methamphetamine use disorder (+ hiv): trials, trends and

Methamphetamineusedisorder(+HIV):Trials,TrendsandTribulations

WHAT-IF?LearningCollaborativeSeptember11,2019

PaxtonBachMD,MSc,ABIM,FRCPCClinicalAssistantProfessorUBCDepartmentofMedicineVancouver,Canada

•  Background•  Physiologyandhealtheffects•  Epidemiology•  Treatment

Outline

•  HigherratesofmethuseinpopulationsatriskforHIV–  Upto20%ofMSMmayreportmethusewithinpast6mo1

•  MethuseisassociatedwithanincreasedriskofcontractingHIV–  Higherratesofriskybehaviours(highriskinjectionand/orsexualpractices)2

–  Impaired/alteredimmunity?3

•  MethuseisassociatedwithworseHIVoutcomes–  DecreasedARTadherence,slowerratesofRNAsuppression,decreasedCD4counts,pooroverallhealthoutcomes3,4

1Shoptawetal.Addiction,2007.2Degenhardtetal.IntJDrugPolicy,2009.3Passaroetal.JNeuroimmunePharmacol,2015.4Fairbairnetal.AddictBehav,2011.

Whythefuss?

HIVprevalenceamongMSMwhoprimarilyinjectedmethwasalmost50%higherthanamongMSMwhoprimarilyinjectedotherdrugs,andthisassociationwasmediatedbysexualrisk.

Background

Ephedrasinica

Methamphetaminepowder-  POorinsufflated

Methamphetaminebase-POorinjected

Crystalmethamphetamine-Smoked,insufflatedorinjected

Ice,crystal,glass,speed,meth,jib,side,gak,chalk,crank,tina,go,geek,tweak,amp,P2P,zip,shards,goofball*

Half-lifeforall3closeto~10hours!

Methamphetamine

Narcolepsy,exhaustion,weight loss,schizophrenia,asthma,morphineaddiction,barbiturate intoxication, alcoholism, excessive anaesthesia administration,migraine, heart block, myasthenia gravis, myotonia, enuresis, dysmenorrhea,Meniere’sdisease,colic,headinjuries,infantilecerebralpalsy,codeineaddiction,tobaccosmoking,pediatricbehaviourissues,Parkinson’sdisease,epilepsy…

Physiologyandeffects

Pharmacology

•  Mania/paranoia/psychosis•  Hypertension,agitation,sweating•  Skin-picking/formication(delusionsofinsectsundertheskin)

•  Abnormalmovement(choreoathetosis,ataxia)

•  Miosis

Acuteintoxication

*Societalharms:environmentalhazards/pollution,crime,violence.

Cardiac Infectious Hematologic Gastrointestinal

Chestpain HIV Necrotizingangiitis Acuteliverinjury

CAD Viralhepatitis Mesentericinfarction

Myocardialinfarction MSK Ischemiccolitis

Tachycardia Neurologic “Methmouth” Pancreatitis

Hypertension ICH Rhabdomyolysis

Dysrhythmias Ischemicstroke Traumas Pulmonary

DilatedCMO Seizure Osteomyelitis Pulmonaryedema

Aorticdissection Cognitiveimpairment Pulmonaryhypertension

Infectiveendocarditis Obstetrical

Dermatologic Fetalgrowthrestriction Renal

Genitourinary Picking/excoriations Prematuredelivery Myoglobulinuria

STIs Cellulitis Abruption Necrotizingangiitis

Abscesses

AdaptedfromVearrieretal.DisMon,2012.

Meth-associatedhealthcomplications

Volkowetal.AmJPsychiatry,2001.

Neurotoxicity(dopamineneurons)

Epidemiology

UNODCWorldDrugReport,2019.

SAMHSANationalSurveyonDrugUseandHealth,2016.

USNationalSurveyonDruguseandHealth:PrevalenceofIllicitDrugUse

DEANationalClandestineLaboratoryRegistry,2004-2012.

MethamphetamineLabDistributionintheUS

UNODCWorldDrugReport,2019.

Psychostimulant-relatedoverdosedeathsinUS,1999-2017

Treatment

StimulantUseDisorderTreatment

Pharmacologic

Anti-Depressants

Anti-Psychotics

AgonistTherapies

Non-pharmacologic

CBT(+/-MI)

ContingencyManagement

ModafinilMethylphenidate

DextroamphetamineBupropion

AripiprazoleRisperidone

SSRIsMirtazapine

Others:gabapentin,baclofen,vigabatrin,topiramate,ondansetron,naltrexone,ibudilast…

StudyDrug EffectPsychostimulants(dexamphetamine,methylphenidate)

9RCTs:maydecreaseuse,craving,and/orseverityofaddiction?

Topiramate 2RCTs:maydecreaseuse,and/orseverity?

Mirtazapine 1RCT:maydecreaseuse?Bupropion 5RCTs:maydecreaseuse?Naltrexone 2RCTs:maydecreaseuseand/or

craving?Modafinil 3RCTs:maydecreaseuse?

AdaptedfromLeeetal.,DrugAlcDep.2018.

*Studieslimitedbyretention,adherence,primaryoutcomes.

Trialmedications

TreatmentofStimulantUseDisorder:PsychosocialTreatments

1.  Contingencymanagement2.  Cognitivebehavioural

therapy3.  Motivationalinterviewing4.  Relapseprevention5.  Psychodynamictherapy6.  Combinationsprograms

•  Overallsmalltomoderateeffects(dropoutratesaretypically>40%)

•  Immediateeffectsnoted,long-termbenefitsformethusedisordernotclear

TreatmentofStimulantUseDisorder:PsychosocialTreatmentsContingencyManagement

•  Goalistoreducereinforcementprovidedbydrugusewhilesimultaneouslyincreasingreinforcementforhealthieractivities

•  Appliescontingenciesintheformofreinforcementandconsequencesinordertoreducesubstanceuse

•  Oftenusesavoucher-basedsystemtogivepossiblerewardsforstayingintreatmentorremainingdrug-free

•  A2016systematicreviewfoundthatcontingencymanagementhelpedtodecreaseuseinadiversegroupofsubstanceusedisorders,withatreatmenteffectthatweakenedbutdidnotdisappearfollowingtreatmenttermination1 1Davisetal.PrevMed,2016.

ClinicalresponsestoCMinPROPweresimilartoCMdeliveredindrugtreatmentprograms.[…]FurtherexpansionofprogramslikePROPcouldaddresstheincreasingneedsforacceptable,feasible,andcost-

effectivemethamphetaminetreatmentinthisgroupwithexceptionallyhighratesofHIV-infection.

Conclusions•  Theprevalenceofmethamphetamineusecontinuestoriseanditisassociatedwithnumerousphysical,psychiatric,andsocialharms

•  MethamphetamineuseisassociatedwithanincreasedriskofcontractingHIVandworseHIVtreatmentoutcomes

•  Evidence-basedtreatmentsareavailableforstimulantusedisorder,psychosocialapproaches(esp.CM)remainthegoldstandardandcanbeimplementedinsettingswithhighratesofHIV

Questions?

paxton.bach@bccsu.ubc.ca