Stimulant use disorder encompasses cocaine, methamphetamine, amphetamines, and other stimulants. Methamphetamine is the dominant illicit stimulant in current US epidemiology — the methamphetamine epidemic has run parallel to the opioid epidemic, with substantially less attention. Mortality is substantial through cardiovascular complications, overdose, psychiatric complications, and adverse social outcomes.
Mechanism: stimulants enter presynaptic terminals through dopamine and norepinephrine transporters, then reverse them — dumping neurotransmitter into the synapse. Methamphetamine produces particularly massive dopamine release with long duration; cocaine blocks reuptake with shorter duration. The supraphysiological surge produces both the high and the addictive learning.
Medical complications accumulate with chronic use: cardiovascular (hypertension, MI, arrhythmias, stroke — even in young patients), dental destruction ("meth mouth" — combination of dry mouth, bruxism, dietary changes, and poor hygiene during use), severe weight loss, skin lesions (often from chronic picking), accelerated cognitive aging, persistent psychotic features after chronic heavy use.
Stimulant-induced psychosis is common with heavy use — particularly methamphetamine. Paranoid delusions, auditory and tactile hallucinations (classic "formication"), agitation, sometimes catatonia. Often resolves with abstinence over days to weeks, but heavy methamphetamine use can produce persistent psychotic features lasting months or unmasking primary psychotic illness in vulnerable individuals.
No FDA-approved pharmacotherapy for stimulant use disorder. This is among the most significant unmet needs in addiction medicine. Several off-label options have modest evidence: bupropion (mixed evidence), naltrexone (some evidence for combination with stimulant agonist replacement), topiramate, modafinil. None produce the dramatic effects that buprenorphine produces in OUD.
Contingency management (CM) is the most evidence-based behavioral intervention — providing tangible rewards (vouchers, prizes) contingent on objective evidence of abstinence (negative urine drug screens). CM substantially outperforms other psychosocial interventions for stimulant use disorder. Underused in real-world settings due to cost, regulatory barriers, and historical resistance.
Emerging research: agonist replacement therapy (extended-release amphetamine for cocaine use disorder; lisdexamfetamine for methamphetamine use disorder), combination CM plus pharmacotherapy, vaccines targeting specific stimulants. None yet standard.
Acute management of stimulant intoxication: benzodiazepines for agitation and to reduce cardiovascular sympathetic load (avoid pure beta-blockers — can produce unopposed alpha stimulation and worsened hypertension), antipsychotics for severe agitation or psychotic symptoms, supportive care.
When you encounter a patient with stimulant use disorder, the treatment toolkit is more limited than for OUD or AUD. Contingency management is the highest-yield behavioral intervention. Address comorbid psychiatric and medical conditions. Long-term recovery is possible but requires sustained support without a single dominant medication.