Methamphetamine prepared to be consumed
Overdose deaths from methamphetamine increased sharply from 2011-2018 based on a recent study in JAMA Psychiatry. While overdose deaths were seen across all racial and ethnic groups, non-Hispanic American Indians and Alaska native communities demonstrated the highest death rates overall.
Over the study period, methamphetamine deaths increased more than 4-fold among non-Hispanic American Indians and Alaska natives. While death rates increased among both men and women, the rise was more significant among men, the data revealed. Study results also revealed that non-Hispanic Blacks had the steepest increases in overdose death rates during 2011-2018. This underscores a concerning trend in a group that had previously experienced quite low rates of methamphetamine overdose deaths.
Long periods of reduced access to education, along with high rates of poverty and discrimination related to delivery of healthcare services are among the factors that are thought to lead to health disparities in these two groups. The sharp rise in deaths reported by the study’s authors illustrates the importance of treatment approaches that address cultural and gender differences.
“While much attention is focused on the opioid crisis, a methamphetamine crisis has been quietly, but actively, gaining steam—particularly among American Indians and Alaska Natives, who are disproportionately affected by a number of health conditions,” said Nora D. Volkow, M.D., NIDA director and a senior author of the study in a press release. “American Indian and Alaska Native populations experience structural disadvantages but have cultural strengths that can be leveraged to prevent methamphetamine use and improve health outcomes for those living with addiction.”
Since recent national data indicates that most people who use methamphetamine are between 25 and 54 years old, the researchers decided to focus on this age group. When they looked at data from this population as a whole, they found a surge in overdose deaths. Specifically, methamphetamine-related deaths rose from 1.8 to 10.1 per 100,000 men, and from 0.8 to 4.5 per 100,000 women. This represents a more than five-fold increase from 2011 to 2018.
Long term methamphetamine use, which leads to structural and molecular changes in the brain, is associated with multiple serious health risks including addiction, psychosis, memory loss, along with a high frequency of relapses and risk for death from overdose. Besides this, the risk for hypertension, increased risk for heart attacks, arrhythmias, strokes, and Parkinson’s disease have been well described. And, as opposed to opioids, there are currently no FDA-approved medications for treating methamphetamine use disorder or reversing overdoses.
That said, there are specific behavioral therapies as contingency management therapy that have been shown to promote harm reduction associated with methamphetamine abuse. This involves providing tangible awards such as vouchers for food, movie passes or even cash prizes to reinforce positive behaviors such as abstinence. This has proven useful for patients in methadone programs and psychosocial counseling.
“What stands out about methamphetamine is how addictive the agent is,” Dr. Scott Krakower, a Child and Adolescent Psychiatrist with Zucker Hillside Hospital. “Recovery can be lengthy and arduous with a high relapse risk.”
“In recent years, there have been increasing numbers of patients abusing this agent. The opioid crisis itself has not necessarily taken away our attention—if anything, it has helped providers to recognize how much addiction has impacted our population,” offered Krakower. He also explained that treatment “may entail individual and group therapeutic techniques such as cognitive behavioral therapy (CBT) and motivational interviewing to encourage abstinence.”
“Identifying populations that have a higher rate of methamphetamine overdose is a crucial step toward curbing the underlying methamphetamine crisis,” said Beth Han, MD, PhD, MPH, lead author of the study. “By focusing on the unique needs of individuals and developing culturally tailored interventions, we can begin to move away from one-size-fits-all approaches and toward more effective, tailored interventions.”
In the Indian health care system, a combination of shared decision-making (between patient and health care provider) and a holistic approach to wellness are well established traditions among some American Indian and Alaska Native groups. Traditional approaches such as talking circles (members of a group provide an uninterrupted discourse) and ceremonies such as smudging (burning herbal products to create a cleansing or purifying smoke bath) have been integrated into the health practices of many Tribal communities.
One way to help prevent drug use among young people may be to incorporate these traditions since they offer a cultural opportunity to promote resilience. A focus on culturally appropriate and community-based preventions engaging teens and families with positive early intervention strategies that highlight provider and community education could also bolster prevention efforts in this population.
In addition, a recent clinical trial published in the New England Journal of Medicine reported therapeutic benefits (reduced methamphetamine use and drug cravings) with the combination of naltrexone with bupropion in patients with methamphetamine use disorder over a period of 12 weeks. Naltrexone is an opioid receptor antagonist used to treat opioid use disorder (OUD), while bupropion is a stimulant-like antidepressant that operates via the norepinephrine and dopamine systems and may lessen the anxiety or restlessness associated with methamphetamine withdrawal which forms the basis for continued use.
The weighted response of the two drugs was better than placebo (13.6% vs. 2.5%), but it was still was quite low. That said, the number needed to treat (NNT) was quite encouraging at 9, making it similar to the therapeutic benefit achieved for treating mental health disorders, such as antidepressant medications prescribed to treat depression and naltrexone to treat alcohol use disorder. (NNT is a measure of the utility of a medical intervention, describing the number of patients that would need to receive a medical treatment to benefit one person).
And while the design of the trial (sequential parallel comparison design along with weighted responses) may be confusing, it ensures a clear way to assess the efficacy of the dual drug approach. Future trials to replicate the results in a more natural design or continuation of this trial would certainly be helpful to determine whether this therapeutic approach (using naltrexone and bupropion) is viable as a pharmacologic approach going forward.
“Long-term methamphetamine misuse has been shown to cause diffuse changes to the brain, which can contribute to severe health consequences beyond addiction itself,” said Madhukar H. Trivedi, MD, University of Texas Southwestern Medical Center, Dallas, in a press release, who led the trial. “The good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”
“It is a pivotal moment to discover this combination of medication [naltrexone and bupropion] can be helpful for methamphetamine use disorder,” said Krakower.
