EVIDENCE-BASED RESOURCE GUIDE SERIES

Treatment of Stimulant

Use Disorders
Treatment of Stimulant Use Disorders 

Acknowledgments 

This report was prepared for the Department of Health and Human Services, Substance Abuse and Mental 

Health Services Administration (SAMHSA) under contract number HHSS283201700001/ 75S20319F42002 

with SAMHSA. Donelle Johnson served as contracting officer representative. 

Disclaimer 

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect 

the views, opinions, or policies of SAMHSA. Nothing in this document constitutes a direct or indirect 

endorsement by SAMHSA of any non-federal entity’s products, services, or policies, and any reference to nonfederal entity’s products, services, or policies should not be construed as such. 

Public Domain Notice 

All material appearing in this publication is in the public domain and may be reproduced or copied without 

permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be 

reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, 

SAMHSA. 

Electronic Access 

This publication may be downloaded from http://store.samhsa.gov 

Recommended Citation 

Substance Abuse and Mental Health Services Administration (SAMHSA): Treatment of Stimulant Use 

Disorders. SAMHSA Publication No. PEP20-06-01-001 Rockville, MD: National Mental Health and 

Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2020. 

Originating Office 

National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services 

Administration, 5600 Fishers Lane, Rockville, MD 20857, SAMHSA Publication No. PEP20-06-01-001. 

Nondiscrimination Notice 

SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, 

color, national origin, age, disability, or sex. 

SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, 

color, nacionalidad, ni edad. 

Treatment of Stimulant Use Disorders 

Acknowledgments II 
Treatment of Stimulant Use Disorders

Message from Assistant Secretary for Mental Health and Substance Use III

MESSAGE FROM THE ASSISTANT SECRETARY

FOR MENTAL HEALTH AND SUBSTANCE USE, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

As the first U.S. Department of Health and Human Services Assistant Secretary for Mental Health and 

Substance Use at the Substance Abuse and Mental Health Services Administration (SAMHSA), I am pleased 

to present this new resource: Treatment of Stimulant Use Disorders. In response to the charge of the 21st 

Century Cures Act to disseminate information on evidence-based practices and service delivery models, the 

National Mental Health and Substance Use Policy Lab has developed the Evidence-Based Resource Guide 

Series focused on the prevention and treatment of substance use disorders and mental illnesses. With this guide, 

SAMHSA’s goal is to inform health care providers, healthcare administrators, policy makers, and community 

members of the rising rates of stimulant use and the need for targeted treatment programs and practices.

Stimulant use is on the rise in the United States. According to the 2018 National Survey on Drug Use and 

Health, an estimated 5.1 million people aged 12 or older misused prescription stimulants in the past year; 

approximately 1.9 million people aged 12 or older used methamphetamine in the past year with significant 

increases in use in those aged 26 and older; and 5.5 million people aged 12 or older used cocaine in the past 

year.1

 Overdose deaths linked to psychostimulants increased approximately 22 percent from 2017 to 2018 and 

have increased more than three fold over the past five years. Deaths from cocaine, which can be laced with 

fentanyl, increased by 5 percent from 2017 to 2018 and are more than double what they were in 2015.2

 The 

combination of all types of stimulants with unknown amounts of fentanyl increases the risk of overdose and 

overdose death substantially.3

This guide discusses effective practices to treat stimulant use disorders, clinical challenges associated with these 

disorders, and implementation strategies that can be used to address those challenges. I encourage you to use 

this guide to identify treatment practices you can implement to address stimulant use in your healthcare settings 

and communities.

Elinore F. McCance-Katz, MD, PhD 

Assistant Secretary for Mental Health and Substance Use

U.S. Department of Health and Human Services

1 Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the 

United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH 

Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services 

Administration. Retrieved from https://www.samhsa.gov/data/. 2 National Institute on Drug Abuse. (2019). Overdose death rates. Retrieved from https://www.drugabuse.gov/related-topics/

trends-statistics/overdose-death-rates 3 National Institute on Drug Abuse. (2019). DrugFacts: What is fentanyl? Retrieved from https://www.drugabuse.gov/publications/

drugfacts/fentanyl
Treatment of Stimulant Use Disorders

Evidence-Based Resource Guide Series Overview 1

FOREWORD

Evidence-Based Resource Guide 

Series Overview

The Substance Abuse and Mental Health Services 

Administration (SAMHSA), and specifically, its National 

Mental Health and Substance Use Policy Laboratory 

(Policy Lab), is pleased to fulfill the charge of the 

21st Century Cures Act to disseminate information on 

evidence-based practices and service delivery models to 

prevent substance misuse and help people with substance 

use disorders (SUD), serious mental illnesses (SMI), and 

serious emotional disturbances (SED) get the treatment 

and support they need.

Treatment and recovery for SUD, SMI, and SED can 

vary based on a number of geographic, socio-economic, 

cultural, gender, race, ethnicity, and age-related factors 

which can complicate evaluating the effectiveness 

of services, treatments, and supports. Despite these 

variations, however, there is substantial evidence to 

inform the types of resources that can help reduce 

substance use, lessen symptoms of mental illness, and 

improve quality of life. 

The Evidence-Based Resource Guide Series is a 

comprehensive set of modules with resources to improve 

health outcomes for people at risk for, with, or recovering 

from mental and/or substance use disorders. It is designed 

for practitioners, administrators, community leaders, and 

others considering an intervention for their organization or 

community. A priority topic for SAMHSA is encouraging 

practices that reduce stimulant use, lower the risk of 

overdose, and promote recovery from stimulant use 

disorders. This guide reviews the literature and science, 

examines evidence-based practices, determines key 

components of those practices, identifies challenges and 

strategies for implementation, and discusses evaluation 

of implemented evidence-based practices. The purpose 

of this document is to identify potential treatment 

strategies and evidence-based practices for stimulant use 

disorders and does not include all resources required for 

implementation of those practices. 

Expert panels of federal, state, and non-governmental 

participants provide input for each guide in this series. 

The panels include accomplished scientists, researchers, 

service providers, community administrators, federal and 

state policy makers, and people with lived experience. 

Members provide input based on their knowledge of 

healthcare systems, implementation strategies, evidencebased practices, provision of services, and policies that 

foster change. 

Research shows that implementing evidence-based 

practices requires a comprehensive, multi-pronged 

approach. This guide is one piece of an overall approach 

to implement and sustain change. Readers are encouraged 

to visit the SAMHSA website for additional tools and 

technical assistance opportunities.
Treatment of Stimulant Use Disorders

Evidence-Based Resource Guide Series Overview 2

Content of the Guide

This guide contains a foreword and five chapters. The chapters are meant to 

stand alone and do not need to be read in order. Each chapter is designed to be 

brief and accessible to healthcare providers, healthcare system administrators, 

community members, policy makers, and others working to meet the needs of 

people at risk for, experiencing, or recovering from mental and/or substance use 

disorders. The goal of this guide is to review the literature on treating stimulant 

use disorders, distill the research into recommendations for practice, and provide 

examples of how practitioners use these practices in their programs. 1

FW Evidence-Based Resource Guide Series 

Overview

Introduction to the series.

1 Issue Brief

Overview of current approaches and challenges to 

addressing stimulant use disorders in communities. 

2 What Research Tells Us

Current evidence on effectiveness of the following practices 

included in the guide to address stimulant use disorders: 

Motivational Interviewing, Contingency Management, 

Community Reinforcement Approach, and Cognitive 

Behavioral Therapy.

3 Guidance for Selecting and Implementing Evidence-based Practices

Practical information to consider when selecting and 

implementing practices to address stimulant use disorders.

4 Examples of Stimulant Use Treatment Programs

Descriptions of programs that use practices from Chapter 2 

to address stimulant use disorders.

5 Resources for Evaluation and Quality Improvement

Guidance and resources for implementing best practices, 

monitoring outcomes, and improving quality.

FOCUS OF THE GUIDE

Stimulant use is rising and becoming 

a public health crisis similar to the 

opioid epidemic. Illicit stimulants, 

like cocaine and amphetamines, 

are more accessible and have 

evolved to be purer, cheaper, and 

more potent. Stimulants are harmful 

to the cardiovascular system and 

can cause lung and brain diseases, 

stroke, and even death. 

Treating addiction to stimulants is 

critical, but especially challenging. 

Unlike opioids, there is no FDAapproved medication currently 

available for stimulant use disorders. 

People who misuse opioids—

which suppress the functioning of 

the central nervous system—and 

stimulants in combination, often do 

so to reverse or modulate the effect 

of the other.1

This guide presents four evidencebased programs and practices that 

address treatment of stimulant use. 

It supports SAMHSA’s Strategic Plan 

Objective 3.4 to: 

“Support the identification and 

adoption of evidence-based 

practices, programs, and policies 

that prevent substance use, increase 

provision of substance use disorders 

treatment, and enable individuals to 

achieve long-term recovery.” 

This guide covers cocaine and 

amphetamine-type stimulants that 

increase alertness and energy; 

heighten arousal; elevate blood 

pressure, heart rate, and respiration; 

and cause behavioral excitement. 

The guide also recognizes the 

misuse of prescription stimulants, 

such as dextroamphetamine 

and methylphenidate, found in 

medications used for conditions 

like attention-deficit hyperactivity 

disorder (ADHD), narcolepsy, and 

depression.
Treatment of Stimulant Use Disorders

Evidence-Based Resource Guide Series Overview 3

The framework below provides an overview of this guide. The guide addresses stimulant use disorders, including illicit and 

prescription stimulants. The focus of the guide is on treatment practices that have been evaluated with adults. The review 

of these interventions in Chapter 2 of the guide includes specific outcomes, practitioner types, and delivery settings for the 

practices.
Treatment of Stimulant Use Disorders

Issue Brief 4

1

CHAPTER

Issue Brief

This chapter presents an overview of stimulant use 

disorders, specifically focusing on its prevalence in the 

population and its impact on individuals and society. 

Stimulant use disorders include a range of problems 

associated with the use of methamphetamine, cocaine, and 

other amphetamines. Diagnosis of a stimulant disorder is 

based on the occurrence of at least two of the following 

within a 12 month period.2

•	 Taking more stimulants than intended

•	 Failing to cut down or control use of stimulants, 

despite wanting to do so

•	 Spending excessive amounts of time in activities 

surrounding stimulant use

•	 Experiencing urges and cravings for stimulants

•	 Failing to meet the obligations of home, school, 

or work

•	 Continuing to take stimulants, even if it has led 

to relationship or social problems

•	 Giving up or reducing important recreational, 

social, or work-related activities because of 

stimulant use

•	 Using stimulants in situations in which it is 

physically hazardous

•	 Continuing to use stimulants even if there is 

an awareness that it is causing or worsening a 

physical or psychological problem

•	 Experiencing an increase in tolerance to 

stimulants

•	 Having withdrawal symptoms when not taken

Misuse of prescription stimulants and abuse of illicit 

stimulants, such as cocaine and amphetamines, continues 

to rise in the United States. In 2018, the amount of 

cocaine and methamphetamines seized in certain parts of 

the country exceeded that of opioids.3

 

The number of people using stimulants for the first time 

has significantly increased since 2015,4 and while the trend 

in overall stimulant use is concerning, increases in related 

overdose deaths may be even greater cause for alarm. 

STIMULANT USE IN PAST YEAR ACROSS GENERAL 

POPULATION, 2007-2018

*Source: CDC WONDER; NCHS, National Vital Statistics System, 

Mortality

In 2018, 5.5 million people 

in the United States aged 12 

or older used cocaine within 

the past year and 1.9 million 

people aged 12 or older 

used methamphetamine in 

the past year.

4

 
Treatment of Stimulant Use Disorders

Issue Brief 5

The number of cocaine- and other psychostimulant-related 

deaths has climbed sharply over the past few years. This 

can be partially explained by an increase in polydrug use. 

In recent years, more than 50 percent of all stimulantrelated overdose deaths have also involved opioids.5

Specifically, the practice of intentional or unintentional 

misuse of fentanyl (a synthetic opioid pain reliever) with 

stimulants is on the rise. Much of the methamphetamines 

and cocaine sold on the streets contain unpredictable 

levels of fentanyl. People buying these street products 

are often unaware of the combination of stimulant and 

fentanyl which suppresses respiration and increases the 

risk for overdose and death. 

STIMULANT-RELATED OVERDOSE DEATHS ACROSS 

GENERAL POPULATION, 2007-2018

*Source: CDC WONDER; NCHS, National Vital Statistics System, 

Mortality

Cocaine misuse is highest among adults aged 18 to 

25, while methamphetamine misuse is highest among 

those aged 26 to 49. Methamphetamine misuse rates are 

particularly high among American Indians and Alaska 

Natives (AI/AN) who, according to Centers for Disease 

Control and Prevention (CDC) data, also have the highest 

risk for methamphetamine-related overdose deaths. 

These data also show that Black or African American 

communities have the highest risk for cocaine-related 

overdose deaths.6

PERCENTAGE OF POPULATION WITHIN SPECIFIC 

AGE GROUPS WHO REPORT USING STIMULANTS 

WITHIN THE PAST YEAR, 2018

*Source: National Survey on Drug Use and Health, 2018

** Numbers in parentheses represent total populations for the 

specific age groups. 

PERCENTAGE OF POPULATION WITHIN SPECIFIC 

RACES WHO REPORT USING STIMULANTS WITHIN 

THE PAST YEAR, 2018

*Source: National Survey on Drug Use and Health, 2018

NH/OPI: Native Hawaiian and Other Pacific Islanders

AI/AN: American Indian Alaska Native
Treatment of Stimulant Use Disorders

Issue Brief 6

Research highlights some of the reasons different genders 

give for using stimulants. For example, females cite 

“increased energy,” while males cite “enhanced sexual 

experience” as their prime reasons.7 There are also 

geographical differences in the prevalence of stimulant 

misuse across the country, with cocaine used more widely 

in eastern states and methamphetamines used more in the 

West and Midwest.8

Impact of the Problem 

Short-Term Impact 

The short-term effects of stimulant use vary depending on 

several factors, including the combination of substances 

used, route of administration, potency, dosage, and level 

of prior use. However, in broad terms, stimulants are 

known to cause increased wakefulness, reduced appetite, 

and feelings of euphoria brought on by the rapid release 

of neurotransmitters, including dopamine, serotonin, and 

norepinephrine.9-10

The adverse effects of stimulant use are welldocumented. Stimulant use can cause acute conditions, 

such as accelerated heart rate, vasoconstriction, and 

bronchodilation, which stress the cardiovascular 

system.10-11 Likewise, use can produce elevated body 

temperature, which can result in potentially deadly 

hyperthermia, either alone or in combination with 

environmental factors.10 In addition, stimulant use can 

cause a host of adverse psychological or neurological 

effects, including panic attacks, hostility, paranoia, 

psychosis, and even violent behavior.12-14 and secondary 

complications such as local injection site infections, lifethreatening sepsis, and/or neurological toxicity.15 

Stimulant overdose can cause other serious symptoms, 

including hypertension, fainting, seizures, and death.16

As is evident by overdose data, the number of stimulant 

overdoses resulting in death are climbing dramatically. 

The subacute effects of stimulant use are often 

experienced once the initial drug reaction of wakefulness 

and euphoria wear off. These effects can include fatigue, 

depression, chronic insomnia, increased appetite, impaired 

memory, and anhedonia (the inability to feel pleasure).17-19

Long-Term Impact 

Chronic stimulant use may result in a number of health 

issues. In the long-term, persistent hypertension and a host 

of other serious cardiovascular complications can occur, 

such as angina, valvular disease, stroke, and an increased 

risk for heart attack.10, 20-21

Chronic stimulant use can permanently alter brain 

structure, leading to impaired cognitive, neurological, and 

emotional systems. Because stimulant use releases large 

amounts of dopamine and serotonin, chronic use may 

cause mood fluctuations, anxiety, and depression, even 

when not taking the drug(s). Long-term use of cocaine 

and methamphetamines can cause decreased attention, 

confusion, impaired memory, inhibited impulse, and 

reduced motor skills.22-24 These long term impacts pose 

challenges for recovery, but successful treatment can 

enable people to return to a productive and meaningful life.

Depending on the substance used and the route 

of administration, chronic stimulant use may also 

cause a variety of other adverse physical effects. 

Methamphetamine use, for example, may result in 

“meth mouth,” a condition characterized by rapid tooth 

decay and gum disease.25 Nasal ingestion (snorting) may 

result in loss of smell, a deviated septum, frequent nose 

bleeds, and other damage to the nasal cavity.26 Smoking 

stimulants may result in lung and airway damage.27 28-2

Impact on Society 

Stimulant use also has detrimental societal effects, 

including negative outcomes for children who have a 

parent who uses, heightened crime in communities, 

costs associated with enforcement and incarceration, 

environmental damage, and premature deaths. 

Stimulant use by pregnant mothers can have long-term 

health and development consequences for their children 

(e.g., delayed motor development, poor language skills, 

and cognitive and behavioral issues). Babies born to 

mothers who use stimulants are often premature and 

smaller in size than babies born to mothers who did not.

30-31

Between 2008 and 2015, amphetamine-related 

hospitalizations more than tripled, increasing 

from 55,447 instances to 206,180.28 As of 2019, 

methamphetamine has surpassed opioids as the 

leading cause of overdose death in many western 

U.S. states.29
Treatment of Stimulant Use Disorders

Issue Brief 7

Continued stimulant use by one or both parents is also 

associated with neglectful or abusive parenting, as well 

as higher prevalence of children entering the foster care 

system and using stimulants themselves.

32-34

People who use methamphetamines are more likely to 

perpetrate domestic violence than those who do not. 

They are also more likely to commit property crimes than 

ASSOCIATION WITH RISKY 

BEHAVIOR 

People who use stimulants are more likely to 

engage in unprotected sex and sex with multiple 

partners.37- 38 In addition, intravenous administration 

of stimulants may result in reusing or sharing 

needles, syringes, and other paraphernalia. These 

behaviors place people who misuse stimulants 

at higher risk for HIV and other blood-borne 

pathogens, such as hepatitis B and hepatitis C. 

This is of concern because chronic stimulant use is 

linked to weakened immune response, increased 

susceptibility to infection, and accelerated retroviral 

replication.1, 30-31

individuals who misuse other substances.35-36 Powder 

cocaine, crack cocaine, and methamphetamine-related 

offenses accounted for more than 75 percent of all 

federally-sentenced drug offenses.39

The process used to produce and synthesize stimulants 

in clandestine laboratories can release toxins into the 

environment and create hazardous by-products. These 

conditions can cause explosions–a potential harm to those 

in the laboratory and neighboring community.40-41 The 

U.S. Department of Justice estimates that every pound of 

methamphetamines produced results in five to six pounds 

of hazardous waste, which is rarely disposed of properly.42 

The greatest societal costs of stimulant use are associated 

with adverse health effects and, tragically, premature 

deaths. Amphetamine-related hospital costs totaled 

$436 million in 2003, and increased to $2.17 billion by 

2015.28 Cocaine overdose caused 14,666 deaths in 2018; 

methamphetamines and other psychostimulants caused 

12,676 deaths. Overall, stimulant-related deaths in 2018 

accounted for roughly 40 percent of all overdose deaths in 

the United States.6

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Association, 1(6), e183758-e183758.
Treatment of Stimulant Use Disorders

Issue Brief 8

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D., Letendre, S., & Grant, I. (2003). Increased 

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38 Novoa, R. A., Ompad, D. C., Wu, Y., Vlahov, D., 

& Galea, S. (2005). Ecstasy use and its association 

with sexual behaviors among drug users in New 

York City. Journal of Community Health, 30(5), 

331-343.

39 Taxy, S., Samuels, J., & Adams, W. (2015). 

Drug offenders in federal prison: Estimates of 

characteristics based on linked data. Washington, 

DC: US Department of Justice.

40 Baldwin, G. C., Roth, M. D., & Tashkin, D. P. 

(1998). Acute and chronic effects of cocaine on 

the immune system and the possible link to AIDS. 

Journal of Neuroimmunology, 83(1-2), 133-138.

41 Salamanca, S. A., Sorrentino, E. E., Nosanchuk, 

J. D., & Martinez, L. R. (2015). Impact of 

methamphetamine on infection and immunity. 

Frontiers in Neuroscience, 8, 445.

42 Scott, M. S., & Dedel, K. (2006). Clandestine 

methamphetamine labs. Washington, DC: US 

Department of Justice. 
Treatment of Stimulant Use Disorders

What Research Tells Us 10

2

CHAPTER

What Research

Tells Us

The purpose of this chapter is to provide an overview of 

four practices to treat stimulant use disorders: 

•	 Motivational interviewing 

•	 Contingency management 

•	 Community reinforcement approach 

•	 Cognitive behavioral therapy 

Stimulant use disorders not only have adverse effects on 

the physical and mental health of individuals, but they 

are also a public health problem with significant negative 

impacts on society. In the absence of pharmacological 

treatment that are approved by the U.S. Food and Drug 

Administration (FDA), practitioners rely heavily on 

behavioral and psychosocial interventions and practices. 

Literature around these practices is often inconsistent, 

making identification of the most effective treatment 

methods challenging.1

Through an extensive literature review and consultation 

with experts, authors identified four practices used to treat 

stimulant use disorders. Based on a systematic review of the 

available evidence, each selected practice received a rating. 

Practice Selection 

To be considered for inclusion in this guide, eligible 

practices had to meet the following criteria: 

•	 Must be clearly defined and replicable 

•	 Address stimulant misuse reduction as a primary 

outcome 

•	 Are currently in use 

•	 Provide evidence of effectiveness 

•	 Have accessible resources for implementation 

and fidelity 

Evidence Review and Rating

Authors completed a comprehensive review of published 

research for each selected practice to determine its 

strength as an evidence-based practice. Eligible research 

studies had to:

•	 Employ a randomized or quasi-experimental 

design, or 

•	 Be a single sample pre-post design or an 

epidemiological study with a strong counterfactual 

study (i.e., a study that analyzes what would have 

happened in the absence of the intervention). 

Descriptive and implementation studies, and metaanalyses were not included in the review, but 

were documented to provide context and identify 

implementation supports for the practices.

Each eligible study was reviewed for evidence of 

measurable reductions in stimulant use. In addition, 

trained reviewers checked each study to ensure rigorous 

methodology, asking questions such as:

•	 Are experimental and comparison groups 

demographically equivalent, with the only 

difference being that participants in the 

experimental group received the intervention and 

those in the comparison group received treatment 

as usual or with no or minimal intervention?
Treatment of Stimulant Use Disorders

What Research Tells Us 11

•	 Was baseline equivalence established between 

the treatment and comparison groups on 

outcome measures?

•	 Were missing data addressed appropriately?

•	 Were outcome measures reliable, valid, and 

collected consistently from all participants?

Using these criteria, each study’s causal impact was 

assessed and given a rating of low, moderate, or high. 

Only randomized controlled trials, quasi-experimental 

designs, and epidemiological studies with a strong 

comparison were eligible to receive a high or moderate 

rating.

After all studies for a practice were assessed and rated, the 

practice was placed into one of three categories based on 

its causal evidence level.4

4 See Appendix 2 for more information about the evidence review 

process.

Causal Impact: Evidence demonstrating that 

an intervention causes, or is responsible for, 

the outcome measured in the study’s sample 

population.
Strong Evidence 

Treatment of Stimulant Use Disorders

What Research Tells Us 12

Motivational Interviewing 

Goal

Motivational interviewing (MI) is a treatment approach 

that helps individuals overcome ambivalent feelings 

and insecurities. In the process, individuals become 

motivated to change their behavior and reduce or stop 

their stimulant use. 

Five underlying principles guide how providers should 

interact with clients while using this practice.2

 Providers 

should:

• Express empathy through reflective listening

• Identify discrepancies between a client’s goals

or values and their current behavior

• Avoid arguments and direct confrontations with

a client

• Adjust to a client’s resistance rather than

opposing it directly

• Support self-efficacy and optimism

Typical Settings

Motivational interviewing is effective in a wide range 

of healthcare settings, from primary healthcare clinics 

to general or specialized hospitals. Studies included in 

this evidence review tested the effectiveness of MI for 

treating people with stimulant use disorders in walk-in 

health clinics, urban trauma centers, private or universityrun health clinics, community-based health clinics, and 

community-based sites.

Demographic Groups for Intervention

Motivational interviewing is intended for use across 

genders, ages, races, and ethnicities.3-4 This counseling 

approach can also be used with specific groups within the 

population, such as men who have sex with men.5

OUTCOMES ASSOCIATED WITH 

MOTIVATIONAL INTERVIEWING

Studies included in this evidence review 

demonstrated that use of MI for people with 

stimulant use disorders was associated with 

reductions in: 

• Number of days of stimulant use

• Amount of stimulant used per day

All outcomes were measured using either urine 

toxicology or participant self-report. The time 

between treatment and follow-up varied from 

zero months (immediately post-treatment) to six 

months. 

Developers of motivational interviewing define it 

as “a directive, client-centered counselling style 

for eliciting behavior change by helping clients 

explore and resolve ambivalence.”2

Identification of Practices Associated with Treatment of 

Stimulant Use Disorders

Studies typically included adult participants who were aged 

18 and older, had no language barriers, and met criteria in 

the Diagnostic and Statistical Manual of Mental Disorders 

(DSM) for stimulant use disorders either through screening 

or self-report. Individuals with cognitive impairment, 

serious mental illness, suicide risk, or inability to provide 

informed consent were not included in these studies. 

This evidence review also included studies, each of which 

included one of the following participant characteristics: 

• Adolescents and younger adults (ages 16–22)

• Men who have sex with men

• Individuals who exhibit co-occurring psychotic

disorders (not requiring acute in-patient

psychiatric services)

• Patients with intentional or unintentional

traumatic injury

Practitioner Types

Motivational interviewing is intended for use by a wide 

variety of practitioners, including primary care and 

behavioral health professionals, peer providers, and

criminal justice personnel. Training on MI is available for 

clinicians, non-clinicians, peers, and those with minimal 

or no training in counseling or therapy. 
Strong Evidence

Treatment of Stimulant Use Disorders

What Research Tells Us 13

Studies of MI for treating stimulant use disorders 

involved clinical staff who were trained in the approach. 

These clinicians were either trained community workers 

or bilingual peers (experienced substance use outreach 

workers who were themselves in recovery).

Intensity and Duration of Treatment 

Use of MI for reducing substance use, and, more 

specifically, for reducing and ending stimulant use, does 

not have a prescribed time period; it can range from 

a single session of 15 minutes to multiple hour-long 

sessions. This review of recent studies shows that there 

are no generalizable conclusions around the number or 

length of sessions needed to reduce stimulant use. 

web-based, facilitating access for people in geographically 

diverse and difficult to reach places.9-10

Studies included in this evidence review tested the 

effectiveness of CM for treating people with stimulant use 

disorders at community-based substance use or mental health 

clinics, private or university-run health clinics, methadone 

maintenance facilities, and community-based sites. Two 

studies also had a web-based component of CM.11

Demographic Groups for Intervention 

Contingency management is used across genders, ages, 

races, and ethnicities in both individual and group 

settings. The approach can also be used with specific 

groups within the population, such as men who have sex 

with men, people with co-occurring opioid use disorders, 

and individuals with severe mental disorders.12-15

Studies included in this evidence review involved adult 

participants who were aged 18 and older, had no language 

barriers, and met criteria in the DSM for stimulant use 

disorders either through screening or self-report. 

OUTCOMES ASSOCIATED WITH 

CONTINGENCY MANAGEMENT

Studies included in this evidence review 

demonstrated that use of CM for people with 

stimulant use disorders was associated with 

reductions in: 

• Number of days of stimulant use

• Stimulant cravings

• New stimulant use

• HIV risk behaviors

All outcomes were measured using either urine 

toxicology, participant self-report, or the Addiction 

Severity Index Scale.11 The time between 

treatment and follow-up varied from zero months 

(immediately post-treatment) to nine months.

Contingency Management 

Goal

Contingency management (CM) is a type of behavioral 

therapy grounded in the principles of operant 

conditioning. Operant conditioning is a method of 

learning in which desired behaviors are reinforced with 

prizes, privileges, or cash. 

For treatment of stimulant use disorders, incentivized 

behaviors might include:

• Attendance at treatment sessions

• Adherence to prescribed medications for other

health conditions

• Provision of stimulant-negative urine specimens

In a clinical setting, reinforcement is often provided in the 

form of vouchers that can be exchanged for retail goods and 

services. It may also include access to certain privileges, the 

opportunity to win a prize, or even direct cash payments. 

While CM may be structured in several different ways, 

two widely used approaches include:

• The Fishbowl Method (popularized by Dr.

Nancy Petry) where clients who have earned an

incentive draw a token from a “fishbowl” for a

chance to win a prize of varying value

• Voucher-Based Reinforcement Therapy

(popularized by Dr. Stephen Higgins) where clients 

earn vouchers for completion of desired behaviors

with the level of vouchers increasing according to

an escalating schedule of reinforcement

Typical Settings

A wide range of healthcare settings, including primary 

healthcare clinics, community outpatient programs, and 

inpatient settings, can use CM effectively.6-8 In addition, 

CM systems have been adapted to be computerized or 
Strong Evidence

Treatment of Stimulant Use Disorders

What Research Tells Us 14

Practitioner Types

A variety of professionals, such as primary care 

physicians, behavioral health professionals, and criminal 

justice personnel, can implement CM.16-18 Training or 

coursework in behavioral analysis is available to support 

implementation of this intervention. 

For most studies in this evidence review, research staff, 

who may or may not have had clinical backgrounds, 

implemented the CM procedures. Some studies specified 

that these staff were trained and tested on CM protocols, 

often with the use of scripts or role-play. 

Intensity and Duration of Treatment 

Contingency management therapy does not have a 

prescribed time period, as it consists of a reinforcerbased framework often used in combination with other 

therapies. Many clinical evaluations of CM follow a 12-

week schedule and feature frequent drug screenings (two 

to three times weekly). 

public outpatient treatment facilities, and urban treatment 

facilities that offer both inpatient and outpatient services. 

One study also used an online CRA learning program.

Demographic Groups for Intervention 

The community reinforcement approach is used across 

genders, ages, races, and ethnicities in both individual and 

group settings. The adolescent version of CRA involves 

immediate family in the treatment program. There is 

also a family training version that aims to increase the 

client’s engagement in the program through a concerned 

significant other. 

Studies included in this evidence review involved adult 

participants who were aged 18 and older, had no language 

barriers, and met criteria in the DSM for stimulant use 

disorders either through screening or self-report. 

OUTCOMES ASSOCIATED WITH 

THE COMMUNITY 

REINFORCEMENT APPROACH

Studies included in this evidence review 

demonstrated that use of CRA for people with 

stimulant use disorders was associated with 

reductions in: 

• Cocaine abstinence

• Addiction severity

• Drug use (e.g., number of weeks of

usage, frequency per week, amount spent

per week)

All outcomes were measured using either 

urine toxicology, participant self-report, or the 

Addiction Severity Index Scale. The time between 

treatment and follow-up varied from zero months 

(immediately post-treatment) to nine months.

Community Reinforcement Approach 

Goal

One behavioral therapy approach that is commonly used 

in combination with CM is the community reinforcement 

approach (CRA). This treatment was originally developed 

by Nathan Azrin and his colleagues for alcohol use 

disorder, and was later adapted for stimulant use disorder, 

particularly cocaine use. The goal of CRA is to identify 

behaviors reinforcing stimulant use and make a substancefree lifestyle more rewarding than one that includes drugs 

and alcohol. 

CRA includes multiple elements such as such as 

analyzing clients’ substance use, relationship counseling, 

vocational guidance, and job skills training. CRA therapy 

also focuses on building social and drug refusal skills. 

Ultimately clients are encouraged to make substantial 

behavioral changes, engage in new recreational activities 

and develop new social networks.19

When used in combination with CM, clients who 

demonstrate positive behaviors such as drug abstinence, are 

typically provided material incentives to encourage skills 

development to build a rewarding substance-free life.

Typical Settings

The community reinforcement approach is often 

delivered through inpatient programs, home visits, and 

in combination with incentives/vouchers. Practitioners 

can also implement it successfully in a typical outpatient 

treatment context, where they see clients weekly at a 

clinic.20

Studies included in this evidence review tested the 

effectiveness of CRA for treating people with stimulant 

use disorders at community-based substance use clinics, 
Strong Evidence

Treatment of Stimulant Use Disorders

What Research Tells Us 15

Practitioner Types

A variety of professionals who possess strong, 

fundamental counseling skills, such as supportiveness, 

empathy, and a caring attitude, can implement this 

approach. This could include primary care and 

behavioral health professionals as well as pharmacists. 

CRA requires therapists to be directive, energetic, and 

engaging. 

For most studies in this evidence review, clinical staff 

implemented CRA by following procedures outlined in 

the manual A Community Reinforcement Plus Vouchers 

Approach.

21

Intensity and Duration of Treatment 

Per the manual mentioned above, CRA recommends a 

24-week treatment program. Each week, clients meet one 

to two times for counseling and submit two to three urine 

specimens.21

COMPUTER-BASED COGNITIVE 

BEHAVIORAL THERAPY

A newer approach to CBT uses a digital format 

for delivery to clients. This format draws on the 

National Institute on Drug Abuse’s CBT manual 

and offers CBT sessions either online or through 

an app. Computer-based CBT can be used in 

regular clinical settings as an effective supplement 

to usual outpatient treatment for stimulant 

dependence.23

Given the multimedia format of the treatment, it is 

more affordable and can be made more broadly 

available than standard therapy treatments. 

Additionally, computer-based CBT can help reach 

and serve minority or geographically remote 

groups who may have limited access to such 

services. 

Cognitive Behavioral Therapy 

Goal

Cognitive behavioral therapy (CBT) is a short-term, goaloriented psychotherapy treatment that enables individuals 

to understand their current problems, challenges, and 

experiences in order to change their behaviors and 

patterns of thinking. CBT helps clients develop accurate 

assessments of circumstances and their feelings so 

they can develop realistic strategies. CBT is used also 

to address depressive cognitions and other cognitive 

distortions associated with depression, generalized anxiety 

disorders, and substance use disorders. 

Through CBT, people with stimulant use disorders are 

trained to evaluate faulty patterns of thinking, actions, 

and negative feelings associated with their drug use. CBT 

is tailored to the needs of the individual, with the goals 
Treatment of Stimulant Use Disorders

What Research Tells Us 16

of each therapy session uniquely based on the client’s 

experiences with stimulant use and personal circumstances. 

Typical Settings

Practitioners can use CBT effectively in a wide range 

of healthcare settings, from inpatient psychiatric 

rehabilitation to community outpatient programs.22

Studies included in the current evidence review looked 

at CBT’s use in private health clinics, community-based 

outpatient treatment programs, outpatient methadone 

programs, and through online formats. 23

Demographic Groups for Intervention

Cognitive behavioral therapy is a widely used approach, 

employed across genders, ages, races, and ethnicities.24

Studies reviewed for this guide included participants aged 

18 and older who met DSM criteria for stimulant use 

and dependence, and who did not have any other mental 

illness or psychotic disorder needing more intensive or 

targeted treatment and only one study focused on men 

who have sex with men.

OUTCOMES ASSOCIATED WITH 

TRADITIONAL AND COMPUTERBASED COGNITIVE BEHAVIORAL 

THERAPY

Studies included in this review demonstrated 

that CBT or computer-based CBT for people with 

stimulant use disorders were associated with 

reductions in: 

•	 Quantity of stimulants consumed per week

•	 Frequency of stimulant use per week

•	 Risky sexual behaviors

All outcomes were measured using either urine 

toxicology, participant self-report, or the Addiction 

Severity Index Scale. The time between treatment 

and follow-up varied between zero months 

(immediately post-treatment) to 12 months.

Practitioner Types

A variety of professionals trained in CBT principles can 

implement it, such as behavioral health professionals, 

primary care staff, and criminal justice personnel. The 

National Association of Cognitive-Behavioral Therapists 

offers CBT training for mental health professionals, as 

well as non-professionals with a four-year college degree. 

In the studies included in the current evidence review, 

trained clinicians delivered all in-person CBT sessions.

Intensity and Duration of Treatment 

Cognitive behavioral therapy is typically customized to 

the needs of each individual. Most people who seek CBT 

for stimulant use disorders receive counseling for a period 

ranging from 5 to 10 months. 

A standard therapeutic session is approximately 50 

minutes. During this time, the therapist and client work 

together to understand existing thought patterns associated 

with the client’s current problems and develop strategies 

to overcome those concerns. Group counseling rarely 

utilizes CBT.
Treatment of Stimulant Use Disorders

What Research Tells Us 17

Summary of Evidence Review 

Practice Motivational 

Interviewing 

Contingency 

Management 

Community 

Reinforcement 

Approach

Cognitive Behavioral 

Therapy

Review rating Strong Evidence Strong Evidence Strong Evidence Strong Evidence

Focus of the practice Resolving clients’ 

ambivalent feelings 

and insecurities 

and enhancing the 

internal motivation 

needed to change 

their behavior

Positively 

reinforcing desired 

behaviors 

Identifying behaviors 

that reinforce stimulant 

use and making a 

substance-free lifestyle 

more rewarding than one 

that includes substances

Helping clients improve 

the quality of their lives 

not by changing their 

circumstances, but 

altering their perceptions 

of those circumstances

Can be used in 

outpatient healthcare 

settings 

   

Can be used in 

inpatient healthcare 

settings

   

Specific training 

available  --  

Web-based version 

available --   

Can be practiced by 

peers

 -- -- --

Has been used 

successfully with 

males and females

   

Special populations 

with whom the 

practice has 

been successfully 

implemented 

Men who have sex 

with men

Men who have 

sex with men;

Co-occurring 

opioid use 

disorder; Severe 

mental disorders

Adolescents --

Intensity and Duration 

of Treatment 

No prescribed 

intensity and duration

No prescribed 

intensity and 

duration; typically 

12 weeks

No prescribed 

intensity and duration; 

recommended for 24 

weeks

No prescribed intensity 

and duration; typical 

range of 5 to 10 months
Treatment of Stimulant Use Disorders

What Research Tells Us 18

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Crescenzo, F. (2018). Psychosocial interventions 

in stimulant use disorders: A systematic review and 

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5 Parsons, J. T., Rosof, E., Punzalan, J. C., & Maria, L. 

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6 Hagedorn, H. J., Noorbaloochi, S., Simon, A. 

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117.

7 Henggeler, S. W., Halliday-Boykins, C. A., 

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8 Barry, D., Sullivan, B., & Petry, N. M. (2009). 

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11 McLellan, A. T., Luborsky, L., Woody, G. E., & 

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12 Menza, T. W., Jameson, D. R., Hughes, J. P., 

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(2010). Contingency management to reduce 

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13 Peirce, J. M., Petry, N. M., Stitzer, M. L., et al. 

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14 Petry, N. M., Alessi, S. M., & Rash, C. J. (2013). 

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Treatment of Stimulant Use Disorders

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Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 20 3

CHAPTER

Guidance for Selecting 

and Implementing 

Evidence-based 

Practices

This chapter provides information for clinicians, program 

administrators, and other stakeholders interested in 

implementing a therapy practice to treat stimulant use 

disorders. It documents some clinical issues and concerns 

health professionals may encounter when engaging and 

treating people with a stimulant use disorder, as well as 

some strategies to address those concerns. When clients 

using stimulants initiate treatment, they may present 

multiple medical and clinical symptoms. Practitioners 

should be aware of these issues, consider them thoroughly 

for each individual client, and address them effectively 

before beginning any therapy. For therapy to be 

successful, these clinical issues must be addressed not 

only at the beginning of treatment, but throughout the 

therapeutic engagement. 

Following a review of the clinical considerations for 

treating people with a stimulant use disorder, the chapter 

provides information about specific implementation 

challenges that stakeholders may encounter when 

implementing a new therapy practice. The chapter 

includes various strategies to overcome these challenges, 

along with examples from the practices reviewed in 

Chapter 2.
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 21

CLINICAL ISSUE MANAGEMENT STRATEGY

Polydrug use An individual may use multiple substances 

to enhance the physical or psychological 

effects of each drug, to counteract the 

effects of one or more drugs, to prolong 

a drug’s effects, or to experience a new 

effect.

•	 Consider the pharmacological, psychosocial, 

and behavioral reasons for combining certain 

substances, evaluate for the presence of 

other substance use disorders, and implement 

targeted treatment options addressing all 

substances for people who use multiple drugs. 

Overdose risk Individuals who intentionally or 

unknowingly mix stimulants with fentanyl 

have an increased risk for overdose.

•	 Assess client awareness of dangers from 

fentanyl and educate about risks.

•	 Train program staff, clients, and family members 

on naloxone use and make naloxone available 

to clients, their families, and the community.

•	 Monitor clients closely for opioid overdose 

symptoms from fentanyl (or heroin) mixed with 

methamphetamine or cocaine.

Intoxication Stimulants increase euphoria, 

hyperexcitability, hypersexuality, 

locomotor activity, agitation, and psychotic 

symptoms, including paranoia and 

hallucinations.

•	 “Talk down” the client in a calm environment.

•	 For clients who exhibit severe symptoms 

of intoxication, consider pharmacological 

treatment, for example benzodiazepines, for 

acute management of agitation and distress, 

antipsychotic medication for psychosis/paranoia/

hallucinations.

Co-occurring mental 

and stimulant use 

disorders 

One of the challenges practitioners face is 

making a distinction between independent 

psychiatric disorders, psychiatric disorders 

as a result of the stimulant use, and 

psychiatric symptoms that arise from 

intoxication and withdrawal.

•	 Consider integrated treatment options 

regardless of the underlying cause for the dual 

diagnosis. 

•	 Since lack of adequate treatment for either 

disorder may interfere with an individual’s overall 

recovery, coordinate services between stimulant 

use disorder therapists and mental health 

providers if stimulant disorder treatment staff do 

not treat mental disorders.

Psychosis Stimulant use can result in psychotic 

symptoms, such as auditory and visual 

hallucinations and paranoia. Stimulantinduced psychosis is generally transient; 

however, methamphetamine can produce 

persistent psychosis like schizophrenia. 

•	 Consider either benzodiazepine or an 

antipsychotic medication to address acute 

symptoms.

•	 Consider continuation of antipsychotic 

medications for long-term management of 

persistent psychosis.

Clinical Issues to Consider When Treating Stimulant 

Use Disorders

There are a number of issues that can present practitioners with clinical challenges and should be considered before making 

decisions regarding treatment planning. The table below summarizes the most common clinical issues encountered and 

strategies to manage them.
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 22

CLINICAL ISSUE MANAGEMENT STRATEGY

Violence Methamphetamine use increases chance 

of violent behavior.1

•	 Be aware of the relationship between stimulant 

use and violence and be cognizant of the 

consequences of violence on individuals using 

stimulants, their families, program staff, and 

other program participants. 

Cognitive deficits Stimulant misuse leads to attention and 

memory problems that can interfere with 

functioning and treatment approaches that 

involve learning.

•	 Inform clients about cognitive deficits and use 

strategies that provide repetition of information 

and do not depend on optimal memory.

•	 Reserve treatments that require more complex 

cognitive functioning until a client’s cognition is 

restored after a period of abstinence.

Stimulant withdrawal As an individual stops stimulant use, 

he or she may experience symptoms 

like severe fatigue, insomnia, cognitive 

impairment, feelings of depression, 

anxiety, loss of energy, confusion, the 

inability to feel pleasure, and paranoia.2

•	 Encourage rest, mild/moderate exercise, and a 

healthy diet to manage withdrawal.

Individuals may experience cravings 

associated with specific cues, such as 

objects (e.g., cash), people (e.g., drug 

user friends), other substances (e.g., 

alcohol), places (e.g., areas where 

stimulants are sold or used), time 

periods (e.g., weekends, after work), 

and emotional states (e.g., depression, 

boredom).3

•	 Educate clients in treatment about the powerful 

impact of cue-induced cravings and help them 

identify strategies to avoid situations in which 

there are “triggers.”

Withdrawal may result in hypersexuality 

and impaired sexual functioning, leading 

to psychological distress.4

•	 Educate clients about the possibility of changes 

in sexual function during early recovery.

Severity of disorder 

and level of care

Clients may receive treatment services 

at various levels within the continuum 

of care; levels ranging from prevention 

and early intervention to inpatient and 

residential services. Assessing the 

required level of care for each client 

based on the severity of client’s disorder 

is critical.

•	 Evaluate the clients’ needs and ensure that that 

they receive services at the appropriate level 

and then step up to more intense treatment or 

down to less intense treatment as needed.

Engaging and treating people actively using stimulants, in withdrawal, or in early recovery is challenging. Understanding the 

experience of the clients in conjunction with clinical concerns is essential for planning and implementing therapy practices to 

meet client needs. 
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 23

Implementation 

Challenges and Strategies

In addition to the important clinical concerns for this 

population, practitioners, administrators, and community 

leaders will be most successful if they understand specific 

challenges and strategies for successful implementation 

of new practices. The following section provides details 

on specific challenges programs could face as they 

implement therapy practices, strategies to deal with those 

challenges, and the role of implementation science in 

enhancing practice implementation. 

When implementing interventions to address stimulant 

use disorders, there are several potential barriers to 

consider. Issues related to implementing motivational 

interviewing (MI), contingency management (CM), 

community reinforcement approach (CRA), and cognitive 

behavioral therapy (CBT) include:

1. Practice selection 

2. Funding, financing, and program cost

3. Program staffing

4. Coordination of care

5. Cultural adaptation of the practice

These challenges are described in detail below, along with 

potential actions to mitigate them.

Practice Selection

Challenge: 

Choosing the right intervention based on the severity of 

client’s illness and where they are in the addiction cycle. 

Strategies:

•	 The effectiveness of various treatment 

interventions may be influenced by the clients’ 

stage in the addiction cycle. It is necessary 

to consider the issue of psychosis and brain 

functioning related to active and recent stimulant 

use when choosing an intervention for stimulant 

use disorders. 

•	 MI can help clients decide to enter treatment and 

serve as a starting point in the recovery process.5

While often implemented successfully at the 

early stages of treatment, due to its flexibility 

as an add-on component to other interventions, 

practitioners can apply motivational strategies 

throughout the recovery process.6

ROLE OF IMPLEMENTATION 

SCIENCE IN HELPING PROGRAMS 

ADDRESS IMPLEMENTATION 

BARRIERS 

Implementation science is the study of methods 

to promote the uptake of proven clinical practices, 

programs, organizational interventions, and 

policies, with the goal of improving health. Use of 

the Consolidated Framework for Implementation 

Research (CFIR) is one way programs can 

conceptualize constructs associated with successful 

program implementation. Programs can use CFIR 

as they plan and execute new programs.

The five main domains of CFIR are: 

Intervention Characteristics - Includes the 

components and attributes of the intervention, such 

as cost, strength of evidence, and complexity

Outer Setting - Consists of the external factors that 

may affect implementation, including the policy and 

regulations in effect, patients’ needs and resources, 

and the sources of implementation pressure

Inner Setting - Considers the characteristics of 

the facility contemplating implementation of a new 

program, including the organizational culture, 

available resources for implementation, and the 

facility’s overall structure

Characteristics of Individuals - Includes the 

attributes of individuals making up the organization 

contemplating program implementation, and 

includes aspects like staff attitudes towards the 

proposed intervention, self-efficacy to adopt new 

programs, and perception of the facility itself

Process - Consists of the stages and constructs 

related to implementation, namely planning, 

engaging, executing, reflecting, and evaluating 

(constructs explain how a course of action for 

implementation is charted and carried out)

Programs can use CFIR to identify both barriers and 

factors conducive to implementation. This allows 

programs to design a detailed strategies when 

considering new therapy practices.6
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 24

•	 CM can serve as a source of positive 

reinforcement for clients in the beginning stages 

of recovery.7

 It can be combined with other 

therapies, such as CRA and vouchers, to enhance 

duration of recovery.8

•	 CBT can be successfully applied at any stage 

of the addiction cycle or encompass the full 

cycle. CBT consists of various modules and 

add-ons (e.g., homework) that practitioners can 

specifically tailor to the client. 

Funding, Financing, and Program Cost

Challenge: 

Obtaining funding to implement treatment practices for 

stimulant use disorders is a common challenge. 

• Practices to treat stimulant use disorders have 

several associated costs, including:

o Planning implementation 

o Training practitioners or interventionists 

o Performing related tasks like urinalysis 

screens 

o Providing incentives or other behavioral 

reinforcement 

o Making any necessary technological enhancements

• Many state Medicaid, Medicare, and private 

insurance entities may not reimburse CM 

and computer-based CBT treatments. 

Reimbursement for both these therapies requires 

careful coordination with funding agencies.

Strategies:

•	 CM costs can be reduced by limiting access to 

only those who test positive for stimulants at 

admission, or by discontinuing the approach 

when practitioners observe no client response to 

treatment.9

•	 Computer-based CBT has potential to substantially 

reduce healthcare costs.10-11 Automated versions 

of CM have also proven effective and can reduce 

costs of tracking participants’ urine and prize 

draw outcomes.12 As internet and computer access 

increase, these treatment options will be more 

accessible, particularly for clients in rural and 

remote locations.9

•	 Additional funding sources, such as federal, 

state, and private grants, as well as contributions 

from or opportunities to share costs with 

community partners can help overcome barriers 

to funding CM reinforcers. 

•	 SAMHSA suggests soliciting in-kind donations 

(which might prove particularly effective at 

providing CM incentives) and make use of 

volunteers or internships to cut costs.13

Program Staffing

Challenges: 

•	 It is vital that properly trained staff be available 

to successfully implement a new treatment 

program or practice and to build program 

capacity. However, this may be difficult to 

achieve due to staff turnover and limited time for 

staff to become familiar with the program.

•	 Practitioners without clinical backgrounds can 

deliver MI and CM. In contrast, CBT is often 

delivered by clinically trained professionals. 

Further, CBT is complex to administer, making 

it difficult to adapt and tailor to a particular 

setting.9

•	 Ongoing supervision and reflective practice 

are essential elements for most stimulant use 

disorder interventions to ensure fidelity of 

implementation.14-15

According to the Surgeon General’s Report on 

Alcohol, Drugs, and Health, the three stages of 

addiction are:

1. Binge and Intoxication - The stage 

at which an individual consumes an 

intoxicating substance and experiences its 

rewarding or pleasurable effects

2. Withdrawal and Negative Affect - The 

stage at which an individual experiences a 

negative emotional state in the absence of 

the substance

3. Preoccupation and Anticipation - 

The stage at which an individual seeks 

substances again after a period of 

abstinence

Some interventions are better suited at the 

starting point of recovery within the early stages of 

stimulant misuse, whereas others can be tailored 

for the end of the addiction cycle, specifically for 

relapse prevention and treatment.
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 25

Strategies:

•	 Computer-based CBT can be a viable substitute 

for in-person CBT, as it requires minimal staff 

assistance and has a degree of flexibility in 

implementation. 

•	 Self-study and the “train-the-trainer” method 

can help practitioners learn how to conduct MI, 

though with varying degrees of effectiveness.16

While self-study does not require an instructor, 

a train-the-trainer approach entails sending staff 

to an expert-led workshop. After learning the 

practice from an expert, these staff typically 

complete a certification process to become 

trainers themselves and then train other staff. 

•	 Having a facilitator—whether an external or 

internal supervisor—can be a key factor in 

successfully implementing practices for stimulant 

use disorders. For example, practitioners using MI 

typically need three or four coaching sessions.14

Coordination of Care

Challenge:

•	 Individuals with stimulant use disorders may 

have other health care needs such as HIV17 or 

life situations affecting their health and recovery 

(e.g., experiencing homelessness).18 Substance 

use disorders and recovery from them are often 

associated with social determinants of health 

such as income and housing instability. 

Strategies:

•	 Using a whole-person approach, practitioners 

need to coordinate treatment for stimulant use 

disorders with care for clients’ other health 

needs. 

•	 Models focused on care coordination, including 

physical, mental, behavioral, and stimulantuse-specific services are more successful than 

those attempting to treat only the stimulant use 

disorder.19

•	 Whenever possible, co-location of stimulant 

use disorder treatment with primary care and 

other services allows for improved coordination 

between physical and mental health care.20

•	 Other life circumstances, such as low income, 

experiencing homelessness, domestic violence, 

and child maltreatment, also affect the 

success of stimulant use disorder treatment. 

Coordination of care should encompass these 

social determinants of health and providers 

should attempt to integrate resources and social 

supports from the client’s community.

•	 Stimulant use treatment providers are well 

positioned to support systemic changes to 

address social determinants in their community. 

Providers and other stakeholders can identify 

gaps in services and promote additional 

resources to improve social and economic 

conditions of their clients.

Cultural Adaptation of Practices

Challenge: 

•	 Behavior change interventions are most effective 

when they are responsive to the clients’ cultural 

practices and ideologies.21-22

•	 When behavior change interventions are adapted 

to make them responsive to clients’ needs, program 

staff may find it challenging to adhere to the 

fidelity of the practice. They may find it difficult 

to maintain the core elements and foundational 

principles of the practice during implementation.

Strategies: 

•	 Motivational techniques are adaptable for 

different cultures. The processes of change and 

motivational enhancement can be tailored to the 

values, beliefs, and experiences of individuals 

within different ethnic and racial categories. 

•	 To ensure adapted practices are implemented 

with their core elements upheld, it is incumbent 

on those doing the adaptation to collect rigorous 

data to assess the intervention for fidelity to the 

practice.

•	 When programs are not able to maintain fidelity 

to the established practice, a rigorous evaluation 

of the adapted practice provides evidence of the 

impact of the adapted practice on stimulant use.

Cultural adaptation of interventions has been 

defined as “the systematic modification of an 

evidence-based treatment (EBT) or intervention 

protocol to consider language, culture, and 

context in such a way that it is compatible with the 

client’s cultural patterns, meanings, and values.”21

Culturally adapted health interventions are more 

effective than usual care.22
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 26

•	 For American Indian/Alaska Native 

communities, the focus of motivational 

interviewing on an equal or balanced 

relationship between the therapist and the 

client seems to fit well with cultural norms.23

Motivational interviewing can also be readily 

incorporated into tribal practices like Talking 

Circles and Sweat Lodge Ceremonies.24

Practice Resources

In addition to the introductory, overarching 

implementation guidance provided above, there are 

several manuals and resources developed specifically to 

help stakeholders implement the practices described in 

Chapter 2. Please note that this guide is not intended to be 

a training manual, but additional resources are available to 

support implementation of these practices

Motivational Interviewing Resources

Motivational Interviewing Network of Trainers (MINT) is 

an international organization affiliated with the developers 

of MI, Bill Miller and Steve Rollnick. The website has 

resources for MI trainings and upcoming events.

TIP 35: Enhancing Motivation for Change in Substance

Use Disorder Treatment is a SAMHSA publication 

outlining motivational strategies and how to use them in 

treating substance use disorders.

Motivational Interviewing Supervision and Training Scale

(MISTS), Motivation Interviewing Skill Code (MISC), 

Assessment of Motivational Interviewing Groups—

Observer Scale (AMIGOS) and Motivational Interviewing

Treatment Integrity (MITI) are all measures for evaluating 

various aspects of MI practice.

Contingency Management Resources

Motivational Incentives-A Proven Approach to Treatment

provides information and resources on the implementation 

of CM practices. This includes an initial training, an 

interactive online course, and free software for managing 

CM clients.

A Treatment Manual for Implementing Contingency

Management provides a CM treatment manual that gives 

attention to prisoner and parolee populations.

Contingency Management: Using Motivational 

Incentives to Improve Drug Abuse Treatment provides 

an overview of CM principles, a case study of a program 

using CM, and guidance regarding how to implement 

and supervise CM procedures. 

The Contingency Management Competence Scale is 

available for both treatments reinforcing abstinence and 

attendance. The scale is intended to be used as a fidelity 

tool, and the associated manual provides suggestions for 

optimal implementation of CM. 

Contingency Management Incentives for Sobriety

provides an overview of CM, its early research, and 

the research supporting its use in treating alcohol use 

disorders and polydrug use. 

Developing a Measure of Therapist Adherence to 

Contingency Management: An Application of the ManyFacet Rasch Model describes the development of an 

adherence tool for CM. 

Identifying Provider Beliefs Related to Contingency 

Management Adoption Using the Contingency 

Management Beliefs Questionnaire describes the 

development of a 32-item questionnaire used to assess 

providers’ beliefs regarding CM treatment interventions. 

Community Reinforcement Approach (CRA) 

Resources

A Community Reinforcement Plus Vouchers Approach: 

Treating Cocaine Addiction describes how to implement 

a CRA that adds a voucher component, primarily with 

cocaine-using populations. The manual describes the 

clinical treatment approach, as well as tips related to cooccurring psychiatric disorders and treatment supervision. 

The Community Reinforcement Approach provides an 

overview of CRA and the research supporting its efficacy.

Chestnut Health Systems EBTx Center offers training and 

certification for CRA and Adolescent CRA.

Robert J. Meyers Website from one of the developers of 

CRA, includes background information for the practice, 

details of ongoing trainings, and links to relevant 

publications. 
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 27

Community Reinforcement and Family Training, Support 

and Prevention (CRAFT-SP) provides a treatment manual 

for CRAFT, an outgrowth of CRA. The manual outlines 

seven treatment sessions and describes the theoretical 

framework for the intervention.

Cognitive Behavioral Therapy (CBT) Resources

Academy of Cognitive Therapy is a group of mental 

health professionals practicing CBT. The website provides 

multiple resources for both administrators and clients, 

training, and certification for CBT administrators. It also 

offers assistance with program implementation.

Beck Academy offers training and certification for CBT 

administrators (i.e., professionals, educators, graduate 

students). The website includes online training courses, 

in-person workshops, newsletters, and other resources. It 

also offers assistance with program implementation and 

utilizing supervisors and consultants. 

SAMHSA Website provides CBT guidelines, training 

manuals, toolkits, workbooks, and training modules. 

It also includes resources for implementing CBT with 

specific populations and for specific applications (e.g., 

substance use disorders, anger management, mental health 

issues). Resources are also available in multiple languages 

like Spanish and Chinese. 

CBT4CBT is a self-guided, web-based program with 

various online modules. The program can be accessed 

through provider or client log-in (paid access). The 

website also has an additional CBT toolkit available for 

purchase. 
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 28

1 McKetin, R., Lubman, D. I., Najman, J. M., Dawe, 

S., Butterworth, P., & Baker, A. L. (2014). Does 

methamphetamine use increase violent behaviour? 

Evidence from a prospective longitudinal study. 

Addiction, 109(5), 798-806.

2 Wise, R. A. (2008). Dopamine and reward: The 

anhedonia hypothesis 30 years on. Neurotoxicity 

Research, 14(2-3), 169-183.

3 Childress, A. R., Mozley, P. D., McElgin, W., 

Fitzgerald, J., Reivich, M., & O’brien, C. P. (1999) . 

Limbic activation during cue-induced cocaine craving. 

American Journal of Psychiatry, 156(1), 11-18.

4 Rawson, R. A., Gonzales, R., & Brethen, P. (2002). 

Treatment of methamphetamine use disorders: An 

update. Journal of Substance Abuse Treatment, 

23(2), 145-150.

5 Center for Substance Abuse Treatment. (1999). 

Enhancing motivation for change in substance abuse 

treatment. Rockville, MD: Substance Abuse and 

Mental Health Administration.

6 Keith, R. E., Crosson, J. C., O’Malley, A. S., Cromp, 

D., & Taylor, E. F. (2017). Using the Consolidated 

Framework for Implementation Research (CFIR) 

to produce actionable findings: A rapid-cycle 

evaluation approach to improving implementation. 

Implementation Science, 12(1), 15.

7 Hirchak, K. A., Leickly, E., Herron, J., et al. (2018). 

Focus groups to increase the cultural acceptability 

of a contingency management intervention for 

American Indian and Alaska Native Communities. 

Journal of Substance Abuse Treatment, 90, 57-63.

8 Secades‐Villa, R., Sánchez‐Hervás, E., Zacarés‐

Romaguera, F., García‐Rodríguez, O., Santonja‐

Gómez, F. J., & García‐Fernández, G. (2011). 

Community Reinforcement Approach (CRA) for 

cocaine dependence in the Spanish public health 

system: 1 year outcome. Drug & Alcohol Review, 

30(6), 606-612.

9 Carroll, K. M. (2014). Lost in translation? Moving 

contingency management and cognitive behavioral 

therapy into clinical practice. Annals of the New York 

Academy of Sciences, 1327(1), 94-111.

10 Olmstead, T. A., Ostrow, C. D., & Carroll, K. M. 

(2010). Cost-effectiveness of computer-assisted 

training in cognitive-behavioral therapy as an 

adjunct to standard care for addiction. Drug and 

Alcohol Dependence, 110(3), 200-207.

11 Hedman, E., Ljótsson, B., & Lindefors, N. (2012). 

Cognitive behavior therapy via the Internet: A systematic 

review of applications, clinical efficacy and cost–

effectiveness. Expert Review of Pharmacoeconomics & 

Outcomes Research, 12(6), 745-764.

12 Ghitza, U. E., Epstein, D. H., Schmittner, J., 

Vahabzadeh, M., Lin, J. L., & Preston, K. L. (2007). 

Randomized trial of prize-based reinforcement 

density for simultaneous abstinence from cocaine 

and heroin. Journal of Consulting and Clinical 

Psychology, 75(5), 765-774.

13 Center for Substance Abuse Treatment. (2009). 

Implementing change in substance abuse treatment 

programs. Rockville, MD: Substance Abuse and 

Mental Health Administration.

14 Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). 

Sustaining motivational interviewing: A meta‐analysis 

of training studies. Addiction, 109(8), 1287-1294.

15 Kauth, M. R., Sullivan, G., Blevins, D., Cully, J. 

A., Landes, R. D., Said, Q., & Teasdale, A. (2010). 

Employing external facilitation to implement 

cognitive behavioral therapy in VA clinics: A pilot 

study. Implementation Science, 5(1), 75.

16 Olmstead, T., Carroll, K. M., Canning-Ball, M., & 

Martino, S. (2011). Cost and cost-effectiveness of 

three strategies for training clinicians in motivational 

interviewing. Drug and Alcohol Dependence, 116(1-

3), 195-202.

17 Novak, R. M., Metch, B., Buchbinder, S., et al. 

(2013). Risk behavior among women enrolled in a 

randomized controlled efficacy trial of an adenoviral 

vector vaccine to prevent HIV acquisition: The Step 

Study. AIDS, 27(11), 1763.

18 Riley, E. D., Cohen, J., Knight, K. R., Decker, 

A., Marson, K., & Shumway, M. (2014). Recent 

violence in a community-based sample of homeless 

and unstably housed women with high levels of 

psychiatric comorbidity. American Journal of Public 

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Reference List
Treatment of Stimulant Use Disorders

Guidance for Selecting and Implementing Evidence-based Practices 29

19 O’Brien, P., Crable, E., Fullerton, C., & Hughey, 

L. (2019). Best practices and barriers to engaging 

people with substance use disorders in treatment. 

Washington, DC: U.S. Department of Health and 

Human Services.

20 SAMHSA-HRSA Center for Integrated Health 

Solutions. (n.d.). Standard framework for levels 

of integrated healthcare. Retrieved June 6, 2020, 

from https://www.thenationalcouncil.org/integratedhealth-coe/resources/ 

21 Bernal, G., Jiménez-Chafey, M. I., & Domenech 

Rodríguez, M. M. (2009). Cultural adaptation of 

treatments: A resource for considering culture in 

evidence-based practice. Professional Psychology: 

Research and Practice, 40(4), 361.

22 Barrera Jr, M., Castro, F. G., Strycker, L. A., & 

Toobert, D. J. (2013). Cultural adaptations of 

behavioral health interventions: A progress report. 

Journal of Consulting and Clinical Psychology, 

81(2), 196.

23 Venner, K. L., Feldstein, S. W., & Tafoya, N. (2006).

Native American motivational interviewing: Weaving 

Native American and western practices. Washington, 

DC: National Institute on Alcohol Abuse and 

Alcoholism.

24 Tomlin, K., Walker, R., Grover, J., Arquette, W., 

& Stewart, P. (2014). Motivational interviewing: 

Enhancing motivation for change--A learner’s 

manual for the American Indian/Alaska Native 

counselor. Rockville, MD: Substance Abuse and 

Mental Health Services Administration.
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 30

4

CHAPTER

Examples of Stimulant 

Use Treatment 

Programs

This chapter highlights three community examples of 

program models providing treatment services and support 

to people with a stimulant use disorder and documents how 

each uses one or more of the practices with strong evidence 

detailed in Chapter 2: 

•	 Motivational Interviewing 

•	 Contingency Management 

•	 Community Reinforcement Approach 

•	 Cognitive Behavioral Therapy 

The chapter describes how each program has implemented 

these practices as part of a comprehensive strategy to 

address the needs of their populations. 

Programs should implement practices with fidelity to 

evaluated models. Fidelity is the degree to which a 

program delivers a practice as intended and must be 

maintained for desired therapy outcomes. However, many 

programs adapt chosen practices to better serve their 

clients. As practitioners modify these practices to address 

the needs and constraints of their population, budget, 

setting, and other local factors, they should adhere to the 

practice’s foundational principles. 

The three programs in this chapter were identified 

through an environmental scan and in consultation with 

experts. At this time, each of the programs predominantly 

serves a distinct population, namely people experiencing 

homelessness, members of a federally recognized tribe, 

and gay and bisexual men who have sex with men (MSM). 

Although the programs highlighted below are population 

specific, the practices they implement have strong 

evidence, target a range of stimulants, and can successfully 

serve a wide range of geographically, racially, and 

ethnically diverse populations. These programs are meant 

to be implementation examples and have not been subject 

to rigorous evaluation.

To be included in this chapter, programs had to: 

•	 Implement one or more of the practices 

identified in Chapter 2

•	 Be replicable (well-defined with guidance 

materials or a manual)

•	 Have research to support their impact on 

stimulant use 

•	 Provide appropriate and effective interventions 

for varied stimulant types, geographic areas, 

practice settings, and diverse populations
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 31

The HPHP primary care facility provides CM as an 

optional component of the Medication-Assisted Treatment 

(MAT) Program. The CM program was initially introduced 

as a 12-week pilot to address the needs of polydrug 

users and former opiate users who were struggling with 

methamphetamine. MAT patients who have positive urine 

drug screens, with exception of buprenorphine and THC, 

are eligible for the program and can opt-in by signing a 

patient agreement form during intake. 

The program employs the “fishbowl” method of CM. 

Participants with negative weekly or biweekly urine samples 

are eligible for one to three weekly drawings. Drawings 

offer $5 to $50 gift cards, or positive affirmations, and occur 

during the program’s group psychotherapy sessions provided 

as a part of the MAT program. 

The program was initially launched in early 2019 at a 

clinic run by the Health Services Agency of the County 

of Santa Cruz and is led by the MAT clinic nurse. The 

program has since expanded to the Agency’s two other 

clinics. It began with 20 to 25 participants and a total 

project budget of about $750 for a 12-week session. 

Model Features and Elements

•	 CM Patient Agreement to facilitate voluntary 

enrollment and ensure patient understanding of 

the program.

•	 Active outreach by program staff in their 

community to build rapport with people 

experiencing homelessness and make their 

transition into the program easier. 

•	 Weekly or biweekly urine drug screens.

•	 Weekly “fishbowl” drawings for $5 to $50 gift 

cards and positive affirmations for clients with 

negative urine drug screens.

•	 Weekly group psychoeducation sessions

using a variety of manualized programs, such as 

“Seeking Safety,” an evidence-based, presentfocused counseling model to help people attain 

safety from trauma and substance use.

•	 Twelve-week cycles with the option to continue 

to a new cycle depending on stage of recovery.

Practice implemented by program

Contingency Management

Setting

Outpatient; Organization is a full-service, primary 

care center serving the needs of homeless and 

low-income populations in Santa Cruz County.

Population of Focus

People experiencing homelessness receiving 

MAT for stimulant use. Typical clients are males, 

Caucasians, with ages ranging from 20 to 60 years.

Program Duration

One session is considered 12 weeks. 

Related Resources

Center for Care Innovations Webinar on 

Contingency Management: https://www.

careinnovations.org/resources/webinarcontingency-management/

Homeless Person Health Project (HPHP)

County Health Services Agency (Santa Cruz County, CA) 

www.santacruzhealth.org
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 32

Findings and Outcomes

•	 Data before and after treatment indicated an 

increase in negative urine drug screens, from 41.6 

percent at baseline to 72 percent at week 48.

•	 Less frequent use documented through client 

self-report.

•	 Increased client attendance.

•	 Patient empowerment evidenced by optimistic 

attitudes about sobriety (e.g., client reactions 

such as “I’ll get it next time” at not receiving a 

gift card).

•	 Positive patient engagement with the program 

(e.g., excitement about sessions, clapping to 

support peers when drawing from the lottery).

Lessons Learned 

•	 Use grants to obtain resources needed to 

implement the program. Nonprofit clinics and 

programs can also ask for donations.

•	 Start small. Implementation of CM can vary 

with every program. Adaptation of CM runs 

the risk of diminishing the efficacy of the 

intervention. When possible adhere as closely 

as possible to established guidelines. When 

implemented in an integrated primary care 

setting, consider including stimulant data in 

electronic medical records of the client.
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 33

The Rosebud Sioux Tribe Alcohol and Drug Treatment 

Program’s Methamphetamine Rehabilitation Program 

(MRP) is based on the Seven Direction Model developed 

by Ed Parsells, in consultation with cultural and spiritual 

leaders, and uses the underlying principles of MI. 

Program staff are trained in and use MI principles during 

therapeutic sessions with clients. Staff adopt a non-directive 

style of interaction, allow the client to challenge them, 

ask questions that engage clients, and encourage clients to 

examine and assess their own behaviors. Staff practice the 

MI technique of empathy while working with clients. 

The Lakota Seven Direction Model is based on the belief 

that spirituality is the foundation for recovery. It relies 

heavily on the concept of conscience and the role it plays 

in stimulant misuse treatment. The program runs for seven 

weeks, with each week focusing on a specific aspect 

of addiction, a particular Lakota value, and a positive 

behavior. For example, during the third week, the program 

focuses on the physical aspect of the addiction and 

encourages the Lakota value of courage and bravery. The 

behavior emphasized during this week is “facing fears.” 

The program is often credited for taking the abstract 

concepts of spirituality and conscience and applying them 

in the Seven Direction Model. MRP empowers people to 

engage in the process of recovery from addiction. Staff 

promote physical, mental, spiritual, and emotional wellness.

Model Features and Elements

•	 Two seven-week cycles focus on different 

curriculum. The first cycle is more didactic 

and helps clients work through their cognitive 

impairment brought on by stimulant use. The 

second cycle adds a Rational Emotive Therapy 

beyond the didactic strategy.1

Practice implemented by program

The Spirit of Motivational Interviewing

Setting

In-patient services on the Rosebud Sioux Tribe 

Reservation in South Dakota. Staff include 

counselors, treatment technicians, case 

managers, and psychologists, all of whom are 

enrolled tribal members. 

Population of Focus

Members of any federally recognized tribe.

Program Duration 

Seven weeks of Lakota Seven Direction Model. 

The program recommends two seven-week cycles. 

Related Resources

Trainer’s Guide: http://www.oneskycenter.org/

wp-content/uploads/2014/03/

AmericanIndianTrainersGuideto

MotivationalInterviewing.pdf

Manual for Counselors in Native American 

Communities: https://www.integration.samhsa.gov/ 

clinical-practice/ Native_American_MI_Manual.pdf

Rosebud Sioux Tribe Alcohol and Drug Treatment 

Program, Methamphetamine Rehabilitation Program

Rational emotive behavior therapy is an activedirective, philosophically and empirically-based 

psychotherapy with the aim of resolving emotional 

and behavioral problems and disturbances and 

helping people lead happier and more fulfilling lives.1

Goals for the first cycle: 

Goal I: Learn the Seven Directions, Seven Life Powers, 

and Seven Lakota Values

Goal II: Develop healthy communication and values and 

resolve internal conflict

Goals for the second cycle: 

Goal I: Reinforce positive changes and healthy 

communication skills

Goal II: Prevent relapse and increase efficacy 

•	 “Talking circle” (a practice for expression of 

thoughts and feelings in the context of complete 

acceptance by participants) and sweat lodge 

ceremonies practiced weekly. 
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 34

•	 Daily, half-hour morning sessions where 

clients share their thoughts and insights. Staff 

use client sharing to determine progress.

•	 Partnership with cultural, spiritual, and 

religious leaders within and outside the 

community, who are invited to address clients 

during their recovery process. 

•	 Weekly, 45- to 60-minute equine therapy 

sessions that emphasize Lakota culture and 

values. Patterns of self-defeating thoughts, 

beliefs, and behaviors identified during the 

equine therapy activities are processed in group 

therapy immediately following the activity.

Findings and Outcomes

Sixty-six percent of clients from Quarter 1 in 2016 

completed the program, while spending an average of 145 

days in therapy. Qualitative data collected from the clients 

highlighted the positive outcomes of the program. In the 

actual words of two clients:

“The Rosebud Sioux Tribe Meth Rehabilitation Program 

not only taught me about my addiction and why I 

could not stop using meth, it also taught me how to 

live a spiritually, mentally, emotionally and physically 

fulfilling life. I no longer need to look outside myself for 

validation.”

“... MRP gave me the opportunity to take a good hard 

look at reality. In treatment I was able to find my true 

self. I was able to see all the wrongs I did to others and 

myself. Finding spirituality helped change my life. The 

RST MRP equipped me with the tools to stay sober and in 

recovery... I will continue to work my recovery program 

using the tools and skills taught at the RST MRP.”

Lessons Learned 

Court-mandated clients complete the entire program. 

Self-referred clients typically terminate the program 

prematurely after about two to three weeks. They may 

need extra encouragement around that time to continue 

the program. Once the self-referred clients stay in the 

program through the first cycle of seven weeks, they tend 

to continue and complete the program. 
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 35

Practice implemented by program

Motivational Interviewing and Cognitive 

Behavioral Therapy for relapse prevention

Setting

Outpatient; Sessions occur at Mount Sinai West 

Hospital in New York City.

Population of Focus

Gay and bisexual men who have sex with men.

Program Duration

There is no prescribed length for the program. 

Typically, clients stay in the program for anywhere 

from a few months to over a year. Length is 

determined by the needs of each client. 

Related Resources

Getting Off Manual:

http://uclacbam.org/wp-content/uploads/2018/04/

Getting_Off_Behavioral_Treatment_Manual.pdf

Dialectical Behavior Therapy: 

https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC2963469/

The Crystal Clear Project (Methamphetamine) is designed 

to address the needs of gay and bisexual men who have 

sex with men (MSM) who misuse methamphetamines. 

The program provides an accepting and culturally sensitive 

environment where clients are encouraged to engage in 

open conversation about alcohol and drug use, sexual 

behaviors and intimacy, and how experiences related to 

homophobia and sexual orientation may have contributed 

to their drug use. The program’s goals are to reduce 

methamphetamine use and risky sexual behavior.

All program staff are trained in motivational interviewing 

and adhere to its principles in their daily interactions with 

clients. Staff also employ Dialectical Behavior Therapy 

and “Getting Off,” an adaptation of Cognitive Behavioral 

Therapy (CBT) focused on the needs of MSM. 

Each client’s treatment is tailored to his individual needs 

and considers the severity of his use and the amount of 

structure he needs and is willing to accept. The program 

offers both day and evening sessions and clients can attend 

as few as one session or as many as five sessions per week. 

Model Features/Elements

•	 Team of practitioners include a family 

therapist, addiction pharmacologist, social 

worker, and psychiatrist.

•	 Holistic and culturally sensitive approach 

addresses stressors related to sexual orientation. 

•	 Individual evaluations conducted according to 

state regulations and by a psychiatrist. 

•	 One to five weekly sessions offered. Sessions 

are individual or in a group, driven by the needs 

and capacities of each client. 

•	 Self-help sessions, based on principles of Alcoholics 

Anonymous, are available but not required.

•	 Both unstructured (open process) and 

structured (following a manualized therapy) 

sessions are offered.

Findings and Outcomes

The program has not had funding to conduct an official

program evaluation. Outcomes reported by program staff 

include:

•	 Reduction in severity of methamphetamine use 

(including lower use, as well as abstinence). 

•	 Reduction in risky sexual behaviors.

Lessons Learned 

•	 The program is exploring the potential of hiring 

peer counselors on staff. 

•	 The program requires staff that are LGBTQ 

friendly and open to discussing these issues.

•	 Conducting trainings and providing ongoing 

supervision can be helpful to raise comfort level 

of the staff, thereby increasing program success.

•	 The program directly addresses clients’ sexual 

behaviors. Crystal methamphetamine is often 

tied to sexual behaviors, so it is important to 

address these behaviors during therapy.

Crystal Clear Project (Methamphetamine)

Mount Sinai West Hospital (New York, NY) 

https://www.mountsinai.org/locations/addiction-institute/services/outpatient
Treatment of Stimulant Use Disorders

Examples of Stimulant Use Treatment Programs 36

1

 Ellis, A. (1995). Rational emotive behavior therapy. 

Current Psychotherapies, 5, 162-196.

Reference List
Treatment of Stimulant Use Disorders

Resources for Evaluation and Quality Improvement 37

5

CHAPTER

Resources for 

Evaluation and Quality 

Improvement

Evaluating a practice or program answers critical 

questions. Evaluation can provide information about how 

well a practice has been implemented, and what is and is 

not working in a program. Evaluation can also show how 

a program or practice benefits clients. This can be helpful 

in securing funding by providing evidence of program 

effectiveness. In addition, stakeholders can use information 

gathered via evaluation to encourage implementation of 

that practice in other programs or communities.

This chapter provides an overview of approaches to 

evaluate implementation and results of practices to 

treat stimulant use disorders. The chapter also includes 

information on implementing a continuous quality 

improvement (CQI) process. U.S. Department of 

Health and Human Services (HHS) defines CQI as, 

“the systematic process of identifying, describing, and 

analyzing strengths and problems and then testing, 

implementing, learning from, and revising solutions.” 

CQI is an essential process for successfully implementing 

a practice. Finally, the chapter concludes with specific 

evaluation resources, including potential outcomes to track. 

Type of Evaluations and 

Study Designs

Although often overlooked, evaluation is an integral part 

of the implementation process and should be planned 

from the start. Programs should consider assessing the 

extent to which a practice can be evaluated in a reliable 

and credible fashion.

Evaluation data provide information on what did and 

did not work. For example, initial information collected 

from clients provides baseline data that can be compared 

with data collected at the end of a program. This allows 

program managers, clinicians, and other providers to assess 

changes or improvements in client attitudes and behaviors. 

Salabarría-Peña, Y., Apt, B.S., Walsh, C.M. (2007). Practical use of program 

evaluation among sexually transmitted disease (STD) programs. Centers for 

Disease Control and Prevention. https://www.cdc.gov/std/program/pupestd/

types%20of%20evaluation.pdf
Treatment of Stimulant Use Disorders

Resources for Evaluation and Quality Improvement 38

Evaluation is typically conducted before a practice is 

implemented to determine its feasibility (formative 

evaluation), during implementation (process evaluation), 

and after the intervention has been delivered to at least 

one client (outcome and impact evaluations). All four 

types of evaluations are necessary to be able to make 

judgments about an intervention’s effectiveness on 

reducing stimulant misuse.

CONTINUOUS QUALITY IMPROVEMENT (CQI)

What is CQI?

CQI involves a systematic process of assessing program or practice implementation and short-term outcomes 

and then involving program staff in identifying and implementing improvements in service delivery and 

organizational systems to achieve better treatment outcomes. CQI helps assess fidelity, the degree to which a 

program delivers a practice as intended. 

CQI differs from process evaluation in that it involves quick assessments of program performance, timely 

identification of problems and potential solutions, and implementation of small improvements to enhance 

treatment quality. CQI is usually conducted by internal staff. Process evaluation involves longer-term 

assessments and is best conducted by an external evaluator. 

The Network for Improvement of Addiction Treatment (NIATx), a project originally funded by SAMHSA’s 

Center for Substance Abuse Treatment (CSAT), offers tools to conduct CQI and improve services in substance 

use disorder treatment settings. NIATx is based on the foundational principle of aiming to accomplish program 

improvement through not one big change, but through a series of smaller changes, tested and implemented one 

at a time, that in the end have a cumulative effect.

Why use CQI? 

CQI takes a broader look at the systems in which programs or practices operate. Because of the pivotal role it 

plays in performance management, organizations implementing new clinical practices or programs for treating 

stimulant use disorders are encouraged to implement CQI procedures. 

What are the steps involved in CQI?

Although steps in the CQI process may vary based on objectives, typical CQI steps are:

•	 Identify a program or practice issue needing improvement and a target improvement goal

•	 Analyze the issue and its root causes

•	 Develop an action plan to correct the root causes of the problem, including specific actions to be taken

•	 Implement the actions in the action plan

•	 Review the results to confirm that the issue and its root causes have been addressed and short-term 

and long-term treatment outcomes have improved

•	 Repeat these steps to identify and address other issues as they arise

New Jersey Department of Children and Families (n.d.) CQI Framework. https://www.nj.gov/dcf/about/divisions/opma/CQI%20framework.pdf

Office of Adolescent Health (n.d.). Continuous Quality Improvement. https://www.hhs.gov/ash/oah/sites/default/files/cqi-intro.pdf

Center for Health Enhancement Systems Studies, University of Wisconsin (n.d.) NIATx program https://www.niatx.net/what-is-niatx/
Treatment of Stimulant Use Disorders

Resources for Evaluation and Quality Improvement 39

Data collected as a part of any of the four evaluations are 

either quantitative or qualitative. 

Quantitative data are those collected in a numerical 

form which can be put into categories, or in rank order, 

or measured in units of measurement. These data can be 

processed by mathematical or statistical analysis. Types 

of quantitative data collection can include close-ended 

survey questions and polling responses.

Qualitative data, on the other hand, are any nonnumeric, text-based information such as verbal, visual, 

or written data. These types of data provide information 

about the acceptability of an intervention and the 

challenges recipients of the intervention face. Examples 

of qualitative data collection methods include interviews, 

focus groups, observations, gathering data from 

documents and images, and case studies.

One benefit of qualitative research is that it enables 

program managers, clinicians, and providers to learn from 

clients and to obtain the perspective of those with lived 

experiences. It also can involve collecting data from staff 

who deliver treatment using the new practice to obtain 

their perspective on facilitators and challenges, or barriers, 

to practice implementation. Qualitative data can provide 

complementary context to quantitative data.

Outcomes

One of the final important but often challenging steps 

in the process of implementing practices is to determine 

whether they have yielded desired outcomes. An outcome

is the change a program hopes to accomplish through the 

implementation of a practice. 

Below is a list of potential outcomes and illustrative 

outcome indicators and data sources that may be used to 

evaluate practices to reduce stimulant use disorders. Many 

of these short- and intermediate-term outcomes may be 

tracked at baseline and throughout the practice or program 

duration through an electronic health record. Longer-term 

outcomes may be obtained from administrative and survey 

data.

Outcome Illustrative Indicators Illustrative Data Sources

Process outcomes

Treatment retention Number of treatment sessions attended Attendance/administrative data 

Treatment engagement Extent of client engagement in the treatment Self-report

Short-term outcomes

Reduced immediate use of 

stimulants

Amount of use

Frequency of use

Number of days/weeks without use

Longest duration of confirmed stimulant abstinence 

Total abstinence

Stimulant-negative urine drug 

screens

Self-report

Reduced craving Feeling of craving Self-report (e.g., Addiction Severity 

Index Scale) 

Standardized scales (e.g., Brief 

Substance Craving Scale)

Long-term individual- and population-level outcomes and impacts

Long-term abstinence Prevalence of continued abstinence and/or 

relapse

Self-report

Readmission to treatment

Reduced prevalence of 

stimulant use 

Prevalence of stimulant use Large scale national surveys

Reduction in co-occurring 

mental health issues in 

individuals with substance 

use disorders

Prevalence of hospitalizations for mental health 

issues related to substance use disorders

Hospitals and medical facilities’ 

administrative data 

Reduction in substance userelated crime Rates of substance use-related arrests Justice system administrative data
Treatment of Stimulant Use Disorders

Resources for Evaluation and Quality Improvement 40

Evaluation Resources 

Evaluating practice or program implementation

•	 A Framework for Program Evaluation from the 

Program Performance and Evaluation Office at 

CDC summarizes essential elements of program 

evaluation.

•	 Introduction to Program Evaluation for Public 

Health Programs is a self-study guide from 

CDC that includes worksheets and checklists for 

implementing the steps in CDC’s Framework for 

Program Evaluation.

•	 CDC’s Evaluation Brief provides information 

about document review and how it can be used 

for program evaluation. 

•	 HHS’s Administration for Families and Children’s 

webpage on evaluation provides multiple tools for 

prevention and treatment evaluation.

Evaluating client- and population-level outcomes

•	 National Science Foundation’s webpage on 

evaluation provides an overview of quantitative 

and qualitative data collection methods. 

•	 National Institute of Health’s webpage on 

evaluation provides information on engaging in 

qualitative research methods. 

Quality improvement and continuous 

performance monitoring

•	 Institute for Healthcare Improvement’s Quality 

Improvement Essentials Toolkit includes 

the tools and templates needed to launch a 

successful quality improvement project and 

manage performance improvement.

•	 The Network for Improvement of Addiction 

Treatment (NIATx)’s model of process improvement

specifically for behavioral health care settings to 

improve access to and retention in treatment.

Resources for evaluating programs and 

practices in Native American communities

•	 Children’s Bureau’s A Roadmap for 

Collaborative and Effective Evaluation in 

Tribal Communities provides Native American 

values and priorities, knowledge of which can 

enhance trust between Tribal programs and their 

evaluation partners and other stakeholders.

•	 SAMHSA’s cultural card provides strategies to 

enhance cultural competence while providing 

services to American Indian and Alaska Native 

communities.

•	 Native American Motivational Interviewing: 

Weaving Native American and Western Practices

is a manual for counselors in Native American 

communities.

•	 SAMHSA’s Behavioral Health Services for 

American Indians and Alaska Natives provides 

tips for providers to improve their cultural 

competence and provide culturally responsive, 

engaging, holistic, trauma-informed services to 

American Indian and Alaska Native clients.

•	 Children’s Bureau’s Creating a New Narrative: 

Collaborative and Effective Evaluation in 

Tribal Communities is a video that guides the 

development of culturally and scientifically 

rigorous evaluation.

•	 Native American Center for Excellence’s Steps 

for Conducting Research and Evaluation in 

Native Communities explores the lessons and 

challenges of research and evaluation in Native 

communities.
Treatment of Stimulant Use Disorders

Appendix 1: Acknowledgments 41

This publication was developed with a significant 

contribution from Thomas Freese, PhD and Rucha 

Londhe, PhD. The guidance is based on the thoughtful 

input of SAMHSA staff and the Expert Panel on 

Treatment of Stimulant Use Disorders from October 

2019 through September 2020. A series of guide 

development meetings was held virtually over a period 

of several months. Three expert panel meetings were 

convened during this time.

SAMHSA Staff 

Christine Cichetti National Mental Health and Substance 

Use Policy Laboratory

Thomas Clarke, PhD National Mental Health and 

Substance Use Policy Laboratory 

Tanya Geiger, PhD, MPH National Mental Health and 

Substance Use Policy Laboratory*

Donelle Johnson, PhD, MHSA National Mental Health 

and Substance Use Policy Laboratory*

Carter Roeber, PhD National Mental Health and 

Substance Use Policy Laboratory*

Onaje Salim, EdD Center for Substance Abuse Prevention*

Expert Panel 

Bradley Donohue, PhD University of Nevada

Holly Echo-Hawk, MS Mental Health Consultant

Molly Evans, MD, MPH Centers for Disease Control 

and Prevention (CDC) 

Daniel Foster, PsyD, MS Rosebud Health Service

Thomas Freese, PhD University of California, 

Los Angeles 

Udi Ghitza, PhD National Institute on Drug Abuse 

(NIDA)

Ted Hall, PharmD Indian Health Service (IHS)

Ed Parsells Rosebud Sioux Tribe Meth/Opioid 

Treatment Program

John Roll, PhD Washington State University

Contract Staff

Margaret Gwaltney, MBA Abt Associates*

Philip Kim, MEd Abt Associates

Rucha Londhe, PhD Abt Associates*

Sarah Steverman, PhD, MSW Abt Associates*

Alec Wall, BS Abt Associates 

*Members of Guide Planning Team 

Appendix 1: Acknowledgments 
Treatment of Stimulant Use Disorders

Appendix 2: Evidence Review Methodology 42

The authors followed a rigorous, systematic evidence 

review process in the development of this guide. This 

appendix provides an overview of the evidence review 

methodology used to identify the ratings for the practices 

included in the guide; motivational interviewing, 

contingency management, community reinforcement 

approach, and cognitive behavioral therapy. Reviewers, in 

coordination with SAMHSA and experts, conducted a four 

step process to select practices, identify related studies, 

review and rate studies, and identify practice ratings.

Step 1: Practice 

Selection 

The authors identified these four practices after a review 

of the literature and in consultation with experts. In 

an effort to include interventions that would be most 

useful to those seeking to reduce stimulant use, eligible 

practices were required to meet the following criteria for 

evidence review: 

•	 Be clearly defined and replicable 

•	 Address the target outcome of reducing 

stimulant misuse 

•	 Be currently in use

•	 Have studies of their effectiveness

•	 Have accessible implementation and fidelity 

supports

At the conclusion of this step, SAMHSA and the guide’s 

Expert Panel reviewed the proposed practices identified 

by the authors and agreed on four for inclusion in the 

evidence review and rating process.

Step 2: Study 

Identification

Once the practices were selected, the reviewers 

conducted a comprehensive review of published 

research on these practices to identify studies of the 

selected practices. This review only included studies 

from eligible sources (i.e., peer reviewed journals and 

government reports) that avoid clear conflicts of interest. 

The reviewers documented all potential studies identified 

through the literature search.

The studies identified in the literature search varied in 

type and rigor, so the reviewers assessed them further for 

inclusion in the evidence review. To be eligible for review 

and study rating, research studies had to: 

•	 Employ a randomized or quasi-experimental 

design, or 

•	 Be a single sample pre-post design or 

an epidemiological study with a strong 

counterfactual—a study that analyzes what 

would have happened in the absence of the 

intervention. 

Literature reviews, descriptive studies, implementation 

studies, and meta-analyses were not included in the 

review, but were documented to provide context and 

identify implementation supports for the practices.

Additionally, to be eligible for further review and rating, 

studies had to:

•	 Be published or prepared in or after 2000

•	 Be publicly available peer-reviewed or research 

report

•	 Be available in English

•	 Include at least one eligible outcome related to 

reduced stimulant use

•	 Have a comparison/control group that is 

treatment as usual or no/minimal intervention 

if using a randomized experimental or quasiexperimental designs

Step 3: Study Review 

and Rating

Next, trained reviewers assessed each study to ensure 

the methodology was rigorous and therefore could 

demonstrate causation between the practice and the 

identified outcomes. Reviewers reviewed and documented 

each study to ensure that: 

•	 Experimental and comparison groups were 

statistically equivalent, with the only difference 

being that participants in the experimental 

group received the intervention and those in the 

comparison group received treatment as usual 

or no/minimal intervention 

Appendix 2: Evidence Review Methodology 
Treatment of Stimulant Use Disorders

Appendix 2: Evidence Review Methodology 43

•	 For randomized experiments with high attrition 

and for quasi-experimental designs, baseline 

equivalence was established between the 

treatment and comparison groups 

•	 For randomized experiments, randomization 

was not compromised. For example, ensuring 

that reassignment of treatment status, usually 

made to balance the distribution of background 

variables between treatment and control groups, 

did not occur

•	 Study did not have any confounding factors 

(factors that affect the outcome but are not 

accounted for by the study)

•	 Missing data were addressed appropriately

o Imputation based on surrounding cases was 

considered valid 

o Complete case analysis was considered valid 

and accounted for as attrition 

o Using model with dummy for missing as a 

covariate was considered valid 

o Assuming all missing data points are either 

positive or negative was not considered 

valid 

o Regression-based imputation was considered valid, mean imputation was not considered valid.

•	 Outcome measures were reliable, valid, and 

collected consistently from all participants

•	 Valid statistical models were used to estimate 

impacts

•	 Practice demonstrated improved outcomes 

related to stimulant use

Based on the study design and these study characteristics, 

reviewers gave each study a rating for causal impact. 

Reviewers used the following scoring metric for each 

study based on the eight factors above to determine if a 

study is rated:

•	 High support of causal evidence

•	 Moderate support of causal evidence

•	 Low support of causal evidence

Only randomized controlled trials, quasi-experimental 

designs, and epidemiological studies with a strong 

comparison were eligible to receive a high or moderate 

study rating. 

Step 4: Practice Rating

After all studies for a practice were assessed for these 

criteria, the reviewers gave each practice a rating

based on the number of studies with strong, moderate, 

or emerging support of causal impact. Causal impact is 

evidence demonstrating that an intervention causes, or 

is responsible for, the outcome measured in the study’s 

sample population. The practice was placed into one 

of the following categories based on the level of causal 

evidence of its studies:

•	 Strong Evidence: Causal impact demonstrated 

by at least two randomized controlled trials, 

quasi-experimental designs, or epidemiological 

studies with a high or moderate rating.

•	 Moderate Evidence: Causal impact 

demonstrated by at least one randomized 

controlled trial, quasi-experimental design, or 

epidemiological study with a high or moderate 

rating.

•	 Emerging Evidence: No study received a high 

or a moderate rating. The practice may have 

been evaluated with less rigorous studies (e.g., 

pre-post designs) that demonstrate an association 

between the practice and positive outcomes, but 

additional studies are needed to establish causal 

impact.

The four-step process described above resulted in 

identification and rating of four practices with strong 

evidence for reducing stimulant use. The rating given 

to each practice is intended to inform decision making 

about adoption of new practices or clinical or system 

enhancements that will improve outcomes for individuals 

with stimulant use disorders.
Photos are for illustrative purposes only. 

Any person depicted in a photo is a model.

Publication No. PEP20-06-01-001

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

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