Diagnostic features

Diagnosis follows DSM-5 criteria for Substance Use Disorder applied to stimulants: impaired control, social impairment, risky use, tolerance and withdrawal. Severity is based on the number of criteria met (mild, moderate, severe).

Epidemiology & impact

• Stimulant use is increasing in many regions, with rising harms from synthetic cathinones and high‑purity amphetamines.
• Associated with psychiatric comorbidity (psychosis, mood disorders), infectious risks (if injecting), cardiovascular and neurological complications, and social harms (employment, criminal justice involvement).

Screening & assessment

1. Screen using brief questions (eg, “In the past year, have you used stimulant drugs?”), ASSIST or the single‑question drug screen.
2. Assess severity with DSM criteria and functional impact—document route, frequency, last use, prior treatments, and readiness to change.
3. Medical assessment: cardiovascular history, seizures, infectious disease screening (HIV, hepatitis B/C), and pregnancy testing where relevant.
4. Mental state examination: assess psychosis, suicidality and other comorbidities; consider neurocognitive screening if cognitive impairment suspected.

Evidence-based psychosocial treatments

• Contingency management (CM): the most robust behavioral intervention — incentives for abstinence (urine testing) improve outcomes across multiple trials.
• Cognitive‑behavioural therapy (CBT): relapse prevention, skills training and addressing triggers.
• Motivational Interviewing (MI): effective for engagement and enhancing readiness to change.
• Intensive outpatient programs and group therapy: provide structure, peer support and relapse‑prevention skills.

Pharmacotherapy — current evidence

No medication is universally approved for stimulant use disorder, but several agents have shown promise in trials; pharmacotherapy is considered adjunctive in specialist settings.

• Bupropion: modest evidence in combination with behavioral therapy for amphetamine dependence, particularly for less severe users.
• Modafinil: mixed evidence—may help with cocaine dependence in some trials.
• Topiramate: some positive signals for reducing stimulant use but tolerability limits use.
• Psychostimulant substitution: experimental approaches (e.g., prescription amphetamines) under research in selected settings.
• Adjunctive medications: antidepressants for comorbid mood disorders, antipsychotics for stimulant-induced psychosis (short-term), and medications to treat specific complications (e.g., manage hypertension, arrhythmia).

Harm reduction & safer-use strategies

• Needle/syringe programs and safer injection education to reduce BBV transmission and SSTIs.
• Education on overdose risk when stimulants are adulterated with opioids—consider naloxone distribution as appropriate.
• Advice on safer dosing, avoiding mixing with depressants, not using alone and ensuring hydration/temperature control at events.

Withdrawal management

• Withdrawal is primarily managed supportively: rest, sleep hygiene, nutrition and monitoring for severe depression or suicidality.
• Short-term pharmacologic support for insomnia or mood symptoms may be indicated; refer to psychiatric services for severe depression or suicidal risk.

Integrated care pathways

1. Stabilise acute medical/psychiatric issues (intoxication, psychosis, cardiovascular events).
2. Initiate engagement: MI, assess for CM eligibility and schedule regular urine testing if CM used.
3. Offer CBT and structured psychosocial programs; consider pharmacotherapy in specialist settings when indicated.
4. Coordinate infectious disease screening, sexual health, social support services, and legal or vocational rehabilitation as needed.

Special populations and considerations

• Pregnancy: manage risks to mother and fetus—specialist obstetric and addiction input required.
• Youth: prevention-focused interventions, family therapy and careful consideration of pharmacotherapy.
• Injecting users: prioritise BBV prevention, wound care and access to opioid substitution if polysubstance opioid use present.
• Mental health comorbidity: integrate psychiatric care for psychosis, mood disorders and suicidality.

Key takeaways

• Contingency management and CBT are the most effective evidence-based psychosocial treatments for stimulant use disorder.
• No universally approved pharmacotherapy exists yet—some agents show promise and should be used in specialist settings.
• Integrate harm reduction, infectious disease screening and social supports into treatment plans to address broader determinants of health.
• Stepped care and multidisciplinary approaches improve outcomes; consider clinical trials for novel treatments when appropriate.