December 2019, Volume XXXIII, No 9
The resurgence of methamphetamine
A dual epidemic
he early and mid-2000s saw a rise in use and production of methamphetamine which generated a substantial policy and public health response. The federal government passed the Combat Methamphetamine Epidemic Act (CMEA) of 2005 to regulate retail over-the-counter sales of ephedrine, pseudoephedrine, and phenylpropanolamine products and to curtail the illicit production of methamphetamine and amphetamine (https://tinyurl.com/mp-1219-01). These efforts aimed at curbing methamphetamine supply resulted in a significant decrease in the availability and an increase in price of methamphetamine, decreased primary methamphetamine treatment admissions, and reduced emergency room visits associated with methamphetamine (https://tinyurl.com/mp-1219-02).
Despite these measures, methamphetamine is now seeing a resurgence. Law enforcement officials have curtailed most in-state manufacturing of the drug, but Mexican cartels now supply more pure and cheaper methamphetamine to Minnesota, fueling a rise in use and abuse.
A fourth wave of the opioid crisis … is primarily characterized by increasing co-use with methamphetamine.
Increase in methamphetamine use
In recent years there has been a stark increase in methamphetamine use. Government officials, researchers, and health care professionals have noted increases in methamphetamine-related hospitalizations, death rates, co-use with other substances, and methamphetamine drug seizures. Amphetamine use is now the fourth most common reason to seek drug treatment in the United States after alcohol, opioid, and marijuana use.
Hospitalization rates related to methamphetamine use increased 270% from 2008–2015 and have increased at a faster rate than for other substances (See Figure 1 and background at https://tinyurl.com/mp-1219-03). These rates correspond with reports from law enforcement; the State of Minnesota Violent Crime Enforcement Teams (VCET) reported that methamphetamine drug seizures in the state have increased nearly five-fold, from 233 pounds in 2014 to 1,145 pounds in 2018 (https://tinyurl.com/mp-1219-04). The increase in methamphetamine use has grown disproportionately in the Western United States but all regions have seen substantial growth (https://tinyurl.com/mp-1219-03).
Figure 1. Amphetamine-Related Hospitalizations in the United States, 2003-2015
Additionally, co-use of methamphetamine has increased among individuals with opioid use disorder. In 2011, 18.8% of treatment-seeking opioid users reported also using methamphetamine. This percentage rose to 34.2% in 2017. In a survey of individuals with opioid use disorder who co-use methamphetamine, respondents said that they used meth because it balanced out their high, was easier to obtain and less expensive than opioids, and induced euphoria (https://tinyurl.com/mp-1219-05). The increase in methamphetamine use among individuals with opioid use disorder may further complicate the opioid crisis. As such, the U.S. Department of Health and Human services has described a fourth wave of the opioid crisis, which is primarily characterized by increasing co-use with methamphetamine.
Health risks and treatment
Methamphetamine carries a variety of health and social risks. Individuals with opioid use disorder who co-use methamphetamine are at greater risk of adverse health outcomes and fatal overdose compared to opioid use alone (https://tinyurl.com/mp-1219-05). In addition to any health impacts of opioid use, health outcomes related to methamphetamine use alone include psychosis and other mental disorders, cognitive and neurological deficits, cardiovascular and renal dysfunction, disease exposure such as HIV transmission and viral hepatitis, and increased mortality (https://tinyurl.com/mp-1219-06).
It is difficult to treat methamphetamine use disorder because there are no pharmacological interventions for methamphetamine use disorder. Contingency management—which reinforces and rewards patients who exhibit positive behavioral change—provides incentives such as food items, movie passes, or other goods or services to reduce substance use, and has been shown to be somewhat effective for treatment of stimulant-related disorders, including methamphetamine use (visit https://tinyurl.com/mp-1219-07 for details on this approach). There are treatments for opioid use disorder—buprenorphine, methadone, and use of extended-release naltrexone—which can be used to treat opioid use disorder for individuals who co-use opioids and methamphetamine. These medications are not FDA-approved for the treatment of methamphetamine use disorder, although there is some preliminary evidence that extended-release naltrexone may reduce methamphetamine use. Individuals who co-use opioids and methamphetamine are encouraged to carry naloxone to treat opioid overdose, but it will not reverse methamphetamine intoxication.
What we can do
Screen for methamphetamine use in at-risk populations. One way health care professionals can identify and help individuals who use methamphetamine is by screening for methamphetamine use during health care visits. Health care professionals in entry-point care settings, such as primary care and emergency medicine, are well positioned to identify patients at high risk of adverse health events related to methamphetamine. However, specialty providers, such as psychiatry, infectious disease, cardiology, and gastroenterology, may also find enhanced screening to be valuable given the known health risks of methamphetamine use.
Health care professionals can also incorporate trauma-informed care practices during patient visits given the high levels of trauma many individuals who use methamphetamine have experienced.
There are no pharmacological interventions for methamphetamine use disorder.
Provide resources. Individuals who use methamphetamine often have multiple health and social needs. Health systems, clinics, and health care professionals can provide referrals to social service organizations, state and county programs, and addiction and recovery specialists. Additionally, health systems could choose to invest in peer supports, like community health workers, to help patients manage appointments and services and to provide informal counseling and encouragement. Recovery requires a team approach.
Harm reduction. For patients who are not ready to stop using methamphetamine, several services can still be provided to reduce infectious risks. Patients who inject drugs can be referred to clean needle exchanges and counseled on the safe use of needles and equipment. Naloxone should be provided for patients who are using both opioids and methamphetamine and counseling should be provided about how to recognize an opioid overdose. Because methamphetamine can be cut with fentanyl, health care professionals may consider providing naloxone to patients using methamphetamine alone. Patients who have hepatitis C should be referred to treatment to reduce transmission risk.
Reducing stigma related to substance use. Health care professionals can destigmatize methamphetamine use disorder by recognizing that it is a chronic disease and can be treated like other common conditions. For example, patients with diabetes who are not able to increase their exercise can be counseled on additional ways to reduce their cardiovascular risk through diet, blood pressure control, and potentially medications. Promoting first person language (i.e., “people who use methamphetamine”) instead of terms like “addict” or “user,” in interactions with patients, students, staff, and other health care professionals can also help destigmatize substance use. Substance use disorder treatment, like other chronic conditions, is characterized by its relapsing and remitting and should be expected on the path to long-term recovery.
Addressing the fourth wave of the opioid crisis
A public health approach to the rise in methamphetamine use should focus on key drivers of demand, like poverty, lack of opportunity, and parental substance use, and should provide improved access to interventions that reduce associated harms. Health care professionals play an important part in recognizing and supporting individuals with methamphetamine use disorder.
Tyler Winkelman, MD, MSc, is a board-certified internist and pediatrician, caring for adults and children in outpatient settings. He conducts health policy research in collaboration with partners locally and across the country at Hennepin Healthcare Research Institute with a focus on criminal justice and health care intersection. He is also an assistant professor at the University of Minnesota Medical School and a physician at the Hennepin County Jail.
Julie Bauch, MS, RN, PHN, is the Opioid Response Coordinator for Hennepin County. She spearheads initiatives to address the opioid crisis by marshalling relevant research and accurate data to help influence decision making. She works collaboratively with a variety of stakeholders in a leadership role to develop strategic interventions to further the role of local government addressing this public health epidemic.
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