Psilocybin-assisted therapy is being investigated for cocaine and methamphetamine use disorders. The clinical aim is sustained change in drug use and everyday functioning. An intense experience, a temporary fall in craving or a convincing account of personal transformation cannot by itself establish recovery.
Cocaine now has preliminary randomised evidence; methamphetamine has a small uncontrolled pilot. These findings justify further investigation, but do not establish psilocybin as routine treatment for stimulant addiction. The two conditions require separate assessment of benefit and harm.12
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What treatment needs to change
Stimulant use disorder involves impaired control and continued use despite important harms. Assessment needs to consider the pattern of use, physical health, sleep, mood, psychotic symptoms and the circumstances that make continued use difficult to avoid. Cocaine and methamphetamine can both be associated with cardiovascular and psychiatric complications; their shared classification does not make their treatment evidence interchangeable.3
A clinically useful intervention should help someone maintain change after returning to familiar relationships, stresses and access to drugs. Frequency of use matters, but so do employment, housing, relationships, treatment engagement and the ability to respond safely when use recurs. A reduction in craving can support recovery without guaranteeing abstinence. Conversely, some people sustain important behavioural changes while continuing to experience urges.
Psilocybin is being explored as an adjunct to psychological treatment because it may alter habitual responses, emotional processing and the meaning attached to drug use. These are proposed pathways, not established explanations of why an individual improves. The methamphetamine research programme combines this rationale with structured psychotherapy and continuing clinical support.4
Cocaine: an encouraging signal that needs replication
A 2026 trial randomised 40 adults to psilocybin or diphenhydramine, with manualised psychotherapy in both groups. Psilocybin was associated with more cocaine-abstinent days and a longer time to first lapse. Complete abstinence through 180 days after treatment occurred in 6 of 20 psilocybin participants and none of 20 controls.1
The result is promising but imprecise: the odds-ratio confidence interval for complete abstinence was 1.92–2468.17. Recognisable drug effects, therapist allegiance, selected eligibility and self-report supplemented by urine testing limit interpretation. Adverse events occurred in 65% versus 10%; no serious treatment-related events were reported. Larger independent trials are needed.1
Complete abstinence and fewer use days answer different clinical questions. Neither should be silently substituted for the other. A treatment can reduce exposure substantially while leaving a continuing need for relapse prevention and other care. Results should therefore be discussed against the person’s agreed goals, rather than compressed into a single claim that addiction has been cured.
Methamphetamine: feasibility before established efficacy
A Sydney outpatient pilot published in 2025 enrolled 15 participants; 14 completed the intervention. It combined preparation, a psilocybin session and integration, without a comparison group. Reported median use over the preceding 28 days was 12 days at screening, zero at day 28 and two at day 90. Different numbers contributed data at different visits, so these are group summaries, not a uniform individual trajectory. No serious adverse events were reported; treatment-related events included raised blood pressure, headache, nausea and noise sensitivity.2
These observations support feasibility and further testing. They cannot separate the effects of psilocybin from psychotherapy, existing treatment, motivation, expectations or the passage of time. An uncontrolled fall in use is not an estimate of benefit over established care.2
An earlier individual account from the same research programme described a person with near-daily methamphetamine use who underwent inpatient withdrawal management before the intervention. Abstinence was reported over three months and supported by urine testing. Craving declined markedly, but rose again between the first and third months; the quality-of-life score was lower at three months than at baseline. These mixed outcomes show why a positive abstinence result should not be treated as evidence that every dimension of life has improved.5
The participant also had continuing community therapy and significant changes in personal circumstances. The case describes a treatment course, not an isolated drug effect. It belongs to the developing clinical programme and should not be counted as an independent replication of its later pilot findings.5
| Finding | Reasonable interpretation | Unresolved question |
|---|---|---|
| Randomised cocaine signal | Evidence worth testing independently | How much benefit persists in routine services? |
| Uncontrolled methamphetamine improvement | A basis for a controlled trial | How much improvement exceeds that from the surrounding treatment? |
| Reduced craving | A potentially useful symptom change | Does it translate into less use and better functioning? |
| No serious event in a small sample | Limited reassurance in selected participants | What happens in larger and medically complex populations? |
Established treatment remains the clinical foundation
The ASAM/AAAP guideline recommends contingency management as a primary component of treatment alongside other psychosocial interventions. This approach uses agreed, tangible incentives to reinforce treatment-related behaviours. Cognitive behavioural therapy, the community reinforcement approach and the Matrix Model are supported accompanying options.3
“Contingency Management (CM) should be a primary component of the treatment plan”
ASAM/AAAP clinical practice guideline, behavioural treatment recommendation 5.3
Interest in psilocybin should therefore prompt a discussion of additional research options, rather than an assumption that useful treatment must wait. Where access to established interventions is poor, that service gap does not establish the effectiveness of a replacement.
Medical stability and continuing care
Trials have selected participants and used safeguards that are easy to overlook when their results are described as a single-session intervention. The methamphetamine programme assessed medical and psychiatric history, cardiovascular stability, current medicines and the person’s support outside the study. Intoxication and acute withdrawal were not treated as opportunities to administer psilocybin.5
Psychosis, mania, cardiovascular vulnerability and medication interactions require individual assessment. A calm treatment room does not remove these risks. Nor does successful participation by one person with substantial difficulties demonstrate that the same procedure is suitable for everyone with a similar diagnosis. Broader psilocybin consensus guidance emphasises the limits of safety information and the possibility of uncommon harms that small trials cannot detect.6
Emerging paranoia, persistent sleeplessness, severe mood deterioration or other concerning symptoms need clinical assessment. They should not automatically be reinterpreted as necessary therapeutic progress. Follow-up must provide a route back into appropriate addiction and mental health care.6
Preparation and integration should connect the intervention with practical recovery work: recognising triggers, rebuilding routines, maintaining treatment contact and responding to a lapse without abandoning care. In the published methamphetamine case, renewed craving and a request for later support remained relevant despite abstinence. The period after the most dramatic experience may be precisely when ordinary, sustained support matters most.5
What would make the evidence clinically decisive?
Future trials need credible comparison treatments, independently assessed outcomes, appropriate biological verification and follow-up long enough to examine recurrence. They should report all participants, including those who do not complete treatment, and distinguish abstinence, reduced use, craving, quality of life and adverse effects. More representative recruitment is needed to understand outcomes in people whose medical or psychiatric complexity has excluded them from early studies.
Costs and access also matter. Preparation, an extended supervised session and follow-up require staff time and continuity. A clinically meaningful effect must be achievable within services that patients can actually use. The relevant question is whether adding psilocybin improves sustained recovery enough to justify its additional burden and risks, while preserving access to effective existing treatment.
References
- Hendricks PS, Lappan SN, Shelton RC, et al. Psilocybin in the Treatment of Cocaine Use Disorder: A Randomized Clinical Trial. JAMA Netw Open. 2026;9:e2611029. doi:10.1001/jamanetworkopen.2026.11029.
- Knock E, Siefried KJ, Bedi G, et al. Psilocybin-assisted psychotherapy for methamphetamine use disorder: A pilot open-label safety and feasibility study. Addiction. Published online 20 September 2025. doi:10.1111/add.70187.
- American Society of Addiction Medicine; American Academy of Addiction Psychiatry. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024;18(1S Suppl 1):1–56.
- Brett J, Knock E, Korthuis PT, et al. Exploring psilocybin-assisted psychotherapy in the treatment of methamphetamine use disorder. Front Psychiatry. 2023;14:1123424. doi:10.3389/fpsyt.2023.1123424.
- Brett J, Knock E, Watson K, et al. Psilocybin-assisted psychotherapy for methamphetamine dependence: a case report involving daily methamphetamine use. Front Psychiatry. 2024;15:1490907. doi:10.3389/fpsyt.2024.1490907.
- Hosein MM, Reid MJ, Walser S, et al. Considerations and cautions for the integration of psilocybin into routine clinical care: a consensus statement from the US National Network of Depression Centers' Task Group on Psychedelics and Related Compounds. EClinicalMedicine. 2025;89:103517. doi:10.1016/j.eclinm.2025.103517.