Generally, stimulants increase alertness and energy, heighten arousal, elevate blood pressure, and cause feelings of euphoria.1 These drugs can also have adverse and potentially fatal effects on both physical and behavioral health, including:1,2,3,4,5,6,7,8,9,10,11
- Cardiovascular symptoms, such as accelerated heart rate and stroke
- Elevated body temperature and hyperthermia
- Injection site and other infections, sepsis, and neurotoxicity
- Panic attacks, hostility, paranoia, psychosis, and violent behavior
- Cognitive impairment
Stimulant use is a growing problem in the US. In 2019, 5.9 million people aged 12 or older reported having used cocaine in the past year, 2 million reported having used methamphetamine in the past year, and 4.9 million reported having misused prescription stimulants.12
The co-use of stimulants and opioids is also a growing problem. Some people are using methamphetamines or cocaine to counteract the sedation of opioids.13,14,15 Others are injecting methamphetamine in combination with heroin.16,17,18 Some people are unknowingly using methamphetamines or cocaine that contain synthetic opioids such as fentanyl.19
Overdose deaths involving stimulants have increased steadily since 2015, driven in part by opioid co-use.20,21,22 From 2013 to 2018, the age-adjusted rate of drug overdose deaths involving cocaine nearly tripled,23 and from 2012 to 2018 the age-adjusted rate of drug overdose deaths involving methamphetamine increased nearly fivefold.24
Stimulant Use Disorders in Primary Care
People with SUDs, including those with stimulant use disorders, often access the health care system via primary and ambulatory care settings for reasons other than their substance use disorder, and do not seek or are unable to access specialty treatment.25 To be able to address increasing stimulant use, primary and ambulatory care practices need to provide patient-centered integrated behavioral healthcare. Adding behavioral health expertise to the care team and establishing clearly defined workflows and protocols are key steps in integrating behavioral health in primary and ambulatory care practices. Primary and ambulatory care practices without integrated behavioral health providers will need to connect patients with external behavioral health providers, specialty care providers, and/or other community resources to complement services available within the practice setting.
This page presents the available research evidence on the treatment of stimulant use disorders, and offers practical guidance and resources for providing patient-centered integrated behavioral health care for stimulant use in primary and ambulatory care practices.
Treating People with Stimulant Use Disorders—What Works?
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), four behavioral interventions have a strong evidence base for the treatment of stimulant use disorders, including:1
- Contingency management
- Community reinforcement approach
- Cognitive behavioral therapy
- Motivational interviewing
Generally, other behavioral interventions, such as psychotherapy and 12-step programs, have demonstrated weak and non-specific effects on stimulant use disorders.34 Treatment models for stimulant use disorder that integrate several psychosocial interventions have been more effective than a single-treatment strategy.35,36 Particularly, contingency management and community reinforcement are most effective when combined.1,37,38,39
Contingency management (also referred to as motivational incentive) is a behavioral therapy approach that aims to retrain the brain by providing rewards for healthy behaviors. In contingency management interventions for substance use disorders, abstinence is rewarded with monetary-based vouchers and other prizes. Contingency management is increasingly being recognized as the most effective, evidence-based option to deal with stimulant use disorders,40 and has resulted in:41,42,43,44,45,46,47,48
- Reductions in stimulant use (duration)
- Reductions in new simulant use
- Reductions in stimulant cravings
- Longer retention in treatment
- Reductions in risky sexual behavior
- Higher utilization of therapy and other psychosocial and medical treatment services
Find more information on contingency management in Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) and Contingency Management in General Treatment Populations and Special Groups.
Community Reinforcement Approach
Community Reinforcement Approach (CRA) is a behavioral therapy approach that aims to make a substance-free life life combination with contingency management for the treatment of stimulant use disorders, particularly cocaine use, and has resulted in:37,38,39,49,50,51
- Reductions in stimulant use (duration, frequency, and amount)
- Sustained cocaine abstinence
- Reductions in addiction severity
Find more information on the community reinforcement approach in Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
Cognitive-behavioral therapy (CBT)
Cognitive-behavioral therapy (CBT) is a behavioral therapy approach that enables individuals to assess their circumstances and experiences in order to change their thinking and behavior. CBT is tailored to each individual’s needs, and can be accessed in clinical and outpatient settings in traditional or computer-based formats. The use of CBT for people with stimulant use disorders has resulted in:43,52,53
- Reductions in stimulant use (amount and frequency)
- Reductions in risky sexual behaviors
Find more information on cognitive-behavioral therapy in Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
Motivational interviewing is a behavioral therapy approach designed to motivate behavior change and commitment to a goal by exploring and resolving ambivalence. The use of motivational interviewing for people with stimulant use disorder has resulted in:54,55,56
- Reductions in stimulant use (duration and amount)
- Reductions in co-occurring psychiatric problem severity
Find more information on motivational interviewing in Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) and TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment (PDF – 432 KB).
Other Nonpharmaceutical Interventions
Researchers are exploring the effectiveness of several other interventions to treating stimulant use, including:
- Physical Exercise – For individuals in recovery from methamphetamine use, physical activity reduced symptoms of anxiety and depression, reduced methamphetamine cravings, and reduced relapse post-discharge.57
- Mindfulness Meditation – Mindfulness-based interventions have demonstrated promise in preventing relapse for people with substance use disorders, including stimulant use disorders.58,59
Harm Reduction – A large portion of participants in a Washington State syringe exchange program expressed interest in reducing or stopping their methamphetamine or opioid use, suggesting these programs are a potential setting for methamphetamine use interventions.60
Emerging and Existing Treatment Models
Emerging and existing treatment models for stimulant use include the following:
- The Treatment of Users of Stimulants (TRUST) integrated behavioral model (PDF – 632 KB) includes motivational incentives, elements of CBT and CRA, motivational interviewing skills, and physical activity, and encourages self-help program participation.
- The Matrix Model provides a framework for engaging individuals using methamphetamine, cocaine, and other stimulants in treatment.
No medications have been approved by the U.S. Food and Drug Administration for the treatment of stimulant use disorders, and there is insufficient evidence showing the effectiveness of pharmacotherapies for the treatment of stimulant use disorders.1,41
Medications that are under consideration include:61,62,63,64
- XR Naltrexone-Bupropion
What Should I Consider When Providing Care for People with Stimulant Use Disorders?
What Should I Consider When Providing Care for People with Stimulant Use Disorders?
Patients with stimulant use disorders will vary widely in the types and intensity of supports they need and those needs will change over the course of treatment and recovery. Primary and ambulatory care practices will vary in what is feasible for them to offer. For practices without integrated behavioral health expertise, providing holistic, comprehensive care that addresses the needs of each individual patient may require connecting patients with external behavioral health providers, specialty care providers, and other community resources to complement services available within the practice setting.
Additionally, there are key aspects of stimulant use that practices should consider when providing care, some related to patient needs and others regulatory in nature.
Stimulant and opioid co-use is on the rise, and is associated with higher risk of morbidity and mortality.65,66 In 2019, 76 percent of cocaine-involved overdose deaths also involved an opioid, and 54 percent of other stimulant-involved overdose deaths involved an opioid.67 Additionally, the rate of inpatient stays involving both opioids and stimulants increased 13.2 percent from 2012 to 2014 and 13.4 percent from 2016 to 2018.68 To identify, address, and manage potential polysubstance use among patients using stimulants, primary and ambulatory care practices can:
- Screen patients for polysubstance use, specifically opioid co-use
- Discuss the risk of infectious disease with patients injecting stimulants and potential harm reduction strategies, such as syringe exchange programs, fentanyl test strips (PDF – 268 KB), and naloxone kits
- Establish treatment rules and policies for stimulant use disorders that address potential challenges like polysubstance use and that support retention in treatment and recovery (e.g., not requiring patients with a co-occurring opioid use disorder (OUD) to be abstinent from stimulants in order to receive OUD treatment15)
Comorbidities and Co-occurring Disorders
Chronic, long-term use of stimulants can lead to psychiatric and medical comorbidities, including persistent hypertension, increased risk of heart attack, stroke, mood fluctuations, anxiety, depression, psychosis, decreased attention, confusion, impaired memory, inhibited impulse, and reduced motor skills.1,6,69,70,71,72,73,74,75,76,77,78 To identify, address, and manage potential comorbidities and co-occurring disorders, primary and ambulatory care practices can:
- Screen patients with stimulant use disorder for symptoms of mental health conditions such as psychosis, depression, anxiety, and attention deficit hyperactivity disorder (ADHD)
- Tailor care teams to meet the physical and behavioral health needs of patients with stimulants use disorders, including having a care navigator/coordinator60
- Involve patients with stimulant use disorder and care team members in developing shared care plans to promote intensive care coordination, care management, and engagement
- Discuss the risk of infectious disease with patients injecting stimulants and potential harm reduction strategies, such as syringe exchange programs, pre-exposure prophylaxis (PrEP) for HIV, and hepatitis C virus screening and treatment
Shifts in Stimulant Use and Mortality Trends
People are using stimulants in riskier ways. From 2015 to 2019, the number of people using methamphetamine and cocaine together increased by 60 percent, and frequent methamphetamine use increased 66 percent.79 The proportion of people using methamphetamine that met the diagnostic criteria for methamphetamine use disorder (MUD) or were injecting methamphetamines also increased.79 Stimulant use patterns, as well as mortality rates, also increased dramatically among certain racial/ethnic populations compared to others. MUD without injection increased most (tenfold) among Black people from 2015 to 2019.79 From 2011 to 2018, deaths involving methamphetamines increased most (more than quadrupled) among non-Hispanic American Indians and Alaska Natives.22,24 The rates of drug overdose deaths involving cocaine were significantly higher for non-Hispanic Black people from 2013 to 2018.23 In response to these trends, primary and ambulatory care practices can:
- Screen patients using methamphetamines for cocaine use and vice versa
- Use tools and resources, such as the SAMHSA Treatment Improvement Protocol 59: Improving Cultural Competence (PDF – 4.03 MB) or Georgetown University National Center for Cultural Competence, to assess and improve cultural responsiveness and competency
Some populations, including pregnant women and adolescents, have a higher risk of stimulant use and stimulant-involved morbidity and mortality. If either of these special populations is using stimulants, specialized treatment is recommended.
Stimulants are the second most widely used substances by pregnant women.80 Prenatal exposure to stimulants can cause increased risk of adverse maternal, perinatal, neonatal, and early and late childhood outcomes, such as maternal migraines, pre-eclampsia, premature birth, lower birth weight, smaller head circumference, jitteriness, respiratory distress, anxiety, depression, attention problems, and poor cognitive function.81,82,83,84,85 To identify, address, and manage potential stimulant use in pregnant patients, primary and ambulatory care practices can>:
- Review ethical responsibilities, legal requirements, and clinical guidance regarding pregnant patient disclosure of stimulant and other substance use, toxicology testing of pregnant patients, and fetal assessment
- Screen pregnant patients for stimulant and other substance use as part of the prenatal history
Suspected overdoses involving stimulants, particularly prescription stimulants, have increased in adolescents.86 Nonmedical prescription stimulant use in adolescence is associated with faster development of substance use disorders, lower educational attainment, and increased substance use disorders symptoms in adulthood.87,88 To identify, address, and manage potential stimulant use in adolescents, primary and ambulatory care practices can:
- Review legal requirements and clinical guidance regarding disclosure of stimulant and other substance use by minors, adolescent-physician confidentiality, and parental/guardian involvement in adolescent care
- Screen adolescent patients for stimulant and other substance use
Barriers to Treatment
There are several financial, practical, and ethical arguments and considerations regarding the implementation of contingency management for the treatment of stimulant and other substance use. Stigma, misperceptions, and lack of knowledge and training on this behavioral therapy approach and restrictions on the use of Federal and State program funds for incentives present potential concerns and challenges to widespread implementation of contingency management.89,90 To understand and mitigate these barriers to treatment, primary and ambulatory care practices can:
- Review a summary of the federal ruling on contingency management incentives, such as this Healthcare Financial Management Association summary (PDF – 1.26 MB)
- Provide contingency management training and education to care team members, such as this Northwest ATTC online training or the Treatment of Users of Stimulants (TRUST) clinician manual (PDF – 1.03 MB)
Resources for Providing Care for People Using Stimulants
- American Academy of Family Physicians: Adolescent Substance Use and Misuse: Recognition and Management
- American Academy of Family Physicians: Stimulant and Designer Drug Use: Primary Care Management
- American Academy of Pediatrics: Promoting Optimal Development: Screening for Behavioral and Emotional Problems
- American Academy of Pediatrics: Substance Use Screening, Brief Intervention, and Referral to Treatment
- American College of Obstetricians and Gynecologists: Methamphetamine Abuse in Women of Reproductive Age
- American College of Obstetricians and Gynecologists: Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy
- American Society of Addiction Medicine: Contingency Management in General Treatment Populations and Special Groups
- Association of Maternal & Child Health Programs and National Association of State Alcohol and Drug Abuse Directors: Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Pregnant and Postpartum Women (PDF – 432 KB)
- Bureau of Justice Assistance: Residential Substance Abuse Treatment (RSAT) for State Prisoners Training and Technical Assistance Resource: Treating Clients with Methamphetamine and Stimulant Use Disorder
- Substance Abuse and Mental Health Services Administration: Treatment of Stimulant Use Disorders
- AHRQ Academy for Integrating Behavioral Health and Primary Care: MAT for OUD Tools & Resources - Screening for Substance Use/Opioid Use Disorder
- Mental Health America: Screening Tools
- National Institute on Drug Abuse: Screening and Assessment Tools Chart
- Rural Communities Opioid Response Program – Technical Assistance: Treatment for Individuals who Use Stimulants (TRUST) Clinician Manual (PDF - 1.04 MB)
- Rural Communities Opioid Response Program – Technical Assistance: Treatment for Individuals who Use Stimulants (TRUST) Patient Workbook (PDF – 1.03 MB)
- Substance Abuse and Mental Health Services Administration: Counselor’s Family Education Manual: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (PDF – 1.05 MB)
- Substance Abuse and Mental Health Services Administration: TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment (PDF – 6.44 MB)
- Substance Abuse and Mental Health Services Administration: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders: Client's Handbook
- Substance Abuse and Mental Health Services Administration: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders: Client's Treatment Companion
- Substance Abuse and Mental Health Services Administration: Matrix Intensive Outpatient Treatment for People with Stimulant Use Disorders: Counselor's Family Education Manual w/CD
- Substance Abuse and Mental Health Services Administration: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders: Counselor's Treatment Manual
Services and Supports
- Cocaine Anonymous: Cocaine Anonymous
- Crystal Meth Anonymous: Crystal Meth Anonymous
- Get Naloxone Now: Naloxone Finder Website
- Narcotics Anonymous: Narcotics Anonymous
- North American Syringe Exchange Network: NASEN Syringe Services Program Location Directory Map
- TreatmentAtlas.org: Addiction Treatment Locator, Assessment, and Standards Platform
Training and Education
- Addiction Technology Transfer Center Network: National Core Curriculum: Stimulants and their Impact on Brain and Behavior: Best Practices and Approaches for Effective Treatment and Recovery
- Addictions, Drug & Alcohol Institute, University of Washington: Opioids and Stimulants: What Are They and How Are People Using Them (PDF – 324 KB)
- National Harm Reduction Coalition: Pregnancy and Substance Use: A Harm Reduction Toolkit Training Guide
- National Institutes of Health: Opioid Use in the Context of Polysubstance Use: Research Opportunities for Prevention, Treatment, and Sustained Recovery
- Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services: State and Community Efforts to Address Stimulant Use
- Substance Abuse and Mental Health Services Administration: Tips for Teens: The Truth About Stimulants
Explore More on the Academy Portal
1. Treatment of Stimulant Use Disorders. SAMHSA Publication No. PEP20-06-01-001. Rockville, MD: National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration; 2020. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-01-001_508.pdf (PDF – 17.29 MB). Accessed September 27, 2021.
2. Paulus MP, Stewart JL. Neurobiology, clinical presentation, and treatment of methamphetamine use disorder: A review. JAMA Psychiatry. 2020;77(9):959–966. https://doi.org/10.1001/jamapsychiatry.2020.0246. Accessed September 27, 2021.
3. Fonseca AC, Ferro JM. Drug abuse and stroke. Curr Neurol Neurosci Rep. 2013 Feb;13(2):325. https://doi.org/10.1007/s11910-012-0325-0. Accessed September 27, 2021.
4. Goldstein RA, DesLauriers C, Burda A, Johnson-Arbor K. Cocaine: History, social implications, and toxicity -- a review. Semin Diagn Pathol. 2009 Feb;26(1):10-7. https://doi.org/10.1053/j.semdp.2008.12.001. Accessed September 27, 2021.
5. Reddy PKV, Ng TMH, Oh EE, Moady G, Elkayam U. Clinical characteristics and management of methamphetamine-associated cardiomyopathy: State-of-the-art review. J Am Heart Assoc. 2020 Jun 2;9(11):e016704. Epub 2020 May 29. https://doi.org/10.1161/jaha.120.016704. Accessed September 27, 2021.
6. Panenka WJ, Procyshyn RM, Lecomte T, MacEwan GW, Flynn SW, Honer WG, Barr AM. Methamphetamine use: A comprehensive review of molecular, preclinical and clinical findings. Drug Alcohol Depend. 2013 May 1;129(3):167-79. Epub 2012 Dec 27. https://doi.org/10.1016/j.drugalcdep.2012.11.016. Accessed September 27, 2021.
7. Wurcel AG, Merchant EA, Clark RP, Stone DR. Emerging and underrecognized complications of illicit drug use. Clin Infect Dis. 2015 Dec 15;61(12):1840-9. Epub 2015 Aug 12. https://doi.org/10.1093/cid/civ689. Accessed September 27, 2021.
8. Isoardi KZ, Mudge DW, Harris K, Dimeski G, Buckley NA. Methamphetamine intoxication and acute kidney injury: A prospective observational case series. Nephrology (Carlton). 2020 Oct;25(10):758-764. Epub 2020 Aug 17. https://doi.org/10.1111/nep.13762. Accessed September 27, 2021.
9. Akindipe T, Wilson D, Stein DJ. Psychiatric disorders in individuals with methamphetamine dependence: Prevalence and risk factors. Metab Brain Dis. 2014;29:351-7. https://doi.org/10.1007/s11011-014-9496-5. Accessed September 27, 2021.
10. Rusyniak DE. Neurologic manifestations of chronic methamphetamine abuse. Psychiatr Clin North Am. 2013;36:261-75. https://doi.org/10.1016/j.ncl.2011.05.004. Accessed September 27, 2021.
11. Davison D, Parrott AC. Ecstasy (MDMA) in recreational users: Self‐reported psychological and physiological effects. Human Psychopharmacology: Clinical and Experimental. 1997 May;12(3):221-6. https://doi.org/10.1002/(SICI)1099-1077(199705/06)12:3%3C221::AID-HUP854%3E3.0.CO;2-C. Accessed September 27, 2021.
12. Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. HHS Publication No. PEP19-5068, NSDUH Series H-54. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf (PDF – 1.59 MB). Accessed September 27, 2021.
13. Hood JE, Banta-Green CJ, Duchin JS, Breuner J, Dell W, Finegood B, Glick SN, Hamblin M, Holcomb S, Mosse D, Oliphant-Wells T, Shim MM. Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington. Subst Abus. 2020;41(3):356-364. https://doi.org/10.1080/08897077.2019.1635557. Accessed September 27, 2021.
14. Pew Charitable Trusts. Opioid Overdose Crisis Compounded by Polysubstance Use: New Strategies Can Reduce the Risks from Using More Than One Drug. https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/10/opioid-overdose-crisis-compounded-by-polysubstance-use. Accessed September 27, 2021.
15. Tsui JI, Mayfield J, Speaker EC, Yakup S, Ries R, Funai H, Leroux BG, Merrill JO. Association between methamphetamine use and retention among patients with opioid use disorders treated with buprenorphine. J Subst Abuse Treat. 2020 Feb;109:80-85. Epub 2019 Nov 18. https://doi.org/10.1016/j.jsat.2019.10.005. Accessed September 27, 2021.
16. Al-Tayyib A, Koester S, Langegger S, Raville L. Heroin and methamphetamine injection: An emerging drug use pattern. Subst Use Misuse. 2017 Jul 3;52(8):1051-1058. Epub 2017 Mar 21. https://doi.org/10.1080/10826084.2016.1271432. Accessed September 27, 2021.
17. Glick SN, Klein KS, Tinsley J, Golden MR. Increasing heroin-methamphetamine (goofball) use and related morbidity among Seattle area people who inject drugs. Am J Addict. 2021 Mar;30(2):183-191. Epub 2020 Dec 10. https://doi.org/10.1111/ajad.13115. Accessed September 27, 2021.
18. Ellis MS, Kasper ZA, Cicero TJ. Twin epidemics: The surging rise of methamphetamine use in chronic opioid users. Drug Alcohol Depend. 2018 Dec 1;193:14-20. Epub 2018 Oct 10. https://doi.org/10.1016/j.drugalcdep.2018.08.029. Accessed September 27, 2021.
19. Volkow, N. Rising Stimulant Deaths Show that We Face More than Just an Opioid Crisis. https://www.drugabuse.gov/about-nida/noras-blog/2020/11/rising-stimulant-deaths-show-we-face-more-than-just-opioid-crisis. Accessed September 27, 2021.
20. Ahmad FB, Rossen LM, Sutton P. NCHS Vital Statistics Rapid Release--Provisional Drug Overdose Death Counts. National Center for Health Statistics; 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed September 27, 2021.
21. Kariisa M, Scholl L, Wilson N, Seth P, Hoots B. Drug overdose deaths involving cocaine and psychostimulants with abuse potential—United States, 2003–2017. MMWR Morb Mortal Wkly Rep. 2019;68:388–395. http://dx.doi.org/10.15585/mmwr.mm6817a3. Accessed September 27, 2021.
22. National Institute on Drug Abuse. Overdose Death Rates. https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates. Accessed October 18, 2021.
23. Hedegaard H, Spencer MR, Garnett MF. Increase in drug overdose deaths involving cocaine: United States, 2009–2018. NCHS Data Brief No 384. Hyattsville, MD: National Center for Health Statistics; 2020 Oct. https://www.cdc.gov/nchs/data/databriefs/db384-H.pdf (PDF – 516 KB). Accessed September 27, 2021.
24. Han B, Cotto J, Etz K, Einstein EB, Compton WM, Volkow ND. Methamphetamine overdose deaths in the US by sex and race and ethnicity. JAMA Psychiatry. 2021;78(5):564–567. https://doi.org/10.1001/jamapsychiatry.2020.4321. Accessed November 18, 2021.
25. Substance Abuse and Mental Health Services Administration, Office of the Surgeon General. Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health [Internet]. Washington, DC: US Department of Health and Human Services; 2016 Nov. Chapter 6, Health care systems and substance use disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424848/. Accessed September 27, 2021.
26. Siu AL; US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, García FA, Gillman M, Herzstein J, Kemper AR, Krist AH, Kurth AE, Owens DK, Phillips WR, Phipps MG, Pignone MP. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016 Jan 26;315(4):380-7. https://doi.org/10.1001/jama.2015.18392. Accessed September 27, 2021.
27. Siu AL; US Preventive Services Task Force. Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2016 Mar;137(3):e20154467. Epub 2016 Feb 8. https://doi.org/10.1542/peds.2015-4467. Accessed September 27, 2021.
28. Screening for unhealthy drug use: Recommendation statement. Am Fam Physician. 2021 Jan 15;103(2):107-112. https://www.aafp.org/afp/2021/0115/p107.html. Accessed September 27, 2021.
29. US Preventive Services Task Force. Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(22):2301–2309. https://jamanetwork.com/journals/jama/fullarticle/2766873. Accessed September 27, 2021.
30. Alcohol Abuse and Other Substance Use Disorders: Ethical Issues in Obstetric and Gynecologic Practice Committee Opinion No. 633. Washington, DC: American College of Obstetricians and Gynecologists; June 2015. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/06/alcohol-abuse-and-other-substance-use-disorders-ethical-issues-in-obstetric-and-gynecologic-practice. Accessed September 27, 2021.
31. Mulvaney-Day N, Marshall T, Downey Piscopo K, Korsen N, Lynch S, Karnell LH, Moran GE, Daniels AS, Ghose SS. Screening for behavioral health conditions in primary care settings: A systematic review of the literature. J Gen Intern Med. 2018 Mar;33(3):335-346. Epub 2017 Sep 25. https://dx.doi.org/10.1007%2Fs11606-017-4181-0. Accessed September 27, 2021.
32. Levy SJ, Williams, JF, Committee on Substance Use and Prevention, Ryan SA, Gonzalez PK, Patrick SW, Quigley J, Siqueira L, Smith VC, Walker LR. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016 Jul;138(1): e20161211. https://doi.org/10.1542/peds.2016-1211. Accessed September 27, 2021.
33. Weitzman C, Wegner L, Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society for Developmental and Behavioral Pediatrics, American Academy of Pediatrics. Promoting optimal development: Screening for behavioral and emotional problems. Pediatrics. 2015 Feb;135(2):384-95. Erratum in: Pediatrics. 2015 May;135(5):946. https://doi.org/10.1542/peds.2014-3716. Accessed September 27, 2021.
34. Farrell M, Martin NK, Stockings E, Bórquez A, Cepeda JA, Degenhardt L, Ali R, Tran LT, Rehm J, Torrens M, Shoptaw S, McKetin R. Responding to global stimulant use: Challenges and opportunities. Lancet. 2019 Nov 2;394(10209):1652-1667. Epub 2019 Oct 23. Erratum in: Lancet. 2019 Nov 16;394(10211):1806. https://doi.org/10.1016/s0140-6736(19)32230-5. Accessed September 27, 2021.
35. Tran MT, Luong QH, Le Minh G, Dunne M, Baker P. Psychosocial interventions for amphetamine type stimulant use disorder: An overview of systematic reviews. Front Psychiatry. 2021 Jun 17;12. https://doi.org/10.3389/fpsyt.2021.512076. Accessed September 27, 2021.
36. De Giorgi R, Cassar C, Loreto D'alò G, Ciabattini M, Minozzi S, Economou A, Tambelli R, Lucchese F, Saulle R, Amato L, Janiri L, De Crescenzo F. Psychosocial interventions in stimulant use disorders: A systematic review and qualitative synthesis of randomized controlled trials. Riv Psichiatr. 2018 Sep-Oct;53(5):233-255. https://doi.org/10.1708/3000.30003. Accessed September 27, 2021.
37. De Crescenzo F, Ciabattini M, D’Alò GL, De Giorgi R, Del Giovane C, Cassar C, Janiri L, Clark N, Ostacher MJ, Cipriani A. Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS medicine. 2018 Dec 26;15(12):e1002715. https://doi.org/10.1371/journal.pmed.1002715. Accessed September 27, 2021.
38. Roozen HG, Boulogne JJ, van Tulder MW, van den Brink W, De Jong CA, Kerkhof AJ. A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug Alcohol Depend. 2004 Apr 9;74(1):1-13. https://doi.org/10.1016/j.drugalcdep.2003.12.006. Accessed September 27, 2021.
39 Higgins ST, Sigmon SC, Wong CJ, Heil SH, Badger GJ, Donham R, Dantona RL, Anthony S. Community reinforcement therapy for cocaine-dependent outpatients. Arch Gen Psychiatry. 2003 Oct;60(10):1043-52. https://doi.org/10.1001/archpsyc.60.9.1043. Accessed September 27, 2021.
40. Haning III, WF (American Society of Addiction Medicine, Rockville, MD). Letter to: Honorable Alex M. Azar II (US Department of Health and Human Services, Washington, DC) 2020 Jul 6. 2 p. Available from: https://www.asam.org/docs/default-source/advocacy/letters-and-comments/20-07-06-asam-letter-to-hon-alex-azar---motivational-incentives.pdf. Accessed September 27, 2021.
41. Ronsley C, Nolan S, Knight R, Hayashi K, Klimas J, Walley A, Wood E, Fairbairn N. Treatment of stimulant use disorder: A systematic review of reviews. PloS one. 2020 Jun 18;15(6):e0234809. https://doi.org/10.1371/journal.pone.0234809. Accessed September 27, 2021.
42. Knapp WP, Soares BG, Farrel M, Lima MS. Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003023. Update in: Cochrane Database Syst Rev. 2015;4:CD003023. https://doi.org/10.1002/14651858.cd003023.pub2. Accessed September 27, 2021.
43. AshaRani PV, Hombali A, Seow E, Ong WJ, Tan JH, Subramaniam M. Non-pharmacological interventions for methamphetamine use disorder: A systematic review. Drug and Alcohol Depend. 2020 Jul 1;212:108060. https://doi.org/10.1016/j.drugalcdep.2020.108060. Accessed September 27, 2021.
44. Brown HD, DeFulio A. Contingency management for the treatment of methamphetamine use disorder: A systematic review. Drug and Alcohol Depend. 2020 Sep 21:108307. https://doi.org/10.1016/j.drugalcdep.2020.108307. Accessed September 27, 2021.
45. Menza TW, Jameson DR, Hughes JP, Colfax GN, Shoptaw S, Golden MR. Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: A randomized controlled trial. BMC Public Health. 2010 Dec 20;10:774-786. https://doi.org/10.1186/1471-2458-10-774. Accessed September 27, 2021.
46. Peirce JM, Petry NM, Stitzer ML, Blaine J, Kellogg S, Satterfield F, Schwartz M, Krasnansky J, Pencer E, Silva-Vazquez L, Kirby KC, Royer-Malvestuto C, Roll JM, Cohen A, Copersino ML, Kolodner K, Li R. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A National Drug Abuse Treatment Clinical Trials Network study. Arch Gen Psychiatry. 2006 Feb;63(2):201-8. https://doi.org/10.1001/archpsyc.63.2.201. Accessed September 27, 2021.
47. Petry NM, Alessi SM, Rash CJ. A randomized study of contingency management in cocaine-dependent patients with severe and persistent mental health disorders. Drug Alcohol Depend. 2013 Jun 1;130(1-3):234-7. Epub 2012 Nov 20. https://doi.org/10.1016/j.drugalcdep.2012.10.017. Accessed September 27, 2021.
48. Bentzley BS, Han SS, Neuner S, Humphreys K, Kampman KM, Halpern CH. Comparison of treatments for cocaine use disorder among adults: A systematic review and meta-analysis. JAMA Netw Open. 2021 May 3;4(5):e218049. https://doi.org/10.1001/jamanetworkopen.2021.8049. Accessed September 27, 2021.
49. Miller WR, Meyers RJ, Hiller-Sturmhöfel S. The community-reinforcement approach. Alcohol Res Health. 1999;23(2):116-21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760430/. Accessed September 27, 2021.
50. Higgins ST, Heil SH, Dantona R, Donham R, Matthews M, Badger GJ. Effects of varying the monetary value of voucher-based incentives on abstinence achieved during and following treatment among cocaine-dependent outpatients. Addiction. 2007 Feb;102(2):271-81. https://doi.org/10.1111/j.1360-0443.2006.01664.x. Accessed September 27, 2021.
51. National Institute on Drug Abuse. Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine, Opioids). https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/community-reinforcement-approach-vouchers. Accessed September 27, 2021.
52. Randall M, Finkelstein SH. Integration of cognitive behavioral therapy into psychiatric rehabilitation day programming. Psychiatr Rehabil J. 2007 Winter;30(3):199-206. https://doi.org/10.2975/30.3.2007.199.206. Accessed September 27, 2021.
53. Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Nuro KF, Gordon MA, Portnoy GA, Rounsaville BJ. Computer-assisted delivery of cognitive-behavioral therapy for addiction: A randomized trial of CBT4CBT. Am J Psychiatry. 2008 Jul;165(7):881-8. https://doi.org/10.1176/appi.ajp.2008.07111835. Accessed September 27, 2021.
54. Polcin DL, Bond J, Korcha R, Nayak MB, Galloway GP, Evans K. Randomized trial of intensive motivational interviewing for methamphetamine dependence. J Addict Dis. 2014;33(3):253-65. https://doi.org/10.1080/10550887.2014.950029. Accessed September 27, 2021.
55. DiClemente CC, Corno CM, Graydon MM, Wiprovnick AE, Knoblach DJ. Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychol Addict Behav. 2017 Dec;31(8):862-887. https://doi.org/10.1037/adb0000318. Accessed September 27, 2021.
56. Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, Rollnick S. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013 Nov;93(2):157-68. Epub 2013 Aug 1. https://doi.org/10.1016/j.pec.2013.07.012. Accessed September 27, 2021.
57. Rawson RA, Chudzynski J, Mooney L, Gonzales R, Ang A, Dickerson D, Penate J, Salem BA, Dolezal B, Cooper CB. Impact of an exercise intervention on methamphetamine use outcomes post-residential treatment care. Drug Alcohol Depend. 2015 Nov 1;156:21-28. Epub 2015 Sep 3. https://dx.doi.org/10.1016%2Fj.drugalcdep.2015.08.029. Accessed September 27, 2021.
58. Priddy SE, Howard MO, Hanley AW, Riquino MR, Friberg-Felsted K, Garland EL. Mindfulness meditation in the treatment of substance use disorders and preventing future relapse: Neurocognitive mechanisms and clinical implications. Subst Abuse Rehabil. 2018 Nov 16;9:103-114. https://doi.org/10.2147/sar.s145201. Accessed September 27, 2021.
59. Glasner-Edwards S, Mooney LJ, Ang A, Garneau HC, Hartwell E, Brecht ML, Rawson RA. Mindfulness based relapse prevention for stimulant dependent adults: A pilot randomized clinical trial. Mindfulness (N Y). 2017 Feb;8(1):126-135. Epub 2016 Aug 4. https://doi.org/10.1007/s12671-016-0586-9. Accessed September 27, 2021.
60. McMahan VM, Kingston S, Newman A, Stekler JD, Glick SN, Banta-Green CJ. Interest in reducing methamphetamine and opioid use among syringe services program participants in Washington State. Drug Alcohol Depend. 2020 Nov 1;216:108243.. Epub 2020 Aug 23. https://doi.org/10.1016/j.drugalcdep.2020.108243. Accessed September 27, 2021.
61. Karila L, Weinstein A, Aubin HJ, Benyamina A, Reynaud M, Batki SL. Pharmacological approaches to methamphetamine dependence: A focused review. Br J Clin Pharmacol. 2010 Jun;69(6):578-92. https://dx.doi.org/10.1111%2Fj.1365-2125.2010.03639.x. Accessed September 27, 2021.
62. Trivedi MH, Walker R, Ling W, dela Cruz A, Sharma G, Carmody T, Ghitza UE, Wahle A, Kim M, Shores-Wilson K, Sparenborg S. Bupropion and naltrexone in methamphetamine use disorder. New England Journal of Medicine. 2021 Jan 14;384(2):140-53. https://www.nejm.org/doi/full/10.1056/NEJMoa2020214. Accessed September 27, 2021.
63. Siefried KJ, Acheson LS, Lintzeris N, Ezard N. Pharmacological treatment of methamphetamine/amphetamine dependence: A systematic review. CNS Drugs. 2020 Apr;34(4):337-365. https://doi.org/10.1007/s40263-020-00711-x. Accessed September 27, 2021.
64. Chan B, Freeman M, Kondo K, Ayers C, Montgomery J, Paynter R, Kansagara D. Pharmacotherapy for methamphetamine/amphetamine use disorder-a systematic review and meta-analysis. Addiction. 2019 Dec;114(12):2122-2136. Epub 2019 Sep 12. https://doi.org/10.1111/add.14755. Accessed November 17, 2021.
65. Pilowsky DJ, Wu LT, Burchett B, Blazer DG, Woody GE, Ling W. Co-occurring amphetamine use and associated medical and psychiatric comorbidity among opioid-dependent adults: Results from the Clinical Trials Network. Subst Abuse Rehabil. 2011;2:133. https://dx.doi.org/10.2147%2FSAR.S20895. Accessed September 27, 2021.
66. O’Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL. Vital Signs: Characteristics of drug overdose deaths involving opioids and stimulants — 24 states and the District of Columbia, January–June 2019. MMWR Morb Mortal Wkly Rep. 2020;69:1189–1197. http://dx.doi.org/10.15585/mmwr.mm6935a1. Accessed September 27, 2021.
67. Hedegaard H, Miniño AM, Warner M. Co-involvement of opioids in drug overdose deaths involving cocaine and psychostimulants. NCHS Data Brief No 406. Hyattsville, MD: National Center for Health Statistics; 2021 Apr. https://doi.org/10.15620/cdc:103966. Accessed September 27, 2021.
68. Fingar KR, Owens PL. Opioid-related and stimulant-related adult inpatient stays, 2012-2018. Healthcare Cost and Utilization Project (HCUP) Statistical Brief #271. Rockville, MD: Agency for Healthcare Research and Quality; 2021 Feb. www.hcup-us.ahrq.gov/reports/statbriefs/sb271-Stimulant-Opioid-Hospitalizations-2012-2018.jsp. Accessed September 27, 2021.
69. Riezzo I, Fiore C, De Carlo D, Pascale N, Neri M, Turillazzi E, Fineschi V. Side effects of cocaine abuse: multiorgan toxicity and pathological consequences. Curr Med Chem. 2012;19(33):5624-46. https://doi.org/10.2174/092986712803988893. Accessed September 27, 2021.
70. Maraj S, Figueredo VM, Lynn Morris D. Cocaine and the heart. Clin Cardiol. 2010 May;33(5):264-9. https://doi.org/10.1002/clc.20746. Accessed September 27, 2021.
71. National Institute on Drug Abuse. What Are The Long-Term Effects of Methamphetamine Misuse?. https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse. Accessed September 27, 2021.
72. Spronk DB, van Wel JH, Ramaekers JG, Verkes RJ. Characterizing the cognitive effects of cocaine: a comprehensive review. Neurosci Biobehav Rev. 2013 Sep;37(8):1838-59. Epub 2013 Jul 20. https://doi.org/10.1016/j.neubiorev.2013.07.003. Accessed September 27, 2021.
73. Volkow ND, Chang L, Wang GJ, Fowler JS, Leonido-Yee M, Franceschi D, Sedler MJ, Gatley SJ, Hitzemann R, Ding YS, Logan J, Wong C, Miller EN. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry. 2001 Mar;158(3):377-82. https://doi.org/10.1176/appi.ajp.158.3.377. Accessed September 27, 2021.
74. National Institute on Drug Abuse. Methamphetamine Abuse Linked to Impaired Cognitive and Motor Skills Despite Recovery of Dopamine Transporters. https://archives.drugabuse.gov/news-events/nida-notes/2002/04/methamphetamine-abuse-linked-to-impaired-cognitive-motor-skills-despite-recovery-dopamine. Accessed September 27, 2021.
75. Salo R, Flower K, Kielstein A, Leamon MH, Nordahl TE, Galloway GP. Psychiatric comorbidity in methamphetamine dependence. Psychiatry Res. 2011 Apr 30;186(2-3):356-61. Epub 2010 Nov 4. https://doi.org/10.1016/j.psychres.2010.09.014. Accessed September 27, 2021.
76. Westover AN, McBride S, Haley RW. Stroke in young adults who abuse amphetamines or cocaine: A population-based study of hospitalized patients. Arch Gen Psychiatry. 2007;64(4):495–502. https://doi.org/10.1001/archpsyc.64.4.495. Accessed September 27, 2021.
77. Lappin JM, Darke S, Farrell M. Stroke and methamphetamine use in young adults: A review. J Neurol Neurosurg Psychiatry. 2017 Dec;88(12):1079-1091. Epub 2017 Aug 23. https://doi.org/10.1136/jnnp-2017-316071. Accessed September 27, 2021.
78. Westover AN, McBride S, Haley RW. Stroke in young adults who abuse amphetamines or cocaine: A population-based study of hospitalized patients. Arch Gen Psychiatry. 2007 Apr;64(4):495-502. https://doi.org/10.1001/archpsyc.64.4.495. Accessed September 27, 2021.
79. Han B, Compton WM, Jones CM, Einstein EB, Volkow ND. Methamphetamine use, methamphetamine use disorder, and associated overdose deaths among US adults. JAMA Psychiatry. 2021 Sep 22:e212588. Epub ahead of print. https://doi.org/10.1001/jamapsychiatry.2021.2588. Accessed September 27, 2021.
80. Wendell AD. Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol. 2013;56(1):91-96. https://doi.org/10.1097/grf.0b013e31827feeb9. Accessed September 27, 2021.
81. Cain MA, Bornick P, Whiteman V. The maternal, fetal, and neonatal effects of cocaine exposure in pregnancy. Clin Obstet Gynecol. 2013;56(1):124-132. https://doi.org/10.1097/grf.0b013e31827ae167. Accessed September 27, 2021.
82. Kalaitzopoulos DR, Chatzistergiou K, Amylidi AL, Kokkinidis DG, Goulis DG. Effect of methamphetamine hydrochloride on pregnancy outcome: A systematic review and meta-analysis. J Addict Med. 2018 May/Jun;12(3):220-226. https://doi.org/10.1097/adm.0000000000000391. Accessed September 27, 2021.
83. Smid MC, Metz TD, Gordon AJ. Stimulant use in pregnancy: An under-recognized epidemic among pregnant women. Clin Obstet Gynecol. 2019 Mar;62(1):168-184. https://doi.org/10.1097/grf.0000000000000418. Accessed September 27, 2021.
84. LaGasse LL, Derauf C, Smith LM, Newman E, Shah R, Neal C, Arria A, Huestis MA, DellaGrotta S, Lin H, Dansereau LM, Lester BM. Prenatal methamphetamine exposure and childhood behavior problems at 3 and 5 years of age. Pediatrics. 2012 Apr;129(4):681-8. Epub 2012 Mar 19. https://doi.org/10.1542/peds.2011-2209. Accessed September 27, 2021.
85 Diaz SD, Smith LM, LaGasse LL, Derauf C, Newman E, Shah R, Arria A, Huestis MA, Della Grotta S, Dansereau LM, Neal C, Lester BM. Effects of prenatal methamphetamine exposure on behavioral and cognitive findings at 7.5 years of age. J Pediatr. 2014 Jun;164(6):1333-8. Epub 2014 Mar 12. https://doi.org/10.1016/j.jpeds.2014.01.053. Accessed September 27, 2021.
86. Roehler DR, Olsen EO, Mustaquim D, Vivolo-Kantor AM. Suspected nonfatal drug-related overdoses among youth in the US: 2016–2019. Pediatrics. 2021 Jan 1;147(1):e2020003491. https://doi.org/10.1542/peds.2020-003491. Accessed September 27, 2021.
87. McCabe SE, Veliz P, Wilens TE, Schulenberg JE. Adolescents' prescription stimulant use and adult functional outcomes: A national prospective study. J Am Acad Child Adolesc Psychiatry. 2017 Mar;56(3):226-233.e4. Epub 2016 Dec 25. https://doi.org/10.1016/j.jaac.2016.12.008. Accessed September 27, 2021.
88. Volkow ND, Han B, Einstein EB, Compton WM. Prevalence of substance use disorders by time since first substance use among young people in the US. JAMA Pediatr. 2021;175(6):640–643. https://doi.org/10.1001/jamapediatrics.2020.6981. Accessed September 27, 2021.
89. Petry NM. Contingency management treatments: Controversies and challenges. Addiction. 2010 Sep;105(9):1507-9.https://dx.doi.org/10.1111%2Fj.1360-0443.2009.02879.x. Accessed September 27, 2021.
90. Glass JE, Nunes EV, Bradley KA. Contingency management: A highly effective treatment for substance use disorders and the legal barriers that stand in its way. https://www.healthaffairs.org/do/10.1377/hblog20200305.965186/full/. Accessed September 27, 2021.