SUZANNE DECKER: “Do I really need medication, or can I do therapy?”  And while it’s tempting to answer in generalities, the evidence actually gives us much clearer guidance, depending on the substance that the patient is using.

NOAH CAPURSO: Hello and welcome to the Carlat Psychiatry Podcast. This is a special episode from the team at The Carlat Addiction Treatment Report. I’m Noah Capurso, the Editor in Chief of the Carlat Addiction Treatment Report, Associate Clinical Professor of Psychiatry at Yale University, and Assistant Medical Director of the Addiction Services Division at Connecticut Valley Hospital.

SUZANNE DECKER: And I'm Suzanne Decker, licensed clinical psychologist and associate professor of psychiatry at Yale School of Medicine. Today, we’re tackling a deceptively simple question that comes up all the time in clinical practice: When should we prioritize medication, when should we emphasize psychotherapy, and when can we recommend both? This question comes up especially often with patients who are new to treatment. They’ll ask, “Do I need a medication?” or “Can I just do therapy?” And while it’s tempting to answer in generalities, the evidence actually gives us much clearer guidelines, depending on the substance that the patient is using.

NOAH CAPURSO: To ground the discussion, we’ll start with a patient scenario described in a recent issue of the Addiction Treatment Report. Here’s the case: Carla, a 38-year-old woman, comes to your office seeking treatment for opioid use disorder. She has had problematic opioid use for the past 10 years, but until recently she has been able to meet family and work obligations. Now her use has escalated, and she finds it difficult to function. She has never had treatment before and wonders whether her best option would be starting a medication or engaging in psychotherapy. What do you tell her? How would your answer change if she were using stimulants instead of opioids? What about alcohol?

SUZANNE DECKER: We’ll organize our discussion around a simple but powerful visual framework that I like to call “the substance use disorder (SUD) treatment continuum”. Let’s take a moment to describe this framework since this is an audio format. Imagine a two-headed horizontal arrow. This is what represents the continuum. On one end, you have medication, and on the other end, you have psychotherapy. Each substance use disorder will lie somewhere along this double-headed arrow. SUDs with strong evidence for medication treatment lie on the medication side of the continuum. SUDs that have stronger evidence for psychotherapy lie on the other end.

NOAH CAPURSO: Importantly, no substance use disorder lives exclusively at one end of the spectrum, though the evidence forces us to place some SUDs much closer to the medication end of the continuum and others at the psychotherapy end.

SUZANNE DECKER: At the far medication end of the spectrum is opioid use disorder. At the opposite end, closest to psychotherapy, lies stimulant use disorder. And sitting in the middle, where both medication and psychotherapy have strong evidence, are alcohol use disorder and tobacco use disorder.

NOAH CAPURSO: This visual turns what can feel like an abstract debate into a practical clinical tool. It helps us explain why we’re recommending a certain approach early in treatment. So, let’s go back to Carla. She asks whether she should start medication or psychotherapy. For opioid use disorder, the evidence is very clear: medication should be the foundation of treatment.

SUZANNE DECKER: And that’s not just about reducing opioid use. Methadone and buprenorphine are the treatments of choice here. They’ve been shown to improve a whole host of outcomes, including all-cause mortality. That includes deaths from overdose, suicide, cardiovascular disease, cancer, and substance-related causes. Few interventions in psychiatry have that kind of impact.

NOAH CAPURSO: That mortality data alone should change how firmly we recommend MOUD. This isn’t one option among many; it’s the lifesaving treatment.

SUZANNE DECKER: We should also mention injectable naltrexone. Its evidence base is smaller, but it’s grown over time. Injectable naltrexone really gained more widespread acceptance after the publication of a landmark 2018 study called the X:BOT Trial. In this study, researchers found that injectable naltrexone was more difficult to initiate than buprenorphine, but once a patient received it, outcomes were similar.

NOAH CAPURSO: So, the key takeaway is that opioid use disorder is mostly on the medication end of the spectrum. Buprenorphine and methadone are the treatments of choice, with injectable naltrexone a close second.

SUZANNE DECKER: Psychotherapy may still have a role for some patients, especially for comorbid psychiatric conditions. But it should be considered as an adjunct to support engagement in MOUD, help patients in supporting coping skills, and support retention in MOUD. What we want to avoid is offering therapy instead of MOUD. Now let’s move to the other end of the continuum: stimulant use disorder. This is where the treatment logic flips.

NOAH CAPURSO: Exactly. Unlike OUD, behavioral interventions are the cornerstone of stimulant use disorder treatment. The strongest evidence supports contingency management.

SUZANNE DECKER: Contingency management (CM) works by providing tangible rewards, often in the form of cash or vouchers, for objective markers of abstinence such as negative urine drug screens. When provided correctly, CM consistently reduces use and improves retention.

NOAH CAPURSO: The problem, of course, is access. Funding and regulatory barriers make CM hard to implement widely. 

SUZANNE DECKER: Fortunately, other psychotherapies also have evidence: cognitive behavioral therapy, motivational interviewing, and even psychodynamic approaches. Meta-analyses show they reduce dropout and improve abstinence outcomes.

NOAH CAPURSO: Medications can help, and there is some limited evidence, but their efficacy is not as strong as behavioral approaches. Medications like topiramate, mirtazapine, or combinations like bupropion plus injectable naltrexone can reduce stimulant use, but again the effects are modest.

SUZANNE DECKER: So, if a patient with stimulant use disorder has access to treatments like contingency management, place your priority there. That’s the most likely route to reduce stimulant use.

NOAH CAPURSO: And that brings us to alcohol use disorder, which sits right in the middle of the continuum, and for good reason.

SUZANNE DECKER: Both medications and psychotherapy work, and neither clearly dominates. This finding was first driven home 20 years ago with the publication of the COMBINE trial. This study compared medications like naltrexone and acamprosate, a cognitive behavioral intervention, and combinations for medication and psychotherapy. Interestingly, benefits were found for naltrexone and combined behavioral intervention.

NOAH CAPURSO: Another interesting and somewhat surprising finding is that combining the two approaches with a medication and psychotherapy did not provide additional benefit.

SUZANNE DECKER: That gives us flexibility- there is evidence for using a medication approach or therapy, and we can have a discussion with the patient about their preferences.

NOAH CAPURSO: On the medication side, naltrexone is often first-line because it’s easy to use and well tolerated. Acamprosate and disulfiram are alternatives, and off-label options like gabapentin or topiramate can also help.

SUZANNE DECKER: On the psychotherapy side, CBT, motivational interviewing, and twelve-step facilitation all have evidence, and this is where shared decision-making really matters. You can start on either side of the continuum and still practice evidence-based care. Like alcohol, tobacco use disorder lies in the middle of the spectrum.

NOAH CAPURSO: There are three medication approaches that have been approved by the FDA: nicotine replacement, varenicline, and bupropion. The best evidence is for varenicline and so-called combination nicotine replacement, which is using a long-acting formulation like the patch, along with a short-acting formulation like a lozenge or gum. Bupropion is also effective, though the evidence is not quite as strong here.

SUZANNE DECKER: In addition to medication, psychotherapy and behavioral-based interventions have also been shown to be effective. This includes individual counseling, cognitive behavioral therapy, motivational interviewing, contingency management, and structured group therapy.

NOAH CAPURSO: And then there are e-cigarettes. These are controversial, but worth mentioning given how popular they've become. Studies have shown us that e-cigarettes can help to stop smoking, but oftentimes people just end up switching to e-cigarettes. That means they’re not fully getting off nicotine, but they are stopping combustible tobacco. And while we don’t have long-term data on the effects of e-cigarette use, they are almost certainly better than traditional cigarettes.

SUZANNE DECKER: So, what do we take away from all this? When constructing a treatment plan, think of where along the treatment continuum your patient’s SUD sits.

• For Opioids → medication must be central 

• For Stimulants → emphasize psychotherapy (especially well-done CM)

• And when it comes to Alcohol and tobacco, there’s evidence for either modality. So, discuss what each entails with your patient and see what your patient would prefer.

NOAH CAPURSO: And the continuum can be useful as an educational tool. It may help patients understand why you’re recommending a particular approach, which can improve engagement and trust. A version of this interview will be available for subscribers to read in an upcoming issue of The Carlat Addiction Treatment Report. Hopefully, people will check it out. Everything from Carlat Publishing is independently researched and produced. There is no funding from the pharmaceutical industry. Our newsletters and books depend entirely on reader support. There are no ads, and our authors have not received industry funding. That helps us to bring you unbiased information that you can trust. And don't forget, you can earn CME credits for listening to our podcast. As always, thanks for listening, and have a great day.