An Equitable Behavioral Engagement Framework for Stimulant Medication Treatment in Methamphetamine Use Disorder

The 2024 American Society of Addiction Medicine and American Academy of Addiction Psychiatry Clinical Practice Guideline includes a conditional recommendation for long-acting methylphenidate as a pharmacologic option for amphetamine-type stimulant use disorder, including methamphetamine use disorder. Although this recommendation is conditional and based on low-certainty evidence, it reflects an evolving consideration of pharmacologic treatment approaches for methamphetamine use disorder and raises questions regarding clinical implementation, particularly given the schedule II regulatory status of methylphenidate and the associated oversight and risk considerations. In this commentary, we review the guideline's recommendation in the context of real-world prescribing challenges, including clinical safety considerations, monitoring requirements, and potential implications for equitable access. We highlight the absence of established behavioral readiness or engagement frameworks to guide the initiation and continuation of schedule II stimulant medications for methamphetamine use disorder. To address this gap, we describe an approach adapted from prior work in office-based buprenorphine treatment. This 5-domain framework-adherence, abstinence progress, attendance, alternative activities, and accessing support-offers a structured method for integrating behavioral engagement into patient selection and ongoing monitoring when considering prescribing a psychostimulant for stimulant use disorders. By emphasizing objective, transparent engagement metrics alongside pharmacologic decision-making, such a framework may help support safety, accountability, and a more equitable application of an emerging treatment option.