The absence of an approved medication treatment for stimulant dependence has intensified the effort to identify existing drugs or drug combinations that could help reduce craving and improve treatment engagement. But history reminds that hype often gets ahead of scientific evidence, which is why a leading researcher would advise caution about the latest potential off-label treatment to have gained attention.
An Indianapolis physician's experience in prescribing the combination of the stimulant modafinil (Provigil) and the antidepressant bupropion (Wellbutrin) to patients with methamphetamine addiction garnered local news coverage that later was shared on social media by a policy adviser with the Office of National Drug Control Policy (ONDCP). Addiction Professional asked Craig R. Rush, PhD, university research professor at the University of Kentucky, for his thoughts, and he pointed out first that according to the media reports, only around 20 patients in the Miller Care Group are currently using the Provigil-Wellbutrin combination.
“While I am certainly an advocate of combining medications, I think the enthusiasm is premature,” says Rush, who has studied numerous aspects of stimulant addiction and spoke on the medication landscape for its treatment at the first Cocaine, Meth & Stimulant Summit in 2018.
The director of the Miller Care Group, Michael Miller, MD, has said that patients in his practice are experiencing a boost in motivation with the Provigil-Wellbutrin combination, which he offers in conjunction with counseling.
A previous attempt
In the late 2000s, there was a sense of excitement, particularly in the drug court arena, over the PROMETA medication protocol that comprised flumenazil, gabapentin and hydroxazine. Initial research efforts, such as a pilot study with offenders in Pierce County, Wash., suggested that the combination promoted abstinence from methamphetamine use. But national reports stating that government officials had invested in the developer of the protocol, including a “60 Minutes” investigation, raised skepticism.
By the early 2010s, interest in the PROMETA combination had waned, following a 120-patient study published in Addiction in 2011 that concluded it was no more effective than placebo in reducing meth craving or use, or in retaining patients in treatment.
Rush says he has not to this point given great thought to the most recent drug combination to be receiving some attention. “I guess my overarching point is that we need to take a deep breath and let science guide clinical decisions,” he says.