Treatment of stimulant use disorder: A systematic review of reviews

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022

INTRODUCTION

Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.

METHODS

In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.

RESULTS

From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.

CONCLUSIONS

The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

[Stimulants : Current insights into the principles, diagnostics and treatment]

BACKGROUND

Consumption of stimulant drugs, a heterogeneous group of addictive substances, has significantly increased in recent years with rising numbers of stimulant-associated intoxication and deaths.

OBJECTIVE

To provide an overview of recent scientific evidence of the diagnosis and treatment of stimulant use disorders.

MATERIAL AND METHODS

A literature review of the neuropathology, clinical presentation, diagnostic criteria and evidence-based treatment for stimulant use disorders.

RESULTS

The chronic use of stimulant drugs is associated with significant physical (e.g., hypertension, tachycardia and dyspnoea) and psychological harm (e.g., dependence, psychotic disorders and affective disorders). Despite major advances in the research of the neuropathology of stimulant use disorder and the refinement of diagnostic criteria, the disorder still presents a challenge, not least because of the lack of effective treatments. There are currently no approved pharmacotherapeutic interventions for stimulant use disorder and meta-analyses show that the efficacy of behavioural interventions is low to moderate, similar to cognitive behavioural treatment.

CONCLUSION

Despite growing insights into the neuropathology associated with stimulant use disorder, treatment remains a challenge. The lack of effective interventions makes it difficult to give clear recommendations for the clinical practice. Further scientific research is thus warranted.

Extended observation of reduced methamphetamine use with combined naltrexone plus bupropion in the ADAPT-2 trial

BACKGROUND AND AIMS

A 12-week placebo-controlled, sequential parallel Accelerated Development of Additive Pharmacotherapy Treatment for Methamphetamine Use Disorder (ADAPT-2) trial evaluated the effects of extended-release injectable naltrexone plus extended-release oral bupropion (NTX + BUPN) on methamphetamine (MA) use over two stages. This study reports on the previously unpublished stage 2 MA use in participants randomized at stage 1 to receive NTX + BUPN through both stages compared with those assigned to placebo.

DESIGN

This is a secondary analysis of the US National Institute on Drug Abuse (NIDA) ADAPT-2 network trial.

SETTING

The parent ADAPT-2 trial was carried out across multiple NIDA Clinical Trials Network (CTN) sites in the United States.

PARTICIPANTS

This analysis includes 403 people with MA use disorder who participated in the ADAPT-2 CTN trial.

INTERVENTION AND COMPARATOR

NTX + BUPN was compared with placebo over the course of the trial.

MEASUREMENT

MA use was measured by urine drug screens conducted twice weekly for 12 weeks, then once in week 13 and once in week 16 post-treatment follow-up.

FINDINGS

Participants on NTX + BUPN in stage 1 showed an additional 9.2% increase [95% confidence interval (CI), 0.09%-17.9%, P = 0.038] during stage 2 in their probability of testing negative for MA, with a total increase of 27.1% (95% CI, 13.2%-41.1%, P < 0.001) over the full 12 weeks of treatment. In contrast, participants on placebo in both stages increased in probability of testing MA-negative by a total of 11.4% (95% CI, 4.1%-18.6%, P = 0.002) over all 12 weeks. The 12-week increase among participants on NTX + BUPN was significantly greater-by 15.8% (95% CI, 4.5%-27.0%, P = 0.006)-than the increase among those on placebo.

CONCLUSION

For people with methamphetamine (MA) use disorder receiving treatment with extended-release injectable naltrexone plus extended-release oral bupropion (NTX + BUPN), continued treatment with NTX + BUPN after 6 weeks is associated with additional reductions in MA use up to 12 weeks.

Structural Determinants of Health and Markers of Immune Activation and Systemic Inflammation in Sexual Minority Men With and Without HIV

Among sexual minority men (SMM), HIV and use of stimulants such as methamphetamine are linked with immune activation and systemic inflammation. Throughout the COVID-19 pandemic, SMM encountered financial challenges and structural obstacles that might have uniquely contributed to immune dysregulation and systemic inflammation, beyond the impacts of HIV and stimulant use. Between August 2020 and February 2022, 72 SMM with and without HIV residing in South Florida enrolled in a COVID-19 prospective cohort study. Multiple linear regression analyses examined unemployment, homelessness, and history of arrest as structural correlates of soluble markers of immune activation (i.e., sCD14 and sCD163) and inflammation (i.e., sTNF-α receptors I and II) at baseline after adjusting for HIV status, stimulant use, and recent SARS-CoV-2 infection. Enrolled participants were predominantly Latino (59%), gay-identified (85%), and with a mean age of 38 (SD, 12) years with approximately one-third (38%) of participants living with HIV. After adjusting for HIV status, SARS-CoV-2 infection, and recent stimulant use, unemployment independently predicted higher levels of sCD163 (β = 0.24, p = 0.04) and sTNF-α receptor I (β = 0.26, p = 0.02). Homelessness (β = 0.25, p = 0.02) and history of arrest (β = 0.24, p = 0.04) independently predicted higher levels of sCD14 after adjusting for HIV status, SARS-CoV-2 infection, and recent stimulant use. Independent associations exist between structural barriers and immune activation and systemic inflammation in SMM with and without HIV. Future longitudinal research should further elucidate complex bio-behavioral mechanisms linking structural factors with immune activation and inflammation.

Mediational pathways among drug use initiation, use-related consequences, and quit attempts

Background

Factors that predict attempts to discontinue drug use are clinically relevant and may inform treatment. This study investigated drug use-related consequences as a predictor of drug quit attempts and treatment seeking among two cohorts of persons who use drugs.

Methods

Drug use and clinical characteristics were assessed among persons who use cocaine (N=176; urine-verified; 'Cocaine Cohort') and among those who use heroin (N=166; urine-verified; 'Heroin Cohort'). Mediation analyses assessed relationships among age at initial drug use, adverse drug-specific use-related consequences, and drug-specific quit attempts, separately for each cohort. Forward conditional logistic regression models evaluated drug use and clinical symptom scores as predictors of drug-specific treatment seeking.

Results

Controlling for age, mediation models showed that drug use consequences fully mediated the relationship between age at initial drug use and number of drug-specific quit attempts for the 'Cocaine Cohort' and 'Heroin Cohort' (R2=0.30, p<.001; R2=0.17, p<.001; respectively). Reporting more consequences predicted more quit attempts in each cohort, accounting for duration of use (ps<.001). Reporting more consequences also predicted greater likelihood of seeking drug use treatment (ps<.001) and was associated with more severe clinical symptoms in each cohort (ps<.05).

Conclusions

Using a parallel analysis design, we showed that reporting more drug-specific use-related consequences predicted more drug-specific quit attempts and greater likelihood to seek treatment in two cohorts: persons who use cocaine and those who use heroin. Our findings suggest that experiencing more drug use consequences predicts more attempts to seek drug abstinence and that assessment of consequences may be informative for treatment.

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Reduced drug use as an alternative valid outcome in individuals with stimulant use disorders: Findings from 13 multisite randomized clinical trials

BACKGROUND AND AIMS

Total abstinence has historically been the goal of treatment for substance use disorders; however, there is a growing recognition of the health benefits associated with reduced use as a harm reduction measure in stimulant use disorders treatment. We aimed to assess the validity of reduced stimulant use as an outcome measure in randomized controlled trials (RCTs) of pharmacological interventions for stimulant use disorder.

DESIGN

We conducted a secondary analysis of a pooled dataset of 13 RCTs.

SETTING AND PARTICIPANTS

Participants were individuals seeking treatment for cocaine or methamphetamine use disorders (N = 2062) in a wide range of treatment facilities in the United States.

MEASUREMENTS

We validated reduced stimulant use against a set of clinical indicators drawn from harmonized measurements, including severity of problems caused by drug use, comorbid depression, global severity of substance use and improvement, severity of drug-seeking behavior, craving and high-risk behaviors, all assessed at the end of the trial, as well as follow-up urine toxicology. A series of mixed effect regression models was conducted to validate reduction in frequency of use against no reduction in use and abstinence.

FINDINGS

More participants reduced frequency of primary drug use than achieved abstinence (18.0% vs. 14.2%, respectively). Reduced use was significantly associated with decreases in craving for the primary drug [60.1%, 95% confidence interval (CI) = 54.3%-64.7%], drug seeking behaviors (41.0%, 95% CI = 36.6%-45.7%), depression severity (39.9%, 95% CI = 30.9%-48.3%), as well as multiple measures of global improvement in psychosocial functioning and severity of drug-related problems, albeit less strongly so than abstinence. Moreover, reduced use was associated with sustained clinical benefit at follow-up, as confirmed by negative urine tests (adjusted odds ratio compared with those with no reduction in use: 0.50, 95% CI = 0.35-0.71).

CONCLUSION

Reduced frequency of stimulant use appears to be associated with meaningful improvement in various clinical indicators of recovery. Assessment of reduced use, in addition to abstinence, could broaden the scope of outcomes measured in randomized controlled trials of stimulant use disorders and facilitate the development of more diverse treatment approaches.

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

Rethinking Substance Use as Social History: Charting a Way Forward

Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.

Loneliness, Methamphetamine Use, and Cardiovascular Risk Factors Among Sexual Minority Men in the COVID-19 Era

BACKGROUND

Important gaps exist in our understanding of loneliness and biobehavioral outcomes among sexual minority men (SMM), such as faster HIV disease progression. At the same time, SMM who use methamphetamine are approximately one-third more likely than non-users to develop cardiovascular disease. This study examined associations of loneliness, stimulant use, and cardiovascular risk in SMM with and without HIV.

METHOD

Participants were enrolled from August 2020 to February 2022 in a 6-month prospective cohort study. The study leveraged self-report baseline data from 103 SMM, with a subset of 56 SMM that provided a blood sample to measure markers of cardiovascular risk.

RESULTS

Loneliness showed negative bivariate associations with total cholesterol and LDL cholesterol in the cardiometabolic subsample (n = 56). SMM with methamphetamine use (t(101) = 2.03, p < .05; d = .42) and those that screened positive for a stimulant use disorder (t(101) = 2.07, p < .05; d = .46) had significantly higher mean loneliness scores. In linear regression analyses, negative associations of loneliness with LDL and total cholesterol were observed only among SMM who used methamphetamine.

CONCLUSION

We observed lower cholesterol in SMM reporting loneliness and methamphetamine use. Thus, in addition to the observed associations of loneliness with cholesterol, there are important medical consequences of methamphetamine use including cardiovascular risk, higher HIV acquisition risk and progression, as well as stimulant overdose death. This cross-sectional study underscores the need for clinical research to develop and test interventions targeting loneliness among SMM with stimulant use disorders.

Pre-COVID Trends in Substance Use Disorders and Treatment Utilization during Pregnancy in West Virginia 2016-2019

Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

Can telehealth expansion boost health care utilization specifically for patients with substance use disorders relative to patients with other types of chronic disease?

OBJECTIVE

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high risk of poor outcomes. Telehealth expansion may boost utilization, but it is unclear whether telehealth can increase utilization for patients with SUDs beyond that expected for other chronic diseases amenable to remote treatment, like type 2 diabetes. This information is needed by health systems striving to improve SUD outcomes, specifically. This study compared the impact of telehealth expansion during the COVID-19 public health emergency (PHE) on utilization for patients with SUDs and diabetes.

METHODS

Using Wisconsin Medicaid administrative, enrollment and claims data 12/1/2018-12/31/2020, this cohort study included nonpregnant, nondisabled adults 19-64 years with SUDs (N = 17,336) or diabetes (N = 8,499). Outcomes included having a primary care visit in the week (any, and telehealth) for any diagnosis, or a SUD or diabetes diagnosis; and the weekly fraction of visits completed by telehealth. Logistic and fractional regression examined outcomes pre- and post-PHE. Covariates included age, sex, race, ethnicity, income, geography, and comorbid medical and psychotic disorders.

RESULTS

Post-PHE, patients with SUDs exhibited greater likelihood of telehealth utilization (percentage point difference (PPD) per person-week: 0.2; 95% CI: 0.001-0.003; p<0.001) and greater fractional telehealth use (PPD: 1.8; 95%CI: 0.002-0.033; p = 0.025) than patients with diabetes despite a larger overall drop in visits (PPD: -0.5; 95%CI: -0.007- -0.003; p<0.001).

CONCLUSIONS

Following telehealth expansion, patients with SUDs exhibited greater likelihood of telehealth utilization than patients with diabetes. This advantage lessened the substantial PHE-induced healthcare disruption experienced by patients with SUDs. Telehealth may boost utilization for patients with SUDs.

Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry

BACKGROUND

In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.

METHODS

We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.

RESULTS

We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.

CONCLUSION

In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

The burden of skin and soft tissue, bone and joint infections in an Australian cohort of people who inject drugs

INTRODUCTION

There are currently limited data regarding the clinical and economic significance of skin and soft tissue infections (SSTI) and bone and joint infections in Australian people who inject drugs (PWID).

METHODS

Retrospective cohort study in adult PWID admitted to Monash Health, a large heath care network with six hospitals in Victoria, Australia. Inpatients were identified using administrative datasets and International Classification of Disease (ICD-10) coding for specific infection-related conditions. Cost analysis was based on mean ward, intensive care and hospital-in-the-home (HITH) lengths of stay. Spinal infections and endocarditis were excluded as part of previous studies.

RESULTS

A total of 185 PWID (61 female, 124 male, median age 37) meeting the study criteria were admitted to Monash Health between January 2010 and January 2021. Admitting diagnoses included 78 skin abscesses, 80 cellulitis, 17 septic arthritis, 4 osteomyelitis, 3 thrombophlebitis and 1 each of necrotising fasciitis, vasculitis and myositis. Pain (87.5%) and swelling (75.1%) were the most common presenting complaints. Opioids (67.4%) and methamphetamine (37.5%) were the most common primary drugs injected. Almost half (46.5%) of patients had concurrent active hepatitis C (HCV) infection on admission. Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) were uncommon. The most significant causative organism was methicillin-susceptible Staphylococcus aureus (24.9%). In 40.0% (74/185) no organism was identified. Patients required a median acute hospital stay of 5 days (2-51 days). There were 15 patients admitted to the intensive care unit (ICU) with median duration 2 days. PICC line insertion for antibiotics was required in 16.8% of patients, while 51.4% required surgical intervention. Median duration of both oral and IV antibiotic therapy was 11 days. Almost half (48.6%) of patients were enrolled in an opioid maintenance program on discharge. Average estimated expenditure was AUD $16, 528 per admission.

CONCLUSION

Skin and soft tissue and joint infections are a major cause of morbidity for PWID. Admission to hospital provides opportunistic involvement of addiction specialty services.

Stimulant Drugs and Stimulant Use Disorder

The authors aim to summarize several key points of stimulant drugs and stimulant use disorder, including their indications, short-term and long-term adverse effects, current treatment strategies, and association with opioid medications. The global prevalence of stimulant use has seen annual increase in the last decade. Multiple studies have shown that stimulant use and stimulant use disorder are associated with a range of individual and public health issues. Stimulant misuse has led to a significant increase of overdose deaths in the United States.

The Modulatory Effects of Atomoxetine on Aberrant Connectivity During Attentional Processing in Cocaine Use Disorder

BACKGROUND

Cocaine use disorder is associated with cognitive deficits that reflect dysfunctional processing across neural systems. Because there are currently no approved medications, treatment centers provide behavioral interventions that have only short-term efficacy. This suggests that behavioral interventions are not sufficient by themselves to lead to the maintenance of abstinence in patients with cocaine use disorder. Self-control, which includes the regulation of attention, is critical for dealing with many daily challenges that would benefit from medication interventions that can ameliorate cognitive neural disturbances.

METHODS

To address this important clinical gap, we conducted a randomized, double-blind, placebo-controlled, crossover design study in patients with cocaine use disorder (n = 23) and healthy control participants (n = 28). We assessed the modulatory effects of acute atomoxetine (40 mg) on attention and conflict monitoring and their associated neural activation and connectivity correlates during performance on the Eriksen flanker task. The Eriksen flanker task examines basic attentional processing using congruent stimuli and the effects of conflict monitoring and response inhibition using incongruent stimuli, the latter of which necessitates the executive control of attention.

RESULTS

We found that atomoxetine improved task accuracy only in the cocaine group but modulated connectivity within distinct brain networks in both groups during congruent trials. During incongruent trials, the cocaine group showed increased task-related activation in the right inferior frontal and anterior cingulate gyri, as well as greater network connectivity than the control group across treatments.

CONCLUSIONS

The findings of the current study support a modulatory effect of acute atomoxetine on attention and associated connectivity in cocaine use disorder.

The IMPACT (Infection Management Plus Addiction Care Together) Pilot: A Case Series of Combined Contingency Management for Substance Use Disorders and Antibiotic Adherence in the Hospital Setting

OBJECTIVES

Psychostimulant-related mortality is rising alongside increasing substance use-related hospitalizations, which are commonly complicated by patient-directed (or "against medical advice") discharges. Contingency management (CM) is an underused evidence-based treatment for substance use disorders with proven efficacy to support medication adherence. Our objective was to describe feasibility and preliminary effectiveness of a novel CM intervention incentivizing both drug use reduction and antibiotic adherence in the hospital setting.

METHODS

We conducted a pilot intervention of twice weekly CM for stimulant and/or opioid use disorder and antibiotic adherence conducted on inpatient wards and/or an embedded skilled nursing facility in an urban public hospital. Based on point-of-care urine drug test results and objective antibiotic adherence review, participants earned increasing opportunities to receive incentives. We measured feasibility via number of visits attempted and cost of gift cards dispensed. We evaluated effectiveness via antibiotic completion, discharge type, and participant perception of intervention effectiveness collected via structured survey.

RESULTS

Of 13 participants enrolled, most had opioid use disorder (fentanyl in 10/13) and stimulant use disorder (methamphetamine in 7/13). Almost all were receiving treatment for osteomyelitis and/or endocarditis (12/13). Feasibility challenges included competing demands of acute care with variable range of completed visits per participant (1-12 visits). Despite this, antibiotic completion was high (92%, 12/13 participants) with only two patient-directed discharges. Participants described CM as very effective in aiding infection treatment but had greater variability in beliefs regarding CM facilitation of reduced drug use.

CONCLUSIONS

Providing CM in the hospital setting may represent an effective approach to improving health outcomes by increasing antibiotic adherence and addressing substance use.

Perceptions of prospective pharmaceutical stimulant substitution treatments among people who use illicit stimulants in Vancouver, Canada

BACKGROUND

Stimulant-involved overdose deaths are increasing, driven by polysubstance use and adulteration of the illicit drug supply. While emerging evidence for prescription stimulant substitution is promising, there are no approved treatment options for stimulant use disorder that address the realities of an unpredictable drug supply. This study explores treatment experiences of people who use illicit stimulants (PWUS) to identify gaps and perceptions of prospective pharmaceutical stimulant substitution treatments (SST).

METHODS

In-depth qualitative interviews were conducted with 86 PWUS in Vancouver, Canada. Thematic analysis focused on experiences of available treatment options for stimulant use and perceptions of prospective SST.

RESULTS

Participants identified how primarily behavioral treatment approaches do not meet the unique needs of PWUS, in contrast with the range of medical treatments available for opioid use disorder. Participants anticipated health and social benefits if they were able to access SST, including avoiding the toxic illicit stimulant supply, reduced engagement in criminalized activities, and greater economic security. Perceptions of prospective SST were informed by knowledge of existing opioid treatments. This led some participants to be unsupportive of SST, citing concerns around agency and highly regulated operational contexts that do not align with the lived realities of stimulant use.

CONCLUSION

Findings demonstrate the need for SST pilot programs in real-world settings and underscore the health and social advantages SST may offer; although drawing on existing opioid treatment models to implement SST pilots may limit success. Thus, any novel treatments for stimulant use must centre the lived realities of PWUS.

Applications of TMS in individuals with methamphetamine use disorder: A review

Methamphetamine abuse results in a host of social and medical issues. Methamphetamine use disorder (MUD) can hinder the brain and impair cognitive functions and mental health. Transcranial magnetic stimulation (TMS) is a non-invasive approach in the treatment of MUD. Recent studies have demonstrated encouraging and positive effects of TMS on the craving, affective symptoms, sleep quality, and cognitive functions in individuals with MUD. The regulation of specific brain activities through TMS has also been found to be a contributing factor to these positive outcomes. It is essential to employ more techniques, participants, and stimulation parameters and targets in the future.

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

Gender identity, stimulant drug use, and criminal justice history on internalized stigma among a nationally representative sample of adults who misuse opioids

PURPOSE

The rise of fatal stimulant use among adults who use opioids is a public health problem. Internalized stigma is a barrier to substance use treatment, which is greater for women and populations with criminal justice involvement.

METHODS

Using a nationally representative sample of adults in the United States from a probability-based survey on household opinions in 2021, we examined characteristics of women (n = 289) and men (n = 416) who misuse opioids. In gender-stratified multivariable linear regression, we investigated factors associated with internalized stigma, and tested for the interaction of stimulant use and criminal justice involvement.

RESULTS

Compared to men, women reported greater mental health symptom severity (3.2 vs. 2.7 on a 1 to 6 scale, p < 0.001). Internalized stigma was similar between women (2.3 ± 1.1) and men (2.2 ± 0.1). Among women and not men, however, stimulant use was positively associated with internalized stigma (0.36, 95% CI [0.07, 0.65]; p = 0.02). Interaction between stimulant use and criminal justice involvement was negatively associated with internalized stigma among women (- 0.60, 95% CI [- 1.16, -0.04]; p = 0.04); among men, the interaction was not significant. Predictive margins illustrate among women, stimulant use eliminated the gap in internalized stigma such that women with no criminal justice involvement had a similar level of internalized stigma as women with criminal justice involvement.

CONCLUSION

Internalized stigma between women and men who misuse opioids differed based on stimulant use and criminal justice involvement. Future research should assess whether internalized stigma influences treatment utilization among women with criminal justice involvement.

The impact of fentanyl on state- and county-level psychostimulant and cocaine overdose death rates by race in Ohio from 2010 to 2020: a time series and spatiotemporal analysis

BACKGROUND

Over the past decade in the USA, increases in overdose rates of cocaine and psychostimulants with opioids were highest among Black, compared to White, populations. Whether fentanyl has contributed to the rise in cocaine and psychostimulant overdoses in Ohio is unknown. We sought to measure the impact of fentanyl on cocaine and psychostimulant overdose death rates by race in Ohio.

METHODS

We conducted time series and spatiotemporal analyses using data from the Ohio Public Health Information Warehouse. Primary outcomes were state- and county-level overdose death rates from 2010 to 2020 for Black and White populations. Measures of interest were overdoses consisting of four drug involvement classes: (1) all cocaine overdoses, (2) cocaine overdoses not involving fentanyl, (3) all psychostimulant overdoses, and (4) psychostimulant overdoses not involving fentanyl. We fit a time series model of log standardized mortality ratios (SMRs) using a Bayesian generalized linear mixed model to estimate posterior median rate ratios (RR). We conducted a spatiotemporal analysis by modeling the SMR for each drug class at the county level to characterize county-level variation over time.

RESULTS

In 2020, the greatest overdose rates involved cocaine among Black (24.8 deaths/100,000 people) and psychostimulants among White (10.1 deaths/100,000 people) populations. Annual mortality rate ratios were highest for psychostimulant-involved overdoses among Black (aRR = 1.71; 95% CI (1.43, 2.02)) and White (aRR = 1.60, 95% CI (1.39, 1.80)) populations. For cocaine not involving fentanyl, annual mortality rate ratios were similar among Black (aRR = 1.04; 95% CI (0.96,1.16)) and White (aRR = 1.02; 95% CI (0.87, 1.20)) populations. Within each drug category, change over time was similar for both racial groups. The spatial models highlighted county-level variation for all drug categories.

CONCLUSIONS

Without the involvement of fentanyl, cocaine overdoses remained constant while psychostimulant overdoses increased. Tailored harm reduction approaches, such as distribution of fentanyl test strips and the removal of punitive laws that influence decisions to contact emergency services, are the first steps to reduce cocaine overdose rates involving fentanyl among urban populations in Ohio. In parallel, harm reduction policies to address the increase in psychostimulant overdoses are warranted.

Associations between stimulant use and return to illicit opioid use following initiation onto medication for opioid use disorder

AIM

The aim of this study was to estimate how ongoing stimulant use affects return to illicit opioid use after initiation onto medication for opioid use disorder (MOUD).

DESIGN

This was a secondary analysis of pooled data from two clinical trials comparing buprenorphine (BUP-NX) and extended-release naltrexone (XR-NTX).

SETTING

Thirteen opioid treatment programs and HIV clinics across 10 states in the United States from 2014 to 2019 took part in this study.

PARTICIPANTS

A total of 528 participants who initiated MOUD as part of trial participation were included. Nearly half (49%) were between 30 and 49 years of age, 69% were male and 66% were non-Hispanic White.

MEASUREMENTS

The primary outcome was first self-reported day of non-prescribed opioid use following MOUD initiation, and the exposure of interest was daily stimulant use (methamphetamine, amphetamines or cocaine). Both were defined using time-line follow-back. Among participants reporting at least 1 day of illicit opioid use, we also examined relapse to ongoing use, defined as (1) 7 days of continuous opioid use or (2) 4 consecutive weeks with self-reported opioid use, one or more positive urine drug screens (UDS) for opioids or one or more missing UDS.

FINDINGS

Forty-seven per cent of participants reported stimulant use following MOUD initiation, 58% returned to illicit opioid use and 66% of those relapsed to ongoing use. Stimulant use was strongly associated with increased risk of misusing opioids after MOUD initiation when measured daily [adjusted hazard ratio (aHR) = 9.23, 95% confidence interval (CI) = 6.80-12.50, P < 0.001] and over a 7-day period (aHR = 1.27 for each additional day, CI = 1.18-1.37, P < 0.001). Using stimulants weekly or more often was associated with increased likelihood of relapse to ongoing opioid use compared with less than weekly or no stimulant use (adjusted odds ratio = 2.30, CI = 1.05-5.39, P = 0.044).

CONCLUSIONS

People initiated on medication for opioid use disorder who subsequently use stimulants appear to be more likely to return to and continue using non-prescribed opioids compared with those without stimulant use. The association appears to be stronger among patients who initiate buprenorphine compared with those who initiate extended-release naltrexone.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities

BACKGROUND

We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time.

METHODS

We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable.

RESULTS

We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29).

CONCLUSIONS

Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

Kratom (Mitragyna speciosa) use in a sample of drug-dependent adolescents in rehabilitation for drug use in Malaysia

BACKGROUND

Leaves derived from the Kratom (Mitragyna speciosa) tree have been traditionally ingested for their curative properties by diverse groups of the population including people who use drugs (PWUDs) in Southeast Asia. This study investigated the motives for using kratom among drug-dependent adolescents.

METHODS

Eighty adolescents who were undergoing mandatory drug rehabilitation volunteered to participate in this mixed-method, cross-sectional study. All respondents answered a semi-structured questionnaire while a few were interviewed in-depth.

RESULTS

The majority were males (70%, n = 56/80). The respondents' mean age at admission was 18.2 years (SD = 1.40), and 65% were between 14 and 18 years old. Sixty-three percent (n = 50/80) had used crystal methamphetamine alone, while the rest had co-used crystal methamphetamine with heroin. About three-fifths (60%, n = 48/80) had a history of kratom use. Kratom was commonly used for many perceived benefits such as increasing energy, reducing crystal methamphetamine intake, intensifying euphoria, easing heroin withdrawal, as a heroin substitute and reducing heroin use. In addition, the multivariate analysis indicated that higher odds of kratom use were associated with those who were employed, used only crystal methamphetamine, were recent drug users, and had no prior incarceration history.

CONCLUSION

While kratom was being used for its multifold perceived benefits, it also functions as a means to self-treat withdrawal from illicit drug use among drug-dependent adolescents.

Implementing Heart Plus: Design and Early Results of a Novel Comanagement Clinic for Patients With Stimulant-associated Cardiomyopathy

We describe the methodology, design, and early results of a novel multidisciplinary co management clinic model with Addiction Medicine and Cardiology providers using contingency management to engage patients with stimulant-associated cardiomyopathy (SA-CMP). Stimulant use, including methamphetamine and cocaine, is increasing in prevalence nationally and is associated with cardiovascular complications. People with SA-CMP have higher rates of mortality and acute care use (eg, emergency department visits, hospital admissions) and lower rates of outpatient care engagement than individuals with non-SA-CMP. This population also has disproportionately elevated rates of mental health and other medical comorbidities, challenges with social determinants of health, including housing and food insecurity, and representation from communities of color. This multidisciplinary comanagement care delivery model, called Heart Plus, was developed and funded as a quality improvement project. It led to a 5-fold increase in outpatient care engagement with a concomitant 53% decrease in acute care use. All participants reported a decrease in stimulant use. With increased clinical stability, patients were able to better engage with outpatient resources for social determinants of health, such as case management, social work, and housing and food service programs. Patients were also empowered to take control over their health while knowing that health care providers cared about their well-being.

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.

The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Impact of COVID-19 on stimulant use disorder treatment: A national cohort study in the Veterans Health Administration

OBJECTIVE

Rates of stimulant overdose have increased dramatically, which may have been exacerbated by treatment disruptions during the pandemic, but no recent studies have examined use of stimulant use disorder (StUD) treatment.

METHODS

In this retrospective cohort study (March 2018 to February 2022) of national Veterans Health Administration patients, we use an interrupted time-series analysis to examine the impact of COVID-19 (starting in March 2020) on treatment use for StUD.

RESULTS

The number of patients receiving StUD care was increasing pre-COVID (22,640-23,020, February 2018-February 2020) but dropped post-pandemic to 18,578 in February 2022. The monthly number of patients receiving StUD care increased by 34.6 patients per month (95% CI, 1.1-68.0; P=0.04) before March 2020, decreased by 2803.3 patients (95% CI, -3912.3 to -1694.3; P <0.001) in March 2020, and, accounting for pre-COVID trends, further decreased by 85.85 patients per month (95% CI,-148.9.2 to -23.0; P =0.01) after March 2020.

CONCLUSIONS

Care for StUD drastically declined during the COVID-19 pandemic and has yet to show signs of a return to pre-pandemic levels despite surging rates of stimulant-involved overdose deaths and a critical need to engage people with StUD in care.

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.

The effectiveness of oxytocin in the treatment of stimulant use disorders: a systematic review

OBJECTIVES

The purpose of this review is to examine human study evidence on the effectiveness of oxytocin in this patient population. Despite stimulant use disorder being a major public health concern, there are no validated pharmacological treatments. Psychosocial interventions show limited effectiveness especially in the more severe cases of stimulant use disorder, whereas animal models suggest that oxytocin may be a useful treatment.

METHODS

A literature search using Medline, Embase, and PsychInfo was undertaken. Search results were subsequently imported into Covidence to identify relevant studies.

RESULTS

Six studies were included in this review, two of which were pilot studies. Although oxytocin was well tolerated across studies, no study showed a statistically significant reduction in reported cocaine use or cravings. One study suggested oxytocin increased the desire to use cocaine, although the population of participants should be taken into consideration. In contrast, one study showed a trend towards reduced self-reported cocaine use.

CONCLUSION

Available research does not support the use of oxytocin in the management of stimulant use disorder; however, included studies are small in sample size and limited in number. There were several noteworthy findings unrelated to this review's primary and secondary outcomes, which are of interest and warrant further research. We provide suggestions for future studies in this area of research. Considering the limited data available at this time, further studies are required before any definitive conclusions can be made regarding the use of oxytocin in stimulant use disorder management.

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

Perioperative Considerations for Patients Exposed to Psychostimulants

Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.

Adverse drug effects as a deterrent against willingness to use in the future among nightclub/festival attendees

INTRODUCTION

It is largely unknown whether adverse effects experienced from recreational drug use affect willingness to use again. This study determined whether adverse effects from select party drugs affect reported willingness to use again in the next month among a high-risk population-people who attend electronic dance music parties at nightclubs or dance festivals.

METHODS

Adults (age ≥ 18) entering nightclubs/festivals were surveyed in New York City in 2018-2022 (n = 2981). Participants were asked about past-month use of common party drugs (cocaine, ecstasy, lysergic acid diethylamide [LSD] and ketamine), whether they had experienced a harmful or very unpleasant effect after use in the past 30 days, and whether they intend to use again in the next 30 days if offered by a friend. The relationship between having experienced an adverse outcome and willingness to use again was examined in a bivariable and multivariable manner.

RESULTS

Experiencing an adverse effect after past-month cocaine (adjusted prevalence ratio [aPR] = 0.58, 95% confidence interval [CI] 0.35-0.95) or ecstasy use (aPR = 0.45, 95% CI 0.25-0.80) was associated with lower risk for willingness to use again. Adverse effects related to LSD use were related to lower risk of being willing to use again in the bivariable model, but in multivariable models, risk was not attenuated for willingness to use LSD or ketamine again.

DISCUSSION AND CONCLUSIONS

Personally experienced adverse effects can deter willingness to use certain party drugs again in this high-risk population. Interventions targeting cessation of recreational party drug use can likely benefit from focusing on deleterious effects of use that have been experienced.

Perspectives and sentiments on contingency management from people who use methamphetamine

INTRODUCTION

Contingency management (CM) is currently the most efficacious treatment for methamphetamine use, yet it is rarely available in routine care. We examined the viewpoints of people who use methamphetamine on CM as a potential treatment for methamphetamine use disorder.

METHODS

Semi-structured qualitative interviews with 30 Australians aged 18 years or older who had used methamphetamine at least weekly in the past 6 months.

RESULTS

Participants reported overall positive attitudes towards CM as a potential treatment option for methamphetamine use disorder. However, there was need for greater flexibility in meeting participant treatment goals (e.g., reduced use or complete abstinence), with particular concern about the viability of initiating abstinence, both in terms of the sufficiency of the initial financial incentive and managing withdrawal symptoms. There was strong interest in the use of digital technologies to provide remote CM, particularly around the convenience and flexibility this offered. Despite this, participants remained keen to access adjunctive treatment and support services but stressed that engagement with these additional services should not be mandatory. Marketing of CM will need to address preconceptions about drug-testing used in abstinence-based CM being punitive (especially urine testing) and its connotations with criminal justice interventions.

DISCUSSION AND CONCLUSION

Positive attitudes towards CM bode well for potential uptake should CM be made available in routine clinical practice. However, there is a need to adapt CM to ensure it is feasible and attractive to people who are seeking treatment for methamphetamine use disorder.

Mortality during and after specialist alcohol and other drug treatment: Variation in rates according to principal drug of concern and treatment modality

INTRODUCTION

For people accessing treatment for problems with drugs other than opioids, little is known about the relationship between treatment and mortality risk, nor how mortality risk varies across treatment modalities. We addressed these evidence gaps by determining mortality rates during and after treatment for people accessing a range of treatment modalities for several drugs of concern.

METHODS

We conducted a cohort study using linked data on publicly funded specialist alcohol or other drug treatment service use and mortality for people receiving treatment in New South Wales between January 2012 and December 2018. We calculated and compared during-treatment and post-treatment crude mortality rates and age- and sex-standardised mortality rates, separately for each principal drug of concern and modality.

RESULTS

Over the study period, 45,026 people accessed treatment for problems with alcohol, 26,407 for amphetamine-type stimulants, 23,047 for cannabinoids and 21,556 for opioids. People treated for alcohol or opioid problems had higher crude mortality rates (1.48, 1.91, 1.09 per 100 person years, respectively) than those with problems with amphetamine-type stimulants or cannabinoids (0.46, 0.30 per 100 person years, respectively). Mortality rates differed according to treatment status and modality only among people with alcohol or opioid problems.

DISCUSSION AND CONCLUSIONS

The observed variation in mortality rates indicates there is scope to reduce mortality among people accessing treatment with alcohol or opioid problems. Future research on mortality among people accessing drug and alcohol treatment should account for the variation in mortality by drug of concern and treatment modality.

The impact of methamphetamine use on medications for opioid use disorder (MOUD) treatment retention: a scoping review

BACKGROUND

An emerging public health threat of methamphetamine/opioid co-use is occurring in North America, including increases in overdoses related to concomitant methamphetamine/opioid use. This presents a potential risk to established treatments for opioid use disorder (i.e., medications for opioid use disorder [MOUD]). To date, few studies have examined the impact of methamphetamine use on MOUD-related outcomes, and no studies have synthesized data on MOUD retention.

METHODS

A scoping review was undertaken to examine the impact of methamphetamine use on MOUD retention. All original published research articles were searched in Embase, MEDLINE, PsychINFO, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Protocols, and Google scholar databases. Data were extracted into a standardized data extraction chart. Findings were presented narratively.

RESULTS

All eight included studies demonstrated an increased likelihood of treatment discontinuation or dropout among patients enrolled in MOUD who used methamphetamine. The frequency of methamphetamine use was also associated with MOUD dropout, in that those who used methamphetamine more often were more likely to discontinue MOUD. The definitions and measurements of MOUD retention varied considerably, as did the magnitude of effect size.

CONCLUSIONS

Results indicate that methamphetamine use has an undesirable impact on MOUD retention and results in an increased risk of treatment discontinuation or dropout. Strategies to identify concurrent methamphetamine use among individuals engaging in MOUD and educate them on the increased risk for dropout should be undertaken. Further research is needed to understand how MOUD retention among patients with concomitant opioid and methamphetamine use can be improved.

Validation of Two Diagnostic Assessments for Opioid and Stimulant Use Disorder for Use by Non-Clinicians

Objective

The United States is in the fourth wave of the opioid epidemic marked by the increase in fentanyl and co-occurring stimulant use related overdose deaths. Measures are needed to quickly diagnose opioid and stimulant use disorders, yet current traditional diagnostic assessments pose barriers to providing rapid diagnoses.

Methods

This study aimed to (1) validate an updated version of the Rapid Opioid Dependence Screen (RODS) from DSM-IV criteria for opioid dependence to the now DSM-5 moderate-to-severe opioid use disorder, the Rapid Opioid Use Disorder Assessment (ROUDA); and (2) create and validate the Rapid Stimulant Use Disorder Assessment to DSM-5 stimulant use disorder (RSUDA) when compared to the substance use disorder module from the DSM-5 version of the Mini International Neuropsychiatric Interview.

Results

One-hundred and fifty adults completed study assessments, 122 reported opioid misuse and 140 reported stimulant misuse within their lifetime. The ROUDA had a sensitivity of 82.5% (95% confidence interval [CI] 75.7, 89.2), specificity of 100.0% (95% CI: 100, 100), and strong internal consistency α = 0.94. The RSUDA had similarly high sensitivity (83.8%, 95% CI: 77.7, 89.9), specificity (91.4%, 95% CI: 86.8, 96.1), and internal consistency α = 0.87. The ROUDA and RSUDA are efficient and valid measures that can be administered in various settings by non-clinical staff to rapidly diagnose opioid and stimulant use disorders and allow for immediate treatment and harm reduction interventions.

Conclusions

The ROUDA and RSUDA are efficient and valid measures that can be administered by non-clinicians to rapidly diagnose opioid and stimulant use disorders.

Use of Cannabis as a Harm Reduction Strategy Among People Who Use Drugs: A Cohort Study

Introduction: While substance use contributes to a substantial burden of disease, access to evidence-based harm reduction interventions remains limited or inaccessible. Preliminary research suggests that some individuals use cannabis to reduce the harms associated with their use of other substances, including opioids and stimulants. This study examines factors associated with the self-reported use of cannabis for harm reduction among people who use drugs (PWUD). Methods: We drew data from three prospective, community-recruited cohorts of PWUD in Vancouver, Canada, between June 2016 and May 2018. Multivariable generalized linear mixed-effects modeling was used to examine factors associated with the primary outcome of "use of cannabis for harm reduction," defined as self-reported use of cannabis to substitute for other substances, treat withdrawal, or come down off other drugs. Results: One thousand nine hundred thirty-six participants contributed 5706 observations. In adjusted analyses, daily methamphetamine use (adjusted odds ratio [AOR]=1.43, 95% confidence interval [CI]: 1.09-1.89), experiencing barriers to accessing addiction treatment (AOR=1.92, 95% CI: 1.21-3.03), and enrollment in addiction treatment modalities other than opioid agonist therapy (AOR=1.64, 95% CI: 1.17-2.29) were positively associated with using cannabis for harm reduction. Older age was negatively associated (AOR=0.97, 95% CI: 0.95-0.98). Among 1281 (66.2%) participants who use cannabis, daily cannabis use and obtaining cannabis from unregulated dispensaries were also independent correlates of using cannabis for harm reduction. Discussion and Conclusions: Individuals who were more likely to use cannabis for harm reduction reported difficulty accessing addiction treatment or used substances, such as methamphetamines, where effective treatments are limited. These findings highlight the need to better understand the potential harm-reducing impacts of cannabis among PWUD in these scenarios.

Trends in substance use disorder diagnoses among Veterans, 2009-2019

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data.

METHODS

We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD.

RESULTS

Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances.

DISCUSSION AND CONCLUSIONS

Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults.

SCIENTIFIC SIGNIFICANCE

These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.

Starting the Discussion: A Call to Enhance Care for People With Stimulant Use Disorder

Stimulant use disorder (StUD) significantly contributes to substance-related morbidity and mortality in the United States. Overshadowed by the country's focus on opioid-related overdose deaths, stimulant and stimulant/opioid overdose deaths have increased dramatically over the last decade. Many individuals who use stimulants illicitly or have StUD have multiple, intersecting stigmatized characteristics which exacerbate existing barriers and create new obstacles to attaining addiction treatment. Illicit stimulant use, StUD, and stimulant-related overdose disproportionately impact minoritized racial and gender, and sexuality diverse groups. Historically, people who use illicit stimulants and those with StUD have been highly stigmatized, criminalized, and overly ignored by health care providers, policymakers, and the public compared to people who use other drugs and alcohol. As a result, most people needing treatment for StUD do not receive it. This is partly due to the lack of evidence-based treatment for StUD, which has resulted in few programs specializing in the care of people with StUD. The lack of available treatment is compounded by high rates of StUD in marginalized groups already reluctant to engage with the health care system. As health care professionals, we can improve outcomes for people with StUD by changing how we talk about, document, and respond to illicit stimulant use, related characteristics, behaviors, and social and structural determinants of health. To do this, we must seek to understand the lived realities of people with StUD and illicit stimulant use and use this knowledge to amend existing models of care.

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

INTRODUCTION

Contingency management (CM) is an efficacious treatment for stimulant use disorders. Research has developed support materials for the clinical delivery of prize-based CM and they are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap.

METHOD/RESULTS

The article outlines a suggested prize CM protocol and discusses the best practices most aligned with evidence-based practices and acceptable-if-necessary modifications. The article also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation.

CONCLUSIONS

Deviations 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.

Identifying early intervention opportunities for illicit stimulant use: A cross-sectional study of factors associated with illicit stimulant use among young people accessing integrated youth services in British Columbia, Canada

INTRODUCTION

Illicit stimulant (cocaine and/or amphetamine) use among young people aged 12-24 is a public health priority given that substance use initiation tends to peak in this developmental period and significant associated immediate and long-term harms are associated with its use. Young people using stimulants must be engaged in services as early as possible to reduce these harms. To inform early intervention opportunities, this study aimed to identify the risk/protective factors associated with illicit stimulant use among young people.

METHODS

We conducted a cross-sectional study on routinely collected self-reported data among young people accessing integrated youth services in British Columbia (Canada) between April 2018 and January 2022. Data were collected on young peoples' socio-demographic characteristics, and social, behavioral, and health profiles. Variable selection was guided by established risk/protective factors for substance use among young people. The study used multivariable logistic regression to identify risk/protective factors that were independently associated with past 30-day illicit stimulant use.

RESULTS

The analytic sample included n = 5620 young people aged 12-24 and a total of 163 (2.9 %) reported past 30-day illicit cocaine and/or amphetamine use. Demographic characteristics that were independently associated with illicit stimulant use included older age (aOR = 1.27, 95 % CI = 1.17-1.38) and gender identity as man vs woman (aOR = 1.71, 95 % CI = 1.10-2.70). Social and environmental risk factors included recently witnessing or experiencing violence (aOR = 2.32, 95 % CI = 1.47-3.68) and higher past-year crime/violent behaviors score (aOR = 1.39, 95 % CI = 1.13-1.69). Finally, regular alcohol (aOR = 6.90, 95 % CI = 2.36-25.42), regular (aOR = 3.74, 95 % CI = 1.95-7.54) or social (aOR = 3.06, 95 % CI = 1.44-6.60) tobacco use, and lifetime hallucinogen (aOR = 3.24, 95 % CI = 1.8-5.91) and ecstasy/MDMA (aOR = 2.53, 95 % CI = 1.48-4.39) use were also statistically significant risk factors.

CONCLUSIONS

These risk/protective factors support identification of young people who may benefit from further screening, assessment, and treatment for illicit stimulant use. This study also underscores the need to expand early intervention and harm reduction programs that can comprehensively respond to young peoples' stimulant use, health, and social needs.

Suspected Nonfatal Cocaine-Involved Overdoses Overall and With Co-involvement of Opioids

CONTEXT

The Centers for Disease Control and Prevention (CDC) developed a syndrome definition for detection of suspected nonfatal cocaine-involved overdoses. The definition can be used to monitor trends and detect anomalies in emergency department (ED) syndromic surveillance data at the national, state, and local levels.

OBJECTIVE

This study describes the development of the nonfatal, unintentional/undetermined intent cocaine-involved overdose (UUCOD) definition and analysis of trends over time.

DESIGN/SETTING

CDC developed the UUCOD definition to query ED data in CDC's National Syndromic Surveillance Program (NSSP). Data between 2018 and 2021 were analyzed from 29 states sharing data access in the Drug Overdose Surveillance and Epidemiology (DOSE) System via NSSP. Using Joinpoint regression, trends were analyzed for UUCOD overall, by sex and age group, and for UUCOD co-involving opioids.

MEASURES

Time trends between 2018 and 2021 were analyzed by examining average monthly percentage change. Individual trend segments and trend inflection points were analyzed by examining monthly percentage change.

RESULTS

During 2018-2021, a total of 27 240 UUCOD visits were identified by the syndrome definition. Analyses identified different patterns in trends for males and females, with largely similar trends for persons aged 15 to 44 years and 45 years or older. Analyses also identified seasonal patterns with increases in spring/summer months in UUCOD overall and UUCOD co-involving opioids and declines for both in fall/winter months.

CONCLUSION

This UUCOD syndrome definition will be useful for ongoing monitoring of suspected nonfatal overdoses involving cocaine and co-involving cocaine and opioids. Ongoing assessment of cocaine-involved overdose trends might identify anomalies requiring further investigation and inform deployment of resources.