People receiving treatment for opioid use disorder sometimes also need medications for other conditions like ADHD. But do stimulant medications increase the risk of overdose? This study explored whether individuals taking prescribed stimulants alongside medications for opioid use disorder face greater risks.
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In recent years, overdose deaths in North America involving both opioids and stimulants — such as methamphetamine or cocaine — have increased substantially. Many of these deaths are believed to be driven by the unregulated drug supply, where unpredictable potency and contamination — especially with fentanyl — make co-use particularly dangerous. In addition, the presence of a stimulant can “mask” the sedating effects of opioids, which can lead to more opioid use, increasing overdose risk. The opposing stimulant and opioid effects on the heart can substantially increase risk for cardiac distress. This co-use pattern has raised pressing clinical questions: specifically, whether it is safe — or potentially harmful — to prescribe stimulant medications, such as amphetamine or methylphenidate (sometimes referred to by their brand names Adderall and Ritalin, which are often used to treat attention-deficit/hyperactivity disorder or ADHD), to individuals who are already receiving medications for opioid use disorder (e.g., methadone or buprenorphine).
While non-prescribed stimulant use (e.g., methamphetamine or cocaine) in combination with opioids is clearly associated with a heightened risk of overdose, less is known about the safety of prescribed stimulant medications for patients taking medications to treat opioid use disorder. Importantly, some people receiving medications for opioid use disorder, like buprenorphine or methadone, also have co-occurring conditions like ADHD, for which stimulants are a first-line treatment. In these cases, clinicians must carefully balance the potential benefits of addressing ADHD symptoms — such as improved focus and treatment retention — with the possibility of increased overdose risk. Without clear evidence, prescribers are often left in a gray area when making these decisions.
This study directly addresses this real-world clinical question. Using a large, population-level dataset from British Columbia, Canada, the researchers examined whether individuals prescribed stimulant medications while receiving medications for opioid use disorder were at greater risk for experiencing a fatal or non-fatal overdose. Their findings may help inform safer, evidence-based prescribing decisions for a high-risk population navigating multiple layers of vulnerability.
This was a retrospective cohort study using health records from British Columbia, Canada, to examine whether prescribed stimulant medications are linked to overdose risk among individuals receiving medications for opioid use disorder. Researchers looked at 9,395 individuals who were receiving 1 of 3 agonist medications for opioid use disorder: methadone, buprenorphine/naloxone (also known by the brand name Suboxone), or slow-release oral morphine (a legally prescribed opioid use disorder medication in Canada). These individuals were followed between January 2015 and February 2020. The main outcome the researchers tracked was whether someone experienced an overdose — either fatal or non-fatal — during the study period. They also looked at whether people were prescribed stimulant medications like methylphenidate or amphetamines during this time. Because the study used government-linked records, the researchers could see both prescriptions filled and health care events, like hospital visits or overdose reports, across multiple systems.
Importantly, the study focused only on stimulant medications that were prescribed by a doctor and dispensed by a pharmacy. These medications are often used to treat conditions like attention-deficit/hyperactivity disorder (ADHD). The researchers did not include use of non-prescribed stimulants, such as cocaine or methamphetamine, which are already known to increase overdose risk when used with opioids.
To understand how stimulant prescriptions related to overdose, the researchers tracked overdose events over time and compared periods when individuals were and weren’t prescribed stimulants. They also considered many other factors that could affect overdose risk, including age, sex, geographic location, treatment engagement (i.e., number of physician visits), other mental health disorder diagnoses, and whether people were prescribed other medications at the same time, such as benzodiazepines. Such statistical adjustments help to isolate the effect of interest – i.e., whether stimulant prescriptions are independently related to overdose among those prescribed an opioid use disorder medication.
Finally, the researchers looked at whether the type of medication used to treat opioid use disorder made a difference. They compared individuals taking buprenorphine/naloxone with those taking methadone or slow-release oral morphine to see if the relationship between stimulant prescriptions and overdose changed depending on whether the prescription was for the partial agonist buprenorphine or one of the full agonists, the latter of which are associated with greater risks (e.g., for accidental overdose).
This approach allowed the researchers to examine a timely and complex clinical question — whether prescribed stimulants are helpful, harmful, or neutral for people already receiving medications for opioid use disorder — and to do so in a way that reflects what is happening in the real world.
Overdose risk differed by type of opioid medication
For individuals taking buprenorphine/naloxone, being prescribed a stimulant medication was linked to a 53% reduced risk of overdose. In contrast, for individuals taking methadone or slow-release oral morphine, being prescribed a stimulant medication was linked to a 51% increased risk of overdose.
Overdose events were uncommon but still present
Out of 1,746 total overdoses during the study period, only 37 were fatal. While the risk of overdose was relatively low overall, it remains a serious concern for individuals receiving treatment for opioid use disorder, particularly those also managing other health needs with medications like stimulants.
These findings suggest that for individuals taking buprenorphine/naloxone, prescribed stimulants were linked to a lower risk of overdose. In contrast, for those taking full opioid agonists such as methadone or slow-release oral morphine, stimulant prescriptions were associated with higher overdose risk. For individuals taking buprenorphine, they had a higher proportion of individuals with ADHD than those taking methadone. Therefore, as a group, they may benefit more from a stimulant medication which could further reduce overdose risk by better treating ADHD among those receiving buprenorphine/naloxone. For example, enhancing cognitive control and reducing impulsivity among those with co-occurring opioid use disorder and ADHD may help improve on buprenorphine/naloxone’s benefit on overdose risk reduction. While the analyses controlled statistically for ADHD, adjustments like these are not perfect controls for factors that account for the correlation between ADHD diagnosis and buprenorphine prescription when predicting overdose.
For individuals taking methadone, the stimulant medication may mask sedative effects of methadone and lead people to use more methadone or other opioids that result in overdose. It is also possible that their increased risk is due to their more complex clinical and social profiles than those prescribed buprenorphine and a stimulant, including higher rates of mental health diagnoses and recent income assistance — factors that may both independently increase overdose risk and exacerbate the risks from a full agonist like methadone. While this study did not examine methadone versus buprenorphine without stimulant prescription on overdose risk, the full agonist methadone has greater risks for overdose than the partial-agonist formulation of buprenorphine/naloxone in part because the latter contains the anti-overdose opioid antagonist, naloxone, which is activated if the medication is misused (e.g., injected or snorted).
These findings highlight an area where further research is needed — studies that examine why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
In this large retrospective cohort study of individuals receiving medications for opioid use disorder in British Columbia, prescribed stimulant medications were associated with different levels of overdose risk depending on medication type. For those taking the partial agonist buprenorphine/naloxone, stimulant prescriptions were linked to a 53% lower risk of overdose. For those taking full opioid agonists like methadone or slow-release oral morphine, stimulant prescriptions were linked to a 51% higher risk. It is possible that for buprenorphine/naloxone patients, stimulant medications reduce overdose risk by better treating ADHD. For methadone patients, stimulant medications may mask the typical sedating effects of their opioid medication, leading them to take more methadone than prescribed or other opioids. More research is needed to understand why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
Young, S., Fairbairn, N., Cui, Z., Bach, P., Mok, W. Y., Budau, J., Slaunwhite, A., Ti, L., Hayashi, K., & Nolan, S. (2025). Association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy: A retrospective cohort study from British Columbia, Canada. Addiction, 120(6), 1184-1194. doi: 10.1111/add.16760.
l
In recent years, overdose deaths in North America involving both opioids and stimulants — such as methamphetamine or cocaine — have increased substantially. Many of these deaths are believed to be driven by the unregulated drug supply, where unpredictable potency and contamination — especially with fentanyl — make co-use particularly dangerous. In addition, the presence of a stimulant can “mask” the sedating effects of opioids, which can lead to more opioid use, increasing overdose risk. The opposing stimulant and opioid effects on the heart can substantially increase risk for cardiac distress. This co-use pattern has raised pressing clinical questions: specifically, whether it is safe — or potentially harmful — to prescribe stimulant medications, such as amphetamine or methylphenidate (sometimes referred to by their brand names Adderall and Ritalin, which are often used to treat attention-deficit/hyperactivity disorder or ADHD), to individuals who are already receiving medications for opioid use disorder (e.g., methadone or buprenorphine).
While non-prescribed stimulant use (e.g., methamphetamine or cocaine) in combination with opioids is clearly associated with a heightened risk of overdose, less is known about the safety of prescribed stimulant medications for patients taking medications to treat opioid use disorder. Importantly, some people receiving medications for opioid use disorder, like buprenorphine or methadone, also have co-occurring conditions like ADHD, for which stimulants are a first-line treatment. In these cases, clinicians must carefully balance the potential benefits of addressing ADHD symptoms — such as improved focus and treatment retention — with the possibility of increased overdose risk. Without clear evidence, prescribers are often left in a gray area when making these decisions.
This study directly addresses this real-world clinical question. Using a large, population-level dataset from British Columbia, Canada, the researchers examined whether individuals prescribed stimulant medications while receiving medications for opioid use disorder were at greater risk for experiencing a fatal or non-fatal overdose. Their findings may help inform safer, evidence-based prescribing decisions for a high-risk population navigating multiple layers of vulnerability.
This was a retrospective cohort study using health records from British Columbia, Canada, to examine whether prescribed stimulant medications are linked to overdose risk among individuals receiving medications for opioid use disorder. Researchers looked at 9,395 individuals who were receiving 1 of 3 agonist medications for opioid use disorder: methadone, buprenorphine/naloxone (also known by the brand name Suboxone), or slow-release oral morphine (a legally prescribed opioid use disorder medication in Canada). These individuals were followed between January 2015 and February 2020. The main outcome the researchers tracked was whether someone experienced an overdose — either fatal or non-fatal — during the study period. They also looked at whether people were prescribed stimulant medications like methylphenidate or amphetamines during this time. Because the study used government-linked records, the researchers could see both prescriptions filled and health care events, like hospital visits or overdose reports, across multiple systems.
Importantly, the study focused only on stimulant medications that were prescribed by a doctor and dispensed by a pharmacy. These medications are often used to treat conditions like attention-deficit/hyperactivity disorder (ADHD). The researchers did not include use of non-prescribed stimulants, such as cocaine or methamphetamine, which are already known to increase overdose risk when used with opioids.
To understand how stimulant prescriptions related to overdose, the researchers tracked overdose events over time and compared periods when individuals were and weren’t prescribed stimulants. They also considered many other factors that could affect overdose risk, including age, sex, geographic location, treatment engagement (i.e., number of physician visits), other mental health disorder diagnoses, and whether people were prescribed other medications at the same time, such as benzodiazepines. Such statistical adjustments help to isolate the effect of interest – i.e., whether stimulant prescriptions are independently related to overdose among those prescribed an opioid use disorder medication.
Finally, the researchers looked at whether the type of medication used to treat opioid use disorder made a difference. They compared individuals taking buprenorphine/naloxone with those taking methadone or slow-release oral morphine to see if the relationship between stimulant prescriptions and overdose changed depending on whether the prescription was for the partial agonist buprenorphine or one of the full agonists, the latter of which are associated with greater risks (e.g., for accidental overdose).
This approach allowed the researchers to examine a timely and complex clinical question — whether prescribed stimulants are helpful, harmful, or neutral for people already receiving medications for opioid use disorder — and to do so in a way that reflects what is happening in the real world.
Overdose risk differed by type of opioid medication
For individuals taking buprenorphine/naloxone, being prescribed a stimulant medication was linked to a 53% reduced risk of overdose. In contrast, for individuals taking methadone or slow-release oral morphine, being prescribed a stimulant medication was linked to a 51% increased risk of overdose.
Overdose events were uncommon but still present
Out of 1,746 total overdoses during the study period, only 37 were fatal. While the risk of overdose was relatively low overall, it remains a serious concern for individuals receiving treatment for opioid use disorder, particularly those also managing other health needs with medications like stimulants.
These findings suggest that for individuals taking buprenorphine/naloxone, prescribed stimulants were linked to a lower risk of overdose. In contrast, for those taking full opioid agonists such as methadone or slow-release oral morphine, stimulant prescriptions were associated with higher overdose risk. For individuals taking buprenorphine, they had a higher proportion of individuals with ADHD than those taking methadone. Therefore, as a group, they may benefit more from a stimulant medication which could further reduce overdose risk by better treating ADHD among those receiving buprenorphine/naloxone. For example, enhancing cognitive control and reducing impulsivity among those with co-occurring opioid use disorder and ADHD may help improve on buprenorphine/naloxone’s benefit on overdose risk reduction. While the analyses controlled statistically for ADHD, adjustments like these are not perfect controls for factors that account for the correlation between ADHD diagnosis and buprenorphine prescription when predicting overdose.
For individuals taking methadone, the stimulant medication may mask sedative effects of methadone and lead people to use more methadone or other opioids that result in overdose. It is also possible that their increased risk is due to their more complex clinical and social profiles than those prescribed buprenorphine and a stimulant, including higher rates of mental health diagnoses and recent income assistance — factors that may both independently increase overdose risk and exacerbate the risks from a full agonist like methadone. While this study did not examine methadone versus buprenorphine without stimulant prescription on overdose risk, the full agonist methadone has greater risks for overdose than the partial-agonist formulation of buprenorphine/naloxone in part because the latter contains the anti-overdose opioid antagonist, naloxone, which is activated if the medication is misused (e.g., injected or snorted).
These findings highlight an area where further research is needed — studies that examine why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
In this large retrospective cohort study of individuals receiving medications for opioid use disorder in British Columbia, prescribed stimulant medications were associated with different levels of overdose risk depending on medication type. For those taking the partial agonist buprenorphine/naloxone, stimulant prescriptions were linked to a 53% lower risk of overdose. For those taking full opioid agonists like methadone or slow-release oral morphine, stimulant prescriptions were linked to a 51% higher risk. It is possible that for buprenorphine/naloxone patients, stimulant medications reduce overdose risk by better treating ADHD. For methadone patients, stimulant medications may mask the typical sedating effects of their opioid medication, leading them to take more methadone than prescribed or other opioids. More research is needed to understand why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
Young, S., Fairbairn, N., Cui, Z., Bach, P., Mok, W. Y., Budau, J., Slaunwhite, A., Ti, L., Hayashi, K., & Nolan, S. (2025). Association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy: A retrospective cohort study from British Columbia, Canada. Addiction, 120(6), 1184-1194. doi: 10.1111/add.16760.
l
In recent years, overdose deaths in North America involving both opioids and stimulants — such as methamphetamine or cocaine — have increased substantially. Many of these deaths are believed to be driven by the unregulated drug supply, where unpredictable potency and contamination — especially with fentanyl — make co-use particularly dangerous. In addition, the presence of a stimulant can “mask” the sedating effects of opioids, which can lead to more opioid use, increasing overdose risk. The opposing stimulant and opioid effects on the heart can substantially increase risk for cardiac distress. This co-use pattern has raised pressing clinical questions: specifically, whether it is safe — or potentially harmful — to prescribe stimulant medications, such as amphetamine or methylphenidate (sometimes referred to by their brand names Adderall and Ritalin, which are often used to treat attention-deficit/hyperactivity disorder or ADHD), to individuals who are already receiving medications for opioid use disorder (e.g., methadone or buprenorphine).
While non-prescribed stimulant use (e.g., methamphetamine or cocaine) in combination with opioids is clearly associated with a heightened risk of overdose, less is known about the safety of prescribed stimulant medications for patients taking medications to treat opioid use disorder. Importantly, some people receiving medications for opioid use disorder, like buprenorphine or methadone, also have co-occurring conditions like ADHD, for which stimulants are a first-line treatment. In these cases, clinicians must carefully balance the potential benefits of addressing ADHD symptoms — such as improved focus and treatment retention — with the possibility of increased overdose risk. Without clear evidence, prescribers are often left in a gray area when making these decisions.
This study directly addresses this real-world clinical question. Using a large, population-level dataset from British Columbia, Canada, the researchers examined whether individuals prescribed stimulant medications while receiving medications for opioid use disorder were at greater risk for experiencing a fatal or non-fatal overdose. Their findings may help inform safer, evidence-based prescribing decisions for a high-risk population navigating multiple layers of vulnerability.
This was a retrospective cohort study using health records from British Columbia, Canada, to examine whether prescribed stimulant medications are linked to overdose risk among individuals receiving medications for opioid use disorder. Researchers looked at 9,395 individuals who were receiving 1 of 3 agonist medications for opioid use disorder: methadone, buprenorphine/naloxone (also known by the brand name Suboxone), or slow-release oral morphine (a legally prescribed opioid use disorder medication in Canada). These individuals were followed between January 2015 and February 2020. The main outcome the researchers tracked was whether someone experienced an overdose — either fatal or non-fatal — during the study period. They also looked at whether people were prescribed stimulant medications like methylphenidate or amphetamines during this time. Because the study used government-linked records, the researchers could see both prescriptions filled and health care events, like hospital visits or overdose reports, across multiple systems.
Importantly, the study focused only on stimulant medications that were prescribed by a doctor and dispensed by a pharmacy. These medications are often used to treat conditions like attention-deficit/hyperactivity disorder (ADHD). The researchers did not include use of non-prescribed stimulants, such as cocaine or methamphetamine, which are already known to increase overdose risk when used with opioids.
To understand how stimulant prescriptions related to overdose, the researchers tracked overdose events over time and compared periods when individuals were and weren’t prescribed stimulants. They also considered many other factors that could affect overdose risk, including age, sex, geographic location, treatment engagement (i.e., number of physician visits), other mental health disorder diagnoses, and whether people were prescribed other medications at the same time, such as benzodiazepines. Such statistical adjustments help to isolate the effect of interest – i.e., whether stimulant prescriptions are independently related to overdose among those prescribed an opioid use disorder medication.
Finally, the researchers looked at whether the type of medication used to treat opioid use disorder made a difference. They compared individuals taking buprenorphine/naloxone with those taking methadone or slow-release oral morphine to see if the relationship between stimulant prescriptions and overdose changed depending on whether the prescription was for the partial agonist buprenorphine or one of the full agonists, the latter of which are associated with greater risks (e.g., for accidental overdose).
This approach allowed the researchers to examine a timely and complex clinical question — whether prescribed stimulants are helpful, harmful, or neutral for people already receiving medications for opioid use disorder — and to do so in a way that reflects what is happening in the real world.
Overdose risk differed by type of opioid medication
For individuals taking buprenorphine/naloxone, being prescribed a stimulant medication was linked to a 53% reduced risk of overdose. In contrast, for individuals taking methadone or slow-release oral morphine, being prescribed a stimulant medication was linked to a 51% increased risk of overdose.
Overdose events were uncommon but still present
Out of 1,746 total overdoses during the study period, only 37 were fatal. While the risk of overdose was relatively low overall, it remains a serious concern for individuals receiving treatment for opioid use disorder, particularly those also managing other health needs with medications like stimulants.
These findings suggest that for individuals taking buprenorphine/naloxone, prescribed stimulants were linked to a lower risk of overdose. In contrast, for those taking full opioid agonists such as methadone or slow-release oral morphine, stimulant prescriptions were associated with higher overdose risk. For individuals taking buprenorphine, they had a higher proportion of individuals with ADHD than those taking methadone. Therefore, as a group, they may benefit more from a stimulant medication which could further reduce overdose risk by better treating ADHD among those receiving buprenorphine/naloxone. For example, enhancing cognitive control and reducing impulsivity among those with co-occurring opioid use disorder and ADHD may help improve on buprenorphine/naloxone’s benefit on overdose risk reduction. While the analyses controlled statistically for ADHD, adjustments like these are not perfect controls for factors that account for the correlation between ADHD diagnosis and buprenorphine prescription when predicting overdose.
For individuals taking methadone, the stimulant medication may mask sedative effects of methadone and lead people to use more methadone or other opioids that result in overdose. It is also possible that their increased risk is due to their more complex clinical and social profiles than those prescribed buprenorphine and a stimulant, including higher rates of mental health diagnoses and recent income assistance — factors that may both independently increase overdose risk and exacerbate the risks from a full agonist like methadone. While this study did not examine methadone versus buprenorphine without stimulant prescription on overdose risk, the full agonist methadone has greater risks for overdose than the partial-agonist formulation of buprenorphine/naloxone in part because the latter contains the anti-overdose opioid antagonist, naloxone, which is activated if the medication is misused (e.g., injected or snorted).
These findings highlight an area where further research is needed — studies that examine why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
In this large retrospective cohort study of individuals receiving medications for opioid use disorder in British Columbia, prescribed stimulant medications were associated with different levels of overdose risk depending on medication type. For those taking the partial agonist buprenorphine/naloxone, stimulant prescriptions were linked to a 53% lower risk of overdose. For those taking full opioid agonists like methadone or slow-release oral morphine, stimulant prescriptions were linked to a 51% higher risk. It is possible that for buprenorphine/naloxone patients, stimulant medications reduce overdose risk by better treating ADHD. For methadone patients, stimulant medications may mask the typical sedating effects of their opioid medication, leading them to take more methadone than prescribed or other opioids. More research is needed to understand why stimulant medications may carry different risks depending on treatment needs or the opioid medication used — to inform safer, more tailored prescribing practices.
Young, S., Fairbairn, N., Cui, Z., Bach, P., Mok, W. Y., Budau, J., Slaunwhite, A., Ti, L., Hayashi, K., & Nolan, S. (2025). Association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy: A retrospective cohort study from British Columbia, Canada. Addiction, 120(6), 1184-1194. doi: 10.1111/add.16760.
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