Psychostimulant Medications for Amphetamine-type Stimulant Use Disorder May Reduce Cravings and Use

High-quality evidence supporting the efficacy of prescription psychostimulants (PPs) for treating amphetamine-type stimulant use disorder (ATSUD) is lacking. Researchers performed a systematic review and meta-analysis of randomized placebo-controlled trials (10 studies with 561 participants), assessing the effect of PPs (methylphenidate, dextroamphetamine, and lisdexamphetamine) on ATSUD treatment retention, adverse events, early-stage ATS craving (<4 weeks treatment), end-point ATS craving (≥4 weeks treatment), withdrawal severity, and depression severity.

• The primary analyses showed no significant difference in early-stage ATS craving among participants receiving PPs versus placebo, but a modest reduction in end-point craving among those receiving PPs (standardized mean difference, -0.29).
• When studies with a high risk of bias were removed from the analyses, participants in the PP group also reduced ATS use as measured by urine drug testing, compared with placebo (relative risk [RR], 0.8).
• Subgroup analyses showed improved treatment retention among participants who received high-dose PPs (>162mg methylphenidate or 75mg dextroamphetamine; RR, 2.31), and who were enrolled in trials that had a longer period of treatment (>20 weeks; RR, 1.83).
• The subgroup of participants receiving PPs who had ATSUD and attention-deficit/hyperactivity disorder (ADHD) experienced reduced depressive symptom severity, compared with those receiving placebo (RR, -7.30).
• There was no significant difference between groups in adverse events or participants leaving the study.

Comments: In the absence of established pharmacotherapy for ATSUD, clinicians should consider the use of PPs. This study suggests that these medications may have a modest effect on cravings among patients with ATSUD, without increasing adverse events. Longer treatment duration, administering higher doses, and the provision of PPs for individuals with concurrent ADHD and ATSUD, may provide additional benefit.

Brigid Adviento, MD, MPH* & Darius A. Rastegar, MD

* 2023–24 Rich Saitz Editorial Intern & Addiction Medicine Fellow, University of Iowa Hospitals and Clinics

Reference: Sharafi H, Bakouni H, McAnulty C, et al. Prescription psychostimulants for the treatment of amphetamine-type stimulant use disorder: a systematic review and meta-analysis of randomized placebo-controlled trials. Addiction. 2024;119(2):211–224.