The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

Abstract

Clinical Guideline Committee (CGC) Members: Steven Batki, MD Daniel Ciccarone, MD, MPH Scott Hadland, MD, MPH Brian Hurley, MD (Co-Chair) Kimberly Kabernagel, DO Frances Levin, MD James McKay, PhD Larissa Mooney, MD (Co-Chair) Siddarth Puri, MD Andrew Saxon, MD Kevin Sevarino, MD, PhD Kevin Simon, MD, MPH Timothy Wiegand, MD ASAM Team: Maureen Boyle, PhD Amanda Devoto, PhD Sarah Framnes-DeBoer Taleen Safarian AAAP Team: Kathryn Cates-Wessel Michelle Dirst IRETA Team: Dawn Lindsay, PhD Piper Lincoln, MS Jillian Helmick Peter Luongo, PhD Funding: The development of this guideline was generously funded with contract support from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA). ASAM and AAAP are honored that this clinical practice guideline has been endorsed by: American College of Medical Toxicology (ACMT) American Society for Adolescent Psychiatry (ASAP) American Society of Addiction Nursing (ASAN) Abstract: The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use. Keywords: Stimulant Use Disorder, Clinical Guideline, Addiction Treatment, Stimulant Intoxication, Prevention - TABLE OF CONTENTS Executive Summary 2 Purpose 2 Background 2 Key Takeaways 2 Summary of Recommendations 3 Treatment of Stimulant Use Disorder Recommendations 3 Stimulant Intoxication and Withdrawal Recommendations 6 Secondary and Tertiary Prevention Recommendations 8 Introduction 10 Purpose 10 Background 10 Scope of Guideline 10 Intended Audience 10 Qualifying Statement 10 Methodology 11 Overview of Approach 11 GRADE Methodology 11 Literature Review 11 Systematic Reviews and Meta-Analyses 12 Primary Literature Search 12 Gray Literature Search 12 Literature Extraction 12 Guideline Development 12 Rating Outcomes 13 Rating Quality of Evidence 13 Developing Evidence to Decision Tables 13 Developing Recommendation Statements 13 Approving the Recommendations 13 Rating the Strength of Recommendations 13 Developing the Guideline Document 13 Engaging Stakeholders 14 Treatment of Stimulant Use Disorder 14 Assessment 14 Initial Assessment 14 Comprehensive Assessment 14 Behavioral Treatment 16 Contingency Management 16 Community Reinforcement Approach 17 Cognitive Behavioral Therapy 17 Matrix Model 17 Behavioral Treatment Recommendations 17 Technology-Based Interventions 18 Continuing Care 19 Pharmacotherapy 19 Non-Psychostimulant Medications 19 Psychostimulant Medications 22 Co-occurring Disorders 24 General Guidance 24 Concurrent Management of StUD and ADHD 25 Population-Specific Considerations 26 Adolescents and Young Adults 26 Pregnant and Postpartum Patients 30 Additional Population-Specific Considerations 31 Stimulant Intoxication and Withdrawal 33 Assessment and Diagnosis 34 Initial and Comprehensive Assessment 34 Assessment and Diagnosis Recommendations 36 Setting Determination 37 Setting Determination Recommendations 37 Managing Stimulant Intoxication and Withdrawal 37 Stimulant Intoxication 37 Stimulant Withdrawal 43 Monitoring 43 Suicidality 43 Managing Stimulant Intoxication and Withdrawal in Pregnant Patients 43 Secondary and Tertiary Prevention 44 Screening 44 Screening Recommendations 44 Assessment 44 Assessment Recommendations 45 Early Intervention for Risky Stimulant Use 45 Interventions to Reduce Risky Stimulant Use 45 Referral to Treatment for Stimulant Use Disorder 46 Harm Reduction 46 Harm Reduction Education 46 Overdose Prevention and Reversal 46 Safer Sexual Practices and Contraception 47 Injection Drug Use 47 HIV Preexposure Prophylaxis 48 Oral Health 48 Nutrition 48 Bibliography 48 Appendix A. Glossary of Terms A1 Appendix B. Abbreviations and Acronyms A4 Appendix C. Differential Diagnosis for Agitation and Psychosis A9 Appendix D. Disclosures of Interest A11 Clinical Guideline Committee Members A11 ASAM Quality Improvement Council Members A14 ASAM Board Members A17 AAAP Executive Committee A24 Appendix E. Clinical Questions A26 Treatment of Stimulant Use Disorder A26 Stimulant Intoxication and Withdrawal A35 Secondary and Tertiary Prevention A38 Appendix F. Topics with Insufficient or Negative Evidence A42 Appendix G. Additional Resources A43 Stimulant Use Disorder: General Information and Guidelines A43 Other Topics A44 Appendix H. Substance Use Disorder Biopsychosocial Assessment A55 Appendix I. Baseline Laboratory Testing A56 Appendix J. Principles of Drug Testing During Withdrawal Management A57 Appendix K. Psychostimulant Medication Dosing A59 Appendix L. Acute Issues and Complications of Stimulant Intoxication and Withdrawal A64 Appendix M. Non-acute Issues and Complications of Stimulant Use A65 Appendix N. Medications for Managing Intoxication A66 EXECUTIVE SUMMARY Purpose The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) developed this Clinical Practice Guideline on the Management of Stimulant Use Disorder (hereafter referred to as the Guideline) to provide evidence-based strategies and standards of care for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. Background Rates of StUDs are rising, as are stimulant potency and rates of stimulant use in combination with opioids. These factors have contributed to overdose death rates increasing three-fold for cocaine and twelve-fold for other stimulants—including methamphetamine, amphetamine, and prescription stimulants—in the past ten years.1 Beyond overdose deaths, StUD can cause a range of serious and long-term health problems, including cardiac, psychiatric, dental, and nutritional complications. Injection stimulant use increases the risk of contracting human immunodeficiency virus (HIV), viral hepatitis, and other infectious diseases such as infective endocarditis. The stable or rising availability of stimulants, low prices, and potential contamination of stimulants with high potency synthetic opioids such as fentanyl and other components such as levamisole are expected to exacerbate risks. Taken together, these factors have propelled StUD and stimulant use to an urgent health crisis. This Guideline aims to assist clinicians in treating individuals with StUD (including adolescents and individuals who are pregnant), as well as individuals experiencing stimulant intoxication or withdrawal, and individuals who are at high risk of developing StUD. Key Takeaways This Guideline focuses on the identification, diagnosis, treatment, and promotion of recovery for patients with StUD, stimulant intoxication, and stimulant withdrawal. It also includes recommendations related to screening for risky stimulant use and secondary and tertiary prevention of StUD. Recommendations that address general practice for all substance use disorders (SUDs) are not included, with a few exceptions. The following are seven key takeaways of this Guideline: Contingency management (CM) has demonstrated the best effectiveness in the treatment of StUDs compared to any other intervention and represents the current standard of can be with other and such as and Recommendations including may be utilized off-label to treat StUD Recommendations clinicians should patients and of and for each Psychostimulant should be to treat StUD by: who are in or and with and for patient Co-occurring not to and other in patients with StUD. disorders or should be StUD with care Recommendations Evidence the use of including to treat ADHD in individuals with StUD. that can be to treat StUD off-label have demonstrated in treating disorders and and can be should provide adolescents and who use stimulants with the treatment, and recovery support as in a the Adolescent and Young Acute stimulant intoxication can result in several life-threatening complications that are not to complications and These should be addressed in an appropriate level of care Recommendations of stimulant may treatment the Stimulant Withdrawal of stimulant and for to It to for and treat these to reduce the risk for and to stimulant use. Secondary and tertiary prevention strategies should be used to reduce harms related to overdose risky and Recommendations SUMMARY OF Treatment of Stimulant Use Disorder Recommendations Assessment Recommendations Initial Assessment Recommendations patients for StUD, the clinical should be to any urgent or or or including intoxication or and provide appropriate treatment or Comprehensive Assessment Recommendations any urgent or or patients should a that Assessment for StUD based on current Clinical and to such as and of and risk of to or and treating StUD should should other clinical as based on each clinical patients with long-term or stimulant clinicians should an of for disorders a for based on of the and a for for based on of the and and an of for disorders Behavioral Treatment Recommendations Contingency Management (CM) should be a of the treatment in with other for StUD The following have the evidence and are Community Reinforcement Approach Cognitive Behavioral Therapy and the Matrix Model Technology-Based Interventions Recommendations can evidence-based or as components to treatment for StUD, should not be used as treatment should to treatment for StUD to patients who may care Pharmacotherapy Recommendations Non-Psychostimulant Medication Recommendations use recommendations patients with cocaine use clinicians can to cocaine can for patients with use as this can also reduce use can for patients with as this can also treat use recommendations patients with cocaine use clinicians can to reduce cocaine use can for patients with use as this can also reduce stimulant use recommendations patients with stimulant use with to 18 stimulant clinicians can to use of can for patients with as this can also reduce use can for patients with as this can also treat stimulant use and recommendations patients with use clinicians can in combination with to use of can this combination for patients with as can also reduce can this combination for patients with as can also reduce use can this combination for patients with as can also treat stimulant use recommendations patients with use clinicians can to reduce use of can for patients with as this can also reduce stimulant use recommendations patients with use clinicians can to use of can for patients with as this can also treat Psychostimulant Medication Recommendations General recommendations Recommendations related to the prescription of to treat StUD are who are in or and with and for patient for StUD, clinicians should a level of with the risk for the and Monitoring may clinical and prescription use recommendations patients with cocaine use and clinicians can to reduce cocaine use and treatment use and recommendations patients with cocaine use clinicians can a combination of and to reduce cocaine use and cocaine can this combination for patients with as can also reduce can this combination for patients with as can also reduce ADHD use recommendations patients with cocaine use clinicians can a to cocaine can for patients with as these can also reduce ADHD a clinicians can at or the the for the treatment of ADHD to reduce cocaine use stimulant use recommendations patients with use clinicians can a MPH to use of can MPH for patients with or of use at treatment 10 or can MPH for patients with as these can also reduce ADHD a MPH clinicians can at or the the for the treatment of ADHD to reduce use Co-occurring General Guidance Recommendations should treat StUD and low should use an treatment that available low clinicians should for StUD to address a StUD and low of or should be with or clinicians should a a of of developing a treatment for of of stimulant use or withdrawal, clinicians based on and are stimulant low and the clinical the expected of the of use intoxication, withdrawal, withdrawal, or are at other low treatment for StUD in a patient with a review the treatment in with the treatment and current as appropriate with for in the of the potential use of stimulants and other Concurrent Management of StUD and ADHD Recommendations patients with StUD and clinicians should address ADHD as of the treatment of StUD should to ADHD the of the the to ADHD the of not the and to a patient with StUD and clinicians should and a level of with the risk for the and may clinical and and patients with StUD and clinicians should for a health or other to of the a and on the of and to Population-Specific Considerations Recommendations Adolescents and Young Adults Recommendations Adolescent and and treatment recommendations should to adolescents and for StUD in patients the of clinicians should patients for to was not of Clinical should to or of ADHD and disorders in and patients clinicians should and patients to treatment and support to address Adolescent and treatment recommendations treating adolescents and for StUD, clinicians that have been demonstrated to be in the treatment of other in adolescents and and in the treatment of StUDs in use an and treatment or to be use for treatment in and adolescents and treatment with low treating adolescents and with StUD with the off-label in the Pharmacotherapy the the harms low to not to stimulant use in adolescents and the of a that of in the treatment of adolescents and with and appropriate be with on to to treatment treating in can with treatment of a or in in other may be with or all of treatment and that not for treatment of clinicians should a with the patient treatment be a Pregnant and Postpartum Patients Recommendations Pregnant and patients recommendations should the of StUD for patients who are to care not and for available that address related to and of care and treatment of StUD screening for and associated with stimulant use in patients who are clinicians should to factors that and development the of a result for patients who are may be the general in patients who are clinicians on and of the potential with the of in this and clinical and not of Clinical Pregnant and Postpartum Patients Treatment Recommendations to the or should be are used to StUD, stimulant intoxication, or stimulant low clinicians should targeted the of patients who are treatment Clinical and treatment should to at in to stimulant should treatment support the of as the may be a of and risk of to stimulant use low Recommendations should patients who use stimulants on the of use and patients not to are stimulants as low Additional Population-Specific Considerations Recommendations Sexual and recommendations should and patients with StUD to may not be in a general related to Patients in the Recommendations of treatment for StUD for individuals in the including and Patients or Recommendations patients experiencing clinicians management or a to a or other appropriate who can the patient health and and a to a recovery based on the Stimulant Intoxication and Withdrawal Recommendations Assessment and Diagnosis Recommendations Initial Assessment Recommendations The clinical should any and complications of stimulant intoxication or that the patient a level of care This includes an of including and The clinical for stimulant intoxication or should a clinical of and review of any available and a of the risk of to and Comprehensive Assessment Recommendations Stimulant intoxication and are based on the patient and as well as from any of the are not available in a the from a of and should be used to the of or for Clinical should be based on and and should a a for of and or Clinical for patients with cocaine intoxication or withdrawal, clinicians should be to as levamisole a in the cocaine and can cause Toxicology Testing Recommendations patients with stimulant intoxication or withdrawal, clinicians can use clinical the diagnosis, with other clinical and substance use that to and of stimulant intoxication or should the of stimulants stimulant intoxication Setting Determination Recommendations Patients with clinical or complications related to stimulant intoxication should be in care settings patients with stimulant intoxication can be in clinical settings the patient with care; the patient to and that can be in the clinical the patient not experiencing or to that can be in the clinical and clinicians are for and complications of stimulant intoxication, and for and of intoxication and complications related to stimulant intoxication, provide provide a the risk of to stimulant and clinical as Managing Stimulant Intoxication and Withdrawal Recommendations Behavioral and of Stimulant Intoxication Recommendations should the patient to factors for other stimulant treatment should address all should use and strategies to patients who are to support with care can treating or with can be a treatment for strategies should not the use of to patients who are and at risk for complications should treat with an The and of should be based on and should the use of and for as these may patients at risk for that to or clinicians a on life-threatening and that for and management and a on the to and that for and not to the available management clinicians should to a level of care that address should be for should for of and of in may intoxication and of Stimulant Intoxication Recommendations patients with clinicians should provide and management of rate and complications that may result from should treat patients in a with can be treatment for this the appropriate in and following treatment with or other clinicians can treatment with the following with for for to are clinicians can other such as and with of other and and may be in treating and clinicians should be to potential including or a patient with stimulant intoxication experiencing a clinicians use such as or low to low and use the patient or of low Acute Issues and Complications Recommendations Recommendations patients experiencing stimulant intoxication, clinicians should treatment for the intoxication with as as are clinical are for management of in patients experiencing stimulant are used in patients with stimulant intoxication, clinicians should a with an was used in a patient who or was stimulant clinicians should also a with treating stimulant intoxication in patients experiencing clinicians should for and other of in stimulant intoxication that not as and of stimulant intoxication should be and following current standards of care Recommendations has at and can cause with in cocaine these are in to treating intoxication, clinicians should to the and this also Recommendations a patient to the with following stimulant not the are well substance use or the of the not well stimulant the and management of should to best stimulant or or clinicians should treat with are to clinicians can treating with or Recommendations should patients for StUD and in or to for for StUD, low Secondary and Tertiary Prevention Recommendations Screening Recommendations general adolescents or for risky substance use should screening for stimulant or low should screening for stimulant in patients who low should to Assessment Recommendations patients who for stimulant should a and clinical to complications of use related to of and of used and provide treatment or as appropriate low should the following to and risky of stimulant and of including use use of stimulants with use of and and other and other of overdose and of and of use low and risky should patients the of stimulant use or Clinical and Clinical should based on clinical of risk factors Clinical Patients who in use of prescription stimulants should be for may also treatment Early Intervention for Risky Stimulant Use Recommendations Interventions to Reduce Risky Stimulant Use Recommendations should to patients with any risky stimulant use to patients to reduce or use low should be of of the of stimulant use and be to and as of for stimulant use or Clinical Referral to Treatment for Stimulant Use Disorder Recommendations patients who for risky stimulant clinicians should or for and treatment for potential StUD with including low patients who are for StUD or treatment, clinicians should to for treatment low should the use of to patients to StUD and treatment Harm Reduction Recommendations Harm Reduction Education Recommendations patients who in risky stimulant clinicians stimulant use to the of substance use of of of to as based on the clinical on overdose prevention and and Overdose Prevention and Reversal Recommendations patients who use stimulants from or are with who clinicians should or overdose or patients to can these in the should that patients including fentanyl a of stimulants from and review the for fentanyl should individuals to available Safer Sexual Practices and Contraception Recommendations patients who in risky clinicians or for at 3 to 6 or on the risk patients can or a to a or that risky for or intervention and and or to Injection Drug Use Recommendations patients who stimulants, clinicians provide or for on and to the and of for cocaine and provide or for and HIV Preexposure Prophylaxis Recommendations should HIV to patients who use stimulants and are at risk for including in risky Oral Health Recommendations who use stimulants are at high risk of such as and patients who use stimulants to and care and to care Nutrition Recommendations who use stimulants may and for appropriate at high risk for nutritional such as and and and patients who use stimulants to Purpose The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) developed this Clinical Practice Guideline on the Management of Stimulant Use Disorder (hereafter referred to as the Guideline) to provide on evidence-based strategies and standards of care for the treatment of stimulant use stimulant intoxication, and stimulant withdrawal. The Guideline also secondary and tertiary prevention of harms associated with stimulant use. This on evidence and clinical with the of the of care for with StUD. Background Overdose stimulant methamphetamine, amphetamine, and prescription the past and the rate of overdose cocaine from in to in increasing on the methamphetamine, amphetamine, and prescription stimulants from in to in The in and in the the clinical the rate of cocaine use has been rates of cocaine use and use are has been a in the risk from use to the increasing potency of stimulants and the increasing use of stimulants in combination with can of with use are stimulants may be that the stimulants use are with fentanyl or other of all overdose in the and Beyond the StUD can also to long-term health problems, including cardiac, psychiatric, dental, and as well as stimulant use at risk for infectious including human immunodeficiency virus and viral hepatitis, as well as other infectious complications such as infective The National Drug Assessment from the Drug stable or rising availability and potency and low for cocaine and that are expected to exacerbate these address this urgent ASAM and AAAP a of experts to a clinical practice guideline for the prevention and treatment of StUD. Scope of Guideline This Guideline focuses on the management of StUD, including the identification, diagnosis, treatment, and promotion of recovery for patients with StUD, stimulant intoxication, and stimulant withdrawal. It also includes recommendations related to screening for risky stimulant use and secondary and tertiary prevention of StUD. a few recommendations that address general for all substance use disorders (SUDs) are not of used in the Guideline can be in Appendix of and can be in Appendix Intended Audience The of this Guideline health and provide treatment for StUD, stimulant intoxication, or stimulant in treatment settings and settings such as care and recommendations to settings care as in the The Guideline may also be for and Qualifying Statement This Guideline to clinicians in clinical and patient It to and clinical that the of patients in Clinical should the and availability of and in the care The recommendations in this Guideline the of an ASAM and AAAP in This Guideline be as clinical and of treatment in this Guideline are the recommendations are as of patient and may clinicians should to the of and to and treatment Patients should be of the and to a treatment and should be to ASAM and AAAP that are to of this Guideline in in to the availability of management (CM) and in and this Guideline aims to the standard for best clinical practice recommendations for the appropriate care of all patients with StUD in in the Guideline used as the for or the should be in of Recommendations in this Guideline not any or Overview of Approach Quality Improvement Council for the development of this The recommendations developed the Clinical Guideline Committee was of 14 (including Board of and (including Board of from ASAM to of the the CGC with on Intoxication and Behavioral Treatment, Co-occurring Adolescents and Young Pregnant and Postpartum Secondary and Tertiary Technology-Based and Other Population-Specific CGC in to The CGC was a from the Institute for Education and in IRETA the systematic literature of evidence development of the of Recommendations and evidence and and of the Guideline of seven patients was with from of and Young in to provide to the CGC at of including the of to the harms and of the patient was not to the patient the that the patient may have to with developed an to that and to few the Guideline was for was to these and other patient was The CGC that strategies are to with patient in this ASAM and AAAP to strategies for patient in the development of of the Board of and as well as external of the Guideline, to all current with and other that may or of These are in Appendix of are with of are to from on any that a potential of the from the CGC to of in to the Disclosures of for of and Board of and Executive Committee and of the and key developed the for each clinical can be in the tables supplemental - Management of Stimulant Use Disorder Scope and Key Questions with StUD (including adolescents and experiencing stimulant intoxication at high risk for developing StUD Interventions Pharmacotherapy for StUD stimulant treatment for StUD Cognitive Behavioral Community Reinforcement and Withdrawal Management and Tertiary Prevention strategies Treatment as Outcomes Stimulant use substance Setting substance use substance use GRADE Methodology The Guideline was developed the GRADE Evidence to Decision for recommendations in health GRADE provides a to developing recommendations based on evidence and the clinical of The GRADE process systematic review of clinical evidence and of stakeholder and and Literature Review systematic literature review was to support the GRADE evidence used as of the development The literature review on systematic and as well as the of systematic The of the literature review on systematic clinical and literature on the management and treatment of StUD. The of the literature review on on for to systematic not available and the

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