Editorial Comment:  Amphetamine use disorder and medication approaches

A December 11 article by Coffin et al. in JAMA Psychiatry suggests efficacy for the use of mirtazapine in management of methamphetamine use disorder, as well as some positive effect upon high-risk sexual behavior. The article particularly stirred up interest among one large group of addiction specialists, stimulating a high baud-rate exchange both pro/con. This I think reflects the frustration that most have in finding an effective medication strategy to aid those in thrall to stimulant use disorders. Quite apart from somatic approaches such as TMS, it would be hard to imagine a mood-altering medication that has not been considered or deployed in the effort to reduce rates of methamphetamine use: bupropion, selegiline, n-acetyl cysteine, ondansetron, modafinil… and then re-deployed, as mirtazapine was a decade ago and is again now.  As is the case with the most recent article, perhaps the best that can be said about the respective impacts is that they generally have some benefit over placebo, though not universally.  This may reflect reliance on diagnostic criteria that remain phenomenological, and unable to account for cultural, genetic, or other influences.  Recommendations for the employment of cannabis and even psilocybin, while not wholly irrational, suggest desperation or Hail Mary plays. Not excluded from consideration are agents that have shown promise in some clinical trials but not as yet definitively, such as methylphenidate. 

As the more senior of our colleagues have underlined, the mainstay of therapy remains psychotherapeutic, whether in individual, group, or milieu settings, whether cognitive-behavioral, motivationally-enhancing or other.  It’s not enough; our patients continue to suffer; but it’s what we have, and it is how physicians practiced for millennia: giving comfort always, providing what information was at hand, and ideally recognizing our limitations without causing more harm.

ASAM Weekly is edited by volunteers and is supported by generous staff efforts.  In the spirit of practicing what is preached while looking after patients and clients, Nick, Deedee, Bob and I will be slowing the operational tempo a bit during this celebratory season. While we will not completely interrupt publication, the content will be somewhat abbreviated.  Please look to your needs and to those of your families, friends, and associates during the coming weeks.

- Editor-in-Chief: William Haning, MD, DFAPA, DFASAM