Treatment Of Stimulant Use Disorder Research Articles

CM group calls on SAMHSA to rescind $75 cap

This month, the Contingency Management Policy Group (CMPG) headed by H. Westley Clark, M.D., issued a statement calling on the federal government to rescind the $75 limit on what can be paid per year to patients being treated for substance use disorder. Contingency management is the only effective treatment for stimulant use disorders, involving payment for negative drug tests, but it doesn't work unless the dollar figure is much higher.

Navigating Evidence, Challenges, and Caution in the Treatment of Stimulant Use Disorders.

Amidst the opioid epidemic, harm reduction-oriented approaches have gained traction, including interventions that focus on prescribing pharmaceutical-grade psychoactive substances, such as opioids, instead of illicit versions, intending to mitigate fatal overdose risks arising from the variability in potency and additives found in illicit drugs. Stimulants have increasingly been found in the victims of opioid overdoses, further prompting some to argue for the prescription of stimulant medications for individuals with stimulant use disorders. Yet, the evidence supporting this practice remains insufficient. In this communication, we critically examine the existing evidence, challenges, and cautions surrounding the treatment of stimulant use disorder.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

Implementing an evidence-based prize contingency management protocol for stimulant use

IntroductionContingency management (CM) is an efficacious treatment for stimulant use disorders. Support materials for the clinical delivery of prize-based CM are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap. Method/ResultsThe article outlines a suggested prize CM protocol and discusses the best practices most aligned with the evidence base and acceptable-if-necessary modifications. This guide also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation. ConclusionsDeviations from evidence-based practices are common, and poorly designed CM is unlikely to impact patient outcomes. This article provides planning stage guidance to support programs' adoption of evidence-based prize CM for the treatment of stimulant use disorders.

Distinct Effects of Methamphetamine Isomers on Limbic Norepinephrine and Dopamine Transmission in the Rat Brain.

Methamphetamine (METH) is a psychostimulant that primarily exerts its effects on the catecholamine (dopamine (DA) and norepinephrine (NE)) systems, which are implicated in drug addiction. METH exists as two distinct enantiomers, dextrorotatory (d) and levorotatory (l). In contrast to d-METH, the major component of illicit METH used to induce states of euphoria and alertness, l-METH is available without prescription as a nasal decongestant and has been highlighted as a potential agonist replacement therapy to treat stimulant use disorder. However, little is known regarding l-METH's effects on central catecholamine transmission and behavior. In this study, we used fast-scan cyclic voltammetry to elucidate how METH isomers impact NE and DA transmission in two limbic structures, the ventral bed nucleus of the stria terminalis (vBNST) and nucleus accumbens (NAc), respectively, of anesthetized rats. In addition, the dose-dependent effects of METH isomers on locomotion were characterized. d-METH (0.5, 2.0, 5.0 mg/kg) enhanced both electrically evoked vBNST-NE and NAc-DA concentrations and locomotion. Alternatively, l-METH increased electrically evoked NE concentration with minimal effects on DA regulation (release and clearance) and locomotion at lower doses (0.5 and 2.0 mg/kg). Furthermore, a high dose (5.0 mg/kg) of d-METH but not l-METH elevated baseline NE and DA concentrations. These results suggest mechanistic differences between NE and DA regulation by the METH isomers. Moreover, l-METH's asymmetric regulation of NE relative to DA may have distinct implications in behaviors and addiction, which will set the neurochemical framework for future studies examining l-METH as a potential treatment for stimulant use disorders.

Transcranial Stimulation for the Treatment of Stimulant Use Disorder

The increasing prevalence of stimulant use disorder (StUD) involving methamphetamine and cocaine has been a growing healthcare concern in the United States. Cocaine usage is associated with atherosclerosis, systolic and diastolic dysfunction, and arrhythmias. Furthermore, approximately one of every four MIs is cocaine-induced among patients aged 18 to 45. Methamphetamine use has been associated with nerve terminal damage in the dopaminergic system resulting in impaired motor function, cognitive decline, and co-morbid psychiatric disorders. Current treatment options for StUD are extremely limited, and there are currently no FDA-approved pharmacotherapies. Behavioral interventions are considered first-line treatment; however, in a recent meta-analysis comparing behavioral treatment options for cocaine, contingency management programs provided the only significant reduction in use. Current evidence points to the potential of various neuromodulation techniques as the next best modality in treating StUD. The most promising evidence thus far has been transcranial magnetic stimulation which several studies have shown to reduce risk factors associated with relapse. Another more invasive neuromodulation technique being studied is deep-brain stimulation, which has shown promising results in its ability to modulate reward circuits to treat addiction. Results showing the impact of transcranial magnetic stimulation (TMS) in the treatment of StUD are limited by the lack of studies conducted and the limited understanding of the neurological involvement driving addiction-based diseases such as StUD. Future studies should seek to provide data on consumption-reducing effects rather than craving evaluations.

Feasibility study on the use of an intensive deep transcranial magnetic stimulation protocol in the treatment of stimulant use disorder

Feasibility study on the use of an intensive deep transcranial magnetic stimulation protocol in the treatment of stimulant use disorder

Stimulant misuse among youth

Rates of stimulant use, including misuse of prescription stimulants and use of cocaine and methamphetamine, are rising rapidly among adolescents and young adults ("youth"). Stimulant misuse is associated with overdose, polysubstance use, substance use disorders, and other medical harms. Substance use is often initiated during adolescence and young adulthood, and interventions during these crucial years have the potential to impact the lifetime risk of stimulant use disorder and associated harms. In this narrative review, we review recent data on prescription and illicit stimulant use in youth. We describe the rising contribution of stimulants to polysubstance use involving opioids and other substances and to overdose, as well as ways to minimize harm. We also discuss prescription stimulant misuse, which is especially prevalent among youth relative to other age groups, and the limited evidence on potential pathways from prescription stimulant use to illicit stimulant use. Last, we assess potential strategies for the prevention and treatment of stimulant use disorder in youth.

Factors predicting incarceration history and incidence amongBlack and Latino men who have sex with men (MSM)residing in a major urban center.

We analyzed data from a cohort of Black and Latino men who have sex with men (MSM) in order to identify correlates of prevalent and incident incarceration, including potential predictors related to their status as sexual and gender minorities (SGMs). Baseline and follow-up self-administered survey data were examined from Los Angeles County participants’ ages 18–45 years at enrollment who were either HIV negative or living with HIV, but recruited to over represent men who used drugs and men with unsuppressed HIV infection. Multivariable logistic regression models were developed to identify predictors of baseline incarceration history and of incident incarceration over study follow-up among 440 and 338 participants, respectively. Older age, Black race, low socioeconomic status, homelessness, stimulant use, and depression symptoms were associated with baseline incarceration history. The only SGM-related factor associated with baseline incarceration history was having experienced violence based on sexual orientation identity. Just one statistically significant, independent positive predictor of incident incarceration was identified: prior incarceration, whereas having four or more friends that could lend money was a statistically significant protective factor against incident incarceration. Fundamental Cause Theory provides a useful framework to explain identified predictors of incarceration. Addressing poverty, housing instability, inadequate access to health care, and their root causes is critical to reducing incarceration rates in this population, as is expanded access to both diversion and anti-recidivism programs and to evidence-based treatment for stimulant use disorders.

CM for stimulant use disorder: No limit imposed by OIG

The oft‐stated assumption that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) bans any gifts of $75 or more as a contingency in the treatment of stimulant use disorder is incorrect. From the Federal Register announcement: “Gifts that implicate the Beneficiary Inducements CMP that exceed these dollar limits are not prohibited but are analyzed on a case‐by‐case basis for compliance under the statute,” according to the OIG December 2020 Federal Register final rule (https://www.federalregister.gov/documents/2020/12/02/2020‐26072/medicare‐and‐state‐health‐care‐programs‐fraud‐and‐abuse‐revisions‐to‐safe‐harbors‐under‐the). “We highlight, however, that this nominal value guidance applies to the value of in‐kind items and services, not to the value of incentive payments in the form of cash or cash equivalents. In other words, cash and cash‐equivalent payments under $75 would not be covered by this guidance. Moreover, this guidance applies only with respect to the Beneficiary Inducements CMP and not to the Federal anti‐kickback statute. Furthermore, we are aware that some industry stakeholders may be under a misimpression that OIG prohibits contingency management program incentives above $75. There is no OIG‐imposed $75 limitation on contingency management program incentives. Rather, the Federal anti‐kickback statute may constrain the ability of individuals or entities to offer contingency management program incentives of any value to Federal health care program beneficiaries, depending on the facts of the arrangement. Moreover, in‐kind incentives above the $75 annual, aggregate limit, and all cash or cash‐equivalent incentives regardless of the amount, must be analyzed on the basis of their specific facts for compliance with the Beneficiary Inducements CMP.”

Pharmacotherapy treatment of stimulant use disorder.

Stimulant use disorder (SUD) is a public health problem in the United States that is associated with increased morbidity and mortality. Psychosocial interventions, such as cognitive behavioral therapy and contingency management, are the main treatment modality for SUDs and no pharmacotherapy is currently FDA approved for this indication. Although some medications show promising data for the treatment of SUD, the evidence remains inconsistent, and the clinical application is limited due to the heterogenicity of the population and the lack of studies in patients with various comorbidities. Selection of pharmacotherapy treatment for methamphetamine intoxication, persistent methamphetamine-associated psychosis with methamphetamine use disorder, and cocaine use disorder in patients with co-occurring OUD are discussed in 3 patient cases.

JSAT call for papers for special issue: Stimulant use disorder

The Journal of Substance Abuse Treatment seeks articles on the changing epidemiology and treatment of stimulant use disorder for a planned Special Issue. JSAT prefers empirical research, however, we will also consider systematic reviews and meta analyses. Recent reports from CDC and other sources has documented that cocaine and methamphetamine play an increasing role in the overdose death crisis in the US. We think a special issue presenting new information on a variety of stimulant-related research topics is merited. We invite high quality research manuscripts on topics related to stimulant use disorder, such as:•Behavioral and pharmacotherapy innovations•Implementation and dissemination science•Treatment in medical and specialty care settings•Assessment and treatment of co-occurring psychiatric symptoms (psychosis, depression)•Withdrawal management•Overdose prevention and overdose treatment•Epidemiological and treatment studies addressing racial, ethnic, sexual, and/or gender minority populations, as well as rural communities To facilitate manuscript development, authors should submit an abstract (maximum of one page) of the proposed paper to Michael McDonell, [email protected] . Authors of selected manuscripts will be invited to submit a full manuscript. When a manuscript is ready for submission, it must be submitted directly to the JSAT Editorial Manager: (https://www.editorialmanager.com/josat/default.aspx). The first step is to indicate “article type.” In the drop-down menu, select “Stimulant Use Disorder” so the paper will be routed to the editors. Articles should follow the outline provided in the guide for authors (https://www.elsevier.com/journals/journal-of-substance-abusetreatment/0740-5472/guide-for-authors). We advise authors to consult the EQUATOR Network for guidance on standardized reporting guidelines (https://www.equator-network.org/) and follow the appropriate guidelines. The due date for abstracts is 1st January 2022. Abstracts will be peer-reviewed and decisions will be announced no later than 1st February 2022. Papers invited for submission will be due on 1st May 2022. All submitted manuscripts will go through a rigorous peer-reviewed process, thus acceptance of your abstract does not guarantee publication. Accepted manuscripts will be published online on a rolling basis (prior to the full special issue being published in late 2022). Please email any questions to the guest editors below. We look forward to receiving your abstracts!

Exploring the effectiveness of dextroamphetamine for the treatment of stimulant use disorder:\xa0a qualitative study\xa0with patients receiving injectable opioid agonist treatment

BackgroundA high proportion of people receiving both oral and injectable opioid agonist treatment report concurrent use of stimulants (i.e. cocaine and or amphetamines), which has been associated with higher rates of continued illicit opioid use and treatment dropout. A recent randomized controlled trial demonstrated the effectiveness of dextroamphetamine (a prescribed stimulant) at reducing craving for and use of cocaine among patients receiving injectable opioid agonist treatment. Following this evidence, dextroamphetamine has been prescribed to patients with stimulant use disorder at a clinic in Vancouver. This study investigates perceptions of the effectiveness of dextroamphetamine from the perspective of these patients.MethodsData were collected using small focus groups and one-on-one interviews with patients who were currently or formerly receiving dextroamphetamine (n = 20). Thematic analysis was conducted using an iterative approach, moving between data collection and analysis to search for patterns in the data across transcripts. This process led to the defining and naming of three central themes responding to the research question.ResultsParticipants reported a range of stimulant use types, including cocaine (n = 8), methamphetamine (n = 8), or both (n = 4). Three central themes were identified as relating to participants’ perceptions of the effectiveness of the medication: 1) achieving a substitution effect (i.e. extent to which dextroamphetamine provided a substitution for the effect they received from use of illicit stimulants); 2) Reaching a preferred dose (i.e. speed of titration and effect of the dose received); and 3) Ease of medication access (i.e. preference for take home doses (i.e. carries) vs. medication integrated into care at the clinic).ConclusionIn the context of continued investigation of pharmacological treatments for stimulant use disorder, the present study has highlighted how the study of clinical outcomes could be extended to account for factors that contribute to perceptions of effectiveness from the perspective of patients. In practice, elements of treatment delivery (e.g. dosing and dispensation protocols) can be adjusted to allow for various scenarios (e.g. on site vs. take home dosing) by which dextroamphetamine and other pharmacological stimulants could be implemented to provide “effective” treatment for people with a wide range of treatment goals and needs.

Use of sustained release dextroamphetamine for the treatment of stimulant use disorder in the setting of injectable opioid agonist treatment in Canada: a case report

BackgroundFor people with opioid use disorder who are not responding to oral opioid agonist treatment, evidence supports the effectiveness of injectable opioid agonist treatment with injectable hydromorphone (an opioid analgesic) and diacetylmorphine (pharmaceutical grade heroin). While this treatment is effective at reducing illicit opioid use, concurrent cocaine use is prevalent. Dextroamphetamine (a central nervous system stimulant) has been found to be a safe and effective treatment for cocaine dependence among people receiving injectable opioid agonist treatment in Europe. We present the first report of dextroamphetamine prescribing offered for the treatment of stimulant use disorder among a patient receiving iOAT outside of a clinical trial. This case report can be used to inform clinical practice in the treatment of cocaine use disorder, an area where interventions are currently lacking.Case presentationDextroamphetamine was prescribed to a 51-year-old male who was diagnosed with concurrent opioid and stimulant use disorder in an injectable opioid agonist treatment clinic in Vancouver, Canada. He reported smoking crack cocaine daily for more than two decades and was experiencing health consequences associated with this use. He presented to his routine physician visit with the goal of reducing his cocaine use and was prescribed dextroamphetamine for the treatment of stimulant use disorder. After 4-weeks the patient was tolerating the medication with no observed adverse events and was achieving his therapeutic goal of reducing his cocaine use.ConclusionsDextroamphetamine can be prescribed to support patients with stimulant use disorder to reduce or stop their use of cocaine. The case demonstrated that when dextroamphetamine was prescribed, a significant reduction in cocaine use was experienced among a patient that had been regularly using cocaine on a daily basis for many years. Daily contact with care for the opioid medication promoted adherence to the stimulant medication and allowed for monitoring of dose and tolerance. Settings where patients are in regular contact with care such as oral and injectable opioid agonist treatment clinics serve as a suitable location to integrate dextroamphetamine prescribing for patients that use illicit stimulants to reduce use and associated harms.

In Case You Haven't Heard…

It's well known that contingency management, in which patients are given monetary rewards for negative drug tests, is the best — i.e., most effective — treatment for stimulant use disorders. As the country gets deeper into a methamphetamine addiction epidemic, isn't it time to reconsider the federal ban on paying patients more than $75 a year? The ridiculous assertion that such payments are kickbacks — inducements to patients to go to treatment centers — is getting hollower and hollower. Let's hope this administration changes the message. Clinical trials of medications have proven less than significant. Also see “HHS OIG doubles down on constraints against contingency management” (ADAW, Aug. 24, 2020). The final rule banning higher payments was published in January.

Case‐by‐case approach in CM rule leaves providers at risk

The final rule on incentives and contingency management was published last week and goes into effect Jan. 19, 2021. The final rule, issued by the Department of Health and Human Services Office of the Inspector General (HHS OIG), applies to the use of contingency management — the only proven method of treatment for stimulant use disorders — and still considers such payments a kickback, and therefore illegal under fraud and abuse statutes (see “CM, only effective treatment for stimulant disorders, on the ropes as methamphetamine surges, ADAW June 8, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32742 and “HHS doubles down on constraints against contingency management, ADAW August 24, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32812).

$75 annual limit for CM hampers stimulant addiction treatment

In August, the federal Department of Health and Human Services (HHS) doubled down on constraints against contingency management (CM), the best treatment for stimulant use disorders. This ruling by the HHS Office of Inspector General (OIG) comes at the same time that HHS releases $1 billion for State Opioid Response (SOR) funds, which, for the first time, can be used for stimulant use disorders as well. It also comes just as stimulant use disorders are on the verge of taking over the opioid epidemic.

Classic Psychedelics as a Psychotherapeutic Aid in the Treatment of Stimulant Use Disorder: a Case Report

Despite nascent research supporting the efficacy of classic psychedelics as a psychotherapeutic aid for the treatment of substance abuse, to date, there is limited published research exploring their use in the treatment of stimulant use disorder and dual diagnosis. A 22-year-old male with a history of mood disorder and polysubstance use presented to a private Australian mental health clinic. While undergoing psychological treatment for mood and stimulant use disorder, this patient reported significant benefit from his use of classic psychedelics. Following consumption of 3.5 grams of psilocybin-containing mushrooms, he decided to seek out psychotherapy for the first time. Throughout treatment, subjective reports of his classic psychedelic use, which among others, included two occasions of having consumed 200 μg of lysergic acid diethylamide and 100 mg of dimethyltryptamine, were recorded and a psychometric tool used to capture mystical experiences was administered. As treatment progressed, the patient reported being better able to consolidate his therapeutic gains through the integration of insights obtained through his use of classic psychedelics, ultimately remaining abstinent from all stimulant drugs. The results of this case report suggest that classic psychedelics may be effective psychotherapeutic aids to be used in traditional substance abuse treatment programs. It is hoped that this case report will inform future research in this field.

Treatment of stimulant use disorder: A systematic review of reviews

Stimulant use disorder contributes to a substantial worldwide burden of disease, although evidence-based treatment options are limited. This systematic review of reviews aims to: (i) synthesize the available evidence on both psychosocial and pharmacological interventions for the treatment of stimulant use disorder; (ii) identify the most effective therapies to guide clinical practice, and (iii) highlight gaps for future study. A systematic database search was conducted to identify systematic reviews and meta-analyses. Eligible studies were those that followed standard systematic review methodology and assessed randomized controlled trials focused on the efficacy of interventions for stimulant use disorder. Articles were critically appraised using an assessment tool adapted from Palmeteer et al. and categorized for quality as 'core' or 'supplementary' reviews. Evidence from the included reviews were further synthesized according to pharmacological or non-pharmacological management themes. Of 476 identified records, 29 systematic reviews examining eleven intervention modalities were included. The interventions identified include: contingency management, cognitive behavioural therapy, acupuncture, antidepressants, dopamine agonists, antipsychotics, anticonvulsants, disulfiram, opioid agonists, N-Acetylcysteine, and psychostimulants. There was sufficient evidence to support the efficacy of contingency management programs for treatment of stimulant use disorder. Psychostimulants, n-acetylcysteine, opioid agonist therapy, disulfiram and antidepressant pharmacological interventions were found to have insufficient evidence to support or discount their use. Results of this review do not support the use of all other treatment options. The results of this review supports the use of contingency management interventions for the treatment of stimulant use disorder. Although evidence to date is insufficient to support the clinical use of psychostimulants, our results demonstrate potential for future research in this area. Given the urgent need for effective pharmacological treatments for stimulant use disorder, high-quality primary research focused on the role of psychostimulant medications for the treatment of stimulant use disorder is needed.

In Case You Haven't Heard…

We have been hearing that housing is what people really need to overcome substance use disorders. With opioids, they could say, instead, “buprenorphine” or “Vivitrol” or, more rarely, unfortunately, “methadone.” And naloxone to reverse opioid overdoses is also essential. But now stimulant use disorders may be getting new funding (in State Opioid Response [SOR] grants, see p. 1), and that has everyone asking what medications can be used for it. Well, it's just possible that what people really need is housing, especially if there just aren't any medications. But there is one evidence‐based treatment for stimulant use disorders: contingency management. If the bias against “paying drug users not to use drugs” can be overcome, vouchers and gift cards and cash may be the fastest path to recovery for people with methamphetamine or cocaine use disorders. As for giving them housing — would it come with a contingency?