An Overview of New Stimulant Use Disorder Guidelines
As rates of stimulant use and stimulant-involved overdoses continue to increase nationally, clinicians are struggling with identifying evidence-based treatments for patients struggling with stimulant use disorders (StUDs). The American Society of Addiction Medicine and American Academy of Addiction Psychiatry recently published the Clinical Practice Guideline on the Management of Stimulant Use Disorder, which provides a comprehensive overview of the literature and offers recommendations for treating StUDs, managing stimulant intoxication and withdrawal, preventing nonmedical use of stimulants from becoming an StUD (secondary prevention), and reducing the harms associated with nonmedical stimulant use (tertiary prevention). This Clinical Guideline provides a roadmap to help clinicians navigate the complexities of managing StUDs. By emphasizing evidence-based interventions, comprehensive care coordination, and a tailored approach to diverse patient populations, these guidelines empower clinicians to deliver effective and compassionate care in a variety of clinical environments.
Key recommendations are described below:
1. Contingency Management (CM): CM has demonstrated the best effectiveness in the treatment of StUDs compared to any other intervention and is recommended as the standard of care. CM is an intervention in which patients are given rewards to reinforce positive behaviors related to treatment engagement or outcomes. Examples of incentives include vouchers, prizes, and access to employment. Integrating CM with psychosocial interventions like the Community Reinforcement Approach and cognitive behavioral therapy enhances treatment outcomes, providing a comprehensive approach to address the complex nature of StUDs.
- Despite the effectiveness of CM, it remains highly underused due to a variety of programmatic and funding barriers. The Guideline offers implementation considerations on pages 44–46 of the document.
2. Pharmacotherapies: There are currently no FDA-approved medications for the treatment of cocaine or amphetamine-type StUDs. However, some medications, including off-label use of psychostimulant medications, have shown promise in helping individuals to reduce or abstain from stimulant use. The Guideline recommends that clinicians exercise caution when prescribing controlled medications, ensuring close monitoring and intermittent re-assessment of risks and benefits.
- Specific medication recommendations for cocaine and amphetamine-type stimulant use disorders are listed on pages 53–66, though most recommendations are low certainty, with several reaching moderate certainty using the GRADE Evidence to Decision framework.
3. Co-occurring Conditions: Recognizing the prevalence of co-occurring conditions in patients with StUD, including attention deficit hyperactivity disorder (ADHD), depression, anxiety, eating disorders, and other substance use disorders (SUDs), the guidelines recommend that these conditions be treated concurrently. In addition, they advocate for care coordination and evidence-based pharmacotherapies, such as psychostimulant medications, for treating ADHD in individuals with co-occurring StUD.
- General guidelines related to managing co-occurring conditions can be found pages 66–69, and guidelines specific to management StUD and ADHD can be found on pages 69–73.
4. Adolescent and Young Adult Care: Adolescents and young adults using stimulants should receive the same treatment, harm reduction, and recovery support services as adults. The guidelines emphasize a developmentally responsive approach, acknowledging the unique challenges faced by this population.
- Recommendations specific to this population can be found on pages 72-79.
5. Acute Stimulant Intoxication: Acute stimulant intoxication can result in a variety of life-threatening cardiovascular, neurologic, and metabolic complications. Clinicians working with people who use stimulants should be equipped to identify stimulant intoxication syndromes and ensure that acute complications are addressed immediately and in the appropriate level of care.
- Guidelines specific to managing stimulant intoxication are found on pages 99–113 and include recommendations for intervention based on presenting symptom/side effect.
6. Stimulant Withdrawal: Abrupt cessation of stimulant use can cause a withdrawal syndrome that lasts 12–24 hours, with primary symptoms of drowsiness and irritability. There are few studies assessing specific interventions for acute withdrawal management, so the primary guidance is supportive care and assessment for underlying psychiatric diagnoses if symptoms do not subside. The guidelines also advise clinicians to assess and treat post-acute symptoms, which may persist for weeks to months. By addressing symptoms like depression, anxiety, insomnia, and paranoia, clinicians can enhance treatment engagement and reduce the risk of relapse.
- There was little published research on management of acute and post-acute stimulant withdrawal, but general guidance can be found on pages 113–115.
7. Secondary and Tertiary Prevention: To mitigate harms associated with StUD, a comprehensive approach includes secondary and tertiary prevention strategies. Recommendations cover overdose risk, risky sexual practices, injection drug use, oral health, and nutrition.
- Secondary prevention recommendations, including screening, assessment, and early intervention, appear on pages 116–121.
- Tertiary prevention recommendations, including harm reduction education and interventions such as overdose prevention and reversal, drug checking, safe consumption sites, safer sexual practices and contraception, nutrition, and infectious disease prevention, appear on pages 122–127.