Treatment of Methamphetamine Cravings With Bupropion: A Case Report

Sir: Methamphetamine abuse is a concern for physicians treating patients in a variety of settings, ranging from emergency rooms to mental health clinics, due to its wide range of psychological and physical effects. The use of methamphetamines rose significantly in the 1990s mostly in the western United States¹ but also in the areas along the United States–Mexico border.² Among the effects of methamphetamine are a sense of euphoria, increased energy, power, and control, which have reinforcing effects contributing to the highly addictive nature of methamphetamine.² These properties along with the low cost and availability of methamphetamine may partly explain the craving associated with its use.³ The cravings can be overwhelming for patients, who can experience very serious cardiovascular, central nervous system, and pulmonary symptoms leading to increased rates of emergency room visits, as were seen in the 1990s.⁴ In the following case, we discuss the promising use of bupropion to diminish cravings in a patient diagnosed with methamphetamine dependence.

Case report. Mr. A, a 31-year-old male Asian Pacific Islander, was referred to a drug and alcohol rehabilitation program following an uneventful 6-day inpatient detoxification for methamphetamine intoxication. He met DSM-IV criteria for methamphetamine dependence, which had lasted for 6 years and consisted of smoking, usually in 2-day binges. He would go through, on average, two tenths of a gram, although at times up to half of a gram, during a binge; for the most part, binges occurred on weekends. He denied any intravenous use and denied any previous psychiatric hospitalizations or medical problems. He had never participated in any type of rehabilitative treatment in the past and denied that he had ever sold any illicit substances. He noted irritability and concentration problems for several days after bingeing, which had contributed to occupational impairment.

Mr. A agreed to participate in an outpatient rehabilitation program consisting of weekly group sessions and individual sessions to assist him in relapse prevention and developing a healthy lifestyle and encouraging his attendance of Narcotics Anonymous meetings, working through the 12 steps of the program, and securing sponsorship. As part of his treatment, he submitted to random weekly drug screens. Mr. A underwent a psychiatric evaluation and neuropsychologic testing to evaluate any possible cognitive deficits stemming from 6 years of methamphetamine abuse. The battery consisted of the Trailmaking Series (A + B),⁵ the Wide-Range Achievement Test, 3rd edition (WRAT-R),⁶ the Wechsler Adult Intelligence Scale-Revised,⁷ the Short Category Test,⁸ the Wechsler Memory Scale-Revised,⁹ and the Minnesota Multiphasic Personality Inventory-Revised (MMPI-2).¹⁰ The results of the MMPI-2 showed that scores on all addiction potential and addictive practice scales were significantly elevated. There was little evidence of any brain damage apparent in his testing record. Both memory and concentration were above average, with no deficits in the ability to solve complex problems. He did show evidence of impulsiveness and a possible learning disability suggested by his poor academic achievement scores on the WRAT-R.

Early on in treatment, the patient related a strong urge to use methamphetamines, scoring a 25 out of 30 on the Penn Craving Scale.¹¹ Based on earlier work by one of the authors (T.R.B.)¹² in treating cravings associated with cocaine cessation, a trial of bupropion sustained release was started at 150 mg once a day for 3 days and then increased to 150 mg b.i.d. Over the next 3 weeks, his cravings decreased and his score on the Penn Craving Scale decreased weekly to a low of 4. Mr. A was able to actively participate in his recovery as well as improve his work performance. His weekly urine drug screens have all been negative for illicit substances, and he has remained substance-free at 3 months.

Methamphetamines are purported to exert their central nervous system effects by stimulating the release of dopamine and norepinephrine in the brain,² a mechanism similar to that of cocaine.¹³ The incentive reinforcement system seems to be primarily linked to dopamine systems, which may account for the addictive potential of methamphetamines.¹⁴ Because of bupropion's unique property of involving inhibition of neuronal reuptake of dopamine (possible reinforcement of the reward system),¹⁵ it was chosen to assist Mr. A with his cravings for methamphetamine. A review of the literature revealed that dopaminergic agonists such as amantadine and bromocriptine have been used to decrease depressive reactions in withdrawal from amphetamines and that tricyclic antidepressants have been used to decrease dysphoric symptoms in withdrawal.¹⁴ Lobeline is currently being investigated in regard to its ability to inhibit the neurochemical and behavioral effects of amphetamines,¹⁶ and the National Institute of Drug Abuse (NIDA) is actively pursuing research to treat stimulant users.¹⁷ However, to my knowledge, the use of bupropion to decrease methamphetamine cravings has not been reported, but bupropion has been used with some success in treating cocaine cravings.^18,19 In this case, bupropion appears to be a promising agent, especially when pharmacotherapy tends to be underutilized in substance abuse treatment.²⁰ We advocate that caution be used when interpreting single case results and that bupropion is not a substitute for a comprehensive multifaceted treatment approach, but it certainly may prove to be a valuable adjunct.

Conclusions and opinions expressed are those of the authors and do not necessarily reflect the position or policy of the U.S. Government, Department of Defense, Department of the Army, or the U.S. Army Medical Command.