Stimulant Use Disorder

Educational Objectives

The goal of this program is to improve the management of stimulant use disorder. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose substance use disorder using the 4 C’s.
2. Optimize use of medications to treat methamphetamine use disorder.

Summary

Methamphetamine Use Disorder (MUD)

Introduction: stimulant drugs produce a temporary increase in the functional activity or efficiency of an organism or any of its parts; meth or amphetamines are used for attention-deficit/hyperactivity disorder (ADHD) or off-label for other purposes; cocaine increases energy and alertness; individuals with undiagnosed ADHD slow down with amphetamine, meth, or cocaine use (indicating the presence of untreated ADHD); meth helps with libido (for some) and euphoria; some individuals may start using meth to keep themselves awake and alert; caffeine is the most commonly used stimulant with lesser adverse effects

Mechanism of action of meth: meth is a synthetic drug that works by releasing neurotransmitters that create euphoria; its repeated use activates the brain’s reward system by inducing neuroadaptations, particularly in the mesolimbic system; this reinforces continued use, despite negative consequences; meth is consumed in various forms, eg, pills, powder, rock (smoked on foil), injections

Physical impacts of meth: its active use results in anxiety, palpitations, cardiac involvement, trouble sleeping, other comorbid psychiatric conditions, headaches, lack of appetite, skin irritation, open sores, and significant tooth and gum issues; overamping, ie, the overuse of meth in patients with active use causes significant adverse effects, eg, paranoia, stroke, increased heart rate, increased blood pressure, seizures, death

Long-term meth use impacts: overdose death, contraction of hepatitis B, hepatitis C, and HIV infection, and syphilis (associated with injectable meth use and uninhibited sexual activity), unplanned pregnancies, meth-induced heart failure, respiratory issues, and mental health issues, eg, depression, anxiety, possibility of suicide; recovery is possible for meth use but takes time, eg, 2 to 3 yr; some damages, eg, consequences of stroke or heart failure, can be permanent

Diagnosis: genetics and environment play a role in meth use initiation; if someone has >7 adverse childhood experiences in their lifetime, they are more likely to engage in chronic substance use as they age; in addition, if they have a genetic predisposition, consider preventive strategies at primary care

Diagnostic criteria: the 4 C’s for diagnosing substance use disorders (SUD) are cravings, compulsive substance use, loss of control, and consequences; tolerance and withdrawal can occur in the absence of an SUD, eg, stopping prescribed opioids; the severity of a SUD is classified as mild (2-3 criteria), moderate (4-5 criteria), or severe (>6 criteria), based on the number of diagnostic criteria met

Off-label Medications and Management of MUD

Overview: there are no US Food and Drug Administration-approved treatments for MUD; the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry consensus has not found any definitive effective treatment strategy for MUD; buprenorphine plus naloxone (Suboxone) is used to treat opioid use disorder and is not effective for MUD; treatment depends on the drug of choice; opioids (eg, fentanyl) and meth are often used together (“speedballing”); off-label medications can be used, but they may not always be effective for MUD

Mirtazapine: in 2 studies, mirtazapine use resulted in a small reduction in amphetamine use, a significant reduction in sexual risk behaviors, and a positive effect on sleep, and weight gain; according to ASAM, clinicians can consider prescribing mirtazapine (preferable to no treatment); prescribe with caution in patients with a history of mental health issues, suicidality, manic depression, eating disorders, and congestive heart failure (CHF; low doses recommended)

Bupropion (Aplenzin, Wellbutrin): bupropion alone is not as effective for individuals with amphetamine use disorder; abstinence outcomes are better (vs cocaine use disorder); it should not be used for patients with a history of seizures (lowers threshold) or mental health issues that may worsen, eg, anxiety; it should also be prescribed with caution in patients with alcohol use and CHF; it is effective for treating sporadic meth users (ie, meth use for <18 days per mo)

Topiramate (Topamax): it is often used for treating alcohol use; it helps with weight loss; it has a worse adverse effect profile compared with bupropion and mirtazapine

Naltrexone extended-release injectable (Vivitrol): it can be used to treat individuals using opioids, eg, fentanyl and meth; 7 days of oral administration of naltrexone may be required in some states; it is an expensive drug and has a difficult prior authorization process; oral naltrexone (an opioid antagonist) counteracts the buprenorphine-naloxone combination and should not be administered together (ineffective); studies show that the combination of extended-release injectable naltrexone (intramuscular only) plus oral extended-release bupropion (450 mg per day) is the most effective

Psychostimulant medications: these can be prescribed for patients with MUD who have undiagnosed or untreated ADHD and are strongly recommended for patients with confirmed ADHD (extended-release psychostimulants); frequent in-person visits and urine drug screenings are required because of the concern about drug diversion; electrocardiography and blood pressure monitoring are essential because of cardiac concerns; these can be used for initiating treatment in individuals using meth for >10 days per month

Managing acute meth intoxication: β-blockers can be considered; ASAM states first-line treatment is benzodiazepines and considers these a high-certainty treatment as they reduce heart rate and help with psychotic features, anxiety, and seizure activity; as meth use induces arrhythmias, auscultation is vital

Managing meth withdrawal: withdrawal symptoms, eg, cravings to eat more or use meth, increased depression, anxiety, or paranoia, can last for ≈14 days; some may experience intense cravings for meth for >5 wk; symptomatic treatment can be provided; aripiprazole (Abilify) or buprenorphine may be prescribed (no proven efficacy)

Contingency management: is effective in managing MUD; the patients are given tangible rewards, eg, a gift card of some amount, to reinforce positive behaviors, eg, treatment attendance (showing up), irrespective of the presence of meth in urine; studies show significant benefit and positive outcomes with contingency management for MUD; positive reinforcement helps in rewiring the brain’s reward system; contingency management has been proven significantly effective for any therapeutic intervention, particularly for MUDs; it is cost-effective; ASAM guidelines strongly recommend referral to cognitive behavioral therapy

Harm reduction: patients should be monitored for return to meth use; abstinence alone does not work; reducing use over time is effective for stimulants, eg, meth and cocaine; it is important to obtain permission and explain confidentiality before screening someone for a use disorder; patients are initially asked to fill out the Screening, Brief Intervention, and Referral to Treatment (SBIRT) form; the Alcohol Use Disorders Identification Test (AUDIT) is the 10-item screening tool for alcohol use; the Drug Abuse Screening Test (DAST-10) enables identification of the substance used; the Community Reinforcement and Family Training (CRAFT) can be used for children (≤21 yr of age)

Takeaway: it is important to spend some time with teenagers and encourage them to fill out the forms without their parents in the room; a detailed substance history and evaluation should be obtained for a positive MUD screen (strong ASAM recommendation); if urine drug screens in patients using meth are positive for other substances, reconfirmation is essential before any clinical decisions, as they may be false positives

Readings

Boness CL, Carlos Gonzalez J, Sleep C, et al. Evidence-based assessment of substance use disorder. Assessment. 2024;31(1):168-190. doi: 10.1177/10731911231177252 View Article; Clinical Guideline Committee (CGC) Members; ASAM Team; AAAP Team; IRETA Team. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024;18(1S Suppl 1):1-56. doi:10.1097/ADM.0000000000001299 View Article; Dominguez-Lopez S, Ahn B, Sataranatarajan K, et al. Long-term methamphetamine self-administration increases mesolimbic mitochondrial oxygen consumption and decreases striatal glutathione. Neuropharmacology. 2023;227:109436. doi:10.1016/j.neuropharm.2023.109436 View Article; Li MJ, Chau B, Belin T, et al. Extended observation of reduced methamphetamine use with combined naltrexone plus bupropion in the ADAPT-2 trial. Addiction. 2024;119(10):1840-1845. doi:10.1111/add.16529 View Article; Mansergh G, Purcell DW, Stall R, et al. CDC consultation on methamphetamine use and sexual risk behavior for HIV/STD infection: summary and suggestions. Public Health Rep. 2006;121(2):127-132. doi:10.1177/003335490612100205 View Article; McPherson SM, Burduli E, Smith CL, et al. A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies. Subst Abuse Rehabil. 2018;9:43-57. doi:10.2147/SAR.S138439.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Hallock-Koppelman’s lecture contains information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Hallock-Koppelman was recorded at the 55th Annual Primary Care Review, held February 12-16, 2024, in Portland, OR, and presented by Oregon Health and Science University. For information on upcoming CME activities from this presenter, please visit ohsu.edu/school-of-medicine/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

FP724202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.