What is the best treatment approach for a patient with opioid use disorder and methamphetamine use, currently on methadone (MOUD) and experiencing triggers for relapse?

Treatment for Opioid Use Disorder with Concurrent Methamphetamine Use

MOUD and behavioral therapy consisting of contingency management (CM) is the best recommendation for this patient with opioid use disorder and concurrent methamphetamine use who is experiencing triggers for relapse despite methadone treatment.

Rationale for Recommendation

The patient presents with a complex clinical picture:

• 10-year history of opioid use, now using illicitly manufactured fentanyl (IMF)
• Currently on methadone but experiencing multiple relapses
• Daily methamphetamine use (0.5-1g smoked daily)
• Self-identifies methamphetamine use as a trigger for opioid relapse

Evidence for Medication for Opioid Use Disorder (MOUD)

Continuing MOUD is essential as:

• The CDC recommends MOUD (methadone or buprenorphine) as the gold standard for treating opioid use disorder 1
• Methadone maintenance therapy is associated with the strongest evidence for effectiveness in preventing relapse among patients with opioid use disorder 2
• Discontinuing MOUD carries a high risk of relapse to illicit drug use 3
• Recent evidence shows methadone remains effective at reducing illicit opioid use even in the era of fentanyl 4

Evidence for Adding Contingency Management

For the concurrent methamphetamine use:

• There are no FDA-approved medications for methamphetamine use disorder 1
• Contingency management has demonstrated incremental value in abstinence rates beyond MOUD alone 5
• Among behavioral interventions, contingency management shows the strongest evidence for addressing stimulant use in patients on MOUD 5, 1
• Recent data shows that methamphetamine use remains persistent in MOUD patients (average 17.7% positivity over 52 weeks) without additional interventions 4

Treatment Algorithm

1. Continue methadone maintenance:

   • Ensure adequate dosing (80-120 mg/day is typically needed for clinical stability) 3
   • Monitor for withdrawal symptoms and cravings
   • Adjust dose as needed to prevent opioid symptoms for 24 hours and reduce drug cravings 3

2. Add contingency management (CM):

   • Implement a structured incentive program where the patient receives tangible rewards for:
     • Negative urine drug screens for methamphetamine
     • Attendance at treatment sessions
     • Meeting treatment goals
   • Gradually increase reward value for consecutive negative tests
   • Restart reward schedule (but don't eliminate) if positive test occurs

3. Consider cognitive-behavioral therapy (CBT) as an adjunct:

   • While CM shows stronger evidence for stimulant use, CBT can help address underlying thought patterns 5
   • Combined pharmacotherapy and CBT has shown better outcomes than either alone 5

Implementation Considerations

• Frequency of monitoring: Initially more frequent (2-3 times weekly) urine drug testing to provide opportunities for reinforcement
• Duration: CM programs typically run 12 weeks or longer 6
• Incentive structure: Start with small rewards that increase with consecutive negative tests
• Addressing barriers: Identify and address practical barriers to attending treatment sessions

Potential Pitfalls and Caveats

1. Resource limitations: CM implementation requires financial resources for incentives and staff training 5

2. Polysubstance use complexity: The patient is using both opioids and methamphetamine, which complicates treatment:

   • Methamphetamine use may persist even when opioid use decreases 4
   • Methamphetamine use is associated with poorer MOUD retention 4

3. Relapse risk: Given this is the patient's fourth readmission in two years, relapse prevention strategies must be emphasized:

   • Provide naloxone for overdose prevention 1
   • Develop specific plans for high-risk situations
   • Establish strong recovery support network

4. Medication interactions: Monitor for potential interactions between methadone and any other medications the patient may be taking 3

By combining continued methadone maintenance with contingency management, this approach directly addresses both the opioid use disorder and the methamphetamine use that the patient identifies as a trigger for relapse, offering the best chance for improved outcomes in this challenging clinical scenario.