Medications for Methamphetamine Use Disorder
There are currently no FDA-approved medications for methamphetamine use disorder; contingency management (a behavioral intervention using financial incentives) is the most effective evidence-based treatment, with methylphenidate showing low-strength evidence as a potential pharmacologic option. 1, 2, 3
Primary Treatment Approach
Behavioral interventions, not medications, are the first-line treatment for methamphetamine use disorder:
Contingency management is strongly recommended as it provides financial incentives (cash or gift cards) for periods of abstinence from methamphetamines, showing the strongest evidence for promoting abstinence and reducing use. 1, 2, 4
Cognitive behavioral therapy (CBT) alone or combined with contingency management demonstrates treatment efficacy in reducing methamphetamine use and craving. 4, 5
The Matrix Model, which combines CBT, family education, individual counseling, drug testing, and 12-step participation, shows evidence of effectiveness. 4, 6
Pharmacologic Options (Off-Label)
No medications have FDA approval for methamphetamine use disorder, but limited evidence exists for certain agents:
Methylphenidate (Low-Strength Evidence)
Two small RCTs suggest methylphenidate may reduce methamphetamine use: one study (n=34) showed 6.5% versus 2.8% methamphetamine-negative urine drug screens (p=0.008), and another (n=54) showed 23% versus 16% (p=0.047). 3
This represents the only medication with even low-strength evidence of potential benefit. 3
Medications with Insufficient Evidence
Antidepressants as a class: Moderate-strength evidence shows no statistically significant effect on abstinence or treatment retention. 3
Bupropion and modafinil: Most commonly studied pharmacologic interventions but evidence remains inconsistent and inconclusive. 5, 3
Anticonvulsants, antipsychotics (aripiprazole), naltrexone, varenicline, and atomoxetine: Low-strength or insufficient evidence of benefit. 3
Topiramate: No effect on cravings based on systematic review evidence. 5
Acute Management of Methamphetamine Intoxication
For acute methamphetamine intoxication presenting with agitation, hypertension, or tachycardia:
Benzodiazepines are the primary treatment for central nervous system stimulation, agitation, hypertension, and tachycardia due to their effects on both central and peripheral manifestations. 1, 2
Cooling measures for hyperthermia, cardiac monitoring, and treatment of arrhythmias as needed. 2
Avoid beta-blockers as they may worsen coronary vasospasm through unopposed alpha-adrenergic stimulation (similar to cocaine intoxication). 1
No specific antidote exists for CNS stimulant overdose. 2
Harm Reduction Services
All patients who use methamphetamine should be offered comprehensive harm reduction services:
Naloxone dispensation and training (for co-occurring opioid use). 1, 2
Safe injection site information where available. 2
These services should be offered regardless of readiness for abstinence-based treatment. 2
Integration with HIV/HCV Care
For patients with HIV or at risk for HIV:
Substance use disorder treatment should be integrated with HIV prevention and treatment services. 1
PrEP (pre-exposure prophylaxis) should be offered to those at sexual risk of HIV acquisition. 1
Innovative service delivery options including telehealth, extended hours, mobile clinics, and peer support staff improve retention. 1
Critical Clinical Pitfalls
Common mistakes to avoid:
Waiting for abstinence before initiating HIV treatment or other medical care—treat both conditions simultaneously. 1
Relying solely on pharmacotherapy without behavioral interventions—behavioral therapy is the evidence-based standard. 1, 4
Withholding harm reduction services from patients not ready for abstinence-based treatment—harm reduction should be universal. 1, 2
Using beta-blockers for acute methamphetamine-induced hypertension or tachycardia—benzodiazepines are safer and more effective. 1, 2