Stimulant use disorder: Psychosocial management

INTRODUCTION — Cocaine, methamphetamine, and other stimulant use disorders (synthetic cathinones, diverted pharmaceutical stimulants) are significant public health problems [1]. People who use cocaine and methamphetamine have elevated rates of medical morbidity and usage of health care resources [2].

Only psychosocial interventions have proven efficacious in reducing stimulant use in patients with stimulant use disorders. However, these treatments alone are insufficient for many patients, prompting research into the neurobiology of stimulant use disorder and trials of several augmenting medications. No medication has consistently shown efficacy for stimulant use disorders.

Psychosocial interventions for stimulant use disorder are reviewed here. Overview of treatment for stimulant use disorder is found separately and in an algorithm (algorithm 1). The epidemiology, clinical manifestations, course, consequences, assessment, and diagnosis of cocaine use disorder and methamphetamine use disorder are also described separately, as are identification and treatment of prescription drug misuse.

●(See "Cocaine use disorder: Epidemiology, clinical features, and diagnosis".)

●(See "Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis".)

●(See "Stimulant use disorder: Treatment overview".)

●(See "Prescription drug misuse: Epidemiology, prevention, identification, and management".)

PRINCIPLES OF TREATMENT — Cocaine, methamphetamine, and diverted pharmaceutical stimulants have similar mechanisms of action and similar manifestations of addiction. This suggests that a treatment with evidence for efficacy in one disorder may be effective in the treatment of another [3].

Continuing care for substance use disorder — We use the principles of continuing care in the treatment of individuals with stimulant use disorder. This is briefly described below and reviewed in detail elsewhere. (See "Continuing care for addiction".)

●We recognize 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.

●We base the intensity and number of psychosocial interventions used to treat a patient with stimulant use disorder on the patient’s clinical status, stimulant use disorder severity, and response to prior treatment.

●We address inadequate response to treatment 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.

Treatment goals — While we encourage complete sustained abstinence from stimulants in all individuals we treat for stimulant use disorder, we use shared decision making in establishing achievable treatment goals that lead to harm reduction and improvement in quality of life. Abstinence may be the most desirable outcome; however, it is often difficult to achieve. Furthermore, patients may find significant improvement in their lives with only a reduction of use [4].

PSYCHOSOCIAL MANAGEMENT AS FIRST LINE — Only psychosocial interventions have demonstrated efficacy in reducing stimulant use in patients with stimulant use disorder [5-7]. Our choice of initial psychosocial management is based on the severity of the disorder. This is defined by the number of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) symptoms of the disorder that are present (algorithm 1) [8].

Mild stimulant use disorder — For individuals with mild stimulant use disorder (two or three criteria) we suggest initial management with individual or group drug counseling. Drug counseling is generally more available than more specialized treatments and often encourages 12-step involvement, which can be helpful to many patients. Additionally, motivational interviewing and mutual help groups may be used at any time during treatment.

Drug counseling — Drug counseling is a broadly defined term that describes individual and group psychosocial interventions that aim to help patients reduce substance use.

●Frequency – Standard outpatient drug counseling typically consists of one or two sessions per week; the duration of an individual counseling session is typically between 30 to 60 minutes, while group sessions are typically 60 to 90 minutes in length.

●Content – The sessions address such topics as helping the patient avoid situations where they are likely to encounter alcohol or drugs, triggers for their use, planning safe social activities, and education about substance use and its effects. The counseling often incorporates elements of cognitive, behavioral, insight-oriented, and/or supportive psychotherapies. The content of the counseling provided in many treatment programs is based on the principles of 12-step programs.

●Duration – We continue individual or group drug counseling for a minimum of three weeks prior to determining effect. In addition to drug counseling, we encourage participation in mutual help groups. Mutual help groups for substance use disorder are described below and in detail separately. (See 'Mutual help groups' below and "Alcohol use disorder: Psychosocial management", section on 'Mutual help groups'.)

●Outcomes – Outpatient drug counseling is the most available and widely used treatment modality; however, the efficacy of standard outpatient drug counseling for cocaine and other stimulant use disorders has not been sufficiently tested. In one study, 487 subjects with cocaine use disorder were randomly assigned to six weeks of treatment with one of four conditions: individual drug counseling plus group drug counseling (IDC/GDC), cognitive-behavioral therapy plus group drug counseling (CBT/GDC), supportive expressive therapy plus group drug counseling (SET/GDC), or group drug counseling alone (GDC) [6]. After six months of treatment, individuals in the IDC/GDC group had the lowest proportion of patients with past month cocaine use as compared with CBT/GDC, GDC alone, or SET/GDC groups (40 versus 58 and 52 and 50 percent, respectively).

Response to drug counseling

●Good response – For individuals with a good response to drug counseling (eg, have achieved treatment goals), we suggest continuing care with ongoing drug counseling and encourage participation in mutual help groups for up to one year. If more intensive treatment is needed, we typically suggest continuing care. (See 'Treatment goals' above and 'Mutual help groups' below and "Continuing care for addiction".)

●Inadequate response – We suggest that individuals with inadequate response to initial management (eg, have not achieved treatment goal), be referred for intensive outpatient treatment preferably with contingency management. (See 'Intensive outpatient treatment' below.)

Moderate or severe stimulant use disorder — For individuals with moderate or severe stimulant use disorder or for those with inadequate response to drug counseling, our preference is intensive outpatient treatment, preferably with contingency management. If contingency management is unavailable, cognitive-behavioral therapy (CBT) is an acceptable alternative treatment. (See "Substance use disorders: Determining appropriate level of care for treatment", section on 'Intensive outpatient programs' and 'Adjunctive treatments' below.)

Intensive outpatient treatment

●Frequency and duration – Intensive outpatient treatments are generally provided daily for at least nine hours per week typically for a period of 8 to 12 weeks.

●Content – In addition to drug counseling, intensive outpatient treatments provide additional treatments such as contingency management or CBT in individual and group formats. Groups tend to focus on education and issues common to individuals who use stimulants (eg, relapse prevention, health promotion), in contrast to individual counseling that focuses more on the unique problems of the individual with stimulant use disorder. Additionally, there are varying levels of family involvement aimed at teaching family members of individuals with stimulant use how to be a supportive advocate for the patient.

●Outcomes – Neither clinical trials nor expert clinicians/researchers have provided a clear consensus on the optimal intensity of intensive outpatient treatment that provides benefit in patients with a stimulant use disorder. Additionally, studies of intensive outpatient treatment programs for stimulant use disorders do not consistently show superior efficacy as compared with standard counselling [9-11]:

•In a clinical trial, 94 subjects with cocaine use disorder were randomly assigned to either a 12-hour per week intensive outpatient treatment or a six-hour per week standard outpatient treatment [11]. At seven months posttreatment, subjects in both groups showed a 52 percent reduction in days of cocaine use and showed improvements in psychiatric functioning and employment. There were no differences in any outcomes between groups.

•A multisite natural cohort analysis of 918 subjects with cocaine use disorder compared 338 subjects receiving intensive outpatient treatment (more than nine hours per week) with 580 patients receiving standard treatment (one or two sessions up to four hours per week) over six months [9]. Groups experienced a similar reduction of over 50 percent in the number of days of cocaine use over the course of the treatment, as well as improvement in overall psychosocial functioning (as measured by increased attendance at work, increased earning, and fewer family/social conflicts).

Adjunctive treatments — These treatments are often given as part of the intensive outpatient program. Their use is based on availability of the treatment and trained clinicians, response to treatment and patient preference. Contingency management and CBT have been found to be efficacious for stimulant use disorder in multiple clinical trials (algorithm 1).

Contingency management — Contingency management is an outpatient intervention for substance use disorders where a reinforcer (eg, incentive or reward) is provided when a patient meets a specific health promoting behavior (eg, abstinence). Contingency management is based on the behavioral principle that rewarded behavior is likely to be repeated. Contingency management is delivered as a component of broader psychosocial treatment rather than alone. Voucher-based reinforcement therapy (VBRT) is a form of contingency management, which provides vouchers redeemable for goods or services, as incentives upon achieving a predetermined therapeutic goal, such as drug abstinence.

VBRT and other forms of contingency management for stimulant use disorders are discussed further elsewhere [12]. (See "Substance use disorders: Principles, components, and monitoring during treatment with contingency management", section on 'Voucher reinforcement' and "Substance use disorders: Training, implementation, and efficacy of treatment with contingency management".)

Meta-analysis and several small randomized trials have shown VBRT, or contingency management to be efficacious in promoting initial abstinence in users of cocaine receiving psychosocial treatment [13-21]. As examples:

●In a meta-analysis of 50 trials including 3301 subjects with cocaine use disorder, contingency management, as compared with other treatments (antidepressants, anticonvulsants, dopamine agonists, psychotherapy, psychostimulants) was associated with the highest percentage of individuals with negative urine test results at treatment end (38 percent; odds ratio 2.13, 95% CI 1.6-2.8) [18].

●In a subgroup analysis of a meta-analysis investigating treatments for amphetamine type stimulant use disorder, treatment with contingency management, as compared with control intervention (eg, counselling) led to a lower risk of stimulant use at treatment end (eight trials, n = 1849; risk ratio 0.82, 95% CI 0.77-0.88) [19].

From among substance use disorders, contingency management appears to be most effective in the treatment of stimulant use disorders [16,22]. However, limitations of VBRT and other forms of contingency management include the cost of the program and the finding that the positive effects of the intervention on cocaine abstinence fade after reinforcers are removed [16,23,24]. Lower cost versions of VBRT using intermittent reinforcement have been shown to be effective [23].

Cognitive-behavioral therapy — CBT is typically used in the treatment of stimulant use disorder when contingency management is unavailable and as part of a more intensive program.

Patients participating in CBT are taught to understand drug use within the context of causes (ie, biologic predisposition, response to stressors) and consequences. The individual is taught to recognize the situations associated with drug use and avoid these whenever possible. Coping skills, such as distraction and recall of negative consequences are reinforced [25].

CBT for substance use disorders is described in greater detail separately. (See "Substance use disorders: Psychosocial management", section on 'Cognitive-behavioral therapy' and "Substance use disorders: Psychosocial management", section on 'CBT-based therapies'.)

Clinical trials suggest that CBT is efficacious in the treatment of stimulant use disorder as compared with treatment as usual and certain psychosocial interventions [5,7,19,26,27]:

●In a subgroup analysis of a meta-analysis investigating treatments for amphetamine type stimulant use disorder, treatment with CBT, as compared with control intervention (eg, counselling) led to a lower risk of drug use at treatment end (six trials, n = 725; risk ratio 0.76, 95% CI 0.64-0.91) [19].

●In a trial, 978 subjects with methamphetamine use disorder were randomly assigned to receive 16 weeks of Matrix treatment, a CBT-based psychotherapy, or treatment as usual [5]. Subjects randomized to Matrix treatment as compared with treatment as usual were 31 percent more likely to have provided urine free test results over the course of the treatment and to have longer periods of abstinence. Measures of drug use and functioning at treatment discharge and six months postadmission indicated improvement in all groups; however, the superiority of the matrix approach as compared with treatment as usual was not maintained at posttreatment or six-month follow-up.

●In a trial, 124 subjects with cocaine use disorder were randomly assigned to coping skills training (a CBT-based intervention) or to a manualized meditation and relaxation training control condition [26]. No difference was seen between groups in the proportion that remained abstinent during the three-month posttreatment follow-up period, but subjects receiving coping skills training had fewer days of cocaine use compared with subjects randomized to the control condition during the period. This difference in days of cocaine use remained present at six months [27].

In contrast, CBT appears to be inferior to combined individual and group counseling. In a trial investigating psychosocial interventions in the treatment of cocaine use disorder, combined individual and group drug counseling as compared with CBT led to a lower proportion of patients with past month cocaine use (40 versus 58 percent, respectively) [6]. (See 'Drug counseling' above.)

Secondary analyses of clinical trials suggest CBT may be more efficacious in patients with cocaine use disorder who have more severe substance use disorder symptoms and in patients with a concurrently depressed mood [7,28].

Limited data suggest that, when efficacious, CBT may provide the most durable treatment effect. In trials showing reductions in cocaine use among patients with cocaine use disorder in response to CBT, cocaine use continued to decrease after the therapy was completed [28,29]. As an example, a one-year follow-up study of 121 individuals with a diagnosis of cocaine use disorder who had been randomized to receive 12-weeks of treatment with CBT, a psychotherapy control condition, or desipramine found that patients originally assigned to receive CBT continued to improve during the follow-up phase of the trial, whereas patients assigned to the other two treatment groups did not [28]. The continuing positive effects of CBT during the follow-up phase was attributed to the continued application of coping skills taught to the patients during the active phase of treatment.

Subsequent treatment

Good response to treatment — For individuals who respond to psychosocial treatment, we continue treatment using the continuing care model for up to one year. We encourage participation in mutual help groups as well. We encourage the individual to return to treatment for recurrence of symptoms or return to use. (See "Continuing care for addiction".)

Poor response — For individuals with poor response to treatment (eg, ongoing use, return to use, recurrence of symptoms) we use pharmacologic augmentation. Limited and inconsistent evidence supports the use of pharmacologic management of stimulant use disorder [30-34]. (See "Stimulant use disorder: Treatment overview", section on 'Pharmacologic management'.)

Additional approaches for all patients — These interventions may be added to the treatment at any point. Mutual help groups are encouraged at all stages of treatment. Evidence for motivational interviewing and mutual help groups, is minimal; however, in our clinical experience each of these interventions can help some individuals with stimulant use disorder to remain abstinent.

Motivational interviewing — Motivational interviewing is a directive, patient-centered counseling approach that aims to help people change problem behaviors. It is used to enhance intrinsic motivation to change by exploring and resolving ambivalence.

Motivational interviewing has been found to be effective for the treatment of substance use disorder in general [35]; however, the efficacy in stimulant use disorders is unclear and further research is needed [36,37].

Motivational interviewing for substance use disorders is described in detail separately. (See "Substance use disorders: Motivational interviewing".)

●A clinical trial randomly assigned 165 subjects with cocaine use disorder to receive either a two-session motivational enhancement therapy (MET) or a meditation relaxation control group followed by either four group sessions of coping skills training or drug education [36]. No differences in cocaine use outcomes were found in patients who received MET compared with the relaxation control.

●A clinical trial randomly assigned 198 subjects with cocaine use disorder to receive a four-session MET intervention or to participate in an assessment control group [37]. There was no difference between groups in cocaine use outcomes at six-month follow-up. A secondary analysis of subjects with more frequent cocaine use found that patients who received MET had lower rates of relapse to cocaine use and greater reduction in cocaine use days.

Mutual help groups — Mutual help groups consist of individuals with a common experience or problem coming together to share their experiences and provide help and support to one another. Mutual help groups are an adjunctive treatment that are encouraged at any time during the treatment of substance use disorders of any kind.

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

●Stimulant use disorder – 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. (See 'Introduction' above.)

●Treatment – 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 'Principles of treatment' above.)

●Mild stimulant use disorder – For individuals with mild stimulant use disorder (two or three criteria), our preference is initial management with individual or group drug counseling. (See 'Mild stimulant use disorder' above.)

•Drug counseling – Drug counseling is a broadly used term to describe individual and group psychosocial interventions that aim to help patients reduce substance use. Counseling typically includes education and may incorporate elements of cognitive, behavioral, insight-oriented, and/or supportive psychotherapies. (See 'Drug counseling' above.)

●Moderate or severe stimulant use disorder – For individuals with moderate or severe stimulant use disorder, we suggest intensive outpatient treatment rather than other forms of outpatient treatment. Our preference is for the outpatient treatment to include a program of contingency management. (See 'Moderate or severe stimulant use disorder' above.)

●Adjunctive treatments – These treatments are often given as part of the intensive outpatient program. Their use is based on availability of the treatment and trained clinicians, response to treatment and patient preference.

•Contingency management – Voucher-based reinforcement therapy, a form of contingency management, is efficacious in promoting initial abstinence in patients with stimulant use disorder. Contingency management is an adjunctive addition to regular treatment such as drug counseling or intensive outpatient treatment. (See 'Contingency management' above.)

•Cognitive-behavioral therapy (CBT) – Patients participating in CBT are taught to understand drug use within the context of antecedents and consequences, to recognize the situations or states associated with drug use, and taught skills to avoid them. Clinical trials suggest that CBT is efficacious in treatment of stimulant use disorder. (See 'Cognitive-behavioral therapy' above.)

●Additional approaches for all – (See 'Additional approaches for all patients' above.)

•Motivational interviewing – Motivational interviewing is a directive, patient-centered counseling approach that aims to help people change problem behaviors. It is used to enhance intrinsic motivation to change by exploring and resolving ambivalence. (See 'Motivational interviewing' above.)

•Mutual help groups – These consist of individuals with common experiences or problems coming together to share their experience and provide support to one another. (See 'Mutual help groups' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges David A Gorelick, MD, PhD, who contributed to an earlier version of this topic review.