Addiction Societies Issue Guidance on Stimulant Use Disorder

In light of recent increases in overdose deaths involving stimulant drugs, two addiction medicine societies have jointly issued a clinical practice guideline on the management of stimulant use disorder (StUD).

The guideline is meant to provide evidence-based strategies for the prevention and treatment of StUD, stimulant intoxication, and stimulant withdrawal, according to the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP).

Overall, the recommendations focus on three key areas: treatment of StUDs, intoxication and withdrawal, and secondary & tertiary prevention.

“Previous to this guideline, there hadn’t been a synthesized clinical practice guideline that pulled together intoxication management, harm reduction, prevention, and then psychosocial treatment and medication treatment all in one place,” Brian Hurley, MD, MBA, president of ASAM, told MedPage Today.

“The main takeaway is that stimulant use disorder is treatable,” Hurley said. “We have a number of evidence-based psychosocial treatments, and medication treatments that clinicians can consider. There are a whole range of prevention, detoxification management, and clinical approaches that can help protect the health and well being of people who use stimulants.”

Regarding treatment, the guideline states that contingency management (CM) is the most effective treatment for StUD, and is the current standard of care. CM focuses on rewarding patients for positive behavior, such as a negative toxicology test. Patients in CM programs typically receive a prize, such as a cash reward, when they prove abstinent from stimulants.

CM can be paired with other psychosocial interventions and behavioral therapies, such as cognitive behavioral therapy (CBT) and community reinforcement approach, which aims to eliminate positive reinforcement for stimulant use.

Pharmacotherapies including psychostimulant medications can be used off-label to treat StUD, the guidance states. Hurley noted that without FDA-approved medications, it was especially important to outline which drugs were the most clinically effective, such as using bupropion (Wellbutrin) for cocaine use disorder.

As for stimulant intoxication and withdrawal, the guidance notes that acute stimulant intoxication can result in life-threatening complications including acute coronary syndrome, hypertensive emergency, myocardial infarction, hyperthermia, and acidosis — all of which should be addressed immediately.

Symptoms of withdrawal include depression, anxiety, insomnia, and paranoia, and can last for weeks to months, according to the guidance, making it important to address them to reduce the risk of return to stimulant use.

Secondary and tertiary prevention strategies should also be used to reduce harms related to overdose risk, risky sexual practices, injection drug use, oral health, and nutrition, the guidance states.

The guidance also includes an extensive set of recommendations for initial and comprehensive assessments of patients with StUD, as well as recommendations for how to handle co-occurring disorders and population-specific considerations.

Overdose death rates have increased three-fold for cocaine and 12-fold for other stimulants, such as methamphetamine, amphetamine, and prescription stimulants, over the past 10 years, driven by drug potency and combination use with opioids, the guidance states.

In fact, a new report from the Substance Abuse and Mental Health Services Administration revealed that roughly 4.5 million people ages 12 and up had a cocaine, methamphetamine, or prescription stimulant use disorder in 2022. It also found that the percentage of people with such disorders was highest among young adults (2.2% or 755,000 people).

Hurley said the guidance was developed in part to show healthcare professionals that StUDs are treatable and that they can help patients who are suffering from them.

“I’ve met clinicians that feel very disheartened that stimulant use disorder is really hard to treat,” Hurley said. “What I would say is it actually is quite treatable. We have a number of options, recovery is possible, and it’s really important to continue to work with patients — even if they’re not fully abstinent from stimulants — because there’s an awful lot that we can do to help support people.”

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