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|Issue 147||October 2018|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Pharmacotherapy for Stimulant Use Disorders: A Systematic Review
Stimulant use disorders, specifically cocaine and methamphetamine use disorders, present ongoing public health problems in the United States, with major medical, psychiatric, cognitive, socioeconomic, and legal consequences. There are more emergency department visits associated with cocaine compared with other illicit substances, and several US cities consider methamphetamine as the drug of abuse associated with the "most serious consequences." To date, there are no FDA-approved pharmacotherapies for cocaine or methamphetamine use disorders. However, several have been proposed as possible experimental interventions to promote reduction in use or cessation. Currently, psychotherapy (e.g., cognitive behavioral therapy, drug counseling, relapse prevention, etc.) is offered as the primary treatment for stimulant addiction. Contingency management strategies employing incentives to increase engagement in treatment and reduce drug use are often commonly used.
In order to guide future VA research and policy decisions, VA's Office of Mental Health, Addictions Program Office and the Seattle and Philadelphia Centers of Excellence in Substance Abuse Treatment and Education (CESATE) asked HSR&D's Evidence-based Synthesis Program (ESP) to provide an up-to-date examination of the benefits and risks of various pharmacologic treatments for stimulant use disorder. Specifically, this review examined the:
Investigators with VA's ESP Center in Portland, OR worked with a research librarian to search multiple data sources (i.e., Ovid MEDLINE and the Cochrane Database of Systematic reviews) from database inception through November 2017 for systematic reviews and randomized controlled trials (RCTs) directly comparing pharmacological interventions against each other, placebo, usual care, or psychotherapy in adults with cocaine or amphetamine/methamphetamine use disorders. After reviewing more than 5,500 titles and abstracts, investigators identified 8 systematic reviews and 61 RCTs that were included in this review.
Summary of Findings
For methamphetamine use disorder, investigators found less promising results. Similar to the body of research examining pharmacotherapy for cocaine use disorder, studies evaluating pharmacotherapy for amphetamine/methamphetamine use disorders were largely of low or unclear quality, and were underpowered. Co-interventions differed widely, and rates of retention varied greatly. Moreover, for nearly all of the pharmacotherapies and almost all of the outcomes, findings were either null or insufficient to form conclusions. With low strength of evidence, investigators did find that methylphenidate and topiramate may be effective at reducing amphetamine/methamphetamine use.
Implications for VA Policy/Practice
For assistance with implementation of CM for stimulant use disorders, providers and programs are encouraged to contact the Philadelphia CESATE (Dominick.DePhilippis@va.gov or Kendall.Browne@va.gov). The Philadelphia CESATE can provide implementation guidance and coaching, material support for motivational incentives, and guidance in implementing point-of-care (POC) testing to support CM.
View the full report — **VA Intranet only**:
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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.
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