A new California program incentivizes people using meth or cocaine with money if they can prove they are clean in an evidence-based system in which participants can earn incrementally more the longer they stay clean. Why? Because California is grappling with substance use disorder “crisis” with deaths from cocaine, meth, and other stimulants soaring in recent years. In 2021 for instance, 65% of drug-related overdose deaths involved stimulants, compared to 22% in 2011. The impulsive nature of stimulant cravings and addiction calls for alternative approaches.

A Medi-Cal initiative called CalAIM provides social and behavioral health services, including addiction treatment to individuals in California . California Healthline reports that CalAIM provides people who use meth and cocaine with an incentive to quit habit-forming drugs that are difficult to kick on your own.

Contingency Management (CM) is a program that provides motivational incentives to treat people who use stimulants like meth or cocaine, and support their path to recovery. It recognizes and reinforces individual positive behavioral change, and requires them to prove it with drug tests showing negative results for stimulants. “CM is the only treatment that has demonstrated robust outcomes for individuals living with stimulant use disorder, including reduction or cessation of drug use and longer retention in treatment,” the program states.

“The Recovery Incentives Program increases access to new evidence-based treatments for Californians living with substance use disorder,” the program’s Fact Sheet states. “Starting in 2023, the program is available to members living with stimulant use disorder in participating counties, in outpatient, intensive outpatient, and Narcotic Treatment Program settings. As part of the program, eligible Medi-Cal members participate in a structured 24-week outpatient program, followed by at least six months of additional recovery support services. Participants meet with a trained contingency management coordinator twice weekly for the first 12 weeks of the program, then weekly for weeks 13 to 24 to complete a drug test. Participants receive a small gift card each time they test negative for stimulants and can earn up to $599 per year in incentives.”

California is the first state in the country to receive federal approval of CM as a benefit in the Medicaid program through the CalAIM 1115 Demonstration. CM also tested other sources of funding.

According to the state Department of Health Care Services, about 2,700 patients from 19 counties have enrolled in the program since April 2023.

Quinn Coburn, 65, who is in the program, told California Healthline, “It’s that little something that’s holding me accountable.”  Coburn received $10 for each clean urine test he provided the first week of the program, and the pay increases in subsequent weeks: $11.50 per test in week two, $13 in week three—up to $26.50 per test.

The program promises as much as $599 a year, and Coburn is proof that it’s doable: As of mid-May, Coburn had completed 20 weeks of clean drug tests and made $521.50.

“The way stimulants work on the brain is different than how opiates or alcohol works on the brain,” said John Duff, lead program director at Common Goals, where Coburn receives treatment. “The reward system in the brain is more activated with amphetamine users, so getting $10 or $20 at a time is more enticing than sitting in group therapy.”.

The average recovery rate for people suffering from meth addiction is around 37%, which is about equal to other physically addictive drugs such as cocaine, heroin, and prescription drugs. Cannabis is also being explored as a potential treatment to help reduce stimulant cravings.

Fighting Meth Abuse at the National Level

The fight against meth abuse is also taking place at the national level.

In 2022, President Joe Biden signed legislation designed to address the rising scourge of meth abuse in the United States.

The new law, titled the Methamphetamine Response Act, “requires the government to declare methamphetamine an ‘emerging drug threat’ and to develop a response plan specific to methamphetamine,” according to a press release.

The bill had bipartisan support in the House of Representatives and Senate: its sponsors were Sens. Dianne Feinstein (D-Calif.) and Chuck Grassley (R-Iowa) and Reps. Scott Peters (D-Calif.) and John Curtis (R-Utah).

According to a study from the National Institutes of Health, “overdose deaths involving methamphetamine nearly tripled from 2015 to 2019 among people ages 18-64 in the United States.” That study showed that the “number of people who reported using methamphetamine during this time did not increase as steeply, but the analysis found that populations with methamphetamine use disorder have become more diverse,” suggesting that “increases in higher-risk patterns of methamphetamine use, such as increases in methamphetamine use disorder, frequent use, and use of other drugs at the same time, may be contributing to the rise in overdose deaths.”

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Plentiful research and anecdotal evidence has suggested that cannabis could be a useful harm reduction tool to help folks wean off of other substances that are more addictive and harmful. While many studies have focused on cannabis to curb opioid use with some looking more broadly at stimulants, new research suggests that it could prove useful for those with crack use disorder (CUD).

In fact, the popular non-psychoactive medicinal cannabinoid CBD, or cannabidiol, seems to be the key element.

The study, published recently in the International Journal of Mental Health and Addiction, utilized a double-blind randomized clinical trial comparing CBD to three drugs commonly used to treat CUD: fluoxetine, valproic acid and clonazepam. Authors represent a number of Brazilian academic and official institutions, comprising various departments at the University of Brasília, the Brazilian Federal District’s secretary of health and forensic institute and the Federal University of São Paulo.

The research ultimately found that participants who took CBD had better health outcomes and fewer adverse effects compared to those who underwent traditional pharmaceutical options.

Monitoring Crack Use Over Time With CBD and Traditional Meds

Participants included adults in Brazil aged 18 to 65 who had used crack regularly over the past year and at least 20 times within the past month. The participants also had a desire to seek treatment for their CUD. Many of the participants used multiple drugs, but crack was noted by participants and the study team as their primary drug.

The initial participant group included 90 people, with 73 ultimately assigned to either the control of the CBD group over 10 weeks of treatment. Of this group, 34 participants completed at least half of the study and 25 completed it fully.

One group received 600 mg of CBD while the control group received a combination of the three traditional drugs. 

Researchers assessed crack use among participants once per week through a questionnaire, which asked about the frequency of crack use over the last seven days, the highest number of consecutive days without crack use, the average number of stones or grams used on days of use and the highest number of stones or grams used in a single day.

They also assessed adverse effects of the medications each week using a questionnaire, prompting participants to describe adverse effects if they happened. Additionally, researchers assessed physical health symptoms once per month, the intensity of cravings each week and collected weekly urine samples. 

CBD ‘Safe’ and ‘Tolerable’ Option with ‘Significantly’ Fewer Adverse Effects

While the study found that there were no significant variations in decrease of crack use or self-reported cravings between the control and CBD groups, researchers noted that CBD showed milder side effects than traditional medications, which could lead to diarrhea, constipation, nausea, dizziness, memory impairment and other outcomes.

The study notes that CBD seems to mitigate the primary symptoms reported by participants, including lack of appetite, difficulty in reducing crack use and the feeling of poor mental health. So, while CBD may not be more effective than standard medications, the study suggests it’s at least as effective as those options while offering fewer unwanted side effects. 

Additionally, researchers state that fewer adverse effects in CBD treatment could be beneficial in ensuring those looking to curb their crack use remain in treatment.

“CBD is a safe/tolerable product that presented significantly fewer adverse events compared to the control group,” the study conclusion states. “The CBD group performed better in more parameters than the control group, reducing crack use, not reducing food intake due to crack use, and greater improvements in self-rated health.”

The actual reasons CBD seems to help with CUD remains somewhat unclear, with researchers explaining that it is “difficult to outline the mechanism of action” behind the cannabinoid given its “broad spectrum of pharmacological properties” affecting a number of targets. Though they note that this “multiple-target action” could be an essential element, adding that “CBD decreases endocannabinoid receptor signaling and inhibits fatty acid amide hydrolase, which may reduce craving and decrease relapse rates in people with CUD.”

For future studies, researchers suggest a larger sample size and conducting similar trials with more intense screening and participant monitoring. They also state that results could be enhanced by reducing stress and environmental factors, improving emotional regulation, implementing strategies to better support individuals and potentially utilizing other cannabinoid compositions like full-spectrum CBD and/or THC.

“If so, this would be an important advance in the pharmacological treatment of stimulant use disorders,” authors conclude.

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Due to a shortage in stimulant-based drugs for ADHD (attention-deficit/hyperactivity disorder), the U.K.’s limited medical cannabis industry is seeing a spike in patients using cannabis for relief as an alternative. The exodus of patients resorting to medical cannabis shows its growing need.

The Guardian reported last September that doctors in England were told not to prescribe ADHD drugs to new patients because of a national shortage. The medications affected include four out of the five top stimulants prescribed to ADHD patients in the U.K.: methylphenidate, lisdexamfetamine, guanfacine,  and atomoxetine.

It’s been compared to the Adderall (amphetamine/dextroamphetamine salts) shortage impacting the U.S. U.S. brand-name drug makers behind Adderall, Vyvanse and Concerta are able to keep up with the shortage, but the generic versions of all three drugs are struggling to keep up. Is it time to panic? Even with these shortages in medication, doctors still say ADHD is under-diagnosed and patients are under-prescribed.

Some of them are turning to cannabis. BBC reports that a medical cannabis clinic said the U.K.’s medical cannabis industry had seen an 86% increase in ADHD patients nationally over the last year.

Some people believe cannabis can alleviate many of the symptoms associated with ADHD as research advances.

Medical Cannabis Is Better Than No Medicine

Medical cannabis, when prescribed by a registered specialist doctor, was legalized in the U.K., mostly in the form of oils and flower, in November 2018. Since then, treatments, including medical cannabis, that meet “appropriate standards” have been reclassified under Schedule 2, meaning that they have medical value. And while the U.K. has very limited availability for medical use, exports are another story: the U.K. was the world’s largest exporter of legal cannabis in 2016.

Research director Dr. Simon Erridge, who also works at Curaleaf Clinic, said it was “natural for people to explore other options” amid the shortage.

The Department of Health and Social Care (DHSC) told the BBC that while there were no cannabis-based medicines licensed for the treatment of ADHD on the NHS, specialist clinicians “can prescribe cannabis-based products where clinically appropriate and in the best interests of patients.”

“Other ADHD products remain available but cannot meet excessive increases in demand,” the DHSC alert states. “At present, the supply disruptions are expected to resolve at various dates between October and December 2023.”

Suddenly losing access to a stimulant-based drug that patients rely on leaves them with few options.

“A lot of people with ADHD may try a number of different medications to find the one that works best for them, if that is suddenly taken away by shortages it’s only natural for people to explore other options and there’s no reason why that might not include medical cannabis,” Erridge said.

Cannabis for ADHD

Depending on the person, cannabis can both help and distract people from focusing.

A January 2020 study called “Cannabinoid and Terpenoid Doses are Associated with Adult ADHD Status of Medical Cannabis Patients” arrived at mixed results, finding that whole-plant cannabis seemed to be more effective.

“The use of purified THC:CBD in a 1:1 ratio (nabiximols) showed no effect on ADHD symptom severity; however, in a qualitative study, 25% of responses indicated that whole-plant cannabis was therapeutic for ADHD,” researchers wrote. “Here, we demonstrated an association between higher CBN and lower ADHD symptoms frequency. It has been previously demonstrated that the combination of CBN and THC is associated with increased psycho-activity of THC in humans. This indicates a more complex story than simply stratifying treatment based on THC and CBD alone.”

Researchers acknowledged that there’s no one-size-fits-all solution to tackling ADHD when it comes to cannabis. 

“There is no ‘simplistic’ method for tracking only the dominant constituents of cannabis to better understand the medical potential of a cannabis cultivar,” researchers continued. “Thus, the novel perspective of our study is extremely valuable for the [medical cannabis] research field.”

Medical professionals who spoke to High Times for an October 2019 article agreed that ADHD treatments are not one-size-fits-all. Brooke Alpert is a licensed cannabis practitioner and founder of Daily Habit. Alpert touched on the correlation between CBD and ADHD. “The studies that focus on ADHD and CBD have shown some conflicting evidence.” 

She added, “I think more research needs to look at what relief people are finding with cannabis so we can have a better picture of how to further recommend CBD and cannabis for those with ADHD.”

Energizing strains like Sour Diesel, Jack Herer, Green Crack have been reported to actually have calming effects on people living with ADHD, even if they make others jittery.

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Unfortunately, the same drugs with high potential for abuse are also the ones that work best for certain individuals with neurobehavioral conditions. According to GlobalData, penetrating the stimulant-dominated pharmaceutical market remains challenging without comparable efficacy from non-stimulants. 

The attention deficit hyperactivity disorder (ADHD) market is a lucrative business: Stimulants, amphetamines, and methylphenidates continue to dominate the ADHD drug market across the seven major markets, Express Pharma reports. (The seven major markets are in France, Germany, Italy, Spain, the UK, the US, and Japan.)

Non-addictive drugs demonstrate a “crippling lower” efficacy in treating ADHD.

Drug makers are in a race to develop safer alternatives. Three out of the four late-stage pipeline drug candidates in Phase III development within those markets have non-stimulant properties: Axsome Therapeutics Inc’s solriamfetol, Otsuka Pharmaceutical Co Ltd’s centanafadine and Neurocentria Inc’s L-Threonate Magnesium Salt. 

The lower abuse potential of solriamfetol and centanafadine is a major selling point created by developers, but without displaying efficacy comparable to stimulants, they will struggle to penetrate the market—even if they are approved.

The use of stimulants for ADHD treatment is increasing.

The key opinion leaders (KOLs) in the treatment of ADHD say that patients and parents have been hesitant to use stimulants for the treatment of ADHD in children and adolescents, but this is changing with time, and the use of stimulants for ADHD treatment is increasing.

“Marketing emphasis on abuse potential is common in non-stimulates both marketed and pipeline; this is despite KOLs viewing the abuse potential of ADHD stimulants as overstated,” said Lorraine Palmer, Pharma Analyst at GlobalData. “The KOLs interviewed by GlobalData were not concerned about whether a treatment is a stimulant or a non-stimulant, rather they are focused on the pharmaceuticals efficacy and side-effect profile.”

Four non-stimulants are commonly marketed: guanfacine, clonidine, atomoxetine and viloxazine. Sleep disturbances and a decreased appetite have been reported from both clonidine and atomoxetine. 

“All four display cripplingly lower efficacy in the treatment of ADHD than stimulants,” Express Pharma reports.

“Rather than an emphasis on abuse potential, a better alternative strategy to penetrate the saturated ADHD market would be to target key unmet needs in ADHD treatment such as improving compliance or providing coverage into the evening without affecting sleep.”

Part of this challenge likely includes the impact of addiction itself.  Regarding the popular ADHD drug Adderall, adults and children 6 years of age and older are eligible to take Adderall, beginning at 5 milligrams, while children 3 to 5 years of age are able to start at 2.5 mg per day. Only children under the age of 3 are prohibited from being prescribed the drug in all cases.

Adderall’s active ingredients are dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate and amphetamine sulfate. Columbia University psychiatry professor Carl Hart famously wrote for Vice in 2016 that meth is “almost identical to Adderall” in terms of chemistry and its effects on the brain.

A 2016 study published in the Journal of Clinical Psychiatry indicates that an increasing number of young adults have been checking into emergency rooms over the past few years due to accidental overdoses on Adderall and similar drugs.

Other Reasons for Stimulant Alternatives

High Times reported last September that leading drug makers and pharmaceutical companies are having little luck addressing nationwide shortages of stimulant-based ADHD medications like Adderall, Vyvanse, and Ritalin.

The Adderall shortage began in Fall of 2022, marked by an FDA notice acknowledging the shortages with an estimate that things would be resolved in a month or two. That is not the case, however, as issued a joint notice on August 1 acknowledging that the shortage had been “understandably frustrating” for patients and providers.

“The current shortage of stimulant medications is the result of many factors. It began last fall due to a manufacturing delay experienced by one drug maker,” the joint notice said. “While this delay has since resolved, we are continuing to experience its effects in combination with record-high prescription rates of stimulant medications. Data show that, from 2012 to 2021, overall dispensing of stimulants (including amphetamine products and other stimulants) increased by 45.5 percent in the United States.” 

Teva Pharmaceuticals, Adderall’s biggest manufacturer, reported shortfalls. Teva CEO Richard Francis told Bloomberg that the company is operating at “full capacity” at the moment and blamed their decreased output in previous years to COVID-induced work shortages which they have only just barely recovered from. Should they wish to increase the amount of Adderall they produce, they would have to buy or build more factories as their current infrastructure cannot handle bigger output. The company has declined to comment on whether or not they plan to invest in such infrastructure.

This adds to the multiple reasons less addictive non-stimulant drugs are needed to treat ADHD.

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