Case Summary
A provider called the Substance Use Warmline about a 32 year old male with history of major depressive disorder, newly enrolled in primary care, and with unknown status for HIV, HCV and HBV. The patient initially presented with a 6-month history of new heroin and methamphetamine use, and also reported a history of alcohol use disorder (now in remission). His heroin use was the primary reason for presenting to care: he recognized his problematic use but had low levels of motivation to address the issue. After an initial visit, the provider subsequently performed an induction and stabilization with buprenorphine, and the patient had attained remission with regard to his heroin use. The patient now has increased mental clarity and insight, however he has continued to snort methamphetamine approximately 3-5 times per week.

The caller’s questions for the CCC consultant were:
1. How to approach and prioritize concurrent substance use disorders?
2. What are evidence based approaches to treating methamphetamine/stimulant use disorder?

CCC Consultant Response
Management of concurrent stimulant and opioid use disorders
Concomitant use of stimulants and opioids is common and typically falls into one of several different patterns of use. Various authors have found in diverse populations that upwards of 80% of heroin users use stimulants in one of two patterns: simultaneous use—with the combination seen as potentiating the effects of each individual drug—and sequential use—with use of one drug typically treating withdrawal or other adverse effects of the other.[1] This case illustrates the importance and potential benefit of addressing both disorders in addressing overall risk reduction for the patient.

The first consideration in treating an individual with concurrent use of opioids and stimulants is that treatment of the opioid use disorder improves treatment outcomes for the stimulant use disorder in two different ways: by improving enrollment and continuity of care of the affected individual, and more directly, because treatment of opioid use disorder with agonist therapy such as buprenorphine seems to decrease overall stimulant use through pharmacologic effects.[2]

Treatment of Methamphetamine Use
Treatments that have shown promise in decreasing independent methamphetamine use include Cognitive Behavioral Therapy, naltrexone, bupropion, and most recently, mirtazapine. In this particular case, the patient has demonstrated progress in addressing his multiple disorders: at present he is in remission with regards to his heroin use, and has newly-gained insight into his simulant use. In addition to bolstering psychosocial treatments for this patient—with consideration to Cognitive Behavioral Therapy—bupropion or mirtazapine could be good options to help address his stimulant use and depression. Finally, best practices for overall treatment of substance use disorders should be utilized, such as continued urine toxicology screening, a treatment agreement, and continual reassessment of the chosen treatment with regard to the particulars of the individual patient.[3]

In addition to the advice given for treatment of opioid and methamphetamine use treatment, it was recommended that the patient be tested for HIV, HCV, and HBV since his status was unknown to the provider.

Conclusion
Co-occurring substance use disorders are common, and utilizing evidence-based modalities in the treatment of each disorder individually can reduce use overall and bolster the patient-provider relationship.

[1] Leri, Francesco, Julie Bruneau, and Jane Stewart. “Understanding polydrug use: Review of heroin and cocaine co‐use.” Addiction 98.1 (2003): 7-22.
[2] Montoya, Ivan D., et al. “Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence.” Clinical Pharmacology & Therapeutics 75.1 (2004): 34-48.
[3] Courtney, Kelly E., and Lara A. Ray. “Methamphetamine: An Update on Epidemiology, Pharmacology, Clinical Phenomenology, and Treatment Literature.” Drug and alcohol dependence 0 (2014): 11–21. PMC. Web. 18 Jan. 2017.

Because CCC consultations are based on information provided by the caller or clinician accessing the online consultation center, without the benefit of a direct evaluation or examination of the patient, consultations are intended to be used as a guide. They do not constitute medical advice and are not to serve as a substitute for medical judgment. This Case of the Month includes consultation based on the most up-to-date evidence at the time of its publication. To learn about current recommendations, please call one of our clinical consultation lines.