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:
- Document frequency, quantity, route of administration, and stated motivation for cannabis use at baseline
- 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.
- Refer for substance use treatment if use reaches threshold of cannabis use disorder
- 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.
- Serial reassessment every 1–3 months, focusing on functioning and seeking objective input on that beyond self-report.
- Random urine drug screens.
- 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
- Sleep hygiene
- Physical activity
- 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
- Some solid guidance here. I’ll add another reason to deprescribe: 30% of ADHD resolves in adulthood (source: Van Meter and Farone). Symptoms improve in adulthood, but do not resolve, for 40-60%.
- To aid accurate diagnosis, I’ve created a free structured interview for ADHD that also screens for other causes of cognitive problems.
- 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
2 comments
K Kilgore
May 24, 2026 at 12:19 pm
“More than 1 in 5 adults prescribed stimulants misuse them, and 1 in 6 divert them.”
Source?
“Some solid guidance here. I’ll add another reason to deprescribe: 30% of ADHD resolves in adulthood (another 30% improves but does not resolve).”
Again — source?
By the way, the Conflict of Interests statement on this consensus is a mile long.
Are you the same Dr. Chris Aiken whose patient form for “Agreement on the Use of Controlled Substances” states:
“Are stimulant medicines addictive?
When taken as prescribed to treat the
symptoms of ADHD, stimulants are not
addictive. People with ADHD rarely abuse
stimulants, and in fact treatment lowers their
rates of substance abuse. However, misuse of
stimulants can lead to addiction.”
I don’t see when this form was published, but what has changed between then and now?
I notice your website has a section on supplements which includes this misleading statement: “Supplements can be just as powerful, and just as risky, as meds. The difference is more legal than scientific.”
The “risky” part is right. But your statement very clearly suggests that supplements can work as well as prescription medications, which is both very broad, and in most contexts, very untrue. No studies have found any supplements to be nearly as effective as prescription medications for conditions like ADHD, autism, and depression.
I don’t know who is paying you to change your tune, or whether you’ve always held these views but denied them in the paperwork you use with patients so that they will want to take medication from you, increasing your profits. But it’s “psychiatrists” like you (and some admittedly much worse than you) who muddle and oversimplify the picture of psychiatric medications, their risks, and their effectiveness.
Jump off of RFK’s bandwagon. You all need to refuse advice and guidelines from a man who doesn’t even have a medical degree and who makes unsupported and even debunked health claims on a regular basis.
Chris Aiken, MD
May 24, 2026 at 3:07 pm
Thank you – I’ve updated the post to link those references. To clarify: The aim of this blog is to make research available to the public, so you will find studies here that you agree with and some you don’t, but none are sponsored (I’ve never accepted industry funding). Regarding supplements, some are more dangerous than average meds (Kava kava), some are more effective (lavender oil beat paroxetine in anxiety), and some treat disorders where medications fail.