Bupropion Use in Comorbid Stimulant and Alcohol Use Disorder
No, bupropion should not be used for stimulant use disorder in patients with comorbid alcohol use disorder due to the FDA contraindication regarding alcohol consumption and the lack of guideline support for this indication.
Critical FDA Contraindication
The FDA label for bupropion explicitly warns that alcohol consumption should be minimized or avoided during treatment, citing rare reports of adverse neuropsychiatric events and reduced alcohol tolerance in patients drinking alcohol while on bupropion 1. This creates a fundamental incompatibility with active alcohol use disorder.
Absence of Guideline Support for Stimulant Use Disorder
No guideline-level recommendations exist endorsing bupropion for stimulant use disorder treatment, as available guidelines focus on ADHD and other approved indications 2.
The most recent 2025 JAMA guidelines on substance use disorders state that there are no FDA-approved medications to treat stimulant use disorders (cocaine or amphetamine-type) 3.
Contingency management (behavioral therapy with financial incentives) is the most efficacious evidence-based treatment for stimulant use disorders and is strongly recommended 3.
Recommended Treatment Approach for This Patient
For Alcohol Use Disorder (Priority Treatment)
FDA-approved medications for alcohol use disorder should be offered first: extended-release naltrexone or oral naltrexone, which reduce alcohol use and improve outcomes 3.
Acamprosate is another FDA-approved option with no hepatotoxicity concerns and renal excretion 3.
These medications have few clinically significant drug-drug interactions and should not be withheld 3.
For Stimulant Use Disorder
Contingency management is the recommended first-line treatment, providing structured behavioral intervention with incentives for periods of recovery 3.
Psychosocial support modeled on motivational principles should be offered in non-specialized settings 3.
Harm reduction services including safe use education and drug test strips should be provided 3.
Evidence Regarding Bupropion in Dual Substance Use
While research exists showing bupropion may reduce stimulant-related emergency admissions in patients with opioid use disorder 4, and small studies suggest benefit in adolescents with ADHD and substance use disorders 5, 6, these findings:
- Do not translate to guideline-level recommendations for adults with primary stimulant use disorder
- Were conducted in populations without active alcohol use disorder
- Conflict with the FDA warning about alcohol consumption during bupropion treatment 1
Common Pitfall to Avoid
Do not prescribe bupropion off-label for stimulant use disorder when alcohol use disorder is present. The seizure risk is already elevated with bupropion (contraindicated in eating disorders and seizure disorders for this reason 2, 1), and alcohol withdrawal or heavy drinking further lowers seizure threshold 1. This combination creates unacceptable risk.
Clinical Algorithm
- Treat alcohol use disorder first with FDA-approved medications (naltrexone or acamprosate) 3
- Implement contingency management for stimulant use disorder 3
- Integrate both treatments with psychosocial support and harm reduction services 3
- Avoid bupropion given the alcohol contraindication and lack of evidence for this specific indication 2, 1