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Robust Treatment Options Remain Limited for Stimulant Use Disorder
SAN DIEGO—Prescribers treating stimulant use disorders remain limited to off-label medication options at a time when stimulant use and overdose rates are on the rise. At Psych Congress 2019, UCLA Associate Clinical Professor of Psychiatry Larissa Mooney, MD, offered an overview of medication treatment choices that are considered promising but far from proven.
“Most of the findings are not particularly robust,” said Dr. Mooney, who also directs the UCLA Addiction Psychiatry Clinic. With these limited options and no novel treatments close to federal approval, the most evidence-based treatments for cocaine or methamphetamine use disorder continue to be behavioral therapies that include cognitive-behavioral therapy and reward-based “contingency management” approaches, Dr. Mooney said.
The more promising news concerning treatment of stimulant addiction, she said, is that despite the brain dysfunction in the dopamine and glutamate systems caused by chronic methamphetamine use, recovery of brain function is apparent within 9 months to 2 years.
Dr. Mooney described some of the similarities between cocaine and methamphetamine, such as their overlapping mechanisms of action, and key differences that contribute to varying use patterns, such as methamphetamine's much longer duration of action.
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Faced with a number of off-label medication options that have not shown particularly strong effectiveness in research, Dr. Mooney says she is guided in her practice by considering any comorbid conditions that also may be affecting the patient. If the patient also exhibits symptoms of anxiety, or depression, she will choose a medication that also is effective for addressing those symptoms, possible leading to a “win-win” scenario.
Bupropion and topiramate are among the medications that have shown promising results for both cocaine and methamphetamine addiction, Dr. Mooney reported. Some research also has pointed to the possible benefits of using prescription stimulants to treat addiction to an illegal stimulant. “This makes people uncomfortable, including me,” Dr. Mooney said.
Treating Comorbid ADHD, SUD
Dr. Mooney sought in her talk to dispel the notion that psychiatrists cannot successfully treat attention-deficit/hyperactivity disorder (ADHD) in patients with a co-occurring substance use disorder (SUD). She added there is no evidence that treating ADHD in young people increases the risk of a later SUD, and early treatment may actually have a protective effect.
The comorbidity of ADHD and SUD presents many challenges, however, as patients tend to have a greater likelihood of polysubstance use and relapse and may need higher doses of ADHD medication to produce a therapeutic effect, Dr. Mooney said. However, research generally has shown that adverse events are not more frequent in ADHD patients with comorbid SUD compared with those with no SUD.
Dr. Mooney recommended long-acting formulations of ADHD medications, such as extended-release methylphenidate and lisdexamfetamine, as options that can reduce the potential for misuse among patients with this comorbidity.
—Gary Enos
Reference
“Stimulant use disorder: clinical issues and treatment challenges.” Presented at Psych Congress 2019: San Diego, CA; October 4, 2019.
