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Stimulant Use Disorders and Behavioral Health Integration

Definition

Stimulant use disorders are substance use disorders (SUDs) that involve cocaine, methamphetamine, and other amphetamine-type stimulants (e.g., MDMA or prescription stimulants).

Adverse Effects

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

Growing Problem

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 (IBH) 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 IBH care for stimulant use in primary and ambulatory care practices.

Nonpharmaceutical Interventions

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

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).

Community Reinforcement Approach

Community Reinforcement Approach (CRA) is a behavioral therapy approach that aims to make a substance-free 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

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:

Pharmaceutical Interventions

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

  • Bupropion
  • Mirtazapine
  • XR Naltrexone-Bupropion
  • Methylphenidate
  • Topiramate

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.

Polysubstance Use

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:

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:

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:

High-Risk Populations

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.

Pregnant Women

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>:

Adolescents

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:

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:

Clinical Guidance

Screening Tools

Treatment Materials

Services and Supports

Training and Education

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.

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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.

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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.

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22. National Institute on Drug Abuse. Overdose Death Rates. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates. Accessed October 18, 2021.

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