Methamphetamine Saskatchewan Provincial Webinar 2017

Transcription

1 Methamphetamine Saskatchewan Provincial Webinar 2017

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

3 Housekeeping Background Introduction

4 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.

5 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.

6 3 A Brief History of Stimulant Use A Pinch of Snuff Verheyden,

7 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

8 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

9 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.

10 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. 8 CCSA 2006

11 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

12 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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14 9 Crystal Methamphetamine Chemistry and Action Photo: USA DEA

15 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)

16 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.

17 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 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 23 From Getting High to Being Down High Normal Down

24 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.

25 21 Prescription Amphetamines Dextroamphetamine Sulphate (Dexedrine) Amphetamine and Dextroamphetamine (Adderall) Lisdexamfetamine (Vyvanse)

26 Clinical Effects of Methamphetamine Intoxication Withdrawal Stimulant Induced Mental Illness 21

27 23 Signs or Symptoms Stimulant Intoxication 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

28 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

29 25 Stimulant Intoxication Treatment ART = Acceptance, Reassurance, Talk down (if not psychotic) Quiet, soft lit room. Benzodiazepines preferred over antipsychotics

30 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.

31 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

32 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

33 29 Stimulant Induced Mental Health Disorders INTOXICATION Psychotic Delusions Bipolar Depression Anxiety OCD Sleep Disorders Sexual Dysfunction WITHDRAWAL Bipolar Depression Anxiety OCD Sleep Disorders DSM 5

34 Stimulant Induced Psychosis 30 Agitation, irritability, paranoia, hallucinations (tactile), thought form disorder, delirium. Schizophrenia: more auditory hallucinations, clear sensorium, persistent symptoms, negative symptoms, bizarre delusions.

35 31 Treatment of Psychosis Similar environment as with intoxication. Olanzapine 10 mg IM or 15 mg po Risperidone 2 mg. OD - BID

36 32 Long Term Consequences of Stimulant Use Tolerance and Withdrawal Sensitization Addiction (Stimulant Use Disorder) Restlessness, anxiety, irritability, paranoia, panic attacks, mood disturbances Insomnia

37 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

38 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

39 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.

40 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 suboptimal use of ART for HIV.

41 36 Effects of Crystal Meth Permission granted by Multnomah County Sheriff s Office

42 36 TREATMENT Transitioning from chaos into care.

43 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.

44 44 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.

45 45 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.

46 42 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)

47 43 CBT for Stimulant Use Disorders Identification of high risk situations Development of coping skills Development of new lifestyle behaviours Development of sense of selfefficacy

48 44 Drug exposure Risk of Relapse Cues: users, high risk sites, paraphernalia Mood: stress, depression

49 45 Emergency and Detox Implications Quiet, secure longer term detox. Appropriate but assertive use of antipsychotics. Focused psychiatric consults for persistent psychosis or concurrent disorder care. Increased concurrent psychiatric care capacity.

50 46 Treatment Implications Drug court intervention. Longer term residential treatment, therapeutic housing, supportive residences or 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.

51 47 Treatment Works! 51

52 48 References DSM 5 Diagnostic & Statistical Manual of Mental Disorders 5 th Ed. Text Revision 2013 The ASAM Principles of Addiction Medicine Fifth Edition. Ries, Fiellin, Miller, Saitz The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2013 National Institute of Drug Abuse (NIDA)

53 48 Thank You! Questions? Contact: