Episode 66 - Meth Abuse - a podcast by Rio Bravo Family Medicine Residency Program

Episode 66: Meth Abuse. 

By Ikenna Nwosu, MD, and Hector Arreaza, MD.  

Discussion about screening, epidemiology, clinical presentation, diagnosis, and treatment of meth abuse. Association between intranasal corticosteroids and lower risk of COVID-19 complications is mentioned.

Introduction: Intranasal corticosteroids associated with better outcomes in COVID-19
By Bahar Hamidi, MS3, American University of the Caribbean 

When I first heard of the news of a pandemic occurring, I never thought it would last more than a couple weeks. Of course, as a medical student the first thing I wanted to know was what bug is causing all this commotion in the news. When I discovered “Coronavirus” my first reaction was a chuckle and blurting out “no way.” Why did I respond this way you may ask? As a student when we studied that coronavirus would cause nothing more than a regular cold, thus a mere pesky virus causing a whole pandemic seemed odd to me at the time. Little did I know almost two years later we are still talking about it! 

“Don’t touch your face before washing your hands.” These are the words that run through my mind anywhere I am nowadays. Why? Well, SARS-CoV-2 spike (S) protein is why. This protein engages ACE2 (angiotensin-converting enzyme 2) as the entry receptor. This virus’s receptor is found to be highly expressed in our nasal mucosa. How much of this ACE2 we have interestingly can correlate with your age; lower in children compared with adults. Other things that can affect a person’s susceptibility is the level of eosinophils in your body. High absolute eosinophil count showed to have a lower hospitalization risk in a group of individuals with asthma and COVID, but we must keep in mind that the study can be confounded by the use of inhaled corticosteroids (iCS). This was taken into account during a study.

The study was done by Ronald Strauss and collaborators, it’s titled, Intranasal Corticosteroids Are Associated with Better Outcomes in Coronavirus Disease 2019, and it was published on The Journal of Allergy and Clinical Immunology: In Practice, September 2021.

So how may inhaled corticosteroids prevent significant illness from COVID? The answer is lower expression of ACE2 and its cellular serine protease TMPRSS2. Theoretically, it makes sense because the less entry gates the virus has the less sick someone may possibly get. Therefore, the study hypothesizes that by suppressing receptor expression, intranasal corticosteroid use is protective against complicated outcomes like hospitalizations, admission to ICU and mortality.

Interestingly in addition, two types of corticosteroids [ciclesonide (Alvesco®) and mometasone (Asmanex® for asthma and Nasonex for allergic rhinitis)] were discovered to suppress replication of coronavirus. This overall study has pertinent findings for the treatment of this everlasting pandemic and proves there is yet much left to discover and continue to research.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

___________________________

Meth Abuse. 
By Ikenna Nwosu, MD, and Hector Arreaza, MD

 

Introduction

Drug use is a growing problem with serious consequences to individuals, families, and whole nations. Today we will discuss one of the most common drugs abused by our patients: Methamphetamine.

 

Definition   

Methamphetamine (street name chalk, crank, crystal, glass, ice, meth) is a stimulant commonly abused in many parts of the United States. It is a psychostimulant that causes the release and blocks the reuptake of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin. Methamphetamine is most often smoked or snorted and is less commonly injected or ingested orally. 

 

Arreaza: Phentermine (appetite suppressant) is not meth. Phentermine is less potent because it acts mostly on norepinephrine, very little on dopamine, and minimally on serotonin. 

 

Epidemiology  

Amphetamine-type stimulants, which include methamphetamine, are the fastest rising drug of abuse worldwide. An estimated 2.1% of the United States population have been reported to have tried methamphetamine at some time in their lives with its rate of use found to be similar among men and women. Data indicates that methamphetamine is a significant public health problem. Mortality has increased by about 40 percent from 2015 to 2016 and drug overdose deaths involving methamphetamine have tripled since 2011.

 

Arreaza: The mortality is high but also the morbidity. I can imagine how costly it is for health systems to take care of the complications of meth use, from dental work to cardiovascular disease, i.e., heart failure. It is a serious problem in Bakersfield, California. As an interesting fact, meth is the most common drug identified in urine drug screenings, then follows marijuana, cocaine, heroin, and fentanyl.

 

Clinical manifestations  

When someone uses meth, they have increased energy and alertness, pupillary dilation, tachycardia, euphoria, decreased need for sleep, grinding teeth, dry mouth, loss of appetite, and other symptoms of sympathetic nervous system activation. 

 

Repeated use causes weight loss, dental decay, chronic adverse mood, and cognitive changes, including irritability, aggression, panic, suspiciousness, and/or paranoia, hallucinations, and memory impairment. 

 

Chronic use also can exacerbate depression and anxiety, and those changes can interfere tremendously in patient care. The risk of suicide is also higher.

 

It can also cause complications in other systems:

-Cardiovascular (cardiomyopathy, myocardial infarction, and stroke)

-Skin (abscesses, aged appearance, and skin lesions)

-Neurologic (confusion, memory loss, slowed learning)

-Oral (dental decay or “meth mouth”)

 

Acute intoxication

Complications of severe acute intoxication: hypovolemia, metabolic acidosis, hyperthermia, disseminated intravascular coagulation (DIC), rhabdomyolysis, tachydysrhythmia, hypertension, and seizures. 

 

Methamphetamine as a psychostimulant, has a half-life of 12 hours, so its effects last longer than those of cocaine. It is metabolized by the liver through the cytochrome P2D6 system. After the acute intoxication you can see the opposite: sedation, slurred speech, hypersomnia. 

 

Screening  

No specific guidelines regarding screening for methamphetamine use are available. 

 

In 2008, The U.S. Preventive Services Task Force concluded that evidence available at that time was insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. 

 

This guideline was updated in June 2020. The USPSTF now gives a grade of recommendation “B” to screening for unhealthy drug use. How do you screen? By asking questions about unhealthy drug use in all adults older than 18 years old. This recommendation does not include testing biological specimens. Screening should be implemented when diagnosis, effective treatment and care can be offered at your clinic or you can refer to other providers for treatment.

 

The American Academy of Pediatrics, the American Medical Association's Guidelines for Adolescent Preventive Services, and the Bright Futures initiative endorse screening adolescents for illicit substance use.

 

On the other hand, the USPSTF concluded in June 2020 that the current evidence is insufficient to recommend screening for unhealthy drug use in adolescents. So, it gives a grade of recommendation “I”. Remember, “I” does not mean “Do not screen”, “I” means “Insufficient or I don’t know”.

 

The American College of Obstetricians and Gynecologists recommends direct questioning of all patients about their use of drugs as part of periodic assessments. Screening for methamphetamine use by history should be considered for pregnant women, teenagers and young adults, persons with criminal histories, men who have sex with men, and persons in high-risk ethnic groups.

 

Diagnostic testing with informed consent can be useful in patients with stimulant-associated symptoms and signs, but this is not screening, this is a diagnostic test.

 

Diagnosis  

DSM-5 criteria — A problematic pattern of methamphetamine use leading to clinically significant impairment or distress, as manifested by two or more of the following within a 12-month period:

• Methamphetamine is often taken in larger amounts or over a longer period than was intended (patient wants more and more meth)

• There is a persistent desire or unsuccessful efforts to cut down or control methamphetamine use (patients want to quit but they can’t)

• A great deal of time is spent in activities necessary to obtain methamphetamine, use methamphetamine, or recover from its effects (patient spends a long time using meth and recovering)

• Craving, or a strong desire or urge to use methamphetamine (patient crave)

• Recurrent methamphetamine use resulting in a failure to fulfill major role obligations at work, school, or home

• Continued methamphetamine use despite having persistent or recurrent social problems caused or exacerbated by the effects of methamphetamine

• Important social, occupational, or recreational activities are given up or reduced because of methamphetamine use

• Recurrent methamphetamine use in situations in which it is physically hazardous

• Continued methamphetamine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by methamphetamine

 

Subtypes of severity of methamphetamine use disorder 

●Mild: Two to three symptoms

●Moderate: Four to five symptoms

●Severe: Six or more symptoms

 

Urine drug test

Methamphetamine can be detected in urine for approximately 48 hours after use. It can be detected in meconium in newborns,indicating maternal use in the second half of pregnancy. Pseudoephedrine can cause a false positive test result for amphetamines.The amphetamine portion of the "tox screen" is susceptible to both false positive and false negative results and must be interpreted in clinical context. 

 

Drugs of abuse, such as benzphetamine and bupropion (a synthetic cathinone), may give positive results. Medications such as selegiline and nonprescription nasal inhalers (decongestants) containing the active ingredient l-methamphetamine (l-desoxyephedrine) may yield positive results for amphetamine.

 

Phentermine can give a false positive result in Utox for meth or MDMA (ecstasy). If a patient states he/she is taking phentermine, you can order a confirmatory test, which will then show that it was phentermine and not amphetamine or methamphetamine. If you are taking phentermine for weight loss, you should stop taking it a week before the drug test.

 

Treatment of acute intoxication

The treatment of acute methamphetamine intoxication is largely supportive. 

-Activated charcoal (after oral ingestion) when there are severe symptoms of intoxication and absorption needs to be reduced

-Benzodiazepines may be indicated for seizures or agitation

-Antipsychotics may be needed for paranoia or psychosis. 

-Cooling measures may be required if there is hyperthermia. 

-If elevated blood pressure is dangerously high, it should be lowered, but there are no data regarding blood pressure goals or which medications to use. 

-Abuse of multiple substances is possible. Patients may have used a combination of marijuana, alcohol, and cocaine, for example.

 

You should also consider testing for several STIs in meth users since high risk sexual behaviors are possible.

 

Treatment of abuse

Outpatient behavioral therapies are the standard treatment for methamphetamine abuse and dependence. Inpatient treatment may be needed in some cases. 

-Cognitive behavior therapy and contingency management programs are successful in treating cocaine addiction and may be effective in treating methamphetamine addiction as well. 

-Contingency programs consists of rewarding patients who provide a drug-free urine sample.

-The Matrix Model is an individualized outpatient regimen that has been used successfully to treat patients who abuse stimulants. It is based on cognitive principles, incorporating individual, group, and family therapies, as well as drug testing and a 12-step program. 

 

Medications to treat meth abuse

There are no medications approved by the U.S. Food and Drug Administration to treat methamphetamine dependence.

 

Some studies on this topic include:

-A Cochrane review showed that fluoxetine (Prozac, 40 mg per day) may have modest benefit in reducing cravings for a short time but does not reduce use of meth, and that imipramine (Tofranil) may improve adherence to therapy in methamphetamine users. 

-One small RCT showing that bupropion (Wellbutrin) decreased subjective methamphetamine-induced effects and craving in a laboratory setting. 

-A randomized controlled trial enrolled 60 men who have sex with men; participants had methamphetamine use disorder and were actively using the drug. All the men received weekly counseling plus mirtazapine (Remeron), 30 mg per day, or placebo. Men in the mirtazapine group had decreased methamphetamine use and sexual risk, despite low adherence.

In Episode 47, Kafiya Arte mentioned the Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), which assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. 403 participants were enrolled. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  Results: 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. The response rate among participants that received naltrexone and bupropion was low, but it was higher than those who received placebo. 

Withdrawal

-Stimulant withdrawal is less dangerous than withdrawal from alcohol, opioids, or sedatives, but seizures are possible.

-Stimulant withdrawal symptoms include depression, somnolence, anxiety, irritability, inability to concentrate, psychomotor slowing, increased appetite, and paranoia. 

-There are no known effective treatments. 

-Methamphetamine withdrawal is associated with more severe and prolonged depression than is cocaine withdrawal, so patients with withdrawal should be monitored closely for suicidal ideation.

 

How is methamphetamine made?

Most methamphetamine used in the United States comes from small illegal laboratories in Mexico and within the US. It is unexpensive, potent, and highly pure. Pseudoephedrine is a common component used in the production of meth, along with many other dangerous ingredients. These chemicals can cause deadly lab explosions and house fires and they may remain in the air of the houses used as laboratories.  

 

Can you get high if you breath second-hand methamphetamine smoke?

Researchers have not proven that people who inhale secondhand methamphetamine smoke get high or have other health consequences but breathing these fumes can cause a positive urine test for methamphetamine. More research is needed in this field.

 

Methamphetamine use is a big problem. Prevention of use is key in fighting this devastating addiction. In patients who are addicted, treatment includes behavioral health strategies. No medications have been approved for treatment of dependence, but we hope new research finds an effective medication to treat it.

 

 

Conclusion: Now we conclude our episode number 66 “Meth Abuse.” This topic is very extensive, but Dr Nwosu presented a good summary. Meth will continue to be a significant problem as long as we do not find a cure for this devastating addiction. Remember to screen your patients for drug use by asking direct and simple questions, then offer the addiction services available in your area. Even without trying, every night you go to bed being a little wiser.

 

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ikenna Nwosu, and Bahar Hamidi. Audio edition: Suraj Amrutia. See you next week!

 

___________________________

 

 References: 

Ronald Strauss, Nesreen Jawhari, Amy H. Attaway, Bo Hu, Lara Jehi, Alex Milinovich, Victor E. Ortega, Joe G. Zein, Intranasal Corticosteroids Are Associated with Better Outcomes in Coronavirus Disease 2019, The Journal of Allergy and Clinical Immunology: In Practice, September 2021, ISSN 2213-2198, https://doi.org/10.1016/j.jaip.2021.08.007.

 

Winslow BT, Voorhees KI, Pehl KA. Methamphetamine abuse. Am Fam Physician. 2007 Oct 15;76(8):1169-74. PMID: 17990840. https://www.aafp.org/afp/2007/1015/p1169.html

 

Klega AE, Keehbauch JT. Stimulant and Designer Drug Use: Primary Care Management. Am Fam Physician. 2018 Jul 15;98(2):85-92. PMID: 30215997. https://www.aafp.org/afp/2018/0715/p85.html

 

Paulus, Martin, Methamphetamine use disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis, Up ToDate, last updated: July 20, 2021. https://www.uptodate.com/contents/methamphetamine-use-disorder-epidemiology-clinical-manifestations-course-assessment-and-diagnosis?search=methamphetamine%20use%20disorder&source=search_result&selectedTitle=2~128&usage_type=default&display_rank=2

 

Boyer, Edward W and Steven A Seifert, et. al, Methamphetamine: Acute intoxication, Up To Date, last updated: December 24, 2019. https://www.uptodate.com/contents/methamphetamine-acute-intoxication?search=Methamphetamine:%20Acute%20intoxication&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Methamphetamine, Drug Facts, National Institute on Drug Abuse (NIDA), accessed on July 28. 2021. https://www.drugabuse.gov/publications/drugfacts/methamphetamine.

 

 

Further episodes of Rio Bravo qWeek

Further podcasts by Rio Bravo Family Medicine Residency Program

Website of Rio Bravo Family Medicine Residency Program