In response to increasing numbers of cocaine- and methamphetamine-related deaths in New York, Governor Andrew Cuomo’s administration has issued guidance on the pharmaceutical options available to prescribers looking to support use management for patients with stimulant use disorders.
Stimulant-involved deaths, often occurring when drugs are mixed with or adulterated by fentanyl, are rising fast—exemplified by the doubling of New York City’s cocaine-related fatality rates from 2014 to 2018. In response, the state’s Office of Addiction Services and Supports (OASAS) are advising service providers on pharmacological treatments that clinicians may consider, though stopping short of a full-out recommendation given the medication’s lack of regulatory authorization.
“While there are no medications approved by the FDA for the treatment of cocaine and stimulant use disorders,” wrote the Medical Advisory Panel of to New York service providers, “several medication classes”—such as anti-depressants, amphetamines, anti-convulsants and opioid addiction medications—”have preliminary evidence for potential benefits.”
However, OASAS added the caveat that “Nothing in this document should be interpreted as an official endorsement.”
Off-label prescribing is currently the only option for clinicians interested in taking a pharmacological approach, but the significance of medication-assisted treatment (MAT) in stemming the opioid-involved overdose crisis hints at its potential impact on stimulant harms. A 2018 literature review found that pooled overdose mortality rates from 21 studies decreased from 4.89 per 100 people to 0.92 per 100 people who used opioid use disorder medications.
Medications like mirtazapine, a common anti-depressant, and naltrexone, a drug prescribed for opioid or alcohol dependence, have been shown to help reduce stimulant cravings. But OASAS suggested that in contrast to opioid use disorder medications, these drugs may not be effective if used alone.
“Off-label medications should be provided along with as robust of a psychosocial treatment plan as individuals are able and willing to engage in.” OASAS wrote. These supplementary treatment tools include contingency management, an intervention that pays patients to reduce their use, and community reinforcement, which encourages patients to participate in drug-free activities, like sports.
OASAS advises service providers to be vigilant when prescribing these treatments. “When off-label medications are prescribed, providers should carefully document that they educated patients about risks, benefits, alternatives, the evidence for using the medications, and the fact that the medications have not been FDA-approved to treat the indication for which they are prescribing them,” the office wrote. “Providers should consider having patients sign treatment agreements detailing this information and the expectations for treatment before starting off-label medications.”
Consideration of medications for stimulant use disorder is far from limited to the Cuomo administration. A spending bill approved by Congress at the end of 2019 “urges” the National Institute on Drug Abuse to “expeditiously find and approve a medication-assisted treatment for methamphetamine.”