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Health See other Health Articles Title: Meth Conference in Hawaii The National Methamphetamine Drug Conference Medical Panel Discussion: A Doctor's Perspective Everett Ellinwood, M.D., Duke University Medical Center Tom Leland, M.D., Community Care Services Scott Lukas, Ph.D., Harvard Medical School Richard Rawson, Ph.D., The Matrix Institute Michael Sise, M.D., Mercy Hospital DR. SISE: Whether we are from law enforcement, treatment or prevention communities, each of us has a different perspective on meth. Over the last day we have shared data and statistics, but it is important to remember there is a human face for each of these numbers. During the last month, I stitched the heart of a woman stabbed by her methamphetamine dealer who stole her money. I operated all night, trying to remove a clot from the gangrenous leg of a young methamphetamine binger. I confronted an agitated, head-injured college student who rolled his car off the freeway ramp because he was driving too fast after a party where he took methamphetamine. I made that long walk down the hospital corridor to tell a mother that her daughter was shot dead during an argument with her methamphetamine-using boyfriend. For every statistic, there is a human face. Sooner or later, "methamphetamine means death:" The death that comes from violence or critical illness, the death of future promise for too many young people, and the death of hope for their families. Methamphetamine carries a prognosis that is worse than many cancers. Sometimes, if things go well, I can give them back their lives, but who is going to give them back their futures? I am at the end of the pipeline, and I struggle to prevent those final effects. We have to remember those human faces behind the statistics. When we work to put together a comprehensive strategy that is measured by the number of arrests, interdictions or labs seized, we should also measure the number of lives saved and the number of people whose futures are restored. It is important to remember this number as we carry on the fight. DR. RAWSON: Performing medications research, I am aware it is important to develop tools. For those people who are currently addicted to methamphetamine and cocaine, the medications are not yet available, and nothing is on the immediate horizon. We need to look at the resources and knowledge we currently have available and do a better job applying it to the patients who are currently seeking treatment. In the last five years, the Center for Substance Abuse Treatment (CSAT) has developed a whole series of resources called Treatment Improvement Protocols (TIPS). These are superb documents that make treatment information available for clinicians to use in their practices. However, I still hear treatment workers say, "We have a model that we know works; we do not want to change; it is too hard to learn this new information." Our challenge as physicians is not to wait for a magic bullet or to say we need more money. There are resources and strategies we can apply now. I think we sometimes underestimate our patients. At the Matrix Institute, we have reviewed the treatment of more than 1,000 methamphetamine users. Many are recovering and lead productive and fulfilling lives. In the follow-up data, more than 150 methamphetamine users achieved an excellent recovery rate. Treatment of the methamphetamine user is not a hopeless condition. The brain changes that occur are, for the most part, reversible over time, and people do become productive. I would hope we would be able to use a meeting like this as an impetus to get some of this new information, as well as that produced by NIDA, to treatment workers. They need to know that treatment strategies are available. We must make this information more accessible and relevant to their needs. DR. LELAND: At the end of the pipeline, the time when the treatment community comes on the scene, we physicians are faced with both an opportunity and a challenge to treat the methamphetamine addict. This addict is a victim of a hideous brain disorder that is not a virus dementia, and it reminds us of the lethal, damaged immune system we see in terminal AIDS patients. When we see brain scans of methamphetamine users, we are appalled at the amount of blood vessel damage and wonder if it is reversible. Our Hawaii "ice storm" is now a decade old and shows no clear sign of ending. Our 4-year-old managed care dual-diagnosis program called Community Care Service is working on this disaster. Initially, we found 30 days of residential treatment to be effective until we realized the ice relapse pattern is often delayed longer than cocaine slips. Treatment must often be extended. The ice addict may reuse after 50 days, and the addiction is severe, each slip producing an immediate paranoid psychosis. The "meth run" completely empties the dopamine storage system, and the resulting dysphoria and paranoia seem relentless. NIDA's positron emission technology (PET) scans confirm what users claim: It takes three months for the dopamine depletion to recover. Amino acid nutrients, such as QUIT vitamins with neurotransmitter replacements, are sometimes helpful. These drug survivors, however, are in for a long journey. It takes months before there is any light in the tunnel; sometimes it is a train wreck, but sometimes it is freedom. We have recently connected our research with the Honolulu drug court. It provides the bridge to a therapeutic locus of control. This drug court, with a census of 180(+), obtains weekly drug screens and ensures daily contact with group therapy. It also adds cognitive "restructuring", provides transportation to appointments, and monitors via home visits and intensive in-community outreach. Dr. Charles Bogdahn and I are doing a small research study on recovering ice hallucinators in the drug court system. Neuropsychological testing is provided if the person is psychotic upon entry at drug court. We repeat testing when the psychosis subsides, and we perform a third scan with neuropsych tests after six months of sobriety. The subjects are placed on low-doses of the new anti-psychotic medication risperidone (Risperdal). This is our best chance to do follow-up evaluations. Is the methamphetamine psychosis persistent? What about the abnormal blood flow pattern? Judge Aiona's drug court may help provide some answers to a frightening concern. In Honolulu's emergency rooms or police cell blocks, it looks like Armageddon. We must bring more scientific research to bear on this problem. DR. LUKAS: As a researcher, I have been trained to live and die by statistics, but we cannot lose sight of the real-life stories and the faces behind those statistics, graphs or charts. Like a broken record, I cannot overemphasize that point enough. Because there is no silver bullet for drug abuse, medication development and treatment research must proceed on many different fronts. This process goes on slowly, too slowly perhaps, indirectly contributing to an increase in the numbers. We must do better. Methamphetamine abuse or dependence is not a homogeneous disease. There are many sub-populations who require specialized treatment, such as the pregnant woman. Last year I had the unfortunate duty, for the first time, of telling three drug dependent women that they were pregnant. Imagine the range of emotions that went through their facial expressions after hearing this and then trying to decide how to deal with this tragic situation. The faces of all three pregnant women are forever etched in my mind. Protecting life—that is what drives researchers to pursue medications. We have also learned there are very different types of users. Some of you may have heard the term "chippers." These are individuals who will use drugs episodically but have not become fully dependent and are not using drugs on a chronic basis. These people may do well with outpatient treatment, but for the abuser whose brain is changed, we may need a completely different therapeutic approach. We have got to find ways to accelerate the process of brain recovery for the heavy abuser. Soon I will meet with the director of medications development division at the National Institute on Drug Abuse. We will discuss a collaborative arrangement to study a new, nontoxic drug that, in a pilot study, actually improves brain function and fixes brain membranes. This is the kind of medication we could give to pregnant women and to their children who are dependent. The challenge for treatment is not unlike that of law enforcement. It may take three, four, or five arrests to finally incarcerate the chemist (the cooker) who made the methamphetamine. Similarly, it may take three, four, or five times for a patient to be treated successfully and remain clean. An analogy would be a situation in which a doctor tries several medications to reduce a persistent ailment. He tries a medication, measures its results, and determines whether to use another medication. In a similar fashion, we need to develop medications for methamphetamine addiction because we are never certain what will work. The problem is not only medical, but it is administrative as well. Clinicians can take someone who is dependent on methamphetamine and lock them on a treatment unit. Yet, at 20 days when their insurance runs out, the health management organization says that we must move them out of the program. Although they leave drug-free, it is not the end of the battle with their addiction. Consequently, relapse prevention is one of the key issues we must address. About a week and a half ago, I ran a study using a process called cue reactivity. It is a process in which we show individuals stimuli or picture situations that remind them of the drug-taking event. There was one fellow who had been dependent for about seven years but was clean for six weeks. We hooked up wires to measure his brain activity, heart, skin temperature and blood pressure and measured his reaction to the stimuli. At the end of the session he said, "You know doctor, I did not feel a thing; you cured me." When I read the tracings from his data, they were off the scale. That told me he had a visceral response inside his mind. His brain and body are still reacting to the simple sight of someone else using a drug. It is our requirement as researchers to take this type of information and disseminate it to those who can use it. In a way, this describes a process called "from bench to trench." Researchers are working on the benches, and my practicing colleagues are working in the trenches. It is important researchers get information to practicing doctors, and we must get it to you. Question: I am from an educational development program for women who are incarcerated, and most are crack addicts. Is there a specific person who uses this drug? DR. RAWSON: In terms of specific groups within those geographic locations where there is a lot of methamphetamine, women are particularly at high risk. Many people who use methamphetamine use it to enhance their work performance. Rather than viewing this as a party or recreational drug, they see it as enhancing their work or child-care activities. The dual-diagnosis patient populations are also at high risk. I think, in all cases, our young people are at risk because they are experimenting. Our youth are curious, and, if methamphetamine is available in the high schools, they will experiment with it. DR. ELLINWOOD: High-risk populations among women include those who are trying to lose weight. Frequently, they have had experience with anorexics. We have college women who graduated to methamphetamine and other stimulants. DR. SISE: We have a stereotypical drug user in the back of our minds; we need to break that stereotype with the methamphetamine user. Officials of the San Diego Police Department tell me about the wealthy people—many are women—who drive expensive cars from Rancho Sante Fe and cruise downtown San Diego to make methamphetamine buys. Many adults, like our young people, have virtually no knowledge of its dangers. As Dr. Musto mentioned, we are in a phase of epidemic stimulant use where methamphetamine is not understood and not feared. We must change this perception. Question: Dr. Leland, could you briefly explain Hawaii's drug court program? DR. LELAND: In the drug court pre-sentence phase, nonviolent felons are faced with the alternative of drug court or incarceration. The court recently received a grant for dual-diagnosis and plans to add eight or nine new staff. It is a very successful program. So far the drug court has 189 subjects and successfully graduated 11 at the end of the first year while 25 more are graduating next month. Although the gender is half and half, the most vulnerable population in Hawaii for incarceration and methamphetamine arrests is the single Hawaiian male. DR. SISE: One of our major problems with screening for methamphetamine, and for alcohol abuse for that matter, is that the language in many health care plans prevents the hospital from being paid if patients are injured from behavior resulting from alcohol or drug use. That is a major disincentive for our trauma centers. Question: What advice would you give to those of us working with programs and policies relating to prevention? DR. RAWSON: I am not a prevention expert, but we are working in a dual-diagnosis adolescent treatment center. We found it tremendously important to use accurate facts. Information about methamphetamine effects on the brain must be presented in a way youth understand. We know from prior research that scare tactics do not work; they discredit prevention activities. Facts must be used. DR. ELLINWOOD: Of all the drugs I know, this is the most frightening one of all. I do not think you need to say too little on methamphetamine abuse. DR. SISE: I want to add a point about drug and urine screen testing. While this is not a substitute for education and good parenting, it is a powerful tool for parents. The son of a retired veterinarian dropped from an IQ of 140 when he was 18 years old to an IQ of 105 when he was 25 as a result of sustained methamphetamine and crack cocaine use. The father wished he had tested his son. Why? First, he would have known immediately that his son was using drugs. Second, his son would have had a powerful excuse not to bow to peer pressure. Certain populations of youth are at-risk, and drug testing, used as part of a parenting program, can be very effective. I strongly recommend it. Question: How much graduation is there from the legal use of amphetamines to the illegal use? Can a pharmacist help identify someone who may be at-risk? DR. ELLINWOOD: We do not have much research on that. However, case studies do show people graduating, perhaps from anorexics in college to methamphetamine. Among bulemic patients, there is a fairly high rate of progression. However, in the amphetamine treatment of narcolepsy and adolescent attention deficit disorder, there are studies showing that the incidence of abuse is not increased. The at-risk patient might be identified as with other controlled drugs, in other words, through "loss of medications," dose escalation, evidence of doctor-shopping and so forth. Post Comment Private Reply Ignore Thread
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