INTRODUCTION — Cocaine, methamphetamine, and other stimulant use disorders are significant public health problems. In the United States, for example, there are 1.5 million regular cocaine users and approximately 353,000 regular methamphetamine users [1]. Cocaine and methamphetamine users have significantly elevated rates of medical morbidity and utilization of health care resources [2].
Only psychosocial interventions have proven efficacious in reducing stimulant use in patients with stimulant use disorders, but these treatments alone are insufficient for many patients. No medications have been shown in randomized trials to be consistently efficacious for stimulant use disorders.
Our approach to selecting treatment for stimulant use disorder is described here (algorithm 1). Pharmacotherapy and psychosocial interventions for stimulant use disorder are described in detail separately. The epidemiology, clinical manifestations, course, consequences, assessment, and diagnosis of cocaine use disorder and methamphetamine use disorder are described separately. (See "Cocaine use disorder in adults: Epidemiology, clinical features, and diagnosis" and "Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis" and "Pharmacotherapy for stimulant use disorders in adults" and "Prescription drug misuse: Epidemiology, prevention, identification, and management".)
STIMULANTS — Cocaine, methamphetamine, and diverted pharmaceutical stimulants all have similar mechanisms of action, and addiction to them leads to similar clinical manifestations. Thus, it is reasonable to try a psychosocial intervention with efficacy in one of them on patients addicted to another.
Cocaine — The reinforcing properties of cocaine are mediated by its ability to block the dopamine transporter and increase dopaminergic activity in critical brain regions. (See "Cocaine use disorder in adults: Epidemiology, clinical features, and diagnosis" and "Cocaine: Acute intoxication".)
Methamphetamine — The reinforcing effects of methamphetamine are mediated both by blockade of the dopamine transporter and by stimulating the presynaptic release of dopamine. (See "Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis" and "Methamphetamine: Acute intoxication".)
Amphetamines — Amphetamines and other diverted pharmaceutical stimulants have a mechanism of action similar to methamphetamine with both blockade of the dopamine transporter as well as stimulate release of dopamine. Methylphenidate has a mechanism of action more similar to that of cocaine with simple blockade of the dopamine transporter. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Stimulants'.)
Synthetic cathinones — Cathinones are beta-ketone amphetamine analogs. Abuse of synthetic cathinones (bath salts) emerged in Europe in 2009 and spread to the United States in 2010 [3,4]. These drugs were initially marketed in the United States as “bath salts” or “plant food” to avoid controlled-substance restrictions. The mechanism of action of cathinones is similar to that of methamphetamine. Cathinones block the reuptake of dopamine, norepinephrine, and serotonin, as well as stimulate the release of dopamine. (See "Acute amphetamine and synthetic cathinone ("bath salt") intoxication".)
APPROACH TO TREATMENT
Continuing care principles — Psychosocial interventions should be used to treat stimulant use disorder based on principles of the continuing care model, described briefly below and in detail separately. (See "Continuing care for addiction: Context, components, and efficacy" and "Continuing care for addiction: Implementation".)
●Recognition that substance use disorders are often chronically recurring conditions that benefit from continuing care at varying levels of intensity rather than short-term treatment limited to periods of acute exacerbation.
●The intensity and number of psychosocial interventions used to treat a patient with stimulant use disorder should be based on the patient’s clinical status, stimulant use disorder severity, and response to prior treatment.
●Continued treatment resistance should be addressed by increasing the intensity of treatment. This could involve additional modalities, more hours per week, and/or more structure or restriction.
●Selection among treatment components is subject to patient preference, geographic variation in the availability of treatments/levels of care, and what payers will allow.
Selecting interventions — Only psychosocial interventions have proven consistently efficacious in reducing stimulant use in patients with stimulant use disorders. No medications have been shown in randomized trials to be consistently efficacious for stimulant use disorders. (See "Pharmacotherapy for stimulant use disorders in adults".)
Treatment choice for stimulant use disorder (algorithm 1) is based on the severity of the substance use disorder. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorizes substance use disorder severity with the specifiers mild, moderate, and severe based on the number of diagnostic criteria for substance use disorder the patient has met over the past 12 months [5] (see "Clinical assessment of substance use disorders", section on 'Assessment/Diagnosis'):
●Mild – Two to three criteria
●Moderate – Four to five criteria
●Severe – Six or more criteria
The 11 diagnostic criteria for substance use disorder address the presence of symptoms (such as cravings or desire to cut back), behaviors (eg, recurrent or continued use despite failure to meet obligations), or physiologic factors (tolerance or withdrawal).
Mild stimulant use disorder — In general, for patients with mild stimulant use disorder, we suggest first-line treatment with individual or group drug counseling. If the patient experiences only a partial response or no response to drug counseling after three weeks, we suggest a transition to intensive outpatient therapy (IOT) rather than to other treatments. Although clinical trials of drug counseling and IOT have been insufficient to establish the efficacy of these interventions as initial treatment, in our clinical experience, they can help patients with stimulant use disorder to maintain abstinence. (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Drug counseling' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Intensive outpatient therapy'.)
If the patient does not achieve sustained abstinence after an 8- to 12-week trial of IOT, treatment can be augmented with contingency management or the individual component of IOT can be replaced by cognitive-behavioral therapy (CBT) or motivational interviewing. CBT and contingency management have been found to be efficacious for stimulant use disorder in clinical trials. Clinical trials have not found motivational interviewing to be efficacious in patients with cocaine use disorder, but more research is needed and, in our clinical experience, motivational interviewing can help some individuals with low motivation to maintain abstinence. (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Cognitive-behavioral therapy' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Motivational interviewing' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Contingency management'.)
Moderate to severe stimulant use disorder — For patients with moderate to severe stimulant use disorder, we suggest first-line treatment with IOT. For patients who do not experience sustained abstinence after 8 to 12 weeks, treatment can be augmented with contingency management or the individual component of IOT can be replaced by CBT or motivational interviewing. Treatment options may be limited by the unavailability of some of these interventions in some geographic areas. (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Intensive outpatient therapy' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Cognitive-behavioral therapy' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Motivational interviewing'.)
Treatment-resistant stimulant use disorder — There is a lack of compelling evidence supporting the efficacy of medication compared with placebo. We typically refer individuals with continued use or return to use after 8 to 12 weeks with the most intensive psychosocial intervention to a clinician experienced using pharmacotherapy for stimulant use disorder. Pharmacotherapy for stimulant use disorders is discussed elsewhere. (See "Pharmacotherapy for stimulant use disorders in adults", section on 'Pharmacotherapy'.)
Some evidence suggests that the combination of medication (desipramine, bupropion, or citalopram) and psychosocial interventions (contingency management or CBT) for stimulant use disorder may be more efficacious than either modality alone [6-8]. As an example, a clinical trial randomly assigned 160 patients with DSM-IV cocaine and opioid dependence (maintained on buprenorphine) to receive desipramine or placebo in conjunction with either contingency management or a noncontingent voucher control [6]. Cocaine-free and combined cocaine and opiate-free urines increased more rapidly over time in patients assigned to receive desipramine or contingency management compared with controls. Patients assigned to receive both contingency management and desipramine had more drug-free urines compared with the other three groups.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stimulant use disorder and withdrawal".)
SUMMARY AND RECOMMENDATIONS
●Stimulants – Because cocaine, methamphetamine, and diverted pharmaceutical stimulants all have similar mechanisms of action, and addiction to them leads to similar clinical manifestations, it is reasonable to try a psychosocial intervention with efficacy in one of them on patients addicted to another. (See 'Stimulants' above.)
●Continuing care principles – Continuing care principles suggest that for substance use disorder patients who do not achieve abstinence or relapse following initial interventions, the intensity of the patient’s treatment should be increased. This could involve additional modalities, more hours per week, and/or more structure or restriction. (See 'Continuing care principles' above.)
●Mild stimulant use disorder – For patients with mild stimulant use disorder, we suggest first-line treatment with individual or group drug counseling rather than other treatments (Grade 2C). (See 'Mild stimulant use disorder' above and "Psychosocial interventions for stimulant use disorder in adults", section on 'Drug counseling'.)
If the patient experiences only a partial response or no response after three weeks of drug counseling, we suggest a transition to intensive outpatient therapy (IOT) rather than to other treatments (Grade 2C). (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Intensive outpatient therapy'.)
●Moderate to severe stimulant use disorder – For patients with moderate to severe stimulant use disorder, we suggest first-line treatment with IOT rather than other treatments (Grade 2C). (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Intensive outpatient therapy'.)
●Subsequent treatment – For patients with mild, moderate or severe stimulant use disorder who do not achieve sustained abstinence after six to eight weeks of IOT, we augment with contingency management. In some cases, we also replace the individual component of IOT with cognitive-behavioral therapy or motivational interviewing. (See "Psychosocial interventions for stimulant use disorder in adults", section on 'Contingency management' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Cognitive-behavioral therapy' and "Psychosocial interventions for stimulant use disorder in adults", section on 'Motivational interviewing'.)
●Treatment-resistant stimulant use disorder – For patients with treatment-resistant stimulant use disorder (ie, they continue to relapse after 8 to 12 weeks with intensive psychosocial treatment), we suggest referral to a clinician experienced in substance use disorder pharmacotherapy for adjunctive medication. Some evidence suggests that combinations of medication and psychosocial interventions may be more effective for stimulant use disorder than either modality individually. (See 'Treatment-resistant stimulant use disorder' above and "Pharmacotherapy for stimulant use disorders in adults".)
