What medications are recommended to reduce cravings in an adult with methamphetamine use disorder?

Medication to Reduce Methamphetamine Cravings

There are currently no FDA-approved medications for methamphetamine use disorder, and the most effective treatment is contingency management (a behavioral intervention using financial incentives) combined with cognitive behavioral therapy. 1, 2

Current Evidence-Based Treatment Approach

First-Line Treatment: Behavioral Interventions

Contingency management is the single most efficacious treatment for stimulant use disorders, including methamphetamine. 1 This involves providing financial incentives (cash or gift cards) for periods of abstinence verified by negative urine drug screens. 1

• Cognitive behavioral therapy should be combined with contingency management, as this combination shows superior outcomes to either intervention alone. 1, 2
• The International Antiviral Society-USA Panel (2025) gives contingency management for stimulant use disorders an AIa evidence rating (highest level). 1

Pharmacotherapy: No FDA-Approved Options

No medications are FDA-approved for methamphetamine use disorder, and clinical guidelines explicitly state that no pharmacotherapy can be recommended for methamphetamine dependence in primary care settings. 2

• The JAMA guidelines (2025) note that "there are no FDA-approved medications to treat stimulant use disorders (eg, cocaine use disorder, amphetamine-type use disorder)." 1
• Pharmacotherapies for stimulant use disorders are recommended only "in certain situations," without clear specification of which situations warrant their use. 1

Investigational Medications Under Study

While not FDA-approved, several medications are being investigated:

• High-dose lisdexamfetamine (250 mg daily) is currently being studied in combination with contingency management in the ASCME trial, representing the largest study to date examining psychostimulants for methamphetamine use disorder. 3
• Bupropion and modafinil were the most commonly studied pharmacologic interventions in a 2023 scoping review, though evidence remains inconsistent and limited by heterogeneity. 4, 5
• A 2023 scoping review found that "nearly all interventions showed signs of potential benefit on at least one methamphetamine-related outcome measure," but most interventions were assessed by only single studies, making effectiveness uncertain. 4

Clinical Implementation Algorithm

Step 1: Initiate Contingency Management

• Establish a system for providing financial incentives tied to negative urine drug screens (typically twice weekly). 1
• This is the only intervention with AIa-level evidence for methamphetamine use disorder. 1

Step 2: Add Cognitive Behavioral Therapy

• Combined pharmacotherapy and CBT shows greater benefit than usual care alone across substance use disorders. 1
• CBT provides training in behavioral self-control skills to achieve and maintain abstinence. 2, 6

Step 3: Integrate Support Services

• Peer/patient support staff, telehealth, extended hours, mobile clinics, and walk-in options should be available. 1
• Harm reduction services including naloxone dispensation, safe use education, and fentanyl test strips should be offered. 1

Step 4: Consider Family Involvement

• Family members should be actively incorporated into treatment through couples/family therapy and mutual help groups. 2
• Failing to address family dynamics negatively impacts treatment outcomes. 2

Critical Pitfalls to Avoid

Do not rely on pharmacotherapy alone for methamphetamine use disorder. Unlike opioid or alcohol use disorders where FDA-approved medications exist, methamphetamine use disorder requires behavioral interventions as the primary treatment modality. 1, 2

• Do not prescribe medications off-label without implementing contingency management and CBT, as the evidence base for pharmacotherapy alone is insufficient. 4, 5
• Do not confuse the treatment approach for methamphetamine with that for opioid use disorder (where buprenorphine, methadone, or naltrexone are first-line) or alcohol use disorder (where naltrexone, acamprosate, or disulfiram are first-line). 1, 7, 2
• Do not delay treatment initiation while waiting for pharmacotherapy options, as behavioral interventions are immediately available and evidence-based. 1

Special Considerations

For Patients with HIV or at Risk for HIV

• Integrated substance use disorder treatment should be provided alongside HIV prevention or treatment services. 1
• PrEP (oral or injectable) should be offered to reduce sexual risk of HIV acquisition in patients who use methamphetamine. 1

Treatment Duration and Monitoring

• Treatment should continue for at least 12 weeks based on current trial protocols. 3
• Regular urine drug screening is essential both for monitoring and for contingency management implementation. 1

Comorbidity Management

• Screen for anxiety disorders, depression, bipolar disorder, PTSD, and personality disorders, which are more common in patients with substance use disorders. 2
• Treat co-occurring psychiatric conditions with appropriate evidence-based interventions. 2