Multiple studies show that CBT and CM are equally effective for treating chronic methamphetamine abuse at a 1-year follow-up, although CM may be more effective than CBT for acute treatment.
The Matrix model is a 4-month intensive, manualized treatment program that uses CBT, education on drug effects, positive reinforcement for intended behavioral change, and a 12-step approach.
Methamphetamine dependence outcomes based on the Matrix treatment model were compared with community treatment as usual in a project sponsored by The Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.30 End-point outcomes were similar, but the Matrix treatment was more effective in early treatment, including decreased urinalyses positive for methamphetamine and increased abstinence.
Methamphetamine abuse increases risk of HIV infection
Recommendations. Select a psychosocial treatment approach with your patient’s strengths, social setting, and community resources in mind. Twelve-step approaches may play an important role.Methamphetamine use is estimated to be 5 to 10 times more prevalent in U.S. urban gay and bisexual groups than in the general population25 and likely is contributing to rising human immunodeficiency virus (HIV) infection rates in men having sex with men (MSM).
Used to enhance sexual performance, libido, and mood, methamphetamine is associated with increased rates of unprotected anal sex and multiple partners in MSM.26 An HIV infection rate of 61% was reported in methamphetamine-dependent MSM seeking treatment in a Los Angeles clinical trial.27 Methamphetamine also results in high-risk sexual practices and multiple partners among heterosexual men and women.28
Although seroconverted men report using methamphetamine to alleviate HIV-associated depression, the combination of HIV infection and methamphetamine use may have powerful negative effects. Methamphetamine use is associated with HIV treatment nonadherence and also may suppress immune function.29 Cognitive impairments associated with HIV and methamphetamine use are additive and are further exacerbated by hepatitis C infection.18
Recommendation. Screen for methamphetamine use in MSM populations, and educate these patients about risks associated with methamphetamine use. In all patient groups who report using methamphetamine, provide counseling on high-risk sexual behavior, screen for sexually transmitted diseases, and ensure that patients are vaccinated against hepatitis A and B infection (see Related Resources). Most important, refer for medical treatment when indicated.
In patients such as Ms. D, the structure of court-ordered treatment can provide accountability, enforced abstinence, and mandated treatment resources. This, in turn, may give your patient a better chance to engage a recovering and better functioning frontal lobe to inhibit urges for methamphetamine use and manage stress.
Table 2
Other agents studied in methamphetamine dependence trials
| Drug | Investigation | Comment |
|---|---|---|
| Baclofen6 (GABAergic) | Clinical trial | No statistically significant effect compared with placebo; post hoc analysis showed ‘small’ treatment effects vs placebo |
| Gabapentin6 (GABAergic) | Clinical trial | No statistically signicant effect compared with placebo; post hoc analysis showed no treatment effects vs placebo |
| Topiramate8 (anticonvulsant) | Laboratory | Accentuated (rather than diminished) subjective effects of MAP |
| Aripiprazole19 (SGA) | Laboratory | Decreased subjective effects of amphetamine |
| Modafinil5 (wakefulness agent) | Clinical trial | Successful trial in cocaine dependence; potential option for MAP |
| MAP: methamphetamine; SGA: second-generation antipsychotic | ||
CASE CONTINUED: Racing thoughts and psychosis
Before hospital admission, Ms. D was being treated with gabapentin, 300 mg bid, and sustained-release bupropion, 150 mg/d, for anxiety and dysphoria. Previously, she has received multiple antidepressants and mood stabilizers with reportedly little effect.
Initially guarded, she at first denies psychotic symptoms but acknowledges their extent several days later. She describes periods of 6 months or more when she feels “lost.” The treatment team titrates quetiapine up to 200 mg/d and restarts duloxetine, 30 mg/d, for depressive symptoms, based on her past positive response to this antidepressant.
2 priorities in managing psychiatric symptoms of ‘meth’ abuse
Methamphetamine abuse can cause and exacerbate psychiatric symptoms. Keep in mind 2 priorities as you approach these symptoms:
Aim for abstinence. Methamphetamine abuse produces a remarkable array of adverse effects. It causes dysphoria, anxiety, and psychosis during active use and in the interval after initial abstinence. Many of methamphetamine’s use and withdrawal symptoms resolve with time, however, and may not require pharmacologic treatment.31 Therefore, achieving abstinence and keeping patients in treatment is high priority.
Use behavioral approaches whenever feasible. Balance the need to use benzodiazepines for ongoing treatment of severe anxiety or agitation with the high risk of addiction or diversion in this group. Anxiety may resolve over time in association with sustained abstinence. Similarly, receiving treatment for methamphetamine dependence and maintaining abstinence appears to ease depressive symptoms, as shown by sustained improvements in Beck Depression Inventory scores at 1 year.32
Manage stress. Stress can worsen psychiatric symptoms, trigger methamphetamine abuse relapse and psychosis, and acutely and chronically augment methamphetamine’s toxic effects.33 You can help patients manage stress by:
- providing case management and CBT training
- advising them about proper sleep, nutrition, and medical care.