Commentary on Stockings et al. (2019): The global amphetamine epidemic-a rising tide of mortality.

Abstract

Amphetamine use disorders are an unrelenting cause of global public health crises. People with regular or dependent amphetamine use are at elevated risk of a range of causes of mortality relative to non-users. As such, interventions to reduce the risks of overdose, suicide and traumatic deaths in this population are clearly warranted—and not yet available. Globally, amphetamine use disorders are an unrelenting cause for public health crises 1. A recent, comprehensive meta-analysis by Stockings and colleagues 2 arrived at an important conclusion: that people with regular or dependent amphetamine use are at elevated risk of a range of causes of mortality—drug poisoning, cardiovascular disease, suicide, accidental injury and homicide—compared with people without regular or dependent amphetamine use. Amphetamine-type stimulants include all substances with a substituted phenylethylamine structure—such as amphetamine, dextroamphetamine and methamphetamine 3—as well as synthetic analogues, including natural cathinones—such as khat—and synthetic cathinones (or ‘bath salts’) 4. While amphetamines are frequently prescribed for the treatment of obesity, attention-deficit/hyperactivity disorder and narcolepsy, prescribed stimulants are often diverted into the illegal market. In the United States, the estimated 12-month prevalence of amphetamine-type stimulant use disorder is 0.2% across all age groups 3. Rates are similar among adult males and females; however, intravenous stimulant use has a male-to-female ratio of 4 : 1 3. Individuals who are exposed to amphetamines can develop amphetamine use disorder as rapidly as within 1 week, regardless of the route of administration 3. Amphetamine withdrawal symptoms, particularly hypersomnia, increased appetite and dysphoria, can occur and can enhance cravings. When injected or smoked, stimulants can produce instantaneous feelings of euphoria, confidence and wellbeing 3. However, acute intoxication with amphetamines may also manifest as pressured speech, paranoia, insomnia, hallucinations, aggression and emotional lability 3. This often creates diagnostic challenges, as amphetamine use disorder is also highly comorbid among those with schizophrenia 5, bipolar disorder 6, attention-deficit/hyperactivity disorder 7 and eating disorders 8. Due to their potent central nervous system stimulant effects and sympathomimetic properties, chronic amphetamine use can lead to myriad medical sequalae, including sinusitis, nasal mucosal bleeds, respiratory problems, elevated risk of HIV and other infections, seizures, as well as cardiovascular disease—including myocardial infarction, palpitations and arrhythmias, sudden death from cardiac arrest and stroke 3. As such, interventions to reduce the risks of overdose, suicide and traumatic deaths in this population are clearly warranted. With the increasing medicalization of addictive disorders as brain-based diseases, their amenability to biological treatments—most commonly pharmacotherapy—has been increasingly explored 9. The efficacy of dopamine agonists and a range of psychostimulant medications have been measured in numerous studies; however, the conclusion of the extant literature examining the potential for pharmacotherapies has been negative 10. As a result, first-line interventions for the treatment of individuals with amphetamine use disorder are primarily psychosocial, including individual and group counselling 11, coping skills training 12, intensive out-patient therapy 13, contingency management 14, cognitive–behavioral therapy 15 and motivational interviewing 16. Increasingly, neurostimulation therapy—particularly repetitive transcranial magnetic stimulation—has been explored for the treatment of amphetamine and other stimulant use disorders, with preliminary evidence of efficacy 17. As Stockings and colleagues identified, mortality among individuals with amphetamine use disorder is high—but unless there are drastic changes in our approaches to the treatment of individuals with amphetamine use disorder, these statistics will not change. Stigma towards people with addictions further estranges those who are in most need of support, and is a large driver of continued morbidity and mortality in this population 18. Anti-methamphetamine campaigns, intended to support those who are interested in quitting or seeking help, are frequently inauthentic, using dramatic imagery that reinforces negative stereotypes of the prototypical ‘white, meth-using zombie’ 19. Taken together, these findings indicate that there is an urgent need for alternative evidence-based strategies to tackle the mounting global amphetamine epidemic. None.