Good afternoon, welcome everyone. We're going to get started. We know that people are trickling in, in between nice, beautiful outdoor weather activities and various other conference activities, but thank you all for coming to our workshop this afternoon on stimulant use disorder, really focused on the recently published AAAP-ASAM clinical practice guideline that's now free, nationally available, online, and we have three speakers who all contributed to this guideline publication. We were all in the work group together. Myself, my colleague, Dr. Hurley, Dr. Severino, we'll each introduce ourselves when we come up to present slides. We'll actually be going back and forth a bit with the slide portion of this workshop, but the goal is for the content to really be a springboard for discussion. We really want to hear from you about cases that you're seeing, patients, your clinical questions. We will take some time to just go through the main categories of the guideline recommendations because the guideline itself is pretty broad in terms of topic areas that we covered for clinical management of stimulant use disorder. This is a, you know, we felt was a really important clinical issue to try to synthesize what does the literature say, incorporating some clinical consensus, and thinking about the approach to management as a comprehensive one. There really isn't one single tool that works for everybody with stimulant use disorder or for any other substance use disorder, but really trying to think of a holistic approach, a comprehensive approach, and covering these major domains in the guidelines. So I will first introduce myself. I'm Larissa Mooney. I'm an addiction psychiatrist at UCLA. I am the immediate past president of AAAP. I've been involved in this organization for many, many years since doing my fellowship years ago. I practice in a couple of settings, an outpatient clinic at UCLA and also at the Greater Los Angeles VA, and I've been, though I trained on the East Coast, I've been in Los Angeles now since 2005, and we see a lot of stimulant use disorder and, in particular, methamphetamine use disorder. So across various practice settings, inpatient, outpatient, over the years now I'm all outpatient. I've treated many individuals with methamphetamine use disorder and also cocaine use disorder. So that's my practice background, and I will just flip ahead here. This is our disclosure slide, and you can read about us on these intros here. These are our learning objectives for the workshop, to identify three evidence-based off-label pharmacotherapy options for the treatment of stimulant use disorder, recognize strategies to reduce harms related to risky stimulant use, identify three evidence-based behavioral approaches for the treatment of stimulant use disorder, and then also recognize the importance of close monitoring and ongoing assessment of risks and benefits when prescribing off-label controlled medications for stimulant use disorder. So this is the basic agenda and organization of our presentation today, moving through, as I mentioned, these major domains in the National Practice Guideline for Stimulant Use Disorder. We will be covering a bit about the methodology, epidemiology, screening and assessment, and behavioral and pharmacotherapy treatment guidelines, population-specific, like co-occurring disorders, and some other specific populations, again, trying to just pull it together and synthesize the key recommendations from the guideline without sufficient time to cover everything in it. And then we'll move to a couple of case discussions, and really, again, eager to hear your input and your clinical questions. So I'm going to pass this off to Dr. Hurley. Thank you. Good afternoon. Good afternoon. Are you able to hear me okay? Yeah. All right. So I'm Brian. I'm an addiction psychiatrist. I work for the Los Angeles County Department of Public Health. Los Angeles County has the fortune and misfortune of having methamphetamine and fentanyl tied as what lands people in the medical examiner's office. So that's one of the things I get to work on, is helping address methamphetamine use disorder from a public health approach. So if ever you want to develop a National Practice Guideline, good luck. This is what it takes. So the Clinical Practice Guideline was developed as a cooperation between ASAM, the American Society of Addiction Medicine. And full disclosure, I'm the president of ASAM, the American Society of Addiction Medicine. And it was a real privilege to work with AAAP on this project. And thank you, Larissa, for co-chairing this project with me. So ASAM's Quality Improvement Council is sort of the council that provided the sort of staffing and oversight. The Clinical Guideline Committee was made up of both ASAM and AAAP members. So we had both addiction medicine representatives and addiction psychiatry representatives. And IRETA provided a fair amount of the chairing, the kind of technical support. So this is the process, right? So there's an expert committee that was the ASAM AAAP committee that defined key questions that we needed to answer. We then looked at the literature and then developed what's called evidence to decision tables. And these are the recommendations we were making on the basis of what evidence. And as sometimes happens, when we want to make a recommendation for which there is no evidence, how do we say that, right? How do we say, you know, this is how you take care of it, this is how we think you should take care of patients? Not based necessarily in any peer-reviewed RCT, right, but based on what we think. So you'll notice for each recommendation, there's a couple statements. There's the strength of the recommendation. How strongly did the committee feel like this was recommended? And then there's the strength of the evidence, which is, is this based on expert opinion? Is this based on weak, moderate, or strong clinical evidence? So that kind of came through with the evidence to decision tables. Then there was draft recommendation statements, the guideline committee rated them, we developed a guideline, it went through external review as well as the boards of directors of our respective organizations. We got comments, we then reconciled the comments, and then we went for a comment reconciliation and final approval. So that is how you develop a clinical practice guideline, and it takes a year-ish worth of time to go from idea to published document. This was the methodology committee, and, you know, we used something called the GRADE approach. So the GRADE approach kind of just references what I said earlier. You're not stuck, for lack of a better phrase, only making recommendation statements on the basis of peer-reviewed literature. You can make other statements. You just have to be transparent about, on the basis in which you're making them, right? So it balances the benefits and harms of the intervention, what's the certainty of the evidence, what's the values and preferences of the populations affected by the evidence, and what's the acceptability and feasibility, and that's the process outlined for this. With that, so that's how you develop a clinical practice guideline. With that, Dr. Severino, can you tell us a bit more about stimulant use here in the United States? There you go. Thanks. Thanks, Brian. Oh, I'm tired already. I wanted to just review a little bit about epidemiology of stimulant use disorders to give you an indication of why ASAM and AAAP actually picked this as a first major collaboration in terms of developing guidelines. Not only do we not have any FDA-approved medications for treatment of stimulant use disorder, but it's actually become more and more of a problem. Stimulant use disorders, many of us have been treating them for many years, but in the last, say, 15 years, really been a bit drowned out by the opioid use disorder crisis. But in fact, what we're seeing is, in the last several years, both cocaine in the navy blue line and principally methamphetamine and psychostimulants with abuse potential have been rising in terms of their involvement in overdose deaths, and in fact, this represents what we call the fourth wave of the opioid epidemic. So you can see that in about 2013, fentanyl started to take off in terms of being detected in the urine or being implicated in the deaths of people. But then about two years, three years later, that was followed by the rise of the stimulants. And now, psychostimulants, cocaine and methamphetamine account, or are implicated in about 30 percent of overdose deaths in the United States. Now, that can often be accompanied by the presence of fentanyl or other opioids. Fentanyl accounts for 70 to 75 percent of the overdose deaths. But you can see that this has become quite a problem. And in fact, psychostimulants are the second most drug class contaminated by fentanyl. So you've got, oops, sorry, you've got not only heroin here, and then prescription stimulants in the gold, prescription opioids in the gold, but you've got cocaine and you've got methamphetamine. In fact, where I am, so I'm in the Northeast, I'm with Yale University, and I principally see cocaine use disorder. It's virtually impossible to get either heroin or cocaine where I am in Connecticut without it being contaminated by fentanyl. So when we're treating people with cocaine use disorder, we're often dealing with some degree of opioid withdrawal as well. And then also then treating a co-occurring OUD after that. I'm in an outpatient clinic. It's dual diagnosis, so it has IOP, PHP, regular outpatient. And our feeder programs are mainly either from Yale University Hospitals, Hartford Health Care Hospitals, or we've got our own detox unit, and so a lot come from there. Now, where you are is going to really determine what you see. So there are some areas of the country, you can see here in the Northeast, and you can see Colorado, and you can see Virginia, that really there's not a high use of methamphetamine, at least in 2022. And then if you flip the script and you look at methamphetamine, look, now you see, you look at cocaine, now you see that the Northeast has quite a bit, Virginia not quite as much, but again, Colorado quite a bit. But it's not always a flip-flop thing, because California is blessed by both. But the reason why I bring this up is these guidelines actually try to parse out at times recommendations having to do with cocaine use disorder, recommendations having to do with methamphetamine use, and then sometimes psychostimulant use disorders having to do with prescription opioids. So with that, how do we then screen for, what do the guidelines say about screening for stimulant use disorder, which would be the first step in identifying that? Okay, sorry about that. First of all, what's important to remember is that stimulant use disorder is complex. You've got those that principally use cocaine. You've got those that principally use prescription stimulants, and those that principally use methamphetamine. And the two areas of greatest overlap are prescription stimulants and cocaine, at least based on 2022 data, and then methamphetamine and cocaine here. And then you've got California in the middle. Some good news before we go on. We're actually seeing in this last year, I'm sure you've read about this, actually seems to be a decline of about 7%, maybe even up to 10% of overdose deaths in the country. This isn't well explained. It may be because of greater awareness of fentanyl. It may be because of availability of fentanyl test strips. It may be because of wider distribution of naloxone. We don't yet know. But does this apply to the psychostimulants? Actually it does appear to. So the brown line is fentanyl, and you can see that overdose deaths with fentanyl implicated are starting to come down. And then also you've got methamphetamine and you've got cocaine also coming down a bit. So I hope those trends continue. So the first set of recommendations have to do with screening and assessment. Stimulant use screening, you should all be aware of the United States Preventative Services Task Force recommendations. I think it was 2018 when those came out, which indicated that we should be screening all adults ages 18 and over for substance use disorders, and that applies for stimulant use disorders as well. The support for that is not as strong for those 12 to 17, and so the U.S. Preventative Services Task Force did not make a specific recommendation there. But our guidelines agreed with that. We give checks. We don't define the particular frequency, but we do say that those that are prescribed prescription stimulants, we might consider screening them more frequently. And then, of course, review your prescription data monitoring program to make sure that there are not other prescribers of medications that you are dealing with, including those that are being used illicitly. For patients who screen positive for stimulant misuse, so, you know, the trend now is not to just look at use disorders, but to look at misuse as well, because that results in significant harms. If consider asking about the context in which the psychostimulants are being used. Your treatment plan for somebody where use is sporadic on the weekends because of chem sex may be quite different than that for somebody who is using it for weight loss or for performance enhancement. And remember, if somebody is using it for weight loss, try to refer them to the appropriate treatment for the weight loss. Don't just ignore the problem. Similarly, for performance enhancement, if you make a diagnosis of ADHD, consider treating that. And as Dr. Mooney, I think, will point out, with ADHD, that doesn't necessarily eliminate the use of a prescribed psychostimulant. Evaluate complications using patient history and clinical exam. I encourage you to remember complications not only psychiatric, but cardiovascular and other medical complications, higher rates of development of hepatitis B, C, HIV. And to detect some of those, remember to conduct baseline clinical labs and an assessment. Basically when assessing patients, and I'm going to read this because it's so important, patients for STUD, the first clinical priority should be to identify any urgent or emergent biomedical or psychiatric symptoms, including acute intoxication and overdose, and provide appropriate treatment and referrals. So things like suicidal ideation, hypertensive crises, et cetera, that's first on the agenda before you move into further assessment. And then after first addressing those considerations, you want an assessment for whether an STUD is actually present. In the United States, that would be using DSM criteria. In the rest of the world, that would be using ICD-11. Here in the United States, we haven't gone to ICD-11 yet. We're still with 10. A mental status exam you want to do to identify co-occurring conditions, especially psychosis, severe depression and suicidality, ADHD, and cognitive impairment. Turns out that cognitive impairment is an unrecognized problem in this patient cohort, not only because they are more exposed to violence and trauma, but because overdose often results in mild forms of anoxic brain damage that we really don't pick up unless we look for it. Clinicians treating STUDs should conduct routine baseline laboratory testing, as I said before, and specialized testing, or a referral for specialized testing if you find indications of, for example, liver dysfunction or renal dysfunction. Frequency patterns of stimulant use include high frequency of use, the amount of use, and binge use. And I would add on that, always look for functional impairment that goes along with that. Use of stimulants when no one else is present because of the risk of overdose. Concurrent use of both prescribed and non-prescribed medications, because that may affect whether that prescriber continues the medication or whether you modify your treatment plan to continue the medication. Especially pay attention to the use of, co-use of CNS depressants, benzodiazepines, alcohol, opioids, and nowadays even things like Seroquel and Gabapentin in higher doses. And of course, a history of overdose and a history of suicide attempts are very important for you to keep your guard up on what may be coming down the road. In your assessment, you should include a history of whether there's been ED visits or actual hospitalizations, the routes of administration, especially IV drug use, risky sexual behaviors, and patients who engage in non-medical use of prescription stimulants. Evaluate them for ADHD even if they have that behavior because that may require additional treatment. And the settings, there's no particular literature that we could identify that identified the best settings to treat stimulant use disorders in the various ranges of intensity, but it would make sense to use something like a multidimensional assessment like the ASAM criteria, which probably is the most widely used in the country, I would guess, and is like a Bible to the insurance industry. And so we've got polling questions, which we're going to get our answers to by raising of hands. So first polling question, and then I'm going to pass this off again, a 32-year-old presents with signs of stimulant intoxication. The first clinical priority should be, A, conduct a urine drug screen, B, assess for risky sexual behaviors, C, evaluate for accompanying psychiatric disorders, or D, identify and address any urgent medical needs. How many would say it's A? Or B, risky sexual behaviors? Or C, accompanying psychiatric disorders? And then finally, D, identify and address urgent medical needs? Very good. So even more definitive than our recent national election. So now we'll pass this. All right. So that's screening and assessment. But what do we know about treatment for stimulant use disorders? So I'm going to actually start with behavioral treatments. The behavioral treatment that ASAM and AAAP identified as being the most impactful for stimulant use disorder is contingency management. We made a pretty strong statement. Contingency management should be a primary component of the treatment plan in conjunction with other psychosocial treatments for stimulant use disorder. High certainty evidence. Strong recommendation. It's probably the single strongest statement in the clinical practice guideline. We actually had an entire plenary on implementing contingency management. So I'm not going to repeat that plenary. So I'm going to go through some of the how do you do contingency management relatively quickly. One of the critiques is, okay, how do you get contingency management? How do I link patients to contingency management? Yeah, that is a relevant question. The evidence is clear, though. When patients get contingency management, they do better. That's the evidence. There are additional behavioral interventions that we identified. The community reinforcement approach, cognitive behavioral therapy, and the matrix model IOP. It's a manualized IOP curriculum. These are additional behavioral interventions that were well demonstrated. So low certainty with a conditional recommendation, moderate certainty with a strong recommendation, and moderate certainty with a conditional recommendation, because there is evidence for these. There is evidence for these. And the nice thing is you can do CM with CBT. You can do CM with CRA. You can do CM as part of a matrix model. It's not an either or. Patients offering evidence-based interventions can do so via digital therapeutics. There's many commercially available digital therapeutics that do some components of contingency management. We did not identify any that we felt that were sufficient as a standalone treatment. That is, you just do the digital therapeutic without involving any other clinicians involved with the patient's care. And that when patients have trouble accessing care in person, telehealth is a great way of extending it. It's not always practical. It kind of depends on exactly what you're doing. But we should consider using telehealth when it helps increase access for our patients. So this is the set of slides I'm going to go through relatively quickly. So CM is based on the principle that behavior can be modified through incentives. The key to CM is that the behavior has to be objective. You did it or didn't do it. You wanted to do it. You thought about doing it. You sort of said you did it. But maybe you didn't. So it's sort of objectively observable. You did it or didn't do it. You can incentivize way more than urine toxicology verified abstinence from stimulants. Any of you who work in an opiate treatment program are probably familiar with a patient comes in more regularly, then they get take-home doses faster, right? If people are adhering to their plan of care, they get more milieu privileges faster. We use contingency management all the time kind of in other areas. Maybe not voucher incentives, but we use CM kind of all the time. You know, if you show up regularly and pee the way you're supposed to, you get a longer buprenorphine prescription. That's an example of like contingency management, right? So we use this all the time actually in clinical care. Many of the options include counseling attendance, toxicology verified substance use, which is the treatment that gets talked a lot about right now when California is implementing, medication adherence, behavioral plan participation, and you can reinforce this with money. Actually, cash works pretty well, but if your payer doesn't permit cash, like the Medicaid program in California, you can't give out cash, but you can give out gift cards and vouchers or setting privileges or take-home doses. Contingency management, particularly when the behavior being modified is stimulant abstinence, does reduce stimulant use. The key is that the stimulants that people use tend to have short detection windows, right? Things are not usually around for weeks. They're around for days, like two, maybe three days, right? Depending on what you're using. So longer intertest intervals sort of allow people windows to use without detection. So good on model CM programs are twice a week, right? Twice a week to reduce some of those intervals where people are not gonna be subject to testing. One question that always comes up is, well, how long does a patient need to be in contingency management? And the short answer to that is until they've learned recovery. How long do you need to be reinforced until you've internalized the things that you're trying to reinforce without the reinforcer? Now, how long does that take? Well, I don't know. How long does people need to be treated with medications for opioid use disorder? Not a day longer than necessary. And for some people, it's their whole lives. It depends, right? So that's actually a clinical decision. But what do we know about the evidence? 24 weeks, which is a fair amount of time, right? 24 weeks. People had a 22 greater likelihood of abstinence after the incentives ended, right? So there is a durability, but the key is the longer the duration of contingency management, the longer the durability of what you're trying to reinforce. And CM seems to work pretty well. There's not huge gender differences, race differences. There's not huge differences in demographic responses. Four months CM outperformed one to two months CM, which outperformed treatment as usual. So if you're just sort of looking at like a rule of thumb, four months is better than two, which is better than not doing CM at all. Cognitive behavioral therapy deserves its own course. I'm not gonna do a whole course in CM other than to say CM is focused on thoughts, behaviors, and emotions. I would encourage you to learn more about cognitive behavioral therapy. All right. Most sessions, you have to really go through the skills with folks. So sessions are 50-ish minutes. And usually the period of teaching people and internalizing CM is a half a year to a year-ish, right? Five to 10 months is a kind of a usual duration. The community reinforcement approach starts with a functional analysis of substance use. What problems does substance use help you with? And then what problems does substance use create, right? Like it's sort of a functional analysis of substance use. A lot of substance use is relational, right? People have a relationship with a substance and also how that impacts their relationship with others. So there's usually relationship counseling that's part of that. The community reinforcement and family training can be part of CRA. Vocational guidance and job skills training is part of the community reinforcement approach. Pro-social therapy and new recreational activities focused outside of substance use is all part of a community reinforcement approach around stimulant use disorder. And the matrix model. There's a free version of this on the SAMHSA website. It's a few years old. It's not brand new, but you can actually download the full manual for free on the SAMHSA website, or you can pay the Matrix Institute for like the latest version that is available under like a license. But it's essentially a structured IOP curriculum. So it's got early recovery skills, a group manual, psychoeducation, social supports is all part of the matrix model. And I have a slide on motivational interviewing, not because the clinical guideline committee even mentioned motivational interviewing. There was no specific findings around motivational interviewing with respect to stimulant use disorder, but because I really like motivational interviewing and I teach motivational interviewing a lot and it is a fundamental communication style I use. So I just wanna mention, motivational interviewing has been very helpful to me at avoiding burning out because I can accept patients for where they are in their journey and understand that I can make progress without necessarily achieving perfection each visit. Please come to more motivational interviewing courses. Okay. Poll question number two. Contingency management for stimulant use disorder is associated with which of the following? I'll read the answers and then we'll do a show of hands. No impact on rates of abstinence. Shorter intervals compromise the contingency reinforcements. So that is when you test more frequently, it actually reduces the reinforcement. Better outcomes with interventions less than 24 weeks or increased likelihood of abstinence 24 weeks after reinforcement ends. How many say A, no impact on abstinence? B, shorter testing intervals or worse? C, better incomes with interventions less than four weeks? Or D, increased likelihood of abstinence 24 weeks? Oh yes, unanimity. All right. With that, I'm gonna pass it over to Dr. Moody to talk more around the medication treatments for stimulant use disorder. Okay, thank you. Moving into pharmacotherapy, medication treatments. I will go through the medications that the guideline recommends for methamphetamine use disorder and cocaine use disorder. Not thoroughly for each medication, we just don't have time for that today. But really with the goal of hopefully being able to walk away with a few takeaways, a few pearls with what are the off-label pharmacotherapy options for stimulant use disorder with some evidence base. I would like to emphasize these are not, this is not robust evidence. The recommendations that we made around medications were conditional, meaning not strong recommendations because the evidence for most of them is considered weak, weak evidence. Couple of them had moderate evidence and support. But for the most part, these were weak evidence, but some evidence. And we do need some pharmacotherapy tools. And I'll also talk about how I think about selecting among these off-label options. So for a first point, the guideline states that pharmacotherapy including psychostimulant medications may be utilized off-label to treat stimulant use disorder. This is one of our tools in the toolbox. When prescribing controlled medications like controlled prescription stimulants, clinicians should closely monitor patients and perform regular ongoing assessment of risk and benefits for each patient. And I want to mention that in the process of developing this guideline, and then circulating it for feedback, for input from our respective organizations and even from the public, the number one point of concern that people expressed was around our recommendations regarding stimulant medications for stimulant use disorder. And we, of course, cannot deny the evidence that exists in some randomized controlled trials with signals of efficacy for these medications, but we tried to be really thoughtful about emphasizing risk mitigation and care, concern, thoughtfulness when prescribing these medications if you do make that choice. So the guideline states that these medications should only be prescribed to treat stimulant use disorder by physician specialists who are board certified in addiction medicine or addiction psychiatry and physicians with commensurate training, competencies, and capacity for close patient monitoring. One additional point I'll make about this is that the trials that showed these signals of efficacy were conducted in very structured settings. These are clinical trials with very frequent monitoring, frequent visits with addiction physicians as the study physicians, and a lot of what's done in the clinical trials is really not generalizable or not the way real clinical practice works. Meeting with a study physician every week with a very short supply of medication, a lot of monitoring along the way. So in light of the relatively weak evidence and some of the risks of this highly controlled medication class that for some individuals they develop a use disorder or they take the medications not as prescribed, we really wanted to emphasize risk mitigation because a clinical practice guideline is used, as it should be, by prescribers to support their decisions. And this really isn't something that should be done in any single setting with or without any degree of monitoring by any discipline without some of the nuances and thoughtfulness around when you might select this medication option. So moving to the summary of medications recommended in the guideline for methamphetamine use disorder, as a summary I'll go through a few points on some of the individual medications. There's bupropion which has a signal for lower frequency methamphetamine use. What that means is in the trials those individuals who did the best were not people who used methamphetamine daily, for example, so the evidence was strongest for people with meth use disorder but with a lower level of frequency at baseline, less than actually grouped as less than 18 days of meth use per month in the month preceding the trial. Another option is a combination of extended release naltrexone and high dose bupropion XL. We'll talk about that one in a moment. Two small studies supporting mirtazapine and we'll talk about that as well. Topiramate for low level methamphetamine use and methylphenidate extended release. The signal is strongest for those with a higher frequency of meth use at baseline. And notice here the additional considerations. And this is important when thinking about, well, which of these might I select as a tool for my patient? We wanted to emphasize where these medications are actually approved or have very strong evidence. Mirtazapine you might consider in a patient who has co-occurring depression or anxiety disorder. Bupropion for tobacco use disorder or depression. Methylphenidate extended release in a patient who also has ADHD. And topiramate, there's good evidence for alcohol use disorder, so you might think about that medication if a patient has co-occurring AUD. Again, none of these are FDA approved, all off label. Just wanna talk a bit about extended release naltrexone combination with bupropion XL. This was a really nice trial published by Trivedi and colleagues in 2021. And this built upon prior research involving both medications that led to this combination study. And the design was interesting. It was the extended release naltrexone, which is a standard monthly injection, branded as Vivitrol, every three weeks. So they dosed it pretty aggressively every three weeks in combo with bupropion XL, titrated to 450 milligrams daily. So high-dose bupropion XL. And this was a 12-week, two-stage design. So six weeks per stage in which actually participants who were placebo non-responders were re-randomized into stage two. The response was defined as at least three meth negative urine samples out of four in the final two weeks. They calculated this weighted average response in the two stages, which I'll show you the figure in a moment. And then based on that difference, the treatment effect was 11.1%. And just to show you the main figure from that trial, showing the two stages and the weighted average difference between the combo and the placebo group. So you might ask, well, what about patients who don't want an injection or maybe you don't have that available in your setting? Do you need to push the dose to 450? What I can say is this is how the study was designed, but it doesn't mean that adaptations on this might not be beneficial to a patient who maybe can't come in every three weeks for the injectable naltrexone or can't tolerate high-dose bupropion. You might think about other alternatives that still allow for this combination, which is also, by the way, in a different dose approved for obesity as an oral combo pill. Mirtazapine, as I mentioned, was demonstrated in two small trials, beneficial showing signals of efficacy for reduction in methamphetamine use on urine drug screen over the course of the trials. These were conducted in predominantly MSM populations favoring mirtazapine. And what I'll mention about this medication, it is the only serotonergic antidepressant that has this signal of efficacy for stimulant use disorder. Straightforward SSRIs have not shown the same effect in prior clinical trials, so could have to do with the effects of this medication, which is particularly notable for insomnia and anxiety. Also, there are some indirect actions on norepinephrine and dopamine associated with mirtazapine that we don't see for SSRIs. This is some of the purported reasons for this effect. Topiramate has shown evidence in some trials for meth use disorder. One example here, more participants randomized to the topiramate arm reduced meth use compared with placebo. No difference in total abstinence. This is one example of how topiramate has been dosed in prior trials and how you might consider the titration. The disadvantage of this medication or the challenge with this medication is tolerability. In different studies, sometimes the target dose can be 200, 300, sometimes even higher. But in general, they all just titrate to tolerability and efficacy. So if you have a target dose in the trial, you titrate based on, and that's how I use it in my clinical practice as well. And you always wanna discuss contraception because of risk of birth defects with this medication and neurodevelopmental effects. So this is one example of a figure from one of the studies showing change over time in the percentage across the arms with meth negative urine samples favoring topiramate. Lastly, I'll mention sustained release methylphenidate, which of the prescribed controlled stimulants that have been studied, this is the one that has shown in a couple of trials some signals of efficacy in meth use reduction. And this is an example of one of the studies conducted by Ling and colleagues in which methylphenidate was titrated to 54 milligrams per day. And there was a platform of CBT across both arms. And I won't go through the results in detail, but the effect was really seen in self-reported days of meth use and in the subgroup who had reported at least 10 days of meth use at baseline. And there was no difference between urine drug screen results across both arms. So again, this is an example of signal of efficacy, but primary outcome was not positive in this study. And some have critiqued that perhaps a higher dose could have been more effective. There are design limitations with all of these studies. And maybe we're not studying the adequate dose. So I'm gonna take a break here since we just mentioned the strongest, though not strong, evidence for use of a stimulant for meth use disorder being methylphenidate ER. We can go through these responses here. When thinking about risk mitigation, if you are working with a patient for whom you're considering prescribing a stimulant, what strategies could you use to monitor patients to treat stimulant use disorder? And we can just show of hands. Might you do more frequent contact and follow-ups? And there's, yeah, great. More than one answer is correct. Random pill counts, another strategy. Urine or serum drug testing, agree. That would be very important to monitor and document along the way. Checking prescription drug monitoring databases, absolutely, when prescribing a controlled stimulant. Does anyone think no specific monitoring is needed? Treat it like any other medication? No, good answer. And relying only on patient self-report. Would that be the only strategy? Oh, we got one strong hand up, okay. Great. All right, now I'm gonna move into cocaine use disorder pharmacotherapy and what evidence exists for some medications and some of the takeaways summarized here. Modafinil in patients without co-occurring alcohol use disorder. I will speak more about that in a moment, though I don't have a good reason why. Topiramate in individuals with lower frequency cocaine use. So that's where the signal, the subgroup that has shown signal of efficacy here. Give this one conditional consideration in a patient with co-occurring alcohol use disorder and alcohol use disorder is common together with cocaine use disorder. Mixed amphetamine salts also in combination with topiramate. So of the prescription stimulants, the evidence and the signal for cocaine use disorder, unlike methamphetamine use disorder, is extended release mixed amphetamine salts. So you can file that away. And in combination with topiramate, we'll talk about. And bupropion, I would say, much weaker signal and less evidence, fewer studies than methamphetamine use disorder. But we did include it as a conditional recommendation with weak evidence. I wanna talk a bit about modafinil. The story is interesting here. The original, the first clinical trial of modafinil for cocaine use disorder, RCT, was conducted by DACUS and excluded participants with co-occurring alcohol use disorder. And it was a positive trial. There were fewer cocaine-positive urine drug screens over the time points in the study. However, alcohol use is common in combination with cocaine use. Individuals will report that it extends the experience and the intoxicating effects of cocaine. And so it was problematic, in a way, or less generalizable that they excluded individuals with alcohol use disorder. So NIDA did a replication trial, multi-site, where they included participants with and without alcohol use disorder. And the overall results of the trial were negative. However, when they looked at, which is the figure here, the subgroup without alcohol use disorder, it, again, separated from placebo in terms of percent of the, across the two arms of cocaine non-use days. So the blue line is non-alcohol use disorder participants. The top green and red shows modafinil 200 and 400. So they both separated from placebo, but not from each other. So the conclusion of this trial was that there was no difference in dose, or difference in effect between 200 and 400 of modafinil. So I would consider this, again, for individuals without co-occurring AUD. And there have actually been quite a few trials of modafinil for cocaine use disorder. Summarized here, as you can see, there's actually mixed findings overall, some negative trials, some positive, but generally favoring modafinil in terms of abstinence rates, and a difference between modafinil and placebo. Topiramate for cocaine use disorder, there have also been a couple of studies that favor topiramate in terms of effects on abstinence rates, continuous abstinence for cocaine use disorder. So topiramate is an interesting medication that really has signals of efficacy for several substance use disorders. Alcohol, methamphetamine, cocaine. It's one that has shown these signals across a few. I wanted to mention the combo trials of extended-release mixed amphetamine salts and topiramate. There was a series of two trials conducted by John Mariani, Francis Levin, the Columbia team. The results from the original study from 2012 are summarized on the left. They took adults with cocaine use disorder, randomized them to the combination of mixed amphetamine salts, titrated up to 60 milligrams per day, and topiramate, the target dose was 300 milligrams per day split, but again, just titrate based on tolerability. The primary outcome was three consecutive weeks of abstinence, and this was significant in the ComboMed arm. However, this effect was moderated by days of cocaine use at baseline, and it was greater than nine days of use, showed a greater signal. So in the replication trial published in 2020, the figure is on the right. They basically replicated the findings, and they enrolled participants who had more than nine days of cocaine use at baseline, and end-of-study abstinence was greater, significantly greater in the Combo arm, and any three-week consecutive abstinence was also greater in the medication arm. I'm including this figure here for bupropion for cocaine use disorder just to show that this study was done a little bit differently than those for meth use disorder. This was in a methadone-maintained population, and there was a signal of efficacy for bupropion in combination with contingency management. So this is one you could consider. Perhaps works better with CM because there are actually four arms in the trial, and we don't have as much data and evidence for this medication for cocaine use disorder. The guideline does summarize interventions for which we have insufficient evidence to make a recommendation. It doesn't mean they don't work, but we maybe lack the trials, or the evidence was just insufficient to make a recommendation. Examples would be technology-based interventions like text messaging, TMS, transcranial magnetic stimulation, some of the other pharmacotherapies like disulfiram, exercise, there have been some interesting clinical trials, but we weren't able to make a recommendation supporting use of these interventions. Doesn't mean, again, that with more study we might not in the future. So I'm also gonna cover a bit about co-occurring disorders, and then pass this back to Dr. Severino. Co-occurring disorders are really important, and we want to treat co-occurring psychiatric disorders together with substance use disorders. This slide shows 2023 rates of any mental illness, substance use disorder, and their intersection, and then similarly for SMI, severe mental illness, substance use disorder, and their intersection, published in the National Survey on Drug Use and Health Findings. So highlighting that they commonly co-occur, and many, many Americans have these disorders. And the committee and the guideline recommends that we treat both disorders simultaneously. We try to integrate treatment when possible, rather than in parallel or in sequence. And when we can integrate care under one roof or in a single intervention, that's preferable. It's not always available, and we appreciate that in terms of behavioral therapy. When possible, a behavioral therapy might be adapted to address a co-occurring disorder, even if it was originally designed to treat a single disorder. And so there are creative ways that you can approach this, and various treatment settings have done so, but the main takeaway is integrated care is best. In terms of the approach, review the existing treatment plan, and if you're inheriting a patient who's already on a medication for a co-occurring disorder, in most cases, you're gonna continue that medication, even as you may conduct your own independent evaluation. It's usually safest to continue the medication, and take your time before considering discontinuing it. I already mentioned really strong recommendation to treat co-occurring disorders concurrently. When using pharmacotherapy, if a patient has symptoms of mania or psychosis, use the appropriate pharmacotherapy. Even if you don't know the origin, the etiology of that mania or psychosis, is it substance-induced? Is it a substance-independent disorder? But these are really acute conditions, and you can't treat them concurrently. These are really acute conditions. Patients may be presenting in an ED setting or not, and we wanna treat those symptoms with pharmacotherapy, regardless of the etiology. When it comes to depression, anxiety, or insomnia, and use of pharmacotherapy, you may consider the stage or the phase of methamphetamine use, meaning if somebody is presenting with acute intoxication, and they have certain symptoms, you may treat the acute symptoms, but if they're, for example, withdrawing from methamphetamine and experiencing depression, which is a common withdrawal symptom, that may resolve. You might not start an antidepressant, for example, during a period of withdrawal from methamphetamine use when you don't know the etiology or the history of the patient. You may treat the more acute symptoms and take a little bit of time to evaluate, but if those symptoms have prolonged duration or they're very severe, patient gets admitted to inpatient with severe depression and suicidality, you're gonna treat rather than wait. So you would consider the severity, the duration, and also what stage of stimulant use are they in. And in some cases, you might take a little time before initiating what might be otherwise a longer-term medication option. For ADHD, the gold standard treatment for ADHD is prescription stimulants, but when approaching ADHD in somebody with a stimulant use disorder, it would be appropriate and prudent to weigh risks and benefits and really consider them when you think about the approach. First of all, are you sure of the diagnosis? That can be challenging in active substance use disorder to sometimes establish the diagnosis. You might consider non-stimulant medications first and conduct trials of non-stimulant medications like adamoxetine, for example. If you do decide to use a prescription stimulant and you have rapport with the patient, you're able to do the risk mitigation, monitoring, more frequent visits, it's recommended to use extended release formulations rather than immediate release to minimize risks of non-prescribed use of the stimulant, minimize risks and harms. You're gonna conduct that monitoring, and then also safe medication storage would be recommended. We've included this for adolescents, but really that's important for everybody. So your algorithm and your approach might be different. It might not be jumping immediately to a prescription stimulant medication, but if somebody, for example, has a known prescription stimulant use disorder, they've already demonstrated that they develop tolerance, they escalate their use. I mean, I've had patients who end up in the hospital with psychosis related to very high dose Adderall use. For example, that's an example where the potential risks and harms are going to outweigh the benefits of treating that person's ADHD with a prescribed stimulant. So every case is different, and the approach may change based on that person's history. So back to Dr. Severino. So the guidelines also tried to address various specific populations for youth and young adults, which I guess in the United States now extends to about age 40. One thing that is important is that we want to avoid routine drug testing to screen adolescents and young adults for STUD. You may get parental pressure to have that, but in fact, that is not supported and can result in some problems. When considering drug testing in patients under the age of 18 ask the patient's permission to test, even if parental and guardian consent was given, and unless obtaining the assent is not possible, such as loss of consciousness or psychosis. Pay particular attention to signs and symptoms of ADHD and eating disorders in adolescents, and refer or provide treatment as appropriate. And when you can, refer those adolescents to age-specific treatment and support groups as those seem to be more effective and better accepted by the patient themselves. Consider behavioral interventions that have been demonstrated to be effective in the treatment of other SUDs in adolescents and young adults. So contingency management, CBT, community reinforcement, and family therapy. And that's actually very similar, except for not as much evidence for family therapy, but for what's effective in adults. Use an adolescent or young adult-specific treatment model if you can. Tailor existing treatments to be developmentally responsive. If possible, use peer age groups, as well as age-specific treatment programs for behavioral treatment where possible, not always available. Avoid incorporating adolescents and young adults into general groups that, for example, maybe in your particular setting, have many more older people. And consider treating adolescents and young adults with SUD with the off-label pharmacotherapies detailed by Larissa when the developmentally contextualized benefits outweigh the harms. Counsel patients and guardians not to conduct home drug tests, as I said before. Recognize that involving family members is often beneficial for the treatment, and involve them or trusted adults when appropriate. But you should, if you can, seek the consent of your young patient. While parental consent's not needed for young adults, discuss with them whether it still might be beneficial. You can almost use an MI approach to having them involve parents if you feel it would be helpful. And initially the patient doesn't think so. Be familiar with state laws on minors' ability to consent. It varies from state to state. Some states you can proceed for any treatment without parental involvement. Others require parental involvement to initiate any treatment, whether it's counseling or medication. So you need to know your state's laws. For pregnant and postpartum patients, so the perinatal period, incorporate additional elements into your plan as appropriate. Coordinate with the OBGYN if you can. Provide referrals to prenatal care. This is a great opportunity for many people that have fallen outside of traditional medical care to get them reengaged in that, to get them on multivitamins, to get them screened, to get them hooked up to more appropriate labor and delivery services where possible. Review eligibility criteria for locally available programs, which specifically address the biopsychosocial needs of those that are pregnant or new parents, or even parents that have been around a long time and still haven't figured it out. And coordinate prenatal care and treatment of STUD with the outside providers as well. Risk versus benefit to the fetus and the infant needs to be taken into consideration when you're looking at any medications that you might use off-label for the treatment of STUD. Remember, episodes of severe STUD intoxication and intoxication and withdrawal can be as harmful to the fetus as possibly using a medication. Whenever possible, clinicians should incorporate psychosocial treatments, which would be safer for the fetus, and that could be parent-focused or family-based treatment modalities. Remember, a positive drug test for a female who's pregnant can have very different ramifications based on the state you're in. So if you're in a state where that triggers a mandated reporting, that mandated reporting could result in the child being, or not the child, but could result in the patient being both charged with crimes and afterwards being at risk of having the newborn taken out of the care of the mother. So know your state's requirements. And so use your clinical judgment on whether it's absolutely essential in states where mandated reporting is needed. Use your clinical judgment about whether you really have to have that urine drug test as opposed to trying to improve your therapeutic relationship with the patient so that self-report can be more reliable. Weigh in on the potential benefits, as I said, of urine drug screening. Obtained informed consent. Always explain to the patient what this, what a positive test on the urine drug test would mean. Also explain to them that this isn't a gotcha kind of thing. You want to use it as a therapeutic tool. And educate patients who use stimulants on the risks of use while pregnant, but while breastfeeding because it will pass into the breast milk. For those where issues of sexual orientation and gender identity occur, clinicians should consider, when you can, referring to sexual and gender minoritized STUD programs. There are actually, for example, methamphetamine programs, I believe in California, that have been described specifically for LGBTQ individuals. And where you've got the specialized services that may allow them to be more comfortable in their treatment, always screen for trauma in those patients. In those in the carceral system, and we heard about that from Dr. Westreich just before this, initiation of treatment of STUDs is recommended for individuals in the criminal or legal systems, including within jails and prisons. And in fact, there is some legal support for the idea that it's actually considered a cruel and unusual punishment not to provide that treatment. But again, it varies by state. So in Connecticut and Massachusetts, there's a very early push to have both methadone and then ultimately buprenorphine in the prison and jail systems. Patients experiencing homelessness, not uncommon in this population, very stressful for people. For those experiencing homelessness, food insecurity, poverty, consider case management services. These can be really critical. It's hard to convince somebody to be sober when they're freezing on the street, and being faced with being beaten up every night. And if possible, if you're blessed with having one nearby like I am, a recovery residence can be quite helpful, not only for keeping the patient safe, but helping them achieve abstinence, if that's the goal. So our last question, when initiating treatment for stimulant use disorder in an adolescent patient, parental and guardian consent is, A, always required before starting any treatment, any hands? No. B, sometimes required, depending on state laws. Well, that's most. Never required as long as the patient consents. And then finally, only required for medication treatment and not counseling. And initially before reviewing these slides, I would have said that possibly is true, but that is not true. And so I'm gonna pass it on back to Dr. Hurley. Or all of us, actually. Yeah. Okay. So we're gonna move to case discussion and Q&A. We hope to make this really interactive. We have two short cases. I'm gonna just briefly present the first case, open it up for your discussion, then we'll take some general questions, and then we can, if time permits, do the second case. So first case, number one, is, oh yeah, thank you. 23-year-old cisgender man using methamphetamine, nicotine, and cannabis. Mr. Brown is a 23-year-old HIV-negative male who smokes methamphetamine in two- to three-day binges, two to four times per month. Methamphetamine use is typically concurrent with group sexual activity. He is sexually active with both men and women, prescribed PrEP, which he takes consistently. He reports no history of chronic medical conditions or taking non-PrEP medications. During his methamphetamine binge episodes, he typically does not sleep. After these episodes, he sleeps for over 20 hours and feels depressive symptoms. He vapes five milligrams of nicotine daily. 20-milligram pod lasts four days. Smokes cannabis daily. He denies consuming alcohol, using opioids, and denies any other substance use. However, he's not ready to stop using methamphetamine, vaping, or using cannabis. Seen patients like this before. Um, how would you approach this case? Would anyone like to share some initial thoughts? And it looks like we just have the one mic here, which is challenging for those in the way back. I can bring it to people. Yeah, okay, brave, thank you. So he's not sleeping. So the first thing I would address is whether or not he would like to sleep on the days when he's binging, and, you know, use pharmaceutical therapy to help him sleep on those nights. Great, so meeting his goal, if that's his goal, and addressing that issue. We can treat that symptom, right? Why is he consulting? Why is he consulting? Well, that would be, I agree, the first question is what are your goals? Why are you here, right? Absolutely. Yes. So my question would be, like, what does methamphetamine do for you? Is it, like, is there concurrent ADHD that he's going through? Like, what is the, like, why is he using methamphetamine? Like, the first question would be that. Yeah, I agree. So that's an important point, is establishing rapport, asking about the role of the methamphetamine, and that can really help to connect with the patient. Dr. Bakke. So just a comment. One of the studies you presented was on mirtazapine, which work we did in San Francisco. It's the only studies that I know of that actually show reduction of risky sexual behavior among men who have sex with men with mirtazapine. Thank you for that comment. So you're right. If this patient actually is presenting for complaints of depression, anxiety, insomnia, is interested in treatment for that, that could be a medication selection that might have some indirect benefit on multiple outcomes. Wonderful. Any other comments on this case? Anything you'd like to add, Dr. Hurley? So what if he says, I know when I use meth I can't sleep. I don't need to sleep when I'm using meth, and I don't necessarily have a sleep problem when I'm not using meth. But you know what meth really helps me with? It helps me feel sexual. I don't know that I can have sex if I'm not using methamphetamine. I don't know if any of you have had patients where that's their experience. Their sexual behavior and their methamphetamine use are sort of hand in hand. If that's the case, and he says, and I'm not ready to give it up yet, what might you say next? And you can just call it out, and I can repeat what you're saying. Condoms. What else? Yes? I'd like to know more about where that thought process comes from. Yeah. So what, where did that process come from? What is this about? Is this a shame-based response? Like what's underneath that dynamic? Anything else that comes to mind for folks? Yes? I mean, you may not have sex, but he may not have Matthew's disorder. He may not have Matthew's disorder. What about, I mean, we might consider doing a diagnostic assessment, perhaps. Yes? I want to know why he's here with me. What brought him into this encounter in the first place? Yeah, so one of the biggest, because this has been brought up now several times. Why is he here? What brings him here in the office? Was he brought in by somebody? Did he walk in? What is his interest in meeting with an addiction psychiatrist? Anything else? All right. I think Dr. Bakke did bring up if sleep is a goal of his, if getting psychiatric medication is a goal of his, right, which is something we need to clarify, and if he's not necessarily ready to stop, like medications that help reduce methamphetamine use behavior, such as vertazamine, might be considered. The other thing I was gonna make the point of, we talk about contingency management being a treatment of choice. I'll point out, if he doesn't stop using meth, he'll never get an incentive, right? So contingency management may or may not actually be where he's at in terms of his readiness, because if he's not gonna pee negative for stimulants, then he's not gonna get an incentive, although he doesn't use stimulants all the time anyway, right, so he might, like, in other words, I think it's part of a shared decision-making, is with contingency management, like we should, I would, if, assuming he's interested in talking about treatment approaches, potentially refer him to a contingency management program, making sure he understands what it will be incentivizing, which is stimulant abstinence. Okay, with that, any other considerations? There's general harm reduction, like, isn't it a condom, fentanyl test for it, it's the risk of sharing classified with other people? Yeah, so the comment was, so, and then there's general harm reduction strategies, which actually, there is a section in our clinical practice guideline on harm reduction strategies, so that includes everything from lowering the risk of sexual behavior, such as condoms, discussing sexual practices with him, he's already on PrEP, and if he is using smoking equipment to make sure he's either, you know, using fresh smoking equipment regularly so he doesn't, you know, cut himself, and has access to harm reduction supplies. Yeah, and I'll also mention Naloxone. Yes, or Test-Trips. Yeah, we mentioned Test-Trips, but Naloxone for overdose prevention and actually providing that education, particularly with fentanyl epidemic. Dr. Maricol. I just wanted to highlight the point that I think, you know, the first thing that came up is the why, so what is his point coming in here, and I think that's really critical, but I wanna point out the two things, Dr. Hurley, that you mentioned that I think were important here. So one is doing an actual diagnostic assessment. Do we think he has a stimulant use disorder, or not, what is the diagnosis and what wants to be treated, but I didn't hear anyone in here mention contingency management, even though we had a whole symposium on it yesterday, and we spent the first half of this lecture talking about really that's the highest evidence base that we have, or any other behavioral treatment options. Granted, if he's not treatment-seeking at all, then, you know, we wanna be cautious about recommending any kind of treatment until the person is at a place to be open to that, but I just wanted to highlight the fact that a room of what I presume is mostly physicians were still, like, so fixed on trying to find that perfect medication, and the perfect medication does not really exist here. Great points, thank you. Yeah, so the comment was sometimes patients with a similar presentation, this gentleman has experienced that they're looking for something to help them come down from the, during the crash period from methamphetamine, such as bupropion or something to relieve those intense dysphoric symptoms. There was a question back there. Oh, I was just going to comment, like, testing for HIV, hepatitis, possibly syphilis. HIV and STI testing, good point. Yes. Yeah, thank you. Just to repeat that comment, similar presentation case experience where the patient actually had an eating disorder, which links to the why. What is the methamphetamine doing for you? And then that heightened the awareness to continue to screen for those issues in future patients. Thank you for that comment. review of symptoms that link with the meth use. So, would anybody think about smoking cessation here? I hadn't heard that. Yeah, I'd think about, smoking cessation, I think, was one thing I was gonna bring up. The other is in the general idea of what substances that people use do for them. A lot of times when we get people abstinent from substances they've used, it's not just sexual activity. They may be stripped of the social network that's really been important to them, and so you always have to think about what you're gonna bring in place for that. Right, so the comment was, always screen for past history of sexual abuse and sexual trauma. Case number two, 32-year-old cisgender woman using cocaine. Ms. Green is a 32-year-old HIV negative cisgender woman who recently became homeless. After the end of a relationship, she began using cocaine to maintain alertness, typo, overnight in the encampment where she's been staying. She was brought in by an ambulance to a local hospital with symptoms of acute agitation. EMS brought her into the emergency room after she became behaviorally disruptive at her encampment. On interview, she reported feeling as though everyone in her encampment was plotting against her, began feeling the sensation of insects crawling under her skin, usually experiences these symptoms when she uses cocaine, but they resolve within a few hours of her last use. Urine labs obtained were positive for benzyl-ecugnine and positive for HCG. Thoughts about this case? Initial thoughts, and then we can prompt for more. So she's either going to give birth to a nice little baby or a giant block of cocaine. Thoughts? Well, I think her safety is number one because she's homeless, and she's using the cocaine to stay awake, so I would try to maybe work on housing for her. Housing might be a consideration for somebody in this situation. Yeah, so a screen for peripartum depression and the other risk factors and drivers of that as well as, you know, what is her understanding of whether she's pregnant or not. I'm going to beat a trauma horse here. If she left a relationship, was there violence in the relationship and is she getting cocaine by exchanging sex as a, if she's homeless and doesn't have an income? And then I'm going to pitch our talk tomorrow on human trafficking and substance use disorder since I have the microphone. Thank you, by the way, for doing the walk. So she's relatively young and I don't see any other medical history, but usually for patients who use cocaine, I do do a history of cardiac disease just to be on the safe side. Be extra supportive so she doesn't leave AMA. Oh, why does she want to stay awake? Sorry, I couldn't understand that. One phrase, stay awake overnight. Is it because she's paranoid? So even before the pain or... Was that true before she started using cocaine or not? Got it. Was she not being paranoid before she was doing it? Yeah, yeah, so we'd want to assess that. Yes. I mean, very, very important. Absolutely. And we have patients, for sure, in our clinics who report that they're not stably housed. And the stimulants are very much linked with that, meaning that's a value of the stimulant use, is to help them stay awake overnight. Over here. Yeah, we see this all the time, and it's usually in the context of fentanyl use, right, where they're worried about nodding off on the fentanyl, getting assaulted. And so they're using, in our area, it's meth. But they're using meth to counteract the sedating effects of the fentanyl, so they can stay safe. So you clearly want to screen for fentanyl. Yeah, that's a great point, too. Mike, here. Before using cocaine, or was she psychotic before using cocaine? Or was she just non-psychotic, and that kind of behaviors are considered just normal as a homeless woman? Yeah, right. I mean, that brings up a lot of diagnostic questions around, did she have an underlying psychotic disorder that even preceded her cocaine use? This could take some time to assess. And again, depending on the symptoms, we do want to treat the psychosis. Yes. And that's worth knowing. But remember, this is homelessness 101 for both men and women. You cannot lock anything, and you are surrounded by people who want your stuff, even if they don't want to hurt your body. And you need your stuff to survive, so you must have a way of staying alert when it's not safe to sleep. This is the basics of not having a home, pretty much anywhere in the world, perhaps, but absolutely in urban and suburban America. Thank you. There's one over there. So I think that the way this case is presented, you're in the emergency room right now, and so focusing on the initial assessment, what you would assess for safety, are critical. In addition to that, I think it's worth remembering that we are looking for ways to engage her and motivate her to engage in longer-term treatment after we've established her initial safety. And when women are pregnant, that is often a time where they're highly motivated to engage in things that they may not otherwise be willing or able to do. In particular, for a stimulant use disorder, I think we're even more cautious with medications for treatment than we would be in a pregnant woman, knowing that the preponderance of data for medications is weaker than we would like for it to be. And so again, I just want to, thinking long-term, harnessing this critical window where somebody really is likely to be more motivated and engage in treatment during the pregnancy, and then going back to the evidence-based treatments that we have. And so potentially, a community reinforcement approach, if you have a recovery residence available, if you have programs that are integrated with some kind of contingency management, where even rewards can be around housing and engagement and other kinds of services. So just thinking not just about that immediate point, but a little bit longer term for somebody like this. Thank you. Comment over here, right? We'll go here and then there. Thank you. I think the patient is pregnant, homeless, and psychotic. Then if I were her doctor, I admitted her, and start coatiapine for him to relax him and stop the psychosis process for the first system. Did anyone ask if she has an ADH history? The comment is you would take an ADHD history. It's not mentioned in the STEM. I would not evaluate her and come to any conclusions and all that without consulting people who know her well, who know her background, and towards what the speaker here was saying, that she'll be more open to involve her family, get them involved in her aftercare management, and so forth. To bring her in and not know anything about her, I don't think is all that helpful. We're just treating symptoms. We have to get her whole background. That will tell us everything we need to know. So collateral information is really important in this instance. And absent of that, we're just treating symptoms without necessarily understanding the full picture. This case is pretty tricky because we don't have enough information to know about her. If we reach out for collateral information, which I agree is important, are we doing harm by contacting a potential abuser? So it's kind of tricky with this case to know. I would focus on stabilizing her first and trying to get her to have the clearmentation to get more information from her and make some decisions. And safety would be safety first for her. Thank you. With both cases, I think that there's something that maybe we haven't mentioned, but I keep going back to, which is we really need to build trust with both of these patients and engagement. And I'm just seeing these scenarios are scenarios where I'm planting seeds to have these other conversations. And for girls like her, I can't even imagine, does she know she's pregnant? When am I going to have that conversation? So that she can welcome it in a place where it feels safe for her. And so it really feels like engagement, engagement, engagement of am I. And that's all I keep thinking about. No plan. Let's talk about past psychiatric issues and all that later. That is not at all what I'm prioritizing other than safety and trust. Thank you for bringing up motivation. It warms my heart. I just want to reinforce, I would really, even as a psychiatrist, push as much as I can to the ED for more medical workup, do blood draw and see how far along she is, and try to advocate for her and consult OB if she is admitted. If no other comments on the case, we can also just open it up in our remaining few minutes to any other questions that you might have. Questions you're having, yes. Do we have like a general question slide? General question slide. Yes, we do. So you look at patterns of substance use, stimulant use, particular cocaine and meth, and geographically how it changes. I now practice in Miami. I trained in Salt Lake City, Utah. The pattern is very different. 80% meth, 20% cocaine, switch it around, 80% cocaine, 20% meth. But are you looking beyond the borders of the United States in terms of 2C or pink cocaine and Captagon? Is that something that you came up with with any data in terms of patterns of that? Because I feel like the meth cocaine is a pretty clear pattern. But if we cross the border, we're coming on to other things that in border cities or ports like Miami are showing up in rare cases. I wanted to know what you guys have on that. I tried to cover that in a chapter that just came out in Alan Tasman's fifth edition. I think it is called World Psychiatry. But I'm sure there's others that have written. I think Mike Farrell in Australia has looked at worldwide patterns of psychostimulant use, both cocaine and methamphetamine, as well as other stimulants. And I'm trying to remember where the last paper was. It might have been Lancet. But it was a very good paper that was only about five pages long. It's even color-coded. But it's very important. We're kind of US-centric here. We also did not look at the global stimulant use patterns when developing this guideline. This guideline was developed around US-based screening, what we know about clinical trials for common US-based stimulants. So just to answer your question, that wasn't part of the guideline development. That's not to say it's not important. But we didn't really cover a lot of epi in the guideline. The guideline was mostly a practice-focused, like, what do we know about what you do when faced with a patient? Less general information. Whereas I don't know if there's anything else you want to say on guideline development to that end. Yeah, I agree. And if your question is really, what are the rates of some of these other stimulants that are starting to come into the US? Yeah, I mean, I've seen random cases and reports. I can't speak to the overall trends and the current statistics, unfortunately. So I have two questions, which may be a little greedy. But the first one is, I suspect I know the answer to, which is, I would say in the majority of my cases, I can't start buprenorphine and naltrexone combination because the patient also needs to be on. Or I can't start bupropion and naltrexone combination because the patient also needs to be on buprenorphine because they have a fentanyl use disorder. And so I'm wondering whether anyone's looked at that combination at all. And then my second question is something that my colleagues in the outpatient setting run into all the time, which is, I'm curious from this remarkable level of expert, what you guys recommend in terms of the approach to an acutely intoxicated patient in a clinic setting, not in an ED, not in a, you know, who really can't participate very effectively. I can try to tackle the first one. If I understood your question, it was buprenorphine plus bupropion. Yeah, when you're sort of like, I can't do naltrexone because you're on bupropion. Yeah, I mean, that would be a real limitation to that combo. And I would just choose if there's indication and select based on current psychiatric symptoms or other co-occurring disorders and consider just the bupropion, for example, without the naltrexone. And you had one other question, which was how to treat acute intoxication in the outpatient setting. Yeah, I'm open to thoughts on this. But any of the medic, it depends on what the symptoms would be. And if you often don't have those medications available right then and there. So you would still be calling in a prescription or ordering a prescription to a pharmacy in that case. So the guideline says de-escalation and transition to an appropriate level of care. Yeah. Hoping to pick your brains. You have a young man with opioid use disorder. Started in his 20s, successfully treated with suboxone and then sublocate. He's off opioids. He's doing well. I diagnosed him with ADHD. He wasn't really progressing in life. Thought it would help with functional improvement. It did not. And then he started misusing, abusing, became dependent on Vyvanse. So I stopped it. Last time I saw him in the clinic, he is buying Benzodrix, propylhexidine, I'm told it is. And it's an inhaler. And that's what he's getting high on. And I really, other than saying, I think you need a higher level of care, go get assessment for residential treatment, I really didn't know what to do with that. Yeah. And actually, this will be our last question because we're out of time. So we'll quickly address it. And then any other questions, we will stay on a bit if you would like to come up and chat with us. But you're right. I would assess for level of care. I would consider a more intensive outpatient program if residential is not either appropriate for this patient or not acceptable to this patient. But it sounds like, yes, more behavioral treatment, more structure. Because some of these other either emerging drugs, et cetera, it's not that we have good or approved pharmacotherapy options. So if your outpatient level of care is not holding him and is not sufficient, he sounds like needs more support and higher level. I don't know if you have other comments. I just want to thank everyone for your time and attention. Thank you so much. Thank you.

AAAP-ASAM guideline

stimulant use disorder

Dr. Larissa Mooney

Dr. Brian Hurley

Dr. Severino

screening and assessment

contingency management

Community Reinforcement Approach

Cognitive Behavioral Therapy

Matrix Model

pharmacotherapy

co-occurring disorders

harm reduction

patient engagement

clinical practice

cognitive-behavioral therapy

methamphetamine

cocaine use disorder

behavioral interventions

addiction specialists

case studies

holistic approach