Stimulants: The Next Wave of SUD
Please be aware that viewing the training video on this page will not result in continuing education credits.
Hello welcome, I'm Dr. Gloria Baciewicz. I'm a psychiatrist specializing in Addiction Psychiatry at the University of Rochester in our substance use disorder treatment program Strong Recovery I'm the Co-PI of this HRSA grant.
The topic today is Stimulants: The Next Wave of Substance Use Disorder the objectives are understanding the next wave of stimulant use which is a wave that we are already in learning about patterns of methamphetamine overdose and cocaine overdose where they are occurring and what patterns of use people have reviewing some validated screening tools for stimulant use disorder and reviewing various treatment options for stimulant use disorder there are no disclosures to make today overdose deaths involving stimulants have increased the rates of overdose deaths involving synthetic opioids other than methadone such as fentanyl cocaine and psychostimulants with abuse potential such as methamphetamine have all increased from 2019 to 2020.
drug overdose deaths involving synthetic opioids increased by 56 percent from 11.4 per 100 000 in 2019 to 17.8 in 2020. deaths involving cocaine increased 22 percent and deaths involving psychostimulants increased by 50 percent so looking at this slide in a graphic form overdose deaths involving stimulants from 1999 to 2020 overdose deaths involving stimulants really started increasing in about the year 2013 which was also when overdose deaths involving opioids started increasing and you could see the two lines there with cocaine and methamphetamine and other psychostimulants what about rural communities is it any different well these statistics are being collected and in 2019 psychostimulant overdose deaths were 1.4
Times Higher in rural counties cocaine overdose deaths were more than twice the rate in rural counties this is an interesting slide because it contains this Venn diagram which shows you the various use patterns that people have surrounding stimulants they are not using only one stimulant so the question being asked here is have you used this drug in the last year so that means in the past year the past 12 month period 2.5 million people used methamphetamine 5.2 million people used cocaine and 5.1 million misused prescription stimulants so in this slide they're separating the cocaine use from the other prescription stimulants and you could see all the different patterns of use where they're switching from one thing to another and and experimenting which is of course a very common pattern in substance use disorder during 2015 to 2018 and looking at methamphetamine only an estimated 1.6
million U.S adults reported past year methamphetamine use 52.9 percent had a methamphetamine use disorder and 22 percent reported actually injecting methamphetamine within the past year and of course co-occurring substance use and mental illness were very common among those who used methamphetamine during the past year so this is a very interesting slide because we can also look at methamphetamine use in terms of how much methamphetamine that the DEA seizes removals of methamphetamine by state in kilograms 2019 and looking at this map certainly there are many many seizures of
methamphetamine in east coast and eastern states in general and Appalachian areas as well the DEA seized more than 53 000 kilograms of methamphetamine nationwide and that was a two percent increase since 2018 and since if you go back to 2014 there's been a 75 percent increase in methamphetamine seizures in terms of methamphetamine overdoses well the last slide said that they were there was more methamphetamine on the East Coast now more seizures and you might think to yourself well but I learned that the pattern was that most of the methamphetamine use and overdoses were in
the west so this slide shows how that figure has been changing starting from 2011 to subsequent years 2018 and you could see some hot spots on the East Coast as well so it's a very different pattern in 2011 only one state had a mortality rate of five per 100 000 methamphetamine overdose deaths and by 2018 there were 18 states with that pattern of mortality rate five or more per 100 000 and states in the Appalachian region who already had high opioid overdoses saw a very substantial increase in methamphetamine overdoses as well so compounding the problem with opioid
overdoses of course so when we look at cocaine the data suggests that the increase in cocaine involved overdose deaths from 2015 to 2020 was driven by opioids the increase in cocaine overdose deaths was mirrored by a corresponding increase in the rate of overdose deaths involving both cocaine and fentanyl and when you look at this graph there's a line for all cocaine and cocaine without any opioid and cocaine in combination with synthetic opioids other than methadone so cocaine with fentanyl during this time period we also saw a substantial increase in the rate of overdose
deaths involving cocaine and Fentanyl but without heroin so just the fentanyl without the heroin and this is thought of as a proxy for deaths where fentanyl might have been present in the cocaine product so of course fentanyl can be added to almost any abusable drug to alter it and again compounding the problem because the person may have thought that they were using cocaine when actually they were using a mixture of cocaine and fentanyl the impact of stimulant use disorder stimulant use disorder has many many many symptoms which are often quite dramatic so I just want to read
a lot of them certainly in the short-term we could get wakefulness reduced appetite a sense of euphoria and accelerated heart rate and vasoconstriction bronchodilatation hyperthermia which can be potentially deadly and many many psychological and neurological effects and these effects are not trivial sometimes people end up in psychiatric emergency departments to evaluate them because they are just floridly psychotic or suicidal or perhaps even very agitated and violent so these can include also panic attacks hostility paranoia psychosis and violent behavior long-term we
might see a some chronic medical problems or exacerbation of pre-existing problems including persistent hypertension angina pain valvular disease stroke increased risk of heart attack alterations in brain structure impairment of cognitive neurological and emotional systems and here we're talking about long-term in the sense that even if the person stops using the cocaine or the methamphetamine it takes a long time to recover from cognitive and emotional problems recovery the state of recovery first 90 days first you know first year can be a very unstable time in which the
person is presented with many challenges fluctuations of cognitive states and fluctuations of mood anxiety and depression inhibited impulse control and reduced motor skills now of course all of these things can contribute to difficulty remaining in recovery programs or engaging in recovery programs and difficulty maintaining sobriety and then the person might relapse to substance use again and the whole thing might start over again so how do we screen for stimulant use disorder we can think of this in terms of the SBIRT modality screening brief intervention and referral to
treatment that many of you may have learned for alcohol use disorder screening it can also be used for drug use disorders so in screening you're identifying people who are at risk for developing substance use disorders and here you know it's good to talk with people about substance use disorders but in your mind it's it's also good to think about sort of a universal screening because sometimes people are surprised when people who they don't think are using substances admit to substance use but you shouldn't be surprised because it does certainly happen and an idea of
universal screening or at least a couple of questions about it is very helpful because certainly there's there's no age at which you can't use stimulants and it doesn't it's no respecter of persons in terms of wealth or education or marital state or anything like that it's it occurs just literally everywhere brief intervention aims to raise awareness of risks to elicit internal motivation for change and to help set healthy goals for the future and the term healthy goals is a good one because uh you know they're seeing you in primary care for health and you know some people
think that that drug use is kind of benign or some drugs are benign but actually the more you point out the possible effects of stimulant use on health the more people might possibly listen to you and acknowledge that it could be a problem and the R and the T stand for referral to treatment so you want to facilitate access to specialized services and then to coordinate care between systems because hopefully you'll be getting the patient back after after they have finished with their outpatient or inpatient rehab SBIRT uses validated screening tools which you can easily obtain
free copies of these from the web just free downloads especially from the NIDA site so there's CAGE-AID many of us learn the CAGE questions for alcohol but it has been adapted to include drugs as well the DAST 10 10 questions drug abuse screening test and the NIDA Quick Screen available for the NIDA site and the NIDA Modified ASSIST so you could look at those and see which one might fit into your practice pharmacotherapy for stimulant use disorder well we've made great strides in pharmacotherapy for alcohol and opiates but there are still no FDA approved medications to treat
methamphetamine use disorder or cocaine use disorder and many many medications have been studied including antidepressants antipsychotics blood pressure medications anti-seizure medications it's all over the map and sometimes there are popular off-label medications that are used so and often these off-labeled medications are used in facilities for treatment of substance use disorder because we have nothing else to offer patients that is FDA approved so sometimes common medications are added that are not FDA approved for an off-label use so you may find that your patient
has gone to an inpatient rehab facility and comes out on various medications that are not approved for cocaine or methamphetamine craving but are sometimes used because we don't have any approved ones and because you know we may have had some good experiences or the patient may have had some good experiences with decreasing cravings with some of these medications so when the patient comes out of the rehab what you might want to think about is figuring out whether the medications are being used for their original stated FDA indication or for the off-label treatment of substance
use disorder especially stimulant cravings and this may not always be clear in the information you get from the inpatient rehab facility treatment of stimulant use disorder through cognitive psychotherapeutic and psychosocial methods has been heavily investigated and there are many evidence-based therapies for stimulant use disorder one of the ones that you are probably more familiar with in Primary Care is Motivational Interviewing you may have even had some training and Motivational Interviewing this is always an important approach to take with any substance use disorder
and the first one right there listening is a very important approach you need to listen to it like it's a any other type of medical problem the patient might bring to you and identify goals and current behaviors and talk about resistance to change and support some optimism and hope for change that the person can make a change and many times this can be very supportive to a patient and can help the patient decide on engaging in in further treatment so the the last one Cognitive Behavioral Therapy I'm sure you've you've all heard of that's probably the approach that is that
is most common in various types of mental health therapies today used for not only substance use disorder but also problems such as depression and anxiety and it includes goal-oriented psychotherapy to understand current problems and experiences and to help the patient change behaviors and patterns of thinking so it's it's psychotherapy but with a with a practical end in mind to change these behaviors and patterns the two boxes in the middle Contingency Management and Community Reinforcement Approach are have been heavily investigated recently and there's a lot of evidence
for Contingency Management the Community Reinforcement Approach is something that's often used in combination with Contingency Management and it's it's what a lot of a lot of things that are done in counseling when you send your your patient to substance use disorder treatment center this will be very these are very common approaches talk about new recreational activities and social networks get a sober support network and that kind of thing all very important Contingency Management though is the therapy where we are giving vouchers or cash incentives to a person to for
example have a urine screen which is negative for stimulants and do primary care offices do this well we'll know that not that's not realistic and in fact it's not been heavily adopted in the substance use disorder treatment world either because of various insurance and implementation problems but we're seeing a lot more excitement and planning about this so so maybe in the next few years you may hear about more and more of this being done in your community and when we're talking about cash incentives the the vouchers are are meant to be small and small cash incentives work
like maybe two or three dollars for a negative urine screen for example so you may hear more about this in the future one thing to remember is to just treat stimulant use disorder as an ordinary medical problem so if the person had a cardiac disorder or COPD maybe you would ask about their functioning level and how closely they're following their treatment plan same thing with substance use disorder so it's important to just check with them and even a simple question about are you still able to be abstinent from the cocaine that you were using that often can just open the
door for the patient to think oh yeah I can talk to this doctor about this and that can be very helpful in sort of just just normalizing the the treatment of substance use disorder in your office well thank you for attending today and here are some contact information for our Recovery Center of Excellence including our website and Twitter handle and our the description of our grant.
Gloria Baciewicz, MD
This 20 minute module will address the growing stimulant use disorder crisis in the United States. It will also focus on methamphetamine and cocaine overdoses, educate on evidence-based screening tools, and discuss the treatment options for stimulant use disorder.