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SCOTTISH ADVISORY COMMITTEE ON DRUG MISUSE: Psychostimulant Working Group Report
ANNEX C: RESEARCH LITERATURE ON TREATMENTS FOR PSYCHOSTIMULANT USERS
Treatment for Cocaine Users
The possible treatments for cocaine misuse and the evidence of their effectiveness have been the subject of reviews conducted by a number of American academics. To date, most of our knowledge about treating cocaine use comes from the United States following an increase in cocaine use in the 1980s. Overall, there is no evidence to strongly support any single treatment (either symptomatic or substitute). The focus of research has been on symptomatic medications that relieve withdrawal, rather than medications that provide a substitute for cocaine. The UK Departments of Health Guidelines (Drug Misuse and Dependence: Clinical Management, 1999) clearly state in their guidelines that there is no indication for the prescribing of cocaine in the treatment of withdrawal.
Controlled trials have mostly focused on despiramine. A meta-analysis shows a benefits (compared to the placebo) for promoting abstinence among cocaine users, but no effect on their retention in treatment. Carbamazepine has also been advocated. However, there is currently no evidence to support the clinical use of carbamazepine in the treatment of cocaine dependence. A systematic review of the five randomised controlled trials of the drug found no evidence to support its use with cocaine users. A further systematic review examining the use of anti-depressants examined 18 randomised controlled studies which concluded that there was no evidence for supporting the clinical use of antidepressants in the treatment of cocaine dependence. Another systematic review that addressed the use of dopamine agonists for cocaine dependence concluded that current evidence does not support the clinical use of these. The authors suggest that given the high rate of drop-out in the population, that clinicians should consider the use of psycho-therapeutic measures to help retain patients in treatment settings. Finally, an American study suggests that combining disulfiram with buprenorphine can reduce cocaine misuse in heroin users who also use cocaine.
Treatment for Amphetamine Users
As with treatment for cocaine users, the overall research evidence on treatments for amphetamine dependence is limited. However, a number of potential treatments have been studied. Fluoxetine, amlodipine, imipramine and desipramine appear to have very limited benefits for amphetamine dependence. Fluoxetine may decrease craving in the short-term and imipramine may increase the duration of adherence to treatment. A further systematic review on treatments for amphetamine psychosis found very limited evidence on effectiveness. The results of two studies among amphetamine users show that agitation and some psychotic symptoms may abate within one hour of an antipsychotic injection.
Dexamphetamine sulphate is the most frequently studied drug for amphetamine users. It has been prescribed in England and Wales for the treatment of primary amphetamine use, though the Department of Health Guidelines suggest that prescribing should be restricted to particular groups. These studies have generally prescribed dexamphetamine sulphate to long term amphetamine injectors. There does appear to be growing evidence for the role of prescribed dexamphetamine. In response, a two-centre randomised controlled trial of dexamphetamine substitution as a treatment of amphetamine dependence is underway in England, funded by the Department of Health. The study will assess the effectiveness of the treatment, describe the nature of benefits and harms associated with the treatment and contribute to the development of best practice guidance. This study will report later in 2002.
Non-pharmacological treatments
As with pharmacological treatments, the evidence of the effectiveness of psychological and psycho-social interventions with psychostimulant users is currently limited, but promising. There are a number of studies underway in this area including a systematic review of pyscho-social treatments for psychostimulant dependants. This review falls under the auspices of the Cochrane collaboration library of systematic reviews. Further, an evaluation of a brief intervention model for young non-injecting stimulant users in London (16-22 years) is underway. The latter evaluation is being funded by the Department of Health and will report in summer 2003.
Systematic counselling forms the basis of most community-based treatments for psychostimulant users. Some authors advocate counselling for short-term, occasional (and non-injecting) users with no other treatment intervention. For longer-term, 'problem' users (including injectors) some authors argue for counselling plus symptomatic medication (e.g. fluoxetine). A range of approaches have been tried.
A further study examined the impact of coping skills training and suggested it could be beneficial for avoiding relapse in cocaine users. A further study used material incentives (usually vouchers) as rewards for cocaine free urines. A controlled trial of this approach indicated there were benefits to using incentives and counselling when compared to counselling alone.
The lack of available psycho-social treatments or interventions is quoted in the research literature as a barrier to service utilisation among psychostimulant users. The major barrier to service up-take, however, is the perception of services as providing treatment and care for opiate users. Evidence suggests that those seeking help for psychostimulant use problems were less likely to have received treatment than those with opiate users.
Complementary therapies
There is little clear evidence of the effectiveness of acupuncture for treatment of psychostimulant dependence as a stand-alone intervention. Nonetheless, it may be a means of attracting drug users into treatment, and encouraging them to remain in treatment. A recent randomised controlled trial of the use of acupuncture in the treatment of cocaine addiction does not support the use of acupuncture as a stand-alone treatment, or when only minimum psychosocial treatments are provided. The authors emphasise the need for further research to identify the possible role of acupuncture in a broader treatment plan for cocaine or amphetamine users. In this study, there were no differences between groups in treatment condition or in treatment retention. However, a further randomised controlled trial of auricular acupuncture for cocaine dependence showed that those participants who received acupuncture were more likely to provide cocaine negative urines relative to controls. Finally, a controlled study conducted in the early 1990s showed limited benefits of acupuncture over 'placebo' acupuncture.
Other information
The English National Treatment Agency (NTA) plans to review the evidence base on 'what works' with stimulant misusers (and in particular with crack misusers) in the next 6-12 months. This evidence base will be used to design a number of evidence-based programmes. The NTA will then work with commissioners to commission these new approaches and will be directly involved in evaluating their implementation and effectiveness.
Another useful source of information on psychostimulants and treatment for psychostimulant users is the recently published Department of Health Models of Care Guidance, one chapter of which is dedicated to psychostimulant users.
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