What medications are effective for treating methamphetamine (meth) use disorder?

Medications for Methamphetamine Use Disorder

Contingency management is currently the most effective intervention for methamphetamine use disorder, as there are no FDA-approved pharmacotherapies specifically for this condition. 1

Current Treatment Landscape

First-line Approach

• Behavioral interventions should be the primary treatment approach:
  • Contingency management (CM) - providing incentives like gift cards or cash for periods of abstinence has shown the strongest evidence for effectiveness 1, 2
  • Cognitive behavioral therapy (CBT) - particularly when tailored to methamphetamine users, either alone or combined with CM 3

Pharmacological Options

Despite extensive research, no medications have FDA approval specifically for methamphetamine use disorder. However, some medications show limited evidence of benefit:

1. Methylphenidate:

   • Low-strength evidence suggests it may reduce methamphetamine use
   • One study showed 6.5% vs 2.8% methamphetamine-negative urine drug screens (UDS) (n=34)
   • Another showed 23% vs 16% negative UDS (n=54) 4

2. Mirtazapine:

   • May be effective in specific subgroups of methamphetamine users
   • More research needed to identify which patients respond best 5

3. Naltrexone:

   • While primarily used for alcohol and opioid use disorders, may help reduce cravings in some methamphetamine users
   • Standard dosing: 50mg daily oral or 380mg monthly injectable 6
   • Not specifically FDA-approved for methamphetamine use disorder 1

Treatment Algorithm

1. Assessment:

   • Determine severity of methamphetamine use (light vs. heavy use)
   • Screen for polysubstance use, particularly alcohol, benzodiazepines, and opioids
   • Assess for co-occurring psychiatric conditions

2. Prioritize treatment:

   • Address life-threatening withdrawal first (alcohol, benzodiazepines)
   • Then address opioid dependence if present
   • Finally address methamphetamine use 6

3. Implement behavioral interventions:

   • Initiate contingency management program
   • Combine with structured CBT
   • Consider residential treatment for severe cases

4. Consider adjunctive pharmacotherapy:

   • For patients not responding to behavioral interventions alone:
     • Trial of methylphenidate may be considered (off-label)
     • Consider mirtazapine for specific subgroups, particularly those with depression
     • Monitor treatment response at 12 weeks

5. Harm reduction:

   • Provide education on safer use practices
   • Screen for HIV and hepatitis C
   • Offer syringe service programs if applicable 1

Monitoring and Follow-up

• Regular urine drug screening to objectively measure abstinence
• Monitor for psychiatric symptoms, particularly psychosis or depression
• Assess medication compliance and early treatment response as predictors of success 5
• Continue behavioral interventions even if pharmacotherapy is unsuccessful

Important Considerations

• Patient subgroups: Light and heavy methamphetamine users respond differently to pharmacotherapy 5
• Comorbidities: Address co-occurring psychiatric conditions
• Polysubstance use: Many methamphetamine users also use other substances requiring concurrent treatment
• Long-term outcomes: Even with treatment, relapse rates are high, requiring ongoing support

Common Pitfalls

• Expecting medication alone to be effective: Unlike opioid use disorder, methamphetamine use disorder lacks highly effective pharmacotherapy
• Overlooking behavioral interventions: Contingency management shows the strongest evidence but is often underutilized
• Inadequate duration: Treatment often requires extended engagement
• Failing to address social determinants: Housing instability, unemployment, and legal issues can undermine treatment success

While research continues to identify more effective pharmacotherapies, the current evidence supports a treatment approach centered on behavioral interventions, particularly contingency management, with consideration of methylphenidate or mirtazapine as adjunctive treatments in specific cases.