Off-label treatments for meth-use disorder

[wellbutrin.girlfriend]

Hi y'all, potentially very naive medical student question incoming:
Background is that I'm from California and worked at a residential mh facility/community psychiatry program for a little over 3 years before starting medical school. Meth addiction is/was devastating to this population and posed tremendous barriers to recovery. Treating SMI within the context of active meth addiction felt essentially,, farcical and, anecdotally, I saw that meth addiction had much poorer outcomes in rehab.

I recently learned that TMS is emerging as a promising treatment for all sorts of addictions, including meth. My question is: since treatment outcomes with meth addiction are so bad, what factors would stop a physician from just ~trying out~ a promising treatment? What separates off-label use of bupropion (something regularly covered by insurance) from off-label use of TMS?

I'm currently in a fellowship on SUD treatment that is based in PA (so primary lens of OUD). When I ask about meth I feel like the answers are mostly ¯\_(ツ)_/¯ because it's less prevalent there than on the west coast. Meth has been so destructive to communities I care about and I wish it were prioritized more in addiction medicine. Thanks in advance for indulging me with any replies to this thread.

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[brazilianpsych]

I don't think anyone would mind using TMS. As for evidence, methylphenidate seems to lower cravings and reduce UDS+ in meth abuse users. None of my attendings use it and I've never seen it being used for that. At my hospital, everyone tries to use anti-psychotics, although no benefit proven in recent meta-analysis.

 

[jbomba]

Some data for mirtazapine too.

 

[Penguin10]

I imagine the barrier to TMS is cost/coverage, at least it would be in my setting. Some of the segments below are paywalled but they have an open article talking about off label evidence for antidepressants and naltrexone for methamphetamine use disorder plus some other stuff on stimulants in case that's of interest:

Psychopharmacology Institute

psychopharmacologyinstitute.com

 

[hallowmann]

Hi y'all, potentially very naive medical student question incoming:
Background is that I'm from California and worked at a residential mh facility/community psychiatry program for a little over 3 years before starting medical school. Meth addiction is/was devastating to this population and posed tremendous barriers to recovery. Treating SMI within the context of active meth addiction felt essentially,, farcical and, anecdotally, I saw that meth addiction had much poorer outcomes in rehab.

I recently learned that TMS is emerging as a promising treatment for all sorts of addictions, including meth. My question is: since treatment outcomes with meth addiction are so bad, what factors would stop a physician from just ~trying out~ a promising treatment? What separates off-label use of bupropion (something regularly covered by insurance) from off-label use of TMS?

I'm currently in a fellowship on SUD treatment that is based in PA (so primary lens of OUD). When I ask about meth I feel like the answers are mostly ¯\_(ツ)_/¯ because it's less prevalent there than on the west coast. Meth has been so destructive to communities I care about and I wish it were prioritized more in addiction medicine. Thanks in advance for indulging me with any replies to this thread.

The biggest factor is cost. TMS machines and staff required are not free. That said, doing so through a study is one way to manage this.

Another issue is really ability to implement the treatment. We are involved in the national TMS study for methamphetamine use disorder, but we have had a great deal of difficulty recruiting enough patients and retaining them through a typical course of treatment. Despite having tons of patients with methamphetamine use disorder and actively recruiting throughout our MAT clinics for almost 2 yrs, I believe we've not even been able to have a dozen actually complete the treatments. Patients are reluctant and often have a lot of social barriers to actually attending treatment 5 days a week for 3-6 weeks.

There simply are not any good pharmacologic treatment options, but bupropion, naltrexone, and stimulants (both for underlying ADHD/impulsivity and purely for craving management) are options. In addition, therapeutic programs like contingency management are also options.

I don't think anyone would mind using TMS. As for evidence, methylphenidate seems to lower cravings and reduce UDS+ in meth abuse users. None of my attendings use it and I've never seen it being used for that. At my hospital, everyone tries to use anti-psychotics, although no benefit proven in recent meta-analysis.

We regularly use stimulants for treatment underlying ADHD in patients with methamphetamine use disorder, but I could probably count on one hand the ones I've seen actually treated with stimulants solely for cravings in methamphetamine use disorder. Are you talking about using antipsychotics for acute withdrawal of meth, or actually to treat it?

 

[wellbutrin.girlfriend]

The biggest factor is cost. TMS machines and staff required are not free. That said, doing so through a study is one way to manage this.

Another issue is really ability to implement the treatment. We are involved in the national TMS study for methamphetamine use disorder, but we have had a great deal of difficulty recruiting enough patients and retaining them through a typical course of treatment. Despite having tons of patients with methamphetamine use disorder and actively recruiting throughout our MAT clinics for almost 2 yrs, I believe we've not even been able to have a dozen actually complete the treatments. Patients are reluctant and often have a lot of social barriers to actually attending treatment 5 days a week for 3-6 weeks.

There simply are not any good pharmacologic treatment options, but bupropion, naltrexone, and stimulants (both for underlying ADHD/impulsivity and purely for craving management) are options. In addition, therapeutic programs like contingency management are also options.


We regularly use stimulants for treatment underlying ADHD in patients with methamphetamine use disorder, but I could probably count on one hand the ones I've seen actually treated with stimulants solely for cravings in methamphetamine use disorder. Are you talking about using antipsychotics for acute withdrawal of meth, or actually to treat it?

Thanks for your reply--it's really valuable to have your perspective on this! <12 patients completing the treatments in 2 years is really shocking but makes a lot of sense when I think about it practically. I went to a talk at the APA conference on the NIDA research updates for MUD, and it's funny to think of the nice charts and statistics they presented juxtaposed with this reality at your MAT clinic.

So basically, outside the context of a clinical trial, off-label TMS is significantly more expensive than off-label bupropion which makes insurance companies less likely to gamble on it which then makes providers less likely to prescribe it?

Also wondering how my original question applies to using ketamine to treat MUD?

 

[brazilianpsych]

The biggest factor is cost. TMS machines and staff required are not free. That said, doing so through a study is one way to manage this.

Another issue is really ability to implement the treatment. We are involved in the national TMS study for methamphetamine use disorder, but we have had a great deal of difficulty recruiting enough patients and retaining them through a typical course of treatment. Despite having tons of patients with methamphetamine use disorder and actively recruiting throughout our MAT clinics for almost 2 yrs, I believe we've not even been able to have a dozen actually complete the treatments. Patients are reluctant and often have a lot of social barriers to actually attending treatment 5 days a week for 3-6 weeks.

There simply are not any good pharmacologic treatment options, but bupropion, naltrexone, and stimulants (both for underlying ADHD/impulsivity and purely for craving management) are options. In addition, therapeutic programs like contingency management are also options.


We regularly use stimulants for treatment underlying ADHD in patients with methamphetamine use disorder, but I could probably count on one hand the ones I've seen actually treated with stimulants solely for cravings in methamphetamine use disorder. Are you talking about using antipsychotics for acute withdrawal of meth, or actually to treat it?

For meth cravings. From what I recently reviewed it does not help, but it is still used in my service. Interesting to see that other programs do use stimulants.

 

[hallowmann]

For meth cravings. From what I recently reviewed it does not help, but it is still used in my service. Interesting to see that other programs do use stimulants.

It certainly isn't common to use stimulants purely for cravings, and its clearly in the name/spirit of harm reduction, but I've seen a few patients get them. Its always long-acting, typically lower dose, clearly defined amount. Most often though the patients that are prescribed stimulants with a history of methamphetamine use disorder in our clinics are getting it for underlying ADHD (with similar restrictions).

Thanks for your reply--it's really valuable to have your perspective on this! <12 patients completing the treatments in 2 years is really shocking but makes a lot of sense when I think about it practically. I went to a talk at the APA conference on the NIDA research updates for MUD, and it's funny to think of the nice charts and statistics they presented juxtaposed with this reality at your MAT clinic.

So basically, outside the context of a clinical trial, off-label TMS is significantly more expensive than off-label bupropion which makes insurance companies less likely to gamble on it which then makes providers less likely to prescribe it?

Also wondering how my original question applies to using ketamine to treat MUD?

Yeah, it was truly shocking to me, because I had been referring patients to the study for a while, and when I talked to our site PI, she was very frank about the barriers.

With regards to cost, you could purchase buproprion with a GoodRx coupon even without going through insurance (like $20-$40/mo at some local pharmacies), so its very easy to justify with low risk and low cost. TMS is hard enough to get covered for the things it is approved for let alone for something that is purely in the experimental stage.

I can't really speak to ketamine, we do not use it for SUD, and we are only doing esketamine and not infusions (at least for psychiatric diagnoses).

 

[deleted1100659]

I think a large portion of patients with meth use disorder lack the insurance or funds to access TMS. Meth use tends to create a downward trend in people, and I think people burn through money/family support. A large portion of my patients who use meth, if not all have basically no resources. Problem is in my facility, giving someone Wellbutrin or Seroquel here is like a form of currency. Even the XR, people get creative. Other areas where patients had family to monitor their medications maybe would be more viable.

I think to effectively use stimulants when a patient has meth use disorder you have to check off a lot of boxes like reliable/involved family member, consistency going to appointments, strong desire to get clean, involvement in SA courses/groups, etc. Thats a very small subset of people for my population here, if any.

 

[littlefred]

I propose an amphetamine clinic that is similar to a methadone clinic.

Similar regulations and expectations in treatment and patients can get more "take homes" once they are more stable.

Who's with me?

 

[deleted1100659]

I propose an amphetamine clinic that is similar to a methadone clinic.

Similar regulations and expectations in treatment and patients can get more "take homes" once they are more stable.

Who's with me?

Sounds promising; can we also specialize in chronic lyme disease and metastatic fibromyalgia? Maybe even do oxygen therapy, you know, for the treatment refractory patients.

 

[comp1]

I'm guessing if a patient can manage and motivate themselves to make it in in every weekday for 45 minutes of TMS for six weeks, their stimulant use disorder might be in the moderate than severe category.

 

[Merovinge]

I'm guessing if a patient can manage and motivate themselves to make it in in every weekday for 45 minutes of TMS for six weeks, their stimulant use disorder might be in the moderate than severe category.

I've treated a lot of MUD and never once encountered a patient with MUD that could complete a TMS course, it baffles me they are even able to study this.

 

[deleted1100659]

i

I've treated a lot of MUD and never once encountered a patient with MUD that could complete a TMS course, it baffles me they are even able to study this.

in my experience at a community health type setting, its always the pt that has strong family support or a supportive spouse. If they're alone in life then yea, not gonna happen most of the time. But if they have meth use disorder, a lot of patients burn bridges with other people so yeah. Unfortunate that there isnt great options to reduce cravings.

 

[whopper]

If the person truly has ADHD (which may be hard to figure out), Naltrexone, a pro-drug stimulant, Wellbutrin, Atomoxetine, NAC.

 

[Stagg737]

For meth cravings. From what I recently reviewed it does not help, but it is still used in my service. Interesting to see that other programs do use stimulants.

This is strange to me and I've never seen someone try and use antipsychotics for cravings. I have seen seroquel used frequently (prescribed and not) with meth to ease withdrawal or associated psych symptoms, but not for cravings.

I think to effectively use stimulants when a patient has meth use disorder you have to check off a lot of boxes like reliable/involved family member, consistency going to appointments, strong desire to get clean, involvement in SA courses/groups, etc. Thats a very small subset of people for my population here, if any.

Definitely depends on the population. Our addiction clinic has more than a few patients on a stimulant, but the docs I've worked with all require an ongoing period of sobriety in the patient before even considering prescribing it (usually 3-6 months) to show they're motivated to remain abstinent.

 

[the5thelement]

Saw a patient recently who has been on zubsolv for years . "Only thing which reduced cravings for meth".

 

[clausewitz2]

If the person truly has ADHD (which may be hard to figure out), Naltrexone, a pro-drug stimulant, Wellbutrin, Atomoxetine, NAC.

Don't forget desipramine.

 

[wellbutrin.girlfriend]

I propose an amphetamine clinic that is similar to a methadone clinic.

Similar regulations and expectations in treatment and patients can get more "take homes" once they are more stable.

Who's with me?

I think I'm a bit too green to understand the finer point of Dr Amazing's joke in response to this suggestion beyond the idea that there isn't a strong evidence base for this practice? To a similar end though, reading this discussion does make me think that providing/facilitating access to TMS or other similarly inaccessible treatments in a long-term rehab/residential program-type situation sounds like a really neat idea. I'm sure ketamine therapy, which is also emerging as a promising treatment, would present many of the same barriers as TMS as far as accessing treatment.

The NIDA presentation I was referencing was really interesting and discussed the promise of 1) naltrexone inj with oral bupropion, 2) TMS, and 3) ketamine. In case anyone wants a little summary, I just wanted to include the talk's description here as well as a slide deck that was shared with us by one of the presenters on TMS (no such sharing from the other presenters):

Rates of past year methamphetamine continues to rise, and according to a CDC report, 52.9% of the methamphetamine users, met criteria for a methamphetamine use disorder (MUD). There has been a 10-fold increase among Blacks; 3-fold rise among Whites; and a doubling of rates among non-White Hispanics. From 2013 to 2019, age-adjusted overdose death rate involving psychostimulant (mainly illicit methamphetamine) rose by 317% next only to synthetic opioids, further compounding the raging opioid epidemic. More than half of those with MUD are women. However, there is little evidence for effective MUD treatments, and there are no FDA approved medications, to date. In this session, three presenters will summarize research updates on treatments for MUD focusing on pharmacotherapy; brain stimulation, including transcranial stimulation (TMS); and ketamine. Each of these presenters will also share the rationale and outline for clinical trials planned to be conducted by National Institute on Drug Abuse (NIDA’s) National Drug Abuse Treatment Clinical Trials Network (CTN). Madhukar Trivedi, MD will review the pharmacology and emerging pharmacotherapy options for MUD, in addition to presenting the results of a recently completed multi-site, placebo controlled RCT conducted in the CTN, the Pharmacotherapy Treatment for Methamphetamine Use Disorder (or ADAPT-2) study, in which the combination of injectable naltrexone and oral bupropion was effective in reducing methamphetamine use. Kathleen Brady, MD will highlight research updates describing the underlying mechanisms of TMS’s therapeutic action on neurocircuitry, brain targets and preliminary efficacy data for the management of MUD. Manish Jha, MD will present cover the neuropsychology and the potential utility of N-methyl-D-aspartate (NMDA) glutamatergic receptor antagonist ketamine. Nora Volkow, MD will serve as the discussant. The session will end with a Chair-moderated panel discussion and audience question and answer segment.​

 

[deleted1100659]

I think I'm a bit too green to understand the finer point of Dr Amazing's joke in response to this suggestion beyond the idea that there isn't a strong evidence base for this practice? To a similar end though, reading this discussion does make me think that providing/facilitating access to TMS or other similarly inaccessible treatments in a long-term rehab/residential program-type situation sounds like a really neat idea. I'm sure ketamine therapy, which is also emerging as a promising treatment, would present many of the same barriers as TMS as far as accessing treatment.

The NIDA presentation I was referencing was really interesting and discussed the promise of 1) naltrexone inj with oral bupropion, 2) TMS, and 3) ketamine. In case anyone wants a little summary, I just wanted to include the talk's description here as well as a slide deck that was shared with us by one of the presenters on TMS (no such sharing from the other presenters):

Rates of past year methamphetamine continues to rise, and according to a CDC report, 52.9% of the methamphetamine users, met criteria for a methamphetamine use disorder (MUD). There has been a 10-fold increase among Blacks; 3-fold rise among Whites; and a doubling of rates among non-White Hispanics. From 2013 to 2019, age-adjusted overdose death rate involving psychostimulant (mainly illicit methamphetamine) rose by 317% next only to synthetic opioids, further compounding the raging opioid epidemic. More than half of those with MUD are women. However, there is little evidence for effective MUD treatments, and there are no FDA approved medications, to date. In this session, three presenters will summarize research updates on treatments for MUD focusing on pharmacotherapy; brain stimulation, including transcranial stimulation (TMS); and ketamine. Each of these presenters will also share the rationale and outline for clinical trials planned to be conducted by National Institute on Drug Abuse (NIDA’s) National Drug Abuse Treatment Clinical Trials Network (CTN). Madhukar Trivedi, MD will review the pharmacology and emerging pharmacotherapy options for MUD, in addition to presenting the results of a recently completed multi-site, placebo controlled RCT conducted in the CTN, the Pharmacotherapy Treatment for Methamphetamine Use Disorder (or ADAPT-2) study, in which the combination of injectable naltrexone and oral bupropion was effective in reducing methamphetamine use. Kathleen Brady, MD will highlight research updates describing the underlying mechanisms of TMS’s therapeutic action on neurocircuitry, brain targets and preliminary efficacy data for the management of MUD. Manish Jha, MD will present cover the neuropsychology and the potential utility of N-methyl-D-aspartate (NMDA) glutamatergic receptor antagonist ketamine. Nora Volkow, MD will serve as the discussant. The session will end with a Chair-moderated panel discussion and audience question and answer segment.​

I thought he was joking with his suggestion? A clinic specializing in giving amphetamine RXs to people with substance use disorder doesn't exactly sound like a fun experience, lol. Being as ADHD is not life threatening and stimulants have limited evidence for SUD where as opiate use disorder is definitely a life threatening disorder. Maybe I misinterpreted what he was saying though?

 

[littlefred]

I thought he was joking with his suggestion? A clinic specializing in giving amphetamine RXs to people with substance use disorder doesn't exactly sound like a fun experience, lol. Being as ADHD is not life threatening and stimulants have limited evidence for SUD where as opiate use disorder is definitely a life threatening disorder. Maybe I misinterpreted what he was saying though?

I wasn't joking.

And the original post was about methamphetamine use disorder and not ADHD, granted you can get a prescription for Desoxyn for ADHD, but I wasn't proposing an ADHD clinic.

There have been some studies that support treating with methamphetamine/cocaine use disorders with stimulants:

• Effects of oral methamphetamine on cocaine use: a randomized, double-blind, placebo-controlled trial Mooney et al 2009
• Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial Nuijten et al 2016

Most of the studies done are for cocaine, but what if we actually prescribed methamphetamine at our clinics in a setting where they don't have to obtain it illicitly, don't have to inject etc. etc. The hard part will be to know if the methamphetamine used in their urine is the one prescribed in the clinic. Or trial with regular amphetamines. Couldn't find any studies that directly give stimulants for MUD, ones I found are for bupropion/naltrexone, bupropion and mirtazapine.

And, MUD/CUD are a problem with actual overdose deaths related mostly to psychostimulant use (so treating MUD/CUD can actually save lives):


Taken from the study Drug overdose deaths involving cocaine and psychostimulants with abuse
potential among racial and ethnic groups – United States, 2004–2019 Mbabazi et al 2021

 

[deleted1100659]

I wasn't joking.

And the original post was about methamphetamine use disorder and not ADHD, granted you can get a prescription for Desoxyn for ADHD, but I wasn't proposing an ADHD clinic.

There have been some studies that support treating with methamphetamine/cocaine use disorders with stimulants:

• Effects of oral methamphetamine on cocaine use: a randomized, double-blind, placebo-controlled trial Mooney et al 2009
• Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial Nuijten et al 2016

Most of the studies done are for cocaine, but what if we actually prescribed methamphetamine at our clinics in a setting where they don't have to obtain it illicitly, don't have to inject etc. etc. The hard part will be to know if the methamphetamine used in their urine is the one prescribed in the clinic. Or trial with regular amphetamines. Couldn't find any studies that directly give stimulants for MUD, ones I found are for bupropion/naltrexone, bupropion and mirtazapine.

And, MUD/CUD are a problem with actual overdose deaths related mostly to psychostimulant use (so treating MUD/CUD can actually save lives):


Taken from the study Drug overdose deaths involving cocaine and psychostimulants with abuse
potential among racial and ethnic groups – United States, 2004–2019 Mbabazi et al 2021

View attachment 356264View attachment 356265

My counter to that would be, would people who have MUD stop using amphetamines because they were prescribed a legal stimulant? I think a lot of them would just use both. I don't think it would necessarily prevent cravings. I cant remember where I read this, perhaps the new K&S or maybe it was uptodate, but there was research on this and they found that 50% percent had improvement, the other half became worse because it did not reduce intake, and now they had a legal and illegal supply. Trying to remember where I read that. Especially in a community health setting where a lot of SUD resides, seems like this would be insanely hard to pull off.

 

[Merovinge]

Most of the studies done are for cocaine, but what if we actually prescribed methamphetamine at our clinics in a setting where they don't have to obtain it illicitly, don't have to inject etc. etc. The hard part will be to know if the methamphetamine used in their urine is the one prescribed in the clinic.

I don't think the pharmacodynamics make daily meth use at all like methadone or suboxone for OUD. The medication will certainly not last throughout the whole day, unless you plan to have people either have take homes daily or come back multiple times/day. I think most users of meth use 100mg at the very low end and given the typical binge cycle use of meth can easily eclipse 1g in a day. I imagine the prescribed dosages for "MAT" that you are describing would be drastically lower (to avoid the neuro and cardiac toxicity and all) and it would surprise me if this actually reduced urges to use rather than fueled more desire for higher dosages.

To your later point, it's actually very easy to know if they are using addition methamphetamine as you can get quantative levels done at x hour after prescribed ingestion a handful of times and if you see a level several times higher than that on a utox then there's clearly been additional use.

 

[littlefred]

I don't think the pharmacodynamics make daily meth use at all like methadone or suboxone for OUD. The medication will certainly not last throughout the whole day, unless you plan to have people either have take homes daily or come back multiple times/day. I think most users of meth use 100mg at the very low end and given the typical binge cycle use of meth can easily eclipse 1g in a day. I imagine the prescribed dosages for "MAT" that you are describing would be drastically lower (to avoid the neuro and cardiac toxicity and all) and it would surprise me if this actually reduced urges to use rather than fueled more desire for higher dosages.

To your later point, it's actually very easy to know if they are using addition methamphetamine as you can get quantative levels done at x hour after prescribed ingestion a handful of times and if you see a level several times higher than that on a utox then there's clearly been additional use.

All good points, just looked up methamphetamine and it has a 5 hour half-life, so indeed the idea of using it for MAT is probably not a good idea unless you give split dosing throughout the day .

Following the methadone/buprenorphine > for OUD analogy maybe focus the energy of the studies on longer acting stimulants like extended release methylphenidate/amphetamines for this.

Again, ideas. Not like I'm doing a proposal for the NIMH here lol

 

[littlefred]

My counter to that would be, would people who have MUD stop using amphetamines because they were prescribed a legal stimulant? I think a lot of them would just use both. I don't think it would necessarily prevent cravings. I cant remember where I read this, perhaps the new K&S or maybe it was uptodate, but there was research on this and they found that 50% percent had improvement, the other half became worse because it did not reduce intake, and now they had a legal and illegal supply. Trying to remember where I read that. Especially in a community health setting where a lot of SUD resides, seems like this would be insanely hard to pull off.

One of the lowest levels of evidence is expert opinion, a RCT would be awesome to see if amphetamines in a controlled setting can be helpful for MUD.

Anecdotal evidence (expert opinion haha), I have seen patients getting RX for Adderall IR and still using street methamphetamines on top, speaks more poorly about the prescriber than it does about the patient IMO.

 

[deleted1100659]

Probably 20% or more of my patients have stimulant use disorder. We have SA courses here 3 day a week that are very intense, and actually a van that picks people up and drops them off.

50% of the people who come to me with SUD could care less and are here to try to obtain more substances to abuse or because their PO forced them. The other half have had enough and are receptive and actually want help. These people do very well in our SA program here. The SA groups give one important factor- accountability. There are a lot of people at these groups- if you dont show up, someone will hold you accountable whether the instructor or a member. We also have supportive employment. People that want help, help them get a job, give them accountabiltiy, structure, and a reason to be clean and a large number of them will do well besides maybe occasional relapses. I have seen many of my patients become clean through the program and hold meaningful employment. I think the best interventions for SUD are psychosocial. Once we start addressing the SUD, we work on the mood disorder as well.

 

[littlefred]

Probably 20% or more of my patients have stimulant use disorder. We have SA courses here 3 day a week that are very intense, and actually a van that picks people up and drops them off.

50% of the people who come to me with SUD could care less and are here to try to obtain more substances to abuse or because their PO forced them. The other half have had enough and are receptive and actually want help. These people do very well in our SA program here. The SA groups give one important factor- accountability. There are a lot of people at these groups- if you dont show up, someone will hold you accountable whether the instructor or a member. We also have supportive employment. People that want help, help them get a job, give them accountabiltiy, structure, and a reason to be clean and a large number of them will do well besides maybe occasional relapses. I have seen many of my patients become clean through the program and hold meaningful employment. I think the best interventions for SUD are psychosocial. Once we start addressing the SUD, we work on the mood disorder as well.

Agreed on alternative non-psychopharmacological programs being effective. Contingency management is the one of the best, if not best treatment for stimulant use disorders. It has been well studied.

The problem with CM is that its effects quickly fade away once the rewards disappear. Another big problem is that insurances will never pay for CM, imagine asking Medicaid to dish out $400 for a patient monthly to help the keep sobriety from stimulants.

California is piloting a Medical CM program that offers up to $438 monthly in a 12 week period for patients, we shall see if other states adopt similar programs in the future.

In your program looks like most patients are in the pre-contemplation phase, giving you a pretty depressing view on SUD's.

 

[deleted1100659]

Agreed on alternative non-psychopharmacological programs being effective. Contingency management is the one of the best, if not best treatment for stimulant use disorders. It has been well studied.

The problem with CM is that its effects quickly fade away once the rewards disappear. Another big problem is that insurances will never pay for CM, imagine asking Medicaid to dish out $400 for a patient monthly to help the keep sobriety from stimulants.

California is piloting a Medical CM program that offers up to $438 monthly in a 12 week period for patients, we shall see if other states adopt similar programs in the future.

In your program looks like most patients are in the pre-contemplation phase, giving you a pretty depressing view on SUD's.

well i work for a community mental health organization, one of the largest in the region so we have a large number of people coming or being referred. Generally the ones forced to come by their PO dont have a great prognosis, but the ones that present on their own accord the success rate is actually quite high. That is why my first question is always "Whose idea was it for you to come today and why?"

I think addiction is such a complex issue. People who have SUD often have comorbid legal issues. Legal issues make it difficult to further a career/education. So what happens? People get depressed and cling to what they know, and relapse.

I dont mind treating SUD, I just get more mentally exhausted because I see the higher acuity ones with many comorbid disorders/issues and it is tiring at times.

 

[Candidate2017]

I thought he was joking with his suggestion? A clinic specializing in giving amphetamine RXs to people with substance use disorder doesn't exactly sound like a fun experience, lol.

This thread reminds of "The Nightmare Season". The San Diego Chargers hired a UCSD psychiatrist who ended up dispensing a ton of amphetamines. 1700 doses of amphetamines and barbituates in the first few weeks of the season. Players actually had to take cocaine to come down from the massive amounts of amphetamines on game day. Psychiatrist was sanctioned for overprescribing but did not lose his license, arguing his dispensing was to wean players off.

 

[adiradirim]

I propose an amphetamine clinic that is similar to a methadone clinic.

Similar regulations and expectations in treatment and patients can get more "take homes" once they are more stable.

Who's with me?

Didn't Cerebral just get shut down for this?

 

[littlefred]

Didn't Cerebral just get shut down for this?

They're still running, I think.

 

[Merovinge]

They're still running, I think.

Here's to holding out hope the government/justice department gets something right for a change...

 

[hallowmann]

I've treated a lot of MUD and never once encountered a patient with MUD that could complete a TMS course, it baffles me they are even able to study this.

This is why we haven't been able to get more than a dozen in 2 yrs. And there are a LOT of support staff involved in checking in with them and coordinating things like transportation and support.

Saw a patient recently who has been on zubsolv for years . "Only thing which reduced cravings for meth".

I've definitely seen OUD patients with MUD that report complete resolution of meth cravings with Suboxone. I wish I knew how to tell that patient apart from the one with OUD that struggles with relapses on meth every month or so.

I think I'm a bit too green to understand the finer point of Dr Amazing's joke in response to this suggestion beyond the idea that there isn't a strong evidence base for this practice? To a similar end though, reading this discussion does make me think that providing/facilitating access to TMS or other similarly inaccessible treatments in a long-term rehab/residential program-type situation sounds like a really neat idea. I'm sure ketamine therapy, which is also emerging as a promising treatment, would present many of the same barriers as TMS as far as accessing treatment.

The NIDA presentation I was referencing was really interesting and discussed the promise of 1) naltrexone inj with oral bupropion, 2) TMS, and 3) ketamine. In case anyone wants a little summary, I just wanted to include the talk's description here as well as a slide deck that was shared with us by one of the presenters on TMS (no such sharing from the other presenters):

Rates of past year methamphetamine continues to rise, and according to a CDC report, 52.9% of the methamphetamine users, met criteria for a methamphetamine use disorder (MUD). There has been a 10-fold increase among Blacks; 3-fold rise among Whites; and a doubling of rates among non-White Hispanics. From 2013 to 2019, age-adjusted overdose death rate involving psychostimulant (mainly illicit methamphetamine) rose by 317% next only to synthetic opioids, further compounding the raging opioid epidemic. More than half of those with MUD are women. However, there is little evidence for effective MUD treatments, and there are no FDA approved medications, to date. In this session, three presenters will summarize research updates on treatments for MUD focusing on pharmacotherapy; brain stimulation, including transcranial stimulation (TMS); and ketamine. Each of these presenters will also share the rationale and outline for clinical trials planned to be conducted by National Institute on Drug Abuse (NIDA’s) National Drug Abuse Treatment Clinical Trials Network (CTN). Madhukar Trivedi, MD will review the pharmacology and emerging pharmacotherapy options for MUD, in addition to presenting the results of a recently completed multi-site, placebo controlled RCT conducted in the CTN, the Pharmacotherapy Treatment for Methamphetamine Use Disorder (or ADAPT-2) study, in which the combination of injectable naltrexone and oral bupropion was effective in reducing methamphetamine use. Kathleen Brady, MD will highlight research updates describing the underlying mechanisms of TMS’s therapeutic action on neurocircuitry, brain targets and preliminary efficacy data for the management of MUD. Manish Jha, MD will present cover the neuropsychology and the potential utility of N-methyl-D-aspartate (NMDA) glutamatergic receptor antagonist ketamine. Nora Volkow, MD will serve as the discussant. The session will end with a Chair-moderated panel discussion and audience question and answer segment.​

Ketamine, if working in the same way as it does for say depression, might actually be more reasonable to implement than TMS. Its not clear to me that the data is actually there though.

I wasn't joking.

And the original post was about methamphetamine use disorder and not ADHD, granted you can get a prescription for Desoxyn for ADHD, but I wasn't proposing an ADHD clinic.

There have been some studies that support treating with methamphetamine/cocaine use disorders with stimulants:

• Effects of oral methamphetamine on cocaine use: a randomized, double-blind, placebo-controlled trial Mooney et al 2009
• Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial Nuijten et al 2016

Most of the studies done are for cocaine, but what if we actually prescribed methamphetamine at our clinics in a setting where they don't have to obtain it illicitly, don't have to inject etc. etc. The hard part will be to know if the methamphetamine used in their urine is the one prescribed in the clinic. Or trial with regular amphetamines. Couldn't find any studies that directly give stimulants for MUD, ones I found are for bupropion/naltrexone, bupropion and mirtazapine.

And, MUD/CUD are a problem with actual overdose deaths related mostly to psychostimulant use (so treating MUD/CUD can actually save lives):


Taken from the study Drug overdose deaths involving cocaine and psychostimulants with abuse
potential among racial and ethnic groups – United States, 2004–2019 Mbabazi et al 2021

View attachment 356264View attachment 356265

So it sounds crazy, but I've seen handfuls of patients that are actually managed like this. They get 3-7 days of a meds at a time. Some of them do a good job with it. A couple take the week's supply in a day or two and lose that option. Its certainly a harm reduction approach, but is difficult to feel great about...

My counter to that would be, would people who have MUD stop using amphetamines because they were prescribed a legal stimulant? I think a lot of them would just use both. I don't think it would necessarily prevent cravings. I cant remember where I read this, perhaps the new K&S or maybe it was uptodate, but there was research on this and they found that 50% percent had improvement, the other half became worse because it did not reduce intake, and now they had a legal and illegal supply. Trying to remember where I read that. Especially in a community health setting where a lot of SUD resides, seems like this would be insanely hard to pull off.

Anecdotally I've seen it happen for the small n that we've actually managed this way, I believe because there is stability in supply and how its used, the cycling of withdrawal and cravings is broken a bit. I would say that 50% sounds about right in our clinic for the few that actually got this.

50% of the people who come to me with SUD could care less and are here to try to obtain more substances to abuse or because their PO forced them. The other half have had enough and are receptive and actually want help. These people do very well in our SA program here. The SA groups give one important factor- accountability. There are a lot of people at these groups- if you dont show up, someone will hold you accountable whether the instructor or a member. We also have supportive employment. People that want help, help them get a job, give them accountabiltiy, structure, and a reason to be clean and a large number of them will do well besides maybe occasional relapses. I have seen many of my patients become clean through the program and hold meaningful employment. I think the best interventions for SUD are psychosocial. Once we start addressing the SUD, we work on the mood disorder as well.

I think different systems work for different people. That system works for that 50%, but just like not everyone is going to respond to the same psychotherapeutic modality for depression or anxiety or a personality disorder, not everyone will for SUD. There's nothing wrong with supporting psychosocial, therapeutic, psychopharmacologic, and CM programs that work.

California is piloting a Medical CM program that offers up to $438 monthly in a 12 week period for patients, we shall see if other states adopt similar programs in the future.

Honestly this is wear I've seen some if the worst MUD patients recover. Its impressive. I would like to see the longterm data from CA's program when the time comes. Certainly fits into the Cal-AIM goals.