Can Prescribed Psychostimulants Help Treat Stimulant Use Disorder?

What you need to know

• Illegal stimulant use, especially methamphetamine, is increasing in Canada and causing significant health problems and deaths.
• Growing evidence supports using prescribed psychostimulants to treat stimulant use disorder, but this treatment is not yet officially approved in Canada.
• Some healthcare providers in Canada have started prescribing psychostimulants for stimulant use disorder on a small scale.
• Prescribing psychostimulants may help reduce use of and harms from illegal stimulants for patients with stimulant use disorder.

The stimulant crisis in Canada

Canada is facing an ongoing crisis of drug poisonings, with synthetic opioids like fentanyl being a major factor. However, stimulant use is also on the rise. In 2022, stimulants were detected in nearly half of all opioid-related deaths in Canada. Using illegal stimulants comes with several risks, including:

• Higher rates of infectious diseases
• Mental health issues like sleep problems and psychosis
• Overdose
• Death from various causes

These risks are especially high for people with existing health conditions or who face challenges related to housing, finances, legal status, or racial discrimination.

What are psychostimulants?

Psychostimulants are medications that stimulate the central nervous system. They work by increasing levels of certain brain chemicals called neurotransmitters, specifically dopamine and norepinephrine. Some common prescribed psychostimulants include:

• Methylphenidate (e.g. Ritalin)
• Dextroamphetamine

These medications are often used to treat conditions like attention-deficit/hyperactivity disorder (ADHD). However, they are now being explored as a treatment for stimulant use disorder.

The potential of prescribed psychostimulants

While no medications are currently approved in Canada specifically for treating stimulant use disorder, psychostimulants are increasingly being prescribed as a harm reduction approach. This follows evidence from clinical trials in Europe, Australia, and the United States.

The idea is that prescribed psychostimulants may help manage cravings and withdrawal symptoms for people with stimulant use disorder. The overall goal is to support reductions in illegal stimulant use.

In 2020, Canada’s federal health minister encouraged provinces and territories to increase access to safer, pharmaceutical-grade alternatives to the contaminated illegal drug supply. So far, British Columbia is the only province to issue official guidance on prescribing psychostimulants to people at risk of overdose.

What does the research say?

A recent review of 38 clinical trials involving 2,889 patients found that prescribed psychostimulants are a safe and effective intervention for stimulant use disorder, particularly for cocaine dependence. The review found that doses of 60 mg or more per day of prescription amphetamines or methylphenidate were most effective.

Some positive outcomes observed in these studies include:

• Reduced use of illegal stimulants
• Improved physical and mental health
• Better focus and attention for patients who also have ADHD

This growing body of evidence can help healthcare providers feel more confident in prescribing psychostimulants for patients with stimulant use disorder, especially those who also have ADHD.

Implementation in Canada

Since 2020, psychostimulants have been prescribed for stimulant use disorder in Canada, but only for a small number of patients. These prescriptions are primarily given by:

• General practitioners
• Addiction medicine specialists
• Nurse practitioners

In the first year of implementation in British Columbia, prescribed psychostimulant medications reached 1,220 people. However, this represents less than 3% of the estimated number of people with stimulant use disorder in the province.

Barriers to widespread use

There are several reasons why prescribed psychostimulants haven’t been more widely adopted:

1. The evidence for using psychostimulants to treat stimulant use disorder is newer compared to treatments for other substance use disorders.

2. Early clinical trials had limitations, such as small sample sizes, restrictive outcome measures (focusing only on complete abstinence), and inappropriate interventions (e.g., using doses that were too low).

3. There are logistical challenges. For example, in British Columbia, psychostimulants are most commonly dispensed daily at community pharmacies. While this is intended to promote safety, daily pharmacy visits can be a barrier for some patients.

4. There are concerns about the potential for misuse or diversion of prescribed psychostimulants.

Safety considerations

While safety concerns have been reported as a barrier to implementation, systematic reviews have concluded that prescribed psychostimulants for stimulant use disorder are generally well-tolerated and not associated with serious adverse events.

One concern is the potential for psychosis. However, psychosis induced by prescribed psychostimulants is much less common than psychosis associated with illegal stimulant use. A 2014 review suggested that psychosis occurs in up to 40% of people using methamphetamine, while it’s much rarer with prescribed psychostimulants.

It’s important to weigh the potential risks and benefits of prescribed psychostimulants against the risks of continued illegal stimulant use. Introducing prescribed psychostimulants for people already using illegal stimulants, along with careful monitoring, is a reasonable approach to reduce the harms associated with using unregulated stimulants.

Recommendations for implementation

To advance the implementation of prescribed psychostimulants in Canada, the authors suggest several actions:

1. Researchers should conduct implementation studies to fill knowledge gaps and inform timely updates of clinical protocols.

2. Centers responsible for clinical guidance should publish and regularly update guidelines as new evidence emerges.

3. Substance use treatment programs should establish protocols to incorporate prescribed psychostimulants into their range of interventions.

4. This process should be collaborative, involving patients and multidisciplinary care teams, and drawing from the experiences of settings where psychostimulant prescribing has already been implemented.

5. Existing protocols for dosing and dispensing prescribed psychostimulants may need to be adapted based on the clinical setting and patient population.

Conclusions

• Broader implementation of prescribed psychostimulants is needed in Canada as an effective option for treating stimulant use disorder.
• This approach could help the growing number of patients seeking to reduce their reliance on the illegal stimulant supply during the ongoing drug poisoning crisis.
• While safety concerns exist, the potential benefits of prescribed psychostimulants should be weighed against the significant risks of continued illegal stimulant use.