Treatment of stimulant use: where are we?

The use of stimulant drugs is a growing issue and continues to pose major challenges to health and justice systems across the world.¹

Stimulants include a range of natural and synthetic drugs that speed up messages between the brain and body, making a person feel more awake, alert, confident or energetic.²

Some commonly used stimulants are:

• amphetamines (ice and speed)
• caffeine
• cocaine
• khat
• nicotine (tobacco, vaping)
• synthetic cathinones.

Stimulant use (particularly heavy use) is associated with a range of harms, including:

• suicide
• injury
• drug poisoning
• mental health issues
• cardiovascular disease
• bloodborne viruses
• dependency.^{1, 3}

The recognition of these harms has led to an emphasis on improving access to evidence-based treatments⁴ – particularly for cocaine and amphetamines.¹
Cocaine and amphetamines are the main focus of stimulant treatment research, due to the large number of people who use them globally and the serious harms they can cause.¹
(Note: while nicotine is more widely used than cocaine and amphetamines and is also very harmful, it is not currently the priority focus for treatment research as we already know the best available treatments.)

Where are we at with stimulant treatment?

One of the shortcomings of stimulant treatment is that there are no effective pharmacotherapy medications available yet.³

Pharmacotherapy involves replacing a drug of dependence with a legally-prescribed substitute to help reduce withdrawal symptoms, drug cravings and the likelihood of use.⁵

For example, methadone and buprenorphine are used in opioid pharmacotherapy to treat opioid dependence.

Similarly, alcohol dependence is often treated with naltrexone and acomprosate.

Usually, these medications are combined with therapy/counselling as part of a comprehensive treatment plan.^{6, 7}

Pharmacotherapy doesn’t suit everyone – but there’s strong evidence showing the effectiveness of it as a first-line treatment.^{7, 8}

Although pharmacotherapy medications are not currently approved to treat cocaine or amphetamine use, research is continuing and some trials are showing promising results.^{9, 10}

In the meantime, specialised treatments for stimulant use typically involve psychosocial interventions, such as:

• cognitive behaviour therapy (CBT): helps the person recognise unhelpful or unhealthy ways of thinking, feeling and behaving that may lead to their substance use¹¹
• community reinforcement approach: helps the person find healthier ways to meet their social and emotional needs, rather than using substances¹²
• peer-based support groups: voluntary self-help groups where people work with other peers to reduce their drug use or maintain abstinence.¹³ For example, Narcotics Anonymous.

Psychosocial intervention can achieve good results, particularly if the person is ready to make a change.³ However, evidence suggests that none of the interventions are significantly better than the others at reducing stimulant use – except for contingency management.^{1, 3, 4, 14, 15}

But, this treatment is rarely used in Australia.

So, what’s contingency management?

Contingency management (CM) is based on the idea that if a desired behaviour is reinforced and rewarded, it is more likely to continue.¹⁶

For example, drug taking is monitored through urine screening, and if no substance is detected the person is provided with a reward or incentive.¹

The three key principles of CM are:

1. frequently monitor the behaviour you’re trying to change
2. provide tangible, immediate positive reinforcers each time the behaviour occurs
3. when the behaviour does not occur, withhold the reward.¹⁷

Aside from reducing drug use, other encouraged behaviours might include attendance at treatment sessions or taking prescribed medications for other health conditions.¹⁸

In the U.S, where contingency management is more common, a variety of reward options are used:

• prizes: the ‘fishbowl’ method allows clients to draw a token from a fishbowl for a chance to win prizes of varying value.¹⁸
• gifts and vouchers: Voucher-based Reinforcement Therapy allows clients to earn vouchers of increasing value. Vouchers can be exchanged for retail goods and services, such as restaurant gift certificates, clothing, sports equipment, movie tickets and electronics.^{16, 18}
• monetary vouchers: clients have a ‘bank account’ which accumulates money with each positive behaviour. The accumulated money can then be used to purchase a counsellor-approved item. No cash is involved.

An example of a monetary reward system for contingency management could look something like this³:

(Note: when a person returns a positive sample, the reward accumulation resets back to 0)

A number of reviews have found contingency management leads to a significant reduction in stimulant use (particularly when combined with a psychosocial therapy like CBT) and is more effective than a single psychosocial intervention alone or treatment as usual.^{1, 4, 14}

Why don’t we have contingency management in Australia?

In Australia, contingency management is poorly understood and rarely used in practice, despite strong evidence of success elsewhere.¹⁷

It’s also attracted opposition from service planners, clinicians, and communities,¹ for reasons such as:

• the principle of paying people to not use drugs doesn’t sit well with everyone
• suggestions that clients might use the money to buy drugs (cash is rarely given for this reason)
• clients may be motivated by rewards rather than a desire to change, raising questions about what happens once treatment finishes
• power imbalances between the clinician and the client (reward and punishment system)
• practical concerns around funding, monitoring and accountability.^{19, 20}

Another concern is that CM doesn’t address any of the underlying causes that contribute to substance use – such as unemployment, mental illness, trauma, housing insecurity or homelessness, and poverty.¹⁹

However, evidence has suggested combining contingency management with other therapies, like a community reinforcement approach or cognitive behavioural therapy, could make it more effective and would address some of the concerns listed above. ^{1, 14, 21}

What else can be done?

Another approach is to focus on reducing the harms from stimulant use – rather than just reducing stimulant use.¹

Mental health and harm reduction interventions can help, for example:

Mental health

• antidepressants to treat depression
• antipsychotics to treat psychosis
• cognitive behavioural therapy for depression^{1, 3}

Harm reduction

• advice/info around safer use practices to prevent overdose and other health issues
• antiretroviral/antiviral treatment for people with HIV or hepatitis
• providing condoms to prevent the spread of sexually transmitted infections
• providing sterile injecting equipment to prevent blood borne virus infections.^{1, 3}

Although the currently available psychosocial interventions don’t have a particularly strong effect on reducing stimulant use, they can be really effective in reducing some of these harms²² – which is often just as important.

Ultimately, we should be willing to trial any proven treatment approaches that show effectiveness to help people recover better.