Evidence-Based Reviews

‘Meth’ recovery: 3 steps to successful chronic management

Current Psychiatry. 2007 July;6(7):29-40

‘Moving the frontal lobe back to the front’ allows for improved executive functioning, decreased impulsivity, and increased motivation to remain drug-free

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References

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Clinicians could become discouraged when confronting methamphetamine-dependent patients’ wide-ranging psychiatric symptoms.

These patients often present with:

overlapping primary psychiatric syndromes and secondary substance abuse
complex histories fraught with psychological trauma, limited social supports, and court involvement.

Treatment can be successful, however, and patients can change their addictive behaviors with a chronic disease management approach that targets the drug’s cognitive sequelae and psychiatric effects. Medications show limited benefit (Box 1),^1-8 but behavioral treatments—including cognitive behavioral therapy (CBT) and motivational incentives—have proven efficacy in treating methamphetamine addiction.

This article discusses how to counteract methamphetamine’s negative cognitive effects and enable patients to engage in psychosocial treatment. Our discussion is informed by an extensive literature search and clinical experience from treating patients in the Midwest—at the geographic heart of the “meth” epidemic.

CASE REPORT: Overwhelmed and suicidal

Ms. D, age 27, presents to the emergency department with anxiety, dysphoria, and a plan to commit suicide by overdose. She feels overwhelmed by her 4-hour-a-day customer service job—a prerequisite for staying at the halfway house where she has lived for 2 months. She has a 13-year history of polysubstance dependence and is under court order to complete chemical dependence treatment or go to jail.

Box 1

Medications for ‘meth’ dependence? Little empiric support

No medications are FDA-approved for treating methamphetamine dependence, and evidence supporting medication use in methamphetamine dependence is extremely limited. Research efforts are aimed at finding medications that might be neuroprotective, decrease craving, block reinforcement mechanisms, or affect other factors behind methamphetamine addiction and relapse.¹ Most trials have been conducted in animal models or controlled laboratory evaluations of drug effects on methamphetamine-induced states.

Bupropion has shown slight treatment efficacy, possibly by decreasing neuronal damage and blocking reinforcement.^2-4 Modafinil⁵ and baclofen⁶ may have potential, but evidence is lacking.

Some results have been unexpectedly negative. Sertraline might be contraindicated in methamphetamine dependence treatment, according to results of a randomized, placebo-controlled trial⁷ of sertraline and contingency management (Table 1). In a human laboratory study,⁸ topiramate accentuated—rather than diminished—subjective response to methamphetamine (Table 2).

Methamphetamine has been Ms. D’s primary drug of abuse for 5 years, with some intervals of treatment and sobriety. She has not used methamphetamine in 3 months, after a severe relapse when she used methamphetamine daily for 6 months.

Ms. D began using drugs at age 14 and has 3 convictions for driving under the influence of alcohol. An average student, she dropped out of high school but obtained a GED certificate. She first had psychiatric contact at age 16 and has been diagnosed at various times with attention deficit/hyperactivity disorder, bipolar disorder, and anxiety disorder. She also has been violently sexually assaulted while engaging in prostitution to support her drug habit.

Ms. D has been hospitalized multiple times—voluntarily and involuntarily—in dual diagnosis treatment centers. Her 5-year-old son no longer lives with her, and she has limited social supports beyond her parents, who live in a neighboring state.

Table 1

Antidepressant trials for treating methamphetamine dependence

Drug	Investigation	Comments
Bupropion^2-4	Laboratory	Safety of bupropion with MAP
	Laboratory	Reduced subjective effects and cue-induced craving
	Clinical trial	Trend toward reduced MAP use compared with placebo
Sertraline⁷	Clinical trial	Sertraline-treated subjects showed higher use of MAP compared with those receiving placebo and were less likely to complete treatment
MAP: methamphetamine

3-step approach

For patients such as Ms. D, clinical evidence supports a 3-step approach to treating methamphetamine dependence:

step 1: institute acute management and stabilization
step 2: eliminate or decrease methamphetamine use to “move the frontal lobe back to the front”
step 3: identify and target psychiatric and psychosocial comorbidities.

Clinical Point

Improved executive functioning (a frontal lobe task) becomes possible as the brain recovers from methamphetamine’s effects

We discussed step 1 and the methamphetamine epidemic in the November 2006 Current Psychiatry.⁹ For Ms. D, step 1 means inpatient psychiatric care to protect her from suicidal intent and manage dysphoria and anxiety. In step 2, we aim to:

help her eliminate or decrease methamphetamine use to allow neuronal systems to recover
target maladaptive behaviors that hinder sobriety while providing motivational incentives to help her maintain a methamphetamine-free life.

Improved executive functioning, a frontal lobe task, becomes possible as the brain recovers from methamphetamine’s effects. Patients then are able to use healthier coping strategies to live drug-free. We call this step “moving the frontal lobe back to the front” because its goal is to restore the normal relationship between the frontal lobe and limbic system.

How ‘meth’ affects cognition

Methamphetamine use has been associated with cognitive dysfunction at initial abstinence and even years later in some patients.¹⁰ Ms. D’s cognitive limitations in a fast-paced customer service job—even though hours are limited—lead to anxiety, dysphoria, and loss of self-esteem when she can’t manage patrons’ requests.