Key Takeaways

Treatment of Stimulant Use Disorder

Stimulant Intoxication and Withdrawal

Secondary and Tertiary Prevention

Appendices

Document Overview

Design and created by Guideline Central in participation with the American Academy of Addiction Psychiatry and American Society of Addiction Medicine.

Management of Stimulant Use Disorder

American Society of Addiction Medicine

American Academy of Addiction Psychiatry

Publication Date: Nov 8, 2023

Page Last Updated: May 5, 2026

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:

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).
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.
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.
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).
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).
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.
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).

Appendix J. Principles of Drug Testing During Withdrawal Management

This appendix outlines the major principles in ASAM’s Appropriate Use of Drug Testing in Clinical Addiction Medicine consensus statement. For additional guidance, please refer to the full statement.

Drug testing can be used to help inform clinical decision-making for patients with SUD or at risk for substance withdrawal.
Drug testing can neither diagnose nor rule out SUD.
Drug test results should be used in combination with patient history, physical exam, and psychosocial assessment to determine the patient’s care plan.
Drug testing can be an important supplement to patient self-report because patients may not be aware of the composition of the substances they have used.
Drug test selection should be individualized based on specific patients and clinical scenarios. Before choosing the type of test and matrix, the clinician should determine the questions they are seeking to answer and consider the benefits and limitations of each test and matrix (eg, urine, blood, saliva, hair). The methods used will impact interpretation of the results:
- Each matrix has advantages and disadvantages (eg, ease of collection, window of detection, susceptibility to tampering).
- Tests are designed to measure if specific substances have been used within particular windows of time.
- Selection of a drug testing panel should be based on the patient’s self-reported use, prescribed medications, and substances commonly used in the geographic area and by the patient’s peer group.
  - Note that many drug test panels do not detect fentanyl and fentanyl analogs.
- It is important to understand the difference between presumptive drug tests, which are routinely used for point-of-care testing, versus definitive tests, which are used to confirm the results of presumptive tests and rule out false positives.
  - Definitive testing is done by CLIA-certified laboratories.
Definitive testing should be used when the results inform clinical decisions with major clinical or nonclinical implications for the patient (eg, changes in medications or legal status).
Drug test results should be interpreted by a clinician whose scope of practice includes ordering drug tests and interpreting drug test results and who will consider the limitations of the specific test used.
Discrepancies between patient self-report and drug tests should be discussed with the patient.
Clinicians should keep drug test results confidential to the extent permitted by law.
Providers should be aware of the adverse legal and social consequences of detecting substance use via drug testing in pregnant patients. The patient should be made aware of local and state reporting requirements before drug tests are conducted.

Appendix N. Medications for Managing Intoxication

Agent/Class	Mechanism	Example Dosing	Indications	Other considerations
Sedatives
Benzodiazepines (BZDs) (first line)	GABAergic	Initial dosing: Lorazepam 1–2 mg IV based on clinical signs and symptoms and duration of effects Diazepam 5–10 mg PO for less severe symptoms based on patient parameters Midazolam 5 mg IM or 0.01-0.05 mg/kg IV for acute agitation in adult patients Redosing frequency and dose should be guided by the degree and duration of the clinical effects of the initial dose	Excitatory symptoms Anxiety/Agitation Neuromuscular excitation Seizures	Parenteral vs. PO administration based on signs and symptom severity and drug availability (eg, parenteral BZD shortages). IM administration allows for administration in agitated patients without IV access. Lorazepam has very slow IM onset (15–30 min) Midazolam has very rapid IV onset, allowing for easy titration, and a relatively fast IM onset If psychosis is primary symptom, antipsychotics should be considered primarily or adjunctively
Phenobarbital (PBO)	GABAergic	Incremental 130–260 mg parenteral/IV/PO based on symptoms and patient parameters Loading strategy (eg, 5-10 mg/kg) Titrate based on clinical effects	BZD shortages or contraindications Patient not responding to escalating doses of BZDs Severe sympathomimetic intoxication	High oral bioavailability; PO dosing can be similar to parenteral dosing Onset of effects, while slower than IV, is still fairly quick compared to other PO medications
Propofol	GABAergic + NMDA receptor antagonism	10–50 μg/kg/min based on symptoms and patient parameters	For critically ill patients in the ICU Severe sympathomimetic intoxication not responding to other agents	Patients can be administered BZDs, PBO, and/or propofol concomitantly Intubation is almost always required for propofol administration
Sympatholytics
Clonidine	Alpha-2 agonism +/- other	0.1–0.2 mg PO every 4 hours as needed	Anxiety	Useful medication adjunct to BZDs Maintain hydration to avoid orthostatic symptoms
Dexmedetomidine	Alpha-2 agonism	Start at 0.2–0.4 μg/kg/hr and titrate every 30 min up to maximum of 1.5 μg/kg/hr	For critically ill patients in the ED or ICU as primary or secondary medication for sedation	Useful medication adjunct to BZDs or other sedation agents Onset of effects generally 30–60 min Sedation without impairments in ventilation
Antipsychotics
Butyrophenones (2nd gen)	Dopamine antagonism	Haloperidol or droperidol 5 mg IM	Acute agitation with psychosis Agitation not responding to BZDs Toxic psychosis	Consider atypical or newer generation antipsychotics as alternatives Consider risk of QT prolongation
Atypical	Dopamine antagonism +/- other	Olanzapine 5 mg PO Quetiapine 50–100 mg PO at night	Anxiety or agitation with psychotic features Stimulant-induced psychosis Stimulant-induced sleep derangements	Consider risk of QT prolongation For olanzapine, degree of symptoms to balance need for PO vs. IM
Other
Keatamine	NMDA receptor antagonism	1–5 mg/kg IM depending on degree of agitation	For severe agitation as primary or secondary agent	Rapid IM onset of action compared to other agents

The information in this table is intended to guide management of stimulant intoxication in a variety of settings. The choice of medication, medication dosing (including initial and redosing), and route of administration should be guided by the patient’s signs and symptoms, degree of intoxication, the level of care, and the resources of the setting. This does not represent a comprehensive list but rather provides illustrative examples of medications discussed in the narrative.

BZD, benzodiazepine; ED, emergency department; ICU, intensive care unit; IM, intramuscular; IV, intravenous; NMDA, N-methyl-D-aspartate; PBO, phenobarbital; PO, per os (by mouth/oral)

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Implications for:	Strong Recommendation (S)	Conditional Recommendation (C)
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not.
Clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their values and preferences.
Policy	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

Certainty in the Evidence
High	H	Low	L
Moderate	M	Very Low	VL

Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).

Document Overview

Document Title: Management of Stimulant Use Disorder

Authoring Societies

American Society of Addiction Medicine

American Academy of Addiction Psychiatry

Document Publication Date: Nov 8, 2023

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: downloads.asam.org/sitefinity-production-blobs/docs/default-source/quality-science/stud_guideline_document_final.pdf?sfvrsn=71094b38_1

Source Citation: Clinical Guideline Committee (CGC) Members; ASAM Team; AAAP Team; IRETA Team. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024 May-Jun 01;18(1S Suppl 1):1-56. doi: 10.1097/ADM.0000000000001299. PMID: 38669101; PMCID: PMC11105801.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) developed this Clinical Practice Guideline on the Management of Stimulant Use Disorder (hereafter referred to as the Guideline) to provide evidence-based strategies and standards of care for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use.

Scope: Assessment and Screening, Counseling, Diagnosis, Management, Rehabilitation, Treatment

Keywords: SUD, StUD, amphetamine, cocaine, methamphetamine, stimulant use disorder

Target Patient Population: Patients diagnosed with or at risk of stimulant use disorder

Target Provider Population: clinicians who provide treatment for StUD, stimulant intoxication, or stimulant withdrawal in both specialty and primary care settings

Inclusion Criteria: Male, Female, Adolescent, Adult, Older Adult

Health Care Settings: Ambulatory, Outpatient

Intended Users: Addiction Treatment Specialist, Counselor, Nurse, Nurse Practitioner, Physician, Physician Assistant, Psychologist

Recommendation Development Processes & Methodology

PICO Questions

What components should be included in the initial assessment for patients presenting with Stimulant Use Disorder?
What components should be included in the comprehensive assessment for patients with stimulant use disorder?
Should baseline laboratory testing be conducted for all patients with stimulant use disorder or based on clinical assessment of risk factors?
What is the effect of conducting baseline laboratory testing when assessing patients with stimulant use disorder?
What contextual factors and implementation strategies may influence the effects of baseline laboratory testing?
What are the most impactful and appropriate baseline laboratory tests to conduct when assessing patients who misuse use stimulants?What are the most impactful and appropriate baseline laboratory tests to conduct when assessing patients who misuse use stimulants?
Should clinicians routinely request or refer patients with stimulant intoxication or withdrawal for a cardiac evaluation or ECG?
Should clinicians routinely request or refer patients with stimulant use disorder for a cardiac evaluation or ECG?
What is the effect of routine screening for cardiac disorders in patients with stimulant use disorder?
For patients diagnosed with stimulant intoxication or withdrawal, should clinicians routinely request or refer patients for an evaluation of renal function?
For patients diagnosed with stimulant use disorder, should clinicians routinely request or refer patients for an evaluation of renal function?
Is Contingency Management an effective and appropriate treatment for stimulant use disorder?
Does the addition of another treatment to Contingency Management improve outcomes for stimulant use disorder?
What contextual factors and implementation strategies may influence the effects of Contingency Management?
What additional considerations and implementation strategies may influence the effects of Community Reinforcement Approach?
What additional considerations and implementation strategies may influence the effects of cognitive behavioral therapy?
Is the Matrix Model an effective and appropriate treatment for StUD?
Does adding CM to the Matrix Model improve outcomes for StUD?
What additional considerations and implementation strategies may influence the effects of the Matrix Model?
What is the effect of computer-delivered treatment for StUD?
What contextual factors and implementation strategies may influence the effects of computer-delivered treatment?
What is the effect of telehealth-delivered treatment for StUD?
What contextual factors and implementation strategies may influence the effects of telehealth-delivered treatment?
Is bupropion safe and effective at reducing stimulant use and increasing treatment retention in patients with cocaine use disorder?
Is topiramate safe and effective at reducing stimulant use and increasing treatment retention in patients with cocaine use disorder?
Is bupropion safe and effective at reducing stimulant use and increasing treatment retention in patients with ATS use disorder?
Is the combination pharmacotherapy of bupropion and naltrexone safe and effective at reducing stimulant use and increasing treatment retention in patients with ATS use disorder?
What contextual factors and implementation strategies may influence the effects of bupropion + naltrexone?
What contextual factors and implementation strategies may influence the effects of bupropion + naltrexone?
Is topiramate safe and effective at reducing stimulant use and increasing treatment retention in patients with amphetamine-type stimulant use disorder?
Is mirtazapine a safe and effective treatment for amphetamine-type stimulant use disorder?
Is modafinil a safe and effective treatment for patients with cocaine use disorder?
Is the combination pharmacotherapy of topiramate and Extended-Release Mixed Amphetamine Salts safe and effective treatment for patients with cocaine use disorder?
What contextual factors and implementation strategies may influence the effects of topiramate + MAS-ER?
Are long-acting amphetamine formulations of prescription psychostimulants safe and effective at reducing stimulant use and increasing treatment retention in patients with cocaine use disorder?
Are long-acting methylphenidate formulations or prescription psychostimulants safe and effective at reducing stimulant use and increasing treatment retention in patients with amphetamine-type stimulant use disorder?
What are the most effective and appropriate behavioral interventions for the treatment of stimulant use disorder in patients with co-occurring psychiatric disorders?
What contextual factors and implementation strategies may influence the effects of behavioral interventions?
Should clinicians use pharmacotherapy to treat psychosis or mania if it is unclear whether the condition is preexisting or stimulant-induced?
What contextual factors and implementation strategies may influence the decision to use pharmacotherapy?
What are the most effective and appropriate interventions for treating psychosis in patients with stimulant use disorder?
What is the optimal duration of antipsychotic treatment for persons who are presumed to be experiencing stimulant-induced psychosis or mania?
What is the clinical effectiveness of different antipsychotic tapering strategies?
Should clinicians use pharmacotherapy to treat depression, anxiety, insomnia, and/or attentional problems in patients with stimulant use disorder if it is unclear whether the condition is preexisting or stimulant-induced?
What contextual factors and implementation strategies may influence the decision to use pharmacotherapy?
What are the most effective and appropriate pharmacotherapies for treating depression, anxiety, insomnia, and/or attentional problems in patients with stimulant use disorder?
Should patients change or discontinue treatment for a co-occurring disorder when initiating treatment for StUD?
What contextual factors and implementation strategies may influence the decision to modify the existing treatment plan?
What are the most effective and appropriate interventions to treat ADHD in patients with StUD?
Are stimulant medications safe and effective to treat ADHD in patients with StUD?
What contextual factors and implementation strategies may influence the safety and effectiveness of attention-deficit/hyperactivity disorder treatment?
When prescribing stimulant medications to a patient with co-occurring StUD and ADHD, what implementation strategies may influence the effect and appropriateness of treatment?
When prescribing stimulant medications to an adolescent or young adult patient with co-occurring StUD and ADHD, what implementation strategies may influence the effect and appropriateness of treatment?
What is the most effective and appropriate use of toxicology testing for the treatment of StUD, stimulant intoxication, and stimulant withdrawal in adolescent and young adult patients?
What contextual factors and implementation strategies may influence the effects of toxicology testing?

Supplemental Methodology Resources: Evidence Tables Data Supplement Data Supplement

Number of Source Documents: 398

Includes peer/external review process?: Yes

Includes public comment process?: Yes

Methodologist involvement?: Yes

Patient involvement?: Yes

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

Management of Stimulant Use Disorder

Key Takeaways

Treatment of Stimulant Use Disorder

Assessment

Initial Assessment

Comprehensive Assessment

Behavioral Treatment

Technology-Based Interventions

Pharmacotherapy

Non-Psychostimulant Medication

Cocaine Use Disorder: Bupropion

Cocaine Use Disorder: Topiramate

Amphetamine-Type Stimulant Use Disorder: Bupropion

Amphetamine-Type Stimulant Use Disorder: Bupropion and Naltrexone

Amphetamine-Type Stimulant Use Disorder: Topiramate

Amphetamine-Type Stimulant Use Disorder: Mirtazapine

Psychostimulant Medication

General Psychostimulant Medication

Cocaine Use Disorder: Modafinil

Cocaine Use Disorder: Topiramate and Extended-Release Mixed Amphetamine Salts

Cocaine Use Disorder: Amphetamine Formulation

Amphetamine-Type Stimulant Use Disorder: Methylphenidate Formulations

Co-occurring Disorders: General Guidance

Concurrent Management of StUD and ADHD

Population-Specific Considerations

Adolescents and Young Adults

Adolescent and Young Adult Assessment and Treatment Planning

Adolescent and Young Adult Treatment

Pregnant and Postpartum Patients

Pregnant and Postpartum Patients Assessment

Pregnant and Postpartum Patients Treatment

Breastfeeding

Additional Population-Specific Considerations

Sexual Orientation and Gender Identity

Patients Involved in the Criminal and/or Legal Systems

Patients Experiencing Homelessness or Unstable Housing

Stimulant Intoxication and Withdrawal

Assessment and Diagnosis

Initial Assessment

Comprehensive Assessment

Toxicology Testing

Setting Determination

Managing Stimulant Intoxication and Withdrawal

Behavioral and Psychiatric Symptoms of Stimulant Intoxication

Hyperadrenergic Symptoms of Stimulant Intoxication

Acute Issues and Complications

Chest Pain

QRS Widening

Seizure

Follow Up

Secondary and Tertiary Prevention

Screening

Assessment

Early Intervention for Risky Stimulant Use

Interventions to Reduce Risky Stimulant Use

Referral to Treatment for Stimulant Use Disorder

Harm Reduction

Harm Reduction Education

Overdose Prevention and Reversal

Safer Sexual Practices and Contraception

Injection Drug Use

HIV Preexposure Prophylaxis

Oral Health

Nutrition

Appendices

Appendix C. Differential Diagnosis for Agitation and Psychosis

Appendix H. Substance Use Disorder Biopsychosocial Assessment

Appendix I. Baseline Laboratory Testing

Appendix J. Principles of Drug Testing During Withdrawal Management

Appendix L. Acute Issues and Complications of Stimulant Intoxication and Withdrawal

Appendix M. Non-acute Issues and Complications of Stimulant Use

Appendix N. Medications for Managing Intoxication

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology