No Approved Medicine, but Not No Treatment: Methamphetamine Use Disorder in a 29-Year-Old, With Contingency Management and the Naltrexone-Bupropion Trial
[Student Name]
University of Phoenix
PMH/502: Neuropsychiatric Pharmacology
Week 7 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. V., a 29-year-old construction worker, has used methamphetamine daily for three years, smoking it to stay awake on long shifts and then on weekends. He has lost weight, has paranoid thoughts when he uses heavily and lost his job last month. He wants to stop. He has no opioid use. This paper explains the treatment plan.
Assessment
He meets DSM-5 criteria for severe stimulant use disorder, methamphetamine type, with tolerance, craving, failed attempts to cut down and continued use despite psychosis and job loss. I screen for depression, suicidal thoughts, psychosis between uses and other substances, and order tests for HIV, hepatitis B and C and a basic metabolic panel. He has depressive symptoms, no suicidal intent and no psychosis when not using.
The Medication Gap
No medication is approved by the FDA for methamphetamine use disorder. Many trials of single medications have been negative. This makes the recent combination trial important.
The ADAPT-2 Trial
Trivedi et al. (2021) randomly assigned adults with moderate or severe methamphetamine use disorder to extended-release injectable naltrexone every three weeks plus oral extended-release bupropion 450 mg daily, or placebo, in a two-stage design. Response, defined by negative urine tests, was 16.5% with the combination compared with 3.4% with placebo in the first stage, and the weighted overall treatment effect was 11.1 percentage points. The authors described the response as low but higher than placebo.
An effect this modest is still an effect, and for a condition with no approved drug, it is a reason to offer the combination alongside what works better.
What Works Best: Contingency Management
De Crescenzo et al. (2018), in a network meta-analysis of psychosocial interventions for cocaine and amphetamine addiction, found that contingency management, particularly combined with a community reinforcement approach, was among the most effective interventions for achieving abstinence, both at the end of treatment and in longer follow-up. The approach rewards verified abstinence with tangible incentives, which directly counters the reinforcing effects of stimulants.
The Combined Plan
I offer Mr. V. a combined plan. Behavioral: enrollment in a contingency management program at a local treatment center, with twice-weekly urine tests and escalating prize draws for negative results, and the community reinforcement approach, which helps him build rewarding alternatives, such as work and relationships. Medication: after discussion of the modest benefit, he chooses to try extended-release naltrexone injections every three weeks and oral bupropion, titrated to 450 mg daily. Before starting naltrexone, I confirm he uses no opioids and review liver tests. Bupropion lowers the seizure threshold, so I confirm he has no seizure or eating disorder history.
Harm Reduction
While he works toward abstinence, I discuss harm reduction: not using alone, avoiding mixing with other drugs, testing for fentanyl contamination, which increasingly appears in stimulants, and carrying naloxone. I prescribe naloxone, following the CDC guideline's advice to offer it whenever overdose risk is elevated, including when opioids or fentanyl-contaminated supplies may be involved (Dowell et al., 2022).
Why Rewards Work
Methamphetamine produces a powerful, immediate reward through dopamine release, while the benefits of abstinence are delayed and abstract. Contingency management provides an immediate, concrete reward for abstinence, shifting the balance. The escalating schedule, in which rewards grow with consecutive negative tests, encourages sustained abstinence and resets after a positive test without punishment.
Barriers to Contingency Management
Despite strong evidence, contingency management is not widely available, partly because of cost and concerns about incentive limits in some programs. I check that the local program offers it and confirm his insurance coverage. If unavailable, the community reinforcement approach and cognitive behavioral therapy remain options.
Bupropion's Role
Bupropion acts on dopamine and norepinephrine, which may reduce craving and the low mood of early abstinence. In the trial, it was combined with naltrexone rather than used alone (Trivedi et al., 2021), and I use it the same way.
Physical Health
Methamphetamine use causes weight loss, dental problems, skin sores and cardiovascular strain. I examine his teeth and skin, check blood pressure and an electrocardiogram and refer him for dental care, which also helps his self-image.
Injection Logistics
Extended-release naltrexone is given as a deep intramuscular injection every three weeks in the trial protocol. Injection site reactions can occur, so I teach him to watch for pain, swelling or hardness at the site. Because naltrexone blocks opioids, he must not use opioids, and any attempt to override the blockade risks overdose; I explain this clearly.
Measuring Progress
Urine results from the contingency management program provide an objective measure. We also track craving, sleep and mood weekly, since reductions in use often come before complete abstinence.
Family and Housing
He lives with a cousin who also uses. Housing where drugs are present makes abstinence harder, and I connect him with a sober living program and a case manager who can help with housing options.
Relapse Planning
We identify triggers, long shifts, payday and certain friends, and plan responses, such as calling his counselor or attending a meeting.
Explaining the Evidence Honestly
I tell Mr. V. that the medication combination helped a minority of people in the trial, more than placebo but far from all, and that the behavioral program has stronger evidence. Honest expectations prevent discouragement if the medication alone does not work.
Documentation
The note records the diagnosis, the options discussed with their evidence, his choices and the harm reduction measures.
Hepatitis and HIV Results
If his hepatitis C or HIV tests are positive, treatment can be offered alongside substance use care, and testing will be repeated periodically while risk continues.
Vaccination
I offer hepatitis A and B vaccination, recommended for people who use drugs.
Coordination
With his consent, I share the plan with the treatment center so that the contingency management team, the counselor and I work from the same goals and urine results.
Nutrition and Sleep
He has lost 11 kg and sleeps irregularly. Regular meals and a consistent sleep schedule support early recovery and reduce the crash of fatigue and low mood after stopping.
Psychosis Risk
His paranoia with heavy use is a warning. I explain that continued use can lead to persistent psychosis and that sleep deprivation worsens it.
Depression
His depressive symptoms may improve with abstinence, and bupropion may help. I will reassess after four weeks.
Work
Returning to structured work supports recovery. I connect him with vocational services through the treatment center.
Follow-Up
Weekly visits for the first month, reviewing urine results, cravings, mood and side effects.
Conclusion
Mr. V.'s severe methamphetamine use disorder has no FDA-approved medication, but the ADAPT-2 trial found a modest benefit of extended-release naltrexone with bupropion, and a network meta-analysis identifies contingency management, especially with the community reinforcement approach, as among the most effective treatments. Combining the behavioral approach with the medication, harm reduction and support for work and mood gives him the best available chance.
References
De Crescenzo, F., Ciabattini, M., D'Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., Janiri, L., Clark, N., Ostacher, M. J., & Cipriani, A. (2018). Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLOS Medicine, 15(12), Article e1002715. https://doi.org/10.1371/journal.pmed.1002715
Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain: United States, 2022. MMWR Recommendations and Reports, 71(3), 1-95. https://doi.org/10.15585/mmwr.rr7103a1
Trivedi, M. H., Walker, R., Ling, W., dela Cruz, A., Sharma, G., Carmody, T., Ghitza, U. E., Wahle, A., Kim, M., Shores-Wilson, K., Sparenborg, S., Coffin, P., Schmitz, J., Wiest, K., Bart, G., Sonne, S. C., Wakhlu, S., Rush, A. J., Nunes, E. V., & Shoptaw, S. (2021). Bupropion and naltrexone in methamphetamine use disorder. New England Journal of Medicine, 384(2), 140-153. https://doi.org/10.1056/NEJMoa2020214
How this PMH 502 Week 7 example is structured
The PMH/502 Week 7 work usually covers stimulants and other treatments for attention and substance use disorders. This paper addresses a disorder where pharmacotherapy is limited, showing how to use modest drug evidence alongside stronger behavioral evidence. Students search this week as PMH 502 Week 7, PMH502 Wk 7 or PMH/502 Wk 7; all three are the same assignment.
PMH/502 Week 7 questions, answered
What does PMH/502 Week 7 usually ask for?
Many sections ask students to address stimulant medications and treatment of substance use disorders, including pharmacological and psychosocial options.
Is there a medication for methamphetamine use disorder?
No medication is FDA-approved, but a randomized trial found that extended-release injectable naltrexone plus oral bupropion produced a higher, though still low, response rate than placebo.
What is contingency management?
A behavioral treatment that provides tangible rewards, such as vouchers or prizes, for objective evidence of abstinence, such as negative urine tests.
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