Approach

The initial clinical priority for any patient with an amfetamine or methamphetamine use disorder is to provide appropriate treatment or referral for any medical or psychiatric symptoms suggestive of a need for urgent care.[14]​ Following stabilisation, long-term management strategies are psychosocial in nature.

Substance use disorders are frequently chronically recurring conditions, and substantial therapeutic effort may be required in order to achieve abstinence; effective management strategies incorporate long-term continuing care in addition to short-term management of exacerbations/relapses.[70][71]​​​​​ Even for people who are unable to achieve complete abstinence, evidence suggests that retention in treatment helps to mitigate against the associated risks of ongoing use.[72]​ Evaluation and management of co-occurring psychiatric conditions is essential. Patients with significant psychiatric symptoms in the setting of acute or chronic stimulant use, or a history of pre-existing mental health issues, may benefit from mental health treatment and/or referral.

Management of acute toxicity in the emergency department

Treatment is focused on preventing further exposure to amfetamines and related compounds.

Acute toxicity is treated by reducing further absorption if the substance was taken orally by giving activated charcoal within 1 hour of ingestion, particularly if body packing or stuffing is suspected.

Presenting symptomatology and ongoing regular assessment will dictate the need for specific condition management (e.g., hypertension, arrhythmia, rhabdomyolysis, chest pain, agitation and/or psychosis, need for mechanical ventilation, and intensive monitoring).

For details on the management of acute intoxication, see Amfetamine overdose.

Support during stimulant withdrawal

Consider the most appropriate care setting for people withdrawing from stimulants; those at risk of harm to self and others require psychiatric inpatient admission.[14]​ Offer general support and reassurance; people who are agitated, delirious, and/or experiencing psychosis should be managed using verbal and non-verbal de-escalation strategies.[14] Abrupt stimulant withdrawal typically does not produce dangerous medical consequences, although dysphoria and other psychiatric symptoms may be significant in the initial period of drug abstinence. Pharmacological treatment is not always required; discussion with a psychiatrist/addiction specialist regarding the need for symptomatic pharmacotherapy, for example, with a benzodiazepine or antipsychotic medication, may be warranted in the presence of severe distress, depending on the individual’s clinical presentation (e.g., where there is severe agitation, confusion, psychosis, or severe acute insomnia).[14][57]​​​

Note that withdrawal may be associated with intense symptoms of depression and suicidal thinking, with associated increased risk of suicidal behaviours, and that it is important to monitor mood and assess and mitigate against risk of suicide during this period.[57]​ As for any patient with suicidal ideation, safety assessment is required, which may include consideration of the need for involuntary psychiatric hospitalisation, see Suicide risk mitigation.

Long-term psychosocial management of amfetamine/methamphetamine use disorder: general approach

Only psychosocial interventions have demonstrated clear efficacy for stimulant use disorders; thus, non-pharmacological treatments are the mainstay of treatment.​[24][57][72][73]

Many people with stimulant use problems/stimulant use disorder are not actively seeking medical treatment or professional services.[74] Special efforts may be necessary to engage hard-to-reach populations in treatment.[57] For patients who have difficulties accessing in-person care, behavioural treatments delivered remotely (e.g., via digital platforms or telemedicine) may be considered, although expert opinion suggests that remote treatments should augment face-to-face treatment wherever possible.[14]​ Harm reduction strategies are important for those who decline treatment.

Specific treatment approaches for methamphetamine use disorder among men who have sex with men recognise that the intensity of methamphetamine use correlates with the risk of HIV infection. These comprehensive approaches address concomitant sexual behaviours and increase the intensity of interventions directed at sexual behaviours and violence in this group.[75]​ One peer network-orientated educator intervention was associated with reduced methamphetamine use, less risky sexual behaviours, and reduced incidence of sexually transmitted infections.[76]

For parents, a psychosocial intervention integrating parenting skills with a substance use component may be helpful.[77]

Support groups such as Narcotics Anonymous may be of benefit: Narcotics Anonymous Opens in new window

Psychosocial management of amfetamine/methamphetamine use disorder: first-line treatments

Evidence regarding effectiveness of psychosocial interventions for stimulant use disorders other than cocaine-use disorder is limited. A further challenge to treatment selection is that modalities are typically resource-intensive, they may require considerable training to deliver, and availability varies depending on location of practice.[73] Treatments may be used in combination; there is some evidence to suggest that for methamphetamine use disorder, more intensive interventions have a greater impact on methamphetamine use and/or psychiatric symptomatology.[78] Treatment may be stepped up (to more intense treatment) and down (to less intense treatment) as required.[24]​ Although in general the evidence supports more intensive treatment, in practice the most commonly available and accessible interventions are often of lower intensity, such as peer-based counselling and support interventions.

Owing to the challenges described above, within this topic a number of psychosocial treatments are listed as equal first-line options, which may be used alone or in combination, dependent on clinician and patient preference, and on service availability.

Contingency management

A type of behavioural therapy grounded in the principles of operant conditioning, a method of learning in which desired behaviours are incentivised with a reward such as a prize or privilege. There is a large body of evidence stating that it modestly increases rates of abstinence in amfetamine use disorder, and increases engagement with treatment; of all of the psychosocial treatment options available for stimulant use disorder, contingency management has the strongest evidence of efficacy.[72][79][80][81][82][83][84]​​​​​ According to one meta-analysis, it is associated with additional positive effects on medical service utilisation and reductions in risky behaviour.[81]​ Further evidence supports its use for other stimulant use disorders, such as cocaine use disorder; although not directly applicable, this evidence supports its use in amfetamine/methamphetamine use disorder, given similarities in mechanisms of action and clinical manifestations between stimulants.[85][86][87]​​​ 

A potential limitation of contingency management for other stimulant use disorders is that its positive effects may be short-lasting.[88] Use in conjunction with other psychosocial interventions (e.g., cognitive behavioural therapy [CBT]) may be beneficial, particularly for people with more complex therapeutic needs.[89]​ Treatment does not have a prescribed time period, but in practice may follow a 12-week schedule, with frequent drug screenings.[24]​ Contingency management may be used within a number of settings, including primary healthcare, community outpatient settings, and inpatient settings. Despite the substantial evidence in favour of its efficacy, contingency management is not widely implemented, owing to a number of barriers including cost and regulatory difficulties.[14]​ Computerised contingency management appears to be effective, and may facilitate access.[90][91]

Cognitive behavioural therapy (CBT)

A short-term, goal-directed type of psychotherapy that enables people to understand their current problems in order to change their thinking and behaviour. There is some evidence that CBT results in significant reductions in frequency of methamphetamine use and methamphetamine use disorder severity, although further studies focusing on the longevity of the effect of intervention are needed.[79][83][92]​​​ There is a more extensive body of evidence in favour of CBT for the management of other stimulant use disorders, which may further support its use in amfetamine/methamphetamine use disorders.[85][93][94]​​[95][96]​ In practice, treatment duration for stimulant use disorders often lasts between 5 and 10 months, with each session lasting around 50 minutes.[24]​ It can be used across a variety of settings, including on both an inpatient and an outpatient (e.g., community-based) basis.

Motivational interviewing

A treatment approach that empowers people to become motivated to change their behaviour and reduce or stop stimulant use. One Cochrane review found motivational interviewing to be effective for a range of substance use disorders compared with no treatment, with a positive effect lasting up to 12 months after treatment.[97] [ Cochrane Clinical Answers logo ] ​​​​ Evidence specific to amfetamine/methamphetamine use disorder is lacking, although its use is recommended for a number of stimulant use disorders (including amfetamine/methamphetamine use disorders) according to some treatment guidelines.[24][57]​ In practice, treatment duration varies significantly, from single 15-minute sessions to multiple hour-long sessions; there is insufficient evidence to support guidance on what constitutes an optimal length or number of sessions.[24] Sessions may take place in primary or secondary care, on an inpatient or outpatient basis.

Matrix model

A structured, multi-component behavioural therapy programme encompassing individual counselling, cognitive behavioural therapy (CBT), family education, social support groups, and motivation for engagement in mutual support groups, typically conducted over a period of 16 weeks.[14]

There is moderate evidence supporting the effectiveness of the Matrix model for treating methamphetamine use disorder. In comparison to waiting list control groups or standard treatments, it diminishes methamphetamine use, cravings, and risky behaviours.[98][99]​​​[100]

The Matrix model is more widely available than many of the other interventions listed in some countries, for example, the US.[14]

Community reinforcement approach

A type of comprehensive behavioural therapy based on operant conditioning theory. Moderate certainty evidence exists for a community reinforcement approach for achieving abstinence from cocaine use disorders, particularly when longer durations of treatment are used.[79][101]​ Although there is a lack of evidence on efficacy of this technique for amfetamine-type stimulant use disorder, expert opinion suggests that it is likely to be similarly effective for this patient population.[14] Based on evidence in cocaine use disorder, community reinforcement approach is particularly effective when combined with contingency management.[79]​ Note that community reinforcement approach is costly and resource-intensive and is not widely implemented beyond research settings.[14]

Psychosocial management of amfetamine/methamphetamine use disorder: adjunctive treatments

Evidence on the effectiveness of the following programmes as stand-alone interventions is very limited, and therefore, based on the available evidence, they are listed here as adjuncts; ideally these programmes have the potential to provide additional input and support to aid recovery.[74]​ However, note that in practice, peer-based counselling is often the most commonly available and accessible intervention for stimulant-use disorder, and, depending on location of practice, may be the only psychosocial intervention available.

Drug counselling

Peer-based programmes are often based on the principles of 12-step recovery programmes such as Narcotics Anonymous (NA). They may also offer education and incorporate elements of CBT and other supportive psychotherapies. Standard outpatient drug counselling may consist of one or two sessions weekly, and take place on either an individual or a group basis.

Intensive outpatient therapy (IOT)

This provides drug counselling on an individual or a group basis with varying levels of family involvement. It is typically used if standard drug counselling is insufficient, although there is insufficient evidence of better outcomes.[102] It typically takes place in sessions delivered on several days weekly for a number of weeks. IOT may provide benefit in patients with methamphetamine use disorder even at relatively low intensity (sessions totalling 2-3 hours per week).[102][103]

Pregnancy

Amfetamine and methamphetamine use during pregnancy is associated both with impaired obstetric outcomes and with impaired long-term behavioural outcomes for the child.[104][105]​​ As for anyone with a stimulant use disorder, the focus of treatment is on psychosocial interventions, and pharmacotherapy is not recommended for routine treatment of dependence. However, because of the risk of harms of ongoing stimulant use to both the mother and the fetus, there is a lower threshold for inpatient withdrawal management, which may include non-teratogenic medications for the short-term management of psychologically distressing symptoms.[106]

Referral for routine antenatal care is important, including screening for fetal and maternal complications, and bloodborne infections, if this has not already taken place, see Routine antenatal care. Women with high-risk pregnancies may need management by a maternal-fetal medicine specialist.[14]​ Clinicians may consider offering contingency management to incentivise antenatal appointment attendance, according to US guidance, although the evidence for this approach is limited and mixed.[14][107]​​

Management of stimulant use disorder should be provided by services specialising in substance use in pregnancy wherever possible, or otherwise there should be co-ordination between antenatal and substance use care. In addition to psychosocial interventions, it is important that appropriate social support is given, including assistance with accommodation, life-skills and vocational training, legal advice, home-visiting, and outreach.[106]​ Clinicians may refer women locally available programmes addressing psychosocial needs related to pregnancy and parenthood, depending on service availability.[14]

Additional treatment support around the time of birth is recommended, as the postnatal period is often a time of increased stress, with associated risk of return to substance use.[14] Guidance on breastfeeding for those who continue to use amfetamine-type substances is mixed. The World Health Organization advises that mothers with substance use disorders should be encouraged to breastfeed unless the risks clearly outweigh the benefits; they note that clinicians should advise and support breastfeeding women with amfetamine/methamphetamine use disorder to cease drug use, but note that continuing use is not necessarily a contraindication to breastfeeding.[106]​ In contrast, US guidelines recommend that patients should not breastfeed if they are actively using stimulants.[14]

Adolescents

When treating adolescents with amfetamine/methamphetamine use disorder, the same general principles apply as in adults.[14]

Consider also the following:[14]

  • Modification of behavioural treatments to maximise developmental appropriateness, or use of adolescent-specific models, for example, adolescent community reinforcement approach

  • Ensuring that group behavioural sessions take place with similarly aged participants (i.e., other adolescents)

  • Involving family members/other trusted adults in treatment where appropriate

  • Being familiar with state/national laws on adolescents’ ability to consent to treatment, which vary considerably between locations

Referral to an addiction specialist

For some patients, psychosocial interventions alone are insufficient, and for these patients an addiction specialist may consider offering adjunctive pharmacotherapy, if maximising psychosocial management strategies has proved ineffective. Most trials of medications for stimulant use disorder have looked at patients using cocaine. No medications have been shown in randomised controlled trials (RCTs) to be consistently effective for any type of stimulant use disorder. A number of agents have been tested in the treatment of methamphetamine use disorder, but, although some are promising, most of the studies were of small sample size and lacked the power to draw firm conclusions about their efficacy.[108][109][110][111]

Maintenance therapy

  • Maintenance treatment approaches have been studied in methamphetamine-dependent patients. In RCTs, modafinil, dextroamphetamine, and methylphenidate have been found to reduce the craving for and use of methamphetamine in dependent patients.[112][113][114]​ However, one study failed to demonstrate superiority over placebo for methylphenidate.[115]​ In a comparative trial with methylphenidate, risperidone also appeared to have efficacy in methamphetamine-dependent patients.[116]

  • One small study has shown naltrexone to blunt cue-induced cravings for methamphetamine.[117] Oral naltrexone has been shown to be effective in reducing cravings for smoked cocaine (and tobacco) but not for oral amfetamines in people who use cocaine.[118]

  • One review of pharmacotherapies for stimulant use disorder found that combination therapies, many of which included naltrexone, gave better results compared with placebo.[119]

  • There is evidence from one RCT to suggest that in people who use methamphetamine, the combination of injectable naltrexone plus oral bupropion was associated with a small but statistically significant increased likelihood of abstinence, compared with placebo.[120]

US treatment guidelines offer a limited degree of support for the use of the following drugs (prescribed by a specialist in addiction medicine/psychiatry) in selected patients with amfetamine-type stimulant use disorder: bupropion monotherapy; bupropion and naltrexone combination therapy; mirtazapine monotherapy; and topiramate monotherapy.[14]

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