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Methamphetamine: Implications for the Dental Team

Course Number: 332

Rehabilitation Programs

As a percentage of all drug abuse treatment admissions since 2002, meth admissions peaked in 2005 at 9.1%. There has been a steady decline in admissions to a low of 5.8% in 2011.33 A SAMHSA report states the meth recovery is about 5% and the life expectancy of an addict is 7 years.22 Although meth abuse has been an issue for more than 70 years, it is only recently that treatment approaches have been investigated and are therefore in the early stages of development and evaluation. Most are borrowed from successful cocaine dependence therapy programs.44 Effective treatment of methamphetamine-dependent patients poses many challenges, some of which are unique. For instance, poor treatment engagement and high treatment dropout rates, severe or ongoing paranoia or psychotic symptoms, high relapse rates, and intense protracted cravings, dysphoria (unease or dissatisfaction with life), and anhedonia (inability to feel pleasure) are among the commonly cited obstacles to success.44 Many of the challenges of meth addiction treatment stem from the effects of the drug itself. Meth abuse results in cognitive impairment such as deficits in attention, impulse control and task performance. These deficits make it difficult or impossible for the abuser to benefit from programs that focus on motivations for abstinence, strategies for avoiding drug use or promoting relapse prevention as these require the patient to attend sessions, comprehend information and remember skills presented.44 In addition, determining the most effective treatment components is further complicated by the special needs of methamphetamine-using subgroups such as women and gay or bisexual men.44 Special needs of female meth addicts include high frequency of personal and social disadvantage, psychiatric illness, and a history of sexual and/or physical abuse. Failure to address these issues and related disorders (for instance, post-traumatic stress from sexual abuse) may contribute to resumption of meth use. For gay or bisexual men, meth use is deeply intertwined with sexual and social behavior and rates of abuse can be as high as 20 times the general population.44 Meth use is known to increase the frequency and duration of sexual encounters and result in the abandonment of safe sex practices. Group treatment sessions that cover such topics as sexual risk reduction, sexual behavior and recognizing meth use in sexual partners yet include heterosexual men could increase the likelihood of poor treatment engagement and early dropout for both groups.

The recommended treatment for methamphetamine abuse is cognitive-behavioral intervention in an intensive outpatient setting.5 This type of treatment teaches clients to recognize the conditioned cues that lead to methamphetamine use and the subsequent cravings produced. Once clients understand and identify their personal cues, they may use the following strategies to avoid meth use: extensive relapse-prevention activities, participation in 12-step programs, urine testing, individual therapy, family therapy and social support groups. The typical treatment protocol lasts 8-16 weeks, and uses a chronic illness model, where monitoring and management is provided for long periods of time, perhaps a lifetime. Shorter treatment intervals show less positive outcomes. Longer treatment times are more successful.12

A cognitive-behavioral intervention program, The Matrix Model, was developed by Richard Rawson, a leading expert on meth addiction. It is specifically designed for those addicted to stimulants such as meth. The Matrix Model is a 16-week comprehensive behavioral treatment approach that combines behavioral therapy, family education, individual counseling, 12-step support, drug testing and encouragement for non-drug-related activities.30 Methamphetamine recovery support groups also appear to be effective adjuncts to behavioral interventions that can lead to long-term, drug-free recovery.13

Adding Contingency Management – using behavioral principles to reinforce the occurrence of the targeted behavior – is effective in rates of abstinence, completion of recovery-related activities and treatment completion.43 The ‘fishbowl’ version uses a variable ratio reinforcement schedule instead of a fixed ratio. Each time the desired behavior occurs, the participant draws a prize voucher. The longer the behavior continues, the more vouchers are drawn. Although each voucher may not equal a tangible prize (much less expensive to do) the chance to collect enough vouchers to exchange for a desired prize is still motivating.42,71 Vouchers can be exchanged for non-cash goods and services that promote a drug-free lifestyle such as food, clothes, housing, electronics and sports equipment.

Research has verified that frequent 15-minute sessions are more effective for meth treatment than the longer, less frequent sessions commonly employed for treating other addicts. This is due to the short attention span of most meth addicts.14

Another rehabilitation concept is a meth boot camp. In Minnesota, addicts spend 6 months detoxifying prior to spending an additional 6 months in a regimented schedule of exercise, literacy, education and military drills followed by reintroduction to the community. A version of this program called Challenge Incarceration Program (CIP) is being used by prison systems. The goal of CIP is to help the inmate gain the resources needed to return to the community drug- and crime-free. Results are promising and costs are less than or equal to non-CIP participants.

All treatment programs should provide testing for HIV/AIDS, hepatitis B and C and other infectious diseases. Counseling can help patients adjust behaviors to reduce the risk of infection for themselves or others. Those already infected should be treated.

The use of technology – computers, websites, mobile devices – has the ability to enhance the power, reach and cost-effectiveness of behavioral treatment.31 Patients who live in remote areas or have limited mobility will have easier access to treatment. Patients who cannot or will not attend live sessions may benefit from computer programs designed to teach relapse-avoidance skills, for example. Supplement or emergency support can be provided via telephone or the web.

Currently, there are no specific pharmacological treatments that counteract the specific effects of meth or that prolong abstinence from and reduce the abuse of meth by an addicted individual.30 Strategies for effective pharmacotherapy include targeting the depressed mood and drug cravings associated with withdrawal, using drugs that elicit an aversive response when meth is ingested, using agents that block the positive effects of meth, treating the co-morbid conditions, and providing agonist therapy. The agonist approach attempts to substitute a drug with less negative side effects that targets the same receptors in the brain, in an attempt to gradually eliminate drug dependence.44 The existing pharmacological approaches are borrowed from experiences with treatments of cocaine and opioid dependence. Unfortunately, these approaches have provided minimal success since no single agent has proven effective in controlled clinical studies. Antidepressant medications are helpful in combating the depressive symptoms frequently seen in meth users who recently have become abstinent. Bupropion, commonly known as Wellbutrin is showing some promise in meth recovery of low to moderate users. It is hypothesized that it reduces the methamphetamine induced “high” as well as drug cravings elicited by drug-related cues. In a small study, bupropion helped the user feel better as well as prolonging periods of drug abstinence. Fluoxetine (Prozac®) has decreased drug cravings in short-term treatment. Imipramine (Tofranil) has increased the duration of adherence to treatment in medium-term treatment. Modafinil (Provigil®) is a drug indicated for use in patients with excessive daytime sleepiness secondary to narcolepsy or sleep apnea. Modafinil (Provigil) acts as a dopamine agonist and may help normalize brain dopamine function and improve abstinence rates in meth abusers. Naltrexone (Revia®) is an opiate receptor antagonist commonly used to treat alcohol and opiate dependence. In a small study, naltrexone was shown to reduce cravings and relapse in meth addicts. These treatment options need further research to verify efficacy in meth addiction treatment.7,32,44

Novel treatment approaches are being researched and tested. Under study is the idea of using the body’s immune system to neutralize the drug in the bloodstream before it reaches the brain.30,37 This approach includes injecting the meth user with antimeth antibodies, such as monoclonal antibody mAb7F9, or a vaccine that would stimulate the body to produce its own antimeth antibodies. A second approach centers on the glial cells which function in the brain like the immune system functions in the body. A drug, AV411 or ibudilast suppresses the neuroinflammatory actions of glial cells and has been shown to inhibit meth self-administration in rats. Research is promising and is being fast-tracked to establish its safety and efficacy in humans.37 A third approach is looking at the role of gamma-aminobutyric acid (GABA) neuron whose function is to decrease dopamine transmission, possibly decreasing the reinforcing effects of meth. In a small study, recipients of the GABA agonist baclofen (Gablofen®) exhibited great numbers of meth-negative urine samples suggesting a small but positive effect in reducing meth use.37

Emergency department treatments focus on the immediate symptoms including control of agitated, hyperactive or violent behavior; airway maintenance; management of cardiac conditions such as ischemia and tachycardia; using ice baths to bring down the dangerous hyperthermia; treating heavy metal toxicity; and administration of anticonvulsants. Patients are then referred for methamphetamine abuse treatment.