Canada should consider prescribing psychostimulant medications to reduce the use and harms from illegal stimulants, such as cocaine and methamphetamine, since nearly half of all people who died from drug poisonings in the country last year had illegal stimulants in their system, according to a doctor on the front lines of the toxic drug crisis.
“It’s time to start prescribing because there’s rising use of illegal stimulants in Canada,” said Scott MacDonald, a family physician at Providence Health Care’s Crosstown Clinic in Vancouver who has worked in the substance-use field for more than 30 years.
In a new commentary, published in the Canadian Medical Association Journal on Monday, Dr. MacDonald and Heather Palis of the University of British Columbia said growing evidence supports prescribing psychostimulants to help patients who are looking to reduce their reliance on the illegal stimulant supply.
Prescribed psychostimulants, such as methylphenidate and dextroamphetamine, are central nervous system stimulants that are often used to treat attention-deficit hyperactivity disorder.
Even though no medication has been approved for treating stimulant use disorder in Canada, prescribed psychostimulants have been used off-label for this purpose on a small scale in certain parts of the country, they said. The authors suggested broader implementation is needed.
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A surge in the combined use of illegal stimulants and fentanyl has been considered by some as a “fourth wave” in the opioids epidemic. (The first wave was related to increased access to prescription opioids, the second was characterized by heroin-related overdoses when opioid prescriptions decreased, and the third was driven by synthetic opioids, predominantly fentanyl.)
Similar to opioid agonist treatment, which uses medications such as methadone, Suboxone or Kadian, to reduce the harms of opioid use, prescribed psychostimulants can help manage cravings and withdrawal symptoms in people with stimulant use disorder, the authors said. They cited a recent systematic review of 38 clinical trials that concluded prescribed psychostimulants constituted a safe, effective intervention.
At Dr. MacDonald’s clinic, a select group of patients who used illegal stimulants, such as cocaine and methamphetamine, benefited from prescribed psychostimulants, he said. “Their cravings went down, they used less, their lives became more ordered.”
He added prescribed psychostimulants can be used together with medications for treating opioid disorder. If someone is already visiting a pharmacy daily for opioid agonist medications, it can be relatively easy to have them pick up or take a witnessed dose of a prescribed psychostimulant at the same time, he said.
Leslie Buckley, chief of the addictions division at the Centre for Addiction and Mental Health in Toronto, said the fact that there’s evidence for a potential benefit to prescribing psychostimulants for those struggling with methamphetamine and cocaine use “is something that we should be looking at carefully,” especially since there are no other medical treatments for stimulant-use disorder.
There has been contradictory evidence about whether there is a benefit in the past, she said.
Dr. Buckley said it’s important to consider whether studies showing a benefit also offered patients wraparound services such as counselling and medical care for their other health issues. “The outcomes might not be as positive if we don’t replicate the wraparound services as well,” she said.
As the commentary suggests, she said, it’s necessary to examine the potential risks, too.
For example, even though the authors mention there are ways to reduce having prescribed psychostimulants end up in the illicit marketplace or other types of misuse, Dr. Buckley said avoiding diversion can be quite difficult in practice.
It’s hard to say whether prescribing psychostimulants would prevent opioid toxicity deaths, she said. But theoretically, reducing the overall consumption of illegal stimulants could help, she said, since many of these deaths currently occur among people who take illegal stimulants, not knowing they contain fentanyl.