81. Mirtazapine for Methamphetamine Use Disorder81. Mirtazapine for Methamphetamine Use Disorder
Addiction Medicine Journal Club
Two addiction physicians review new research on mirtazapine for methamphetamine use disorder, behavioural add-ons to buprenorphine, and ZYN nicotine pouches as harm reduction tools. Their conversation weighs modest medication benefits against real-world side effects, resource constraints and the ethics of making therapy a condition for accessing life-saving medications.
32:12•10 Aug 2026
Mirtazapine, Meth and More: What Actually Works in Addiction Treatment?
Episode Overview
- Mirtazapine produced a small but statistically significant reduction in methamphetamine use compared to placebo, with common side effects of drowsiness and weight gain.
- Behavioural treatments added to buprenorphine did not improve opioid abstinence in a pragmatic trial, questioning their role as mandatory requirements.
- Medication for opioid use disorder should never be withheld or made contingent on engaging in therapy, though therapy can still help those who choose it.
- There is a major mismatch between methamphetamine-related deaths and the resources devoted to evidence-based treatment compared with other common health problems.
- Nicotine pouches such as ZYN may represent a harm reduction step down from cigarettes, but flavours and marketing raise concerns about youth uptake.
“The neurobiologic dysregulation of the brain from fentanyl is just too severe to be treated with therapy. It requires a pharmacologic solution.”
Understand the complexities of addiction with insights from two practising addiction medicine doctors as they break down new research on methamphetamine, opioids and nicotine. Aimed squarely at clinicians and serious recovery geeks, this episode of *Addiction Medicine Journal Club* keeps things evidence-focused but relaxed, with plenty of dry humour and real-world frustration. Dr John Keenan and Dr Sonya Del Tredici centre their chat on a JAMA Psychiatry trial of mirtazapine for methamphetamine use disorder.
They outline just how under-resourced stimulant treatment is compared with conditions like breast cancer and flu, despite similar death counts. As Sonya points out, they’re still asking basic questions such as, “What does work mean when you’re treating addiction?” They walk through the Australian study of entrenched daily meth users, covering inclusion criteria, design, and outcomes. Mirtazapine did beat placebo, but only modestly: about a two-day reduction in use per month, with plenty of drowsiness and weight gain.
John sums up the mood: statistically impressive, clinically a bit underwhelming. Yet, as Sonya notes, it’s “a safe and cheap generic medicine” that can at least offer patients something more than a shrug. Along the way, they tackle the hot debate around behavioural therapies alongside buprenorphine for opioid use disorder.
A JAMA Network Open paper showing no added abstinence benefit leads to the strong takeaway that therapy should **never** be mandatory for access to medication: “The neurobiologic dysregulation of the brain from fentanyl is just too severe to be treated with therapy. It requires a pharmacologic solution.” They also touch on FDA-approved marketing of ZYN nicotine pouches as lower-risk products, framing them as harm reduction tools that still carry addiction risks—especially for young people.
If you’re managing substance use in clinic or just keen to understand why “just do therapy” isn’t enough, this one might sharpen how you think about meds, resources and what truly counts as effective care.
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