doing enough of either. It’s impossible not to wonder how different my experience might have been if I had been diagnosed and medicated as a child.
Which brings us to the Wall Street Journal story and its baffling headline: “Millions of Kids are on ADHD Pills. For Many, It’s The Start Of A Drug Cascade.” The thesis of the story is basically this: Millions of kids are put on stimulants (like Adderall and Ritalin) for ADHD. Those kids are more likely than kids not on ADHD meds to end up on an additional psychiatric medication four years later.
There are many misleading and obfuscatory parts of the story. I’m assuming— though it’s never said—that the kids who were not on ADHD medications didn’t have ADHD, which makes perfect sense. In addition to substance use disorders, people with ADHD are significantly more likely to have co-occurring psychiatric disorders. According to the CDC4, “nearly 78 percent of children with ADHD have at least one co-occurring mental, behavioral, or developmental condition (which may include anxiety, conduct problems, autism, etc).”
In other words, kids with a condition that typically requires medication often have a second condition for which medication is recommended. Rather than necessarily being the product of the medication (or overmedication) as the story implies, it’s likely that clinicians are following established, evidence-based guidelines for treating each condition.
Dr. Ryan Marino, a medical toxicologist, emergency physician, and addiction medicine specialist, was equally baffled by the story. “For ADHD in particular, the gold standard is medication. It is one of the most evidence-based interventions in all of medical practice,” he told me. “So, it’s very weird that they thought it was a bad thing that children with a condition that should be medicated ended up on medication.”
Dr. Marino acknowledges there will always be outliers of misdiagnosis and overprescribing. “I’m sure there are situations where kids were overmedicated,” he says. “But that’s not unique to this condition, it’s not the norm, and certainly not something that anyone would be able to say is the standard of care.”
It’s also not nearly as widespread or harmful as the consequences of untreated ADHD. “If you look at any substance use, across the board, problematic substance use is much higher in people with ADHD who are never even offered medication,” Dr. Marino says.
In addition to lower rates of substance use disorders, people whose ADHD is treated have improved social function, improved self-esteem, and better educational and professional outcomes than those who aren’t. Medication for ADHD is associated with reduced rates of suicidal behaviors, substance misuse, accidents, and criminality5. Similarly, a recent study comparing individuals with ADHD who started medication vs. those who did not — over 2 years — and found that medication was associated with reduced risk of all-cause mortality and “unnatural-cause” mortality (e.g., accidental injuries, poisonings, suicide6).
“People get so worked up about children being on a controlled substance. But if their parents want them to have a normal life expectancy, success in the educational and social domains, medication is the gold standard,” Dr. Marino says. “In some cases, leaving these kids unmedicated ultimately results in them buying meth off the street—it’s not uncommon.”
Put simply, the so-called “drug cascade” alluded to by the Wall Street Journal (which, again, was defined as kids being on two, or occasionally three medications at a time) is nothing compared to the actual cascade of harmful effects associated with untreated ADHD.
Dealing with addiction is harder for people with ADHD when they don’t know they have it. ADHD is often underdiagnosed in adults with a substance use disorder because the symptoms of ADHD are attributed to the substance use (if I come home wasted, no one’s going to think my lost phone is the result of ADHD; understandably, they’ll assume it was the drinking). If you have a loved one with substance use issues who seems to have symptoms of ADHD, encouraging them to get a formal assessment is a good first step.
I’d also recommend reassuring them that the evidence suggests that treating their ADHD with medication improves outcomes for addiction recovery. In some recovery circles, there’s unfortunately a stigma around stimulants for ADHD, but it’s simply not based in science. [Important caveat: some individuals in recovery can find the effects of stimulant medications too triggering. Everyone is different. But many others find it helps them stay sober because it mitigates ADHD symptoms.]
If all else fails, ask your loved one how you can best support them. Sometimes people need to know that another person understands why their brain works the way it does, and not only doesn’t judge them, but loves them regardless.
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Lee SS, Humphreys KL, Flory K, Liu R, Glass K. Prosisorder mostective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev. 2011 Apr;31(3):328-41. doi: 10.1016/j.cpr.2011.01.006.
Luderer M, Ramos Quiroga JA, Faraone SV, et. al. Alcohol use disorders and ADHD. Neurosci Biobehav Rev. 2021 Sep;128:648-660. doi: 10.1016/j.neubiorev.2021.07.010.
Koller D, Mitjans M, Kouakou M, Friligkou E, Cabrera-Mendoza B, et. al. Genetic contribution to the comorbidity between attention-deficit/hyperactivity disorder and substance use disorders. Psychiatry Res. 2024 Mar;333:115758. doi: 10.1016/j.psychres.2024.115758.
https://www.cdc.gov/adhd/data/index.html
Zhang L, Zhu N, Nourredine M, Li L, Garcia-Argibay M et al. ADHD drug treatment and risk of suicidal behaviours, substance misuse, accidental injuries, transport accidents, and criminality: emulation of target trials BMJ 2025; 390 :e083658 doi:10.1136/bmj-2024-083658
Levin FR, Hernandez M, Mariani JJ. Treating Attention-Deficit/Hyperactivity Disorder Matters. JAMA. 2024 Mar 12;331(10):831-833. doi: 10.1001/jama.2024.1755. PMID: 38470393; PMCID: PMC11562873.
As someone with late diagnosed ADHD and two teenagers with the disorder I appreciate this! One thing though - not everyone in recovery can tolerate being put in a stimulant after getting sober. Speaking from personal experience, I was put on methylphenidate for my ADHD in the first year of sobriety - which similar to you, is when I realized what I had been dealing with for most of my life. But I quickly learned that I could achieve a high/ quick dopamine rush if I took a pill and a half. I convinced myself it was fine - since ya know, it was my script. 1.5 pills soon became 2 pills. Then I started dipping into my son’s stash. Long story short, it was not fine and I found myself on the same path I was on with my drinking - hiding, sneaking and searching for the escape. Anyway, this is just one cautionary tale from one sober person. We are all different 🙃
Most of the time, I see people with ADHD or other mental health conditions using substances to self-medicate. People with ADHD often describe their minds like rush-hour traffic—lots of thoughts, impulses, and ideas all happening at once, but without the internal “traffic lights” that are supposed to regulate what moves and what stops. It’s not that the brain is too fast—it’s that the regulation system isn’t working properly.
Because of that internal overwhelm, some people turn to stimulants (amphetamine, meth, cocaine) to give their body enough activation to “keep up,” while others turn to depressants (benzos, opioids, alcohol, marijuana) to slow the mental traffic down. The problem is that unlike prescribed medications, substances don’t offer consistent or controlled dosing, so the imbalance gets worse over time and creates more problems. And while certain medications can take a couple of weeks to reach full effect—especially non-stimulant meds—street drugs don’t provide that stability. Your point about the alternative being worse is a hard truth that many people don’t want to acknowledge.
There’s also the classic “chicken or the egg” issue: Which came first? Did the mental health condition exist before substance use (leading to self-medication)? Did the symptoms appear during substance use as a result of the substance’s effects? Or did they show up afterward as long-lasting changes, substance-induced disorders, or part of ongoing PAWS? This makes assessment difficult, but it’s an important conversation for people in recovery to understand.
This is a really good post, and it’s incredibly helpful for people in recovery. Keep up the good work!