Nonmedical Stimulant Use and Stimulant Use Disorders in Palliative Care #522

Introduction

Stimulants are amphetamines or amphetamine-like drugs. These include illegal substances such as cocaine and illegally manufactured and distributed methamphetamine, as well as the prescription medications methylphenidate and dextroamphetamine that are used for a variety of Food and Drug Administration (FDA)-approved and off-label indications (e.g., attention-deficit/hyperactivity disorder [ADHD], cancer-related fatigue). ¹ Rates of stimulant misuse and stimulant use disorders (StUDs) are rising, and stimulants are involved in 32% of fatal overdose deaths.^2,3 This Fast Fact discusses assessment and management strategies for patients with a serious illness who are impacted by nonmedical stimulant use and/or StUD.

Definitions

StUD is a pattern of regular stimulant use (whether prescription, methamphetamine, and/or cocaine) that leads to clinically significant impairment in functioning or distress within a 12-month period. ⁴ As with other substance use disorders, StUD criteria include a persistent desire to use, inability to cut down or control use, cravings, and use leading to recurrent social or interpersonal consequences that impact quality of life. ⁴ While tolerance and withdrawal are included as diagnostic criteria for StUD, these clinical manifestations are not diagnostic of StUD in isolation. Nonmedical stimulant use refers to the use of prescribed or nonprescribed stimulants in ways that are not sanctioned by a prescriber or are otherwise dangerous or harmful, without such use meeting criteria for StUD.

Assessment

When assessing stimulant use, clinicians should utilize open-ended, nonjudgmental questions and perform a comprehensive substance use history. They should also examine for comorbid psychiatric conditions, as you would for any other assessment of a substance use disorder.^5–7 Many psychostimulants are Schedule II controlled substances (e.g., methylphenidate, dextroamphetamine); as such, when prescribing psychostimulants, clinicians should utilize best safe prescribing practices such as reviewing state prescribing databases and scheduling frequent follow-up visits. ⁸

Management of Stimulant Use Disorder

Promotion of recovery as well as support in use reduction for patients with StUD can have a positive impact on quality of life. ⁹ Treatment of co-occurring substance use disorders (e.g., alcohol, opioid) and psychiatric conditions is essential and provides opportunity to improve patients’ lives even if treatment of StUD is less effective. ¹⁰

Nonpharmacologic treatments: Strong evidence supports behavioral strategies as first-line treatments for StUDs. These include contingency management (a type of learning in which positive behaviors are incentivized and reinforced), motivational interviewing, and cognitive behavioral therapy, ⁶ usually provided by a psychotherapist or substance use treatment counselor. Access to these resources in the community, however, can be limited.

Management Considerations in Palliative Care

There is a need for more evidence-based guidelines to aid clinicians when caring for patients impacted by symptoms from a serious illness who have concomitant substance misuse and/or substance use disorders, including StUD. Pain management in a patient with a serious illness and StUD for whom opioids are appropriate can be especially challenging. Management strategies include optimization of nonopioid medications and nonpharmacologic strategies for pain, treating psychiatric comorbidities, and collaboration with addiction medicine/psychiatry when possible. ⁵ ASAM/AAAP guidelines support the careful use of prescription stimulants to treat ADHD even in patients with StUD. Among a cohort of palliative care and addiction experts, continuing opioids for cancer-related pain with increased monitoring (e.g., more frequent visits, short-course prescriptions) was felt to be appropriate for some patients with advanced cancer and evidence of nonmedical stimulant use via urine drug testing, regardless of prognosis. ¹³ However, it is unclear how clinicians should navigate prescribing opioids when indicated for symptom management in patients with severe StUD. Clinicians must make individualized treatment decisions to balance the risks and benefits of opioids for someone with high-risk stimulant use. It is also important to use patient-first language when discussing addiction with patients (see Fast Fact #429) and to optimize support from the multidisciplinary team, which can include social workers, chaplains, and peer addiction support specialists when available, to address stigma and existential contributions to suboptimally controlled symptoms. ¹⁴ To reduce the risk of psychostimulant diversion, the FDA has published resources for patients, families, clinicians, and hospice agencies regarding the safe disposal of controlled substances such as psychostimulants should the patient not need the medication anymore. ⁸

Conclusions

Nonmedical stimulant use, misuse of prescription stimulants, and/or StUDs present unique challenges for patients with serious illness. Appropriate screening, awareness of treatment strategies, collaboration with addiction and behavioral medicine experts in a transdisciplinary team model, and judicious safe prescribing practices are essential clinician skills.