What is the recommended treatment for stimulant use disorder?

Recommended Treatment for Stimulant Use Disorder

Contingency Management (CM) combined with Community Reinforcement Approach (CRA) is the most effective treatment for stimulant use disorder, requiring only 4 patients to be treated for 1 additional patient to achieve abstinence compared to usual care. 1, 2

First-Line Treatment: Behavioral Interventions

Contingency Management as Standard of Care

• CM represents the current standard of care for stimulant use disorder treatment, providing positive reinforcement for target behaviors indicating treatment progress 1, 3
• CM+CRA shows the highest efficacy among all behavioral interventions, with superior outcomes for morbidity, mortality, and quality of life 1, 2, 4
• CM alone or combined with CBT demonstrates superior efficacy compared to treatment as usual 2, 5
• Psychosocial treatments reduce dropout rates significantly (RR 0.82,95% CI 0.74-0.91), which is critical since many patients leave treatment prematurely 6
• These interventions increase continuous abstinence at end of treatment (RR 1.89,95% CI 1.20-2.97) and reduce frequency of drug intake (SMD -0.35,95% CI -0.50 to -0.19) 6

Cognitive Behavioral Therapy as Alternative

• CBT is recommended as an alternative when CM+CRA is not available, though it shows less efficacy 1, 2, 4
• When combined with pharmacotherapy, CBT should be favored over usual care to improve clinical outcomes 7
• Brief and extended motivational interviewing, skills training, and problem-solving approaches can be effective treatment components 4

Pharmacotherapy Considerations

Current Evidence Status

• No FDA-approved pharmacotherapy currently exists for stimulant use disorder 8, 3
• Pharmacotherapies may be utilized off-label to treat stimulant use disorders, but evidence remains insufficient to support routine use 5, 3
• The lack of FDA-approved medications is particularly problematic for cocaine/stimulant use disorder, contributing to variability in treatment outcomes 7

Specific Clinical Scenarios Requiring Pharmacotherapy

For co-occurring opioid and stimulant use disorders:

• Medications for opioid use disorder should be initiated without delay 1, 2
• Do not withhold opioid agonist therapy due to concurrent stimulant use 1

For co-occurring ADHD:

• Non-stimulants like atomoxetine, clonidine, or guanfacine should be considered as first-line treatment options 1
• Avoid stimulant medications that could trigger relapse in patients with active stimulant use disorder 1

For co-occurring anxiety or Tourette's syndrome:

• Non-stimulant medications are preferred over stimulant-based treatments 1

Harm Reduction Services

Essential Components

• All patients reporting stimulant use should be offered harm reduction services including: 1, 2, 4
  • Naloxone dispensation (given high rates of fentanyl contamination)
  • Safe use education
  • Fentanyl test strips
  • Referral to syringe services programs

Service Delivery Innovations

• Implement extended hours, mobile clinics, walk-in options, telehealth, and peer support to improve retention in care 1, 4
• Regular contact through telephone, home visits, or brief interventions maintains treatment engagement 4
• Early intervention is likely to have increased benefits, although intervention is recommended at any stage 4

Assessment Requirements

Comprehensive Evaluation

• Evaluate pattern, duration, and severity of stimulant use, including symptoms of dopamine depletion 1
• Screen for co-occurring mental health conditions, as stimulant use disorders frequently co-occur with other psychiatric disorders 1, 2, 4
• Assess for medical complications, particularly cardiovascular issues (coronary artery spasm, tachycardia, hypertension) 1, 2
• Assessment and feedback alone have been shown to positively influence reduction of substance use 4

Suicide Risk Assessment

• All patients with stimulant use disorder should be asked about thoughts, plans, or acts of self-harm 7
• Restrict access to means of self-harm when individuals present with suicidal ideation 4

Management of Acute Complications

Stimulant Withdrawal

• Presents with fatigue, depression, and intense cravings requiring supportive care and monitoring 1
• Provide appropriate level of care for life-threatening complications of acute stimulant intoxication 3

Cocaine-Associated Chest Pain

• Benzodiazepines are first-line treatment 2
• Nitroglycerin can relieve chest pain and reverse cocaine-associated vasoconstriction 2
• Avoid beta-blockers as they worsen coronary vasoconstriction through unopposed α-adrenergic stimulation 1, 2, 4
• Calcium channel blockers should not be used as first-line but may be considered for non-responders 2

Critical Pitfalls to Avoid

• Do not rely solely on drug testing without clinical context, as standard tests may detect substances not causing observed symptoms 1, 4
• Do not use selective β1-blockers in patients who may continue cocaine use due to risk of unopposed α-adrenergic stimulation 1, 2, 4
• Do not fail to recognize that stimulant use disorders frequently co-occur with other substance use and mental health disorders requiring integrated treatment 1, 2, 4
• Do not focus solely on abstinence rather than harm reduction approaches, as retention in treatment reduces risks even without complete abstinence 2, 6
• Do not perpetuate stigmatizing behaviors, as stigma remains a significant barrier to treatment engagement 4