PRESCRIBING STIMULANTS

There is no indication for the prescription of cocaine or methylamphetamine in the treatment of stimulant misuse, and it is not recommended that other stimulants such as methylphenidate or phentermine, are prescribed. There may be a limited place for the prescription of dexamphetamine sulphate (5mg tablets) in the treatment of amphetamine misuse, but this should only ever take place following the receipt of documented advice from specialist services in support of such prescribing. In contrast to the wealth of evidence supporting the prescription of substitute medication in opiate dependency, there is no conclusive evidence to guide practice when it comes to the stimulant drug class. This represents a major deficit in treatment available for the substance misusing population, especially given the relatively high prevalence of amphetamine misuse, and the increasing prevalence of cocaine misuse. Additionally, there is thought to be a large population of injecting amphetamine misusers who are exposed to all the risks of injecting drug use, but who fail to engage with services due to absence of effective pharmacological interventions.

The rationale for prescribing will usually be one of removing the patient from their drug-using environment (including drug-dealers) in order to support a successful withdrawal from drug misuse. In this case the doses prescribed will aim to limit the effects of withdrawal (lower dose) rather than provide euphoria (higher dose). Prescribing in this context should also be time-limited according to a plan agreed with the patient, and a reduction regime should be instituted sooner rather than later. An alternative rationale may be one of harmminimisation in that it may be safer for a patient to use non-contaminated drugs of known purity rather than street drugs, and that for injecting amphetamine misusers, the frequency of injecting may be reduced. In this case, prescribed doses may be higher, and reduction of dosage not a primary aim. As for injectable opioid prescription, there is no reliable evidence-base in support of the provision of dexamphetamine prescription, whatever the rationale.