Adult-Onset ADHD: Treatment in Primary Care

Matthew F. Watto, MD; Paul N. Williams, MD


March 24, 2023

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. Today we're going to be talking about attention-deficit/hyperactivity disorder (ADHD). We had a great guest, Dr Kevin Simon, who taught us all about this. Paul, is it possible for adults to develop ADHD de novo?

Paul N. Williams, MD: I'm glad you asked, Matt, because I love absolutes and I'm happy to answer any question yes or no. This question came up during our podcast, and the safest answer is probably "not commonly." It can happen, but by and large, ADHD is probably present in childhood.

The question is whether ADHD is recognized. It may declare itself in adulthood rather than coming into existence in childhood. The individual might have been able to compensate, or their ADHD might manifest only under certain stressors until they get to advanced or graduate studies, and their inattention is uncovered all of a sudden. Their ADHD has probably always been there. But there is still some argument about whether ADHD can actually occur de novo in adulthood.

Watto: The reason we wanted to cover this topic is because I have had many adult patients tell me, "I think I have ADHD. I was never formally diagnosed with it." We were trying to figure out what to do with that. I wasn't comfortable just starting medication.


Dr Simon gave us some really clear advice, including how he thinks about the medications, especially the stimulants. We have methylphenidate and amphetamine salts. He prefers to start with methylphenidate because it's a little bit softer and has fewer side effects. And he prefers long-acting formulations for many reasons. Abuse deterrence is part of it, but it's also fewer pills for the patient to take. What else would you like to highlight about the medications for ADHD?

Williams: I thought his overall approach made sense, starting with one of the two major drug classes. He prefers long-acting methylphenidate, but if that doesn't work, then you could certainly try mixed amphetamines. For patients who aren't tolerating the side effects, treatment options include the nonstimulants. They don't have as much evidence behind them, but they do work in some instances. There may even be secondary indications for a drug such as bupropion, which might be a reasonable choice for patients with ADHD and comorbid depression.

Watto: Since we recorded that podcast with Dr Simon, I've prescribed stimulants to a couple of patients. We are beholden to the formulary, but we should make sure the drug is affordable, and start at a low dose and keep in close contact with the patient. He sometimes prescribes a 2-week supply, and then check in with the patient to make sure the patient isn't having side effects. We can always increase the dose at that time rather than giving the patient a 90-day supply and then finding out it was the wrong dose. I have been using that tip.

What if a patient has a history of substance use disorder? Would that be a total contraindication to treating ADHD?

Williams: The short answer is no. It might impact the agent you prescribe. If the patient has a history of stimulant use disorder and doesn't have a lot of initial success with a nonstimulant drug, then I might have that patient see a specialist rather than trying to manage it myself.

But if it's opioid use disorder or some other substance use, you would be cautious and mindful, but you can keep patients more engaged in care by treating their ADHD than by withholding the medications out of concerns for diversion, especially if you're prescribing the long-acting drugs. They are rarely diverted because they're designed to prevent misuse by being extended-release agents. The fact that you can keep the patient more engaged in care if you treat their ADHD was actually a really important point to take away from our discussion with Dr Simon.

Watto: Prescribing a safe drug at a safe dose is a form of harm reduction if the patient is less likely to try to self-treat their ADHD.

Williams: This is a little bit off topic, but I loved the discussion about the urine tox screens, and how Dr Simon uses them not to find out if the patient is getting away with something, but to have an informed discussion about the substances they might be taking. For example, if the patient thought that they were using cocaine but the urine drug screen comes back negative for cocaine, you can caution the patient, "I'm not sure what you thought you were taking, but that's not what the tox screen shows. So please be careful." I thought this was a nice way to have a helpful conversation and is also very practical in terms of how to manage patients for whom you are prescribing controlled substances.

Watto: We covered a ton of other topics with Dr Simon. Click on ADHD With Dr Kevin Simon to hear the full podcast. This has been another episode of The Curbsiders bringing you a little knowledge food for your brain hole. Until next time, I'm Dr Matthew Frank Watto.

Williams: And as always, I'm Dr Paul Nelson Williams. Thank you and goodbye.

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