Caring for Patients Using Methamphetamines: An Interprofessional Collaborative Approach

Abstract

Methamphetamine use is increasing in the U.S. and in Missouri, as are the number of deaths associated with its use. Many systemic and mental health issues are associated with methamphetamine use or methamphetamine use disorder (MUD). Given the range of health issues associated with methamphetamine use or MUD, a collaborative approach to the care of patients can improve outcomes. This article provides an overview of a collaborative approach to caring for patients using or have used methamphetamine, from the perspective of the primary care, behavioral and dental clinician.

Introduction

Methamphetamine is a highly addictive stimulant that affects the central nervous system. National data from 2015–2018 estimated that 1.6 million U.S. adults over age 18 years reported past–year methamphetamine use; 52.9% had a methamphetamine use disorder (MUD) and 22.3% reported injecting methamphetamine within the past year.¹ Although the population use rates have remained relatively stable, mortality associated with methamphetamine use has increased in the U.S.² These increased death rates for methamphetamine are thought to be related to opioids being laced with methamphetamine.³

Missouri is not immune from this drug epidemic. In 2013, the Missouri Highway Patrol Report ranked Missouri third by state in methamphetamine seizures.⁴ A 2020 report from Millennial Health ranked Missouri ninth in the U.S. with 10.2% of the population testing positive for methamphetamine use, with Arkansas ranking first.⁵

National data show that individuals who use methamphetamine are more likely to use or misuse other substances including cannabis, prescription opioids, cocaine, prescription sedatives, tranquilizers, or stimulants, and/or heroin.¹ Methamphetamine use in Missouri continues to cause significant health problems for the population. In addition to increasing death rates, from 2012–2018, the number of Missourians receiving treatment for MUD increased 76%.⁶ (See sidebar for an example of an individual who has used and recovered from MUD.)

Since the implementation of federal and state regulations restricting the sale of pseudoephedrine used in the manufacturing of methamphetamine, production in Missouri has decreased considerably. Meth lab incidents have decreased 96% between 2006 and 2018. Today, methamphetamine is thought to be transported from Mexico to U.S. cities. In Missouri, St. Louis appears to be a transportation hub for methamphetamine and accounts for the majority of methamphetamine incidents in the state.⁶

Methamphetamine use is associated with a variety of health issues, including cardiovascular and renal disease, oral diseases, infectious disease transmission, psychosis and other mental health illness, and overdose.¹ Primary care and behavioral health clinicians will see patients with health and mental health disorders related to methamphetamine, or patients with chronic diseases who are using methamphetamine. Dentists will see individuals in which methamphetamine has destroyed their dentition. This article describes the physical, behavioral, and oral health issues associated with methamphetamine use and an approach to treatment planning using a collaborative approach to care.

Prevalent Health Issues

Given the prevalence of methamphetamine use in Missouri, primary care clinicians should be familiar with the health effects that stem from chronic methamphetamine use. Primary care considerations of long–term methamphetamine use include cardiovascular complications; a higher incidence rate of risky sexual behavior; an increased chance of contracting and/or transmitting HIV; and potential concomitant misuse of other substances, including prescription medications. The primary care provider should also be familiar with opportunities for treatment and harm reduction.

The physical sequelae of chronic methamphetamine use are numerous and may affect several organ systems. Cardiovascular and cerebrovascular events most often contribute to morbidity and mortality associated with methamphetamine use. These effects are mediated by methamphetamine’s effect on the sympathetic nervous system. Cardiovascular complications of chronic methamphetamine use are among the leading causes of death in chronic methamphetamine users; these complications include malignant hypertension, myocardial infarction, stroke, aortic dissection, and methamphetamine–associated cardiomyopathy.⁷

Chronic usage of methamphetamine can lead to hypertension and predispose the user to methamphetamine–associated cardiomyopathy, a condition characterized by left ventricular dilation and left ventricular dysfunction. Importantly, methamphetamine–associated cardiomyopathy may be reversible with cessation of methamphetamine usage. Methamphetamine use is associated with about a five–fold increased risk of stroke, which are often hemorrhagic.⁷ Chronic methamphetamine use is increasingly being recognized as a cause of pulmonary arterial hypertension (PAH), causing progressive dyspnea and hypoxemia, right ventricular failure, and eventual death.⁸

One important consideration related to chronic methamphetamine use that may be overlooked is its association with risky sexual behavior and risk for HIV and other sexually transmitted infections. In the U.S., methamphetamine is used more frequently among men who have sex with men (MSM) than among other men. Use of methamphetamine and other substances to enhance sex has often been referred to as “chemsex.” Chemsex is a practice often seen among methamphetamine users in the MSM community.

Methamphetamine usage has been associated with a greater number of sexual partners, reductions in condom use, and poor adherence to antiretroviral pre–exposure prophylaxis and antiretroviral treatment and has been clearly established as a factor contributing to HIV transmission in the U.S.⁹ The route of administration must also be considered when linking methamphetamine use with an increased risk for communicable diseases as methamphetamine may be smoked, snorted, inserted rectally, or injected. Injected methamphetamine may increase risk for transmission of HIV and Hepatitis C.¹⁰

When caring for patients with methamphetamine use disorder, one should consider concomitant use of other substances. Co–use of methamphetamine and opioids has been linked to an emerging epidemic of opioid–related mortality. It is thought that rising rates of stimulant–related death may be related to co–use with opioids, particularly high–potency synthetic opioids like fentanyl. The reasons for increasing co–use of these substances requires further study.¹⁰

Prevalent Mental Health Issues

Primary mental health issues associated with regular methamphetamine use include depression, anxiety, and psychosis. Often, it is difficult to ascertain whether the mental health condition preceded the methamphetamine, however, it is safe to say that regular methamphetamine use would most certainly exacerbate any underlying biological bases related to mental health issues.¹¹ Methamphetamine intoxication can result in hallucinations, paranoia, and psychosis.¹² Methamphetamine use can be conceptualized as activating, resulting in major changes in impulse regulation and mood.¹³ Symptoms associated with impulse regulation can include agitation, irritability, suicidality, and even aggression. Other symptoms associated with activation include panic and anxiety.¹⁴ Methamphetamine withdrawal symptoms can result in a sharp decline in mood resembling depression. A majority of methamphetamine users report experiencing depression with symptoms of low mood and anhedonia.¹⁵

Methamphetamine use sets itself apart from other drug use because of the increased risk of psychosis. Individuals experiencing psychosis do not recognize that they are suffering from mental illness.¹⁶ The experience of psychosis, or a psychotic episode, is a defined by losing touch with reality and the experience of hallucinations, delusions, disorganized thinking, and disorganized movement or motor behaviors. Delusions are fixed false beliefs and often revolve around themes of persecution, hidden meanings in every day occurrences, physical experiences, religion, and grandiosity. Hallucinations are unreal sensory perceptions that occur without an external stimulus. Despite the lack of an external stimulus, it is important to remember that those experiencing hallucinations sense them as very real and will respond as such. Disorganized thinking will present itself as speech that is disjointed, incoherent, or even randomly spoken words. Disorganized behavior can present as behavior that includes purposeless movements, talking to oneself, or even being childlike and silly.¹⁶

Specific to methamphetamine users, psychotic symptoms can be short–lived and resolve once the bloodstream is free of the drug.¹⁷ The psychotic symptom profile of methamphetamine users often includes auditory and visual hallucinations as well as delusions revolving around persecution (e.g., being followed, being spied on, being lied to).¹⁸

The activating nature of methamphetamines can result in agitation, and there is evidence that methamphetamine use is related to irrational, violent behavior. Large population studies and some longitudinal studies have provided strong evidence for a causal relationship between violent behavior and methamphetamine use, but more research is needed in this area.^19,20

Significant evidence indicates that increased usage of methamphetamines is related to increased rates of depression and anxiety.²¹ Methamphetamine users report high rates of a lifetime prevalence of depression and a third of users report having been diagnosed with depression or anxiety at some point in their lives.²² Drawing a distinction between independent mood and anxiety disorders, and symptoms of methamphetamine use and withdrawal is easier said than done.

The hyperarousal associated with use can mimic symptoms of unease and panic, while the withdrawal period after use can result in feelings of fatigue, lethargy, and apathy. Clinicians, when given the time, can work to make accurate diagnoses of mood, anxiety and substance use disorders by paying close attention to onset of episodes as it relates to lifetime usage.²³

More frequent use of methamphetamines is associated with higher levels of suicidality.¹³ In addition to understanding patient mood, anxiety, and substance use profiles; particular attention should be paid to the assessment of suicide in patients using methamphetamines. The rates of suicide attempts and completions remain higher than the general population among methamphetamine users with a history of self–harm or attempts and current mental illness serving as the best predictors of attempted or completed suicides.²³

The relationships between psychotic, mood, and anxiety disorders and methamphetamine use are complex and demand comprehensive assessment and diagnosis. Fragmented screening and assessment methods can lead to poorer health outcomes for methamphetamine users.²⁴ Understanding these complex relationships, assessment, and treatment methods, and by using a strong interprofessional referral network, the physician or dentist can contribute to better outcomes for their patients.

Prevalent Oral Health Conditions

Sam Quinones in his book, The Least of Us, described the ravaged teeth and tooth destruction caused by methamphetamine use.²⁵ Methamphetamine use is associated with changes in the saliva, exposure to noxious chemicals, and changes in behavior that result in a pattern of oral diseases seen primarily among methamphetamine substance users called “meth mouth” (See Figure 1).²⁶

Figure 1.

Example of oral destruction that can result from methamphetamine use.

Source: American Dental Association. Mouthhealthy.org. accessed 3/30/22

Methamphetamine causes the body to release a wave of dopamine that stimulates the sympathetic nervous system (SNS), constricting smooth muscle. In the oral cavity, salivary glands constrict and salivary flow is reduced.²⁶ As the saliva decreases, the acidity of the saliva increases and buffer capacity diminishes, creating an environment that is hyper–susceptible to oral disease. One study found that 95% of participants experienced dry mouth or xerostomia.²⁷ This hypersusceptible oral cavity when exposed to methamphetamine’s acidic and noxious chemicals favors pathogenic bacteria and tooth decay.

The tooth destruction seen in methamphetamine use occurs in an unusual pattern. Dental caries usually occurs in the pits and fissures of the chewing surfaces of the teeth. Dental caries on smooth surfaces of the enamel occurs between the teeth where plaque accumulates, and is difficult to remove. With methamphetamine use disorder, dentists see tooth decay presenting as black holes on the buccal or facial surfaces (smooth surfaces) of the teeth, in addition to the usual locations for dental caries.

Users of methamphetamine are increasingly likely to use sugar sweetened beverages such as carbonated soft drinks (soda pop).²⁸ This use of sugar increases the risk for tooth decay by providing a substrate for pathogenic bacteria known to cause tooth decay. While this substrate could be mitigated with increased oral hygiene, patients who are experiencing a dopamine high may be unable to complete oral health practices and/or unable to remember to do so.

High levels of dopamine can trigger bruxism or the clenching of teeth together. Pathogenic bruxism (grinding) on teeth that are fragile and brittle due to tooth decay and exposure to chemicals can result in tooth fracture.²⁹

Treatment Planning – Primary Care Clinician

Management of patients with methamphetamine use disorder in the primary care setting is challenging and requires an interdisciplinary approach that includes linkage to behavioral health services.³⁰ There are no FDA–approved medications for methamphetamine use disorder, and no medications that have shown consistent efficacy for treating this condition across multiple clinical trials. Behavioral treatments remain the standard of care. Medications that have been studied in treating methamphetamine use disorders include bupropion, naltrexone, and mirtazapine.

One promising recent randomized controlled trial studied 12 weeks of combination pharmacotherapy with injectable extended–release naltrexone with oral daily bupropion compared with placebo, and did show a statistically significant decrease in methamphetamine use with naltrexone/bupropion combination therapy.³¹ Overall response rate to this treatment was low overall and prescribers may face other logistical challenges including cost, but may be a treatment option for selected patients. Pharmacotherapy currently has a limited role in treating methamphetamine use disorder and is an area requiring further study.

Harm reduction is an important consideration for primary care physicians. Even in patients who are not yet ready to reduce or stop using methamphetamine, PCPs can engage in treatment planning to reduce certain risks of chronic methamphetamine use. For patients who inject methamphetamine, PCPs can provide education on safer injection practices and linkage to syringe service programs to reduce risk of contracting HIV, Hepatitis B and Hepatitis C. For patients who use methamphetamine with sex, PCPs should counsel on safer sex practices including condom use, offer HIV pre–exposure prophylaxis (PrEP), and provide regular screening for sexually transmitted infections. Maintaining a therapeutic alliance and non–judgmental approach can strengthen efforts at harm reduction and open opportunities for behavior change when patients are ready to consider change.

Treatment Planning – Behavioral Health

The primary care clinician should be comfortable assessing the level of anxiety, depression, suicidality, and substance abuse in a patient. Being able to distinguish between a true psychotic disorder and substance–induced psychosis will be critical to the successful treatment of patients. When patients present with acute methamphetamine intoxication, the provider’s first response is to use de–escalation techniques to build a rapid rapport and sense of connectedness with the patient. These techniques include the use of collaborative language, providing the patient with your full attention, empathy, and reflective listening. If a patient presents in an acute psychotic episode, referral to a behavioral specialist is indicated.

While clinical trials have explored the use of antipsychotics, antidepressants, and anticonvulsants as tools to decrease cravings, usage, and withdrawal symptoms, the results of these trials do not provide evidence for their usage.³² Long–term treatment of patients with methamphetamine addiction will likely focus on evidence–based behavioral therapies, such as cognitive behavioral therapy, motivational interviewing (MI) and contingency management interventions provided by a mental health professional.³³

Cognitive behavioral therapy (CBT) is a psychotherapeutic approach designed to identify and modify the dysfunctional or maladaptive behaviors and thinking patterns that cause and maintain addiction. Mental health providers will focus specifically on the behavioral component of CBT and use contingency management strategies to shape behavior.¹⁷ Contingency management strategies reinforce positive behaviors, such as treatment adherence and abstinence, by providing tangible incentives.³⁴ Motivational interviewing techniques have proven to be effective in the treatment of addictions through the exploration of any ambivalence towards change.

Due to the interaction of thoughts, behaviors, and the environment in which one operates, clinicians created a Matrix Model treatment approach aimed at integrating behavioral therapy, family education, individual counseling, 12–step support, drug testing, and encouragement for non–drug–related activities. This model has been shown to be effective in reducing methamphetamine misuse.^35,36

Understanding current evidence–based behavioral health treatment approaches allows clinicians to collaborate in the interprofessional treatment planning process. It provides a common language between the patient in recovery and their providers. Because these treatments target the development and maintenance of addiction and addiction behaviors, a thorough understanding of these treatment approaches allow providers the tools to gain greater insight into their patients’ history and relationship to addiction.

Treatment Planning – Dental Clinician

To assist in coordinating care for patients with SUD, the National Council for Mental Wellbeing developed a toolkit to facilitate the coordination and integration of oral, mental, and substance use treatment.³⁷ This toolkit provides examples of how mental health and oral health clinicians have worked together and improved patient outcomes.

Lack of access to needed dental care for methamphetamine users often results in their arriving in emergency departments for toothaches, which are a leading cause of avoidable emergency department visits, providing evidence of lack of access to regular oral health care.

When treatment planning patients who use methamphetamines, referring these patients to a dental home is an essential first step. The dentist will evaluate the patient for inflammatory periodontal disease, severity of tooth decay, tooth infections and the risk for oral cancer or other oral lesions.²⁹ The patient will be treated initially for any acute infection by removing infected teeth or those that are unable to be saved and receiving therapy for the inflammatory periodontal (gum) disease.

After the acute phase of treatment is complete, the oral health care team will address the patient’s xerostomia, educate them on oral health behaviors, and provide in–office preventive treatments to improve their quality of life. Patients often require frequent preventive treatments including fluoride in the form of a varnish and/or silver diamine fluoride that can be provided in a physician or dental office.

The dental team can provide a patient with severe tooth destruction from methamphetamine use with a plan for restoring his/her smile. This plan can include a combination of fillings (restorations), crowns (caps), implants, and/or removable dentures. For patients who are currently using methamphetamine, the dentist should provide treatment 24 hours after their last dose of meth.³⁸ However, restoring the patient’s smile is typically most effective when the patient is undergoing or has completed rehabilitation. Continued use of methamphetamine after dental replacements is likely to break down any new restorations that were placed.

Summary

With methamphetamine use increasing in Missouri, primary care physicians, behavioral health professionals, and dentists should be aware of the signs and symptoms of this disorder, the diagnosis of methamphetamine use disorder and approaches to care for these patients. Given the range of symptoms in which patients can present, these patients can benefit from a collaborative approach to their management, as outlined in this article.