By Leigh Anne Hulva, BSN, RN— Women’s Health Educator
ADHD and substance use disorder often overlap in adults, especially when untreated ADHD symptoms feel like restlessness, racing thoughts, impulsivity, or difficulty winding down. For people in Nashville who are sober, in recovery, or worried about substance use, integrated care can help sort out ADHD symptoms, addiction risk, medication choices, and safe next steps.
Meet Maren: When Sobriety Reveals ADHD Symptoms
Maren, at age 39, has been sober for three years. For the first several months of sobriety, she experienced an uncomfortable sense of restlessness. She figured that this had to do with her nightly glass (or three) of wine no longer being available to calm her down. She figured that, like the cravings, this restlessness would fade with time.
Maren is used to telling herself stories. For ten years, she told herself that her evening wine wasn’t a problem. She told herself it was just her way of relaxing after a solid day’s work. Of course, she drank on weekends too, but that was more social and celebratory. She always seemed to drink more than she’d planned on drinking, which was her first clue that she might have a problem. Still, even when the nightly glass of wine turned to three, she maintained that it really did help her calm down before bed. Somehow, it was when she started finishing the bottle more nights than not that she realized she really did have a problem.
She credits a support program with weekly meetings (more when needed) with saving her life. It all seemed so benign from the inside. No crushing hangovers, no embarrassing public shenanigans, just a slow uptick in how much she drank until it was a daily habit that she could no longer control.
But back to restlessness. The wine had seemingly helped with that sense of unease at the end of the day. She had expected to feel it for a while after getting sober. But, months into sobriety, she still felt it: A sort of noisiness in her mind, a humming of energy, difficulty engaging in everyday tasks. It didn’t get any easier as time went by. Even after the cravings faded (for the most part, anyway), she was still feeling like her brain was not quite able to power itself down.
She mentioned this to her sobriety counselor after eight or nine months, not sure quite how to word it. Fortunately, her counselor had witnessed just this pattern before. She knew the questions to ask. There were a few careful questions about Maren’s childhood, her school years, her work history.
“I think,” her counselor said eventually, “it might be worth having you evaluated for adult ADHD. What you’re describing didn’t start with the drinking. I’m wondering if the drinking started— at least in part— as a way to manage something that was already there.”
How Common is the Overlap between ADHD and Substance Use Disorders?
Research in this area consistently points to a meaningful overlap between ADHD and substance use disorders. The figures vary depending on the study, but several large studies suggest that adults with ADHD may be at a higher risk for developing substance use disorder at some point in their lives (compared to the general population). This higher risk appears to apply across a variety of substances, including alcohol, nicotine, and cannabis. There is also some research that points to a higher risk with stimulant misuse, which can potentially complicate the treatment of ADHD.
It is important to know what this information tells us and what it does not. It’s a bit of a chicken-and-egg question in that there isn’t a simple answer. A higher rate of co-occurrence doesn’t mean that ADHD causes substance use disorders. And it certainly doesn’t mean that every person with substance use disorder has underlying ADHD.
What the research does suggest is that the two conditions share some underlying vulnerability. This shared vulnerability is worth understanding. This might be especially true for women, where both conditions are often viewed through the lens of “usual” male symptoms. That is to say, ADHD in males more often presents as the hyperactive type, whereas in females it’s more often the inattentive type. Substance use disorders in women more often appear without the hallmarks of the same disorders in men: Women are less likely to be violent while under the influence of drugs than men. They are less likely to commit crimes while impaired than men. These are situations where substance abuse is often recognized and (hopefully) treated. A woman is more likely, statistically speaking, to have a “silent” substance use problem, drinking quietly at home while maintaining work performance and relationships.
Why ADHD and Substance Use Disorder Can Occur Together
The Self-Medication Hypothesis
One possible explanation for the overlap between these two disorders is what researchers call the self-medication hypothesis. This is the idea that some people with undiagnosed (or undertreated) ADHD may turn to substances for relief. This can happen consciously or unconsciously, as a way to manage symptoms such as restlessness, racing thoughts, emotional intensity, or difficulty winding down.
Maren’s experience fits into this hypothesis in that she can look back and see the point in life where she began “self-medicating” for just these reasons. Still, she’s careful not to reduce her story to a simple one-liner. “There was a lot going on at the time that I started drinking regularly. But it’s very possible that my ADHD symptoms were part of the driver in making it a daily habit. It makes sense now that when I stopped drinking, it wasn’t quite the resolution that I was hoping for.”
Dopamine, Reward, and Neurobiology
There is some research being done that considers the brain’s dopamine (reward) system and how both disorders share some similarities in this regard. The dopamine system (which helps motivate people) is something that has been studied in ADHD. Studies of the same system in substance use disorder point to the possibility that this shared biological territory might eventually give us some clues as to why the two disorders so often overlap.
Impulsivity, Risk-Taking, and Social Stress
Impulsivity refers to the tendency to act quickly and without planning, without the consideration of long-term consequences. It is linked to seeking an immediate reward without being entirely rational. Impulsivity is one of the main features of ADHD. It has also been linked to substance use disorder… that drive for quick relief in spite of the consequences. This might be one contributing factor when it comes to both initial experimentation and difficulty moderating use. There is a wide range of genetic, social, and psychological reasons behind this.
ADHD, Women, and Hidden Substance Use
It’s definitely worth noting that the strain of undiagnosed ADHD can be great, almost crippling for some. Girls and women in particular are underdiagnosed due to their tendency to have the “inattentive” type of ADHD. This has been discussed in previous articles, but in short, girls tend to get diagnosed less frequently than boys because the inattentive types don’t cause disruptions in class, whereas the hyperactive types do. The “daydreamers” don’t get early treatment, while the “troublemakers” do. Those daydreamers who don’t get diagnosed and treated go on to try to manage their ADHD without the help of being able to name the problem or the potential benefits of medication.
Maren, as a child, was considered “daydreamy” and “forgetful.” She did not make trouble in class, but she seemed to always be disappointing parents and teachers with her academic performance. They knew she was smart— she knew she was smart— and yet her grades were rarely better than mediocre. Nobody thought of having her tested for ADHD. And so, Maren spent the next three decades dealing with issues she had no name for. The restlessness, for example. The difficulty starting and completing tasks. She felt the strain of— time and time again— waiting until the last minute to finish a school or work project. Her relationships suffered occasionally from her seeming inability to remember special dates or to show up on time. She felt a sort of low-key chronic shame around these problems.
For Maren, there is no single cause to her substance use disorder, but she was able to recognize undiagnosed ADHD as part of the problem. Understanding this really helped her move forward to the next steps. As her counselor had suggested, she sought out an ADHD evaluation. She was, as she had suspected after doing her own internet research, found to have ADHD, the “inattentive type.” This diagnosis helped Maren view her substance use disorder through a more forgiving lens. It also helped her move forward with ADHD treatments that she hopes will help her avoid falling into similar traps in the future.
Integrated Treatment for ADHD and Substance Use Disorder
When ADHD and substance use disorder are both present, most specialists agree that treatment is generally more effective when it addresses both issues together.
Maren’s treatment has included her continued attendance at her recovery program, weekly meetings with a therapist, and a non-stimulant medication to treat the ADHD. She finds the treatment to be “good enough for now,” not a perfect fix but certainly a step in the right direction. She has noticed a subtle quieting of her mind over the past few months of treatment.
Stimulant Medication, ADHD, and Addiction Risk
A common concern when it comes to treating people with ADHD who also have a history of substance use disorder is whether or not stimulant medication is an option.
Current research suggests the opposite of what you might think. This is an area of ongoing study, so no hard-and-fast rules apply, but there is evidence to suggest that treatment with stimulant medications is not off the table even in the case of substance use disorder.
Treatment options should always be a careful and ongoing conversation between patient and provider. In Maren’s case, she and her doctor considered her history of self-medicating, her current sobriety, her social support network, and her willingness to attend follow-up appointments on a strict schedule.
How to Find the Right ADHD and Addiction Medicine Provider in Nashville
If you are fortunate enough to find a provider who specializes in both adult ADHD and substance use disorder, these are some areas worth discussing with them:
- Your full substance use history, including patterns that predate any diagnosed mental health condition.
- Whether ADHD symptoms were present before the substance use began
- The length and stability of your recovery or sobriety
- Your current support system
- Whether starting with a non-stimulant medication might be an appropriate starting point for treatment
- How your treatment success will be monitored
Moving Forward with ADHD and Recovery
Maren is careful not to describe her experience as a tidy before-and-after. Her sobriety is an actively ongoing journey. Her ADHD treatment is similarly a process. When she catches herself blaming ADHD for her substance use, she stops that overly simplified narrative. What she does know is that getting diagnosed with and treated for ADHD has helped her maintain sobriety. She hopes her story can inspire others to seek both sobriety and treatment as well.
You can be diagnosed with ADHD and seek treatment for it at any point; it’s never too late. If ADHD or substance use disorder (or both) are holding you back, now is the time to find a healthcare provider with experience treating adults with ADHD. Dr. William Conway of Nashville Concierge Medicines specializes in both Adult ADHD and Addiction Medicine. If this article resonates with you, consider talking to your doctor about potential treatments. Find a provider who helps you figure out how to move forward into your best life!
H2: Comments from Dr. Conway
In this elegant article, Leigh Anne communicates subtly the reality of living with untreated ADHD, and its implications for risk of substance use to frank addiction. Leigh Anne is modest in her explanations of the treatment effectiveness of ADHD associated with comorbid substance use. Stimulants are an effective treatment in patients with ADHD with substance use disorder. Stimulant treatment in ADHD is a foundational treatment in sustained effective remission of substance use disorder, particularly with opioid use disorder combined with adult ADHD.
Frequently Asked Questions (FAQs):
Are people with ADHD more likely to develop substance use disorders?
Research suggests there may be an elevated risk, but the risk is complex and not yet fully understood. Several studies have found that adults with ADHD appear to develop substance use disorder at higher rates than the general population, but the research is ongoing. It’s important to note that many people with ADHD never develop substance use problems.
Should ADHD and substance use disorder be treated together?
Most specialists in this area suggest that treating the two conditions together tends to produce better outcomes than treating them separately. Having healthcare providers who work together (or having a single provider with experience treating both conditions) appears to produce the most successful outcomes.
How can I tell if my substance use is linked to undiagnosed ADHD?
This isn’t something that can be determined by self-assessment alone, but the fact that you’re asking this question means you owe it to yourself to find a provider who will consider your concerns. Getting evaluated for adult ADHD will be an important early step. It is worth noting whether your symptoms of restlessness, poor focus, or executive functioning difficulties can be traced back to childhood, before substance use began. Some providers suggest a waiting period before an ADHD evaluation if you are early in your sobriety journey. After you’ve reached a point of stability in your recovery, a proper ADHD evaluation by a specialist is the likely next step.
About Leigh Anne Hulva, RN, BSN
I’m Leigh Anne Hulva, BSN, RN- a registered nurse, women’s health educator, mother of teenage daughters, and passionate advocate for women navigating perimenopause and menopause. I recently completed the Harvard Medical School course on Women’s Health and in these pages, I relish sharing what I learned there alongside what I know from lived experience. I bring to this work not only my training, but also my personal experience of navigating the very transition I write about. It is my privilege to share both, because this work is personal to me. I hope it feels that way to you, too.
I have been on the other side of this conversation, and I understand how much it matters to feel truly heard. At Nashville Concierge Medicines, my work is supervised by Dr. William Conway, MD, and I work directly under his licensure as a nurse educator.
Who is Leigh Anne Hulva by William Conway, MD.
Leigh Anne is an elegant writer in the American tradition. Leigh Anne communicates from the soul, illuminating deep truths.
Leigh Ann should be read for the enriching insights that bring clarity to human life. Leigh Anne writes in the best tradition of American humanism.
Recommendations for Literature Review
Overall efficacy
- Psychostimulants (methylphenidate, amphetamine formulations) remain the most effective pharmacotherapy for core ADHD symptoms in adults; comorbid SUD complicates—but does not preclude—benefit. Extended‑release and prodrug preparations are preferred to lower misuse/diversion risk and improve adherence. SAMHSA, 2015 Wilens et al., 2009 Capriotti et al., 2023
Impact on substance outcomes
- Long-term risk: Meta-analytic data indicate childhood stimulant treatment does not increase, and may reduce, later risk for SUD relative to untreated ADHD. Wilens et al., 2003 Humphreys et al., 2013 Humphreys et al., 2013 (PMC)
