In recent years, medical literature has increasingly highlighted the connection between HIV transmission and stimulant use disorder—particularly “chemsex,” or the use of substances (mostly stimulants) during sex with the aim of heightening and lengthening the sexual experience. The good news is that research also shows that several available generic drugs are effective in treating stimulant use disorder.
At the 2022 Association of Nurses in AIDS Care conference, Steve Shoptaw, Ph.D., presented an overview of the treatment of stimulant use disorder in HIV clinical settings. Shoptaw, the director of the Center for HIV Identification, Prevention and Treatment Services at the University of California-Los Angeles, noted that HIV settings in particular can be an important venue for identifying and treating stimulant use disorder.
Why Do People Use Stimulants?
Stimulants are used for many reasons, Shoptaw stated. For shift workers, stimulants can be a way to stay awake through difficult schedules. Unhoused people may use stimulants to stay awake and protect their belongings at night. Meanwhile, meth use can also be common among groups such as suburban white women, due to a combination of the pressures and stresses they face in their daily lives, Shoptaw suggested.
That said, when it comes to HIV, the conversation about stimulant use often comes back to men who have sex with men (MSM). For a subset of MSM, stimulants—commonly methamphetamine, but also cocaine, gamma hydroxybutyrate/gamma butyrolactone (GHB/GBL), ketamine, and mephedrone—are the drugs most often used for chemsex. Sex and stimulants can form a combination that, according to Shoptaw, “takes (users) to places that they maybe wouldn't have otherwise gone.”
Among MSM in particular, stimulants and sex are strongly linked with HIV. “Men who have sex with men [and are] living with HIV are significantly more likely to use methamphetamine than [those] not living with HIV,” Shoptaw said. Meanwhile, MSM who use meth and are not living with HIV have a higher likelihood of becoming infected because meth use is a driver of HIV transmission among MSM, he added.
Overall, about 29% of MSM in the U.S. engage in some level of stimulant use, even if not on a regular basis, Shoptaw said. This can increase behaviors that correspond with a greater risk for HIV infection. Importantly for clinicians caring for PLWH, meth use also corresponds with not taking antiretroviral medications regularly, Shoptaw stated.
Treating Stimulant Addiction: Pharmaceutical Options
The reason stimulants at high doses, primarily meth, create such a strong and lasting hold on users is because of how they affect neurocircuitry: the drugs co-opt different neural networks within the brain to develop behaviors that become automatic. Meth users who seek to reduce their intake can relapse because stimulant use creates positive reinforcement both for ending the physical symptoms of withdrawal and for stimulating the good feelings that come with using the drug. “That makes it hard to treat [stimulant use disorder] from a behavioral science perspective, because our bodies are meant to go, not to stop [using],” Shoptaw said.
Shoptaw noted that there were several forms of therapy for chemical dependence, such as cognitive behavioral therapy and 12-step programs. However, his presentation focused specifically on pharmacotherapies—which, he said, are highly effective and can be the foundation on which stimulant use disorder intervention is built. The idea is to start by addressing the biology of addiction, and then add “whole person” or integrated strategies to address behavior and culture. “Medication therapies have mechanisms that affect neural transmission, which is what makes them effective as a starting point,” Shoptaw said.
Shoptaw shared research underscoring this argument, including a 2021 study published in the New England Journal of Medicine showing that, in a large, 12-week trial, extended-release bupropion plus naltrexone were effective in treating moderate or severe meth use disorder, when compared to a group taking a placebo.
Mirtazapine, an antidepressant, is also used for the treatment of stimulant use disorder. But Shoptaw cautioned that its effect is a reduction in use, not complete cessation, which is similar to naltrexone for heavy alcohol use.
Shoptaw also pointed to a randomized, controlled trial in Biological Psychiatry showing that extended-release mixed amphetamine salts plus topiramate for three weeks was superior to a placebo for cocaine dependence.
It is important to remember that there is still no FDA-approved treatment for cocaine or meth addiction—and there is unlikely to be, Shoptaw said. This is because the medications that could be effective for substance use disorders, primarily mirtazapine and naltrexone, are generics, and they’ve already been studied for their primary uses—depressive disorder and alcohol dependency, respectively. As a result, clinicians who want to use these medications for substance use disorder will have to prescribe them off-label.
Shoptaw urged that these drug combinations be considered in HIV settings now, while novel medications for stimulant use disorders are evaluated over the next three years. He emphasized that if clinicians wait for FDA approval for these generic medications in treating stimulant use disorder, they’ll be waiting a very long time.
“If we can give our patients something that works, medications that show this efficacy, it means that their behavior can shift” prior to the commencement of 12-step programs and other therapies that are helpful to many.
He continued, “The evidence is there; let's start treating the population. And remember that the treatments are best facilitated by nurse case management.”