In a recent article published in CMAJ, Drs. Palis and McDonald1 present evidence from a systematic review to support a claim that prescription psychostimulants are not associated with serious adverse events in patents with stimulant use disorders.2 Although this review offers valuable insights, it may not be sufficient to allow conclusions to be drawn about the safety and efficacy of prescribed psychostimulants in real-world settings. It is crucial to assess whether the results can be generalized to broader populations, particularly considering the complexities and variability in stimulant use disorder cases.
In our retrospective cohort study of 30 227 people,3 we observed that the use of prescriptions for oral stimulants to treat cocaine use did not yield clinically significant benefits among patients receiving opioid agonist therapy in a real-world setting. In fact, patients who received prescriptions for oral stimulants showed an increase in cocaine consumption compared with patients without an oral stimulant prescription. We considered that the lack of impact on cocaine use may be attributed to the potential need for higher doses of psychostimulants to yield more substantial effects, which, in turn, increases the risk of adverse effects, including heart attacks and strokes.
Two additional important factors not discussed by Palis and McDonald warrant consideration. First, the existing literature does not provide clear guidance on the appropriate duration of prescriptions of oral stimulants, even when benefits are observed. Prolonged use of these medications without specific guidelines may lead to an increased risk of adverse effects. Second, Palis and MacDonald emphasized the substantial risk of diversion, and they proposed strategies such as delaying take-home dosing, regular monitoring for adverse events and urine drug screening. However, it is important to note that these strategies have not been practically implemented in the context of treatment for stimulant use disorder, and currently no standardized procedures exist for prescribers to adopt these strategies or evaluate their effectiveness. Given these uncertainties, it is crucial that we approach this topic with caution and carefully consider the potential implications to safeguard the safety and well-being of patients.
Addressing the unregulated drug supply is a critical aspect of managing stimulant use disorders. However, any approach to integrating prescribed stimulants into the continuum of care should be thoroughly evaluated, considering the potential unintended consequences. Rigorous real-world research is needed to maintain a critical perspective, understand the full scope of efficacy when prescribing oral stimulants and to clarify the risk–benefit decision-making and develop evidence-based clinical use guidelines before widely recommending the strategy of prescribing oral stimulants for stimulant use disorders.
Footnotes
Competing interests: None declared.
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