So it’s a large kind of a picture of all the things a disease such as this does to us, and it’s kind of measured in dollars. I don’t think that’s a bad way to evaluate the burden of a disease. One thing we can say is that this disease, its prevalence has sort of been stable if not declining in the last five years and that has to be interpreted with a grain of salt and it should be looked at with multiple caveats. But we can just leave it at that and say that its prevalence and use has remained stable or slightly decreased over the last five years. Let’s move on with it. The methamphetamine, since many of you may know, it’s a powerful central nervous system stimulant and its acute use and chronic use have very major problems in terms of behavior, addiction and neurotoxicity and neurocognitive degeneration.
Each one of those areas creates a bigger and bigger problem that builds on the previous issue of starting to use and becomes more difficult to handle. What do I mean by that? If you’re a chronic user, there appears to be neurotoxic effects. What do I mean by that? The nerves themselves have degeneration, deterioration and loss over time. The mechanisms is a different question, but what does that really end up translating into? It means cognitive functioning. You’re having cells in your brain that are dying off. There’s also, neurocognitive degeneration from chronic use. For example, your control of your inhibition and decision making is affected. Your motor movements are affected. You’re asleep, mood, emotional regulation, all of this is more and more effective in the long run and many people, as high as 40% as we discussed in another video, have essentially psychosis at some point during their use and some, not a large number but not a small number, end up having chronic psychosis.
The literature discusses quite a bit in terms of treatment and I will just briefly mention some of that. We do know that at this moment, there is no particular pharmacological agent that can medicate this disease, stop it in its track, or have any kind of value in the same way that we have with medication-assisted treatment and opiate use disorders. Many medications and classes of medications have been tried and at this time there are some up front runners. I’m a little bit hesitant to mention these only because I don’t want it to be taken as, “Oh, this worked for these people and I can take it and it’ll help.” So I’m quite resistant to mentioning particular names, but I will say there’s different classes of medication under different study settings. Very few what we call double blind placebo studies that show us something of a stronger value in terms of making decisions after this study. I will only say that there’s multiple of medications. They show some efficacy, and we can leave it at that.
In terms of psychosocial treatment, there’s a few things that have shown some efficacy. One of those is cognitive behavioral therapy. Another one is motivational interviewing and contingency management. Okay? Motivational interviewing is a type of technique used when interviewing the patient. That allows a patient to sort of explore, through your guidance of interview technique, the positive values and the negative effects of their action and behavior, and through that route, you sort of want the patient to come to their own conclusions about the choices they make. Then there’s contingency management, which is a little bit of a reward system to sort of encourage clients to take actions towards a positive reward system of behavior.
In additional videos over time, I might pick one of these areas, whether it’s pharmacological treatment, maybe I’ll pick one or two medications and/or psychosocial treatments and delve a little bit deeper about that modality and its limitations and what we actually know. But for now, I really want you to understand the big picture. There is pharmacological treatment. We don’t have anything like medication assisted treatment and many different classes of medications have been looked at. Then psychosocial treatment, we do know that cognitive behavioral therapy, motivational interviewing and contingency management have shown some benefits, but even that should be taken with a grain of salt.
Let’s move forward to actual on the ground treatment and what are some of the complexities that a practitioner might be faced with. One of the areas that I deal with often is very few people seem to present for purely methamphetamine use disorder. Oftentimes it’s mixed with opiate use disorder. When that is the case, I always address the area that can be fixed or addressed. Not fixed, can be addressed with medications. So if someone has a heroin use disorder or an opiate use disorder, and I can mitigate the issue by initiating Suboxone, I almost leave to the side for a minute the methamphetamine use and abuse. This does quite a bit for me.
Number one, I’m separating this polysubstance issue into multiple issues, looking at which one I can treat first and often times, and there are some old studies that show some efficacy in this end, if I start Suboxone somewhere between 16 to 24 milligrams, it can potentially mitigate to some extent in some people the methamphetamine cravings and withdrawal. That would be nice, and sometimes I get that. So I control what I can first and oftentimes it’s polysubstances and it’s opiates. Once I have that under control in the first couple of weeks, I look very closely at the methamphetamine use and abuse that they have. This is kind of important because it allows me to practice harm reduction. So if someone’s coming into the practice and they have polysubstance issues, I’m not going to fire you nor am I going to judge you for getting clean from heroin, but you’re still having a methamphetamine problems.
This is no way to approach a very complex situation. I make sure that their opiates is under control and now I institute further evaluation for the methamphetamines. So for example, I might have a 32 year old female that comes in for polysubstance of heroin and methamphetamines and I get the heroin under control and she’s been using methamphetamines for six months, and now I start to have her come in quite regularly over the next couple of weeks. Number one, I can adjust the opiate use disorder and the medication to make sure that’s perfect. Number two, this creates a clinical, professional intimacy trust rapport with that client where it almost negates the need for urine toxicology. They come in and they tell me under what conditions they used what, and they’re very happy that their opiates are under control.
It’s in this situation where I really get a sense of the underlying pathology that may exist and the extent and how robust the methamphetamine use and abuse is. So if they come in and I start to look at things like their cravings, their frequency of use, the amount of use, the circumstances under which they use, I also try to get a sense of sleep, anxiety, depression, eating habits, who they hang out with. Every single one of these gives me an opportunity to understand the extent, the depth and the breadth of their pathology, and they’re also building a very trusting rapport with me. They’ll take an Uber and get over there and say, “Oh, I screwed up today again and I used.”
Now, over the next few days to a couple of weeks, it might be an opportunity to institute some medications and this has to be really a subtle approach to that because I certainly don’t want to mask certain issues that are caused by methamphetamines. So for example, if you’re on what’s classically called a methamphetamine run and you’ve been up for three days, I’m certainly not going to start to prescribe you any kind of sleep medication or anxiety medication. So I really need to get that under control to see what I can prescribe and start chopping at this little by little.
On the other hand, maybe there is a nothing to be prescribed. Either way, I start holding you accountable. Instead of coming in every once a month, like a regular doctor, while you’re using that substance, you’re going to be coming in once a week, maybe twice a week, and you are going to come and report to me the events of what happened. This doe a very interesting thing and this is a possible example patient that I’ve got the opiates under control. This does something very interesting. As the patient keeps coming in, they’re describing the narrative history of the recent abuse. This is a sort of opportunity for them to have insight and intellectual and emotional exploration into their issue and their disease.
Over time, assuming there’s no medications introduced initially, we start to decrease the frequency of use and abuse, and as that’s occurring, there is a kind of therapy going on with that doctor and a patient where they start to kind of … it’s sort of an extended motivational interviewing technique. They start to cut back themselves and really look at it, again, things going ideally, but oftentimes this works. Now, once I get to a point where I know the frequency of methamphetamine use is much less and stable, and I can get a clear picture of things like anxiety, depression, sleep, or any other things including psychosis, now I can start introducing medications.
Some mild medications maybe a little bit to help with sleep. Maybe a little bit short term to help out with depression, and that might turn into a longterm medication thing. The most acute thing I address in all of this, and the one thing I don’t wait to address and I try to get it under control quite rapidly, is any evidence of psychosis. Whether they’re hearing things, seeing things and paranoia. Even that, their frequency of visits will continue and I sometimes use my Suboxone prescriptions to be able to control and not force the patient to come back, but sort of get them kind of hooked onto the weekly meetings. All of this, I believe, is therapeutic and I do get positive outcomes because at this time, as I said, there’s no other medication for methamphetamine abuse in the same way that there is for opiate abuse.
So in short, in a situation where I have very limited resources and I have methamphetamine abuse, I try to approach it using a harm reduction model, frequency of visits, constant clinical vigilance and evaluation, and most importantly, for you to get to that spot, you have to make the patient feel at ease and not judged and a clinical professional comfort zone. Putting all that together, there is no particular pharmacological intervention that’s validated by data. There’s a few different psychosocial interventions that show some efficacy and outcomes. I keep that in mind, I get the patient in, assess all the other substances and start chopping away at it little by little, creating a nonjudgmental, professional, comfortable environment for the patient that can come in there and start to truly explore their own methamphetamine issues, whatever they may be, and then I start to introduce medication as I see fit over time.
I hope this video helps a little bit to really get a grasp on this awful disease. If you found this video helpful, please press above to the left to the related videos, please push the subscribe button and the bell button. Thank you very much. See you next time.