What is the most effective medication for methamphetamine (meth) use disorder?

Best Medication for Methamphetamine Use Disorder

There is currently no FDA-approved medication for methamphetamine use disorder, and behavioral interventions—specifically Contingency Management combined with Community Reinforcement Approach—represent the most effective first-line treatment. 1

Current State of Pharmacotherapy

The evidence is clear and consistent across multiple high-quality sources:

• No pharmacological agent has demonstrated sufficient efficacy to receive FDA approval for methamphetamine use disorder treatment 1, 2
• Behavioral interventions remain the principal treatment approach for stimulants without FDA-approved pharmacotherapy 3
• Multiple medication classes have been evaluated without establishing clear benefit, including antidepressants, antipsychotics, anticonvulsants, and opioid antagonists 2

Most Promising Pharmacological Data (Limited Evidence)

While no medication is approved, methylphenidate shows low-strength evidence of potential benefit:

• Two small RCTs demonstrated statistically significant reductions in methamphetamine use (6.5% vs 2.8% negative urine screens in one study, P=0.008; 23% vs 16% in another, P=0.047) 2
• This represents the only medication class with even preliminary positive signals in systematic reviews 2
• However, the evidence remains insufficient for routine clinical recommendation 2

Evidence-Based Treatment Recommendations

Behavioral interventions should be prioritized as first-line treatment:

Optimal Approach

• Contingency Management (CM) plus Community Reinforcement Approach (CRA) provides superior outcomes with a Number Needed to Treat (NNT) of 2.1 for abstinence at 12 weeks, 4.1 at end of treatment, and 3.7 at longest follow-up 1
• This combination also improves treatment retention (NNT 3.1 at 12 weeks, 3.3 at end of treatment) 1

Alternative Behavioral Approaches

• Contingency Management alone shows significant efficacy during active treatment (NNT 5.4 for abstinence), though effects diminish after treatment completion 1, 4
• Cognitive Behavioral Therapy (CBT) is recommended when CM+CRA is unavailable, though it demonstrates less efficacy 1, 5
• Twenty of 21 studies examining CM showed positive effects on abstinence outcomes 4

Combined Treatment Strategy

When pharmacotherapy is considered alongside behavioral interventions:

• CBT combined with any pharmacotherapy performs better than usual care alone (effect size range 0.18-0.28) 3
• However, CBT does not outperform other evidence-based behavioral modalities (such as motivational enhancement therapy or contingency management) when added to pharmacotherapy 3
• Best practices should include pharmacotherapy (when available for co-occurring conditions) plus CBT or another evidence-based therapy, rather than nonspecific counseling 3

Critical Clinical Considerations

Assessment Requirements

• Evaluate pattern, duration, and severity of methamphetamine use, including symptoms of dopamine depletion 6
• Screen for co-occurring mental health conditions, particularly depression and suicidality 6
• Assess cardiovascular complications, as methamphetamine causes coronary artery spasm, tachycardia, and hypertension 6

Harm Reduction Services

• Provide naloxone dispensation (given frequent co-use with opioids) 6, 7
• Offer fentanyl test strips and safe use education 6
• Refer to syringe services programs 6, 7

Co-occurring Opioid Use Disorder

• Initiate medications for opioid use disorder without delay when both conditions are present 6, 7
• Do not withhold opioid use disorder treatment while addressing methamphetamine use 6

Common Pitfalls to Avoid

• Do not rely solely on brief interventions without structured follow-up, as methamphetamine addiction requires sustained support 1
• Avoid using non-contingent rewards in behavioral programs, as they lack the motivational power of contingency-based approaches 1
• Do not focus exclusively on short-term abstinence without addressing long-term psychological and social factors necessary for sustained recovery 1
• Recognize that stimulant use disorders frequently co-occur with other substance use and mental health disorders requiring integrated treatment 6, 7