What are the guidelines for screening and treating stimulant use disorders, including laboratory testing and pharmacological interventions?

Guidelines for Screening and Treatment of Stimulant Use Disorders

Contingency management combined with community reinforcement approach is the most effective treatment for stimulant use disorders, showing superior efficacy for improving morbidity, mortality, and quality of life outcomes. 1, 2

Screening Approaches

• Drug testing is not recommended as a general screening procedure for stimulant use in unselected populations due to low sensitivity 3
• The 2-item Screen of Drug Use (SoDU) is highly effective for detecting stimulant use disorders with 93.67% sensitivity and 89.12% specificity, making it appropriate for routine screening in primary care settings 4
• Adding a follow-up question to the SoDU maintains sensitivity while improving specificity to 99%, significantly reducing false positives 4
• Integration of substance use disorder screening into routine care is recommended, particularly for high-risk populations 3
• False-positive urine immunoassay screening tests for amphetamines can occur in patients taking bupropion, requiring confirmatory testing such as gas chromatography/mass spectrometry 5

Assessment Components

• Evaluate the pattern, duration, and severity of stimulant use, including symptoms of dopamine depletion (fatigue, anhedonia, depression, craving) 1, 6
• Screen for co-occurring mental health conditions that may complicate treatment 1, 6
• Assess for medical complications of stimulant use, particularly cardiovascular issues, as stimulants can cause coronary artery spasm, tachycardia, and increased blood pressure 6, 7
• Consider the risk of medical and neurological emergencies such as rhabdomyolysis and stroke, which are significantly elevated even in younger stimulant users 7

Treatment Approaches

Psychosocial Interventions (First-Line)

• Contingency Management (CM) plus Community Reinforcement Approach (CRA) is the most effective treatment combination for stimulant use disorders 1, 6, 2
  • CM provides rewards (e.g., cash, gift cards) for drug-free urine samples
  • CRA involves functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements
• Cognitive Behavioral Therapy (CBT) is recommended as an alternative when CM+CRA is not available, though it shows less efficacy 1, 6, 2
• Continue psychosocial support even after acute withdrawal phase and monitor for signs of relapse 1

Pharmacological Interventions

• Currently, no medications are FDA-approved specifically for stimulant use disorders 2, 8
• For patients with co-occurring conditions:
  • In acute stimulant intoxication with agitation, benzodiazepines or antipsychotics can effectively manage symptoms in 70-90% of cases 7
  • For stimulant-induced psychosis, antipsychotic medications may be necessary 8
  • When treating patients with both opioid and stimulant use disorders, medications for opioid use disorder should be initiated without delay 3

Harm Reduction

• Harm reduction services should be offered to all who report stimulant use, including naloxone dispensation, safe use education, fentanyl test strips, and referral to syringe services 3
• Innovative service delivery options should be considered to improve retention in care, including extended hours, mobile clinics, walk-in options, telehealth, and peer support 3

Special Considerations

• Patients taking bupropion may have false-positive urine tests for amphetamines, requiring confirmatory testing 5
• For patients with co-occurring ADHD, specialized treatment approaches are needed to balance addressing underlying ADHD while avoiding stimulant medications that could trigger relapse 1
• Stimulant withdrawal can present with fatigue, depression, and intense cravings, requiring supportive care and monitoring 1, 7
• Stimulant epidemics tend to follow patterns, and prevention/intervention strategies should be tailored to the current phase of the epidemic 9

Common Pitfalls to Avoid

• Relying solely on drug testing without clinical context can lead to misdiagnosis, as standard laboratory tests may detect substances present but not causing observed symptoms 3
• Overlooking cardiovascular complications of stimulant use, which can occur even with small amounts 6, 7
• Failing to recognize that stimulant use disorders frequently co-occur with other substance use and mental health disorders, requiring integrated treatment approaches 3, 6
• Using selective β1-blockers in patients who may continue to use cocaine, which can lead to unopposed α-adrenergic stimulation 6