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.
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).
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 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 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?
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 – 1.06 MB)
- 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
- 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 - 1.06 MB)
- Rural Communities Opioid Response Program – Technical Assistance: Treatment for Individuals who Use Stimulants (TRUST) Patient Workbook (PDF – 4 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
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