Is buprenorphine (Suboxone) effective in treating methamphetamine use disorder?

Buprenorphine for Methamphetamine Use Disorder

Buprenorphine is NOT FDA-approved for methamphetamine use disorder and current guidelines do not recommend it as a standard treatment, though emerging research suggests it may reduce methamphetamine craving and use in select patients. 1

Current Evidence Status

Guideline Position

• No FDA-approved pharmacotherapies exist for methamphetamine use disorder, unlike opioid use disorder where buprenorphine has established efficacy 1
• Guidelines specifically address buprenorphine only for opioid use disorder treatment, with documented 80% reduction in illicit opioid use when properly prescribed 1
• The CDC and American College of Physicians recommend buprenorphine combined with behavioral therapies exclusively for opioid use disorder, not stimulant use disorders 1, 2

Emerging Research Findings

For patients with methamphetamine use:

• A 2021 randomized controlled trial showed buprenorphine as add-on to Matrix program significantly reduced methamphetamine craving (measured by CCQ-Brief scores) compared to placebo over 8 weeks 3
• The same study demonstrated significant reductions in anxiety, depression, and stress scores in the buprenorphine group 3
• A 2023 retrospective cohort study of long-acting injectable buprenorphine found that 70% of active methamphetamine users reduced or ceased use at 6 months, while all past users remained abstinent 4

Critical caveat for co-occurring opioid use disorder:

• Patients with baseline methamphetamine use who initiate buprenorphine for opioid use disorder show 54% increased risk of continued illicit opioid use (aRR=1.54) compared to those without methamphetamine use 5
• Methamphetamine co-use is associated with 3.86 times higher risk of self-reported illicit opioid use at 12 weeks 5
• However, methamphetamine use did not affect buprenorphine retention rates or treatment adherence 5

Clinical Decision Algorithm

When to Consider (Off-Label)

Only consider buprenorphine for methamphetamine use disorder in these specific scenarios:

• Patient has co-occurring opioid use disorder requiring medication-assisted treatment 6
• Patient has failed behavioral interventions (Matrix program) alone and has severe, refractory methamphetamine craving 3
• Patient can be closely monitored in a structured treatment program with behavioral therapy 3

When NOT to Use

• Do not use buprenorphine as monotherapy for methamphetamine use disorder without behavioral interventions 3
• Do not prescribe for isolated methamphetamine use disorder without co-occurring opioid use disorder, as this remains investigational 1
• Avoid in patients who cannot commit to integrated behavioral treatment programs 2

Implementation Protocol (If Pursuing Off-Label)

Stabilization requirements:

• Ensure patient is stabilized on 8-24 mg daily sublingual/buccal buprenorphine for minimum 7 consecutive days before considering long-acting formulations 2, 7
• Verify buprenorphine tolerance to minimize precipitated withdrawal risk 2

Dosing approach from research:

• Sublingual buprenorphine was used in the positive trial showing craving reduction 3
• Long-acting injectable buprenorphine (300 mg monthly × 2 doses, then 100 mg monthly maintenance) showed promise in the retrospective study 4

Mandatory concurrent treatment:

• Must combine with Matrix program or equivalent behavioral therapy - this was the protocol in the positive trial 3
• Weekly monitoring during first 8 weeks with craving assessments 3
• Monthly follow-up for at least 4-6 months 3, 4

Critical Warnings

Provider requirements:

• Physicians must have SAMHSA waiver certification to prescribe buprenorphine, requiring 8-hour training course 1
• Initial patient cap of 30 patients in year 1, expandable to 100 in year 2 (or 275 with additional qualifications) 1

Drug interactions:

• Contraindicated with QT-prolonging agents due to risk of fatal arrhythmias 2, 7
• Risk of serotonin syndrome, paralytic ileus, and precipitated withdrawal with various drug combinations 2, 7

Special populations:

• For hospitalized patients with both opioid and methamphetamine use, enhanced interventions like patient navigation and mHealth monitoring improve linkage to outpatient care 6
• Pregnant women with opioid use disorder benefit from buprenorphine, but data for methamphetamine co-use is limited 2

Bottom Line

Buprenorphine should only be prescribed for its FDA-approved indication of opioid use disorder 1. While preliminary research suggests potential benefit for reducing methamphetamine craving when added to behavioral therapy, this remains investigational and should not be standard practice 3, 4. The strongest evidence supports using buprenorphine in patients with co-occurring opioid and methamphetamine use disorders, where it treats the opioid use disorder while potentially providing secondary benefits for methamphetamine craving 6, 4. Any off-label use requires informed consent, close monitoring, and integration with evidence-based behavioral interventions 3.