What If Withholding ADHD Medication Carries Risks of Its Own?

One of the most acute frustrations I encounter in my work with adults with ADHD is the difficulty some of my clients face in accessing effective medication. Harmful stereotypes and misinformation about ADHD and its treatment are widespread, and prescribers themselves face considerable pressures and concerns surrounding the potential for medication misuse and diversion. In my experience, those concerns can sometimes overshadow the substantial research supporting stimulant medication as an effective treatment for ADHD.

So I’m always on the lookout for careful, grounded research examining the relationship between ADHD and substance use disorders. A recently published paper raises an important question: When someone has both ADHD and a substance use disorder, what are the risks of leaving ADHD untreated?

For decades, fears about addiction have influenced how stimulant medications are discussed. Some of those concerns reflect appropriate clinical caution, while others may rest on assumptions that deserve closer examination. A study published in the Journal of the American Academy of Child & Adolescent Psychiatry in October 2026 offers a compelling reason to reconsider how we weigh those risks.

A Striking Difference in Prescribing

Researchers analyzed electronic health records for around 1.24 million adolescents and young adults with ADHD, including more than 288,000 who also had a documented substance use disorder (SUD). They found that young people with both ADHD and a substance use disorder were far less likely to receive stimulant medication.

After accounting for several demographic and psychiatric differences, 40.5% of those with ADHD alone had stimulant prescriptions, compared with just 25.5% of those who also had a substance use disorder. When researchers examined new stimulant prescriptions, the difference was even more pronounced: 34.35% versus 16.89%.

The study wasn’t designed to establish why prescribing decisions were made for each individual, but the disparity raises an important question about how concerns about substance use influence access to effective ADHD treatment.

Part of the problem lies in the way stimulant medications are discussed. Decades of research have consistently found that stimulant medications are, on average, more effective than nonstimulant medications at reducing core ADHD symptoms, which is why major clinical guidelines have long recommended them as first-line pharmacological treatments. Discussions of stimulant medication can also blur important distinctions between misuse, diversion, and addiction, as though these terms describe essentially the same behavior. They do not.

Misuse can include taking a medication differently than prescribed, while diversion involves transferring medication to someone for whom it wasn’t prescribed. Neither automatically means that someone has developed an addiction, and neither is interchangeable with the compulsive use of illicit stimulants such as methamphetamine. Obviously misuse and diversion can carry real risks, but treating them as the same thing as addiction distorts our understanding of those risks.

What Happened When People Received ADHD Medication?

The researchers compared clinical outcomes among young people with both ADHD and a substance use disorder, examining those who were prescribed ADHD medication and those who did not.

After matching participants on several measured characteristics, the medicated group had consistently better outcomes across multiple important measures.

Over one year:

• Hospitalizations: 13.36% among those receiving medication, compared with 17.58% among those without medication.
• Emergency care: 20.29% versus 27.58%.
• Accidental overdose: 3.97% versus 4.93%.
• Recorded suicidal ideation or attempts: 6.18% versus 7.52%.

The researchers also compared stimulant medications with nonstimulant ADHD medications. Stimulant treatment was associated with lower rates of hospitalization, accidental overdose, and suicidal ideation or attempts. Additional analyses examining people with at least two prescriptions found similar favorable associations. These findings are particularly relevant given that decades of research have established stimulants as the most effective first-line medication option, on average, for treating core ADHD symptoms.

But these findings are particularly noteworthy because people with substance use disorders are often considered higher-risk candidates for stimulant treatment. Concerns about misuse, diversion, and addiction can understandably influence prescribing decisions, but those risks warrant individualized assessment rather than assumptions based solely on a person’s history of substance use. Yet in this large clinical population, young people with substance use disorders who received ADHD medication experienced fewer serious adverse outcomes.

When Caution Becomes a Barrier to Treatment

The research findings point to a troubling possibility: Some of the people who could benefit most from stimulant medication may be the very people who have the hardest time getting it prescribed.

ADHD can affect impulse control, emotional regulation, decision-making, and the ability to follow through with treatment. These difficulties can contribute to problematic substance use, whether through impulsive decisions, attempts to manage difficult emotions, or use of substances that temporarily relieve certain ADHD symptoms. Someone may not even recognize that they’re using substances to manage difficulties associated with ADHD. Effectively treating those underlying ADHD symptoms could therefore play an important role in addressing the substance use itself.

This isn’t an argument for prescribing stimulants indiscriminately. But avoiding stimulant medication is itself a clinical decision, one with potential consequences when untreated ADHD symptoms may contribute to problematic substance use. This concern is reflected in guidance from addiction medicine: The 2024 American Society of Addiction Medicine and American Academy of Addiction Psychiatry clinical practice guideline specifically recommends addressing ADHD in people with co-occurring stimulant use disorders, and supports considering prescription stimulants when their benefits outweigh the risks, with appropriate monitoring.

In my counseling practice, I’ve worked with adults with ADHD who have encountered considerable suspicion when seeking medication. Some have been refused treatment because of current legal recreational substance use or experimentation with drugs earlier in their lives. Others have described having their ADHD symptoms minimized or dismissed, or their diagnosis questioned when seeking medication. I’ve seen how frustrating and discouraging these experiences can be for people already struggling to manage their symptoms, and it’s difficult to watch as a therapist trying to help them.

I’ve also worked with thoughtful, well-informed prescribers whose understanding of ADHD and careful treatment decisions have made an enormous difference in my clients’ lives. I recognize that prescribers must weigh medical risks and responsibilities that fall outside my professional education and expertise, and I’ve seen firsthand what effective, collaborative care can accomplish.

That makes it especially frustrating when other clients encounter suspicion or barriers to treatment. My concern is with the assumptions that can influence those decisions, particularly when people seeking effective ADHD treatment feel they must defend their credibility simply to have their symptoms taken seriously. Research like this gives all of us, whatever our professional role, good reason to examine the assumptions we bring to decisions about ADHD medication and substance use.

Rethinking What We Mean by Safer Treatment

When stimulant medication is discussed in the context of substance use disorders, the conversation often centers on what might go wrong if someone receives a prescription. That’s a legitimate consideration, but a complete assessment of risk must also account for what may happen when someone doesn’t receive effective treatment for ADHD.

The Baweja study can’t tell us whether withholding medication caused worse outcomes. But it does show that young people with substance use disorders were substantially less likely to receive stimulant medication, even though those prescribed ADHD medication had fewer hospitalizations, emergency visits, overdoses, and recorded suicidal thoughts or attempts.

Taken together, these findings challenge the assumption that avoiding stimulant medication is automatically the safer choice for someone with a substance use disorder. The potential consequences of untreated ADHD deserve the same careful consideration as the risks associated with medication.