Introduction Provisional estimates indicate that drug overdose deaths increased in 2019 after a slight decrease in 2018. In 2018, overdose deaths primarily involved opioids, with continued increases in deaths involving illicitly manufactured fentanyls (IMFs). Deaths involving stimulants such as cocaine and methamphetamine are also increasing, mainly in combination with opioids. Methods CDC analyzed data on drug overdose deaths during January-June 2019 from 24 states and the District of Columbia (DC) in the State Unintentional Drug Overdose Reporting System to describe characteristics and circumstances of opioid- and stimulant-involved overdose deaths. Results Among 16,236 drug overdose deaths in 24 states and DC, 7,936 (48.9%) involved opioids without stimulants, 5,301 (32.6%) involved opioids and stimulants, 2,056 (12.7%) involved stimulants without opioids, and 943 (5.8%) involved neither opioids nor stimulants. Approximately 80% of overdose deaths involved one or more opioid, and IMFs were involved in three of four opioid-involved overdose deaths. IMFs, heroin, cocaine, or methamphetamine (alone or in combination) were involved in 83.8% of overdose deaths. More than three in five (62.7%) overdose deaths had documentation of at least one potential opportunity for overdose prevention intervention. Conclusions and implications for public health practice Identifying opportunities to intervene before an overdose death and implementing evidence-based prevention policies, programs, and practices could save lives. Strategies should address characteristics of overdoses involving IMFs, such as rapid overdose progression, as well as opioid and stimulant co-involvement. These efforts should be complemented by efforts to prevent initiation of prescription opioid and stimulant misuse and illicit drug use.

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Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids and Stimulants — 24 States and the District of Columbia, January–June 2019

In the United States, combined stimulant/opioid overdose mortality has risen dramatically over the last decade. These increases may particularly affect non-Hispanic Black and Hispanic populations. We used death certificate data from the US National Center for Health Statistics (2007-2019) to compare state-level trends in overdose mortality due to opioids in combination with 1) cocaine and 2) methamphetamine and other stimulants (MOS) across racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian American/Pacific Islander). To avoid unstable estimates from small samples, we employed principles of small area estimation and a Bayesian hierarchical model, enabling information-sharing across groups. Black Americans experienced severe and worsening mortality due to opioids in combination with both cocaine and MOS, particularly in eastern states. Cocaine/opioid mortality increased 575% among Black people versus 184% in White people (Black, 0.60 to 4.05 per 100,000; White, 0.49 to 1.39 per 100,000). MOS/opioid mortality rose 16,200% in Black people versus 3,200% in White people (Black, 0.01 to 1.63 per 100,000; White, 0.09 to 2.97 per 100,000). Cocaine/opioid overdose mortality rose sharply among Hispanic and Asian Americans. State-group heterogeneity highlighted the importance of data disaggregation and methods to address small sample sizes. Research to understand the drivers of these trends and expanded efforts to address them are needed, particularly in minoritized groups. 

https://academic.oup.com/schizophreniabulletin/article-pdf/48/4/871/44157294/sbac018.pdf

OUP accepted manuscript

Background Cocaine use contines to be a significant public health problem world-wide. However, despite substantial research efforts, no pharmacotherapies are approved for the treatment of cocaine use disorder (CUD). Argument Studies have identified positive signals for a range of medications for treating CUD. These include long-acting amphetamine formulations, modafinil, topiramate, doxazosin and combined topiramate and mixed amphetamine salts extended-release (MAS-ER). However, valid conclusions about a medication's clinical efficacy require nuanced approaches that take into account behavioural phenotypes of the target population (frequency of use, co-abuse of cocaine and other substances, genetic subgroups, psychiatric comorbidity), variables related to the medication (dose, short-/long-acting formulations, titration speed, medication adherence) and other factors that may affect treatment outcomes. Meta-analyses frequently do not account for these co-varying factors, which contributes to a somewhat nihilistic view on pharmacotherapeutic options for CUD. In addition, the predominant focus on abstinence, which is difficult for most patients to achieve, may overshadow more nuanced therapeutic signals. Conclusion While there is an emphasis on finding new medications with novel mechanisms of action for treating CUD, currently available medications deserve further investigation based on the existing literature. Evaluating refined metrics of treatment success in well-defined subgroups of patients, and further exploring combination therapies and their synergy with behavioural/psychosocial interventions, are promising avenues to establishing effective therapies for CUD.

Pharmacotherapeutic strategies for treating cocaine use disorder-what do we have to offer?

In the United States, combined stimulant/opioid overdose mortality has risen dramatically over the last decade. These increases may particularly affect non-Hispanic Black and Hispanic populations. We used death certificate data from the US National Center for Health Statistics (2007-2019) to compare state-level trends in overdose mortality due to opioids in combination with 1) cocaine and 2) methamphetamine and other stimulants (MOS) across racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian American/Pacific Islander). To avoid unstable estimates from small samples, we employed principles of small area estimation and a Bayesian hierarchical model, enabling information-sharing across groups. Black Americans experienced severe and worsening mortality due to opioids in combination with both cocaine and MOS, particularly in eastern states. Cocaine/opioid mortality increased 575% among Black people versus 184% in White people (Black, 0.60 to 4.05 per 100,000; White, 0.49 to 1.39 per 100,000). MOS/opioid mortality rose 16,200% in Black people versus 3,200% in White people (Black, 0.01 to 1.63 per 100,000; White, 0.09 to 2.97 per 100,000). Cocaine/opioid overdose mortality rose sharply among Hispanic and Asian Americans. State-group heterogeneity highlighted the importance of data disaggregation and methods to address small sample sizes. Research to understand the drivers of these trends and expanded efforts to address them are needed, particularly in minoritized groups.

Racial/Ethnic and Geographic Trends in Combined Stimulant/Opioid Overdoses, 2007-2019.

Recent attention has focused on the growing role of psychostimulants, such as methamphetamine in overdose deaths. Methamphetamine is an addictive and potent stimulant, and its use is associated with a range of physical and mental health harms, overdose, and mortality. Adding to the complexity of this resurgent methamphetamine threat is the reality that the increases in methamphetamine availability and harms are occurring in the midst of and intertwined with the ongoing opioid overdose crisis. Opioid involvement in psychostimulant-involved overdose deaths increased from 34.5% of overdose deaths in 2010 to 53.5% in 2019-an increase of more than 50%. This latest evolution of the nation's overdose epidemic poses novel challenges for prevention, treatment, and harm reduction. This narrative review synthesizes what is known about changing patterns of methamphetamine use with and without opioids in the United States, other characteristics associated with methamphetamine use, the contributions of the changing illicit drug supply to use patterns and overdose risk, motivations for couse of methamphetamine and opioids, and awareness of exposure to opioids via the illicit methamphetamine supply. Finally, the review summarizes illustrative community and health system strategies and research opportunities to advance prevention, treatment, and harm reduction policies, programs, and practices.

Methamphetamine use in the United States: epidemiological update and implications for prevention, treatment, and harm reduction.

Aims Stimulant use disorder contributes to a substantial worldwide burden of disease, although evidence-based treatment options are limited This systematic review of reviews aims to: (i) synthesize the available evidence on both psychosocial and pharmacological interventions for the treatment of stimulant use disorder; (ii) identify the most effective therapies to guide clinical practice, and (iii) highlight gaps for future study Methods A systematic database search was conducted to identify systematic reviews and meta-analyses Eligible studies were those that followed standard systematic review methodology and assessed randomized controlled trials focused on the efficacy of interventions for stimulant use disorder Articles were critically appraised using an assessment tool adapted from Palmeteer et al and categorized for quality as ‘core’ or ‘supplementary’ reviews Evidence from the included reviews were further synthesized according to pharmacological or non-pharmacological management themes Results Of 476 identified records, 29 systematic reviews examining eleven intervention modalities were included The interventions identified include: contingency management, cognitive behavioural therapy, acupuncture, antidepressants, dopamine agonists, antipsychotics, anticonvulsants, disulfiram, opioid agonists, N-Acetylcysteine, and psychostimulants There was sufficient evidence to support the efficacy of contingency management programs for treatment of stimulant use disorder Psychostimulants, n-acetylcysteine, opioid agonist therapy, disulfiram and antidepressant pharmacological interventions were found to have insufficient evidence to support or discount their use Results of this review do not support the use of all other treatment options Conclusions The results of this review supports the use of contingency management interventions for the treatment of stimulant use disorder Although evidence to date is insufficient to support the clinical use of psychostimulants, our results demonstrate potential for future research in this area Given the urgent need for effective pharmacological treatments for stimulant use disorder, high-quality primary research focused on the role of psychostimulant medications for the treatment of stimulant use disorder is needed

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Jano Klimas

Papers

Treatment of stimulant use disorder: A systematic review of reviews.