methamphetamine effects and treatment options richard rawson, ph.d. ucla isap la jolla, ca. oct 2004
TRANSCRIPT
Methamphetamine Effects and Treatment Options
Richard Rawson, Ph.D.
UCLA ISAP
La Jolla, Ca. Oct 2004
Organ Toxicity from MA Abuse
• Central nervous system toxicity
• Cardiovascular toxicity• Pulmonary toxicity• Renal toxicity• Hepatic toxicity
CNS Toxicity from MA Abuse
• Acute psychosis• Chronic psychosis• Strokes• Seizures
Cardiovascular Toxicityfrom MA Abuse
• Arrhythmic sudden death
• Myocardial infarction• Cardiomyopathy
Pulmonary Toxicityfrom MA Abuse
• Acute pulmonary congestion
• Chronic obstructive lung disease
Renal / Hepatic Toxicity from MA Abuse
• Renal failure• Hepatic failure
Fetal Toxicity from MA Abuse
• Early effects: fetal death small for gestational
age• Late effects: learning disability poor social adjustment
Children• Children who live in and around the area of the
meth lab become exposed to the drug and its toxic precursors and byproducts.
• 80-90% of children found in homes where there are meth labs test positive for exposure to meth. Some are as young as 19 months old.
•
Children
• Children can test positive for methamphetamine by:– Having inhaled fumes during the manufacturing
process – Coming into direct contact with the drug– Through second-hand smoke.
Memory Difference between Stimulant and Comparison Groups
0
1
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7
Mea
n S
core
s
Word Recall** Picture Recall**
Stimulant (n=80) Comparison (n=80)
Differences between Stimulant and Comparison Groups on tests requiring perceptual speed
0
20
40
60
80
100
Mea
n S
core
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Digit Symbol** Trail Making A* Trail Making B**
Stimulant (n=80) Comparison (n=80
Summary
• Actively using MA addicts demonstrate impairments in:– the ability to manipulate information– the ability to make inferences – the ability to ignore irrelevant
information– the ability to learn – the ability to recall material
Longitudinal Memory Performance
test
num
ber
corr
ect
0
5
10
15
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25
rclw rclp wrec prec
controlbaseline3 mos6 mos
Summary (cont.)
• Some deficits are resolved after a period of 12-weeks of abstinence:
– The ability to ignore irrelevant information
– The ability to manipulate information
Summary (cont.)
• Some abilities get worse in the early periods of abstinence:
– Recall and recognition both show more impairment at 12 weeks of non-use
than is evident in current users
MethamphetamineAcute Physical Effects
- Increases -DecreasesHeart rate AppetiteBlood pressure SleepPupil size Reaction timeRespirationSensory acuityEnergy
MethamphetamineAcute Psychological Effects
• Increases
– Confidence – Alertness – Mood– Sex drive– Energy– Talkativeness
• Decreases – Boredom– Loneliness– Timidity
MethamphetamineChronic Physical Effects
- Tremor - Sweating- Weakness - Burned lips; sore
nose- Dry mouth - Oily
skin/complexion- Weight loss - Headaches- Cough - Diarrhea- Sinus infection - Anorexia
MethamphetamineChronic Psychological Effects
- Confusion - Irritability- Concentration - Paranoia- Hallucinations - Panic
reactions- Fatigue - Depression- Memory loss - Anger- Insomnia - Psychosis
MethamphetaminePsychiatric Consequences
• Paranoid reactions• Permanent memory loss• Depressive reactions• Hallucinations• Psychotic reactions• Panic disorders• Rapid addiction
Typical Day of MA Use
Amount -- 1 gramRoute -- Smoke
First Use -- “When I wake up”Other uses -- “Every few hours”Amount each use -- 1/5 gram
Typical Day of MA Use
Amount -- 3/4 gramRoute -- Shoot
First Use -- “When I get up”Other uses -- “Noon and Afternoon”
Amount each use -- 1/4 gram
MA Treatment Issues
• Acute MA Overdose• Acute MA Psychosis• MA “Withdrawal”• Initiating MA Abstinence• MA Relapse Prevention• Protracted Cognitive Impairment
and Symptoms of Paranoia
Acute MA Overdose
• Slowing of Cardiac Conduction• Ventricular Irritability• Hypertensive Episode• Hyperpyrexic Episode• CNS Seizures and Anoxia
Acute MA Psychosis
• Extreme Paranoid Ideation• Well Formed Delusions• Hypersensitivity to Environmental
Stimuli• Stereotyped Behavior “Tweaking”• Panic, Extreme Fearfulness• High Potential for Violence
Treatment of MA Psychosis
• Typical ER Protocol for MA Psychosis– Haloperidol - 5mg– Clonazepam - 1 mg– Cogentin - 1 mg– Quiet, Dimly Lit Room– Restraints
MA “Withdrawal”
- Depression - Paranoia- Fatigue - Cognitive
Impairment- Anxiety - Agitation- Anergia - Confusion
• Duration: 2 Days - 2 Weeks
Treatment of MA “Withdrawal”
• Hospitalization/Residential Supervision if:– Danger to Self or Others, or, so
Cognitively Impaired as to be Incapable of Safely Traveling to and from Clinic.
– Otherwise Intensive Outpatient Treatment
Treatment of MA “Withdrawal”
• Intensive Outpatient Treatment– No Pharmacotherapy Available– Positive, Reassuring Context– Directive, Behavioral Intervention– Educate Regarding Time Course of
Symptom Remission– Recommend Sleep and Nutrition– Low Stimulation– Acknowledge Paranoia, Depression
Initiating MA Abstinence• Key Clinical Issues
– Depression– Cognitive Impairment– Continuing Paranoia– Anhedonia– Behavioral/Functional Impairment– Hypersexuality– Conditioned Cues– Irritability/Violence
Initiating MA Abstinence• Key Elements of Treatment
– Structure– Information in Understandable
Form– Family Support– Positive Reinforcement– 12-Step Participation
• No Pharmacologic Agent Currently Available
Treatment of MA Disorders
• Traditional Treatments– Therapeutic Community– Minnesota Model– Outpatient Counseling– Psychotherapy
Treatment of MA Disorders• State of Empirical Evidence
– No Information on TC or “Minnesota Model” Approaches
– No Pharmacotherapy with Demonstrated Efficacy
– Results of Cocaine Treatment Research Extrapolated to MA Treatment
Behavioral/Cognitive Behavioral Treatments
• Cognitive/Behavioral Therapy-CBT
• Motivational Interviewing-MI
• Contingency Management-CM
• Community Reinforcement Approach-CRA
• Matrix Model of Outpatient Treatment
Cognitive Behavioral Therapy
• Based upon Social Learning Theory (Bandura and others)
• Also referred to as Relapse Prevention Therapy• Applied to treatment of alcoholism, cocaine
dependence, nicotine dependence and marijuana abuse.
Cognitive Behavioral Therapy
• Key Concepts– Encouraging and reinforcing behavior change – Recognizing and avoiding high risk settings– Behavioral planning (scheduling)– Coping skills– Conditioned “triggers”– Understanding and dealing with craving– Abstinence violation effect– Understanding basic psychopharmacology principles– Self-efficacy
Cognitive Behavioral Therapy
• Resources– Marlatt and Gordon 1985– NIDA CB Manual– NIAAA Project Match CB Manual – Gorski Publications– Washton Publications
Motivational Interviewing
• Based upon Prochaska and DiClemente Stages of Change Theoretical Model
• Also referred to as Motivational Enhancement Therapy
• Applied with many substances, data primarily with alcoholics
• Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH
Motivational Interviewing
• Basic Assumptions– People change their thinking and behavior according to
a series of stages– Individuals may enter treatment at different “stages of
change”– It is possible to influence the natural change process
with MI techniques– MI can be used to engage individuals in longer term
treatment and to promote specific behavior changes– Confrontation of “denial” can be counterproductive and
or harmful to some individuals
Motivational Interviewing
• Key Concepts– Empathy and therapeutic alliance– Give feedback and reframe – Create dissonance– Focus of discrepancy of expected and actual– Reinforce change– Roll with resistance
Motivational Interviewing
• Resources– Miller and Rollnick 1991– NIAAA Project MATCH manual– CSAT TIP on Motivational Techniques– NIDA Tool Box
Community Reinforcement Approach
• Basic assumptions– Drug and alcohol use are positively reinforced
behaviors. They can be reduced/eliminated by proper application of behavioral techniques.
– To successfully build an effective intervention, some techniques should focus on reducing drug and alcohol use and others should focus on acquisition of new incompatible behaviors
Community Reinforcement Approach
• Key concepts– Behavioral analysis and teach conditioning information.– Positive reinforcement with vouchers for drug free urine
samples– Behavioral marriage counseling– Shape and reinforce new behavioral repetiore.– Coping skill/Drug refusal skill training– Vocational Counseling– Frequent urine testing
Community Reinforcement Approach
• Resources– Meyers and Smith 1995– NIDA CRA Manual– Higgins and Silverman 2000
Contingency Management
• Basic Assumptions– Drug and alcohol use behavior can be controlled using
operant reinforcement procedures– Vouchers can be used as proxy’s for money or goods– Vouchers should be redeemed for items incompatible
with drug use– Escalating the value of the voucher for consecutive
weeks of abstinence promotes better performance– Counseling/therapy may or may not be required in
conjunction with CM procedure
Contingency Management
• Key concepts– Behavior to be modified must be objectively measured
– Behavior to be modified (eg urine test results) must be monitored frequently
– Reinforcement must be immediate
– Penalties for unsuccessful behavior (eg positive Ua) can reduce voucher amount
– Vouchers may be applied to a wide range of prosocial alternative behaviors
Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program
Relapse Prevention Family and Group Therapy
Motivational Interviewing
12- Step Involvement
Psychoeducation Social Support
Matrix Model ofOutpatient Treatment
Organizing Principles of Matrix Treatment
•Create explicit structure and expectations
•Establish positive, collaborative relationship with patient
•Teach information and cognitive-behavioral concepts
•Positively reinforce positive behavior change
Matrix Model ofOutpatient Treatment
Organizing Principles of Matrix Treatment(cont.)
•Provide corrective feedback when necessary
•Educate family regarding stimulant abuse recovery
•Introduce and encourage self-help participation
•Use urinalysis to monitor drug use
Elements of the Matrix Model
• Engagement/Retention• Structure• Information• Relapse Prevention• Family Involvement• Self Help Involvement• Urinalysis/Breath
Testing
The Matrix Model
Monday Wednesday Friday
Early Recovery Skills
Weeks1-4
Family/education
Weeks 1-12
Early Recovery Skills
Weeks1-4
Relapse Prevention
Weeks 1-16
Social Support
Weeks 13-16
Relapse Prevention
Weeks 1-16
Urine or breath alcohol tests once per week, weeks 1-16