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Best practice portal:
Treatment options for amphetamines users

This page refers to the current evidence on the effectiveness of the available treatment options for amphetamines users. Amphetamines refers to the broad family of amphetamines, including methamphetamines, dextroamphetamines, etc. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 06.2016     Next update:12.2016

Effects of available treatments for amphetamines users

Beneficial

No interventions met the criteria for this category.

Likely to be beneficial

No interventions met the criteria for this category.

Trade-off between benefits and harms

The adrenergic uptake inhibitor imipramine as a medium-term treatment

The adrenergic uptake inhibitor imipramine (150 mg/day), in medium-term treatment*, significantly increased the duration of adherence to treatment (Srisurapanont et al., 2001)

* defined by the authors and not specified.

The antidepressive agent fluoxetine as a short-term treatment

The antidepressive agent fluoxetine (40 mg/day) as a short-term treatment* was found to be effective (in a systematic review of five studies totalling about 150 patients) in significantly decreasing craving (if compared with an adrenergic uptake inhibitor, imipramine) (Srisurapanont et al., 2001).

* defined by the authors and not specified.

Withdrawal management for pregnant women with stimulant dependence

Evidence-based international guidelines (WHO, 2014) recommend using psychotropic medication in pregnant women to assist detoxification from stimulants, but should be reserved when specific symptoms emerge.
Harms to mother and fetus of ongoing use of psychostimulants use have been shown to be high, thus the potential benefits of this approach strongly outweigh the harms of providing psychopharmacological treatment of symptoms, if required, during psychostimulant withdrawal.

Unknown effectiveness

Psychostimulants versus placebo for amphetamine dependence

Psychostimulants (including dexamphetamine, bupropion,methylphenidate and modafinil) were found in a systematic review (Pérez-Mañá et al., 2013) to have no different effect than placebo in:

  • retaining people in treatment (RR 1.01, 95 % CI 0.9 to 1.14, 11 studies, N=791)
  • reducing use (MD -0.26, 95 % CI -0.85 to 0.33, 7 studies, N=473)
  • reducing cravings (MD 0.07, 95 % CI -0.44to 0.59, 2 studies, N=144)
  • improving abstinence (RR 1.12, 95 % CI 0.85to 1.47, 6 studies, N=559)

Evidence of ineffectiveness

Pharmacotherapy for pregnant women

Evidence-based international guidelines (WHO, 2014) do not recommend pharmacotherapy for routine treatment of dependence to stimulants and cannabis in pregnant women

References and definitions

List of references

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

 

 

About amphetamines use

Case definition

The Diagnostic and statistical manual, 5th edition, describes amphatamine use disorder as the problematic pattern of use of amphetamine (or similar drug) leading to clinically significant impairment or distress. Typically includes a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and a physical withdrawal state. Chronic use can cause: chaotic behavior, social isolation, aggressive behaviour, sexual dysfunction, legal problems, depression, social and occupational failure. High-dose use causes psychotic episodes.

Aetiology

The mean age of amphetamine users entering treatment is 29 years. The proportion of women is higher than for other drugs, with a male to female ratio of about 2:1.
Amphetamine users in treatment frequently report the use of other drugs, primarily cannabis and alcohol, and sometimes opioids. In those countries where primary amphetamine users make up a high proportion of those entering treatment, injection is the most frequently reported method of use (63–83 %).

Prevalence

Recent population surveys indicate that lifetime prevalence of the use of amphetamines in Europe varies between countries, from nearly zero to around 11 % of all adults (aged 15–64 years). On average, it is estimated that around 3 % of all European adults have used amphetamines at least once. Last year use of the drug is much lower, with a European average of less than 1 %. These estimates suggest that around 12 million Europeans have tried amphetamines, and about 2 million have used the drug during the last year. Among young adults (15–34 years), lifetime prevalence of amphetamine use varies considerably between countries, from 0.1 % to 15.3 %, with a weighted European average of about 5 %.

Treatment

Users of amphetamines generally receive treatment in outpatient drug services that, in countries with histories of significant levels of the use of amphetamines, may specialise in treating this type of drug problem. Treatment for the most problematic users of amphetamines may be provided in inpatient drug services or in psychiatric clinics or hospitals. Specific services targeting amphetamine users are available in few countries in Europe and not much information is available. Dexamphetamine has long been available for the treatment of highly problematic users of amphetamines in England and Wales; however, information on this practice in the United Kingdom is limited.

Outcomes

Treatments may not be effective in achieving all the desired outcomes, these outcomes are prioritised.

Primary outcomes

  • Retention in treatment (observational studies* showed that people in treatment are less likely to take risks, and to be involved in crimes).
  • Mortality.
  • Relapse to use.
  • Criminal activity.

* studies such as National Treatment Outcome Research Study – NTORS, Australian Treatment Outcome Study – ATOS

Prognosis

Tolerance to amphetamines develops, and often leads to substantial escalation of the dose. Conversely, some individuals with amphetamine dependence develop sensitisation, which is characterised by enhanced augmentation of effect following repeated exposure. In these cases small doses may produce marked stimulant and other adverse mental and neurological effects.

References

  • American Psychiatric Association (2000), Diagnostic and statistical manual of mental disorders, 4th edition, text revision, American Psychiatric Association, Washington, DC.
  • EMCDDA statistical bulletin
  • EMCDDA , Annual report: the state of the drugs problem in Europe, EMCDDA, Lisbon
  • Shoptaw, S. J., Kao, U. and Ling, W. (2009), ‘Treatment for amphetamine psychosis’, Cochrane Database of Systematic Reviews, Issue 1.
  • Shoptaw, S. J., Kao, U., Heinzerling, K. and Ling, W. (2009)‚Treatment for amphetamine withdrawal’, Cochrane Database of Systematic Reviews, Issue 2.

Ongoing studies

Amphetamines related ongoing studies (PDF, updated January 2011)

Page last updated: Thursday, 23 June 2016