A 32-year-old man comes to the office for evaluation of attention-deficit hyperactivity disorder (ADHD). Although never treated, he had behavioral problems starting in kindergarten, frequently getting into trouble both at school and at home for not listening, talking out of turn, and inability to sit still. Many of these difficulties persisted throughout high school and college. The patient continues to struggle with distractibility, forgetfulness, disorganization, and impulsivity. He is concerned that ADHD is affecting his relationships and work performance and mentions that he has been passed over for promotion several times. The patient has a history of alcohol and cocaine use disorder from age 18-24 and a family history of alcohol and opioid abuse in his father and paternal uncle. The patient does not use alcohol or any illicit drugs. He hopes that medication can help but is concerned about taking anything addictive. Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old man comes to the office for evaluation of attention-deficit hyperactivity disorder (ADHD).  Although never treated, he had behavioral problems starting in kindergarten, frequently getting into trouble both at school and at home for not listening, talking out of turn, and inability to sit still.  Many of these difficulties persisted throughout high school and college.  The patient continues to struggle with distractibility, forgetfulness, disorganization, and impulsivity.  He is concerned that ADHD is affecting his relationships and work performance and mentions that he has been passed over for promotion several times.  The patient has a history of alcohol and cocaine use disorder from age 18-24 and a family history of alcohol and opioid abuse in his father and paternal uncle.  The patient does not use alcohol or any illicit drugs.  He hopes that medication can help but is concerned about taking anything addictive.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood and can cause significant impairment in occupational, academic, and social functioning. Stimulants (eg, amphetamines, methylphenidate) are the most effective treatment for adult ADHD but have potential for misuse or addiction, especially in patients with a history of substance use disorder. Among nonstimulant options, the norepinephrine reuptake inhibitor atomoxetine is considered the treatment of choice. Atomoxetine is not addictive and has been shown to reduce ADHD symptoms and improve executive functioning and quality of life. Other nonstimulant options with efficacy for adult ADHD include bupropion and tricyclic antidepressants. (Choice B) Alpha-2 adrenergic agonists (eg, clonidine, guanfacine) have been used to treat ADHD in children and adolescents, but have limited data showing efficacy in adult ADHD. (Choice C) Medication is generally considered first-line treatment for adult ADHD. Cognitive-behavioral therapies can be added when medication is not fully effective or used as monotherapy if medication is contraindicated or psychotherapy is preferred. This patient has requested medication and can be effectively treated with the nonstimulant atomoxetine. (Choice D) Although tricyclic antidepressants (eg, desipramine) are not addictive and have some efficacy for adult ADHD, they are not considered first-line as they have risk for cardiotoxicity and are more poorly tolerated than atomoxetine. (Choices E and F) These medications are stimulants and carry increased risk of misuse and addiction. (Choice G) The wakefulness promoting agent modafinil has been used to treat narcolepsy but has little evidence of efficacy in adult ADHD. Educational objective: Stimulant medication is a first-line treatment for most adults with ADHD. The nonstimulant atomoxetine, however, is preferred in patients with history of substance use disorder to avoid the risks of drug misuse and addiction. References: Atomoxetine treatment in adults with attention-deficit/hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26343377) Pharmacological interventions for adolescents and adults with ADHD: Stimulant and nonstimulant medications and misuse of prescription stimulants. (http://www.ncbi.nlm.nih.gov/pubmed/25228824) Adult attention-deficit/hyperactivity disorder diagnosis, management, and treatment in the DSM-5 era. (http://www.ncbi.nlm.nih.gov/pubmed/27907271)

A 32-Year-Old Man Comes to the Office for Evaluation of Attention-Deficit