Models of intervention and care for psychostimulant users, 2nd edition - monograph series no. 51

Chapter 13: Future research directions

Page last updated: April 2004

Edited by Amanda Baker, Nicole K. Lee and Linda Jenner

This chapter presents key points of chapter authors' recommendations for addressing identified gaps in the literature based on findings from the indicated monograph chapters. The symbol *, when it appears, denotes the research recommendation is considered a high priority.

Prevalence and patterns of psychostimulant use
Risks associated with psychostimulant use
Psychosocial interventions for psychostimulant users
Management of acute psychostimulant toxicity
Psychostimulant withdrawal and detoxification
Pharmacological interventions for psychostimulant users
Psychostimulants and young people
The psychiatric comorbidity of psychostimulant use
Psychostimulant use in pregnancy and lactation

Prevalence and patterns of psychostimulant use

  1. Monitoring systems that focus on understanding patterns of use among specific populations are required, including for:

    • pregnant women;

    • children whose parents use drugs, including a focus on generational transfer of patterns of use;

    • Indigenous Australians, including a focus on social and health impacts;

    • those in rural areas, especially effects of use on individuals and communities and implications for treatment options and access; and

    • those at high risk of blood borne viruses, sexual risk-taking and mental health problems, such as injecting methamphetamine use, the gay community (including implications for HIV treatment), and those with a history of mental health disorders.

  2. Research examining gender differences among psychostimulant users including reasons for use, route of administration, health and social effects and treatment considerations.

  3. *Cohort and retrospective history studies are required to gain an understanding of the natural history of psychostimulant use, including protective and risk factors for continued use and/or later problematic use.

  4. Integration of treatment demand data into routine monitoring on psychostimulant use is required to improve responsiveness of treatment services to the needs of psychostimulant users.

  5. Studies that assist our understanding of the prevalence and nature of physical harms (e.g., cardiovascular and cerebrovascular pathology) associated with psychostimulant use and also associated risk of mortality.

  6. More accurate estimates of the number of dependent or injecting methamphetamine users who are more likely to impact on services in Australia.

  7. Research is required to understand the impact of psychostimulant use on frontline workers such as ambulance and emergency workers and police officers and to identify the training and resource needs of these groups to effectively manage psychostimulant users.Top of page

Risks associated with psychostimulant use

  1. *Continued monitoring of drug purity, such as via the Illicit Drug Reporting System (IDRS), is necessary to document changes in drug purity and inform harm minimisation interventions among users.

  2. The possible relationship between psychostimulant use and sexual risk-taking behaviour among sex workers and men who have sex with men should be investigated using quantitative and qualitative research methodologies.

  3. Due to the high prevalence of tobacco use among psychostimulant users and illicit drug users in general, interventions for tobacco dependence should be evaluated among users.

Psychosocial interventions for psychostimulant users

  1. *Further RCTs of brief versus intensive outpatient interventions employing MI and CBT are urgently needed among different groups of amphetamine users (infrequent but heavy; instrumental and regular).

  2. RCTs evaluating the effectiveness of CBT in preventing transition to injection and regular use of amphetamines are needed.

  3. Service evaluations of the characteristics of clients, client outcome and staff training needs are required.

  4. *The issue of retention in outpatient and residential treatment also requires urgent attention. There is a lack of information about the possible mechanisms that may enhance retention.

Management of acute psychostimulant toxicity

  1. There are few research papers evaluating efficacy and safety of sedation protocols specifically in psychostimulant use populations within an emergency setting. Further research needs to explore use of urgent sedation techniques in a range of emergency settings, especially the pre-hospital setting.

  2. A clear and unambiguous case definition for serotonin toxicity is lacking; diagnostic criteria have been proposed but not tested prospectively. No prospective studies have been done to evaluate the treatment of serotonin toxicity. Prospective studies of serotonin toxicity are required to test diagnostic criteria and determine long-term outcomes for psychostimulant users. Controlled studies are required to evaluate the treatment of serotonin toxicity and determine an optimal dosing regime.

  3. Prospective studies of cardiovascular toxicity are required, particularly among those with amphetamine and MDMA use complications.

  4. Prospective studies of cerebrovascular complications secondary to psychostimulant use are required.

Psychostimulant withdrawal and detoxification

  1. Prospective studies examining the natural history of cocaine withdrawal among both in-patients and outpatients, with attention to gender differences in withdrawal characteristics among dependent cocaine users are required to clarify issues for the Australian situation.

  2. *Due to the widespread use of potent methamphetamine in Australia, studies that describe the natural history of withdrawal among dependent Australian users in a range of settings, with mixed gender samples, are urgently required to inform the development of appropriate services and responses.

  3. The role and efficacy of psychosocial interventions in withdrawal management should be determined.Top of page

Pharmacological interventions for psychostimulant users

  1. *Future controlled trials of pharmacotherapies in Australia should focus on those treatment groups experiencing the most harm including cocaine injectors, methamphetamine injectors, methamphetamine smokers and dually dependent opioid/stimulant users. Such research should be integrated with psychosocial interventions.

Psychostimulants and young people

  1. RCTs are required to determine the efficacy of various treatment modalities for young people using psychostimulants.

The psychiatric comorbidity of psychostimulant use

  1. There needs to be more systematic investigation of comorbid conditions among psychostimulant using populations employing diagnostic instruments to determine the proportion, duration and severity of affective, anxiety and other psychiatric disorders among this population.

  2. *Prospective cohort studies are needed to determine the proportion of amphetamine users who will have a psychotic episode, the course of the disorder and, in particular, whether there are identifiable risk factors or variables that may indicate longer course or poorer outcome for a particular group of amphetamine users.

  3. *There needs to be more consideration of the relative effectiveness of treatment modalities for comorbid conditions among psychostimulant users.

  4. *Further research is required into non-psychotic comorbid conditions and their treatment among amphetamine users.

  5. There needs to be further systematic investigation of the use of conventional antipsychotics, atypical antipsychotics and benzodiazepines in the treatment of amphetamine psychosis.

  6. Further work is required to investigate the reliability of the symptoms associated with withdrawal and to determine the course of the withdrawal syndrome to ascertain which features are more enduring and should be medicated.

  7. Research into mood and anxiety disorders among psychostimulant users should aim to improve differentiation between people with pre-existing disorders at the start of treatment from those with current disorders and, in turn, ascertain whether pharmacological management of a comorbid mood or anxiety disorder improves prognosis.

  8. The course of residual or sub-clinical symptoms persisting beyond an acute episode of stimulant-induced psychosis is not well documented and should be studied.Top of page

Psychostimulant use in pregnancy and lactation

  1. Large prospective studies are required to accurately assess the relationship between psychostimulant use in pregnancy and neonatal/early childhood outcomes, particularly for methamphetamine and MDMA.

  2. The role of engagement in prenatal care in contributing to improved neonatal/early childhood outcomes needs to be further evaluated. Barriers to participation in prenatal care and methods to enhance participation should also be explored.

  3. Parenting interventions should be evaluated among psychostimulant users.

Footnotes

* This research recommendation is considered a high priority.