Demographic and Clinical Predictors of Attention-deficit/Hyperactivity Disorder Treatment Among Youth and Adults With Co-occurring Substance Use Disorder

Objectives: This study examined sociodemographic and clinical factors associated with attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy receipt in youth and adults with co-occurring ADHD and substance use disorder (SUD). Methods: This retrospective cohort study analyzed the TriNetX US Collaborative Network (2008–2025). Among 2,219,248 patients aged 15–65 with ADHD, 529,550 had co-occurring SUD. ADHD medication prescribing was assessed within one year of diagnosis and stratified by sociodemographic variables and SUD type. Propensity score matching was used for relative risk analyses; Cox proportional hazards models identified predictors of medication receipt. Results: Patients with ADHD and SUD were older and had more psychiatric comorbidities than those with ADHD only. CNS stimulants were prescribed less frequently in patients with SUD than in those without—amphetamines (RR: 0.73, 95% CI: 0.73–0.73) and methylphenidate (RR: 0.62, 95% CI: 0.62–0.63)—and this pattern persisted across subgroups. Nonstimulant prescribing was less affected, with higher rates among adolescents and those with stimulant, opioid, or cocaine-use disorders. Black patients experienced nearly double the SUD-associated reduction in stimulant prescribing compared with white patients. Psychotic disorders were associated with a lower hazard of receiving both medication classes, anxiety disorders with a higher hazard of either class, and mood disorders with a lower stimulant but higher nonstimulant hazard. Conclusions: Concurrent SUD was associated with lower CNS stimulant prescribing across sociodemographic and clinical factors, with disproportionate reductions among minoritized patients and those with psychiatric comorbidities, while nonstimulant prescribing was comparatively less affected. These findings underscore the need for guideline updates and structural reforms to promote equitable treatment.