Methamphetamine

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Methamphetamine

• Matthew E Markve MA CRC
• Region VIII RCEP
• University of Northern Colorado

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SAMHSA (2005)

• 1.2 Million people used methamphetamine or
  prescription stimulants in the past month (2003)
• Lifetime use of methamphetamine is estimated at
  12.3 million people (Over 5 of the US
  population)
• Methamphetamine is the most commonly abused
  illegal stimulant in this country
• Dependence/Abuse is highest in the 12-25 year old
  category

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MethamphetamineWhy People Use

• Increases
• Confidence
• Alertness
• Mood
• Sex drive
• Energy
• Talkativeness

• Decreases
• Work
• Boredom
• Loneliness
• Timidity

MATRIX Institute/UCLA
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Northern Colorado Methamphetamine Use Survey

• Markve and Masley (2004) n.p.
• We engaged in a dialogue with a number of current
  and former MA users to determine perspective and
  rationale for use
• Some of the feedback

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Physical Effects/Chronic User(CA 2007)

• Chronic use changes the brain
• Tolerance
• Over sensitization
• Mental flexibility
• Information Manipulation
• Problem Solving
• Abstract Thinking
• Structural damage

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Physical Effects/Regular Use(CA 2007)

• Increased heart rate/blood pressure
• Irregular heartbeat
• Pulmonary hypertension or edema
• Chronic obstructive pulmonary diseases
• Other lung problems

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Acute Intoxication/Overdose (CA 2007)

• Severe hyperthermia
• Convulsions
• Renal (kidney) failure
• Stroke
• Heart attack

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Routes of Administration

• Oral
• Intranasal (snorting)
• Smoking
• Injecting

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Colorado MA Drug Assessment (2003)

• 19 Snorted MA
• 43 Smoked MA
• 32 MA IV Use
• 6 Used Multiple Methods
• 53 Jurisdictions in CO reported High Abuse levels
• 8 Moderate
• 10 Low or no abuse

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Physical Effects/Injectors

• Nonsterile injections
• Adulterant/impurities not filtered (injected
  directly into bloodstream
• Injector Hepatitis C rates approach 44 in recent
  study
• HIV rate relatively low for population
• High risk sexual behaviors are common
• Rates may increase

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Skin/Mouth

• Tingly skin (blood vessel constriction) leads to
  scratching
• Formication (bugs crawling) in chronic users
• Scratching/digging to remove meth bugs causing
  permanent damage
• Meth Mouth rapid decay of teeth and gums due to
  acidic content of drug
• Additionally low saliva production/sugary soft
  drinks/poor hygiene contribute to this
  deterioration

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Teratogenic Effects

• Methamphetamine as a teratogen lacks research
• One study showed
• Premature birth rates higher in MA group
• Lower birth weight overall in MA group
• Growth problems in children after birth
• Rates of DD higher in MA group
• Children in MA households also at risk
• Neglect
• Chemical contact if a cook site
• Establishing safety of children primary concern
  (duty to warn)

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MethamphetamineChronic Psychological Effects

• - Confusion -
  Irritability
• - Concentration -
  Paranoia/Anxiety
• Hallucinations - Panic
  reactions
• - Fatigue -
  Depression
• - Memory loss - Anger
• - Insomnia -
  Psychosis
• - Delusions

MATRIX Institute 2005/CADP 2007
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MethamphetamineChronic Physical Effects

• - Tremor - Sweating
• - Weakness - Burned lips sore nose
• - Dry mouth - Oily skin/complexion
• - Weight loss - Headaches
• - Cough - Diarrhea
• - Sinus infection - Anorexia

MATRIX Institute 2005/CADP 2007
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MethamphetaminePsychiatric Consequences

• Paranoid reactions
• Permanent memory loss
• Depressive reactions
• Hallucinations
• Psychotic reactions
• Panic disorders
• Rapid addiction
• Higher rates of suicidal ideation

MATRIX Institute 2005/CADP 2007
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Acute MA Psychosis

• Extreme Paranoid Ideation
• Well Formed Delusions
• Hypersensitivity to Environmental Stimuli
• Stereotyped Behavior Tweaking
• Panic, Extreme Fearfulness
• High Potential for Violence

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MA and the BrainLiska (2004) CA (2007)

• Primary Neurotransmitters Impacted (DA and 5-HT)
• Dopamine (DA) (induces release)
• Pleasure chemical
• Mesolimbic system Memory and emotions
• Extrapyramidal system Coordination and
  integration of fine muscular movement
• Serotonin (5-HT) (induces release)
• Sleep, appetite, sexual behavior and aggression,
  painkilling
• Jacobs/Trulson suggest 5-HT plays an inhibitory
  role in behavior (modulating behavior within
  tight boundaries)
• Higher doses of MA over longer time periods
  nerve damage
• Norepinephrine (NE) also affected (induces
  release)

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MA and the Brain II

• Can indirectly impact other neurotransmitters at
  higher concentrations acting as an MAOI
  (Monoamine Oxidase Inhibitor)
• Monoamine class neurotransmitters present in the
  synapse are not broken down (oxidized) as usual,
  and thus remain active in the synapse for
  extended periods
• As a side note, MAOIs are utilized as potent
  antidepressants (SSRIs are favored due to fewer
  potential side effects/lethality with other
  drug/food interactions)

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Normal Nerve Cell
Nerve Cell
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Sim, Richardson and Carnell (1999)

• How does stimulant use impact cognition?
• Study analyses differences in cognitive tasks
  between a stimulant group and a control group

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Memory Difference between Stimulant and
Comparison Groups
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Differences between Stimulant and Comparison
Groups on tests requiring perceptual speed
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Cognitive Effects of MA Use Conclusions of Study

• Actively using MA addicts demonstrate impairments
  in
• the ability to manipulate information
• the ability to make inferences
• the ability to ignore irrelevant information
• the ability to learn
• the ability to recall material

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Cognitive Effects of MA Use Cont

• Some deficits are resolved after a period of
  12-weeks of abstinence
• The ability to ignore irrelevant information
• The ability to manipulate information

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Recovery of Brain Function (CA 2007)

• Many of the changes in the brain caused by
  chronic MA use are reversible, however timelines
  for the reversal vary
• Some (not all) memory deficits recover in first
  few weeks of abstinence
• Sleep patterns/dream states disrupted for months
• High emotional levels persist for first few
  months of recovery
• Anhedonia minimum of 4-6 months

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Differences in Treatment Needs for MA Abusers

• NAADAC 2005 Conference Discussion Findings
• Cognitive issues (as described in last slides)
  can severely compromise treatment outcomes
• Call for nontraditional approach to treatment
• Dont assume these deficits are treatment
  resistance, or symptoms of criminality

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Differences in Treatment Needs for MA Abusers

• One year is cited as being necessary for brain
  chemistry to return to normal (although the 07
  California DAP report mentions effects can linger
  as long as 2)
• More frequent sessions than traditional SUD
  therapy are indicated
• Shorter duration sessions are indicated

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MA Treatment Differences

• Some abilities get worse in the early periods of
  abstinence
• Recall and recognition both show more impairment
  at 12 weeks of non-use than is evident in current
  users

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CA 2007 Implications for Clinicians

• Treatment materials need to be simple/repeated to
  ensure retention (especially during early weeks
  of treatment)
• Assist consumers with structuring activities and
  scheduling time (hour by hour at the beginning)
• Emotional management techniques/emotion based
  counseling in early stages of recovery
• Physical exercise/healthy eating/sleeping habits
  to reduce anhedonia

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Prevalence Data 2002-2005 (SAMHSA 2006)
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18-25 (SAMHSA 2006)
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Prevalence Estimates Averages (02-04)
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Methamphetamine Myths (2007)

• MA dependence is not treatable
• Average length of time from first use to death is
  5 years
• MA use causes holes in the brain
• Using MA once results in addiction
• No special treatment is needed for MA users
• MA is used primarily by White male bikers and
  truck drivers

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Guidelines for Assessment and Treatment Planning

• Psychotic Characteristics
• Paranoid Characteristics
• Physical Safety
• Cognitive Dysfunction
• Medical/Dental Condition
• Recent Sexual History
• Route of Administration
• Frequency of Use

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Treatment Strategies

• Assessment interview to determine patterns and
  severity of use
• Biological testing (urinalysis)
• Include range of treatment options (MATRIX for
  example)
• 12 step social supports
• Medical and psychiatric care
• Individualized treatment

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Treatment Approaches

• Contingency Management
• Cognitive Behavioral Therapy
• MATRIX Model

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Appendix 1

• Matrix Mode of Outpatient Treatment

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Matrix Mode of Outpatient Treatment

• Matrix Institute on Addictions
• UCLA Addictions Services
• Principles of Matrix Mode

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Matrix Model ofOutpatient Treatment
Organizing Principles of Matrix Treatment

• Create explicit structure and expectations
• Establish positive, collaborative relationship
  with patient
• Teach information and cognitive-behavioral
  concepts
• Positively reinforce positive behavior change

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Matrix Model ofOutpatient Treatment
Organizing Principles of Matrix Treatment (cont.)

• Provide corrective feedback when necessary
• Educate family regarding stimulant abuse recovery
• Introduce and encourage self-help participation
• Use urinalysis to monitor drug use

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Matrix Differences from Typical Therapy
1. Focus on behavior vs. feelings 2. Visit
frequency results in strong transference 3. T
ransference is encouraged 4. Transference is
utilized 5. Goal is stability (vs. comfort)
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MATRIX Differences from Typical Therapy
6. Focus is abstinence 7. Bottom-line is
always continued abstinence 8. Therapist
frequently pursues less motivated
clients 9. The behavior is more important
than the reason behind it
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MATRIX Differences from Typical Therapy
10. Family system support is
encouraged 11. Therapist functions in
coach/advocate role 12. More
directive 13. Therapeutic team approach is
utilized
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MATRIX Differences from Inpatient Programs
1. Less confrontational 2. Progresses
slower 3. Focus is on present 4. Core
issues not immediately addressed 5. Allegia
nce is to therapist (vs. group)
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MATRIX Differences from Inpatient Programs
6. Non-judgmental attitude is basis of
client-therapist bond 7. Change recommendations
based on scientific data 8. Changes
incorporated immediately into lifestyle
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Outpatient Recovery IssuesStructure - Ways to
Create

• Time scheduling
• Attending 12-step meetings
• Going to treatment
• Exercising
• Attending school
• Going to work
• Performing athletic activities
• Attending church

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Outpatient Recovery IssuesInformation - What
- Substance abuse - Sex and recovery and
the brain - Relapse prevention issues -
Triggers and cravings - Emotional
readjustment - Stages of recovery - Medical
effects - Relationships and recovery -
Alcohol/marijuana
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Appendix 2 Research

• Matrix Model of Stimulant Abuse Treatment
  Frontrunner in supporting evidence and results
  for MA and Cocaine treatment today.
• Longitudinal studies ran from 1988-1995 and
  1998-2001 showing promising results for this
  model of treatment.

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Project Overview Matrix Institute 1999

• Charts of all stimulant users included
• Clients entered treatment between 1988-95
• Large sample
• 500 methamphetamine users
• 224 cocaine users
• Demographics, drug use information, urine
  toxicology, and treatment outcome ratings

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Drug Use Information

• MA Users COC Users
• Age First Used 21.4 23.7
• Heavy Use 41.2 mos. 39.7 mos.
• Route
• Intranasal 55.5 21.5
• Smoking 7.2 48.0
• Multiple Routes 22.7 16.7
• Any IV use 13.5 13.1

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Other Substance Use

• MA Users COC Users
• Cocaine, past yr. 10.8
  100.0
• Meth, past yr. 100.0
  17.9
• Marijuana, past yr. 56.2
  42.4
• Halluc./PCP, past yr. 6.4
  0.0
• Barbiturates, past yr. 2.8
  2.2

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Drug Use Information

• MA Users
  COC Users
• Frequency of Use
• None in 30 days 14.8
  17.4
• 1-2 times/week 24.8
  44.6
• 3-6 times/week 17.0
  16.8
• daily 43.6
  21.2
• Recent Use
• Days / past mo. 12.8
  8.8
• Money / past mo. 123
  275
• Longest Abstinence 1-2 mos.
  2-3 mos.

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Self-Reported Medical Problems

• MA Users COC Users
• Chest pain 29.8
  25.5
• Headaches 42.4
  32.8
• Seizures 2.0
  4.2
• Loss of consciousness 7.7
  6.5
• Need medical tx. 10.7
  5.8
• NOTE Answers reflect current medical problems.

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Self-Reported Psych Problems

• MA Users COC Users
• Previous psych tx. 14.4
  16.5
• Current psych problems
• Depressed, a lot 19.3 12.1
• Suicide thoughts 6.9
  2.8
• Hallucinations 34.8
  25.1
• Paranoid thoughts 28.8 25.5
• NOTE Answers reflect current psychiatric
  problems.

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Comparisons of IV/non-IV Users

• IV Users Other Users
• Use gt 3g/ week 38.1
  11.4
• Use daily 65.1
  40.1
• Severe withdrawal 36.5
  22.0
• Buy direct / deal 33.3
  13.2

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Comparisons of IV/non-IV Users

• IV Users Other Users
• Felony convictions 36.8
  17.4
• No Family Rels. 22.2
  5.8
• Bankruptcy 44.3 19.3
• Unemployed gt 1yr. 58.0 28.2

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Comparisons of IV/non-IV Users

• IV Users Other Users
• Hallucinations/paranoia 55.5
  33.2
• Seizures/loss of consc 30.2
  14.2
• Problems with Sex 29.7
  12.8
• Drug/sex connected 22.5
  9.6

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Treatment Matrix Model

• Combination of individual, family, and group
  sessions
• Program to last 6 months
• Strong emphasis on cognitive-behavioral approach
• Designed in phases that decrease in intensity
• Look at Matrix

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Treatment Services Received(hours received)

• MA Users COC Users
• Individual Sessions 13.3
  16.3
• Stabilization Group 3.4
  3.7
• Relapse Prevention 23.7
  21.0
• Family Education 11.6
  12.2
• Social Support 4.4
  4.3

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Urinalysis Results

• Tested randomly, about once a week
• Samples not always collected when patient
  self-reported drug use
• MA users COC users
• Number of urine
• samples collected 8.3 8.1
• Percent positive (dirty)
• for drug of choice 10.4
  8.1

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Treatment Retention
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MA - CocaineFollow-up Comparison

• Matrix Clinic in Rancho Cucamonga, San Bernardino
  County located 50 miles East of Los Angeles
• One to five years follow-up of 100 MA and 100
  cocaine users in a CSAT funded study

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Follow-up of 114 MA Users Treated with Matrix
Model
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Follow-up of 114 MA Users Treated with Matrix
Model
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Follow-up of 114 MA Users Treated with Matrix
Model
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2001 Repeat Study of Matrix Model

• Similar positive findings, Including this because
  one of the sites researched was in Billings, MT
  and perhaps can provide a more representative
  sample of users in our region.

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MATRIX Institute (2003)

• In the overall sample, and in the majority of
  sites, those who were assigned to Matrix
  treatment
• attended more clinical sessions
• stayed in treatment longer
• provided more MA-free urine samples during the
  treatment period
• and had longer periods of MA abstinence than
  those assigned to receive TAU

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SURE Rural Users (Gorman, 1999)

• Different from urban meth scene / different
  groups
• High risk of Hep C, B and HIV due to
  inaccessibility to needle exchange, lack of
  prevention
• Underestimation of needle users in rural areas,
  high degree of needle sharing
• Typical Use Progression
• Snorting of meth --gt smoking meth --gt shooting
  meth --gt shooting heroin
• Reports of meth cut with heroin
• Rural areas feature inadequate prevention
  efforts lack of appropriate treatment capacity

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Conclusions Rural-Urban Dynamics

• Initiation Urban-peer based Vs. Rural -
  intergenerational
• Poverty, underemployment , meth traditions may
  provide impetus for prevalence of meth and
  other drug/alcohol use
• Blue collar cultural issues prevention
  implications
• Supporting the habit
• Rural theft, robbery, distribution
• Urban shoplifting, dumpster diving, panhandling
• FEW RURAL HEALTH OR SOCIAL SERVICES
  INFRASTRUCTURES

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MethamphetamineAcute Physical Effects

• - Increases -Decreases
• Heart rate Appetite
• Blood pressure Sleep
• Pupil size Reaction time
• Respiration
• Sensory acuity
• Energy