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Treatment for Stimulant Use Disorders: Updated 2021 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 33.)
Despite an increase in research into psychosocial treatments for people with stimulant use disorders, currently the only treatment with significant evidence of effectiveness is contingency management (CM).
Other psychosocial treatments that have some support (especially if used in combination with CM) are cognitive–behavioral therapy/relapse prevention, community reinforcement, and motivational interviewing.
There currently are no Food and Drug Administration-approved medications for stimulant use disorders, making it even more important that behavioral health and healthcare service providers understand and offer (or offer referrals for) CM or other psychosocial treatments.
Other nonpharmacologic treatment approaches and strategies may also be useful for supporting recovery and improving health and well-being, including physical exercise, the Matrix model of neurobehavioral treatment, family or couples therapy, and mindfulness meditation.
Clinicians need to promote harm reduction (e.g., through educating about needle exchange programs, offering naloxone, encouraging the use of fentanyl test strips) to people with stimulant use disorders who are not interested in formal treatment, because harm reduction techniques can help save lives.
Many clinical management strategies have been developed to deal with clinical issues common in people with stimulant use disorders, like cognitive problems, intoxication issues, and co-occurring mental disorders.
During the early and mid-1980s, various unconventional remedies for substance use disorders (SUDs), including health foods, amino acids, hot tubs, electronic brain tuners, and other “New Age” treatments, emerged and disappeared. Research efforts to develop scientifically based treatments during this period often focused on behavioral techniques like contingency contracting (Anker & Crowley, 1982). Since these early efforts, an entire stimulant use disorder treatment literature has developed.
This chapter reviews the current state of knowledge on the treatment of people with stimulant use disorders, beginning with the approaches that have the most rigorous empirical support: contingency management (CM), cognitive–behavioral therapy (CBT)/relapse prevention (RP), community reinforcement, and motivational interviewing (MI). Other approaches with less support in the scientific literature are presented later in the chapter. These are physical exercise, the Matrix model, family or couples therapy, and mindfulness meditation.
Although at the time of this writing there are no Food and Drug Administration-approved medications with demonstrated clinical efficacy, an ongoing research program sponsored by the National Institute on Drug Abuse (NIDA) holds great promise for important treatment advances for stimulant use disorders.
ACCELERATING THE DEVELOPMENT OF STIMULANT USE DISORDER PHARMACOTHERAPIES.
This chapter reviews effective treatments for people with stimulant use disorders. To be judged effective, a treatment must have been tested and demonstrated to be effective in a randomized controlled trial (RCT). Many psychosocial and pharmacologic treatments have been investigated in such trials. Several psychosocial treatments for stimulant use disorders have proved effective, although no reliably effective pharmacologic treatments have been found to date. What has been learned so far about the use of psychosocial treatments for stimulant use is summarized below.
RCTs are the best available method for determining whether an intervention improves health. An RCT is a prospective study comparing the effect of some intervention against a control intervention in patients who are randomly assigned to the intervention group or the control group (Bhide et al., 2018).
In such trials, patients from a particular population sample (e.g., all admissions to clinic X during 2018 meeting a particular list of inclusion and exclusion criteria) who consent to participate are randomly assigned to the intervention under study or to a control condition. Random assignment helps ensure against possible bias in assigning particular kinds of patients to the different groups and helps distribute evenly between the groups any participant characteristics that might influence outcomes.
Prospective means that researchers study the groups from the start of the intervention, as opposed to retrospectively compiling the information after the intervention is completed.
Retrospective observations are not RCTs but are still commonly used approaches to research. For instance, they are often used in studies relying on administrative claims and electronic health records databases. These studies tend to be less accurate because relevant information is not always available or may be distorted through reliance on people's recall. Having a comparison or control group is essential because most problems have some level of variability (i.e., they wax and wane over time) and because many health problems resolve over time without any formal treatment. The most effective way to determine whether any observed changes are due to the treatment being investigated rather than to natural variability is by comparing against a similar group of patients who either received no treatment or received a standard treatment.
Some of the alternatives to RCTs common in the SUD treatment field can provide useful information but have serious limitations that must be recognized. For example, following a group of patients who received a particular treatment in the absence of a comparison group can be informative in terms of characterizing what has happened to them (e.g., percentage who returned to use, percentage who received additional treatment, amount of change from pretreatment to posttreatment). However, such observations do not permit making any scientifically valid inferences about the role of the treatment provided in bringing about any of the changes observed during follow-up. For that purpose, a comparison group is necessary. Any changes observed might have occurred in the absence of treatment. Without a comparison group, there simply is no way to rule out that possibility.
Similarly, when patients themselves select group membership, as opposed to being assigned by the researcher, one cannot make valid inferences about the role of treatment in the outcome. For example, comparing treatment completers to dropouts is common and may be informative in terms of characterizing how the groups fared, but it is not scientifically valid to infer that any differences observed between them were due to the different amounts of treatment received. Some other factor (e.g., differences in the amount of other demands on their time) could have been responsible both for the differential retention rates and for the subsequent differences observed at follow-up.
THE IMPORTANCE OF TEACHING HARM REDUCTION.
The psychosocial interventions demonstrated to date to be efficacious in RCTs and other high-quality studies with people with stimulant use disorders share a common feature of incorporating well-established psychological principles of learning. Currently, these psychosocial approaches to treating people with stimulant use disorders have the most research support: CM, CBT/RP, community reinforcement approaches, and MI. Many studies look at combinations of these treatments. Thus, in making treatment decisions, clinicians should consider whether one of these approaches alone versus a combination of two might be best for a given patient.
It is impossible to quantify all aspects of psychosocial treatment or to account for all factors that affect patient outcomes. However, given that effective treatments and associated manuals are available, using them is prudent and helps ensure that patients receive the services that research has shown to be effective. An often-stated but unsubstantiated belief is that using a manual will limit or eliminate clinicians' flexibility and ability to exercise clinical judgment. A carefully prepared manual recognizes the importance of clinical judgment and flexibility in addressing the individual needs of patients and incorporates those features.
CM is a well-known behavioral intervention designed to increase desired behaviors by providing immediate reinforcing consequences (in the form of incentives) when the target behavior occurs, and withholding those incentives when the target behavior does not occur. CM has been used with considerable effectiveness in treating individuals with a variety of SUDs and is very useful for treatment planning because it sets concrete short- and long-term goals and emphasizes positive behavioral changes (Benishek et al., 2014; Minozzi et al., 2016).
A meta-analysis found that CM had small and medium-sized effects on stimulant use at 3-month follow-up but not at 6 months (Sayegh et al., 2017). In a network meta-analysis of almost 7,000 participants across 12 different psychosocial interventions for cocaine and/or amphetamine use disorder, the combination of CM and community reinforcement approach was the most efficacious and most acceptable treatment in both the short and long term (De Crescenzo et al., 2018).
AshaRani and colleagues (2020) found that, across 44 studies of nonpharmacologic interventions for methamphetamine (MA) use, CM interventions showed the strongest evidence favoring the outcomes assessed, although tailored CBT alone or with CM was also effective in the target population.
Finally, H. D. Brown and DeFulio (2020) found that, across 27 studies looking at CM for MA use, nearly all (26 of the 27) reported reduced MA use.
Other positive outcomes across studies included longer retention in treatment, greater number of therapy sessions attended, higher utilization of medical and other services, reduced high-risk sexual behavior, increased positive affect, and decreased negative affect.
When considered collectively, CM interventions have by far the greatest amount of empirical support for their efficacy in promoting therapeutic behavioral change among people with stimulant use. In fact, interventions other than CM have demonstrated weak or nonspecific effects on stimulant use disorder-related problems (Farrell et al., 2019). People who use stimulants are sensitive to systematically applied CM interventions.
Like the other psychosocial interventions discussed in this chapter, CM may also be effectively used with other treatment approaches. In a review of 50 RCTs on 12 psychosocial interventions for cocaine or amphetamine use, CM plus community reinforcement was the only approach to result in increased rates of abstinence by the end of treatment, at short-term follow-up, and at long-term follow-up (De Crescenzo et al., 2018). This combination was also more effective than CBT alone, CM alone, CM plus CBT, and 12-Step programs plus noncontingent incentives. Treatment dropout rates were also lower with CM plus community reinforcement. These findings are consistent with those from other reviews that support CM (alone and in combination) as being highly effective for stimulant use disorders (Ronsley et al., 2020).
The size of the incentive may be important in generating positive outcomes, with higher-value cash incentives generally leading to more positive behavior changes (such as abstinence) than lower-value cash incentives (Stitzer et al., 2020). However, some research has found no difference in outcomes based on magnitude of incentive. For instance, Petry and colleagues (2015) studied differences in outcomes from standard-sized cash prizes (about $300 on average) versus larger-sized cash prizes (about $900 on average) in a CM program for people with cocaine use disorder and maintained on methadone. The two prize groups had no differences in drug-negative urine samples or duration of abstinence.
Pregnant women are an important subgroup for CM research. For instance, a study of women with cocaine use disorder who were pregnant or had young children found that CM is associated with longer cocaine abstinence and more cocaine-negative urine tests compared with use of noncontingency vouchers (Schottenfeld et al., 2011). For more information about stimulant use disorders in women who are pregnant, see Chapter 6.
Another population vulnerable to SUDs are individuals with serious mental illness (SMI). For SMI and stimulant use disorders specifically, McDonell et al. (2013) found that CM plus treatment as usual (mental health, SUD treatment, housing, and vocational services) was associated with fewer days of stimulant use and alcohol use and lower rates of injection drug use compared with treatment as usual. Researchers have also found CM added to usual treatment to be cost-effective (Murphy et al., 2016).
A WARNING ABOUT REIMBURSEMENT FOR CONTINGENCY MANAGEMENT.
WHAT CLINICIANS SHOULD KNOW ABOUT IMPLEMENTING CONTINGENCY MANAGEMENT.
Despite the increase in research on CBT for stimulant use disorders over the past two decades, its effectiveness is still unclear (De Crescenzo et al., 2018; Ronsley et al., 2020). Nonetheless, many clinicians and researchers find CBT to be helpful. A Cochrane review from 2018 found mixed outcomes for CBT (including some positive findings, like an increase in percentage of abstinent days over a 90-day period and a reduction in symptoms). However, the review authors concluded that many CBT studies are small in size or poorly designed, making it difficult to have full confidence in their findings (Harada et al., 2018).
CBT in combination with CM may be especially helpful (De Crescenzo et al., 2018). One study reported that adding CM to CBT enhanced CBT's positive outcomes (e.g., cocaine-negative urine specimens) among people with cocaine use disorder (Carroll et al., 2016). Other researchers have found that CBT can have delayed positive effects on cocaine use disorder, with improvements appearing after study treatment has ended (Ronsley et al., 2020).
RP is a form of CBT that teaches patients strategies, skills, and lifestyle adaptations to help them change their thoughts and behaviors related to substance use. RP emphasizes (Hendershot et al., 2011):
Ways to cope with substance craving.
Substance refusal and assertiveness skills.
General coping and problem-solving skills.
Strategies to prevent a full-blown return to use should an episode of substance use occur.
Carroll and various colleagues have adapted RP for cocaine use and demonstrated the efficacy of the adapted approach (Carroll, Rounsaville, & Gawin, 1991; Carroll, Rounsaville, Gordon, et al., 1994; Carroll, Rounsaville, & Keller, 1991; Carroll, Rounsaville, Nich, et al., 1994). In an initial study, RP was compared with interpersonal psychotherapy (IP), which teaches strategies for improving social and interpersonal problems (Carroll, Rounsaville, & Gawin, 1991). Retention was better with RP than IP, and trends suggested cocaine abstinence may have been as well, but that difference was not significant.
Using as a sample more than 300 individuals who had completed outpatient SUD treatment for people with stimulant use disorders, Farabee, McCann, and colleagues (2013) assessed 14 RP strategies designed to help with abstinence maintenance at baseline and 3-month and 12-month follow-up. They found avoidance strategies to be the most effective predictor of drug-free urines at all time points assessed. The strategies significantly correlated with negative urine screens at all time points were:
Reducing use of other drugs.
Avoiding friends with active drug use.
Avoiding places where drugs are available.
Participating in 12-Step meetings significantly predicted negative urines at baseline and 12-month follow-up. (For more information about 12-Step and other mutual-help programs, see Chapter 5.)
THE PREVENTION AND TREATMENT OF PRESCRIPTION STIMULANT MISUSE.
Community reinforcement is an individualized treatment designed to promote key lifestyle changes that are conducive to successful recovery (see Meyers & Smith, 1995; Sisson & Azrin, 1989):
Patients with partners/spouses who do not use stimulants are offered marital therapy to improve the quality of their relationships in a reciprocal and rewarding manner.
Patients who are unemployed, employed in jobs that are high risk for substance use, or need vocational assistance for some other reason receive help in that domain.
Patients are counseled and assisted in developing new social networks and recreational practices that promote and support recovery. Mutual-help group participation is not mandatory but is often used as an effective means of developing a new social network.
Various types of skills training are provided depending on individualized patient needs, including substance refusal and associated skills, social skills, time management, and mood regulation.
Patients with alcohol use disorder (AUD) and no medical contraindications are offered a program of disulfiram therapy coupled with strategies to support medication compliance.
Very few recent studies have examined community reinforcement alone, so it is unclear whether this approach delivers better substance use outcomes than other psychosocial approaches or usual care (Ronsley et al., 2020). One study of community reinforcement did find increased treatment retention and abstinence and decreased addiction severity after 24 weeks (De Giorgi et al., 2018).
More recently, research on community reinforcement has focused on the effectiveness of adding it to CM (Ronsley et al., 2020). When used together, these treatments appear to (De Crescenzo et al., 2018):
Do a better job than usual care at retaining individuals in treatment.
Do a better job than noncontingency-based approaches (either used alone or with 12-Step programs) at helping people achieve abstinence.
Have better patient acceptance than treatment as usual.
In one review, community reinforcement combined with noncontingent vouchers was less effective at achieving abstinence from cocaine than was community reinforcement combined with CM (Schierenberg et al., 2012).
MI has been found to be an effective evidence-based, group- or individual-based treatment for people with SUDs, especially AUD (SAMHSA, 2019). MI and motivational counseling, as applied to SUDs, have been associated with decreased substance use, improved SUD treatment retention, lower rates of relapse, and better adherence to HIV risk-reduction behaviors (SAMHSA, 2019).
Recent studies of MI alone for stimulant use disorders show mixed results, with some finding no benefit and others finding improvements in reducing the number of days of cocaine use (De Giorgi et al., 2018). Intensive MI designed specifically for MA use disorder demonstrated no different outcomes in MA use or in anxiety compared with an education control group that also received MI, although it was nonintensive (Polcin et al., 2014). A Cochrane review of psychosocial interventions for stimulant misuse (Minozzi et al., 2016) included five studies comparing MI with no intervention. In these studies, receiving any psychosocial treatment (including MI) was associated with better treatment retention and greater abstinence than no treatment at all. However, the authors noted a fair amount of bias and study design problems across all of the studies in their review, including those pertaining to MI. Thus, results should be interpreted with caution.
Recent studies on combining MI with other treatment approaches were either inconclusive or had unreported results. One review noted that MI combined with CBT has yet to demonstrate reliable improvements over other treatments (De Giorgi et al., 2018). However, some individual studies have reported good results from adding MI to CBT.
In a sample of military veterans with SUDs, MI combined with CBT or combined with CBT and continuing care both showed significant decreases in substance use (including cocaine use) and reductions in aggression compared with treatment as usual (Chermack et al., 2019). MI added to CBT tailored to the unique needs of gay and bisexual men who are HIV positive was associated with lower MA use, better HIV medication adherence, and reduced risky sexual behavior (i.e., having sex without condoms) over the course of 12 months (Parsons et al., 2018).
THE ROLE OF TELEHEALTH IN TREATING STIMULANT USE DISORDERS.
Physical activity is an area of robust and fast-growing research for therapies for stimulant use disorders. Aerobic exercise has been an increasing focus of SUD treatment studies broadly (as an add-on therapy, not as the lone treatment), including studies on stimulant use disorders (Sanchez et al., 2017). A review of physical activity interventions for people with MA use (Morais et al., 2018) found that, compared with nonexercise intervention controls, improvements were observed for:
Aerobic performance.
Muscle strength and endurance.
Body composition.
Heart rate variability.
Depression.
Anxiety.
MA use.
MA cravings.
Inhibitory control.
Other researchers have similarly found that structured aerobic exercise and resistance training help reduce depression and anxiety in MA use disorder (Morris et al., 2018; Rawson, Chudzynski, Gonzales, et al., 2015), which may be useful in helping patients remain in treatment and sustain abstinence.
A study by Rawson, Chudzynski, Mooney, et al. (2015) found that participants with a lower severity of MA use assigned to an exercise intervention reported fewer days of drug use and had fewer positive urine screens, compared with participants with a lower severity of MA use who received a health education intervention. In the STimulant Reduction Intervention using Dosed Exercise (STRIDE) study (Trivedi et al., 2017), a 12-week dosed exercise intervention in residential SUD treatment settings was associated with a significantly higher percentage of days abstinent compared with a health education intervention. (Both interventions were add-ons to treatment as usual.)
Benefits of physical exercise to people who use stimulants may include enhanced antioxidant mechanisms, reduced oxidative stress, and decreased reward-seeking behaviors (Morais et al., 2018). Evidence from human trials of exercise for stimulant use indicates an improvement in neurotransmitter systems that become deranged with cocaine or MA exposure (especially dopaminergic systems; Morais et al., 2018). Exercise by people using MA may help increase their striatal D2/D3 receptor availability (Morais et al., 2018). Preliminary data suggest that exercise for MA use disorder may also lead to better MA-related outcomes by increasing dopamine receptor binding in the brain (Robertson, Ishibashi, et al., 2016).
The Matrix model (originally referred to as the “neurobehavioral model”) is a manualized outpatient treatment approach that was developed during the mid-1980s for the treatment of individuals with cocaine and MA use disorders (NIDA, 2018a). The model integrates treatment elements from a number of specific strategies, including RP, MI, psychoeducation, family therapy, and 12-Step program involvement. The approach's basic elements consist of a collection of group sessions (early recovery skills, RP, family education, and social support) and individual sessions, along with encouragement to participate in 12-Step activities (NIDA, 2018a; Rawson, 2010).
In seven research projects evaluating the treatment model, application of the model was shown to be associated with significant reductions in cocaine, MA, and other substance use (Rawson et al., 1993; Shoptaw et al., 1994). Treatment participation in the Matrix model has also been demonstrated to be associated with a significant improvement in psychological symptoms and significant reduction in risky sexual behaviors associated with HIV transmission (NIDA, 2018a). Adaptations of the Matrix model are available to address the unique treatment needs of women with stimulant use disorders in such areas as trauma, pregnancy and parenting, body image, and sexuality (SAMHSA, 2012).
People with SUDs often have extensive marital, relationship, and family problems. Stable marital and family adjustment is associated with better treatment outcomes. Including family members in treatment is based on the view that they can provide important support for the patient's efforts to change and offer additional information about the patient's substance use and other behavior. Interventions directed at improving marital and family adjustment have therefore been judged to have the potential to improve treatment outcomes. Studies with people with AUD have supported this hypothesis, at least in part (Klostermann et al., 2011). Few studies have focused on stimulant use, however.
Research on family and couples therapy for stimulant use disorders is scant, but outcomes appear promising. In a study of women with SUDs who have children, family systems therapy was associated with a reduction in both likelihood of cocaine use and frequency of use over time, and, compared with control participants, a faster decrease in frequency of cocaine use over time (Slesnick & Zhang, 2016).
For more information about providing family and couples therapy for people with SUDs, see SAMHSA's Treatment Improvement Protocol (TIP) 39, Substance Use Disorder Treatment and Family Therapy (https://store.samhsa.gov/product/treatment-improvement-protocol-tip-39-substance-use-disorder-treatment-and-family-therapy/PEP20-02-02-012).
Mindfulness-based interventions have gained popularity as potential tools to help prevent return to use by people with SUDs (Chiesa & Serretti, 2014). Mindfulness-based psychotherapy for people with cocaine use disorder (Dakwar & Levin, 2013) resulted in a 73-percent treatment completion rate and a 55-percent abstinence rate.
Among people with stimulant use disorders who received 12 weeks of CM, concurrent use of mindfulness-based RP was associated with greater reductions in depressed mood, greater reductions in Addiction Severity Index score, and lower odds of stimulant use compared with a health education control group (Glasner-Edwards et al., 2017). Close to half the sample had major depressive disorder (43%), and approximately one-quarter had generalized anxiety disorder (24%). Compared with CM plus health education, CM plus mindfulness RP was associated with lower scores of negative affect, greater reductions in depression severity and psychiatric symptom severity, and—among people with depressive and anxiety disorders—decreased stimulant use (Glasner-Edwards et al., 2017).
A residential mindfulness-based intervention for women with SUDs (most of whom had amphetamine/MA use) similarly showed greater chances of treatment completion compared with the control condition. Also, program attendance significantly correlated with improvements in mindfulness, distress tolerance, and mood (D. S. Black & Amaro, 2019).
Mindfulness-based RP combined with a single dose of ketamine was associated with longer cocaine abstinence than mindfulness plus midazolam in a 2019 study by Dakwar and colleagues. The mindfulness-ketamine participants were also 53 percent less likely to return to use and had significantly lower scores on craving.
Case management and coordinated care are SUD treatment approaches with strong support, especially in terms of their ability to link people with SUD treatments and services and to retain patients in treatment (Vanderplasschen et al., 2019). These approaches are person centered and help ensure that care delivery is organized and includes all needed interventions and services, to the extent possible.
A small but promising line of research has looked at case management or coordinated care specifically among people with stimulant use disorders:
In a pilot study, a strengths-based case management intervention for people with HIV who used injection drugs or smoked crack cocaine was associated with a decrease in detectable viral load (Kral et al., 2018).
A study of women who used crack cocaine found case management was associated with improvements in drug and alcohol use (i.e., lower frequency of use), mental and emotional health (e.g., less depression or anxiety), and employment (Corsi et al., 2010).
Men and women who were receiving public assistance and had a long history of substance use (including cocaine use) benefited from a coordinated care management approach designed to help link patients to SUD treatment, provide them with SUD-related services, and help them find employment (Morgenstern et al., 2009). Compared with the usual care group, women (but not men) in the program saw an increase in employment over time.
Vocational services are an important part of case management and coordinated care approaches; they can help people with SUDs, including stimulant use disorders, reintegrate into the workforce, learn valuable skills, and earn wages. Employment is an important aspect of long-term recovery and is associated with successful SUD treatment completion and 6-month abstinence (Sahker et al., 2019). Case management and coordinated care that incorporate vocational training or employment assistance may improve patients' chances of stopping stimulant use and staying in recovery following treatment.
For instance, the Compensated Work Therapy (CWT) program is a Department of Veterans Affairs clinical vocational rehabilitation service that supports veterans in finding and retaining employment. CWT interventions have been combined with CM to help veterans with SUDs not only improve employment outcomes but reduce substance use (Cosottile & DeFulio, 2020). Employment-based CM programs have been particularly successful for patients with cocaine use and opioid use disorders (OUDs; Cosottile & DeFulio, 2020).
For more information about vocational services, see SAMHSA's TIP 38, Integrating Substance Abuse Treatment and Vocational Services (https://store.samhsa.gov/product/TIP-38-Integrating-Substance-Abuse-Treatment-Vocational-Services/SMA12-4216), and SAMHSA's Advisory, Integrating Vocational Services Into Substance Use Disorder Treatment (https://store.samhsa.gov/product/integrating-vocational-services-substance-use-disorder-treatment/pep20-02-01-019).
Although case management and care coordination is still a growing area of research, these positive findings, along with the research showing support for case management and coordinated care for SUDs in general, suggest that using these approaches, when possible, can help patients benefit further from treatment, even in non-SUD outcomes (like employment and HIV status).
Evidence on transcranial magnetic stimulation (TMS) suggests this could be a safe and effective treatment for people with SUDs, although this research area needs further study. TMS involves nonsurgical stimulation of the brain through magnetic electrodes placed on the scalp. It is painless and noninvasive. It is thought to work on SUDs in part by increasing dopamine delivery to certain parts of the brain (e.g., the limbic system) and by reducing impulsivity/increasing self-control mechanisms in the prefrontal cortex network.
Repetitive TMS (rTMS) has been shown to be effective in reducing cravings in AUD (De Sousa, 2013). A review of six studies looking at rTMS for cocaine use disorder found a reduction in cravings and an increase in cocaine-free urine screens but noted that the evidence is still preliminary and needs to be replicated in larger studies (Bolloni et al., 2018). Data also suggest that only high-frequency rTMS (rather than low frequency) is effective in reducing cocaine, amphetamine, or MA craving (Ma et al., 2019).
Network therapy is based on the theory that people can recover from SUDs if they have a stable social network to support them in psychotherapeutic treatment. In this model, a patient receiving individual psychotherapy develops a network of stable, nonsubstance-using support people, such as family, a partner, and close friends. These support people learn strategies from the clinician to support the therapeutic process for the individual being treated. They may interact regularly with the clinician, participate in treatment sessions with the patient (SAMHSA, 2020k), and be involved in setting up treatment plans for the patient.
“Inpatient treatment” is a broad term encompassing the highest levels of medical care for patients who may be experiencing acute medical or psychiatric needs secondary to recent use of substances or acute withdrawal. Specifically, acute treatment services may involve 24-hour medical management or medical monitoring, particularly in instances where stimulant use has led to life-threatening medical problems, such as rhabdomyolysis, significant electrolyte imbalances, or severe cases of sleep deprivation.
Historically, inpatient treatment began in the 1800s for patients experiencing severe AUD in an attempt to reduce the community-level concerns related to uncontrolled alcohol consumption. Programs like the Washingtonian Home in the city of Boston were specifically designed to help patients detoxify from alcohol and return to society (White, 2004). Over time, these programs shifted to hospital-based or medically monitored care to reduce the morbidity and mortality associated with alcohol withdrawal.
Inpatient treatment for AUD traditionally consisted of a 28-day stay in a hospital or residential treatment facility, during which daily activities such as group psychotherapy and relaxation practice were provided in a structured format. Generally supportive and sometimes confrontational in nature, inpatient treatment was aimed at detoxifying patients, combating their denial, and beginning the process of engaging with mutual-help programs.
The 28-day standard treatment regimen also became common for patients experiencing other SUDs. It was especially widespread in the early 1980s, when the numbers of patients seeking treatment for cocaine use disorder began to rise dramatically. Most of these inpatient programs for treating cocaine use were adapted with few or no modifications from the alcohol regimens and with little input from empirically based research. Such inpatient programs were called into question by insurance providers, and subsequently, their use steadily declined (Malcolm et al., 2013).
Today, acute treatment programs, colloquially referred to as “detoxes,” may admit patients for between 3 and 10 days for observation during initial cessation of substance use and restoration of physiologic homeostasis (the body's natural ability to maintain critical functions, like normal core temperature and normal blood glucose levels) after significant periods of severe substance use. Acute treatment services vary greatly in the amount of recovery support available to patients and the number of medical staff onsite for the care and monitoring of patients.
Patients with significant medical or psychiatric comorbidity may be voluntarily admitted to medically or psychiatrically managed SUD care, often referred to as “Level 4 facilities” after the level that is assigned in the American Society of Addiction Medicine's (ASAM) levels of care (ASAM, 2015b; K. Hartwell & Brady, 2018). These hospital-based residential programs are capable of accommodating the highest acuity patients and are used for acute stabilization of medically or psychiatrically complex patients.
Clinical stabilization programs, or transitional support services, are inpatient programs for patients with fewer medical or psychiatric comorbidities. These programs typically offer more recovery services for patients, including mutual-help groups, therapeutic communities (TCs), education or therapy groups, individual counseling, a therapeutic milieu, and other integrated psychosocial services (ASAM, 2015b). These programs may last anywhere from 2 to 4 weeks (and often longer) and because of their extended nature may be the most beneficial in monitoring patients in early recovery from stimulants.
Special considerations should be made in treatment plans for patients experiencing stimulant withdrawal in inpatient settings (Braunwarth et al., 2016). Given the profound fatigue and excessive sleeping that can occur, considerations for exemptions from therapeutic sessions and educational services should be considered.
Nutritional support for patients recovering from SUDs is vital (Szydlowski & Amato, 2017). Increased access to high-calorie foods and foods with increased nutritional value may help in augmenting patients' weight and correcting electrolyte imbalances (Braunwarth et al., 2016). Programs should consider consultation with appropriate nutrition or dietary specialists when necessary.
Additionally, given the possibility of increased depressive symptoms throughout acute withdrawal from stimulants, patients should be assessed for changes to risk for self-injury or self-harm regularly while in the inpatient unit, and safety plans should be in place in case patients develop thoughts of self-harm or self-injury. Suicide has been shown to be a significant cause of mortality for individuals who misuse stimulants (Butler et al., 2017; Farrell et al., 2019; Marshall & Werb, 2010).
Legislation regulating involuntary commitment to inpatient treatment settings (also known as mandated treatment) for SUDs varies throughout the United States. Many states have enacted legislation that allows clinicians or, in some instances, family members to file petitions for involuntary assessment of SUDs when patients are unable to adequately care for themselves or they pose serious risks to themselves or others. A judge may dismiss the petition or issue a court order for SUD treatment. Patients can choose to refuse treatment and ignore court orders, which may result in undesirable legal consequences. For patients admitted for involuntary treatment, special consideration should be given to identifying the reason for the involuntary commitment and the best strategy to mitigate that condition.
Involuntary treatment may be confrontational initially, and staff generally use MI techniques to elicit change talk and capitalize on patients' mandated treatment status. In the setting of involuntary treatment, it is vital to establish referral partners for when the patients have completed their requisite amount of time in SUD treatment.
Inpatient treatment varies in both insurance coverage and credentialing of staff. It is important to understand the nuances of different inpatient treatment programs, especially the duration of treatment, the medical/psychiatric credentials of the staff, and the program's ability to collaborate with outpatient treatment partners (Office of the Surgeon General, 2016). Given that stimulant use disorders are chronic, relapsing conditions, treatment should not end once patients leave an inpatient setting. These patients should always be “stepped down” into outpatient care.
In the past two to three decades, more patients have received primary SUD care in outpatient settings rather than inpatient treatment facilities. As this shift continues, inpatient treatment will remain reserved for patients experiencing the most severe forms of an SUD, with the highest risk of morbidity or mortality related to their medical or psychiatric presentation while using or stopping their use.
Residential treatment may be indicated for people with SUDs who need more structured support for a specific period of time in early recovery. The structure of residential treatment allows positive changes and stabilization in patients' attitudes and lifestyles. The duration of residential treatment varies. Some treatment may be as short as 30 days, whereas other treatment may last up to 1 year.
TCs, a common type of long-term residential treatment, typically use group activities directed toward effecting significant changes in the residents' lifestyles, attitudes, and values. They emphasize prosocial behavior and strengths-based strategies for improved decision making (NIDA, 2015). Many referrals to TCs take place through the court system. In fact, TCs were originally designed for patients with heroin use disorder, low socioeconomic backgrounds, and long-term histories of criminal involvement.
Halfway houses (also known as sober living environments or facilities) provide transitional support for people who have completed residential treatment and are still attending formal treatment, like outpatient care (Polcin et al., 2010), but would benefit more from increased structure or support than from solitary community living. Halfway-house program requirements usually include specified community involvement (e.g., employment or enrollment in school), and abstinence from mood-altering substances. Evening group activities are structured around residents' work schedules. Programs generally require out-of-pocket expenses and have limited insurance coverage or reimbursement.
PATIENT PLACEMENT: AVOIDING THE COOKIE-CUTTER APPROACH.
Clinicians should be prepared to take into account a number of clinical challenges when doing treatment planning with patients. Exhibit 4.1 summarizes the most common clinical issues encountered and strategies to manage them (Rawson et al., 2021).
EXHIBIT 4.1. Stimulant Use: Managing Common Clinical Issues.
Engaging and treating people who are actively using stimulants, in withdrawal, or in early recovery is challenging. Understanding the experience of the patients in conjunction with clinical concerns is essential for planning and implementing therapy practices to meet patient needs and preferences. Again, when working with these patients, keep in mind that the psychosocial approach with the most research support is CM, with CBT/RP, community reinforcement, and MI also being well-supported interventions. Moreover, mutual-help programs, such as Crystal Meth Anonymous and Narcotics Anonymous, can help individuals with stimulant use disorders manage relapses and enhance recovery.
Several empirically tested nonpharmacologic treatments for stimulant use disorders are available, with CM having the strongest weight of evidence. CBT/RP, community reinforcement, and MI also have good though less robust data to support their use to treat stimulant use disorders. Less rigorously studied yet still appropriate approaches, such as mindfulness meditation and prescribed physical activity, can also be used to supplement SUD care and potentially help patients improve abstinence and other health outcomes. Clinicians have a wide range of options to help patients with stimulant use disorders reduce or stop their substance use, improve their health, regain functioning (e.g., obtain or return to work), and achieve long-term recovery.
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