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