CADDRA ADHD and Substance Use Program (CASUP)

The development of this course was based on a systematic review of meta-analyses and review articles published over the past ten years, as well as key articles in the field identified by an expert panel, to ensure the information provided to learners is up to date and of the highest possible quality. In some specific cases, we used other types of studies to discuss available research on topics where no reviews or meta-analyses were available. In cases where we state that no research is available, it may be that some small-scale studies have been done, but do not translate into clinical practice or are insufficient to provide clinical guidance and as such, have not been included. Our literature review was limited to articles available in English.

Information on process addictions (e.g., food, sex, gambling), while important with regards to ADHD diagnosis and treatment, is outside the scope of this course and is therefore not included. CASUP focuses on SU that has begun to cause harm to a person’s health, safety or well-being, and SUDs as defined by the DSM-5. The focus is on the intersection of ADHD and SU/SUDs, rather than ADHD or SUDs alone. If you are looking for additional information specific to ADHD, please visit the other courses, guidelines and resources on CADDRA’s website. Select resources specific to ADHD or SUDs alone are also provided in the Resource section of each module.

In addition to the comprehensive research done in developing this course, we conducted a needs assessment with over 550 contributors and worked closely with a number of IWLE. From this work, we extracted insightful, thought-provoking information, which has been provided as quotes and examples throughout the course. The aim is to bring the information to life, provide practical insights into the patient experience, and build empathy. All of the contributors have been given pseudonyms to protect their privacy. CADDRA staff also worked closely with multiple Healthcare Professionals with extensive experience working with ADHD and SU/SUDs to ensure all information was accurate and aligned with best clinical practice.

The development of this course was based on a systematic review of meta-analyses and review articles published over the past ten years, as well as key articles in the field identified by an expert panel, to ensure the information provided to learners is up to date and of the highest possible quality. In some specific cases, we used other types of studies to discuss available research on topics where no reviews or meta-analyses were available. In cases where we state that no research is available, it may be that some small-scale studies have been done, but do not translate into clinical practice or are insufficient to provide clinical guidance and as such, have not been included. Our literature review was limited to articles available in English.

Information on process addictions (e.g., food, sex, gambling), while important with regards to ADHD diagnosis and treatment, is outside the scope of this course and is therefore not included. CASUP focuses on SU that has begun to cause harm to a person’s health, safety or well-being, and SUDs as defined by the DSM-5. The focus is on the intersection of ADHD and SU/SUDs, rather than ADHD or SUDs alone. If you are looking for additional information specific to ADHD, please visit the other courses, guidelines and resources on CADDRA’s website. Select resources specific to ADHD or SUDs alone are also provided in the Resource section of each module.

In addition to the comprehensive research done in developing this course, we conducted a needs assessment with over 550 contributors and worked closely with a number of IWLE. From this work, we extracted insightful, thought-provoking information, which has been provided as quotes and examples throughout the course. The aim is to bring the information to life, provide practical insights into the patient experience, and build empathy. All of the contributors have been given pseudonyms to protect their privacy. CADDRA staff also worked closely with multiple HCPs with extensive experience working with ADHD and SU/SUDs to ensure all information was accurate and aligned with best clinical practice.

In creating CASUP we wanted to bring together a strong evidence base, lived experience, and best practices. The research and other information were paired with a desire to focus on diversity, equity and inclusion, per CADDRA’s values, and in alignment with the project’s funding source, Health Canada. One way we did so was to make use of non-stigmatizing language whenever possible throughout the course. For the language choices, we consulted with healthcare professionals, individuals with lived experience, inclusive language experts and best practice guidelines.

Using language that patients consider non-stigmatizing can be a valuable tool for fostering positive patient interactions and improving healthcare outcomes. It is of note that these suggestions and the use of non-stigmatizing language in CASUP are not mandates, but are instead offered as guidance to help healthcare professionals enhance their communication and better support their patients. While the goal of using non-stigmatizing words is to provide an approach that promotes respect and empathy, we recognize that each healthcare professional has their own communication style and patient relationships. The course provides these language tips as flexible options to consider, rather than strict rules to follow, empowering professionals to choose words that best fit their unique context and interactions with patients while considering what language makes the most sense to each patient. By offering these suggestions, we aim to equip you with strategies that may help strengthen patient trust and create a more inclusive environment, while allowing room for professional judgment and adaptability in day-to-day practice.

Our word choices in discussing research results related to SUD treatment reflect the available research. While we have noted throughout that treatment for both SUD and ADHD should be aligned with the patient’s own health goals, which in regards to SU may or may not include abstinence, much of the research focused on SUD treatments uses abstinence or treatment adherence as the main measure of success. To avoid extrapolating research results we aim to balance this by relaying available findings and providing ideas for implementing those research findings in practice for patients with varying goals.

For many years ADHD research was focused on cisgender male patients. More recently, research has included and occasionally focused on cisgender female patients with ADHD. This is a step in the right direction but more work still needs to be done to improve diagnostic and treatment access for females with ADHD, as we address in the course. Unfortunately, at this point, there is limited information on diagnosing and treating ADHD in patients who are transgender, non-binary, and/or gender-diverse. Because of the limited research, we cannot provide evidence-based information specific to transgender patients with ADHD and SU/SUD at this time. Additionally, much of the available research is focused on sex, rather than gender, or refers to sex and gender interchangeably. Given the language used in available research, the lack of differentiation between the impacts of sex and gender in ADHD research, and the limited availability of research on patients of varying gender identities, we have opted to focus on sex in discussing the available information. This is reflected in this course by the use of male and female when describing applicable research findings, referring to the sex of the patient, rather than their gender. This does not mean that healthcare professionals should avoid discussing gender with their patients or that gender does not have an impact, simply that we are aiming to use the language from available research.

As with sex, similar issues arise with race and ADHD research. Much of the foundational research in the field of ADHD has been carried out with primarily Caucasian participants. While we know that ADHD presentation may vary by race and ethnicity, based on the experiences reported by racialized IWLE with ADHD, there is limited research and clinical guidance on how differences may show up or how healthcare professionals can best respond to or manage this. We have presented the information that is currently available in the course content and discuss some options for working to create equitable access to care, but further research in this area is certainly needed.

AA: Alcoholics Anonymous
ACEs: Adverse childhood experiences
ADHD: Attention-deficit/hyperactivity disorder
AUD: Alcohol use disorder
BD: Bipolar disorders
CBT: Cognitive behavioural therapy
CD: Conduct Disorder
CM: Contingency management
CUD: Cannabis use disorder
DBT: Dialectical Behaviour Therapy
LAS: Long-acting psychostimulant medications
MI: Motivational interviewing
MDD: Major depressive disorder
NA: Narcotics Anonymous
NMU: Non-medical use [of prescription medication]
OAT: Opioid Agonist Treatment/Therapy
ODD: Oppositional defiant disorder
OUD: Opioid use disorder
PFC: Prefrontal cortex
PTSD: Post-traumatic stress disorder
RCT: Randomized Control Trial
SBIRT: Screening, brief intervention and referral to treatment
SES: Socio-economic status
SMART: Self-Management And Recovery Training
SU: Substance use
SUD: Substance use disorder
UDS: Urine drug screening