Transcript Slide 1

Methamphetamine:
Review of The Problem
Igor Koutsenok, MD
Assistant Professor of Psychiatry
University of California San Diego
Associate Director,
Center for Criminality & Addiction Research, Training & Application
www.ccarta.ucsd.edu
What Is Methamphetamine?
•
Powerfully addictive stimulant that
dramatically affects the central
nervous system
•
Made easily in labs with OTC
ingredients
The active ingredient in making
methamphetamine is ephedrine or
pseudoephedrine, commonly found in over
the counter cold remedies.
Methamphetamine
CH2CH NH CH3
CH3
Ephedrine and Methamphetamine
Forms of Methamphetamine
Methamphetamine Powder
IDU Description: Beige/yellowy/off-white
powder
Base / Paste Methamphetamine
IDU Description: ‘Oily’, ‘gunky’, ‘gluggy’
gel,moist, waxy
Crystalline Methamphetamine
IDU Description: White/clear
crystals/rocks; ‘crushed glass’ / ‘rock
salt’
Speed
Methamphetamine powder ranging in color from white,
yellow, orange, pink, or brown.
Color variations are due to differences in chemicals
used to produce it and the expertise of the cooker.
Other names: shabu, crystal, crystal meth, crank, tina,
yaba
Ice
High purity
methamphetamine
crystals or coarse
powder ranging from
translucent to white
Methamphetamine Lab Seizures
A small percentage of labs are labeled “Super Labs” and
are capable of producing over 10 lbs per batch.
Super Labs are operated by Mexican National Drug
Trafficking Organizations (MNDTO’s), and supply the
majority of meth to the market.
Chemical Ingredients
Trichloroethane (Gun Scrubber)
Ether (Engine Starter)
Toluene (Brake Cleaner)
Methanol (Gasoline Additive)
Gasoline
Kerosene
Methamphetamines
A Brief History
1887
1919
1932
Amphetamine developed
Methamphetamine developed
Amphetamine &
methamphetamine used as
decongestant
Methamphetamines
A Brief History
WW II
Extensive use by:
- Fighter pilots
- German Panzer troops
- Japanese workers
- Kamikaze
Methamphetamines
A Post-War Epidemic
JAPAN
FACTORS
Large quantities
Social disorganization
“Work pills”
500,000 addicts
Methamphetamines
Epidemic in Sweden
SWEDEN
FACTORS
Large supply
3% are users
Preludin use
widespread
Mostly oral use
Methamphetamines
Factors Related to Epidemic
Over supply
Opportunity to experience
Widespread knowledge
A reliable market
No need for injections (in most
cases)
Many “speed labs”
Worldwide Trends of
Methamphetamine Use
WHO 2005 data estimates 42 million meth
users worldwide; 15M- heroin; 12M- cocaine
Areas of very heavy use: Thailand,
Philippines, Indonesia, SE Asia, Eastern
Europe, Russia, China
Areas of increasing use; Northern Mexico,
USA, Canada, South Africa, Europe
The Eastward Spread of
Methamphetamine Epidemic
Number of Admissions
Total Number of Primary
Methamphetamine Admissions:1998-2002
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
50% Increase
from 1998-2002
1998
1999
2000
2001
2002
SAMHSA, Treatment Episode Data Set: 1992-2002.
Methamphetamine: A Growing Problem
in Rural America
In 1998, rural areas
nationwide reported
949 methamphetamine
labs.
In 2003, 9,385 were
reported.
Source: El Paso Intelligence Center (EPIC),
U.S. DEA, 2005
Methamphetamine/Amphetamine Treatment
Admissions, by Route of Administration:
1992-2002
A Major Reason People
Take Methamphetamines
is
they Like
What It Does to Their
Brains
Dopamine Pathways
Serotonin Pathways
striatum
frontal
cortex
hippocampus
substantia
nigra/VTA
Functions
•reward (motivation) nucleus
•pleasure,euphoria
accumbens
•motor function
(fine tuning)
•compulsion
•perseveration
raphe
Functions
•mood
•memory
processing
•sleep
•cognition
Methamphetamine: Neurochemical
Mechanisms
Methamphetamine enters the brain through
dopamine transporters
Enters dopamine vesicles
Vesicles deplete themselves of dopamine
Free-floating DA produces “free radicals”
(neurotoxins).
The synapse is flooded with dopamine,
producing a profound sense of pleasure
Natural Rewards Elevate Dopamine Levels
FOOD
SEX
DA Concentration (% Baseline)
150
100
Empty
50
Box Feeding
200
150
100
15
10
5
0
0
0
60
120
Time (min)
180
Female 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
% of Basal DA Output
200
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
Accumbens
% of Basal Release
400
DA
DOPAC
HVA
0
1
2
3
4
250
20
0
100
0
5 hr
0
NICOTINE
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
250
% of Basal Release
200
COCAINE
DA
DOPAC
HVA
300
Time After Amphetamine
% of Basal Release
% of Basal Release
Effects of Drugs on Dopamine Levels
1
Accumbens
2
3
4
Time After Cocaine
5 hr
MORPHINE
Dose (mg/kg)
0.5
1.0
2.5
10
200
150
100
0
Source: Di Chiara and Imperato, 2004
0
1
2
3
4
Time After Morphine
5hr
Dopamine
Reward
Pathway
Activation
without drugs
Methamphetamine Addiction
The brains of people addicted to
methamphetamine are
different than those of nonaddicts
Axon
МАО
storage
Reuptake
Neurotransmitter
Synapse
Receptors
Dendrite
G-protein
Signal
Prolonged Drug
Use Changes the
Brain In
Fundamental and
Long-Lasting Ways
Dopamine Transporter Loss After Heavy
Methamphetamine Use
Comparison Subject
METH user
Partial Recovery of Brain Dopamine
Transporters in Methamphetamine Abuser
After Protracted Abstinence
Meth abuser
Normal control
(1 month detox)
Meth abuser
(24 month in recovery
Volkow, ND, Journal of Neurscience, 21, 2001
Methamphetamine
Cognitive
and
Memory Effects
Executive Systems Functioning
Deficits on executive tasks associated with:
– Poor judgment.
– Lack of insight.
– Poor strategy formation.
– Impulsivity.
– Reduced capacity to determine consequences
of actions.
Reasons for Meth Use
Reasons for using meth were wide-ranging:
– To get high (56%)
– To get more energy (37%)
– To cope with mood (34%)
– To lose weight/feel more attractive (29%)
– To party (28%)
– To escape (27%)
– To enhance sexual pleasure (18%)
Patterson and Semple (2003) Journal of Urban Health, 80: iii77-iii87
Meth and Women
Typical gender ratio of heroin users in
treatment : 3 men to 1 woman
Typical gender ratio of cocaine users in
treatment : 2 men to 1 woman
Typical gender ratio of methamphetamine
users in treatment : 1 man to 1 woman *
*among large clinical research populations
to
to
or
k
lo
se
w
t
r
ei
gh
be
tte
ur
s
female
*t
o
ra
te
n
ru
g
ho
er
d
m
or
e
th
sio
pr
es
en
t
er
gy
60%
en
t
nc
w
co
*t
o
de
an
o
ve
e
lie
en
ax
e
ak
e
pe
rim
ex
or
e
aw
re
l
ur
es
s
to
pr
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pe
ig
ca
th
es
ge
st
ay
er
tm
to
ge
la
c
re
re
p
*t
o
to
to
pe
to
to
Self-Reported Reasons for Starting
Methamphetamine Use
80%
70%
* p< .001
male
50%
40%
30%
20%
10%
0%
Methamphetamine and Sex
My sexual drive is increased by the
use of …
100
% Responding "Yes"
90
85.3
80
70.6
70
55.6
55.3
60
50
43.9
male
female
40
30
18.1 20.5
20
11.1
10
0
opiates
alcohol
cocaine
meth
Primary Drug of Abuse
(Rawson et al., 2002)
My sexual pleasure is enhanced by
the use of …
100
% Responding "Yes"
90
80
73.5
70
60
44.7
50
38.2
40
30
66.7
male
female
24.4
16.0 18.2
20
11.1
10
0
opiates
alcohol
cocaine
meth
Primary Drug of Abuse
(Rawson et al., 2002)
% Responding "Yes"
My sexual performance is improved
by the use of …
100
90
80
70
60
50
40
30
20
10
0
58.8 61.1
32.4
male
female
24.4
19.1
18.4
15.9
11.1
opiates
alcohol
cocaine
meth
(Rawson et al., 2002)
Primary Drug of Abuse
Methamphetamine
Incarceration
Primary Substance Reported
by California Inmates
(N=22,903)
6
Marijuana
11.5
Alcohol
15
Heroin
17.4
Other
21.5
Cocaine
28.8
Methamph.
0
5
10
15
20
25
Cartier J, Farabee D, Prendergast M. Journal of Interpersonal Violence. 2006;21:435-445.
30
Those who used MA (81.6%) were significantly
more likely than those who did not use MA
(53.9%) to have been returned to custody for
any reason or to report committing any violent
acts in the 30 days prior to follow-up (23.6% vs.
6.8%)
MA use is significantly predictive of violent crime
and general recidivism
Offenders who use MA may differ significantly
from their peers who do not use MA and may
require more intensive treatment interventions
and parole supervision than other types of drug
involved offenders
Cartier J, Farabee D, Prendergast M. Journal of Interpersonal Violence.
2006;21:435-445.
A history of physical or sexual violence
(controlling for gender) is significantly
related to meth use and a number of
negative treatment outcomes.
These results suggest the importance
of understanding client background
factors before they enter treatment.
CSAT Methamphetamine Treatment Project 2003
Drug Endangered Children in
California:
Methamphetamine Use and
Manufacture
Children are not small adults!
Different diet
Growing & developing rapidly
Higher metabolic & respiratory rate
Developing nervous system
Unusual habits (hand-to-mouth behaviors;
close to floor, contact with many surfaces, at
risk for all poisonings)
Biologic & developmental vulnerability
• Children who live in and
around the area of the meth
lab become exposed to the
drug and its toxic precursors
and byproducts.
• Nationally, over 20% of the
seized meth labs in 2002 had
children present.
• 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
In 2002, a total of 142 children were
present at lab seizures in Riverside and
San Bernardino Counties.
Most children reported as being present
during a seizure were school age.
Methamphetamine
Treatment
Treatment Effectiveness?
Common rumors re treatment of
clients with MA problems:
– MA users are untreatable
– Negligible recovery rates (5% to less than 1%
have been quoted in newspaper articles)
– The resulting conclusion is that spending
money on treating MA users is futile and
wasteful,
– No data exists that supports these statistics
Limitations on Current Treatments
Training of clinical personnel is essential to
successfully treat MA users.
Training alone is insufficient if the funding
necessary to deliver effective treatment is not
available.
Treatment funding that promote short duration or
non-intensive outpatient services are
inappropriate for providing adequate care for MA
users.
MA Treatment Issues
Acute MA Overdose
Acute MA Psychosis
MA “Withdrawal”
Initiating MA Abstinence
MA Relapse Prevention
Protracted Cognitive Impairment and
Symptoms of Paranoia
MA Acute Withdrawal
Depression
Paranoia
Fatigue
Cognitive Impairment
Anxiety
Agitation
Anergia
Confusion
Duration: 2 Days - 2 Weeks
Psychiatric Symptoms
Hallucinations are reported by one-third of MA
users.
Majority of MA users entered treatment in a state
of severe depression.
Many are suicidal at treatment admission
Intense paranoid ideation are very common in MA
users.
Medications
Currently, there are no medications that can
quickly and safely reverse life threatening
MA overdose.
There are no medications that can reliably
reduce paranoia and psychotic symptoms,
that contribute to episodes of dangerous
and violent behavior associated with MA
use.
Medication Research for
Methamphetamine Dependence
Negative Results
Imipramine
Desipramine
Tyrosine
Ondansetron
Fluoxetine
Unclear
Gabapentin
Modafinil
Topirimate
Disulfiram
Lobeline
Aripiprazole
Promising Evidence: Bupropion
Bupropion: An effective
pharmacotherapy?
Newton et al. 2005.
– Bupropion reduces craving and reinforcing
effects of methamphetamines
Elkashef (recently completed)
– Bupropion reduces methamphetamine use in
an outpatient trial, with particularly strong
effect with less severe users.
Special treatment consideration should be
made for the following groups :
Individuals under the age of 21
Female MA users (higher rates of depression; very
high rates of previous and present sexual and
physical abuse; responsibilities for children).
Injection MA users (very high rates of psychiatric
symptoms; severe withdrawal syndromes; high rates
of hepatitis).
MA users who take MA daily or in very high doses.
Homeless, chronically mentally ill and/or individuals
with high levels of psychiatric symptoms at
admission.
Gay men (at very high risk for HIV and hepatitis).
Treatments for Stimulant-use Disorders
with Empirical Support
Motivational Enhancement Strategies
Cognitive-Behavioral Therapy (CBT)
Community Reinforcement Approach
Contingency Management
12 Step Groups
Treatment of MA-Use Disorders
No medications currently are available with
evidence of efficacy
Two approaches - Contingency
Management and Cognitive Behavioral
Treatment have data to support efficacy
MA users appear to respond to other
treatment interventions in rates comparable
to other types of drug users.
MA users are responsive to treatment
Contingency Management
A technique employing the systematic delivery of
positive reinforcement for desired behaviors. In
the treatment of methamphetamine
dependence, vouchers or prizes can be “earned”
for submission of methamphetamine-free urine
samples.
Cognitive Behavioral Therapy and
Contingency Management
CM is an effective treatment for reducing
stimulant use and is superior during treatment to
a CBT approach alone.
CM is useful in engaging substance abusers,
retaining them in treatment, and helping them
achieve abstinence from stimulant use.
CBT also reduces drug use from baseline levels
and produces comparable outcomes on all
measures at follow-up.
Rawson, RA et al. Addiction, Jan 2006,
Roll, JM et al, Archives of General Psychiatry, (In Press)
Summary
Methamphetamine is a significant public
health problem in the US and in the world
It produces significant damage to the body
and the brain
Recovery from methamphetamine
dependence is possible and most brain
changes are reversible.
There are effective treatments for
methamphetamine dependence.
If you have more questions…
[email protected]
858/551 2946