Welcome to the American Osteopathic Academy of Addiction Medicine's topic on stimulant use disorders. My name is Dr. Gregory Landy, and at this point, let me make mention of the fact that I have no ethical or financial conflicts in relation to this presentation. So during our brief time together, we're going to be covering a number of areas, and let me point those out to you in brief. We'll begin by a very thorough review, the DSM Diagnosis Criteria for Stimulant Use Disorders. This presentation will focus solely on the following topics, cocaine, amphetamines, methamphetamines, and the synthetic cathinones, otherwise popularly known as bath salts. We'll also spend a fair amount of time looking at the epidemiology of these particular illicit drugs so that we can place them into some clinical perspective within the larger spectrum of substance use disorders. And finally, we will conclude this presentation with evidence-based management principles. Now let me point out as we go through this presentation that the references are embedded on each slide for your convenience. So anything we're talking about at a particular moment, you can look at the bottom of the slide and see the reference from which the material was derived. Also at the very end of this presentation, there will be a summation of all the references in one location. So without further ado, let's begin our discussion of the Stimulant Use Disorders as per DSM-5. And during this talk, we're going to talk about the Stimulant Use Disorder, Stimulant Intoxication, and Stimulant Withdrawal. We will not be reviewing other Stimulant-Induced Disorders, nor will we be reviewing unspecified Stimulant-Related Disorders. Now I'll be the first to admit that going line by line through the DSM-5 diagnostic criteria is tedious, but it really is very important for the foundation for this Essentials in Addiction Medicine talk. So we're going to do just that. So bear with me. So Stimulant Use Disorders require a pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12-month period. So let me stress the last part of this, at least two of the following criteria within a 12-month period. So what are the criteria? The stimulant is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use. A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects. Craving or a strong desire or urge to use the stimulant is present. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home. There is continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant. Important social, occupational, or recreational activities are given up or reduced because of the stimulant use. Recurrent stimulus use in situations in which it is physically hazardous, perhaps think of driving. Stimulant use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant. And of course, the last two criteria, tolerance and withdrawal, constitute then the entire set of criteria for a stimulant use disorder. Now, in addition, it's also important for clinicians to specify if the stimulant disorder is in early remission. What this means is that at some point in time, the individual met the full diagnostic criteria for a stimulant use disorder, but now they have not met the criteria for at least three months, but for less than 12 months, with the exception of craving. Now, if the individual is in sustained remission, that means that they, again, at one time, met the full diagnostic criteria for a stimulant use disorder, but now, for a period of time, 12 months or longer, they have met none of the diagnostic criteria, again, with the exception of cravings. And it's also important to specify if the individual is in a controlled environment where access to a stimulant would be expected to not be available. It's also important in the diagnosis of stimulant use disorders, according to DSM-5, to specify the current severity. If the individual has a mild stimulant use disorder, they have two or three symptoms. And again, for the point of reiteration, there must be at least two of the diagnostic criteria for a 12-month period to even meet the criteria for the diagnosis. If the individual has a moderate stimulant use disorder, then there are four to five symptoms present. And if the individual has a severe stimulant use disorder, there are six or more symptoms present. Now, let's move on to stimulant intoxication, according to DSM-5. Now, here, the individual has the recent use of an amphetamine-type substance, cocaine, or other stimulant, as a consequence of which they have clinically significant problematic behavioral or psychological changes. And DSM-5 gives some examples, such as euphoria or affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity, anxiety, tension, or anger, and stereotypical behaviors, and obviously impaired judgment, all of which would be expected to occur during or shortly after the use of the stimulant. There also must be two or more of the following signs or symptoms that develop during or shortly after stimulant use. This includes tachycardia, or alternatively, bradycardia, elevated or lowered blood pressure, perspiration or chills, nausea or vomiting, evidence of weight loss, psychomotor agitation, or, again, it's alternative, retardation, muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. And on the more serious end, confusion, seizures, dyskinesias, dystonias, and even a coma. And as the case with all DSM-5 diagnoses, what you're looking at cannot be attributable to some other diagnosis that would better explain what you're seeing. Now, the final DSM-5 category we're going to take a look at is stimulant withdrawal. And this involves the cessation of or the reduction in prolonged amphetamine-type substance, cocaine, or other stimulant use, which in turn causes a dysphoric mood and two or more of the following physiological changes, which will develop within a few hours to several days after the cessation of or reduction in the stimulant. Those criteria could include fatigue, vivid, unpleasant dreams, insomnia, or hypersomnia, increased appetite, psychomotor retardation, or, again, it may be agitation. And again, as is the case with all DSM-5 diagnoses, the symptoms and signs must cause clinically significant distress or impairment. Now, let's turn our attention to the next area of this presentation, and that's looking at the epidemiology, or more specifically, the prevalence of these specific illicit drugs that we're focusing on during this presentation. And what we're going to look at initially is key substance use and mental health indicators that have been developed from the probability sample, the 2019-2020, National Survey on Drug Use and Health. This particular series of slides is looking at the initiation of the use of these particular drugs, meaning any use within the preceding year. So let's begin with cocaine use. Now, as I go through the fast facts, focus your attention more on the chart. So in the fast facts category, among those 12 or older, past year cocaine users decreased from 2.5% in 2002 to 2% in 2019. Now, as we're going to do with all these slides, we're going to drill down into specific age groups, and we'll start with those 12 to 17. And past year cocaine users in this age group also decreased. But look at this, from 2.1% in 2002 to 0.4% in 2019. The next age range of 18 to 25, past year cocaine users decreased from 6.7% in 2002 to 5.3%. Now, as you've been studying the chart, you do notice that among those 26 years and older, those trends have fluctuated over this time period. Now, let's turn our attention to methamphetamine use. And let me begin by annotating that most amphetamines used in the United States are illicitly produced and distributed. So with that in mind, those 12 or older in 2019, 0.7% or 2 million people indicated in this probability survey that they had used methamphetamine in the previous year. Among those 12 to 17 in 2019, 0.2% or 41,000 people in that youngest age group. 18 to 25, the young adults, 0.8% or 275,000 people in the probability survey. And among those 26 or older, the percentage who were past year methamphetamine users increased. Now, let's look at this. From 0.5% or 1.1 million in 2016 to 0.8% in 2019. Or 1.7 million three years later, almost doubled in that short time span. Now, we're going to look at misuse of prescription stimulants. Now, here what we're talking about based on the survey are amphetamine products, methylphenidate products, anorectic or weight loss stimulants, such as Provigil or any other prescription stimulant. Now, again, as you look at the chart, I'll be going through the fast facts. So among those 12 or older in 2019, 1.8% or 4.9 million people indicated in this survey that they misused a prescription stimulant in the past year. Among those in the youngest age range, 1.7% or 430,000 people misused a prescription stimulant based on this probability survey in the previous year. Among young adults, 18 to 25, 7.5% or 2.6 million people misused in the prior year. And among those 26 years or older in 2019, 1.2% or 2.5 million people indicated they had misused a prescription stimulant in the past year. Now, if you combine the groups, 18 to 25 and 26 or older, you're looking at over 5 million people. Now, I've included this chart just to put the drugs that we're talking about in this presentation in some perspective in terms of their use with the other drugs that are surveyed. And you can see I've highlighted across all the years from 2002 to through 2019. But if we simply focus on the last year in 2019, we see that both cocaine and heroin and methamphetamine are tied at 0.4, the prescription stimulants are at 0.2. These are not insignificant numbers. And as you can compare them to the others, of course, marijuana would naturally lead the list of single illicit drugs. Now, we're turning our attention to use disorders. And again, this is the most recent information available from the 2019 National Survey on Drug Use and Health, which is a probability sample. And from this, we learn the following. Individuals 12 or older, past year cocaine use disorder, again, I remind you we're talking about use disorders. Declined from 0.6% or 1.5 million people in 2002 to 0.4% or 105,000 people in 2002 to less than 0.1% or 5,000 people in 2019. So let me restate that among young adults, 12 to 17, I mean, the youngest age group. 12 to 17, past year cocaine use disorder, declined from 0.4% or 105,000 people in 2002 to less than 0.1% or 5,000 people in 2019. So among the youngest group, there's been a significant decline in cocaine use disorders. 18 to 25 young adults in 2019, it went from 0.7% or 250,000 people, quarter million people had a past year cocaine use disorder. And among those 26 years or older in 2019, 0.3% or just a little bit over three quarters of a million people, based on this probability survey, had a cocaine use disorder of 0.4%. In the past year. Now let's turn our attention to the methamphetamine use disorders. So again, as before, study the chart and I'll narrate the fast facts. Among those in the largest group of 12 or older, past year methamphetamine use disorder increased, and I'll repeat, increased from 0.3% or 684,000 people in 2016 to 0.4% or 1 million people in 2019. Now let's drill down into the age groups and see what's going on here. 2019, 0.1% of adolescents or 19,000 people had a methamphetamine use disorder in the past year. Among young adults, 0.4%, 18 to 25 age range here, or 125,000 people had a methamphetamine use disorder in the past year. Now let's look what's going on among those 26 and older. Past year methamphetamine use disorder increased from 0.3% or 539,000 people in 2016 to 0.4% or 904,000 just three years later in 2019. Not quite doubling, but pretty close. In terms of methamphetamine use disorders among those 26 years or older. Now, prescription stimulant use disorders. And again, the fast facts. Among those 12 or older, past year prescription stimulant use disorder remained fairly stable between 2015 and 2019. Now among this population in 2019, 0.2% or a little over a half a million people had a prescription stimulant use disorder in the past year. Among those 12 to 17 in 2019, 0.3% or 66,000 people had a prescription stimulant use disorder based on this 2019 national survey. Among young adults in 2019, 0.6% or 188,000 people met the criteria for a stimulant use disorder in the past year. And finally, among those 26 years or older in 2019, 0.1% of adults age 26 or older or 303,000 people had a prescription stimulant use disorder. And we're gonna look into this a little bit later and try to figure out what's going on here. Now let's look at some specific information about these particular drugs. And these charts will provide very succinct, concise information that should be helpful in remembering the key attributes of these particular drugs. So we'll start with cocaine, and it has a lot of street names and this list is surely not complete, but blow or flake, nose candy, white rock. When it's combined with heroin, it's referred to as speedball. Now, of course, cocaine does have some limited commercial uses as an anesthetic in certain medical slash surgical procedures. And in its common form, cocaine is either a white powder or a white rock or crystal. And cocaine can be snorted, smoked, or injected. Now, what are some of the issues about cocaine? Well, there are short-term and long-term health effects. Now, being that it's a stimulant, short-term effects would include such things as vasoconstriction. It does enlarge the pupils. It increases body temperature and heart rate and blood pressure. It can cause headaches, abdominal pain. Naturally, it causes euphoria. That's the reason they take it. Increased energy, alertness, restlessness. But getting to the more serious end, it can cause erratic and violent behavior. Paranoia, psychosis, and it can affect the heart. Conductivity issues, even heart attacks, stroke, seizures, and coma. Now, there are long-term effects from cocaine. Not surprisingly, many of those, for those snorting cocaine, are gonna be related to the nose. But there can also be complications from this vasoconstriction, damage to body organs. Or nutrition and weight loss, and from smoking, of course, lung damage. Now, I wanna draw your attention to its combination with alcohol, where there's a greater risk of cardiac toxicity, perhaps related to cocaethylene. And at the very bottom of this particular chart, there are no FDA-approved medications to treat a cocaine use disorder. Methamphetamine, similar chart, different data. Street names, Crank, Rocket Fuel, Speed. Methamphetamine is combined with cocaine, it's called Croak, perhaps that's what it does to you, and Shabu. Methamphetamine is combined with MDMA, hugs and kisses, party and play. Sounds very alluring. Methamphetamine is available in a prescription form, referred to as Dazoxan, which some clinicians use to treat ADHD. In its more common formulations, methamphetamine is a white powder or a pill. But crystal meth looks like pieces of glass. And a little bit later, we'll actually be able to visualize it. Methamphetamine is fairly versatile. For the user, it can be swallowed, snorted, smoked, and injected. There are short-term and long-term effects with methamphetamine. Again, it's a stimulant, so it's gonna cause increased wakefulness and physical activity. It's use will decrease the appetite, causes an increase in the heart rate and blood pressure and temperature, and like cocaine, can cause cardiac arrhythmias. The longer-term methamphetamine poses some other issues. It can cause mood problems, violent behavior, psychotic symptoms, and of course, severe dental problems, the so-called meth mouth, and classically, the intense itching of the skin. In combination with alcohol, methamphetamine decreases the depressant effect of alcohol, which increases the risk of an alcohol overdose. And the withdrawal symptoms of methamphetamine, typically the inverse of its buforic effects, so depression, anxiety, and tiredness. And again, there are no FDA-approved medications to treat methamphetamine use disorders. Now, when it comes to prescription stimulants, we have to focus our attention on the types. If we're referring to the amphetamine-type products like Adderall, on the street, they're referred to as Addy's or Banny's, Black Beauty's, Pep Pills, or Speed, or Uppers. If we're talking more methylphenidate, such as Concerta or Ritalin, they have different street names, such as Diet Coke, or Study Buddies, or the Smart Drug. Now, depending on the particular prescription stimulant the individual's using, they can be a tablet or a capsule, or even a liquid. And prescription stimulants can be swallowed, snorted, smoked, and injected. Methylphenidate can also be chewed. Now, prescription stimulants also have short and long-term health effects. Again, as stimulants, they can increase alertness and energy, raise the blood pressure and heart rate, they're vasoconstrictors, increase blood sugar, but higher doses can be dangerous. By raising the body temperature to very unhealthy levels, cause significant cardiac arrhythmias, heart disease, and seizures. And again, let me point out that there are no FDA-approved medications to treat the prescription stimulant use disorders. Now, let's turn our attention to the last drug in this category that we're spending time on, and that's the synthetic cathinones, otherwise known as bath salts. And I've listed some examples of the synthetic cathinones, the methadrone, the methylone, and I'll leave it to you to pronounce the next one. I will refer to it as MDPV. And it too, of course, has a street name, such as Bloom or Bubbles, Cloud Nine, Vanilla Sky, White Lightning, Wicked X. The synthetic cathinones have no commercial use, but apparently there's some confusion among users that Epsom salts may also be synthetic cathinones or bath salts. And it would be important to disabuse your patients of that relationship. Now, the synthetic cathinones can be white or brown crystalline powders, but their real trademark is they're typically sold in small plastic or foil packages, conspicuously labeled not for human consumption. And they're sold for a variety of intended uses. Synthetic cathinones can be swallowed, snorted, or injected. And of course, they're a DEA Schedule I. In terms of the possible health effects associated with usage of the synthetic cathinones, again, being stimulants, they'll increase the heart rate and blood pressure. They cause euphoria, increased sociability, but again, on the more serious end, agitation, paranoia, violent behavior, depression, reduced motor control, and they can definitely interfere with the individual's cognition. Long-term use of the cathinones can result in the ultimate side effect, being death. And again, as we've repeated many times with the stimulant use disorders, there are no FDA-approved medications to treat synthetic cathinone use disorders. Now, let's drill down into these drugs a bit more. Now, here's a picture of what bath salts might look like or could look like. This image furnished by the DEA. So it's important to keep in mind that synthetic cathinones are synthetic stimulants that are related to the cathinones that are found in botanicals, and specifically the cot plant. For use, they're labeled as bath salts, plant food, not sure the plants would like them, jewelry cleaner, or a phone screen cleaner. This is the Wild West that we're talking about here. This is largely unregulated mind-altering substances with no legitimate medical use. Now, chemically, they behave like the amphetamines or cocaine. And the one point to keep in mind is, just as one example, MDPV is actually 10 times more powerful than cocaine. Now, the worst outcomes using synthetic cathinones are chalked up to those individuals who snort or eject the cathinones, and among that group, death is a possibility. And it would be useful to disabuse any individuals who think these are not addictive. They are indeed addictive. Now, here is a slide that I've labeled caveat mTOR. Now, why is that? Well, MDMA is often adulterated, and it can be adulterated with just a whole host of chemicals such as caffeine or methamphetamine. And so, individuals that are using MDMA or methamphetamine, and so individuals that are interested in MDMA have come to learn this, and so they've gravitated towards moly, short for molecular, because this is supposed to be the pure crystal powder form of MDMA. In other words, it's clean and it's okay. But unfortunately, moly capsules may also contain other substances. And among those substances, there may be the synthetic cathinones. So, caveat mTOR. Now, we're talking a bit about the mechanism of action of the stimulants. We're gonna focus principally on cocaine and use this as the illustrative example that applies to the stimulants. There are some fast facts we'll go over. You see the graphic here that helps visualize what we'll be talking about. But cocaine binds to the dopamine transporter. Now, in doing so, it obviously blocks the removal of dopamine from the synaptic space, the consequence of which is that dopamine increases in the synaptic space, leaving a greater amount to affect the post-synaptic neuron and produce an amplified signal to that receiving neuron, which the individual will interpret as euphoria. But the use of cocaine also produces some other actions, and that is neuroadaptation. So, the body and the brain in particular, at least for purposes of this discussion, tries to adjust to the presence of habitual cocaine in the central nervous system. And it does that through processes of neuroadaptation, which are not always kind to the user. One of which is profound changes in glutamate neurotransmission, which increasingly is understood to have significant roles in emotional regulation. Cocaine also elevates stress hormones, which induces neuroadaptations that further increase the sensitivity to the drug. That's also important to note that researchers have identified that cocaine, particularly chronic cocaine use, decreases glucose metabolism in the orbital frontal cortex. So, what is the significance of that? Well, it seems to be that decreased glucose metabolism in the orbital frontal cortex leads to the poor decision-making, the inability to adapt to the negative consequences of the drug use, and the lack of insight is commonly seen among those that have a cocaine use disorder. And you can visualize that in the slide. Now, some other facts about cocaine. Users can develop a sensitization to it. What does that mean? It means that less cocaine is needed to produce anxiety, convulsions, or the other toxic effects associated with its use. And cocaine, particularly again, cocaine use disorders, chronic use, damages many, many organs in the body, far beyond what we can cover during this presentation. But for example, it can cause strokes, seizures, chest pain, other cardiac arrhythmias, obviously problems intranasally and in the lungs. But isn't it interesting that there are 750,000 cocaine exposed pregnancies every year? Now, here we have a picture of crack cocaine. Roughly 6% of all admissions to drug treatment programs involve cocaine as the principal drug. Now, the majority of individuals, slightly over two thirds in 2013, who sought treatment for cocaine were smoking crack. And surely not surprisingly, most of those individuals were also poly drug users. Now, I just threw this in as an interesting item. There's been a pharmacogenetic study, had a small in or a small number of patients, but it suggests that patients with a specific genotype appear to respond well to the cocaine vaccine, which is still in clinical trials. Now, let's talk about methamphetamine a bit. Now, there's one word that can describe and capture the essence of methamphetamine, and that is devastating. Methamphetamine is devastating both to the individual user and the community. In terms of the individual methamphetamine user, and particularly, of course, a methamphetamine use disorder, it can provoke aggression, psychotic behavior, could damage the cardiovascular system, leads to severe malnutrition, and of course, severe dental problems. For the community that has a nexus of methamphetamine users, crime, unemployment, child neglect, and a whole host of other social ills accompany that. Now, methamphetamine also seems to have a regional distribution. And where does that come from? Well, it's partly based on the fact that treatment admissions for methamphetamine, where it's the primary substance of use, range from 12 to 29% in the sites west of the Mississippi. But there's another point that we need to pay attention to, and that's the chart. In 2017, there was an increase in methamphetamine overdose deaths in five states, Washington, Colorado, Texas, Florida, and Georgia. Now, I put this table in so we could see and take a moment and compare methamphetamine versus cocaine, at least in a few variables. Of course, they're both stimulants. Cocaine can also be a local anesthetic. As we mentioned previously, the methamphetamine we're talking about during this presentation is man-made and distributed illicitly, cocaine being plant-derived. But here's an important difference. Methamphetamine, when it's smoked, produces a long-lasting high, whereas cocaine, it's quite brief. And what is the significance of that or the derivation? Well, for methamphetamine, keep in mind that 50% of the drug is removed from the body in 12 hours, takes half a day, whereas with cocaine, it's much briefer. 50% of the drug is removed from the body in one hour. Now, there's also a difference in the mechanism of action between these two drugs. Methamphetamine works by two mechanisms. It increases dopamine release from the presynaptic terminal, and it also blocks the dopamine transporter. Alternatively, cocaine functions only by blocking the dopamine transporter. So methamphetamine kind of has a two-punch effect. Now, let's take a little bit closer look at what methamphetamine does for those individuals that choose to use it chronically. It can cause significant confusion, mood disturbances, and violent behavior. Psychotic symptoms, including the full range, hallucinations, delusions, and paranoia. And of course, the classic one is the sensation of insects or bugs in the skin. The individual responds by vigorous scratching, which of course excoriates the skin. It's also important to note that methamphetamine's psychotic-induced symptoms can last for months or years after the individual stops using the drug. That may be a consequence of severe structural and functional changes that occurred in important areas of the brain that are associated with emotion, memory, and an individual's mental agility or adaptability, which in turn may be related to reduced binding of dopamine to the dopamine transporters in the striatum. Now, the good news is that may improve with abstinence. And the images here provide some evidence of that. Now, again, it's just a kind of a footnote kind of comment. Methamphetamine vaccines, yeah, they're actually being researched, would recruit the body's immune system to prevent the drug from entering the brain. And they're currently being tested in animal research. Now, in terms of prescription stimulants, we have an interesting trend that we need to be aware of. But here we're talking about dexramphetamine and methylphenidate, which, of course, act in the brain on the monoamine neurotransmitters. There's been a dramatic increase in stimulant prescriptions over the last 20 years. Now, obviously, prescription stimulants increase wakefulness, motivation, and they improve certain aspects of cognition and learning and memory. Now, some people are taking advantage of this and using prescription stimulants in the absence of any medical need in an effort to enhance mental performance. They're using these drugs for cognitive enhancement. Now, where do you think is a specific category that may be at risk for doing this? Well, if you said students, that is correct. So when interviewing individuals within the young adult range, this may be something to keep in the back of your mind. So the final portion of this presentation, we're gonna look at the evidence-based treatments for stimulant use disorders. Now, I've put it in red and bold-faced it. There are no pharmacological treatments that are approved by the US Food and Drug Administration for the treatment of stimulant use disorders, evidence-based treatments. So where does that leave the clinician? Well, that leaves the clinician resorting to behavioral treatments. And the booklet that is on this slide, Treatment of Stimulant Use Disorders by SAMHSA is a useful reference that delves into this in great detail. And as I said at the outset of this presentation, the reference is at the bottom of the slide and you can obtain a copy by pointing your browser in that direction. But the four evidence-based behavioral treatments, motivational interviewing, contingency management, community reinforcement approach, and cognitive behavioral therapy, we will cover each of these briefly in turn. We'll begin with motivational interviewing. And before proceeding, let me hasten to add that we have a separate presentation on this topic that would allow you to delve into this in greater detail. But setting that aside for the moment, there is strong evidence for the efficacy of motivational interviewing for stimulant use disorders. And just as the briefest overview motivational interviewing involves, you're expressing empathy with your patient through the use of reflective listening. Your goal is to identify discrepancies between what the individual states in their current values and behaviors. You definitely wanna roll with the individual, resistance and their arguments and their defensiveness. You don't wanna argue with them and you won't want to directly confront them. But as a clinician doing motivational interviewing, you do wanna support self-efficacy. And basically what that means is reassuring the individual that the therapy they're involved with can have a positive outcome. Now, based on the evidence, we can conclude that motivational interviewing can reduce the number of days of stimulant use and the amount of stimulant used per day. Now let's take a look at contingency management, which also has a strong evidence basis. This is a behavioral therapy that's grounded in the principles of operant conditioning. And this is basically a method of learning that emphasizes and tries to reward positive behaviors with prizes, privileges, or whatever. Examples of behavior that you might want to recognize in this manner through contingency management might be regular attendance at treatment sessions or stimulant negative urine specimens. Now, again, the use of contingency management may result in the number of days of stimulant use declining, decreasing stimulant cravings, avoiding new stimulant use, and decreasing risky behaviors. Now let's take a look at community reinforcement, which also has strong evidence underlying its use in the treatment of stimulant use disorders. And the goal with community reinforcement is to identify behaviors reinforcing stimulant use and making a substance-free lifestyle more rewarding. Now, having said that, you can see where it would partner with contingency management very nicely. Some of the principles that are used in community reinforcement include vocational guidance, job skills training, helping the individual refuse drugs, helping them learn new recreational activities, and obviously developing more pro-social networks. And so the community reinforcement approach has been evidence-based in terms of cocaine abstinence, in terms of reducing addiction severity, and the drug use in terms of number of weeks and its usage, and so on. And then the final one is cognitive behavior therapy, which also has strong evidence supporting its use as a treatment for stimulant use disorders. Keep in mind that cognitive behavior therapy is short-term goal-oriented psychotherapy. And the goal here is to work with the individual to understand their current problems and experiences in an effort to change their predictable behaviors and their habitual patterns of thinking. And that's done by identifying faulty patterns of thinking that then of course leads to negative feelings and behaviors. The use of CBT has been demonstrated to reduce the quantity of stimulants consumed per week, reduce the frequency of stimulant use per week, and to reduce risky behaviors. Now, I've been mentioned many times that the pharmacotherapy for stimulant use disorders has not been recognized by the FDA. There's no specific medication. That certainly does not mean that there's not been a great deal of active clinical investigation into the use of pharmacotherapy in the treatment of stimulant use disorders. And although it's beyond the limits of this particular presentation, I wanted to provide you with one systematic review that is very comprehensive in nature and covering the wide range of medications that have been used in clinical settings for the treatment of stimulant use disorders. And so this is a useful reference. But I've extracted a couple of comments that kind of give you sort of the gist or the flavor of this systematic review. So in terms of pharmacotherapy for cocaine use disorder, and they considered a wide range of medications including antidepressants, antipsychotics, anticonvulsants, and many others, and I quote, it is difficult to draw strong conclusions given the limitations of this body of evidence, end of quote. In terms of pharmacotherapy for methamphetamine use disorders, the review was not much more encouraging. The systematic review reported no benefit of any of these medications over placebo. But again, I invite you to look at the reference and it's a useful opportunity to really drill down into all these medications and see what their effects have actually been. And that brings us to the conclusion of this presentation. And let me provide a quick summary. We reviewed in detail the DSM-5 diagnoses of stimulant use disorders in an effort to place this in the proper full context. This presentation focused on cocaine, amphetamines, methamphetamines, and the synthetic cathetones. We looked at the epidemiology in some detail looking at how these particular drugs are used and the incidence of their use disorders. And finally, we concluded the presentation with a look at some evidence-based interventions. And throughout, you were provided with a number of references that you can delve into for further review and detail. And so with that, let me thank you for sharing this presentation with me and I hope you found this information useful.

stimulant use disorders

cocaine

amphetamines

methamphetamines

DSM criteria

epidemiology

substance use disorders

behavioral treatments

cognitive behavioral therapy