From the Guidelines
Outpatient management of cocaine and methamphetamine use disorders should primarily involve a combination of contingency management (CM) and community reinforcement approach (CRA), as this approach has been shown to be the most effective and acceptable intervention for both short- and long-term treatment. This is based on a systematic review and network meta-analysis of 50 clinical studies, including 6,943 participants, which found that CM plus CRA was superior to other psychosocial interventions, including cognitive-behavioral therapy (CBT) alone, CM alone, and 12-step programs alone 1.
Key components of this approach include:
- Contingency management, which provides incentives for abstinence, such as rewards for drug-free urine samples
- Community reinforcement approach, which involves functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements
- Regular urine drug screening to monitor abstinence
- Addressing co-occurring mental health conditions, such as depression or anxiety, which often accompany stimulant use disorders
- Participation in support groups, such as Narcotics Anonymous
- Connection with community resources for housing, employment, and legal assistance, if needed
While medications are not specifically approved for stimulant use disorders, some clinicians may prescribe medications off-label to address specific symptoms, such as bupropion, mirtazapine, or topiramate 1. However, the primary focus should be on behavioral therapies, as they have been shown to be the most effective approach for achieving sustained recovery from stimulant addiction.
It's worth noting that the combination of CM and CRA has been found to be more effective than other interventions, including CBT alone, and should be considered the first-line treatment for individuals with cocaine and/or amphetamine addiction 1.
From the Research
Outpatient Management of Cocaine and Methamphetamine Dependence
- Cognitive-behavioral therapy (CBT) and contingency management (CM) are effective interventions for treating methamphetamine dependence, with CBT showing reductions in methamphetamine use and other positive changes, even over short periods of treatment 2.
- Contingency management is among the most effective interventions for reducing methamphetamine use, with broad benefits including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior 3.
- For cocaine dependence, contingency management has been shown to increase cocaine abstinence, improve treatment retention, and be of benefit in pharmacotherapy trials, suggesting it is a promising add-on intervention for cocaine dependence treatment 4.
- Combining CBT and CM may be complementary, with CM rapidly reducing cocaine use and CBT producing reductions months after treatment, and signs of additive benefits post-treatment 5.
- A systematic review comparing CBT and CM for cocaine dependence found that CM alone reliably reduced cocaine use during active treatment, while the positive effect of CBT emerged after treatment, with synergistic effects of the combination of CM plus CBT shown in some trials 6.