New Guidance on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) have joined forces and issued an evidence-based clinical practice guideline on the management of stimulant use disorder (StUD).

"This clinical practice guideline by ASAM and AAAP is the first of its kind that synthesizes prevention, intoxication management, withdrawal, harm reduction, evidence-based medications, and psychosocial treatment in a single, comprehensive guideline that speaks to the best practices for treating StUD," Brian Hurley MD, MBA, president of ASAM, told Medscape Medical News.

"The most important takeaways are that we should have universal screening for StUD, and that it’s treatable by medications that can be combined with effective psychosocial interventions as well as harm reduction and contingency management [CM] strategies, when appropriate," he said.

The guideline was published on online November 7 on ASAM’s website.

Urgent Health Crisis

"StUD has long posed a threat to the health and well-being of Americans," Hurley said. "We have good treatment options for opioid use disorder [OUD] and alcohol use disorder [AUD], but there has been a huge gap between what research has indicated is effective and what’s actually in place in clinical practice for StUD."

Although "there are no FDA-approved treatments for StUD, medications approved for other indications can be effective for StUD as well," he said.

They created the guideline because of a "concerning increase" in overdose deaths involving stimulant drugs over the past decade, in addition to StUD’s long-term health sequelae, including cardiac, pulmonary, psychiatric, dental, nutritional, cognitive, and skin-related conditions.

"Taken together, these factors have propelled StUD and stimulant use to an urgent health crisis," the authors wrote.

Screening and Assessment

The guideline recommends secondary and tertiary prevention strategies "to reduce harms related to overdose risk, risky sexual practices, injection drug use, oral health, and nutrition."

They also recommend universal screening. "Any patient should be screened for StUD; and when it’s identified, the immediate response should be a conversation about the patient’s use [of stimulants] and medical risks, so all of those risks can be assessed and managed," Hurley said.

The assessment process begins with identifying "any urgent or emergent biomedical or psychiatric signs or symptoms, including acute intoxication or overdose," and providing "appropriate treatment or referrals."

Comprehensive assessment also includes the history and physical examination, mental status exam, biopsychosocial assessment, and baseline laboratory testing.

In patients with long-term or heavy stimulant use, clinicians should consider potential cardiac disorders, rhabdomyolysis, and renal disorders.

Behavioral treatment options include CM, which should be a "primary component of the treatment plan, in conjunction with other psychosocial treatments for StUD," said Hurley.

In CM, "patients are provided with an incentive for a desired behavior — in this case, they receive an incentive for providing a urine toxicology test that’s negative for stimulants," he explained.

Other recommended psychosocial interventions include cognitive behavioral therapy (CBT), the Community Reinforcement Approach (CRA), and the Matrix Model.

In the aggregate, the guideline advocates "a wraparound approach that looks at different drivers of why someone might use stimulants and supports helpful changes," Hurley summarized.

When to Refer

"Clinicians treating StUD shouldn’t hesitate to use the medications described in the guideline," Hurley emphasized. These include topiramate, bupropion, bupropion and naltrexone, and mirtazapine.

The guideline also recommends psychostimulant medications for StUD (eg, modafinil, topiramate and extended-release mixed amphetamine salts, amphetamine formulations, and methylphenidate); but they should only be prescribed by physicians who are board certified in addiction medicine or addiction psychiatry and physicians with "commensurate training, competencies, and capacity for close patient monitoring."

For stimulant withdrawal, "we recommend using comfort measures. That doesn’t mean not using a medication, but there’s no specific medication strategy we recommend," said Hurley.

Withdrawal symptoms (eg, depression, anxiety, insomnia, paranoia) can last for weeks to months and should be addressed to reduce the risk of return to stimulant use.

The document details approaches to stimulant intoxication, including assessment, toxicology testing, determining the most appropriate clinical setting, managing psychosis and agitation, de-escalation strategies, and medications to address various symptoms.

"Sometimes when patients use stimulants, there’s a reflex to refer them to treatment facilities," Hurley noted. "Although I want to see these referrals take place, I’m not under the misperception that every patient referred to a treatment program will go."

He encouraged clinicians to "think about their existing practices" and recognize that treating StUD "isn’t fundamentally different than treating other medical conditions, like hypertension and diabetes, which incorporate medication and lifestyle counseling into routine clinical practice, offering supportive referrals when needed."

He said his hope is that the guideline "will be useful in guiding this effort."

Under-Resourced, Few Treatment Options

Commenting for Medscape Medical News, Elie Aoun, MD, MRO, assistant professor of clinical psychiatry, Columbia University College of Physicians and Surgeons, Division of Law, Ethics and Psychiatry, New York City, said the guideline is "good and comprehensive, but it’s disappointing to remember how limited the resources and treatment options are for StUD, although it’s one of the most common and prevalent addictions."

Author of Addiction Psychiatric Medicine, Aoun noted that CM "isn’t available for your average patient." Although it’s effective, it’s been tested primarily in large group settings, such as Veterans Administration medical centers or Kaiser Permanente. "CM may not be as applicable for individual patients going to see an individual therapist or psychiatrist."

Moreover, in settings like the Veterans Administration, small financial incentives are effective. But for a Wall Street executive, a $10 or even $100 reward might not be as enticing, said Aoun, who wasn’t involved in developing the guideline.

"So the reward has to be operationalized for the population you’re working with, which hasn’t been studied, although the same principles could be applied in other settings."

He added that the guideline alludes to co-occurring stimulant and opioid use. "A lot of the stimulants available in communities are laced with other drugs, mostly opioids," he said.

So it’s important "to educate patients about harm reduction measures, what an opioid overdose looks like, and medications to reverse an opioid." He recommended that all patients who struggle with CUD have access to naloxone.

The development of this Guideline was funded with contract support from the Centers for Disease Control and Prevention and the National Institute on Drug Abuse. Hurley and Aoun report no relevant financial relationships.

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