Caring for Hospitalized Adults with Methamphetamine Use Disorder: A Proposed Clinical Roadmap

Methamphetamine-related overdose is an emergent public health issue.¹ Trends in hospitalization reflect downstream impacts of this evolving crisis; between 2008 and 2015 amphetamine-related inpatient admissions increased in frequency, had longer lengths of stay, were more frequently associated with in-hospital mortality, and most often paid for by Medicaid.² Of these patients, most were hospitalized primarily for psychiatric disorders (including substance use disorders [SUD]), infection, congestive heart failure, or diabetes.² These data suggest this health crisis is directly impacting acute care delivery systems. Unfortunately, health systems, hospitals, and hospitalists have not received guidance on how to best care for inpatients with methamphetamine use disorder (MUD). There is an urgent need to understand how to effectively approach care for this complex hospitalized population. We propose a clinical roadmap (see Table 1) informed by national evidence-based guidelines for ambulatory patients³ and veterans,⁴ peer-reviewed scholarly work, and the expertise of a multi-disciplinary authorship team comprised of peer support specialists and addiction-specialized medicine, psychiatry, and social work.

Table 1.

Summary of Clinical Domains and Recommendations

Domain	Recommendation
1. Recognizing Acute Intoxication and Withdrawal	Identify signs and symptoms early in hospitalization to anticipate patient needs.
2. Managing Acute and Sub-Acute Methamphetamine-Related Symptoms	Address acute agitation secondary to methamphetamine use with non-pharmacologic and pharmacologic means.
3. Assessing and Treating Concurrent Psychiatric Disorders	Complete a comprehensive SUD assessment and when applicable a full psychiatric evaluation, with appropriate management.
4. Administering Behavioral Interventions	Initiate evidence-based behavioral interventions using the expertise of interprofessional teams.
5. Providing Harm Reduction Education and Supplies	Offer harm reduction support to all hospitalized patients with MUD.
6. Facilitating Transitions of Care	Develop discharge plans to be patient-centered, focused on recovery goals, and ongoing social needs.

Table Notes. SUD = substance use disorder; MUD = methamphetamine use disorder.

Domain 1: Recognizing Acute Intoxication and Withdrawal.

Recognizing acute intoxication and withdrawal may be difficult due to symptom heterogeneity,^5,6 resemblance to psychiatric disorders,⁷ and medical conditions. Symptoms of acute intoxication may include increased euphoria, hyperexcitability, hypersexuality, locomotor activity, agitation, and psychosis.³ Objective signs of a methamphetamine-related toxidrome⁵ can include diaphoresis, tachycardia, hyperthermia,⁸ and a positive urine drug test. In contrast, withdrawal is poorly defined due to an insufficient evidence base.⁶ Some researchers propose acute (days 1 to 10 since last use) and sub-acute (2 to 3 weeks since last use) phases.^9,10 Others posit a more chronic syndrome lasting for months.⁶ Systematic review suggests that a methamphetamine withdrawal syndrome often includes: 1) depressive symptoms (e.g., dysphoria, anhedonia, anergia); 2) agitation and irritability; 3) fatigue (e.g., increased need for sleep); and 4) cognitive impairment (e.g., poor concentration). Additional symptoms can include red/itchy eyes, mild paranoid ideation, hyperphagia, and cravings.¹⁰ Symptom resolution varies after cessation; within one week for depressive symptoms¹⁰ for some patients and a week¹⁰ to a year or more¹¹ for psychotic symptoms. Cravings can continue without significant reduction for up two weeks and may continue for up to five weeks.¹⁰

Domain 2: Managing Acute and Sub-Acute Methamphetamine-Related Symptoms.

The first step in managing acute methamphetamine-related symptoms is to stabilize the patient. If the patient is agitated the American Association of Emergency Psychiatry recommends: a) ensuring physical safety for all; b) managing patient distress; c) avoiding restraints when possible; and d) avoiding coercive interventions that escalate agitation.¹² Patients may benefit from placement in a quiet non-stimulating environment⁵ and pharmacological interventions (e.g., benzodiazepines, antipsychotics).³ Sub-acute and chronic withdrawal management pose a challenge because there is no Food & Drug Administration approved medication for MUD. However, two recent clinical trials may hold promise: a multi-site trial of extended-release intramuscular naltrexone and extended-release oral bupropion¹³ and a single-site study of mirtazapine for cisgender men and transgender women who have sex with men.¹⁴ Hospital-based practitioners could consider prescribing these medications for concurrent FDA-approved indications (e.g., mirtazapine for depression).

Domain 3: Assessing and Treating Concurrent Psychiatric Disorders.

Other psychiatric disorders are common for inpatients with MUD² and may complicate acute presentation, hospital management, and post-acute care. Patients may benefit from addiction/psychiatric consultation to help distinguish symptoms and identify concurrent disorders. There is limited evidence to guide the management of concurrent psychiatric diagnoses, however, targeted treatment is recommended (e.g., buprenorphine for opioid use disorder, lithium for bipolar).³ The literature-base is primarily focused on methamphetamine associated psychosis (MAP), which is treated with a second-generation antipsychotic medication.¹¹ MAP may resolve within one week of cessation and longer-term pharmacotherapy may not be necessary.¹¹ For patients with protracted MAP (> 6 months), treatment should focus on cessation¹¹ and an antipsychotic taper.

Domain 4: Administering Behavioral Interventions.

A systematic review of reviews on stimulant use disorder treatment concluded that contingency management (CM) had the strongest evidence for use.¹⁵ CM uses a reward-based system as positive reinforcement for specific behaviors (e.g., incentivizing negative urine drug screens or attending healthcare visits with small prizes). CM is well-studied in outpatient settings, but little is known about hospital-based implementation. A pilot project in a Canadian hospital suggests that CM could be feasible during hospitalization.¹⁶ Future studies could explore adapting CM to hospitals.

Domain 5: Providing Harm Reduction Education and Supplies.

Many hospitalized patients with SUD desire harm reduction services,¹⁷ which should be offered regardless of methamphetamine cessation. Experts suggest asking about route of administration (inhalation vs. rectal vs. injection).¹⁸ For inhalation, education should discourage pipe sharing to decrease infection risk, encourage the use of mouthpieces to prevent burns to lips and oral mucosa, and to suggest petroleum jelly for skin barrier protection.¹⁸ Safer use education for rectal administration may include suggestions to mix the substance with sterile water, to use lubrication to protect the skin barrier during administration, and to avoid sharing equipment.¹⁸ For those who inject, education should promote the use of sterile equipment (e.g., needles) and hygienic administration (e.g., alcohol preps for skin cleaning).¹⁸ All patients should receive overdose education and take-home naloxone.

Domain 6: Facilitating Transitions of Care.

Hospitalization is a critical time to engage adults with SUDs with treatment and linkage to care at discharge.¹⁹ Health systems can partner with community providers to facilitate referral to the appropriate level of care at discharge³ and offer referrals to housing supports for those in need. Disposition planning should begin early in hospitalization and focus on individually identified recovery goals. Anticipate challenges to transition for patients with a history of aggression while intoxicated, incarceration, premature patient-initiated discharges, cognitive impairment, and rural residents.

In short, hospitalized adults with MUD often have complex needs. To address complexity, we propose an interprofessional and systematic approach to care. A protocolized approach may be effective as demonstrated by a Colorado emergency department pilot project to address MAP.²⁰ There is an urgent need to study, trial, and implement effective treatment approaches for inpatients with MUD.