Vyvanse Prescription Guidelines for ADHD Patients with Substance Abuse History

Evidence-Based Rationale for Vyvanse Selection

• Lisdexamfetamine is the only prodrug stimulant, containing dextroamphetamine bound to a lysine molecule that must be metabolized by red blood cells after oral ingestion to become active, making it impossible to abuse through crushing, snorting, or injection, and is prescribed to patients with ADHD and substance abuse history due to its low abuse potential 1
• Extended-release formulations like Vyvanse demonstrate markedly slower brain absorption and dopamine transporter occupancy compared to immediate-release stimulants or intravenous cocaine, preventing the euphoric "high" that leads to abuse, and are recommended for patients with substance abuse concerns 2

Clinical Decision Algorithm

• ADHD symptoms cause moderate to severe functional impairment requiring first-line treatment efficacy, and Vyvanse is preferred for patients who are stable in recovery and engaged in addiction treatment programs, with a commitment to monitoring and follow-up appointments 1
• Concern exists about medication diversion or misuse with immediate-release formulations, and Vyvanse is recommended due to its lower abuse potential 2, 1

Required Monitoring Framework

• Monitor for cardiovascular effects, such as changes in blood pressure and pulse, appetite changes, and sleep disturbances at each visit, and discontinue stimulants if the patient continues to relapse and use substances, shows evidence of medication diversion, or fails to attend monitoring appointments 3

Integrated Treatment Approach

• Combine Vyvanse with addiction treatment programs and cognitive-behavioral therapy for optimal outcomes, and ensure the patient has a signed release for exchange of health information between the prescriber and any opioid treatment program or addiction services 4
• Educate patients and families about safe storage of medications away from individuals at risk of misuse, signs of overdose, and proper disposal of unused medication, and consider prescribing naloxone rescue kits if the patient has concurrent opioid use history 4

Approach to Stimulant Treatment in ADHD with Substance Use History

Evidence-Based Recommendations

• The American Academy of Child and Adolescent Psychiatry explicitly states that patients with histories of using or abusing other substances may have stimulants given to treat their ADHD, and even a history of abuse of stimulants may not represent an absolute contraindication, particularly if the patient is stable in recovery and closely monitored 5, 6
• The American Academy of Child and Adolescent Psychiatry guidelines state that substance abuse history is not an absolute contraindication to stimulant therapy, and the patient's methadone treatment indicates engagement in recovery, supporting stimulant use 5, 6
• The American Academy of Child and Adolescent Psychiatry recommends that patients with substance abuse history must be monitored even more carefully than would otherwise be the case, including monthly follow-up visits to assess ADHD symptom response, medication adherence, and substance use patterns 5, 7
• The American Academy of Child and Adolescent Psychiatry recommends discontinuing stimulants if the patient continues to relapse and use substances, with specific criteria for discontinuation including active substance use, evidence of medication diversion, or failure to attend monitoring appointments 7
• Atomoxetine may be a preferable alternative to stimulants in patients with active substance use concerns, carrying no abuse potential and requiring 6-12 weeks to achieve full therapeutic effect 8
• Clonidine or guanfacine extended-release may be preferable options in patients with comorbid substance use disorders, though they have smaller effect sizes than stimulants 7
• Switching from an effective stimulant to a non-stimulant will likely result in worse ADHD symptom control and potentially worse functional outcomes, emphasizing the importance of continuing effective treatment 8