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Stimulant Summit: As Stimulant Use Surges, Behavioral Therapies are Best Bet for Now

November 20, 2020

Largely fueled by a surge in methamphetamine and cocaine use, as well as fentanyl, overdose deaths in the United States increased 4.6% in the United States in 2019, NIDA director Nora Volkow, MD, told attendees in a Cocaine, Meth & Stimulant Summit keynote address presented Friday.

Deaths involving methamphetamine (16,539) and cocaine (16,196) outpaced those involving prescription opioids (14,347) and heroin (14,278), each of which decreased compared to 2018. Like methamphetamine- and cocaine-involved deaths, however, fentanyl-involved deaths (37,137) continued a rapid climb that began in 2013.

In terms of demographics, Volkow noted that methamphetamine-involved deaths have increased most rapidly among Native Americans, while cocaine-involved deaths have seen their steepest increase among Black Americans.

“This is crucial because one of the aspects we’ve seen with the opioid epidemic was in the beginning, mortality was predominantly [associated with] white Americans, but it’s increasingly evident that that’s no longer the case,” Volkow said. “The steepest increases in [overdose-involved] mortality is among Black individuals, which is very likely driven in part by cocaine in combination with opioids.”

Methamphetamine use, meanwhile, has also been linked with high-risk sexual behaviors. In one particular study released in September, Volkow said the 14% of men in the study who reported persistent methamphetamine use accounted for one-third of new HIV cases.

Current treatment options

One of the primary challenges of treating stimulant addictions is a lack of FDA-approved medications similar to what exists for the treatment of opioid use disorder, as well as overdose reversal medications like naloxone for opioids, Volkow said.

Currently, the most effective treatment for stimulant use disorders has been a combination of contingency management—providing a reward for evidence of abstinence—and community reinforcement—making a non-drug-using lifestyle more rewarding than substance use. Even this path has its challenges, however. Studies on the effectiveness of contingency management have provided over $200 per patient, per year, but most treatment programs receiving federal funds are allowed $75 per patient, per year, Volkow said.

“That limits the effectiveness of the intervention because it might not be sufficient enough to reinforce the behavior,” she said. “This is important to look into because this is something that could be relatively easy to address if there was an approval to increase the amount a program can provide in contingency management rewards to individuals.”

Treatment modalities in the pipeline

There are no drugs for the treatment of stimulants in Phase 3 of the development cycle, Volkow said, but several studies have reached Phase 2. One of those is a rescue drug for methamphetamine overdoses similar to naloxone for opioids. The medication is also being evaluated for treatment of methamphetamine addiction.

Further out, there is an anti-methamphetamine vaccine in the late preclinical stage, meaning it is 10 to 12 years away, as well as an anti-cocaine vaccine in Phase I, which would put it 6 to 10 out. In the meantime, researchers are also evaluating the use of transcranial magnetic stimulation for cocaine and methamphetamine addiction, using electrical currents to stimulate executive control areas of the brain to self-regulate desires and emotions or target hot spots on the brain that would inhibit reward pathways, Volkow said.

“Researchers are starting to understand how to optimally apply neuro modulation technologies, what frequencies, what areas of the brain should be stimulated in order to see what leads to the best outcomes,” Volkow said.

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