Administering A Long-Acting Amphetamine to Individuals with Cocaine Use Disorder May Lead to Modest Reductions In Cocaine Use

No pharmacotherapies have been shown to reduce cocaine use among individuals with cocaine use disorder. Providing long-acting stimulants—analogous to opioid agonist treatment for opioid use disorder—is one potential approach. In this Dutch study, people with DSM-IV cocaine dependence and concurrent heroin dependence receiving heroin-based treatment were randomly assigned to receive sustained-release dexamfetamine (dextroamphetamine, 60 mg/day) or placebo over 12 weeks; the administration of both was directly supervised. The main outcome was self-reported cocaine use; secondary outcomes included craving, use of other substances, and criminality.

• Of 111 patients assessed, 73 were enrolled and randomized; 65 completed treatment. All 73 were included in the intention-to-treat analysis.
• Over the 84 days of treatment, the mean number of self-reported days of cocaine use was significantly lower in the dexamfetamine group (45 versus 61 days), compared with placebo.
• Patients receiving dexamfetamine were significantly more likely to have at least one cocaine-negative urine test in the last 4 weeks (21% versus 8%), compared with placebo.
• There were no significant differences in craving, use of other substances, or criminality.

Comments:

Providing a sustained-release stimulant in a supervised fashion resulted in modest declines in cocaine use over a relatively brief period. It is not clear whether this would lead to improved clinical or psychosocial outcomes, and there is a potential for long-term harm, particularly cardiovascular complications among those with other risk factors. While this approach seems promising—particularly in settings where medication administration can be supervised—we need much more information before we can advocate prescribing long-acting stimulants to individuals with stimulant use disorder.

Darius A. Rastegar, MD

Reference:

Nuijten M, Blanken P, van de Wetering B, et al. Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial. Lancet. 2016;6736:1–9.