Step 3 in the chronic disease management approach to methamphetamine dependence is to identify and target psychiatric and psychosocial comorbidities. When approaching psychiatric symptoms, high priorities are to aim for abstinence and manage the patient’s stress (Box 3).31-33
Clinical Point
Some patients may need low-dose antipsychotics as maintenance treatment to manage residual post-acute psychotic symptoms
Psychotic symptoms may present acutely, continue as residual symptoms, or reappear at stressful times long after an individual no longer abuses methamphetamine. Acute psychotic symptom intensity appears to be methamphetamine dose-related.34
In clinical practice, we find it difficult to diagnostically categorize and treat methamphetamine-abusing patients who show residual post-acute psychotic symptoms. Some appear to have no risk factors for primary psychotic illness, and their symptoms show an association with the severity of their past methamphetamine abuse.
Other patient presentations can be difficult to separate from family histories of psychotic illness. Research suggests that genetic risk factors may be associated with methamphetamine psychosis in some vulnerable patients.35
Unfortunately, no data exist to guide the use of antipsychotics to maintain symptom control. Some patients may need low-dose antipsychotics for maintenance treatment, and second-generation antipsychotics may have a theoretical advantage over first-generation antipsychotics. Use your clinical judgment in determining dosing and treatment duration, and in weighing risks and benefits of continued treatment.
Clinical Point
Abstinent ‘meth’ abusers show long-standing elevated baseline aggression, compared with controls
Residual violent behavior. Violence, aggression, and poor impulse control are synonymous with methamphetamine abuse and have devastating individual, societal, and public health effects. Even abstinent methamphetamine abusers show long-standing elevated baseline aggression, compared with controls.
Using imaging, researchers found aggression severity to be directly correlated with past total methamphetamine use and globally decreased serotonin transporter density.36 Serotonin transporter densities were 30% lower in methamphetamine users vs controls after >1 year of abstinence.
CASE CONTINUED: Discharge plans
Because of the severity of her psychiatric symptoms, Ms. D is unable to return to the halfway house after discharge. As her treatment team works to coordinate discharge placement, Ms. D continues to improve. Her psychotic and dysphoria symptoms resolve, and she shows increased spontaneity. These changes—attributed to supports during hospitalization, decreased stressors, and quetiapine treatment—continue until her discharge to a combined mental illness and chemical dependence program.
Clinical Point
Many ‘meth’ abuse and withdrawal symptoms resolve with time and may not require pharmacologic treatment
Ms. D’s report of “racing thoughts” is clarified; rather than mania, they represent recurrent thoughts and ruminations about past sexual abuse. Her psychotic symptoms resolve quickly with quetiapine, but she struggles with morning sedation. The team reduces the dosage, and she tolerates quetiapine, 25 mg hs, with trazodone, 100 mg hs, for sleep, anxiety, and psychotic symptoms. She is discharged on this regimen plus duloxetine, 60 mg/d, with plans to continue psychosocial treatment for methamphetamine dependence and posttraumatic stress.
National Institute on Drug Abuse Blending Initiative. Promoting Awareness of Motivational Incentives (PAMI). www.drugabuse.gov/blending/PAMI.html.
Drug brand names
Aripiprazole • Abilify
Baclofen • various
Bupropion • Wellbutrin
Duloxetine • Cymbalta
Gabapentin • Neurontin
Modafinil • Provigil
Quetiapine • Seroquel
Sertraline • Zoloft
Topiramate • Topamax
Trazodone • Desyrel
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
