The overdose crisis in the US has long been associated with opioids, but there has also been a steady rise in the use of stimulants: in the last five years, overdose deaths involving cocaine have doubled nationally, and those linked to methamphetamine have tripled. Misused stimulants may include prescribed medications like Adderall, or illicit substances.

Now, thanks to a $900,000 grant (each year for five years) from the federal Bureau of Substance Addiction Services (BSAS), CHD has developed a program—its Stimulant Treatment and Recovery Team (START)—that is treating individuals with primary and co-occurring stimulant use disorder: In fact, START’s effectiveness was recently recognized with an Innovation Award from the Western Mass Substance Use Providers Association (WMSAPA). The accolade was presented at WMSAPA’s annual meeting on June 14. Pictured are SUD Nurse Case Manager Jennifer Barr (left) and Program Director Heather Pietras-Gladu.

START operates at CHD’s Pine Street Outpatient Clinic in Springfield using a multidisciplinary group that includes Program Director Heather Pietras-Gladu, an administrative manager, a registered nurse, recovery coaches, and a psychiatric nurse practitioner. Individuals are now able to access much-needed treatment that previously didn’t exist in the outpatient clinical setting—until recently, there was a shortfall in treatment services, especially because stimulant use diagnoses had been typically regarded as secondary when co-occurring with opioid use.

Indeed, BSAS has recognized that the care for stimulant use disorders has lagged behind care for other substance use disorders, and CHD Senior Vice President of Medical Services Jalil Johnson agreed. “Stimulant disorders are somewhat undertreated,” said Dr. Johnson. “There are many reasons—sometimes a person who has stimulant use disorder may not necessarily require hospitalization or immediate treatment. Because of that, it is not often a primary diagnosis for people to be admitted for hospitalization.” Also, people with stimulant use conditions are typically not admitted for detox or overnight stays to treat stimulant misuse as a standalone condition, which limits the immediate access they need to recover.

The lag in treatment, said Dr. Johnson, may also be due to the fact that there isn’t a high mortality rate related to withdrawal from stimulant use compared to other drugs. “You can die from withdrawal from, say, alcohol or benzodiazepines, which are depressants such as Valium and Klonopin,” he said.

While the stimulant epidemic has certainly been overshadowed by the opioid epidemic, in recent years, cocaine and methamphetamine are now involved in more deaths than either prescription opioids or heroin. 

“Generally, opioid use disorders have been known to lead to fatalities, which is why there has been such an emphasis and a lot of treatment programs, both outpatient and inpatient—because of the opioid epidemic,” said Dr. Johnson. “However, we know that stimulant use disorders have plagued lots of communities since the 1970s and 1980s, but historically there hasn’t been a lot of clinical programming dedicated to these disorders.”

Misuse of prescription stimulants continues to rise as well, and START also treats individuals who overuse prescribed amphetamines—medicines generally used to treat ADHD and narcolepsy—and non-prescribed amphetamine medications.

Nationally, the prevalence of stimulants in opioid overdose deaths has increased dramatically in the last 15 years because of “speed-balling”—some individuals co-using or taking a stimulant and an opioid sequentially. A mistaken belief exists among some substance users that mixing stimulants and heroin can help them avoid overdosing—that one drug counters the other. But several studies have found that people who used opioids and stimulants together were twice as likely to experience a fatal overdose compared to those who only used opioids. Additionally, there is morbidity or illness associated with stimulant misuse. Dr. Johnson cautions that “while preventing death from stimulant misuse is a primary goal, an additional goal is to prevent illness associated with stimulant misuse, as it can lead to psychological and psychosocial problems, as well as cardiovascular, respiratory, kidney, and intestinal systems.”

D’Arcy Gebert, psychiatric nurse practitioner and lead prescriber at START, said she is proud to be part of a program that has been expanding access to stimulant use disorder treatment. “This taps into a population that has been historically underserved,” she said. “The problem has been costing lives.”

There has been an absence of broadly effective pharmacological treatment to stimulant use disorder, but certain medicines, including benzodiazepines, can be used when a patient is “over-amping”—or overdosing—on a stimulant. “There are also medicines that can be helpful for stimulant users with underlying psychiatric issues that need to be addressed,” said Dr. Johnson. The Pine Street Clinic has a dedicated cool-down space for over-amping individuals who are experiencing extreme anxiety and agitation. The room has dim lighting, comfortable seating, lockers for personal items, drinking water and snacks, sensory toys and activities, psychoeducational brochures in multiple languages, and access to supportive supplies like condoms and Narcan.

Practitioners dealing the stimulant use disorder rely on behavioral and psychosocial interventions, and Contingency Management is the first line of treatment with the START program. This is an evidence-based approach centered on providing incentives to support positive behavior change, and it is used in all of CHD’s clinical programs. Individuals undergoing Contingency Management receive rewards or incentives in exchange for specific behaviors (e.g., negative urine tests). “We have interventions such as recovery coaching, case management, and traditional outpatient therapies such as cognitive behavioral therapy,” said Dr. Johnson, because many mental health conditions, especially depression and bipolar disorder, can co-occur alongside stimulant use disorder and exacerbate the severity of someone’s addiction.

Pietras-Gladu said that among the START therapy groups is one focusing on the medical impacts of stimulants within a person’s body. Simulants increase extracellular dopamine levels in the brain, resulting in euphoria. “We emphasize exercise as an activity that boosts dopamine release,” she said. “In Contingency Management treatment for substance use orders, promoting exercise is effective in getting positive outcomes.”

Johnson said there is also primary care and specialist follow-up to the clinic visits. “Primary care interventions screen for any kind of secondary health concerns, like dental problems, cardiovascular problems, and other issues associated with prolonged stimulant use.” said Dr. Johnson. Complications from stimulant use include cracked teeth from extreme jaw clenching. And, because some stimulant users take a depressant to decrease excessive stimulation—or to combat difficulty sleeping following stimulant use—this combination causes spasms of coronary arteries that can damage the heart, or cause an abnormal growth of heart valve cells, leading to heart failure.

Individuals served by START are treated using the nurse care management model called OBAT (Office Based Addiction Treatment), a model that relies on interprofessional collaboration between members of the care team, with nurses taking a lead role. “OBAT was developed by Boston Medical Center and involves nurses providing the initial screening and helping coordinate care, including care from medical specialists” and other service providers, said Johnson.

Pietras-Gladu said that in the short time START has operated it has celebrated numerous success stories. “The team is doing phenomenal work,” she said. “We’ve had one individual come in and initially say, ‘I’m never going to stop using cocaine,’ and now he doesn’t use it. The therapeutic interventions are working—people are really healing.”