Stimulant misuse and overdose are on the rise in the United States, prompting presenters at AMCP Nexus 2022 to recommend providers and health plans adopt new management strategies for stimulant use disorder to ensure patient access to treatment.

In 2020, more than 10 million people misused central nervous system stimulants in the United States, said Kimberly Lenz, PharmD, MBA, FAMCP, senior director of pharmacy, UMass Chan Medical School–Commonwealth Medicine, Office of Clinical Affairs/MassHealth.

Approximately 40% of all overdose deaths were stimulant-related in 2018, according to data from the Centers for Disease Control and Prevention (CDC). Between 2018 and 2019, the number of deaths caused by psychostimulant overdose increased by 28%.

“With COVID-19 came a whole lot of social isolation, and with social isolation came drug use, now alone, that may otherwise have been with a friend or other people,” Dr Lenz said. Isolated use of stimulants laced with opioids is “definitely contributing to the rise we are seeing in overdoses,” she added.

The uptick in opioid involvement is due in large part to the surge in illicit fentanyl use in 2014, Dr Lenz said. Opioids were involved in over half of psychostimulant overdose deaths in 2019, largely in the Northeast (80%) and Midwest (60%).

“Of the overdose deaths we had from 2019 where there was a toxicology report present, 93% of them were positive for fentanyl, and over 50% were positive for cocaine,” Dr Lenz said of her home state, Massachusetts.

Stimulant misuse may cause adverse events such as psychoses, organ failure, and heart attacks. In addition to impacting individuals’ health, these adverse events are associated with high societal costs.

“Amphetamine-related costs totaled over $400 million in 2003, and that was estimated to increase to $2 billion by 2015. This is so outdated at this point, so these numbers have to be much, much higher,” Dr Lenz said.

Additionally, stimulant-related overdoses disproportionately affect Black, American Indian, and Alaska Native individuals, Dr Lenz said. CDC data from 2019 shows Black and White individuals used cocaine at approximately the same rates, yet Black individuals were more than twice as likely as White individuals to experience cocaine overdose deaths.

“What we need to do, as health care professionals, is focus on what this data shows and try to understand what we can do to help address these [inequities],” Dr Lenz said.

A provider Dr Lenz spoke with advised health plans to support members by removing barriers to treatment and in-patient stays. Given the increase in overdoses involving multiple drugs, Dr Lenz said, payers should consider removing prior authorization requirements for patients to be treated with naloxone.

“Ensuring that we have access to harm reduction modalities is incredibly important,” Dr Lenz said.

Medicaid plans across the country have adopted various strategies for reducing stimulant misuse, including quantity/dose limits, age restrictions, restrictions for those with substance use disorder, drug screening requirements, diagnosis checks, and emphasis on long-acting formulations.

These “are all important steps to ensure the safe and appropriate use of prescription stimulants,” said Ashley N Chiara, PharmD, MBA, BCPS, clinical consultant pharmacist, UMass Chan Medical School–Commonwealth Medicine, Clinical Pharmacy Services. “Implementing quantity and dose limits not only serves a cost-containing function but also safety purposes.”

In addition to health plans, pharmacies and professional organizations are taking actions to curb stimulant misuse, Dr Chiara said.

Walgreens and CVS Pharmacy announced in May 2022 they would restrict prescription fills for controlled substances, specifically those obtained via telehealth startups Cerebral and Done Health. In 2023, the American Professional Society of ADHD and Related Disorders is expected to release the first set of US guidelines for diagnosing and treating attention deficit hyperactivity disorder in adults.

There are currently no medications approved by the US Food and Drug Administration to treat stimulant use disorder, but agents like topiramate, mixed amphetamine salts, naltrexone-bupropion, and mirtazapine may be used for harm reduction, Dr Chiara said.

“Behavioral interventions, particularly contingency management, has been shown in multiple studies to be the most effective treatment option that we have at this time,” Dr Chiara said.

Contingency management entails offering incentives and rewards at the completion of recovery activities, with rewards increasing as patients undergo longer durations of treatment. Research shows contingency management is most effective when paired with other harm reduction strategies such as 12-step programmes, Dr Chiara said. Digital therapeutics also can be considered for delivering cognitive behavioral therapy on demand.

For patients with acute need, nonpharmacologic treatment may involve de-escalation, monitoring, and supportive care. Providers should pay increased attention to patients presenting with suicidal ideation, psychosis, and panic, Dr Lenz said.

“Ensuring access to appropriate treatment options is critical,” Dr Chiara concluded. “Allowing patients to get the treatment they need for stimulant use disorder is of utmost importance.”