Updated: Sep 13
The off-label prescribing of psychostimulants for patients with stimulant use disorder could reduce harms that result from the use of illegal stimulants, according to a new commentary.
Unregulated drugs are contributing to an ongoing crisis of poisonings in Canada, write the authors. Although many of the poisonings are related to synthetic opioids, such as fentanyl, the use of stimulants is increasing, too. In nearly half of all opioid deaths in Canada in 2022, a stimulant was also detected.
"Prescribed psychostimulants like methylphenidate and dextroamphetamine have been shown to reduce craving for and use of cocaine and methamphetamine," Heather Palis, PhD, one of the authors of the commentary, told Medscape Medical News. "For people using these drugs for energy, to stay awake, for focus, concentration, or attention, the prescribed stimulant can offer a similar effect and reduce the need to seek out cocaine or methamphetamine for these effects." Palis is a postdoctoral fellow in psychiatry at the University of British Columbia in Vancouver.
No Approved Treatments
Accumulating evidence from clinical trials in Europe, Australia, and the United States supports the treatment of stimulant use disorder with prescription psychostimulants. No pharmacologic treatments for stimulant use disorder are currently approved in Canada, however, according to the authors.
Despite a federal directive to promote increased access to pharmaceutical-grade alternatives to the contaminated drug supply, British Columbia (BC) is the only province to implement a Safer Supply Policy Directive and risk mitigation guidance for prescribing psychostimulants to people at risk of overdose. Even so, "in the first year of implementation in BC, prescribed psychostimulant medications reportedly reached 1220 people, reflecting less than 3% of people estimated to have stimulant use disorder," write the authors.
The failure to prescribe psychostimulants more widely may be explained partly by safety concerns and the fact that "the evidence base for pharmacologic treatment of stimulant use disorder is newer than for pharmacologic treatments of other substance use disorders," suggest the authors.
Nevertheless, there is still adequate evidence to support this approach, Palis told Medscape. "Clinical trials have demonstrated the safety and effectiveness of prescription psychostimulants for people who use cocaine and for people who use methamphetamine. These trials have included a number of drugs, including modafinil, methylphenidate, and amphetamine drugs, including mixed amphetamine salts, lisdexamphetamine, and dextroamphetamine," she said. "People have differing preferences for medication effects and duration of action, and a range of medications will be needed to meet these diverse patient needs."
Palis also emphasized the need for a continuum of care and services. "There is no one-size-fits-all approach. Prescribing psychostimulants is just one option across a continuum of interventions that could be offered. This practice could play a role in helping the growing number of patients who are seeking to reduce their reliance on the illegal stimulant supply during the ongoing unregulated drug poisoning crisis."
Commenting on the authors' suggestions for Medscape, Elaine Hyshka, PhD, Canada research chair in health systems innovation at the University of Alberta's School of Public Health, in Edmonton, said, "I strongly agree with the need to expand prescribed psychostimulants as a harm reduction measure and think that the authors provide reasonable recommendations for a path forward."
Hyshka, who until recently served as co-chair of Health Canada's Expert Advisory Group on Safer Supply, said that barriers must be addressed to scale up access to prescription psychostimulants. For example, the long-standing policy of limiting prescriptions of psychoactive medications (which was intended to prevent iatrogenic addiction) does not reflect the highly toxic, illegal drug market and the increasing mortality from drug poisoning. "Developing expert clinical guidance for prescribing psychostimulants will help regulators align their oversight with the best available evidence," she said. "I would also like to see more national collaboration amongst regulators, clinical experts, and provincial, territorial, and federal governments to facilitate expanded access to safer supply for those at risk of fatal drug poisoning, monitor outcomes, and adapt practice, as needed."
In addition, current programs that demonstrate positive patient outcomes do not have stable operational funding. "While prescribers' services may be covered by provincial health plans, there is often a need to pay for uninsured medication costs, as well as nurses, outreach workers, and other staff that can help ensure care continuity and work towards addressing patients' other unmet health and social needs," said Hyshka.
Alternate routes of medication administration also should be developed, she added. "Oral medications are unlikely to meet the needs of all people who are currently using illegal psychostimulants, and we should be developing and evaluating pharmaceutical-grade drugs that can be safely consumed via inhalation, and potentially other routes of administration."