Addiction Medicine · Supplementary · from Addiction Medicine

Case 3: Stimulant Use Disorder with Contingency Management

Patient Presentation

Demographics: 36-year-old male restaurant line cook

Chief Complaint: "I can't stop using meth no matter how hard I try — I've lost my apartment and my girlfriend left me"

History of Present Illness: This 36-year-old male restaurant line cook presents to the addiction medicine clinic after being referred by an emergency department social worker. He was seen in the ED 3 days ago for chest pain and hypertension (BP 192/110, HR 130) while intoxicated on methamphetamine. Cardiac workup was negative for acute coronary syndrome, and he was discharged with a referral to addiction services.

He reports a 5-year history of methamphetamine use, initially smoking crystal methamphetamine on weekends at parties. Over the past 2 years, his use has escalated to daily smoking, with binges lasting 3-5 days ("runs") followed by 1-2 day crashes where he sleeps 18-20 hours. During binges, he does not eat or sleep and reports consuming 1-2 grams of methamphetamine daily.

His most recent binge ended 4 days ago, and he is currently in the "crash" phase. He reports profound fatigue, hypersomnia (sleeping 16 hours/day for the past 3 days), increased appetite, dysphoria, and anhedonia. He denies current suicidal ideation but reports passive death wishes during the crash ("I wouldn't care if I didn't wake up"). He has experienced methamphetamine-induced psychotic symptoms during binges, including paranoid delusions (believing people were following him) and visual hallucinations (shadow people), which resolve within 24-48 hours of cessation.

He has tried to quit multiple times on his own, with his longest period of abstinence being 3 weeks. He has never received formal addiction treatment. He is currently homeless, staying in a shelter, after being evicted from his apartment 1 month ago for non-payment of rent.

Past Medical History:

• Methamphetamine use disorder, severe
• Methamphetamine-induced psychotic disorder (during binges, resolved with abstinence)
• Hypertension (untreated, likely stimulant-related)
• Dental caries (multiple, "meth mouth")
• Unintentional weight loss (20 lbs over 6 months)
• No prior addiction treatment
• No prior psychiatric hospitalizations
• STI history: chlamydia (treated 1 year ago)

Medications:

• None prescribed
• Active methamphetamine use (smoking, 1-2 g/day during binges)

Social History:

• Restaurant line cook (at risk of losing job due to absences during binges and crashes)
• Currently homeless (staying at a shelter for 1 month)
• Former girlfriend ended relationship 2 months ago due to his drug use
• No children
• High school graduate
• Some college (dropped out after 1 year)
• No current partner
• Smokes cigarettes (1 pack/day)
• Occasional alcohol (2-3 beers on non-binge days)
• Sexual risk behaviors during binges (unprotected sex with multiple partners)
• No IV drug use
• Limited social support (most friends are also users)

Family History:

• Mother with bipolar disorder
• Father with alcohol use disorder
• Maternal uncle with methamphetamine use disorder
• No family history of cardiovascular disease

Physical Examination

• Vital Signs: BP 142/88 mmHg (improved from ED, still elevated), HR 68 bpm (bradycardic during crash phase), RR 14/min, Temp 36.6°C, SpO2 99% on room air, BMI 20.8, Weight 65 kg (down from 74 kg 6 months ago)
• General: Thin male appearing older than stated age. Fatigued appearance, psychomotor retardation. Oriented x3. Flat affect
• HEENT: Multiple dental caries and areas of tooth decay ("meth mouth"). Gingival recession. Dry, cracked lips. No oral lesions. Pupils 4 mm, equal, reactive
• Cardiac: Bradycardic (crash phase), regular rhythm, no murmurs. No S3 or S4
• Lungs: Clear to auscultation bilaterally
• Abdomen: Thin, soft, non-tender. No hepatosplenomegaly
• Skin: Multiple excoriations on forearms and face (from skin picking/formication during binges). Some with secondary infection (crusted, erythematous). No track marks. Dry skin. Poor wound healing
• Neurologic: Alert, oriented x3. Psychomotor retardation. Flattened affect. Speech is slow but coherent. No tremor. No hallucinations or paranoid ideation at this time. No focal deficits
• Musculoskeletal: Generalized muscle wasting. No joint swelling
• Psychiatric: PHQ-9: 20 (severe depression — reassess after abstinence). No active suicidal ideation. No homicidal ideation. No current psychotic symptoms. Insight: fair. Motivation: ambivalent but presenting voluntarily

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• ECG: Sinus bradycardia 62 bpm (crash phase). Normal QTc (420 ms). No LVH. No ST changes
• Echocardiogram (ordered from ED): LVEF 55%, mild concentric LVH. No regional wall motion abnormalities. No valvular disease
• Chest X-ray: Clear. Mild cardiomegaly
• Dental panoramic X-ray: Multiple carious lesions, periapical abscess at tooth #19, generalized periodontal disease
• Montreal Cognitive Assessment (MoCA): 24/30 (borderline, deficits in attention, delayed recall, and executive function — expected in early abstinence, reassess at 3 months)
• Columbia Suicide Severity Rating Scale: Passive death wish present during crash, no active suicidal ideation, no plan or intent

Clinical Image

Diagram illustrating the mesolimbic dopamine reward pathway affected by methamphetamine, showing the ventral tegmental area, nucleus accumbens, and prefrontal cortex, and the principle of contingency management reinforcement. Source: Educational illustration.

Diagnosis

Methamphetamine Use Disorder, Severe (DSM-5), with Methamphetamine-Induced Psychotic Disorder (in remission), Methamphetamine-Induced Depressive Disorder, and Stimulant-Related Cardiovascular Complications

Key Diagnostic Criteria (DSM-5 — meets 9 of 11 criteria, Severe):

• Stimulant taken in larger amounts/longer than intended
• Persistent desire or unsuccessful efforts to cut down (multiple failed quit attempts)
• Great deal of time spent in stimulant-related activities (binge-crash cycles)
• Craving or strong desire to use stimulant
• Recurrent use resulting in failure to fulfill role obligations (job at risk)
• Continued use despite social/interpersonal problems (girlfriend left, homeless)
• Important activities given up
• Use in physically hazardous situations (driving, risky sexual behavior)
• Continued use despite physical/psychological problems
• Tolerance (escalating doses and frequency)
• No physiologic withdrawal per DSM-5 criteria, though "crash" symptoms are recognized

Treatment Plan

1. Contingency management (CM) — primary evidence-based behavioral intervention:

• Enroll in a structured CM program: urine drug screening 2-3 times per week for 12 weeks
• Reinforcement schedule: earn vouchers or prizes for each stimulant-negative urine specimen. Escalating reinforcement (increasing voucher value with consecutive negative specimens: $1 first specimen, $1.50 second, $2 third, escalating up to $20 per specimen). Reset to $1 if positive specimen, with bonus for return to negative
• Target: 12-week CM program with potential earnings of $300-600 in total incentives
• Evidence: CM is the ONLY intervention with consistent, robust evidence for treatment of stimulant use disorders (NNT=4-5 for achieving sustained abstinence)

1. Cognitive behavioral therapy (CBT): Weekly individual CBT sessions focused on:

• Functional analysis of stimulant use (triggers, consequences)
• Coping skills training (managing cravings, high-risk situations)
• Relapse prevention planning
• Sleep hygiene and routine establishment
• Pleasurable activity scheduling (behavioral activation for depression)

1. Pharmacotherapy (limited evidence for stimulant use disorder, but adjunctive use):

• Mirtazapine 30 mg at bedtime: dual benefit for depression and methamphetamine use reduction (some evidence for reduced use in clinical trials). Also addresses insomnia and appetite stimulation
• Bupropion SR 150 mg twice daily: may reduce methamphetamine craving and has antidepressant properties. Weak norepinephrine-dopamine reuptake inhibitor that may partially address dopamine depletion
• Naltrexone 50 mg daily: emerging evidence for reducing methamphetamine use and craving
• Monitor cardiovascular status: lisinopril 10 mg daily for hypertension. Repeat echocardiogram in 6 months to monitor for stimulant cardiomyopathy

1. Psychotic symptom monitoring: Methamphetamine-induced psychotic symptoms typically resolve with sustained abstinence. If psychotic symptoms recur during abstinence, consider independent psychotic disorder and initiate antipsychotic medication. Avoid typical antipsychotics if possible (dopamine system sensitivity in stimulant users)
2. Nutritional rehabilitation: High-calorie, high-protein diet. Vitamin D 50,000 IU weekly x8 weeks then 2000 IU daily. Multivitamin daily. Oral nutritional supplements. Dental referral for comprehensive treatment
3. Housing and social services:

• Referral to transitional sober housing program
• Case management for housing assistance, food stamps, Medicaid enrollment
• Vocational support to maintain current employment
• Healthy social network development (sober recreational activities, community groups)

1. Harm reduction: STI/HIV screening every 3-6 months. PrEP counseling if ongoing sexual risk. Condom distribution. Hepatitis A and B vaccination
2. Follow-up: Clinic visits 2-3 times/week for CM specimen collection and brief check-ins. Weekly CBT sessions. Monthly psychiatry for medication management. Cognitive reassessment (MoCA) at 3 months of sustained abstinence to evaluate for persistent neurocognitive effects

Key Learning Points

• There are NO FDA-approved medications for stimulant (methamphetamine or cocaine) use disorder; contingency management is the most effective evidence-based treatment, with consistent superiority to all other interventions in randomized controlled trials
• Contingency management works by providing immediate, tangible reinforcement for objectively verified abstinence (negative urine specimens), leveraging the same operant conditioning principles that maintain addiction but redirecting behavior toward prosocial outcomes
• Methamphetamine-induced psychotic symptoms (paranoia, auditory/visual hallucinations, ideas of reference) occur in 25-40% of chronic users and typically resolve within 1-2 weeks of sustained abstinence; however, they represent a vulnerability marker for future psychotic episodes with resumed use
• Chronic methamphetamine use causes significant neurotoxicity including dopaminergic and serotonergic terminal degeneration, with neuropsychological deficits in attention, memory, executive function, and processing speed; these deficits partially recover with sustained abstinence (6-12 months) but may not fully normalize
• Stimulant-related cardiovascular complications include acute coronary syndrome, aortic dissection, cardiomyopathy, arrhythmias, and stroke; all patients with stimulant use disorder should receive cardiovascular screening and ongoing monitoring even after achieving abstinence

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