Management of stimulant use disorders in adults

Stimulant use disorder is characterized by a pattern of misuse of stimulants (eg, cocaine, methamphetamine, or diverted pharmaceutical stimulants) that are taken in greater amounts for longer than intended. There are unsuccessful attempts to cut down despite desire and a great amount of time is spent craving, obtaining, using, or recovering from its effects. The recurrent use leads to failure fulfilling obligations, reduction in social, recreational, or occupational activities and use in physically hazardous situations. Tolerance or withdrawal may be present.

Mild stimulant use disorder has 2 to 3 of the diagnostic criteria.
Moderate stimulant use disorder has 4 to 5 of the diagnostic criteria.
Severe stimulant use disorder has up to 6 of the diagnostic criteria.

Counseling types (refer to UpToDate content for further discussion of counseling for substance use disorders):

Individual or group substance use disorder counseling includes cognitive therapy, supportive therapy, and behavior therapy directed at reaching the goals mutually decided upon.
Motivational interviewing is a counseling type that guides a person through a patient-centered conversation to help them consider whether there is a health-related behavior to change, how to do it, and why to do it.
Intensive outpatient is a program of variable length that includes group and individual counseling.
Contingency management provides incentives to individuals with substance use disorder contingent upon treatment attendance and/or verifying abstinence.
Continuing care model for addiction includes routine assessment and treatment customized to the needs and preferences of the individual.

* Stimulant use disorders include cocaine use disorder, methamphetamine use disorder, and diverted pharmaceutical stimulants. Refer to legend for diagnosis and severity of stimulant use disorder.

¶ While we encourage complete and sustained remission from stimulants in all individuals treated for stimulant use disorder, we use shared decision making to establish achievable goals that lead to harm reduction and improvement in quality of life. Patients may find significant improvement in their lives with only a reduction of use.

Δ When contingency management is unavailable, cognitive-behavioral therapy (with intensive outpatient therapy) is an acceptable alternative.

◊ Patients occasionally use more than one stimulant and may be unclear which is the primary problematic one. In these cases we reinforce the need for an accurate history and, after using shared decision making, treatment is directed at the one thought to be the stimulant of primary misuse. There are no safety considerations if the medication used for treatment of cocaine use disorder is used for amphetamine-type stimulants or vice versa.

§ For each agent, we treat and monitor for at least three months prior to deciding on clinical efficacy.

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Management of stimulant use disorders in adults