Experts advocate prescribing psychostimulants for stimulant use disorder

Poisonings from unregulated drugs are rising in Canada. Although synthetic opioids (e.g., fentanyl) are the leading cause, stimulant use—particularly methamphetamine—is also rising, with a stimulant detected in nearly half of all opioid deaths in Canada in 2022.1 A physician in British Columbia working in the substance use field notes that accumulating evidence supports treatment of stimulant use disorder with prescribed psychostimulants; however, no pharmacologic treatments for stimulant use disorder are currently approved in Canada. Prescribed psychostimulants can support the management of cravings and withdrawal symptoms in patients with stimulant use disorder, with the overall goal of supporting a reduction in illegal stimulant use.1 In 2020, the Canadian federal minister of health issued a letter to provincial and territorial ministers of health and regulatory colleges to encourage increased access to safer pharmaceutical grade alternatives to the contaminated drug supply. However, to date, British Columbia is the only province to issue a Safer Supply Policy Directive, including guidance for prescribing psychostimulants to people at risk of overdose. In the first year of implementation in B.C., psychostimulant medications were prescribed for 1,220 people, but this reflects less than 3% of people estimated to have stimulant use disorder.1 A recent systematic review involving 2,889 patients found prescribed psychostimulants (amphetamines or methylphenidate) to be a safe and effective intervention for stimulant use disorder. These agents were particularly useful in the treatment of cocaine dependence, and when prescribed at doses of ≥ 60 mg/day. Prescribed psychostimulants reduced the use of illegal stimulants, improved physical and mental health, and improved focus and attention for patients with concurrent attention-deficit/hyperactivity disorder.1 The B.C. physician believes this evidence supports the off-label prescribing of psychostimulants to patients with stimulant use disorder, particularly patients with attention-deficit/hyperactivity disorder and stimulant use disorder. Prescribed psychostimulants could be offered with nonpharmacologic interventions (e.g., contingency management) to provide patients with a comprehensive range of treatment options across the continuum of care.1 In B.C., psychostimulants are most often prescribed by physicians providing care to patients with substance use disorders. The drugs are dispensed daily at community pharmacies, to promote safety. However, daily pharmacy visits may be a barrier to accessing prescribed psychostimulants; therefore, take-home dosing for prescribed psychostimulants (as is offered for opioid agonist treatment) has been proposed.1 Diversion of prescribed psychostimulants can be reduced by establishing standardized protocols, including waiting to initiate take-home dosing until the patient has titrated to an optimal dose, regular monitoring for adverse events to confirm the suitability of the medication, and urine drug screens to monitor for the presence of the medication. Reinstating witnessed dosing may be needed in situations where a patient does not take the medication as directed, or where new adverse events arise.1 The B.C. physician suggests that substance use treatment programs can establish protocols to systematically incorporate prescribed psychostimulants into the range of interventions offered to patients with stimulant use disorder. Broader use of prescribed psychostimulants for stimulant use disorder across Canada would help patients reduce poisonings from use of illegal stimulants.1 Reference 1. Palis H, MacDonald S. Incorporating prescription psychostimulants into the continuum of care for people with stimulant use disorder in Canada. CMAJ July 17, 2023;195:E934-5. (accessed July 20, 2023).

Experts advocate prescribing psychostimulants for stimulant use disorder

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