Why Is Alcohol Riskier in ADHD? Impulsivity and Self-Medication

The hardest thing about writing this article was finding the tone. Every text about alcohol either frightens or brushes the subject aside; both leave the reader alone.

What made me take this subject seriously was this: when I learned that there is a concept called self-medication, I recognized its logic in my own everyday movements. When I cannot start a job and get up and go to the kitchen, when I reach for my phone in the middle of a hard day, all of it says the same sentence: trying to fix the setting inside with something from outside. This is the job alcohol does too; only the price is much heavier.

It is reported that substance use problems are seen more often in adults with ADHD than in the general population (Faraone et al., 2021; Katzman et al., 2017). The other direction of the relationship has been measured as well: in the meta-analysis by van Emmerik-van Oortmerssen and colleagues (2012), the prevalence of ADHD among patients with a substance use disorder who were seeking treatment was found to be 23.1 percent on average. That is, about one in every four people who come to a clinic with a substance use problem has ADHD.

This information is not for blaming; it is for making the risk visible. It also shows something else: if ADHD is never asked about in a place that deals with the substance side, an untreated picture may be left where it is.

Two mechanisms

1. Impulsivity.

Alcohol is something that requires limiting the amount. A picture that makes it hard to say stop comes into play right here.

There is also a second layer: alcohol itself weakens inhibition. So the brake that was already weak gets weaker with alcohol. This is a circular effect.

2. Self-medication.

This is the mechanism that is talked about less but is more widespread. In the glossary it appears as self-medication.

In the short term alcohol does several things at once:

• It quiets inner restlessness
• It reduces the noise in the mind
• It lowers anxiety in social settings
• It feels as if it makes falling asleep easier

All of these are areas in which people with ADHD struggle. So alcohol seems to really do something useful, and that is exactly why it is dangerous.

That something works in the short term makes it the hardest thing to give up.

The matter of sleep

This is the most concrete and least known harm.

Alcohol makes falling asleep easier but disrupts the structure of sleep: in the second half of the night sleep becomes shallow and stops being restful.

The review by Kooij and Bijlenga (2013) shows that a delayed sleep phase is already common in adult ADHD. So when alcohol is added on top, two problems combine.

The next day all the symptoms get heavier: attention, emotion regulation, impulsivity. And on that day too, something is needed to cope with the tiredness.

The cycle works like this:

1. Restlessness or sleeplessness
2. Alcohol
3. Disrupted sleep
4. Heavier symptoms the next day
5. Back to the start

Does treatment increase the risk

No, and this is an important correction.

The meta-analysis by Wilens and colleagues (2003) did not find that receiving stimulant treatment in childhood leads to substance abuse later on.

The consensus statement of the World Federation (Faraone et al., 2021) likewise states that there is no evidence that the risk of substance use is increased in people who are treated.

On the contrary, going untreated is counted among the risk factors. I covered the details in the article on whether ADHD medications are addictive.

What can be done

Decide the amount beforehand. The decision is one you cannot make once you have started drinking. Deciding before you leave how many glasses you will have is much more reliable than deciding in the moment.

Make it countable. From a glass, not from the bottle; counted, not topped up.

Ask why you are drinking. For pleasure, or to quiet something? The second answer is a warning sign, and that thing may have another solution.

Do not use it for sleep. This is the most expensive way to use it. If you have a sleep problem, tell your doctor; there are other ways.

If you take medication, tell your doctor. You need to tell them about your alcohol consumption and the amount. This is not a confession; it is information needed to plan the treatment correctly.

Keep a non-alcoholic alternative at hand. Having something in your hand in a social setting makes it easier not to drink.

When to ask for help. If you struggle to limit how much you drink, if you feel restless on the days you do not drink, if you have tried to stop and it did not work, or if your close ones say they are worried, talk about it with a specialist. This may not be something to be solved by willpower, and it has treatment. In an emergency in Türkiye you can reach the 112 emergency call center, and you can ask for a referral from the ALO 183 Social Support Line.

Nicotine and the others

The same pattern is seen with nicotine, and it is reported that smoking is more common in ADHD. The mechanism is similar: nicotine briefly gives a feeling of alertness and focus. I wrote the details in the article on ADHD and smoking.

Caffeine is the most harmless end of the same family; I covered it in the article on why coffee calms you in ADHD.

The social settings side

There is a part that is talked about little: for many people with ADHD, the appeal of alcohol comes less from its taste than from its making the social setting bearable.

Following the conversations at a crowded table, guessing when your turn is coming, reading how what you said is received are already tiring jobs. Alcohol lifts part of this load temporarily. For me the name of this load is social battery, and after a point it runs out.

Knowing this changes something concrete: if the reason for drinking is the setting itself, the place to work on stops being the amount and becomes the setting. A smaller table, a shorter time, a leaving hour decided in advance. For me the sum of these three settings is exactly what determines how long I can last that evening.

The common mistake

The most common mistake is trying to make the decision in the setting. The decision "I'll drink little today" is the hardest decision to make in that setting and at that hour, because the system that has to make the decision is exactly the system alcohol weakens.

The second is trying to solve sleep with alcohol. Because it works in the short term, this is the harm that goes unnoticed the longest.

The third is never talking about the ADHD side. A person trying to cut down on alcohol who does not know how much of her restlessness comes from withdrawal and how much from a picture that was already there reaches the wrong conclusion.

What remains

The alcohol risk in ADHD comes from two places: impulsivity making it hard to limit the amount, and alcohol really quieting something.

Its effect on sleep is the most concrete harm and it worsens all the symptoms of the next day.

Treatment does not increase this risk; going untreated does. The decision on diagnosis and treatment is the doctor's job, but deciding to talk about this subject with a doctor is in your hands, and you do not need to wait for the picture to get heavier for it.