Misuse of Prescription Stimulant Medication Among College Students: Summary of the Research Literature and Clinical Recommendations

Appropriate treatment (which may include pharmacologic, psychological, or academic accommodation components) for individuals with these psychiatric disorders or psychological symptoms may reduce the misuse of stimulant medications among college students, especially if these students are misusing in order to reduce their symptoms (ie, a self-medication hypothesis).

Treatment

There are currently no FDA-approved medications to treat stimulant medication misuse. In fact, studies exploring pharmacotherapy for stimulant medication misuse are limited. Most trials focus on stimulants such as cocaine or methamphetamine and not stimulant medications alone. Additionally, these trials primarily include only individuals that meet criteria for stimulant dependence. Various medications and medication classes have been examined for the treatment of stimulant dependence, including naltrexone, various antipsychotics, and various antidepressants including bupropion, modafanil, baclofen, ondansetron, and dexamphetamine, with little to no effect [60]. In a review of the literature, one study examined the use of naltrexone versus placebo for stimulant dependence in 80 treatment-seeking Swedish individuals [61]. The different types of stimulants on which these individuals were dependent were not clearly delineated, though the study authors noted that the major amphetamine abused in Sweden was the racemic mixture d/l amphetamine and not methamphetamine. Naltrexone was superior to placebo in this trial, as evidenced by higher percentage of amphetamine-free urine samples. A large majority of this sample used intravenously (65%–76%) and had been using between 6 to 8 years, limiting the applicability to individuals with stimulant medication misuse. At this time, investigation into evidence-based pharmacotherapies for stimulant medication misuse remains in the early stages.

Generally speaking, efficacious behavioral treatments, such as contingency management (CM), cognitive behavioral therapy (CBT), skills training, motivational interviewing (MI), relapse prevention, couples and family treatments, and drug counseling, exist for drug abuse [62]. CBT, cognitive therapy, CM, MI, and community reinforcement approach (CRA) [63,64] have been explored for stimulant dependence and are currently the primary interventions for amphetamine-type stimulant dependence [60]. Similar to pharmacotherapy studies, most psychotherapy studies to date have examined primarily cocaine and methamphetamine dependence and not misuse of stimulant medications. In fact, no studies examining psychotherapy for stimulant medication misuse were found by our group in a search using the PubMed database. Therefore, discussion of psychotherapeutic interventions that may be efficacious for stimulant medication misuse extrapolates outcomes from studies of stimulant dependence, appreciating this is an approximation and imprecise as there are significant differences between stimulant medication misusers and those dependent upon stimulants such as methamphetamine or cocaine. As such, in a review from 2009 [63], Vocci and colleagues compared psychotherapy studies for cocaine and methamphetamine dependence and concluded that CBT and CM were moderately effective and that adding CM to standard treatment may help improve outcomes. A study of 214 amphetamine users (including methamphetamine users), with the majority (70%) enrolled in a methadone maintenance program and a large proportion (58.9%) using amphetamines intravenously, found that either 2 or 4 sessions of CBT, along with self-help material, increased rate of abstinence at 6 months post-intervention compared to the use of self-help material alone [65]. Baker and colleagues [64] recommend a practical stepped approach to treatment for stimulant dependence, including conducting a thorough assessment, offering education and self-help materials, monitoring use and consequences of use, and then transitioning to more intensive psychosocial interventions if needed, which may be applicable to those with stimulant medication misuse and is clinically reasonable. Offering a psychosocial intervention may require referral to more specialized treatment services than can be offered in a general primary care clinic. Additionally, harm reduction techniques for stimulant medication misusers to reduce the medical and social consequences can be considered as well as prevention strategies and methods, which can be utilized in any treatment setting or in high-risk populations, such as college students.