Management of Stimulant Use Disorder

This Guideline focuses on the identification, diagnosis, treatment, and promotion of recovery for patients with StUD, stimulant intoxication, and stimulant withdrawal. It also includes recommendations related to screening for risky stimulant use and secondary and tertiary prevention of StUD. Recommendations that address general practice for all substance use disorders (SUDs) are not included, with a few exceptions. The following are seven key takeaways of this Guideline:

1. Contingency management (CM) has demonstrated the best effectiveness in thetreatment of StUDs compared to any other intervention studied and represents thecurrent standard of care. CM can be combined with other psychosocial interventionsand behavioral therapies, such as community reinforcement approach (CRA) andcognitive behavioral therapy (CBT) (See Recommendations 5-6).
2. Pharmacotherapies, including psychostimulant medications, may be utilized off-label to treat StUD (See Recommendations 9-20).
   • When prescribing controlled medications, clinicians should closely monitorpatients and perform regular ongoing assessment of risks and benefits foreach patient.
   • Psychostimulant medications should only be prescribed to treat StUD by:
     • physician specialists who are board certified in addiction medicine oraddiction psychiatry; and
     • physicians with commensurate training, competencies, and capacityfor close patient monitoring.
3. Co-occurring conditions—including but not limited to attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, eating disorders, and other SUDs—are common in patients with StUD. Any co-occurring psychiatric disorders or SUDs should be treated concurrently alongside StUD with care coordination (See Recommendations 21-25).
   • Evidence supports the use of pharmacotherapy, including psychostimulant medication, to treat ADHD in individuals with co-occurring StUD.
   • Some pharmacotherapies that can be considered to treat StUD off-label have demonstrated efficacy in treating common co-occurring psychiatric disorders and SUDs and can be given additional consideration.
4. Clinicians should provide adolescents and young adults who use stimulants with the same treatment, harm reduction, and recovery support services (RSS) as adults in a developmentally responsive manner (See the Adolescent and Young Adult Section).
5. Acute stimulant intoxication can result in several life-threatening complications that include but are not limited to cardiovascular complications (eg, acute coronary syndrome [ACS], hypertensive emergency, myocardial infarction [MI]), hyperthermia, and acidosis, among others. These acute issues should be addressed immediately in an appropriate level of care (See Recommendations 55-72).
6. Treating symptoms of stimulant withdrawal may help supporting ongoing treatment engagement (See the Stimulant Withdrawal section).
   • Post-acute symptoms of stimulant withdrawal—which include depression, anxiety, insomnia, and paranoia—can last for weeks to months. It is important to assess for and treat these symptoms to reduce the risk for decompensation and return to stimulant use.
7. Secondary and tertiary prevention strategies should be used to reduce harms related to overdose risk, risky sexual practices, injection drug use, oral health, and nutrition (See Recommendations 79-92).