Methamphetamine Saskatchewan Provincial Webinar 2017 This webinar - - PowerPoint PPT Presentation

Methamphetamine Saskatchewan Provincial Webinar 2017

This webinar is brought to you in partnership by the Regional Health Authorities and the Ministry of Health.

• Housekeeping
• Background
• Introduction

Objectives

• Describe the history of stimulant use, including

current patterns.

• Explain the pharmacology and impact of

methamphetamine on the human body, particularly its potential to cause addiction.

• Understand the typical pattern for

methamphetamine intoxication, withdrawal and induced mental illness.

• Consider the implications for treatment.

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Presenter Disclosure

• No relevant commercial disclosures.
• Community based Associate Professor,

College of Medicine, University of Saskatchewan.

• Consultant on Addiction Medicine to

the Saskatoon Health Region.

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A Brief History of Stimulant Use

A Pinch of Snuff Verheyden, 1806 - 1890

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History of Stimulants

• Cocaine: chewing of coca leaves prevalent

in the Andean regions of South America for more than 2000 years

• 1860 German Graduate student Albert

Niemann, isolated cocaine as the active ingredient of coca leaf

• Coca-Cola: introduced 1886 (containing

4.5mg of cocaine per 6 oz.)

• 1903 cocaine removed from Coca-Cola

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History of Stimulants

• Amphetamine: first synthesized in 1887
• Methamphetamine: first synthesized in

1919

• Amphetamines widely used during WWII
• Methamphetamine currently available

with a prescription for obesity, attention deficit hyperactivity disorder, and narcolepsy ex: Desoxyn

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History of Stimulants

• Ecstasy: used unsuccessfully in

psychotherapy in 1970’s, became popular in rave scene in late 1980’s, early 1990’s.

• Crack Cocaine: 1984/1985 appears in New

York, Los Angeles and Miami.

• In late 1980’s smokable form of Crystal Meth

was created in Asia and then surfaced in California in the 1990’s, spread west to east.

• Use waxes and wanes in different regions.

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Canadian Methamphetamine Use

• Canadian Addiction Survey (2004) – 15 & over:

– 6.4% used at least once in lifetime – Less than 1% reported use in last year

• Peak use during late adolescence/early

adulthood (15-30 years)

• Use more common in street involved youth, gay

men and homeless populations

– 71% of a convenience sample of street involved youth in Vancouver had used – 37% of homeless youth in Toronto used at least once a month.

CCSA 2006

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Canadian Methamphetamine Use Summary

• West >> East
• Predominately (but not exclusively) marginalized

populations, “Out of Care’s Way”

• 1 in 10 who use become dependent
• Few dependent users present for treatment

CCSA 2006

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Stimulant Use in Saskatchewan

• Unique predilection for IV methylphenidate.
• Decreased with introduction of tamper

resistant Concerta, but coincided with increase in cocaine use.

• Methamphetamine transiently significant in

late 1990’s - early 2000’s.

• More significant in last 4 years.

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Crystal Methamphetamine Chemistry and Action

Photo: USA DEA

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Crystal Meth

• Chemically similar to amphetamines
• White, odourless, bitter-tasting

crystalline powder

• Route: oral, smoked, snorted, or

injected

• Made in illegal labs by chemically

altering OTC medicines (pseudoephedrine)

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Pharmacology of Stimulants

• Water soluble
• Onset of action depends on route of

administration: rapid onset of action with injection or smoking

• Duration of action dependent on route of

administration and chemistry: oral administration produces longer duration of action, methamphetamine persists longer than amphetamine.

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Central Nervous System Effect

• Methamphetamine

– Inhibit reuptake of synaptic dopamine AND promotes direct dopamine release – Promotes catecholamine (adrenalin, noradrenalin) release. *Direct effect on dopamine creates the greatest likelihood of dependency.

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Progression to Addiction

• Loss of normal reward and motivational

systems.

• Everything becomes drug focused.
• It becomes harder to feel “high”.
• One then uses simply to feel “normal” and

avoid depression or withdrawal.

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From Getting High to Being Down

• High
• Normal
• Down

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Metabolism and Excretion

• Metabolizes from methamphetamine to

amphetamine.

• Excreted in urine.
• UDS may show: methamphetamine,

methamphetamine and amphetamine, or amphetamine.

• Prescription amphetamines also test positive

as amphetamines on UDS.

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Prescription Amphetamines

• Dextroamphetamine Sulphate

(Dexedrine)

• Amphetamine and

Dextroamphetamine (Adderall)

• Lisdexamfetamine (Vyvanse)

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Clinical Effects of Methamphetamine

Intoxication Withdrawal Stimulant Induced Mental Illness

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Stimulant Intoxication

• Signs or Symptoms
• 1. Tachycardia or bradycardia
• 2. Pupillary dilation
• 3. Elevated or lowered blood pressure
• 4. Perspiration or chills
• 5. Nausea or vomiting
• 6. Evidence of weight loss
• 7. Psychomotor agitation or retardation
• 8. Muscular weakness, respiratory depression, chest

pain, or cardiac arrhythmias

• 9. Confusion, seizures, dyskinesias, dystonias, or coma

DSM 5 23

Stimulant Intoxication

• Problematic behavioural or psychological

changes:

• 1. euphoria or affective blunting
• 2. changes in sociability
• 3. hypervigilance
• 4. interpersonal sensitivity
• 5. anxiety
• 6. tension or anger
• 7. stereotyped behaviours
• 8. impaired judgement

DSM 5 24

Stimulant Intoxication Treatment

• ART = Acceptance, Reassurance, Talk down

(if not psychotic)

• Quiet, soft lit room.
• Benzodiazepines preferred over antipsychotics

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Acute Consequences of Stimulant Use

• Neuro: seizures, strokes
• CVS: tachycardia, arrythmia, MI,

HTN

• Kidneys: cocaine induced

rhabdomyolysis

• Blood: Agranulocytosis (levamisole)
• Obstetrics: placenta previa
• ENT: nosebleeds
• Infectious Disease: STI’s, cellulitis,

bacterial endocarditis, HIV, HCV.

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Stimulant Withdrawal

• Dysphoric mood and two (or more) of the

following, developing within hours to several days after cessation of prolonged stimulant use

• 1. Fatigue
• 2. Vivid, unpleasant dreams
• 3. Insomnia or hypersomnia
• 4. Increased appetite
• 5. Psychomotor retardation, or agitation

DSM 5 27

Stimulant Withdrawal

• Rarely require hospitalization or medications
• Supportive treatment
• Impulsivity and craving problematic
• Managed, efficient transition to treatment
• Residential treatment superior to outpatient

treatment

• Relapse prevention skills need to be

instituted early

• Suicide prevention

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Stimulant Induced Mental Health Disorders

INTOXICATION WITHDRAWAL Psychotic Delusions Bipolar Bipolar Depression Depression Anxiety Anxiety OCD OCD Sleep Disorders Sleep Disorders Sexual Dysfunction DSM 5 29

Stimulant Induced Psychosis

• Agitation, irritability, paranoia, hallucinations

(tactile), thought form disorder, delirium.

• Schizophrenia: more auditory hallucinations,

clear sensorium, persistent symptoms, negative symptoms, bizarre delusions.

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Treatment of Psychosis

• Similar environment as with intoxication.
• Olanzapine 10 mg IM or 15 mg po
• Risperidone 2 mg. OD - BID

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Long Term Consequences of Stimulant Use

• Tolerance and Withdrawal
• Sensitization
• Addiction (Stimulant Use Disorder)
• Restlessness, anxiety, irritability,

paranoia, panic attacks, mood disturbances

• Insomnia

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Sensitization

• Sensitization (opposite of tolerance)

more you use the drugs more likely of symptoms happening such as:

– Seizure – Psychosis (paranoia, visual, auditory, and tactile hallucinations) – Stereotypical behaviors

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Long Term Consequences

• Reproduction: irregular menses, prematurity
• ENT: nasal septum perforation, loss of sense
• f smell, chronically runny nose
• Infectious Disease: HCV, HIV
• Weight loss
• Neurocognitive impairment
• Dental: “meth mouth”
• Psychosocial: homelessness, legal

involvement, trauma

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Methamphetamine and HIV/AIDS

• Increased use of transmission through IVDU,

contaminated pipes and unprotected sex.

• Ongoing use and treatment avoidance

interferes with 1) engagement and 2) retention in care.

• Inability to take meds daily results in

progression of HIV to AIDS and death.

• May be hastened by increased

catecholamine, cortisol and immune suppression.

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Methamphetamine and HIV/AIDS

• Progression to AIDS and death most

commonly associated with ongoing stimulant use. (WSCC data)

• People on OAT for Opioid Use Disorder may

relapse on methamphetamine. Retention in care often compromised by lack of attendance at pharmacy or clinic, and sub-

• ptimal use of ART for HIV.

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Effects of Crystal Meth

36 Permission granted by Multnomah County Sheriff’s Office

TREATMENT Transitioning from chaos into care.

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The Complexity of Active Addiction

• Typically psychosocial chaos. May be street

and / or gang involved. May be homeless. Disrupted education or vocation. Often legal consequences from crime or sex trade work to obtain drugs.

• Personal growth and development typically

disrupted.

• Often poly-substance use: drugs and

alcohol.

• Highly marginalized and stigmatized.

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The Complexity of Active Addiction

• Frequently associated with concurrent health issues
• Mental health, either pre-existing or drug induced:

mood, anxiety disorders or psychosis.

• Blood borne infections: HIV, AIDS, HCV.
• Other infections: superficial abscesses, heart, lung,

bone, joints, nervous system (spine and brain) and / or deep pelvic abscesses.

• Poor nutrition.
• Sub-optimal care.

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Personal Context

• Security: food, shelter, safety, income
• Addiction: diagnosis, consequences, stage,

stability

• Readiness: stage of change, denial vs. gains
• Co-morbidity: medical and psychological
• Competency: coping skills, education,

training

• Often hard to reach, or “Out of Help’s Way”.

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Treatment of Stimulant Use Disorders

• SBIRT (Screening, Brief Intervention, Referral to

Treatment)

• Harm Reduction (needle exchange/crack pipe

programs)

• Motivational Enhancement Therapy
• Cognitive Behavioural Therapy
• Contingency Management
• Residential Treatment
• Self Help Support
• Treatment of Underlying Mental Health Disorders
• Treat any Medical Complications (HIV, HCV)

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CBT for Stimulant Use Disorders

• Identification of high risk

situations

• Development of coping skills
• Development of new lifestyle

behaviours

• Development of sense of self-

efficacy

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Risk of Relapse

• Drug exposure
• Cues: users, high risk sites, paraphernalia
• Mood: stress, depression

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Emergency and Detox Implications

• Quiet, secure longer term detox.
• Appropriate but assertive use of anti-

psychotics.

• Focused psychiatric consults for persistent

psychosis or concurrent disorder care.

• Increased concurrent psychiatric care

capacity.

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Treatment Implications

• Drug court intervention.
• Longer term residential treatment,

therapeutic housing, supportive residences

• r Mental Health Group Home models.
• Mobilization of CBO and private sectors in

conjoined housing and treatment partnerships.

• Linkage to housing support, education,

vocational training or return to work.

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Treatment Works!

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References

• DSM 5 Diagnostic & Statistical Manual of

Mental Disorders 5th Ed. Text Revision 2013

• The ASAM Principles of Addiction

Medicine Fifth Edition. Ries, Fiellin, Miller,

• Saitz. 2014
• The Canadian Tobacco, Alcohol and

Drugs Survey (CTADS) 2013

• National Institute of Drug Abuse (NIDA)

www.drugabuse.gov

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Thank You! Questions?

Contact: peter.butt@usask.ca

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