Pharmacological Treatment of Stimulant Use Disorder
Direct Answer
There are currently no FDA-approved pharmacological treatments for stimulant use disorder, and psychosocial interventions—specifically contingency management combined with community reinforcement approach—remain the most effective evidence-based treatment. 1, 2
Current State of Pharmacological Evidence
No Approved Medications
- No medications have received FDA or European Medicines Agency approval for treating methamphetamine, amphetamine, or cocaine use disorder 3
- The evidence base for pharmacological interventions remains insufficient, inconsistent, and limited by heterogeneous study populations 4, 3
Medications with Insufficient Evidence
The following have been studied but lack sufficient evidence to support clinical use:
- Psychostimulants (methylphenidate): Low-strength evidence suggests potential benefit (6.5% vs 2.8% negative urine drug screens in one small trial, n=34), but this is insufficient for clinical recommendation 3
- Antidepressants: Moderate-strength evidence shows no statistically significant effect on abstinence or treatment retention 3
- N-Acetylcysteine: Insufficient evidence to support or discount use 2
- Opioid agonist therapy: Insufficient evidence to support or discount use 2
- Disulfiram: Insufficient evidence to support or discount use 2
- Antipsychotics (aripiprazole): Low-strength or insufficient evidence of no effect 3
- Anticonvulsants: Low-strength or insufficient evidence of no effect 3
- Naltrexone: Low-strength or insufficient evidence of no effect 3
- Varenicline and atomoxetine: Low-strength or insufficient evidence of no effect 3
Recommended Treatment Approach
First-Line: Psychosocial Interventions
Contingency management combined with community reinforcement approach is the most effective treatment for stimulant use disorder, showing superior efficacy for improving morbidity, mortality, and quality of life outcomes. 1
- This combination demonstrates the highest efficacy for both short-term and long-term treatment outcomes 5
- Contingency management alone has high-certainty evidence for reducing dropout rates (RR 0.82,95% CI 0.74-0.91) and increasing continuous abstinence at end of treatment (RR 1.89,95% CI 1.20-2.97) 6
- Cognitive behavioral therapy serves as an alternative when contingency management is unavailable, though with less efficacy 1
Harm Reduction Services
- Naloxone dispensation, safe use education, fentanyl test strips, and referral to syringe services should be offered to all patients with stimulant use 1
- Extended hours, mobile clinics, walk-in options, telehealth, and peer support improve retention in care 1
Special Clinical Situations
Co-occurring Opioid Use Disorder
- Initiate medications for opioid use disorder (methadone or buprenorphine) without delay 1
- Do not withhold opioid agonist therapy while waiting for stimulant use to cease 1
Co-occurring ADHD and Stimulant Use Disorder
Non-stimulant medications should be used as first-line treatment for ADHD when comorbid stimulant use disorder is present. 1
- Atomoxetine (norepinephrine reuptake inhibitor): Provides "around-the-clock" effects, is an uncontrolled substance, and is specifically recommended as a first-line option for comorbid substance use disorders 5, 1
- Alpha-2 agonists (clonidine or guanfacine): Also recommended as first-line options for comorbid substance use disorders, providing continuous coverage without abuse potential 5, 1
- Avoid prescribing stimulant medications (methylphenidate, amphetamines) in active stimulant use disorder due to relapse risk 1
Cardiovascular Complications
- Avoid selective β1-blockers in patients who may continue cocaine use, as this can lead to unopposed α-adrenergic stimulation causing coronary vasoconstriction 1
- Screen for cardiovascular complications including coronary artery spasm, tachycardia, and hypertension 1
Critical Pitfalls to Avoid
Assessment Errors
- Do not rely solely on drug testing without clinical context—standard tests detect presence but not causation of symptoms 1
- Always screen for co-occurring mental health disorders (depression, anxiety, psychosis) and other substance use disorders, as these frequently co-occur and require integrated treatment 1, 4
Treatment Errors
- Do not prescribe stimulant medications for ADHD in patients with active stimulant use disorder 1
- Do not use β-blockers for cardiovascular symptoms in active cocaine users 1
- Do not delay treatment for co-occurring opioid use disorder while addressing stimulant use 1