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It`s time to be proactive on stimulant use
An increasing number of voices are warning that time might be short in getting policy and program leaders to engage on the potential re-emergence of stimulants as a drug crisis. In many ways, this development would be just as scary as the current opioid epidemic that rightfully continues to dominate the field's attention.
Not only are stimulants such as methamphetamine and cocaine highly addictive, but there is no gold standard treatment for them, as there is in medication-assisted treatment for opioid use disorders. In addition, prescription stimulants, used in the treatment of attention-deficit hyperactivity disorder (ADHD), are far easier to obtain than prescription opioids.
“United States national drug control policy is historically reactive, addressing the latest crisis long after it is established,” writes John Carnevale, PhD, who worked for the federal Office of National Drug Control Policy (ONDCP) in three administrations, in a June issue brief. While prevention is the most important policy tool for emerging drug problems, it is only effective if it is implemented “before problems become well-entrenched,” Carnevale writes.
If ignored, an emerging trend of cocaine use could be damaging, with Carnevale noting that “cocaine-involved overdoses have exploded.” ONDCP reports that federal prevention resources have declined by 27.9% in nominal dollars and 44% in real dollars from 2004 to 2017, Carnevale adds.
Rising cocaine use by young adults is resulting in more cocaine-involved deaths, often with the drug mixed with opioids. Carnevale first noted the re-emerging cocaine problem in August 2016, in an issue brief showing that coca cultivation was increasing in Colombia and first-time cocaine use was on the rise in the United States. This trend has continued and strengthened, with falling prices contributing to rising street supply.
According to the National Survey on Drug Use and Health (NSDUH), cocaine initiation (first-time use) increased by 70% from 2012-2016, reaching a total of just over 1 million new users in 2016. These kinds of numbers had not been seen since 2002-2007. It is important to note that new users are likely to become regular users. Anyone who remembers the 1980s knows that this can become a huge problem.
Methamphetamine is raising renewed concerns as well. Around 2005, when Congress made it more difficult to obtain pseudoephedrine, the methamphetamine supply was reduced, but production moved to Mexico. Ed Craft, PhD, senior public health advisor at the Substance Abuse and Mental Health Services Administration (SAMHSA), explains that pseudoephedrine is no longer necessary in making methamphetamine.
“It used to be little shacks with Sudafed and Drano,” Craft says. Now, a new compound—P2P—is being used to make the drug. “As a result of the switch from Sudafed to the P2P as a base chemical, the quality of the product is much higher, it gives a stronger stimulant feeling, it is 95% pure, and it’s more addictive,” he tells Addiction Professional. And because availability is going up, the price is going down.
Trends in prescription stimulants
But methamphetamine use (192,000 new users, according to the 2016 NSDUH) pales in comparison to the number of new cocaine users (1.1 million) and misusers of prescribed stimulants (1.4 million), says Steve Daviss, MD, senior medical advisor at SAMHSA.
Prescriptions for stimulants have been going up for the past 10 to 15 years, and with them, diversion, says Daviss. “Someone gets a prescription for Adderall or Ritalin and shares it with someone else, possibly sells it,” he tells Addiction Professional.
The NSDUH is one the best places to go for data, Daviss says, and the survey shows that the prevalence of new users of prescription stimulants is highest among college-age students—those who reportedly use stimulants to improve academic performance. In the 2016 survey, 1.4 million people started misusing prescription stimulants for the first time in the past year, and 45% of them were ages 18 to 25 (18% were ages 12 to 17 and 37% were ages 26 and up).
Prescription stimulants such as Adderall and Ritalin are among the top three categories of prescription drugs misused by young people, including opioids and benzodiazepines, says Timothy E. Wilens, MD, chief of the Division of Child and Adolescent Psychiatry and co-director of the Center for Addiction Medicine at Massachusetts General Hospital and Harvard Medical School. “The nonmedical misuse of stimulants has been relatively steady over the past decade,” Wilens says.
Are these drugs addictive? The data show that immediate-release prescription stimulants, such as Adderall and Ritalin, have a higher abuse liability, says Wilens. They are more frequently misused than extended-release preparations, such as Concerta, Focaline XR, Adderall XR and Vyvanse.
Of people who take prescription stimulants without a prescription, surveys and Wilens’ own data indicate that 10 to 15% develop a stimulant use disorder, with almost half having “some subthreshold symptoms of a stimulant use disorder,” he says.
Mixing stimulants and opioids
“Now, we’re seeing the double danger of illicit fentanyl, plus either cocaine or methamphetamine,” says Daviss. The question of whether these users are looking for opioids or stimulants, or for the combination known as a speedball, depends on the market, he says.
“If you’re selling cocaine in a market where there’s a lot of cocaine use, and if you have a certain client who wants a speedball, you’re going to deliver that,” Daviss says. But if they’re asking for just cocaine, they might not get it, because the cartels are experimenting by combining different proportions of cocaine and fentanyl. “We don’t know if they’re doing that to increase the addiction rate,” he says.
Daviss adds, “I think the attraction to speedballs, combining opioids and stimulants, a downer and an upper, is that the opioids take some of the agitated edge off of the stimulants, and on the other side of the coin, the stimulant keeps you from falling asleep, and allows you to ride the high for a longer period of time.”
Even methamphetamine on its own has benefits perceived by users, says Craft. “It gives you energy, whether you’re a truck driver or a housewife—and it can be a real enhancer for sex,” he says. However, “People can overdose on stimulants alone,” says Daviss. “Often it will be a cardiac or hypertensive event.”
Prescription stimulants as a gateway?
Unlike in the opioid epidemic, in which prescription opioid abuse has largely given way to use of heroin and illicit fentanyl, there does not seem to be an expected migration from prescription stimulant abuse to illicit stimulants, or vice versa, says Wilens.
“It does not appear that in studies of individuals who misuse stimulants, other stimulants such as cocaine or methamphetamine are the preferred drug of choice,” he says. “However, it is notable that almost one-half of those individuals who misuse stimulants nonmedically have a full diagnosable substance use disorder,” with alcohol, marijuana or a combination usually present.
“As far as I know, no prescription medicine is a gateway to methamphetamine,” says Craft. “This might be more likely with cocaine, but I’m not familiar with cases of it.”
“I haven’t seen data on this,” adds Daviss. “If I wanted to ask the question, I would start with an animal study. It would be very easy to dose animals clinically on something like Adderall or a placebo, and then expose them to methamphetamine, and see what the difference is in their uptake of using it.”
However, Craft does say, based on speculation only, that with the cost of methamphetamine being less than half of what it was 10 years ago, a possible switch from prescription stimulants to methamphetamine might take place if restrictions were placed on the prescriptions. “In the past month, about 1.7 million people admitted to misusing a prescribed stimulant, whether from their own doctor or someone else,” he says.
Ironically, while adolescents and adults who use prescription stimulants for ADHD or attention deficit disorder (ADD) typically do notice an improvement in focus (and presumably, improved performance at school or work), Daviss says the medications appear to have the opposite effect for people who misuse them. They do not improve performance in those cases because the user doesn’t actually have the condition they are intended to treat, he says.
The states are telling SAMHSA, which manages the Substance Abuse Prevention and Treatment block grant, that some people are trying to substitute methamphetamine for opioids, because they perceive the risk of overdose as lower, says Craft. With fentanyl so prevalent today, that might be a dangerous assumption.
Treatment considerations
Craft says that with stimulant use, the need for residential treatment is greater than it is for opioid use. The medications buprenorphine, methadone and injectable naltrexone are all approved for the treatment of opioid use disorders, but there are no medications approved for the treatment of stimulant use disorders. Even with a great deal of research going on in this area, approval of a medication for stimulant dependence still could be years away.
The Matrix Model, developed in the 1980s by Richard Rawson, Ph.D., at UCLA, at this point remains the best known treatment method for stimulant use disorders. It is a structured intensive outpatient program that has documented success in combining numerous therapeutic approaches, from cognitive-behavioral therapy and motivational interviewing to 12-Step work.
Alison Knopf is a freelance writer based in New York.
Five ways to prevent a new epidemic
Former federal anti-drug official John Carnevale, PhD, offers these recommendations for preventing a new drug epidemic:
Enhance local prevention efforts. Local preventionists are most familiar with the specific prevention needs of their community. Enhancing local prevention efforts is the most effective way of ensuring that available resources are targeting key areas of need. Federal and state agencies should expand the availability of funding for local prevention entities, particularly funding for school- and community-based prevention services.
Training, technical assistance and evaluation. More research is needed, but data supports the efficacy of specific prevention strategies in certain situations. Yet many preventionists are unaware of the latest findings, or lack the capacity to implement proven strategies. Federal and state governments should expand funding for training and technical assistance programs targeting local preventionists. This should include how to evaluate prevention efforts as part of a feedback loop to improve local responses, and how to disseminate findings to build evidence for the field.
Focus on local data. With most drug control efforts occurring at or focusing on the local level, it is vital that stakeholders have access to plentiful, high-quality local data to assess local trends. Federal and state governments must build the capacity to collect and analyze local data, including training and funding local stakeholders.
Reinvest in surveillance. The federal government must reinvest resources for surveillance systems to detect emerging drug trends. In fiscal year 2000, the Office of National Drug Control Policy (ONDCP) estimated that a 15-city expansion of the Arrestee Drug Abuse Monitoring (ADAM) system would cost only $4.8 million; adjusted for inflation, this would be approximately $7 million in fiscal 2018. Although the true cost may be higher for logistical reasons, it would be a small price to pay to regain an information system that proved invaluable to consumption estimates, says Carnevale.
Prepare for future emerging trends. Because a long lag time is inherent to the evaluation process, prevention researchers should allocate some resources to issues that are not “hot topics” of the day, strengthening the initial evidence base from which to work if and when issues do arise.
