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For several years during the s and 80s, Ken Van Velzen worked for one of the most successful drug importers in the US. Walking down the hallway of Grace church to meet him, the first thing I notice is a bright smile and a bandaged arm. At sixty-nine years old, Ken is recovering from hand surgery. Ken was raised in a Christian home in Michigan, the fourth of five sons. He had a fairly unremarkable childhood filled with sports, schoolwork, and church. When he was nineteen years old, he married Sharon, his high school sweetheart. We had so many dreams for our life together. It was a call from a friend who happened to be the top importer of marijuana in the US. I finished the house, sold it, and moved to Florida in My friend was a multi-millionaire, all from the importation of marijuana, and I wanted some of that. I met dangerous people. I became a dangerous person. With that lifestyle came a lifestyle of cocaine and heavy drinking. He survived, but the following week Ken was arrested for the second time since joining the industry. His lawyer advised him to check into a mental hospital. Incredibly, he was only charged with drunk driving. I got home and continued trying to make it big for three more years. The body of believers surrounded and loved him. They asked him to share his testimony with the whole church. It was a long process to rebuild their marriage and family, but they did. Looking back, Ken believes his teenage conversion under the guidance of his Christian parents was authentic. He wandered long and far, but God faithfully brought him back. Decades later, Ken would endure the greatest sorrow of his life. On May 30, , at pm, Sharon passed away from ovarian cancer. I always have and always will. Save my name, email, and website in this browser for the next time I comment. Give Service Times. Hit enter to search or ESC to close. Close Search. Jeanne Harrison. Jeanne Harrison May 31, Kelly Adkins May 31, T Munroe May 31, Latoya Richards says:. September 20, at pm. Gayla Stahler says:. October 8, at pm. Leave a Reply Cancel Reply. Share Tweet Share Pin.

Polysubstance use in the U.S. opioid crisis

Velzen buy cocaine

Federal government websites often end in. The site is secure. Preview improvements coming to the PMC website in October Learn More or Try it out now. SS provided critical input to the drafting of the section on interventions and the interpretation of this evidence. MF led the writing of the full draft of the paper. All authors provided substantial critical review of the manuscript and approved the final manuscript. We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health suicidality, psychosis, depression, and violence , and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions except for contingency management had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use. Stimulant drugs are used globally to produce euphoria, increase confidence, sociability, energy, and wakefulness, and reduce hunger. These drugs include a broad spectrum of natural and synthetic compounds appendix p 4 , but cocaine and amphetamines particularly methamphetamine have been a focus of attention because of the global scale of their extramedical use and the serious harms related to their use. Cocaine is a natural product of coca leaves Erythroxylum coca Lam leaves extracted as a hydrochloride salt or free base so-called crack cocaine. Amphetamines and cocaine increase noradrenaline and dopamine neurotransmitter activity and sympathetic arousal. They can be ingested, snorted in powder form, injected, and when in the form of crack cocaine and crystalline methamphetamine smoked. Other synthetic stimulants that are used extramedically are discussed by Peacock and colleagues. This Series paper synthesises evidence on the extent of extramedical use and dependence on cocaine and amphetamines, the associated harms, and the effect of interventions to address these harms. We estimate the excess fraction of deaths associated with stimulant dependence globally and use epidemiological modelling to explore the contribution of stimulant use to harms in people who inject drugs, men who have sex with men MSM , and transgender trans women. Cocaine and amphetamine have potential medicinal uses. Amphetamines are prescription medications used to treat narcolepsy, obesity, and attention-deficit hyperactivity disorder along with less potent stimulants eg, methylphenidate. Substantial variations exist in the global distribution and use of illicitly produced cocaine and amphetamines. The production of cocaine is mainly done in Latin American countries that grow the coca plant, such as Bolivia, Columbia, and Peru. In , global cocaine output reached metric tonnes, the highest ever estimated appendix p 7. Amphetamines primarily methamphetamine are manufactured using precursor chemicals in laboratories, so their production is geographically wider. Methamphetamine can be efficiently synthesised from pharmaceutical ephedrine and pseudoephedrine with readily available chemical reagents. Its ease of manufacture has created lucrative burgeoning markets for amphetamines in lower-income countries that have weak regulations on precursor chemicals. Cocaine and amphetamines are two of the most widely used illicit drugs worldwide. Prevalence estimates are only available for a few countries in southeast and west Asia, but methamphetamine is believed to be one of the most commonly used illicit drugs in these regions. Drug dependence data from the Global Burden of Disease study For methods used to generate these estimates see appendix p Amphetamines estimates include use of prescription stimulants. Analysis by the UN Office on Drugs and Crime 5 of the global changes in drug manufacture and production suggests that cocaine and amphetamine supply and use might be increasing globally. Several specific populations—including MSM, people who inject drugs, sex workers, and people who use stimulants for occupational reasons—have a higher proportion of people that use stimulants than others appendix p Dependence on the use of stimulants is a major problem for public health. The highest estimates of the prevalence of amphetamine dependence were in Australasia and high-income North American countries; cocaine dependence was most prevalent in high-income North American countries. People who use stimulants typically use a range of drug types. Cannabis use is very common, as is the use of other stimulants eg, ecstasy , particularly in recreational settings. Heavy consumption of alcohol is common, which when used with stimulants increases the risk of cardiotoxicity 9 and violent behaviour. The combined injection of stimulants and opioids increases exposure to blood borne viruses because it is associated with multiple injections per day and the reuse of syringes. Summary of causes of mortality summarised across cohorts of people with regular or problematic amphetamine or cocaine use. Suicide and overdose are substantial causes of mortality for people that use amphetamines 17 and cocaine. This estimate equated to UI — excess all-cause deaths associated with amphetamine dependence and — excess all-cause deaths associated with cocaine dependence in These estimates do not account for any overlap between stimulant-dependent populations, but more than half of the excess amphetamine dependence deaths occurred in east and southeast Asia where deaths related to cocaine dependence were low appendix p The fraction of all-cause deaths associated with amphetamine and cocaine dependence vary from region to region figure 2 ; appendix pp 28 — Amphetamine dependence was associated with a substantially higher proportion of excess mortality in Australasia than other regions. By contrast, the highest associated fraction and the most excess all-cause deaths associated with cocaine use was in high-income North American countries. Globally, stimulant dependence accounted for an important number of suicides, accidental injuries, cardiovascular disease, and homicide deaths appendix p We assessed the reviews of evidence on the effect of stimulant use on non-fatal health harms table 2 , separately for amphetamines and cocaine appendix p The evidence on whether amphetamine or cocaine are linked to injuries and diseases varied by outcome. Some causal relationships were plausible eg, stroke or myocardial infarction , but no pooled estimate of the magnitude exists. For this reason, the comparisons of health outcomes for amphetamines and cocaine need to be interpreted with caution. Evidence for potential causal impacts of amphetamine and cocaine use on a range of non-fatal health harms. Many of the non-fatal harms of stimulant use table 2 , are acute problems that might result in contact with emergency health-care services and law enforcement, placing substantial burdens on these frontline services. Dependence upon stimulants is a common non-fatal harm. Other harms include elevated risks of stroke, myocardial infarction, 30 , 31 and respiratory disease. The use of amphetamines 28 and cocaine 18 is associated with double the odds of depression table 2 ; appendix p Depressive symptoms are common in people seeking treatment for stimulant dependence. Evidence for an association between cocaine 18 use with anxiety is not compelling and is poor for amphetamines, 28 although panic can occur during acute intoxication. An association between stimulant use and violent behaviour exists, particularly interpersonal and intimate partner violence. Psychotic symptoms occur in a subset of people who use stimulants. These symptoms are typically transient, occur after chronic heavy use, and feature paranoia intense suspiciousness and auditory or visual hallucinations. In systematic reviews people who use amphetamines have double the odds of psychotic symptoms. Symptoms of psychosis associated with stimulant use usually abate after the person reduces or stops use. People who have developed psychotic symptoms have been suggested to be more likely to develop psychotic symptoms at reduced drug use if they return to use—so-called sensitisation. People who use stimulants have an elevated risk of HIV infection through sexual risk particularly in MSM 52 and sex workers, 18 although sexual risk might play some role in people who inject drugs and injecting risk. People who inject stimulants also have elevated hepatitis C HCV prevalence and so do those who use drugs through non-injection routes probably by sharing other equipment. Given the higher prevalence of stimulant use and associated harms in people who inject drugs 54 and MSM, we undertook mathematical modelling to quantify select health harms associated with stimulant use in these populations. In people who inject drugs panel 1 , we investigated the excess risk of HIV and HCV in people who inject stimulants in three illustrative scenarios Bangkok, Thailand; Montreal, Canada; and St Petersburg, Russia with varying patterns of stimulant use, using risk associations appendix p We found that a disproportionate number of incident HIV and HCV cases in all settings occurred in people who inject stimulants and that stimulant injection was associated with an important fraction of new HIV and HCV cases among people who inject drugs in the next year. Given the associations between stimulant injection and HIV and HCV infection table 2 , syringe sharing, 55 — 59 and sexual risk in people who inject drugs, these associations were used to estimate the contribution of stimulant injection to HIV and HCV transmission in people who inject drugs across different scenarios with varying stimulant injection prevalence and predominant type cocaine or amphetamine. Our dynamic modelling appendix p 27 explored the potential contribution of stimulant injection to HIV and HCV epidemics in three illustrative scenarios Bangkok, Thailand; Montreal, QC, Canada; and St Petersburg, Russia selected to mimic settings with different stimulants injected and varying prevalence of stimulant injecting in people who inject drugs. For these analyses, we simulated increased injecting and sexual risk in people who inject stimulants, calibrating these excess risks to elevated HIV incidence and HCV prevalence in people who inject stimulants by stimulant type obtained from our global review appendix p We note each setting has published associations between stimulant injecting and HIV or HCV, or both, consistent with global estimates. These findings were robust to sensitivity analyses with lower HCV prevalence and differing turnover assumptions for stimulant injection appendix p Our reviews indicated needle and syringe programmes can protect against HIV and HCV risk table 4 , but modelling from these associations indicates that scaled-up needle and syringe programmes for people who inject stimulants can ameliorate, but not eliminate, excess risks. Indeed, we could underestimate the effect of stimulant injecting as we neglect potential excess risk associated with polysubstance injection. Additionally, our results emphasise the urgent need for scale-up of harm reduction interventions targeting people who use stimulants and inject drugs, such as needle and syringe programmes, and the development of effective novel interventions to reduce risk in people who inject stimulants. A separate modelling exercise panel 2 quantified the excess risk of HIV and suicide in MSM and trans women who use stimulants. Stimulant use is more prevalent in MSM and trans women compared with heterosexual and cisgender men appendix p Stimulant use has been associated with increased frequency of unprotected anal sex and risk of HIV infection 64 , 65 table 2 , although causality is not well established. Rather, engagement in stimulant use and participation in higher risk sexual behaviours are considered to co-occur within a broader risk environment. In MSM and trans women, stimulant use has also been associated with increased suicide ideation and attempts, 66 , 67 supporting global findings of increased suicide mortality in people who use stimulants table 1. On the basis of these findings, we used an epidemic model of HIV transmission and suicide in MSM and trans women in Lima, Peru 68 differentiating homosexual from heterosexual and bisexual, self-identified MSM, male sex workers, and trans women to quantify the contribution of MSM and trans women who use stimulants to HIV and suicide incidence and to estimate the effect of prioritising HIV pre-exposure prophylaxis PrEP for MSM and trans women who use stimulants appendix p We chose Peru as a useful case study, given the strong data available on HIV and drug use in MSM and trans women, and also because stimulant use characteristics in Lima are similar to global estimates in MSM. These findings suggest that MSM and trans women who use stimulants experience a disproportionate burden of HIV infection and suicide, and that prioritising PrEP on the basis of stimulant use, in addition to sexual behaviour, or gender identity criteria, could increase its effect. Importantly, as the world moves towards integration of HIV services, providing comprehensive and integrated substance use, mental health, and HIV care could address the multiple harms in MSM and trans women who use stimulants. The interventions designed to reduce stimulant use table 3 and the interventions to reduce harms associated with stimulant use table 4 have varying effects appendix p The current standard of care for stimulant dependence is primarily psychosocial interventions combined with case management. However, the majority of evidence does not support their effectiveness when compared with treatment as usual. Cognitive behaviour therapy is commonly used to help people reduce their stimulant use, but Cochrane reviews conclude it is no more effective in reducing use than treatment as usual. Meta-analytic reviews indicate that contingency management leads to a statistically significantly reduction in stimulant use. Nonetheless, contingency management has not been applied in routine care because of substantial opposition from service planners, clinicians, and communities to contingency management. A notable exception is the US Department of Veterans Affairs, which has used contingency management to treat cocaine use disorder with promising outcomes. Some evidence suggests that adding a community reinforcement approach or cognitive behavioural therapy to contingency management is more effective than contingency management alone. However, benefits seen following residential rehabilitation are often not sustained, and few patients receive the ongoing support needed to prevent relapse. No medications have been approved to treat either cocaine or amphetamine or methamphetamine dependence, whether in managing withdrawal, maintaining abstinence, or preventing relapse table 4. Other psychostimulants eg, bupropion, modafinil, dexamphetamine, lisdexamfetamine, methylphenidate, mazindol, methamphetamine, mixed amphetamine salts, and selegiline can produce a small temporary increase in abstinence from cocaine use, but the quality of evidence was classified as very low. Fewer drugs have been trialled for methamphetamine or amphetamine dependence. Dexamphetamine, bupropion, methylphenidate, and modafinil do not reduce use, craving, or increase abstinence, or retention in treatment. Treatments under investigation include long-acting stimulant medications, , combination pharmacotherapies, compounds that target brain systems involved in reward learning, and proantioxidant compounds with neuroprotective properties eg, ibudilast and N-acetyl-cysteine. This research is in its infancy, with insufficient evidence to support the clinical use of these medications. More trials are also needed to determine if the opioid antagonist, naltrexone, is useful in treating stimulant problems table 3. Imprisonment is an added risk for people who use stimulants in most countries. Far too often people with stimulant problems are detained in prisons, or, in some Asian countries, in compulsory drug detention centres. Major infringements of human rights occur within these settings; the number of relapses and reincarcerations are very high after release. Prisons and jails increase risky injecting behaviours and blood borne virus exposure in people who use stimulants. Drug courts are often seen as an alternative to prison and a bridge between the criminal justice and the health-care systems. Drug court evaluations might reduce the number of reimprisonments, but studies are often confounded by participant selection bias. Well established, effective interventions exist to reduce blood borne viruses and sexually transmitted infections in people who use drugs generally rather than in people who use stimulants specifically although globally a third of people who use stimulants primarily administer the drugs through an injection. Effective approaches include the provision of sterile injecting equipment through needle and syringe programmes, which reduces injecting risk, 89 , 90 HIV, 91 and potentially HCV transmission; 40 provision of materials for safer inhalation of drugs, which might reduce injecting risk behaviour; 95 , 96 and professionally supervised drug consumption rooms. We examined the potential effect of needle and syringe programmes on HIV and HCV infection in people who inject stimulants panel 1 , finding needle and syringe programmes could ameliorate, but not eliminate, excess injecting-related HIV and HCV transmission in this group. Our results were consistent with empirical findings of insufficient needle and syringe programme coverage for people who inject drugs transitioning to stimulant methamphetamine injection. Provision of condoms 85 and pre-exposure prophylaxis PrEP for both HIV and sexually transmitted infections reduce sexual risk behaviours, and the transmission of HIV, HCV, and sexually transmitted infections in people who inject drugs and MSM, rather than specifically in people who use stimulants table 4. Condoms and treatment for infectious diseases will probably prevent blood borne viruses and sexually transmitted infections in people who use stimulants, but who do not inject them as these interventions do in the general population. However, there is a poor understanding of blood borne virus and sexually transmitted infection risk in this context eg, via pipe sharing and sexual risk behaviour , and of the effectiveness of interventions to mitigate these risks. Our modelling of people from Lima panel 2 indicates that prioritising HIV PrEP in MSM and trans women who use stimulants could enhance PrEP prioritisation that is based on sexual behaviour only, or sexual orientation and gender identity. The addition of stimulant use as a criterion guiding PrEP prescription or implementing substance use campaigns might be warranted in MSM and trans women, as has occurred in some settings in Australia and the USA. Developing effective responses around comorbid mental health issues is essential because of the high prevalence of the comorbidity and the strong associations between stimulant use and mental health problems. Multiple effective interventions are available appendix p The use of the interventions is complicated in people who use stimulants because mental health problems can be both premorbid and induced or exacerbated by stimulant use. The implementation and evaluation of the interventions is an essential area for further research because very few mental health interventions have been evaluated in people with stimulant dependence. Acute psychoses can be treated effectively with antipsychotics, but there is only a small amount of evidence regarding the effectiveness of antipsychotics in managing acute stimulant psychosis. These patients are often excluded from mainstream services for psychotic disorders because of their comorbid stimulant dependence. Managing agitation and violence in stimulant-induced psychoses is a substantial challenge for frontline emergency medical and police services. This risk of violent behaviour has an immediate, but unquantified adverse effect on family and peers. More research is needed on the effectiveness of protocols to reduce agitation related to stimulant intoxication and to manage violence risk more generally. Therefore, treatment needs to be delivered in ways to reduce the risk of violent behaviour. Evidence-based strategies to reduce depression include psychological therapies cognitive behavioural therapy, contingency management, acceptance and commitment therapy, and meditation-based therapies; appendix p Cognitive behavioural therapy can also reduce suicide risk in people who use drugs and it is effective for depression. Harm reduction approaches to reducing risky stimulant use and the harms of acute intoxication are not well evaluated table 4. Common strategies include providing information and education about avoiding rapid-onset routes of administration such as smoking and injecting , limiting the quantity and frequency of stimulant use, identifying early signs of stimulant psychosis eg, illusions and persecutory ideation , general advice on risk assessment eg, drug driving , and tips on general health eg, sleep hygiene, diet, and dental health. Overdose prevention approaches to stimulants emphasise awareness of drug strength and avoiding high-dose toxicity complications, such as seizures, by reducing dose. No substantial attention has been given to reducing accidents and injuries, nor to reducing cardiovascular risk in this population appendix p Responses to the growing global problems related to the illicit use of stimulants have often been modelled on services for problem opioid use. These provide a poor basis for responding to stimulants whose consumers can be difficult to engage and when many services are not equipped to manage acute stimulant problems. The development of evidence-based forms of care is urgently needed. The absence of an effective policy response to the scale and severity of harms related to stimulant use, combined with the fear and stigmatisation of so-called problem users, has restricted the allocation of resources to reduce stimulant-related harms. Insufficient long-term investment into the development and implementation of evidence-based treatment strategies have been made, with an over-reliance on law enforcement. Globally, and particularly in the Asia-Pacific region, policy has been dominated by incarceration, with an estimated people detained in compulsory drug detention centres in which major infringements of human rights occur. A key challenge for policy is the absence of readily implementable effective interventions to reduce long-term stimulant use and dependence. Contingency management is the only treatment with robust evidence of effectiveness, but it has not been widely implemented. A need exists to identify and remove barriers to using this approach and assessing its acceptability and effectiveness in clinical settings. Effective pharmacotherapies are needed. Trials designed to overcome high attrition and poor adherence are needed to develop a better evidence base. Study inclusion criteria need to be more pragmatic and researchers should engage with people who use stimulants to ensure that trial methods are feasible and outcome measures are relevant and realistic. Replacement psychostimulant therapies have a small benefit in treating cocaine dependence, but the quality of evidence for this approach is very low so substantial caution is warranted before its widespread application. Most people who use stimulants have little contact with treatment services, and these services do not always provide respectful, tailored, and specific treatment panel 3. Major barriers to seeking help include stigma, low perceived need to reduce use, self-medication of poor mental health, and concerns about confidentiality. The design of treatment and other health services should respond to the needs and experiences of people who use stimulant drugs eg, by being available in acute care settings where people who use stimulants are over-represented. These perspectives were submitted in response to an email, circulated between March and June on our behalf by researchers and peer-based organisations, inviting input from people from various regions of the world with lived experience of using drugs. Crystal \[meth\] helps me to re-energise, to feel freer, and able to speak without fear. We are just like them, we deserve the same respect. There were always Speed Heads, but with the sheer amount of product coming onto the market I guess… \[the\] scene has changed. Right now it is stronger. It changes colour; white, yellow, dark grey. Drug treatment facilities are notoriously difficult to access, huge burden of bureaucracy, usually create huge barriers to access services. Rehabilitation services are hardly comprehensive and many adhere to the tired, old abstinence dogma and a just say no mantra. The gaps in services are massive. There is no support, no understanding of what we need to get back to society. Effective ways to reduce some of the harms of heavy or dependent stimulant use, such as psychosis, depression, suicide, and blood borne virus risks, do exist. Effective ways for mainstream approaches to mitigate stimulant-related harms are urgently needed. A greater focus on the prevention and treatment of these harms might improve the overall outcome for stimulant problems. In these populations, needle and syringe programmes, HIV antiretroviral treatment and PrEP, HCV treatment, and mental health care are needed to reduce the full range of harms. This integrated strategy is well suited for people who use stimulants because they can often require interventions from a range of specialties, such as behavioural science, infectious diseases, primary care, psychiatry, and social work. A community approach requires a broader ambulatory care system of services that provide screening, early intervention, primary care, community interventions, criminal justice programmes to divert people into treatment, and prison-based treatment programmes. Community-based day programmes are essential before and after residential treatment to maximise residential treatment capacity and effectiveness. Overall, service users derive benefits from residential treatment, but its effects are often hard to sustain over time. Engagement with people who use stimulants needs to be improved including people who inject drugs to deliver effective harm reduction interventions. More innovative approaches and evaluations are needed to produce better ways for justice and health services to work together. These approaches need the strong engagement of people who use drugs, family, and community engagement if they are to be sustainable. This Series paper has focused on stimulants; many people who take stimulants use multiple substances, including alcohol. An overlap exists between people who use opioids and those who use stimulants, particularly in people who inject drugs. We need to better understand how stimulant use administered through injection and non-injection pathways in combination with opioid use affects the risk of transmitting blood borne viruses eg, pipe sharing and skin picking , sexually transmitted infections eg, increased libido , and endocarditis. Heavy concurrent cannabis use might increase the risk of mental health harms, particularly psychosis, and concurrent use of stimulants with sedatives might alter the effects of intoxication and increase risks of injury or violence. Research investment needs to be strategically focused on developing cost-effective interventions that can be delivered to scale and in a sustainable way within a community health-care and social-care system. Access and delivery of psychosocial interventions at every stage of the evolution of stimulant drug use needs to be broadened. Existing clinical interventions focus on the importance of self-help and family support. Broader community-based intervention approaches that incorporate primary care and other opportunities for early intervention and that engage communities, peers, families, and other key stakeholders need to be adopted. The views expressed in this publication do not necessarily represent the position of the Australian Government. MF and LD have received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior, Mundipharma, and Seqirus. NKM has received unrestricted research grants to her university from Gilead and Merck unrelated to this work. JR has received educational grants from Lundbeck GmbH. SS has received clinical supplies from Alkermes and Medicinova for randomised trials outside of the submitted work. As a library, NLM provides access to scientific literature. Author manuscript; available in PMC Nov 2. PMC Copyright notice. The publisher's final edited version of this article is available at Lancet. This article has been corrected. See Lancet. Associated Data Supplementary Materials Appendix. Abstract We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Background Stimulant drugs are used globally to produce euphoria, increase confidence, sociability, energy, and wakefulness, and reduce hunger. Medicinal uses of stimulants Cocaine and amphetamine have potential medicinal uses. Epidemiology of extramedical stimulant use and dependence Substantial variations exist in the global distribution and use of illicitly produced cocaine and amphetamines. Prevalence of extramedical cocaine and amphetamine use Cocaine and amphetamines are two of the most widely used illicit drugs worldwide. Open in a separate window. Figure Prevalence of A cocaine 6 and B amphetamine 6 use and estimated age-standardised prevalence of C cocaine 8 and D amphetamine 8 dependence per population Drug use data from the UN Office on Drugs and Crime World Drug Report Prevalence of cocaine and amphetamine dependence Dependence on the use of stimulants is a major problem for public health. Polydrug use People who use stimulants typically use a range of drug types. Table 1: Summary of causes of mortality summarised across cohorts of people with regular or problematic amphetamine or cocaine use. For details of the search strategies used see appendix p Fraction of regional all-cause deaths associated with cocaine and amphetamine dependence in For methods used to generate these estimates see appendix p Non-fatal harms We assessed the reviews of evidence on the effect of stimulant use on non-fatal health harms table 2 , separately for amphetamines and cocaine appendix p Table 2: Evidence for potential causal impacts of amphetamine and cocaine use on a range of non-fatal health harms. Modelling the effect of stimulant use on non-fatal harms Given the higher prevalence of stimulant use and associated harms in people who inject drugs 54 and MSM, we undertook mathematical modelling to quantify select health harms associated with stimulant use in these populations. Interventions to address stimulant use and related harms The interventions designed to reduce stimulant use table 3 and the interventions to reduce harms associated with stimulant use table 4 have varying effects appendix p Table 3: Summary of the evidence of interventions to reduce stimulant use. Table 4: Summary of the evidence of interventions to reduce stimulant related harms. Psychosocial treatment to reduce stimulant use The current standard of care for stimulant dependence is primarily psychosocial interventions combined with case management. Pharmacotherapy and medication to reduce stimulant use No medications have been approved to treat either cocaine or amphetamine or methamphetamine dependence, whether in managing withdrawal, maintaining abstinence, or preventing relapse table 4. Incarceration, compulsory detention, and law enforcement responses Imprisonment is an added risk for people who use stimulants in most countries. Prevention and treatment of blood borne viruses and sexually transmitted infections Well established, effective interventions exist to reduce blood borne viruses and sexually transmitted infections in people who use drugs generally rather than in people who use stimulants specifically although globally a third of people who use stimulants primarily administer the drugs through an injection. Interventions to improve the mental health of people who use stimulants Developing effective responses around comorbid mental health issues is essential because of the high prevalence of the comorbidity and the strong associations between stimulant use and mental health problems. Interventions to prevent and treat overdose, injuries, and other harms Harm reduction approaches to reducing risky stimulant use and the harms of acute intoxication are not well evaluated table 4. Challenges and future considerations Responses to the growing global problems related to the illicit use of stimulants have often been modelled on services for problem opioid use. Panel 3: Perspectives of people who use stimulants. What is one thing you would like people to know about people who use drugs? What changes have you seen in the types of drugs people are using and how they are using them? What are the current gaps in the availability, quality, and suitability of drug treatment services, health services, and harm reduction services for people who use drugs? How can people who use drugs and other stakeholders work together to improve health and harm reduction for people who use drugs? Problems arising from stimulant use continue to grow globally, presenting major challenges to health and justice services in many parts of the world. These problems require sustained and comprehensive strategies to reduce mortality and non-fatal harms poor mental health, violence, injury, sexually transmitted infection and blood borne virus risk, and harm to the fetus. People who use stimulants have a six times higher risk of mortality, accounting for approximately excess deaths associated with amphetamine dependence and associated with cocaine dependence in Comprehensive harm reduction approaches are needed to reduce these risks. The risks for suicide, psychosis, depression, and violence are significantly elevated. Evidence-based approaches for these mental health harms need to be tailored to, and effectively delivered to, people who use stimulants. Psychosocial interventions other than contingency management have weak and non-specific effects on stimulant problems and there are no effective pharmacotherapies. Substantial research investment is needed to develop more effective, innovative, and impactful prevention and treatment. The acute disruption caused by the more severe problems associated with stimulant use produces fear and stigma in the community, hindering access to health care for people who use stimulants and reducing capacity to deliver structured and effective responses. Many governments rely on punitive responses, such as involuntary detention in drug centres, despite the absence of evidence for their effectiveness and their potential to increase harm. Supplementary Material Appendix Click here to view. Footnotes Declaration of interests MF and LD have received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior, Mundipharma, and Seqirus. References 1. New psychoactive substances: challenges for drug surveillance, control, and public health responses. 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