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Heroin Addiction and Related Clinical Problems: 2026, 28: 209-214

Applying the opioid agonist treatment model to cocaine use disorder with comorbid ADHD and bipolar disorder

Alessandro Pallucchini, Filippo Della Rocca, Manuel Glauco Carbone, Silvia Bacciardi, Matteo Pacini, and Angelo Giovanni Icro Maremmani

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2026-23

Summary: Background: The opioid agonist treatment model provides a clinical rationale for investigating maintenance treatment with prescribed psychostimulants in cocaine use disorder (CUD). Its application to cocaine requires consideration of different pharmacological mechanisms and a substantially less established evidence base. Comorbid attention-deficit/hyperactivity disorder (ADHD) may provide an additional treatment indication. Case presentation: A 34-year-old man with ADHD, severe CUD and a diagnosis of bipolar disorder reported that cocaine initially reduced anxiety and improved attention and organisation. Oral modified-release methylphenidate was introduced during ongoing cocaine use and titrated from 20 to 40 mg/day. Clinical observations and patient reports indicated initial improvements in daily functioning, reduced cocaine use and less gambling. Craving and restlessness subsequently recurred in the evening, followed by worsening mood, renewed cocaine use and gambling, voluntary treatment discontinuation and loss to follow-up. Discussion: The initial response was not consolidated into sustained clinical stabilisation. Incomplete daily coverage, the dose achieved, treatment adherence and mood instability are relevant considerations, although their respective contributions cannot be established. Improvement in ADHD symptoms cannot be separated from a direct effect on CUD. Conclusions: This case illustrates the clinical rationale and limitations of applying maintenance-treatment principles derived from opioid agonist treatment to CUD with ADHD and bipolar comorbidity. It supports investigation of individualised exposure, continuity of care and concurrent management of psychiatric comorbidity, rather than establishing methylphenidate efficacy or a minimum effective dose for CUD.

Keywords: Cocaine Use Disorder; Methylphenidate; Psychostimulant Maintenance Treatment; Opioid Agonist Treatment; Adhd; Bipolar Disorder; Dual Disorder