With Stimulant Crisis Evolving, Treatment Providers Respond With Multi-Faceted Approach

On Saturday at the West Coast Symposium on Addictive Disorders in Palm Springs, California, James Peck, PsyD, licensed clinical psychologist and senior clinical trainer, UCLA Integrated Substance Abuse Programs, discussed the epidemiology, and impact on brain and behavior of the nation’s growing stimulant crisis. He also went into behavioral treatment interventions and certain adaptations that are often necessary to engage and retain patients in care for stimulant use.

Earlier this week, Dr Peck spoke with Addiction Professional about emerging trends with regards to stimulant use, and the unique impact of stimulants on the body and brain compared with other illicit substances. Dr Peck also shared examples of effective interventions to treat stimulant use disorder and treatment modalities that can be combined to improve outcomes.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional (AP): What are the most notable national trends we are currently seeing in stimulant use? How has the landscape changed compared to even a few years ago?

Dr Peck: We’ve seen a number of changes over the past 5 years or so. The National Forensic Laboratory Information System tracks reports submitted to state and local law enforcement labs. The number of methamphetamine-related reports has steadily increased over the last 5 years. We’ve seen domestic production of methamphetamine plummet to almost nothing while production has largely shifted to large labs in Mexico. Methamphetamine use had been most prevalent among the 18- to 25-year-old range until 2019, when the increasing use among people 26 and older actually caught up with the 18- to 25-year-old group. Cocaine use, on the other hand, seems to have largely plateaued over the last 5 years.

We’ve also seen a steep increase in the number of people using stimulants in combination with opioids. This is particularly concerning because we’re increasingly seeing both heroin and stimulants like cocaine and meth being cut with fentanyl. Fentanyl is a synthetic opioid that is about 50 times more potent than heroin. A very small amount of fentanyl can be lethal, and often stimulant users don’t know that it’s present in their drugs. The combination of opioids and stimulants increases the risk of overdose, due to both the respiratory depression produced by opioids and the cardiovascular event risk of stimulants. In fact, drug poisoning deaths involving cocaine or methamphetamine are now more prevalent than deaths involving heroin or prescription opioids (not including fentanyl). It’s also more challenging to treat combination stimulant/opioid users because while we have FDA-approved medications to help treat opioid use disorder, there are none for cocaine or methamphetamine use disorders.

AP: How do stimulants affect the body and brain? In what ways are stimulants’ impact on the body and brain unique from other types of illicit substances?

Dr Peck: Cocaine and especially methamphetamine have profound impacts on the user’s body and brain. They can cause damage to organ systems including the respiratory, neurological, and cardiovascular systems as well as causing liver or kidney failure in more extreme cases. Stimulants increase heart rate, blood pressure, and respiration. The psychological effects of stimulants are also profound. Imagine you could take a drug that would make you feel more alert, confident, invulnerable, talkative, and sociable as well as increasing your sex drive, while reducing boredom, loneliness, and shyness. That’s what makes stimulants so seductive. Unfortunately, those initial effects tend not to last the longer someone uses stimulants. Those effects that are experienced as positive quickly turn into fatigue; confusion; insomnia; reduced ability to focus, concentrate, and remember things; anxiety; depression; and in more severe cases paranoia and psychosis. One of the major differences between stimulants and other substances is the degree to which they cause the release of dopamine and norepinephrine in the brain. Alcohol and other drugs stimulate dopamine release, but not to the same extent. Cocaine produces a rush of dopamine that is 300% to 400% above baseline levels, and methamphetamine causes a release of dopamine that can be over 1000% of our baseline levels.

AP: Can you provide examples of effective interventions for stimulant use disorder? Are there different interventions that can be combined to improve outcomes, such as cognitive behavioral therapy and contingency management?

Dr Peck: Unfortunately, there are still no FDA-approved medications for the treatment of stimulant use disorders. Research is ongoing, and a couple of studies have shown promise, but nothing is definitive yet. So, we have to rely on behavioral and psychosocial interventions. Evidence-based approaches include cognitive behavioral therapy, motivational interviewing, the community reinforcement approach, and contingency management, also known as motivational incentives. Contingency management is a form of positive reinforcement provided when someone demonstrates abstinence from the targeted drug, i.e., a urine sample negative for drug metabolites. It has been consistently shown to be effective with cocaine and methamphetamine users, but there are federal regulations that make implementing it difficult. The California Department of Health Care Services has obtained a waiver from the Centers for Medicare and Medicaid Services to implement a pilot contingency management program as a benefit of their Medicaid (known as Medi-Cal) program, specifically for stimulant users. If successful, it will provide a model for other states. Research has shown that contingency management is effective both on its own and when combined with another intervention like cognitive-behavioral therapy.

Reference

Peck J. The growing stimulant crisis: epidemiology, impact on brain & behavior, and treatment approaches. Presented at: West Coast Symposium on Addictive Disorders; June 2-4, 2022; Palm Springs, California.