Methamphetamine Use Disorder (Nicholson, 1/8/2020)

Thank you so much to Dr. Lisa Nicholson for her excellent presentation this week during Grand Rounds on Methamphetamine Use Disorder.

Most of you are well aware that methamphetamine has some health effects and societal implications, but did you know that our very own health care system and pharmaceutical companies are responsible for introducing methamphetamine to our military pilots in WW2 (to keep them awake), to the general market OTC in 1939 (brand nameBenzedrine) and is still available even today with a prescription?

Meth has been marketed for the treatment of depression, obesity, fatigue, low libido, inattentiveness, menopause, nasal congestion, asthma, and even the common cold. (Check out the ads to the Right) 

Methamphetamine is typically smoked, inhaled, or ingested. In California, the majority of people who use meth smoke it, but in Texas, the majority inject it.

·        1.2% of Californians have used meth in the last year

·        6% of Sonoma County 11^th graders have tried meth (yikes!)

·        Meth is the most common illicit substance used worldwide (after MJ)

·        In Sonoma County, meth is by far the most commonly used substance in families involved with the Sonoma County court system implicated in the abuse or neglect of children (second to alcohol)

This is MIND-BLOWING! Meth is the most addictive substance that exists: 47% of people will become addicted after first use, 60% after second use

Medical implications of meth use:

·        Acute intoxication: malignant hypertension, stroke, cardiac arrest, meth psychosis

·        Post-meth: altered mental status, irritability, violence

·        Long term: meth cardiomyopathy, dental problems, cerebral atrophy, mood disorders

A bit on Meth psychosis. . .

·        Up to 40% of users get meth psychosis, it is dose dependent, on average 1 week duration, but users with >5 years of use can have prolonged psychosis (>1 month).

o  If a patient has experience meth psychosis in the past, they are “sensitized” and more likely to experience it again in the future

·        Meth psychosis can mimic other mental illness: mania, schizophrenia, mood disorders.

o  At Zuckerberg SFGH inpatient psych facility estimates 47% of patients admitted to the inpatient ward are not mentally ill—they are high/coming down from meth (2019 study)

·        To distinguish primary psychosis from meth induced: you must have meth use BEFORE psychosis, and abstaining from meth likely will improve/make recede the psychosis

·        There is limited evidence on the use of atypical antipsychotics for thetx of meth psychosis: generally olanzapine, quetiapine. There is also evidence for the use of benzodiazepines for the treatment of meth withdrawal

A bit on hypertension. . .

Severe hypertension of meth should be treated with BETA BLOCKERS: labetolol. Tachycardia can be treated with  metoprolol (correct the catecholamine flood)

Patients with severe hypertension and chest pain are at risk for acute MI, dissection, and/or aortic aneurysm. Get a head CT if you cannot examine them thoroughly.

Meth cardiomyopathy very common (usually dilated non-ischemic, VERY low EF ~10%).

A 2017 German study found that with meth abstinence average EF increased from 20% to 43%, so STOPPING METH can improve cardiac function markedly!!!

There are no FDA approved treatments for meth use disorder. Mixed evidence for:

·        Bupropion (Wellbutrin): blocks dopamine reuptake, can help in early abstinence, modest evidence, not recommended after 4 weeks abstinence (can be triggering)

·        Mirtazapine: helps with sleep, appetite, modest reduction in meth use

·        Naltrexone: appears to decrease meth high and cravings, mixed results

·        Modafinil (Provigil): some evidence in cocaine use disorder, 2010 RCT said no better than placebo for meth

·        Adderall/Ritalin: jury still out

      

Psychosocial approaches:

Best evidence in non-pharm management of patient is for contingency management (=monetary or other tangible short term rewards for abstinence)PLUS Community reinforcement (healthy restructuring of social environment)

Not great evidence for 12-step, CPT or supportive therapy. Hmmm. No one in Sonoma County appears to currently be using contingency management—MediCal does Not cover it

Don’t forget harm reduction in patients with meth use disorder:

1)     Condoms 2) PrEP 3) Needle exchange (when appropriate) 4) Dental Care 5) Clinic structures that don’t punish people for no-shows, tending more to drop-in