Federal Officials Pursuing Response to Rise in Stimulant-Involved Deaths

Stimulants are among the most highly addictive drugs available, and a rise in the number of methamphetamine- and cocaine-involved deaths in the US in recent years has federal health officials and researchers looking for solutions, Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA), told attendees of the Cocaine, Meth, and Stimulant Summit in a virtual session presented on Wednesday afternoon.

In the 2000s, an overdose crisis emerged in the US fueled largely by misuse of prescription opioids, Dr Volkow said. Around 2011, heroin began to contribute significantly to overdose deaths, followed by a steep rise in deaths driven by fentanyl starting in 2015. In recent years, however, there has been a sharp increase in mortality associated with stimulants as well.

According to provisional data from the National Center for Health Statistics (NCHS), a record 109,247 drug overdose deaths were reported in the 12 months ending in March 2022, a 9.7% year-over-year increase. The rise in overdose deaths was driven largely by a 24.9% year-over-year increase in cocaine-involved deaths (25,959) and a 23.9% rise in other psychostimulant-involved deaths, especially methamphetamine (33,994).

“What we know—and we’ve always known—is that cocaine and methamphetamine, which are described as stimulant drugs, are among the most addictive drugs that are currently available,” Dr Volkow said. “And this explains why. They have been [highly addictive] throughout our civilization, particularly cocaine. Methamphetamine is a synthetic drug that when it basically came into the market, that’s when it started to be misused. But that's not the case with cocaine, which has a very, very long history of use.”

Dr Volkow explained that like all drugs of abuse, cocaine and methamphetamine release dopamine into the main reward center of the brain, the nucleus accumbens. Stimulants produce the largest increases in dopamine released, making them highly addictive.

“And of the two drugs that are most problematic, cocaine and methamphetamine, methamphetamine is the one that generates the largest dopamine increases,” Dr Volkow said. “Not surprisingly, when you look at the number of people that become addicted with exposure to any one of the drugs, the one that shows the highest percentage of people becoming addicted is methamphetamine. And cocaine follows behind. [This] explains why these drugs have a high value in the illicit market and why it has been so very difficult to get rid of them. They are highly, highly addictive.”

Based on data from the Substance Abuse and Mental Health Services Administration (SAMHSA), cocaine users are predominantly between the ages of 18 and 25. For methamphetamine users, the prevalence is higher among individuals over the age of 26. However, Dr Volkow said, while the rate of methamphetamine use disorder has risen among all age groups each year dating back to 2017, but that has not been the case for cocaine use disorder. Health officials, then, have wrestled with a question: If cocaine use disorder rates aren’t climbing, what, then, is fueling the rise in cocaine-involved deaths?

“Approximately two-thirds of the cases of individuals that died from a cocaine overdose had opioids on board,” Dr Volkow said. “The reason why we're seeing such a striking rise in mortality from cocaine is likely to be predominantly driven by the fact that cocaine is laced with the synthetic opioid fentanyl.”

While it is possible that some users may seek to combine cocaine and fentanyl, it is likely that in most cases, users do not realize that the cocaine is laced with the illicit synthetic opioid, Dr Volkow said. Given these findings, Dr Volkow said it is no longer sufficient to treat only opioid use disorders to prevent fentanyl-involved deaths.

“We need to target the treatment of individuals with a stimulant use disorder, because their risk right now of using those substances and overdosing is also very, very high,” Dr Volkow said. “Unfortunately, for stimulant use disorder, or methamphetamine and cocaine use disorder, we do not have FDA-approved medications, as is the case for opioid use disorder. So…where does the evidence tell us of interventions that can be beneficial for individuals with stimulant use disorder?”

Dr Volkow explained that data has shown that behavioral interventions, such as contingency management programs, have shown significant positive effects in helping individuals with stimulant use disorders to abstain from substance use and achieve recovery. To date, contingency management has been an underused tool, largely because of limits imposed on the financial rewards that can be offered for abstaining from substance use. The federally approved limit for financial rewards for contingency management programs is $75 per year, “a relatively small amount to actually achieve optimal results,” Dr Volkow said. The limit is being reviewed, however, and “it appears that it is going to be much easier to provide a higher amount of funds as part of contingency management.”

Reference

Volkow N. Stimulant use disorder response and treatments—insight from the National Institute on Drug Abuse. Presented at Cocaine, Meth and Stimulant Summit. November 2-4, 2022; virtual.