Treatments for substance use disorders are rare or non-existent. The FDA hopes to change that

When Amanda isn’t taking her attention deficit hyperactivity disorder (ADHD) medication, she struggles to function both mentally and physically. Depression, anxiety and chronic pain from fibromyalgia have all become more prominent for the 46-year-old, which has exacerbated her ADHD symptoms, making everyday tasks like bathing washing becomes a challenge. While she didn’t face any disruptions from this year’s Adderall shortage — now in its second year — there was a time when she couldn’t buy the drug at one of the 16 pharmacies near her home. Metro Detroit area. .

Amanda, who asked to be called by her first name, had been using Suboxone since 2010 after two decades of using methamphetamine, cocaine and other drugs, including several years of continuous heroin use. After deciding to get treatment and stop using drugs, she continued to have to overcome many challenges to obtain not only Suboxone but also her Adderall prescription.

She said she has to make monthly visits to her provider to get her prescriptions refilled and get monthly urine screenings, both of which come with additional copays. There were also other shortages, in which she had to go in person to multiple pharmacies and was sometimes turned away. Ultimately, she looked at more than 10 different providers before finding one that could provide consistent service for both through Medicare, she said. But she had friends diagnosed with ADHD and couldn’t connect with treatment.

Many people use drugs as a means of coping with undiagnosed mental, behavioral or neurological health conditions.

“The whole system of just being able to get your ADHD medication is a huge problem and challenge,” Amanda told Salon in a phone interview. “A lot of people have an easier time getting it from the street.”

Amanda’s experience highlights a series of factors that have contributed to the rise in substance use in the United States in recent years: Many people use drugs as a means of coping with mental health conditions. undiagnosed mental, behavioral or neurological. Dr. Mark Willenbring, an addiction psychiatrist at the Expanse clinic in St. Paul, Minnesota.

“I have patients who have been using it in a controlled manner for 30 years, as if they were self-treating ADHD,” Willenbring told Salon in a phone interview. “Their doctors won’t prescribe anything for them, so they’re kind of stuck between a rock and a hard place.”

Last year, the Drug Enforcement Agency’s (DEA) quota for drugs like Adderall used to treat ADHD failed to meet growing demand, contributing to shortages. Just as taking prescription opioids off the market is thought to have pushed people to become addicted to illegal opioids like heroin, restricting the prescription of stimulants like Adderall could push people toward the supply. illegal grant.

“I’ve had people say to me, ‘Why don’t you take a shot of meth and it’ll keep you awake all day?'” Amanda said. “I don’t want to have to do that. I have a prescription and I just want to get my medicine.”

Although stimulants are increasingly implicated in overdose deaths in what some have called the “fourth wave” of the overdose crisis, treatments for this type of use There is very little left of this drug. Earlier this month, the US Food and Drug Administration (FDA) called on drugmakers to develop new treatments that could be used to treat meth, cocaine or substance abuse addiction. prescription stimulation.

In a statement, Marta Sokolowska, deputy director of the Substance Use Unit in the FDA’s Center for Drug Evaluation and Research, said: “There are currently no FDA-approved medications for use disorder stimulant. When finalized, we hope that this guidance will support the development of critically needed new therapies to address treatment gaps.”

One of the main challenges in finding treatment for substance use is that it can vary significantly depending on the person, the drug chosen, and the route of administration. Cocaine, prescription stimulants, and meth all work differently in the brain, have different effects on the body, and are used in different ways, including snorting, smoking, or injecting.

In its draft substance use treatment guidelines, the American Society of Addiction Medicine (ASAM) cites a number of pharmacological medications that may be prescribed off-label to treat substance use disorders. . Some research shows that bupropion, an antidepressant used to treat tobacco addiction, may be effective for cocaine use disorder as well as amphetamine use disorder, especially when combined. with a drug used to treat opioid use disorder called naltrexone later.

In addition to several other off-label medications showing some benefit in treating stimulant use disorders, a 2020 study published in the journal Psychopharmacology found that stimulants used to treat ADHD may reduce the use of cocaine, including methylphenidate (also called Ritalin) or mixed amphetamine salts. like Adderall. Similarly, methylphenidate, approved by the FDA to treat narcolepsy, may also reduce amphetamine use.

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The idea of ​​using meth or amphetamine to treat these conditions is similar to the idea behind using opioid agonist treatments such as buprenorphine and methadone to treat opioid use disorder. These two drugs have been shown to be very effective in treating opioid use disorder because, being opioids themselves, they target opioid receptors that cause cravings and withdrawal.

However, stimulant use activates not just one but many different receptors, and giving patients drugs such as dextroamphetamine will not produce the same level of appetite reduction or withdrawal in humans. used methamphetamine, said Dr. Brian Hurley, medical director of the Bureau of Substance Abuse. Los Angeles County Department of Public Health Prevention and Control. Hurley said the reasons for using these drugs also vary: While people who use opioids tend to do so daily or more frequently to prevent withdrawal, people who use stimulants likes are also different in that they are used more often when intoxicated.

“Despite the similarity [comparing] Opioid agonists for opioid use disorders and psychostimulants for stimulant use disorders are reasonable, combining the mechanism of action of stimulants and the diversity in reasons why people use stimulants beyond the pure craving type that makes stimulant agonists less effective,” Hurley told Salon in a phone interview.

ASAM recommends the use of psychostimulants to treat underlying ADHD in people with both ADHD and substance use disorders, although their use remains “controversial” due to the potential for “abuse.” use”. However, there are some dextroamphetamine prodrugs used to treat ADHD, such as Vyvanse, that have a slow onset of action and can be used in these patients, Willenbring said. However, providers may be hesitant to prescribe any controlled substance that shows promise in treating off-label stimulant use because of all the additional regulations they must face. compliance through DEA.

In lieu of any FDA-approved medications to treat substance use disorders, ASAM also recommends turning to behavioral interventions, including contingency management, a program based on evidence in which people who use stimulants are given small monetary rewards for not using.

The California State Health System has implemented contingency management across 24 counties. Essentially, when a patient tests negative on a urine drug screen, they receive a gift card, with the maximum reward capped at $599 over a six-month period. However, so far this is just a pilot program and access is limited, said Dr. Chelsea Shover, assistant professor in residence at the University of California, Los Angeles. Plus, contingency management in general tends to stop working for people when they stop attending, Willenbring said.

“It’s out there but it’s pretty limited and scattered,” Shover told Salon in a phone interview.

Why it is not more widely accepted traces the stigma that continues to limit harm reduction efforts. Federal anti-kickback regulations prohibiting medical providers from rewarding patients for generating business could make health care providers nervous about providing providing services such as backup management. Although the U.S. Department of Health and Human Services Office of Inspector General issued an advisory opinion saying such programs pose a “minimal risk” of being penalized through statutes against As a result, a clinic in Montana that provided contingency management services was investigated for fraud last year. , illustrates the complexity of the problem.

Just as opioid agonist treatments are being used in conjunction with safe injection sites and needle exchange programs to minimize the effects of opioid use, any medication that uses opioid Any stimulation needs to be combined with behavioral and social interventions to respond to people using these drugs where they live. also. However, both pharmacological and behavioral interventions combat the stigma that can prevent them from reaching patients even when they prove effective.

“There’s no molecule I’ve seen in the literature that has a really strong response, but that doesn’t mean some molecules can’t help,” Hurley said. “I’m very happy [the FDA] is calling for additional research because we certainly need additional options.”

For Amanda, the combination of Suboxone and Adderall to treat her substance use and ADHD was “life-saving,” she said. Not only did it help reduce cravings and attention problems, but it also helped treat the fibromyalgia and depression that had contributed to her substance use.

“That combination helped me stabilize my life, control my pain and help me get out of depression,” she said. “It helps a lot but people don’t want to believe it. There’s so much stigma around it.”

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