Title : Case report: Ethical analysis of prescribing stimulant medications to a patient with comorbid attention-deficit/hyperactivity disorder and cocaine use disorder
Abstract:
Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with many comorbidities, including substance use disorders (SUD). However, treating both ADHD and SUD can be challenging. While first-line pharmacological treatment for ADHD is a stimulant medication, physicians are less likely to prescribe stimulants for patients with comorbid ADHD and SUD because of concerns for misuse, medication diversion, and worsening of SUD symptomatology.
Case Description: The patient is a 39-year-old male with comorbid ADHD and cocaine use disorder (CUD), a type of SUD. He developed tolerance to cocaine, experienced severe cravings, and was even admitted inpatient for his cocaine use. His primary care physician prescribed 20 mg of amphetamine-dextroamphetamine mixed salt, which was discontinued after his inpatient hospitalization. With his psychiatrist, he agreed to produce two urine toxicology screens that were negative for cocaine before he was restarted on his stimulant prescription. However, he has not been successful. Meanwhile, he continues to endorse symptoms of ADHD. This case highlights not only a clinical challenge but an ethical one. Ultimately, our ethical commitments to principles such as beneficence and justice may justify treating comorbid ADHD and CUD with stimulant medication, despite the risks that often deter physicians.
Discussion: The patient has continued to exhibit capacity to make their own decisions during outpatient visits to his psychiatrist, with intact cognition and adequate insight and judgment. Thus, he can provide informed consent. If he is appropriately educated about the therapeutic effects and the risks of stimulant medication for his comorbid conditions, we should conduct a nuanced benefit?to?burden analysis before withholding the medication. In that analysis, there has been research indicating that prescription of stimulants can reduce both ADHD and CUD symptoms. Although other studies suggest that stimulants do not necessarily improve symptoms of either disorder, the results of these studies must be examined against other conflicting research that has demonstrated positive results for reducing SUD symptoms, and other studies which have demonstrated that higher doses of stimulants could reduce ADHD symptoms and decrease the impact of stimulants on ADHD patients who are dependent on stimulants. Also, the risk of abusing stimulants decreases with extended-release formulation of medication, further mitigating the risks. The requirement of two negative urine toxicology screens before he can be reinstated on stimulants also mitigates the risks of stimulant prescription. Additionally, the concept of social justice in terms of distribution should be weighed. He belongs to a particularly vulnerable population, to whom healthcare professionals have a moral obligation to provide necessary pharmacological tools like stimulants under the idea of contractarianism. This idea holds that people are morally obligated to share basic necessities with everyone in an unbiased manner to address disparities in healthcare that are inherent to our society. Thus, if the results of two urine toxicology screens are negative, increasing the dosage of his amphetamine-dextroamphetamine mixed salt appears both clinically and ethically justified.
