How to Deprescribe Stimulants

A first-ever consensus on deprescribing ADHD medications

STUDY: Goodman DW et al, European Neuropsychopharmacology 2026;111:112863

STUDY TYPE: Expert consensus statement

FUNDING: Independent

Background

Stimulants gained approval for adult ADHD in 2004, but the diagnosis is difficult to make in adults. Most research is focused on children, and many adult disorders cause cognitive problems that have broad overlap with ADHD (eg, sleep apnea, temperamental differences, cognitive problems from psychiatric disorders, insomnia, cannabis or other drug use).

More than 1 in 5 adults prescribed stimulants misuse them, and 1 in 6 divert them. These guidelines, from the American Society of Clinical Psychopharmacology, focus on deprescribing stimulants in adult ADHD.

The Process

• Task force of 45 international psychopharmacology experts from 12 countries.
• Using a two-round Delphi survey, panelists rated 11 statements about when stimulants warrant deprescribing.
• Consensus required at least 75% agreement.

When to Deprescribe

Ten of 11 statements reached consensus. The panel agreed that stimulants warrant deprescribing when:

• The ADHD diagnosis turns out to be incorrect
• Cognitive complaints have a better explanation than ADHD
• The medication isn’t helping
• It worsens a psychiatric or medical condition
• Side effects can’t be managed
• The patient is misusing it (taking more than prescribed, taking for performance enhancement rather than treating a problem, or diverting it)
• A comorbid substance use disorder is untreated

The panel also agreed there’s no evidence base for prescribing two stimulants from different classes simultaneously and recommends deprescribing one of them if that happens (eg, amphetamine plus methylphenidate; indeed Wikipedia claims they counteract each other but I can’t find evidence for that, and there are no clinical trials of using the two together).

When to Lower the Dose

The guidelines didn’t cover a common presentation: Patients on ultra-high stimulant doses. Here’s a new study on max doses, and these may be even lower in the elderly (mean daily dose of dextroamphetamine 9.4 mg, methylphenidate ER 26.8 mg).

Cannabis and Stimulants

The one statement that fell just short of consensus: that regular cannabis use alone is not enough reason to deprescribe. Seventy-one percent agreed; close, but not over the bar. Here’s what they recommend:

1. Document frequency, quantity, route of administration, and stated motivation for cannabis use at baseline
2. Obtain validated ADHD symptom measures (e.g., the ASRS), input from independent informants, and assessments of functional outcomes, and screen for cannabis use disorder using DSM-5-TR criteria.
3. Refer for substance use treatment if use reaches threshold of cannabis use disorder
4. Educate the patient about how cannabis causes symptoms of ADHD and impedes stimulant benefits (meds have failed to treat ADHD in all trials of ADHD with cannabis use disorder). Aim for a collaborative trial of cannabis reduction or cessation.
5. Serial reassessment every 1–3 months, focusing on functioning and seeking objective input on that beyond self-report.
6. Random urine drug screens.
7. If cannabis is blocking or reducing the benefits of stimulants, consider deprescribing or a non-stimulant alternative.

See our Carlat Interview with Sara Polley, MD for more guidance on this area.

How to Taper

The guidelines do not cover tapering schedules, citing a lack of evidence. They recommend a gradual, personalized taper. During the taper, emphasize

1. Sleep hygiene
2. Physical activity
3. Structured behavioral strategies support executive functioning (they don’t say what, but here are some ideas)

I monitor with the ASRS during stimulant tapers, and here’s a pearl. When patients are on inappropriate stimulants or ultra-high doses, this self-rated scale often improves even as we lower the dose. Why? Stimulants are not universal cognitive enhancers. They also worsen cognition, disrupting sleep, and in high doses cause perseveration, self-doubt, lack of spontaneity, and difficulty shifting tasks.

Here’s a review of withdrawal from ADHD meds.

Practice Implications

1. Some solid guidance here. I’ll add another reason to deprescribe: 30% of ADHD resolves in adulthood (another 30% improves but does not resolve).
2. To aid accurate diagnosis, I’ve created a free structured interview for ADHD that also looks for other causes of cognitive problems.
3. Learn more about cognitive problems that mimic ADHD in our Carlat interview with Thomas Gualtieri, MD.

— Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

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