#5 Amp Up Your Treatment of Stimulant Use Disorder

August 4, 2022 | By Carolyn Chan

With Dr. Paxton Bach

Amp up your learning on stimulant use disorder! We are joined by Dr. Paxton Bach (@PaxBach) who is the Co-Medical Director for the British Columbia Centre on Substance Use and Director of their Clinical Addiction Medicine Fellowship Program. We discuss commonly used stimulants, how to recognize when someone is “overamping,” different treatment options, and so much more!

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Credits

• Produced and Cover Art by: Kenneth Morford, MD
• Written by: Natalie Stahl, MD, MPH
• Show Notes and Infographics: Zina Huxley-Reicher, MD
• Hosts: Carolyn Chan, MD,  Natalie Stahl, MD, MPH,
• Reviewer: Katherine Mullins, MD
• Showrunner: Carolyn Chan, MD
• Technical Production: Castos
• Guest: Dr. Paxton Bach

Production Partner: ACAAM

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio 1:40
• Guest one-liner 2:42
• Case from Kashlak, Definitions 4:10
• Defining stimulants 5:10
• Reasons for stimulant use 8:15
• Stimulant intoxication 11:40
• Stimulant withdrawal 20:00
• Approach to treating stimulant use disorder 23:15
• Contingency management 26:50
• Medications for stimulant use disorder 36:00
• Harm reduction for stimulant use 54:40
• Take-Home Points 58:00
• Outro 1:00:01

Stimulant Use Disorder Pearls

1. The category of stimulants includes multiple substances; cocaine and methamphetamine are increasingly prevalent in the North American drug supply and commonly encountered in clinical settings.
2. Negative symptoms associated with stimulant intoxication (“overamping”) include tachycardia, palpitations, hyperthermia, paranoia, agitation, seizures, and cardiac complications.
3. Manage overamping supportively by creating a quiet and calm environment. For more severe cases, consider benzodiazepines and/or involvement of psychiatry for psychotic symptoms. 
4. Stimulant withdrawal involves dysphoria, fatigue and overall discomfort that can drive ongoing use.
5. Understanding the reasons for stimulant use is an important step in developing a treatment plan.
6. Contingency management is the gold standard treatment for stimulant use disorder.
7. There are no FDA-approved medications for stimulant use disorder. Off-label medications include mirtazapine, naltrexone combined with bupropion, topiramate, and prescribed psychostimulants. 
8. All patients using stimulants should be educated about fentanyl contamination in the stimulant drug supply and given naloxone. Additional harm reduction techniques include counseling on safer routes of administration; provision of sterile supplies for injection, inhalation, and intranasal use; and avoidance of using alone.
9. Use of stimulants is not a contraindication for the use of beta blockers.

Stimulant Use Disorder – Notes

What are stimulants?

Stimulants are a broad category ranging from caffeine to cathinone, but the most common clinical stimulants we encounter are cocaine and methamphetamine. 

Cocaine is a monoamine reuptake inhibitor that increases the concentration and prolongs the duration of dopamine, norepinephrine, and serotonin in the synaptic cleft. Common effects include alertness, euphoria, and enhanced concentration. Cocaine can be used intranasally (by insufflation), orally, intravenously, or by inhalation. It is generally available as a powder (water soluble and thus better for injecting, intranasal use, etc.) or as a solid form known as crack cocaine that is more easily smoked (NIDA, 2022).

Methamphetamine & amphetamines are also monoamine reuptake inhibitors but additionally promote efflux of the neurotransmitters into the synapse, resulting in a longer duration of action and much higher levels of dopamine in the brain compared to cocaine (NIDA, 2021). Methamphetamine can be used intranasally (insufflated), smoked, or injected. Less common routes of administration include swallowing (“parachuting”) or per rectum (“booty bumping,” “boofing” or “hooping”). 

Ask your patients how they refer to different substances and routes of administration since terms vary across geographic locations.

Why do people use stimulants? 

People may use stimulants to find pleasure (Lorvick 2012), enhance concentration, self-treat ADHD symptoms, offset the effects of other substances, enhance sexual activity, or ensure survival (for instance, unhoused people may use stimulants to stay awake and vigilant overnight). People may use stimulants daily, intermittently, or in a binging pattern. The reason for use often influences the pattern of use. 

Defining “overamping”

Overamping is the stimulant equivalent of an overdose but differs from opioid overdose in the sense that it is not an acute, well-defined event. Instead, it refers to negative or uncomfortable symptoms of stimulant intoxication (Harding, 2022). These symptoms can include anxiety, palpitations, hypertension, hyperthermia, paranoia, psychosis, seizures, and cardiovascular or cerebrovascular events (Ciccarone & Shoptaw, 2022). It is important to ask patients what overamping means to them and what specific symptoms are causing discomfort. 

How do you treat a patient who is overamping?

Treatment for mild overamping is supportive. Symptoms in these cases may include anxiety, paranoia, or palpitations. In these cases, treat conservatively by creating a quiet and comfortable place for the patient to rest and recover. Minimize stimulation by dimming lights, applying cold compresses, and providing water. It’s important to speak calmly and softly to de-escalate the situation and let them rest.

In patients with more severe agitation or discomfort, low-dose benzodiazepines (e.g., lorazepam, midazolam) can help. If possible, clarify what other drugs or sedating agents the patient has used that day before administration. 

In patients presenting with frank psychosis, it can be challenging to distinguish stimulant intoxication from an underlying psychiatric condition. In these cases, psychiatry should be consulted to develop a collaborative plan and determine the need for antipsychotics (Shoptaw 2009).

In all situations of overamping, avoid restraints. Restraints can upset patients, escalating the situation. 

What is stimulant withdrawal? 

Stimulant withdrawal is not medically dangerous like withdrawal from alcohol or benzodiazepines but causes people to feel lousy. It can last for days to weeks and may result in the return to or compensatory use of other substances. Common symptoms include dysphoria, fatigue, irritability, general discomfort, and an ability to perform everyday activities (Ciccarone & Shoptaw, 2022). 

Screen for additional substance use

People who use stimulants often use other substances. Be sure to ask patients if, how, and why they use additional substances. People using stimulants may also have unknown drug exposures due to contamination of the drug supply, particularly with fentanyl (Ciccarone, 2021). In British Columbia, up to 10% of stimulants contain fentanyl (CCSA, 2020). Anyone using cocaine or methamphetamine should receive naloxone to prevent fatal opioid overdose! 

Treating stimulant use disorder

Dr. Bach identifies multiple components to the treatment of stimulant use disorder:  

• Medical Comorbidities
• Social Determinants of Health
• Psychosocial Treatments (non-pharmacologic)
• Pharmacologic Treatment Options
• Harm Reduction

Social determinants of health and comorbidities 

It is important to consider physical and psychological comorbidities as well as social determinants of health that contribute to a patient’s stimulant use. Housing status is particularly important. As Dr. Bach explained, “People use stimulants for specific reasons. And if we don’t understand those reasons, we’re barking up the wrong tree.”

Psychosocial treatment 

Psychosocial treatment is the gold standard for treating stimulant use disorder, but is often hard to access. For both cocaine and methamphetamine, contingency management is the most effective treatment. Cognitive behavioral therapy has some demonstrated benefits as well.

Contingency Management 

Contingency management (CM) is based on operant conditioning – the idea that providing immediate rewards can reinforce and promote positive behavior change. CM programs set goals collaboratively with each patient. Plans can include reduction in use, management of related health concerns, or appointment attendance and do not necessarily need to include abstinence. Treatment involves the distribution of a reward when identified goals are met. Patients may have the option to draw from a prize bowl (“fishbowl approach”) that contains vouchers for monetary or other rewards. Rewards may increase over time as the patient achieves pre-defined goals on an ongoing basis. CM can be performed individually or in group settings, in outpatient or inpatient settings. 

The number needed to treat is 3-5 for stimulant use disorder (Crescenzo, 2018). This treatment modality has been embraced by the US Department of Veterans Affairs (VA, 2020), and there are discussions to expand in California through Medicaid (DHCS, 2022). Unfortunately, it is difficult to access this treatment modality in most places, despite its demonstrated cost-effectiveness (Murphy, 2015). Consider connecting patients with an addiction medicine team that may know how to link someone to this treatment.

Pharmacologic treatment

No medications are approved by the FDA for stimulant use disorder. Dr. Bach explains that most published data comes from small trials that focus on abstinence as the outcome. Most of these studies are underpowered with high dropout rates (>40%), which makes the literature challenging to interpret. However, evidence suggests that a few medications can help in some contexts and are safe to use

Mirtazapine

A study published in 2019 that included cisgender men and transgender women who have sex with men, treated with 30 mg of mirtazapine for 24 weeks in conjunction with counseling, showed a significant reduction in methamphetamine use (Coffin, 2020).

Naltrexone in combination with Bupropion

The ADAPT-2 trial was a large multisite trial that evaluated a combination of IM naltrexone every 3 weeks and bupropion 450 mg daily for treatment of methamphetamine use disorder. The study found significantly increased abstinence with this therapy with a number-needed-to-treat of 9  (Trivedi, 2021). An important caveat is that many people with stimulant use disorder also use opioids. Naltrexone is contraindicated in individuals who use opioids, including methadone or buprenorphine.  

Psychostimulants

Editor Note: U.S. clinicians should note that expert opinion considers the prescription of psychostimulants solely to treat stimulant use disorder (i.e. in the absence of another established indication such as ADHD or narcolepsy) to be a violation of Federal Law.  If an individual has a co-occurring ADHD diagnosis, it is ok to use psychostimulants to treat ADHD and it may also benefit the stimulant use disorder

There is discussion around prescribing slow-release psychostimulants (dextroamphetamine, amphetamine salts) for withdrawal symptoms and maintenance, in logic that mirrors the use of methadone or buprenorphine for opioid use disorder. Most studies have not demonstrated any change in outcomes. However, one meta-analysis that included all prescribed psychostimulants for cocaine or methamphetamines found higher rates of abstinence, with a number-needed-to-treat of 16 (Tardelli, 2020). The safety profile of these medications is generally good, although trials have excluded patients with significant cardiovascular or psychiatric disease. 

For patients who use stimulants and have attention-deficit/hyperactivity disorder (ADHD), treating ADHD with psychostimulants may alleviate the need for non-prescription stimulants (Levin, 2018).

Topiramate

The evidence for topiramate is mixed and primarily focuses on cocaine use disorder. A recent study investigating topiramate (titrated to 150 mg twice daily) combined with amphetamine salts found higher rates of three consecutive weeks of abstinence than placebo over 12 weeks (Levin, 2012).

Harm Reduction for Stimulant Use 

It is important to discuss harm reduction for stimulant use with patients, especially if abstinence is not their goal. Harm reduction includes considering safer routes of administration based on a patient’s comorbidities (e.g. avoid inhalation in a patient with COPD), safer use of equipment (e.g. discuss that hepatitis C can be transmitted from sharing pipes), and provision of naloxone for overdose prevention. Patients should be encouraged to use with people rather than alone, avoid sharing supplies, and test drug supplies with a small starting dose. Refer patients to additional resources including overdose prevention centers, local syringe exchange programs, the never use alone hotline, and additional patient handouts available for free online.

Also, despite the common belief that unopposed alpha stimulation is dangerous in people who use stimulants, no strong evidence supports this idea. Use of stimulants is not automatically a reason to withhold treatment with beta blockers.

Links

1. Never Use Alone Hotline
2. Overamping Basics from National Harm Reduction Coalition
3. Patient Handout on Overamping from NextDistro

Goal

Listeners will be able to diagnose and manage patients with stimulant use or stimulant use disorder. 

Learning objectives

After listening to this episode listeners will…  

1. Recognize common stimulants (e.g., cocaine and methamphetamine) and common routes of administration.
2. Describe the management of acute stimulant intoxication.
3. Describe evidence-based psychosocial and medications treatment strategies for individuals with stimulant use disorder.
4. Discuss harm reduction strategies for people who use stimulants.

Disclosures

Dr. Paxton Bach reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Huxley-Reicher Z, Bach, P,  Stahl, N, Mullins, K,  Morford K, Chan, CA, “#5 Amp Up Your Treatment of Stimulant Use Disorder with Dr. Paxton Bach”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/addiction  August 4th, 2022.