A recent commentary suggests that prescribing psychostimulants off-label could potentially mitigate the adverse effects resulting from the consumption of illicit stimulants. This proposition comes amidst an escalating crisis of poisonings linked to unregulated drugs in Canada.
The Rising Crisis and a Possible Solution
A commentary recently published in the Canadian Medical Association Journal (CMAJ) proposes an innovative approach to tackle the escalating problem of drug-related poisonings in Canada. The authors highlight that while synthetic opioids like fentanyl are usually linked to these poisonings, the usage of stimulants is also on the rise. In fact, stimulants were detected in nearly half of all opioid-related deaths in Canada in 2022.
“Prescribed psychostimulants such as methylphenidate and dextroamphetamine have shown potential in reducing cravings for and the use of cocaine and methamphetamine,” says Heather Palis, Ph.D., a postdoctoral fellow in psychiatry at the University of British Columbia. She adds that these prescribed stimulants can mimic the effects that some people seek from cocaine or methamphetamine, thus reducing reliance on these illicit drugs.
The Current State of Treatments
Despite the growing body of evidence from clinical trials in Europe, Australia, and the United States supporting the use of prescription psychostimulants to treat stimulant use disorder, no pharmacological treatments for this condition are currently approved in Canada.
British Columbia (BC) is the only province that has implemented a Safer Supply Policy Directive and risk mitigation guidance for prescribing psychostimulants to individuals at risk of overdose. However, during its first year of implementation, prescribed psychostimulant medications reached less than 3% of people estimated to have stimulant use disorder in BC.
Barriers to Wider Implementation
The authors identify several barriers to the wider implementation of psychostimulant prescribing:
- Safety concerns and the relative novelty of the evidence base for pharmacologic treatment of stimulant use disorder.
- Policies limiting prescriptions of psychoactive medications don’t reflect the current state of the highly toxic illegal drug market.
- Lack of stable operational funding for programs demonstrating positive patient outcomes.
A Call for a More Comprehensive Approach
Palis emphasizes that a “one-size-fits-all” approach is inadequate. According to her, “prescribing psychostimulants is just one option across a continuum of interventions that could be offered.”
Elaine Hyshka, Ph.D., Canada research chair in health systems innovation at the University of Alberta’s School of Public Health, agrees with Palis and calls for more action:
- Expert clinical guidance for prescribing psychostimulants needs to be developed.
- National collaboration among regulators, clinical experts, and provincial, territorial, and federal governments should be encouraged to facilitate expanded access to safer drug supplies.
- Alternate routes of medication administration should be explored.
- Nonmedical models of safer supply need to be developed and tested to further reduce risks of drug poisoning across the population.
While the off-label prescribing of psychostimulants may not be a panacea for the ongoing unregulated drug poisoning crisis, it could play a critical role in reducing reliance