On May 1, Dr. Christopher Jones of the CDC presented the opening plenary at the Governor’s Institute’s Addiction Medicine 2020 conference on “The Evolving Overdose Epidemic in the U.S. and the Public Health Response.” We followed up with Dr. Jones to get answers to some participant questions. Attendees can access the Powerpoint and recorded presentation at eeds.com.
Q: Cocaine and methamphetamine cause toxicity by preventing reuptake and buildup of toxic metabolite. Do other dopamine reuptake inhibitors (bupropion, other antidepressants, modafinil) cause the same?
- A: Cocaine and methamphetamine cause toxicity via multiple routes, including overstimulation of the CNS system and cascading effects on the CV system as a result of dopamine reuptake inhibition (and direct dopamine release in the case of methamphetamine). It is possible that other dopamine reuptake inhibitors or drugs that are agonists of the dopamine receptor could have similar effects. From my read of the literature on bupropion and modafinil, they do tend to present as CNS stimulation, including agitation, excitation, and in some cases seizures during an overdose.
Q: From the ASAM conference 2-3 years ago the data for naltrexone + bupropion was sort of promising. For those practicing right now would you recommend agonist therapy with XR amphetamine over this combo as a better medication option for SUD, combining with CM and/or CBT of course?
- A: I have not seen any particularly compelling or consistent data related to naltrexone + buprenorphine or naltrexone alone or extended-release amphetamine for stimulant use disorder. I think for things like cocaine and methamphetamine, the best approaches at this point in time are combinations of non-pharmacological approaches such as CBT + CM. Hopefully research will provide more direction on pharmacological approaches +/- non-pharmacological approaches for stimulant use disorder.
Q: Does the cocaine vaccine confer protection from the cardiovascular (MI) and cerebrovascular (stroke) effects of cocaine?
- A: In theory a cocaine vaccine that produced sufficient antibodies to cocaine such that cocaine was bound and inactivated in the periphery could provide protection from the CV effects because there would be no activation by cocaine centrally or peripherally. However, it would depend on the ability to sufficiently bind all active cocaine in the body, the rate of clearance of the bound molecule, and the ability to sustain antibodies over time.
We’ll answer more questions from the virtual Addiction Medicine Conference in upcoming newsletters. Be on the lookout!