Amphetamines are the second-most commonly used drug in the world and their use is rising in the US. There are currently no FDA-approved medications for treating methamphetamine use disorder (MUD). This multisite randomized controlled trial evaluated the efficacy and safety of extended-release naltrexone (380mg every 3 weeks) plus oral extended-release bupropion (450mg daily), compared with placebo for 6 weeks. The primary outcome was treatment response, defined as at least 3 out of 4 methamphetamine-negative urine drug tests over the last 2 weeks of the study.
The study enrolled 403 patients with moderate or severe MUD.
15% of eligible patients were randomized; 69% of the participants were men.
Overall, 13.6% of patients in the intervention group had a treatment response, compared with 2.5% in the placebo group; this translates to a number needed to treat of 9.
The most common adverse effects were gastrointestinal disorders, tremor, malaise, hyperhidrosis, and anorexia.
Comments: Medications that are accessible and effective are urgently needed to treat MUD. Behavioral treatments like cognitive behavioral therapy and contingency management show favorable benefit, although their access remains very limited. This trial demonstrates a possible new treatment for MUD; however, limiting factors may be cost of the treatments and patient preference, both of which were not assessed.
Researchers have begun testing drugs approved for other substance use disorders to treat people with methamphetamine addiction. Examples include naltrexone—which is used for the treatment of opioid use disorder—and bupropion, which helps people quit smoking.
Both treatments have shown some effectiveness when used alone to treat methamphetamine addiction. A research team led by Dr. Madhukar Trivedi at the University of Texas Southwestern Medical Center launched a clinical trial to see if a combination of the two might help more people quit.
Among adults with methamphetamine use disorder, the response over a period of 12 weeks among participants who received extended-release injectable naltrexone plus oral extended-release bupropion was low but was higher than that among participants who received placebo. (Funded by the National Institute on Drug Abuse and others; ADAPT-2 ClinicalTrials.gov number, NCT03078075..)
The misuse of this term ‘overdose’ is quite common in the illicit drug use culture, and it has become synonymous with an event where a drug user has died or come very close to death and has had to receive urgent medical attention or even been hospitalized to prevent death, as a result of taking illicit drugs – psychotropic toxins. Of course, the term does legitimately apply to one using a prescription drugs – with prescribed dosage – in a ‘recreational’ or self-medicating context.
When it comes to illicit drugs, then the use of the term ‘overdose’ is a misnomer. Making such an association of the term ‘overdose’ with use of illicit drugs implies there is a safe dose, and we would argue that this should not be the case at all.
Firstly, we need to anchor the term in a legitimate context. In the pharmaceutical and medical arenas, licit drugs are applied for therapeutic purposes of healing or management of symptoms. A safe therapeutic dose is prescribed by the medical professional to achieve what thorough research has determined it may accomplish.
In this legitimate context, for a patient to go ‘over’ that professionally prescribed dose rate, is to put themselves at significant risk of unintended harms. To consistently or acutely exceed that prescribed dose can create the overdose scenario which is the very theme of the Overdose Awareness Day.
So, let’s create awareness.
This year’s Overdose report snapshot again revealed the single largest contributor to overdose harms, was indeed from the misuse of pharmaceuticals including Opioid Substitute Treatments. The continual use of emotive language to highlight concerns, and even repeat statements in relation to ‘knowing what to do to fix it’ and emerging mantras of need to remove ‘stigma’ to help solve the problem, were highlighted in the reel, but again, how is that focus applied and what the anti-stigma process will entail?
123 percent increase with up to 4 or more drugs, including alcohol, implicated in the harm creating episode
In the last 24 months things have not changed a great deal. The latest report commentary is now framing the issue in 5 and 10 year trajectory, in what appears to be an attempt to amply issue. Again, the use of ‘save lives’ was replete through the report. How that is done, of course, has far more approaches than simple harm reduction only practices that ignore or exclude demand reduction and drug use exiting recovery.
Changes to drug deaths over the last two decades have been significant. Twenty years ago, the most common drug causing accidental death was heroin, an illicit opioid. Today, it is pharmaceutical opioids that are responsible for the majority of overdose deaths, with a strong association between increases in prescription of opioids and increased mortality.
While drugs and overdose are issues stereotypically associated with younger people, this report shows that it is middle-aged (30-59 years) Australians who bear the greatest burden of drug-related mortality. Further, the gap between this middle-age cohort and Australians under-30 or over-60 has expanded rapidly in the last fifteen years and continues to widen. 3
Road toll juxtapose of 2019
News interviews with staff from the Penington Institute in 2019 revealed expressions, and rightly so, of real concerns about these escalations and that deaths by drug use/misuse had now exceeded that of national road toll. Remarks were made to the effect that, these death rates wouldn’t be tolerated in our Road Toll Campaign, and that serious measures needed to be taken to reduce the incidence of deaths from misuse of prescription drugs and the illegal use of illicit substances.
Of course, we could not agree more. But what are the strategies and/or tactics that will be promoted as ‘effective’ in addressing the issue?
Whilst juxtaposing the escalating overdose deaths in our nation with the national road toll may have a perceptibly sensationalist, but effect for rallying action, it has the very real risk of ending up being not only a flawed comparison, but a disingenuous one.
Road toll and drug use deaths – poor analogy
Driving is a legitimate, productive, efficacious and helpful skill that takes years to learn how to do well and safely. Strict rules and laws surround this skill/activity and a fully tested and vetted license is required before one can drive a car without supervision.
Drug use for the medical purposes of health improvement or disease management under the full and thorough care of licensed and trained medical professionals is also legitimate.
But misuse of legal drugs and the use of illicit drugs has no legitimacy on any medical grounds – or ethical, legal and even moral grounds for that matter.
So why invoke the road toll and our efforts to stem it as a vehicle to manage overdose episodes?
Some quick questions that spring to mind;
Are proponents suggesting that the use of illegal drugs and misuse of prescription drugs has the same legitimacy as the privilege of and acquired skill to drive a car?
If so, are they then suggesting years of training and supervision are needed to teach people how to use illegal and misuse prescription drugs to minimise the very likely harms of these dangerous behaviours?
Do they acknowledge that it is the escalating excessive use legal and use of illegal substances that is adding significantly to the road toll, and reducing the road toll requires the removal of these abuses of legal and illicit drugs?
Zero target for road toll does not require the cessation of driving, but of all activities and other factors that contribute to the accidents that do occur, which would also include a ‘no tolerance of drug use’ for any driver. So, is it the contention that misuse of prescription drugs or the use of illicit substances can be managed so that zero harms come from these practices whilst driving – zero harms to the user and those around them?
We must be very careful about the messages that we can unintentionally convey, particularly to a general public that has little proper insight into this issue.
Teaching citizens to use drugs ‘safely’?
With more and more pro-drug use activists and pro-drug propaganda infiltrating the very important Harm Reduction space of drug use management, the messaging around ‘overdose management’ is becoming increasingly convoluted and emotive, with less and less to do with drug use cessation – the best practice for health and well-being.
Unequivocally, the best way to prevent drug deaths, is to stop using drugs. No rational mind will contest this fact.
Of course, that statement is qualified when it comes to pharmaceutical products. These drugs are administered, under the lawful supervision of a medical professional with the sole purpose to restore health so that both disease/injury and management of them ends – it stops. All physicians know that relentless and/or long-term use of toxins (of which even some licit drugs are) is ultimately bad for the overall health and well-being of the patient.
However, talk of cessation of illicit drug use – exiting drug use – preventing uptake or escalation of drug use – has almost disappeared from the public discourse, at least in the Australian media space.
The conversation focuses more and more on the inevitability or even normalcy of drug use and the need to ensure greater safety around these dangerous practices.
This is where the Road Toll juxtapose is presented for support in attempting to bring positive change to the death toll from prescription and illicit drugs. Again, the subtext in this comparison appears to affirm that somehow driving a car and illicit drug use are equally legitimate practices. Of course, as we have only briefly looked at, this couldn’t be further from the truth!
When we look at the current Road Toll campaign in Australia, ZERO is the goal – no deaths on our roads. Our goal is, not ‘no cars on our roads’. When it comes to driving, as mentioned, greater training, supervision, skill development and experience are all proactive elements that can be taught and monitored to this achievable end, i.e. licensing, training and legal penalties all have proven effective at reducing the road toll in Australia.
But all that good and proper investment in training, behaviour modification and skill development is not what causes the accidents that create the road toll is it?
No, it is the breaching and ignoring of best practice and/or introducing conduct and behaviours that diminish capacity, that distracts from alertness/awareness and/or depletes both skills and responsibility that creates the chaos. None of these elements are permitted for the person who gets behind the wheel of a car. Even if an accident doesn’t occur whilst a driver was speeding, taking drugs, or being on one’s mobile phone, if detected, penalties are swiftly and irrevocably applied, all for the purpose of stopping these harmful behaviours, not just trying to prevent the harms from these dangerous behaviours.
We want all road users to be safe as possible.
So, how does this apply to illicit drug use, or misuse of legal drugs? Again, we must be very careful about our messaging, if we don’t want to end up validating or normalising drug use.
Are the advocates for harm preventing measures implying (al-be-it unwittingly) that;
all people should be taught how to use illicit drugs and legal drugs safely, under full two-year training, then licensing?
along with the road user, can we expect reasonable and responsible, ‘safety first for all’ behaviour from the drug user after the use of psychoactive toxins (alcohol included) ensuring that no harms come from the erratic behaviours produced by drug use?
we will be able to ensure that idiosyncratic and unpredictable responses of the illicit drug user or misuser of prescription drugs be ‘trained/coached/supervised’ out of their patterns of conduct whilst continuing to use these psychotropic toxins?
It would be a ‘miracle worker’ indeed who could establish such a change management vehicle that eliminated serious harms!
Mimic what is good about the Zero Road Toll campaign
Time to reduce, remediate and facilitate drug use exiting recovery from drug use
We have seen, over the same past two decades that the overdose figures reflect a consistently growing focus, not on prohibition, but passive permission for drug use. Much of the interpretation of the current National Drug Strategy has been done through a lens of reducing harm of continuing and unchallenged drug use. We have for twenty plus years essentially (by default) declared drug use inevitable, or irreversibly socially entrenched or just plain personal choice, and thus pushing the culture into a normalisation perspective on drug use.
It is no surprise then, that our growing ‘overdose’ predicament follows this culturally manipulated trend. When society is led to believe by clandestine or overt drivers that these manufactured perceptions are sound, then the uninformed majority begin to simply concede.
However, sadly, it is not simply the current drug using cohort that is left to health, productivity, familial and life diminishing on-going drug use, but an entire new emerging generation who are led to believe this ‘conduct’ is almost legitimate; and if not legitimate, at least accepted. It is this recruitment vehicle, of acceptance/permission that will see even greater harms to Generation Next and our entire nation.
So, we will concur with the essential intention of the juxtapose with the Road Toll Campaign and agree our nation should seek zero deaths and zero injuries from drug use of all kinds.
The road toll campaign does not teach learning drivers to take risks or do that which is dangerous – that which diminishes responsibility, agency and capacity. So must be the approach toward reducing the drug toll. The driver training does not enable, equip, empower or endorse activities that make us less human, less able, less responsible, less capable, less safe. No, it seeks to avoid, remove and eliminate all such activities from the ‘drivers’ repertoire.
The training then, must start with not engaging with the very thing that creates harm – rather Demand Reduction must be our highest priority. The National Drug Strategy 2017-26 has placed it as such, and all politicians, policy maker and practitioners should be implementing and promoting this priority, (as they have done so with tobacco) not simply damage management vehicles.
Those ‘courting’ addiction by using or misusing drugs, as with the Road Toll management process, are to be corrected, amended and trained to end behaviours that make them and others around them unsafe/unhealthy.
Those who are tragically caught in addiction are to be afforded all legal, ethical and professional assistance to exit drug use, not merely be equipped, enabled or empowered to continue drug use. The latter is more often a mere ‘endorsement’ process, which is counter to the campaigns zero goal.
Pragmatically this can mean instead of Needle & Syringe Programs and Injecting rooms, we have
Opioid Substitute Programs, that have a clear sunset clause and exit from drug use strategy as integral and immovable aspect of the programs.
Therapeutic Communities Placement in these restorative communities, with proactive psycho-social contagions for recovery.
Subscription to 12 Step Programs, providing wider access of the public to proactive and proven contagions and restorative drug use exiting recovery methods.
Counselling with Cognitive Behavioural, Motivational Interviewing Therapy and/or Acceptance & Commitment Therapy to address the underlying issues facilitating drug use/misuse, not just servicing an ongoing destructive routine.
We at the Dalgarno Institute encourage the Australian community this 2020 Overdose Awareness Day does not just focus on what is happening with overdose deaths, but focuses on more proactive measures that go beyond the no so ‘soft bigotry’ which is the paternalizing of the substance dependent person? Placing our sole priority on Damage Management vehicles alone, will do just that.