2. Methamphetamine Effects and Treatment Options Richard Rawson, Ph.D. UCLA ISAP La Jolla, Ca. Oct 2004

3. Organ Toxicity from MA Abuse Central nervous system toxicity Cardiovascular toxicity Pulmonary toxicity Renal toxicity Hepatic toxicity

4. CNS Toxicity from MA Abuse Acute psychosis Chronic psychosis Strokes Seizures

5. Cardiovascular Toxicity from MA Abuse Arrhythmic sudden death Myocardial infarction Cardiomyopathy

6. Pulmonary Toxicity from MA Abuse Acute pulmonary congestion Chronic obstructive lung disease

7. Renal / Hepatic Toxicity from MA Abuse Renal failure Hepatic failure

8. Fetal Toxicity from MA Abuse Early effects: fetal death small for gestational age Late effects: learning disability poor social adjustment

9. 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.

10. 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.

12. Memory Difference between Stimulant and Comparison Groups

13. Differences between Stimulant and Comparison Groups on tests requiring perceptual speed

14. 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

15. Longitudinal Memory Performance test number correct

16. 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

17. 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

18. Methamphetamine Acute Physical Effects - Increases -Decreases Heart rate Appetite Blood pressure Sleep Pupil size Reaction time Respiration Sensory acuity Energy

19. Methamphetamine Acute Psychological Effects Increases – Confidence – Alertness – Mood – Sex drive – Energy – Talkativeness Decreases – Boredom – Loneliness – Timidity

21. Methamphetamine Chronic Physical Effects -Tremor - Sweating - Weakness - Burned lips; sore nose - Dry mouth - Oily skin/complexion - Weight loss - Headaches - Cough - Diarrhea - Sinus infection - Anorexia

22. Methamphetamine Chronic Psychological Effects - Confusion - Irritability - Concentration - Paranoia - Hallucinations - Panic reactions - Fatigue - Depression - Memory loss - Anger - Insomnia - Psychosis

23. Methamphetamine Psychiatric Consequences Paranoid reactions Permanent memory loss Depressive reactions Hallucinations Psychotic reactions Panic disorders Rapid addiction

24. Typical Day of MA Use Amount -- 1 gram Route -- Smoke First Use -- “When I wake up” Other uses -- “Every few hours” Amount each use -- 1/5 gram

25. Typical Day of MA Use Amount -- 3/4 gram Route -- Shoot First Use -- “When I get up” Other uses -- “Noon and Afternoon” Amount each use -- 1/4 gram

26. MA Treatment Issues Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

27. Acute MA Overdose Slowing of Cardiac Conduction Ventricular Irritability Hypertensive Episode Hyperpyrexic Episode CNS Seizures and Anoxia

28. Acute MA Psychosis Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

29. Treatment of MA Psychosis Typical ER Protocol for MA Psychosis – Haloperidol - 5mg – Clonazepam - 1 mg – Cogentin - 1 mg – Quiet, Dimly Lit Room – Restraints

30. MA “Withdrawal” - Depression- Paranoia - Fatigue- Cognitive Impairment - Anxiety- Agitation - Anergia- Confusion Duration: 2 Days - 2 Weeks

31. 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

32. 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

33. Initiating MA Abstinence Key Clinical Issues – Depression – Cognitive Impairment – Continuing Paranoia – Anhedonia – Behavioral/Functional Impairment – Hypersexuality – Conditioned Cues – Irritability/Violence

34. Initiating MA Abstinence Key Elements of Treatment – Structure – Information in Understandable Form – Family Support – Positive Reinforcement – 12-Step Participation No Pharmacologic Agent Currently Available

35. Treatment of MA Disorders Traditional Treatments – Therapeutic Community – Minnesota Model – Outpatient Counseling – Psychotherapy

36. 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

38. Behavioral/Cognitive Behavioral Treatments Cognitive/Behavioral Therapy-CBT Motivational Interviewing-MI Contingency Management-CM Community Reinforcement Approach-CRA Matrix Model of Outpatient Treatment

39. 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.

40. 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

41. Cognitive Behavioral Therapy Resources –Marlatt and Gordon 1985 –NIDA CB Manual –NIAAA Project Match CB Manual –Gorski Publications –Washton Publications

42. 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

43. 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

44. 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

45. Motivational Interviewing Resources –Miller and Rollnick 1991 –NIAAA Project MATCH manual –CSAT TIP on Motivational Techniques –NIDA Tool Box

46. 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

47. 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

48. Community Reinforcement Approach Resources –Meyers and Smith 1995 –NIDA CRA Manual –Higgins and Silverman 2000

49. 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

50. 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

51. Matrix Model An Integrated, Empirically-based, Manualized Treatment Program

52. Matrix Model of Outpatient 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

53. Matrix Model of Outpatient 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

54. Elements of the Matrix Model Engagement/Retention Structure Information Relapse Prevention Family Involvement Self Help Involvement Urinalysis/Breath Testing

55. The Matrix Model MondayWednesdayFriday 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