In their CMAJ article, Drs. Palis and MacDonald1 advocate for expanded utilization of prescribed psychostimulants as a treatment option within the care continuum for people with stimulant use disorders. Although addressing the drug overdose crisis is imperative, the evidence supporting the authors’ proposal is limited, and their argument does not adequately address the potential risks.
Unlike substitution therapies for opioid use disorders, the effectiveness of prescribed psychostimulants for stimulant use disorders is uncertain. Most reviews and meta-analyses, including Tardelli and colleagues’ study, concluded that evidence supporting pharmacologic interventions for these disorders is lacking and the benefits of prescribed stimulants in treating stimulant use disorders are not well established.2,3
Prescribed stimulants carry substantial risks, particularly for people using methamphetamines, where the risk of psychosis is high.4 Evidence of their potential to reduce cravings for illicit stimulants remains inconclusive.5
Prescribed stimulants might have a role for some select individuals with opioid and stimulant use disorders (without a history of psychosis), but broader integration is not supported by evidence. 6 Rigorous clinical trials assessing factors such as adherence, substance use patterns, retention, cravings and overdoses are essential before widespread implementation. Comprehensive services should accompany prescribing, including housing, medical care and psychiatric support, alongside evidence-based strategies like contingency management.
Although exploring the role of prescription stimulants is promising, careful consideration is vital to avoid unintended harm. Well-designed clinical trials will yield insights into benefits and risks, guiding treatment decisions and ensuring patient safety in managing stimulant use disorders.
Footnotes
Competing interests: Anees Bahji reports receiving an educational scholarship and research grant from the Canadian Institutes of Health Research (CIHR) and the Calgary Health Trust. Dr. Bahji has also received consultation fees as a City of Calgary independent medical examiner; honoraria from TED-Ed; and travel support for meetings from the Canadian Academy of Addiction Psychiatry, Canadian Psychiatric Association, Canadian Centre on Substance Use and Addiction (CCSA) and Canadian Society of Addiction Medicine. Tony George reports receiving a project grant from CIHR and an R21 grant from the National Institute on Drug Abuse, as well as consulting fees from Roche, Frutarom and Aelis. Dr. George has held paid roles as the co-prinicpal editor of Neuropsychopharmacology and chair of the CCSA’s Scientific Advisory Committee. Marlon Danilewitz reports receiving an educational grant and personal fees from Eisai Ltd; personal fees from the Ontario Brain Institute, Winterlight Labs and the British Columbia Psychiatric Association; travel support from the Canadian Academy of Addiction Psychiatry and Ontario Shores Centre for Mental Health Sciences; personal fees for participation on the advisory board of Eisai Ltd.; and a stipend for administrative work from the Canadian Psychiatric Association. No other competing interests were declared.
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