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
4 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.
3 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.
3 A Brief History of Stimulant Use A Pinch of Snuff Verheyden, 1806 - 1890
5 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
6 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
7 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.
8 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
9 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
10 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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9 Crystal Methamphetamine Chemistry and Action Photo: USA DEA
11 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)
12 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.
13 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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22 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.
23 From Getting High to Being Down • High • Normal • Down
20 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.
21 Prescription Amphetamines • Dextroamphetamine Sulphate (Dexedrine) • Amphetamine and Dextroamphetamine (Adderall) • Lisdexamfetamine (Vyvanse)
21 Clinical Effects of Methamphetamine Intoxication Withdrawal Stimulant Induced Mental Illness
23 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
24 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
25 Stimulant Intoxication Treatment • ART = Acceptance, Reassurance, Talk down (if not psychotic) • Quiet, soft lit room. • Benzodiazepines preferred over antipsychotics
26 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.
27 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
28 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
29 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
30 Stimulant Induced Psychosis • Agitation, irritability, paranoia, hallucinations (tactile), thought form disorder, delirium. • Schizophrenia: more auditory hallucinations, clear sensorium, persistent symptoms, negative symptoms, bizarre delusions.
31 Treatment of Psychosis • Similar environment as with intoxication. • Olanzapine 10 mg IM or 15 mg po • Risperidone 2 mg. OD - BID
32 Long Term Consequences of Stimulant Use • Tolerance and Withdrawal • Sensitization • Addiction (Stimulant Use Disorder) • Restlessness, anxiety, irritability, paranoia, panic attacks, mood disturbances • Insomnia
33 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
34 Long Term Consequences • Reproduction: irregular menses, prematurity • ENT: nasal septum perforation, loss of sense of smell, chronically runny nose • Infectious Disease: HCV, HIV • Weight loss • Neurocognitive impairment • Dental: “meth mouth ” • Psychosocial: homelessness, legal involvement, trauma
35 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.
36 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- optimal use of ART for HIV.
36 Effects of Crystal Meth Permission granted by Multnomah County Sheriff’s Office
36 TREATMENT Transitioning from chaos into care.
43 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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