#497 Tailoring and Ramping up Management of Methamphetamine Use Disorder for the Current Era with Dr. Phillip Coffin

September 8, 2025 | By Era Kryzhanovskaya

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Transcript available via YouTube

In this high-yield episode of Curbsiders Addiction Medicine, we dive deep into a practical and compassionate approach to caring for patients using methamphetamines and/or living with methamphetamine use disorder. We explore the latest pharmacologic options, harm reduction strategies, contingency management, and innovative ideas for monitoring and supporting patients. Whether you’re in primary care or other subspecialty settings, this episode is packed with pearls for every clinician with our amazing guest, Dr. Phillip Coffin, Director of the Center on Substance Use and Health in the SFDPH. 

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The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Learn more about their educational offerings and resources here.”

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Case from Kashlak; Definitions
• Four-tier approach to taking care of patients with methamphetamine use/use disorder
• Medications for treatment
• Psychosocial treatment
• Harm reduction
• New horizons in treatment 
• Outro

Methamphetamine Use Disorder (MeUD) Pearls

1. The diagnosis of  methamphetamine use disorder (MeUD) can be made using DSM-5 criteria. Criteria can be broken down into three buckets: 1) Tolerance, Withdrawal, 2) Use Characteristics (use more than mean to, trouble cutting down, spend time obtaining/using product, cravings), 3) Problems that result from use (issues in relationships/activities/responsibilities, physical danger, health problems). 
2. Dr. Coffin presents a 4-tiered approach to addressing methamphetamine use: 1) Assessment, 2) Screening and preventive care, 3) Use Reduction (Treatment), and 4) Toxicity Prevention.
3. Strategies for preventing methamphetamine toxicity (cardiac and neuropsychiatric) include the three S’s: addressing the patient’s sleep, smoking, and considering a statin. 
4. Contingency management remains the most effective behavioral treatment for methamphetamine use disorder, but there is some evidence for off-label pharmacologic options like mirtazapine, bupropion +/- naltrexone, and prescribed stimulants 

Methamphetamine Use Disorder Notes

Diagnosing Methamphetamine Use Disorder (MeUD)

Dr. Coffin divides 11 DSM-5  substance use disorder criteria into three buckets: 1) Tolerance, Withdrawal 2) Use Characteristics (use more than they mean to, trouble cutting down, spending time obtaining/using product, cravings) 3) Problems that result from use (issues in relationships/activities/responsibilities, physical danger, health problems).  Individuals must meet at least 2 of these criteria in the past 12 months to be diagnosed with MeUD. 

In addition to exploring the downsides of use (as described in the DSM-5 criteria), Dr. Coffin also suggests exploring the benefits that patients experience from stimulant use, as these substances often serve a functional purpose (self-treating ADHD, promoting wakefulness/alertness, etc.) Understanding the “why” for stimulant use can help the clinician tailor treatment to the individual. Next, he recommends assessing cumulative methamphetamine exposure and binge usage patterns, as these factors may be linked to methamphetamine-related morbidity and mortality. Dr. Coffin will assess a gram-year history to determine cumulative exposure. For instance, in San Francisco, methamphetamine costs $10 per gram, so if an individual spends $10 daily over a period of 10 years, this results in a cumulative “10 gram year history.”

Addressing Methamphetamine Use via Dr. Coffin’s Four-Tier Approach

Dr. Coffin will specifically tell patients that he is going to address their use with a four-tier approach:

1. Assessment
2. Screening, preventive care 
3. Use Reduction (treatments for MeUD)
4. Toxicity Prevention; summarized: Are we addressing the patient’s…
   1. Sleep
   2. Smoking
   3. Starting a Statin

1) Assessment 

Review the DSM-5 criteria as above to discuss the diagnosis in a patient-centered way.  Focus on what the patient sees as a benefit from their use, their cumulative exposure, and if they have a binge pattern of use. 

2) Screening, Preventive Care

It is important to address the basics in preventive care for patients with MeUD. Ensure comprehensive screening with particular attention to cardiovascular health (blood pressure and lipids), neuropsychiatric health, screening for HIV and other sexually transmitted infections, hepatitis B/C screening, vaccinations (e.g. HPV, Hep A/B), consideration of PrEP and DoxyPEP, along with general healthcare maintenance items like age-appropriate cancer screenings based on risk factors. Additionally, prescribing naloxone is crucial, along with discussing the common occurrence of patients unintentionally using fentanyl when they intend to use methamphetamine.

Clarification regarding the term “fentanyl exposure” as mentioned in the case: Dr. Coffin, in his expert opinion, notes that “exposure” is not the correct terminology for what’s happening in the current drug landscape, especially on the West Coast. Exposure invokes the misconception that touching small amounts of fentanyl powder causes an overdose. He reminds the audience that fentanyl does not absorb well transdermally, and the term “exposure” and related fears can be stigmatizing and harmful to people who use drugs. Instead, the term “fentanyl use” is recommended. In local San Francisco paramedic data, over 40% of confirmed opioid overdoses were in people who denied intending to use an opioid (Bazazi 2024); follow-up interviews (data presented locally) demonstrated that this was in the setting of using the wrong drug or the wrong supplies (picking up the wrong pipe, for example). There are reports of regional differences in the degree to which supply contamination plays a role (Park, 2021).

3) Use Reduction

This is where psychosocial or pharmacologic treatment comes in, based on the patient’s goals to reduce or stop use.  Consider referencing the ASAM/AAAP stimulant use disorder guideline document for more information on treatment options. Dr. Coffin will begin his treatment conversations by reviewing contingency management (CM) and then discussing medication options using a whiteboard to help patients select the approach that works best for them. 

First, start treatment of MeUD by offering and encouraging contingency management. CM has the strongest evidence base for methamphetamine/stimulant use disorder treatment (ASAM/AAAP Stimulant use disorder guidelines). The approach rewards patients with money, incentives, or prizes for exhibiting a desired behavior (for example, not using a drug). Key elements include timing and immediacy of reinforcement, meaningful rewards, and reliable point-of-care testing. In California, CM is supported through a Medicaid pilot (in addiction settings), but broader implementation is still limited. 

Other psychosocial or behavioral therapies play a role in managing MeUD. Dr. Coffin mentions that the Matrix Model and Cognitive Behavioral Therapy (CBT) have demonstrated effectiveness (ASAM/AAAP Stimulant use disorder guidelines). For outpatient primary care settings, “CBT-lite” strategies can be adapted to help patients manage triggers and reduce risk of return to use in Dr. Coffin’s opinion.

Pharmacologic Interventions: The first line medications to consider are bupropion or mirtazapine, with or without naltrexone. The first step in pharmacologic treatment is to determine whether to start bupropion or mirtazapine. In Dr. Coffin’s practice, this decision depends on 1) why a patient is using and 2)the medical issues/goals for the patient. 

• Bupropion: Dr. Coffin recommends to consider bupropion especially in patients who are younger, have a healthy heart (e.g. ideally, without CV dz or HTN), may have co-occurring depression or tobacco use disorder, and who are using methamphetamine to wake up and get things done, as bupropion is an activating antidepressant. The target dose is 300–450mg/day (try to push to 450mg to match the data). Data from the ADAPT-2 trial (Trivedi, 2021) support its effectiveness when used in combination with naltrexone.
• Mirtazapine: Consider mirtazapine in patients who would like to gain weight and/or struggle with insomnia and/or have depression. 30mg is the dose studied for methamphetamine use disorder (Coffin, 2020). Dr. Coffin cautions that higher doses substantially increase the risk of weight gain.  
• Naltrexone: Both oral and injectable formulations are discussed as options for treatment in combination with bupropion. Naltrexone combined with bupropion (and possibly driven by the power of high-dose bupropion) lead to reduced methamphetamine use based on the ADAPT-2 trial. In ADAPT-2, 380mg of IM naltrexone was administered every 3 weeks in combination with 450mg of bupropion. However, oral naltrexone may be effective as well. Naltrexone is also used to treat alcohol use disorder, and it is Dr. Coffin’s expert opinion that clinicians should strongly consider prescribing naltrexone PO (scheduled or PRN) in patients who use methamphetamine after a night of drinking. Naltrexone may also reduce the risk of opioid overdose if a person who uses methamphetamine uses fentanyl (intentionally or unintentionally). 
• Topiramate: Limited role for methamphetamine use disorder treatment, especially with cognitive side effects; some evidence when combined with amphetamine salts for cocaine or if co-occurring alcohol use disorder. 
• Stimulant therapy (e.g. mixed amphetamine salts): Although the evidence is mixed, stimulants (e.g. methylphenidate, lisdexamfetamine) may reduce methamphetamine use in patients with moderate to severe methamphetamine use disorder (Chan 2019, Ezard 2024, ASAM/AAAP guidelines). State law differs on the legality of prescribing stimulants specifically for stimulant use disorder (Suen, 2025), and in certain legal/regulatory contexts, stimulants like mixed amphetamine salts or lisdexamfetamine can be used to treat methamphetamine use disorder under structured treatment plans for other specific conditions (for example, ADHD). The 2023 ASAM/AAAP guidelines recommend that only addiction medicine/psychiatry specialists (or those with commensurate training and the ability to provide close monitoring) consider prescribing stimulants for methamphetamine use disorder. If Dr. Coffin makes a tentative ADHD diagnosis as an adult based on screening techniques, he then deploys these medications (for example, lisdexamfetamine at higher doses for patients using more regularly) in a rigorous treatment program, seeing the patient weekly to ensure they are taking it and have reduced or ceased methamphetamine use. Dr. Coffin notes that some states, like California, limit the duration controlled substances can be used off-label to treat substance use disorders. For states that limit the use of stimulants for stimulant use disorder, but allow it for ADHD, a structured treatment plan for ADHD, with a reduction of methamphetamine use, can be considered as a key element of the plan.

Support for patients in the clinic is very important. When initiating medications for methamphetamine use, more intensive follow-up (weekly) may be needed. Medication success often depends on careful titration and monitoring, particularly in patients with more severe use patterns. Dr. Coffin notes that in his practice, many patients start to engage in the clinic to first reduce toxicities and later on may be more interested in discussing medications to help reduce their use. 

Emerging & Off-Label Options: New frontiers include GLP-1 receptor agonists, which have shown promise in reducing use of certain substances (Martinelli, 2024, Hendershot, 2025). Psilocybin and ketamine are under investigation in clinical trials. Check out clinicaltrials.gov to see if there are resources available in your local area. 

Monitoring & Engagement Tools: Some data exists that CRP levels are elevated in individuals with methamphetamine use disorder compared to healthy controls (Tanrikulu, 2022). In his expert opinion, Dr. Coffin introduces an innovative use of high-sensitivity C-reactive protein (hs-CRP) as a motivational biomarker. While not diagnostic, reductions in hs-CRP levels can correlate with self-reported reduced stimulant use and serve as a tangible, positive reinforcement for patients. 

4) Toxicity Prevention:

Discussing toxicity prevention is both exciting and novel for patients, engaging them in a unique way. Dr. Coffin categorizes toxicities into two main categories: cardiovascular and neuropsychiatric. Both of these are influenced by cumulative exposure and binge pattern use. Ask patients questions like: Do you go on runs? How many nights do you stay up in a row when you’re using? Some people use methamphetamine just in the morning to get through their day, or only in the evening to stay awake/protect themselves on the street. Other people use for days in a row. Given that losing sleep shortens lifespan (Itani, 2021), the same is presumably the case for patients using methamphetamine.

 To prevent toxicities, in addition to reducing use, Dr. Coffin encourages discussing with patients the importance of getting good sleep (potentially using pharmacologic strategies), stopping smoking, and starting a statin (in Dr. Coffin’s expert opinion). While there aren’t controlled studies to support statins in reducing the toxicities of methamphetamine, Dr. Coffin’s recommendation to start a statin comes from a mechanistic suggestion provided by in-vitro studies (Nikeafshar 2022, Saez 2014). Animal studies suggest that statins may reduce neuropsychiatric and cardiovascular toxicity of stimulants Kumar 2012; Tuominen 2025; Eslami 2021). It is important to discuss the limited evidence with patients and balance the hypothetical benefits with the known risk of statins (such as a slightly higher risk of diabetes and myopathies).

Take-Home Points:

1. When assessing use, focus first on the benefits the person perceives from use. 
2. Try to determine a patient’s cumulative exposure and binge pattern use. 
3. Think about stimulants, methamphetamine especially, like alcohol (rather than opioids), when it comes to potential harms to patients; stimulants rarely cause a true acute overdose death. 
4. Use the 4-tier approach to managing methamphetamine use. Run through each element explicitly with patients. Introduce the idea of a statin as part of toxicity prevention–it will get people thinking about toxicities, and they might come back asking for help cutting back on use.
5. Be nonjudgmental and an ally to the patient. Consider how you document in the chart and how stigmatizing that may be for patients.

Links

1. Dr. Coffin’s costume opportunities: Burning Man, Edwardian Ball, Bay to Breakers
2. Dr. Coffin and Dr. Suen’s paper introduces the aforementioned 4-tier approach: Methamphetamine Toxicities and Clinical Management in NEJM Evidence. 

Goal

Listeners will appreciate the nuances of management of methamphetamine use disorder in the complex current era of unpredictable drug supply and lack of FDA-approved treatment. 

Learning objectives

After listening to this episode, listeners will be able to

1. Describe the current landscape in terms of unpredictable drug supply and lack of treatment options for patients with methamphetamine use disorder.
2. Recognize the limitations and opportunities in psychosocial and pharmacologic treatment of methamphetamine use disorder.
3. Employ strategies to discuss individualized treatment plans for patients with methamphetamine use disorder.

Disclosures

Dr. Phillip Coffin reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Kryzhanovskaya E, Coffin P,  Leyde S, Surani Z, Chan CA “#497 Tailoring and Ramping up Management of Methamphetamine Use Disorder for the Current Era with Dr. Phillip Coffin”. The Curbsiders Addiction Medicine Podcast.https://thecurbsiders.com/addiction  Final publishing date, September 8th, 2025.