MAOIs in former meth users

[AnnTaylor]

So like a fair number of us "newer generation folks," I cannot brag that I have a robust treatment portfolio when it comes to MAOIs. Lately, I seem to have a cluster of former meth users who insist they get nardil. One of them was on it when I took over care. A few others are pushing hard (including one who had 10 yrs sobriety but relapsed last yr and is mainly personality disordered who had of course tried every med under the sun and using that as a launching pad). I know buproprion snorted would maybe attract a "high seeker" but nardil? Unfortunately I think the one pt who was put on it before I took over actually does do meth on some weekends when pt "allows" the nardil to "run out."
I really struggle with former substance users who have been psychiatricized because some ppl think it's a liability not to do so and they still
have a drug seeking mentality
(which I do call them out on).

In a similar vein, some of our busy ED's who push hard for us to see an acutely meth intoxicated person (who has not yet become a schizophrenic/schizoaffective) pre utox and psychiatricize with psychotropics +/-admit instead of metabolizing and
peacing out w substance
resources are huge culprits.

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[notdeadyet]

I don't know where you practice, but it could be that you have a cluster of meth users seeing the same psychiatrist or practice that pushes a lot of Nardil. Or their mental illness is refractory to treatment by more firstline meds (which, if someone is treating their addiction with antidepressants, that would explain why it's "refractory").

I think we probably have different views on methamphetamine users. IMHO, they should be "psychiatricized," because substance abuse is a form of mental illness. And I've yet to meet a meth addict that didn't have a co-morbid psychiatric illness. Often Axis II granted, but a majority of times they also have Axis I, some of which it is appropriate to treat with medications. I'm curious what you're calling them out on, when they're approaching you for Nardil?

As for the ED thing, it's a mixture of policy and ethics. I agree that sometimes the ED will pressure to admit meth patients, which can be bad juju, as they often clear and are fine the next morning (though sometimes now, which is why they need to stay somewhere). But I don't think there's any problem with "pscyhiatricizing" them. If the patient is having A/VH or delusions that are distressing the patient, I disagree with the sentiment some have of just letting the patient suffer, since it's drug-induced. If a patient's in pain, I can't think of an ethical argument for not treating.

I don't mind when the ED wants med recs for treating meth-induced psychosis. But I'm with you if they want us to admit any patient whose meth intoxicated.

 

[OldPsychDoc]

N of 1--but had a guy who similarly was insistent that the ONLY thing that would work was Nardil. I don't know if they've just gotten themselves so dopamine depleted that their receptor and transporter DNA is permanently supressed or what...
(He did also have a history of being treated by an very old-line psychiatrist for a long time as well.)

 

[AnnTaylor]

I don't know where you practice, but it could be that you have a cluster of meth users seeing the same psychiatrist or practice that pushes a lot of Nardil. Or their mental illness is refractory to treatment by more firstline meds (which, if someone is treating their addiction with antidepressants, that would explain why it's "refractory").

I think we probably have different views on methamphetamine users. IMHO, they should be "psychiatricized," because substance abuse is a form of mental illness. And I've yet to meet a meth addict that didn't have a co-morbid psychiatric illness. Often Axis II granted, but a majority of times they also have Axis I, some of which it is appropriate to treat with medications. I'm curious what you're calling them out on, when they're approaching you for Nardil?

As for the ED thing, it's a mixture of policy and ethics. I agree that sometimes the ED will pressure to admit meth patients, which can be bad juju, as they often clear and are fine the next morning (though sometimes now, which is why they need to stay somewhere). But I don't think there's any problem with "pscyhiatricizing" them. If the patient is having A/VH or delusions that are distressing the patient, I disagree with the sentiment some have of just letting the patient suffer, since it's drug-induced. If a patient's in pain, I can't think of an ethical argument for not treating.

I don't mind when the ED wants med recs for treating meth-induced psychosis. But I'm with you if they want us to admit any patient whose meth intoxicated.

I'm on the west coast and in a county setting where there is no "psych ED." There is only pressure to admit +/- medicate and if the ED doc feels "comfortable," discharge. In this cluster of pts I have, there is a strong personality disordered component that led to, as you may imagine, many many lukewarm med trials from which the provider before me decided the only fruit left on the branch was nardil. I don't call pts out on wanting nardil (though I was curious to know if there is any known euphoria associated with it? Certainly the insomnia must feel like using meth). I call former substance dependent pts out when I suspect they still have drug-seeking/med manipulating mentalities lingering on during their psychopharm treatment (esp if they are complaining that nothing works, demanding one med, keeping stashes of meds, and are mostly axis II pts). That also explains why I don't like acutely psychiatricizing this subset (which I feel often stems from liability concerns).

I respect your views on substance users and "psychiatricization." When I was an intern, the ED culture made it such that I felt as though I almost reflexively had to order antipsychotics for stimulant intoxicated (and even some cannabis intoxicated, spice being a different story) patients. One day I had an attending on call that stopped me and said, "We don't need to psychiatricize this guy." I was baffled, "But?" Sure enough the guy metabolized with a sitter at bedside with prn precautions and went on his way. He didn't want substance treatment nor is our inpatient unit equipped with such perks. From a do-no-harm perspective, no one should suffer acute distress from their drug use. However, in the ED setting, it's more often the ED doc that is distressed than the patient. In reality, it's just a matter of keeping them in a safe environment until they are able to go back out on their own. I have yet to see anyone high on meth and really distressed about their symptoms. Sometimes psychiatricizing them negates the fact that in my opinion, UNTIL proven otherwise, their primary modifiable issue is substance dependency. Psychiatricizing them enables the pt to say, "I'm not a meth addict, I'm bipolar."

Also, I think some level of psychosocial discomfort (relatives have kicked them out and they won't have a nice bed tonight, they have no money left, etc) does serve as aversive conditioning which might actually help some people. Admittedly, this is often not the case with meth dependency.

I don't know where you practice, but it could be that you have a cluster of meth users seeing the same psychiatrist or practice that pushes a lot of Nardil. Or their mental illness is refractory to treatment by more firstline meds (which, if someone is treating their addiction with antidepressants, that would explain why it's "refractory").

I think we probably have different views on methamphetamine users. IMHO, they should be "psychiatricized," because substance abuse is a form of mental illness. And I've yet to meet a meth addict that didn't have a co-morbid psychiatric illness. Often Axis II granted, but a majority of times they also have Axis I, some of which it is appropriate to treat with medications. I'm curious what you're calling them out on, when they're approaching you for Nardil?

As for the ED thing, it's a mixture of policy and ethics. I agree that sometimes the ED will pressure to admit meth patients, which can be bad juju, as they often clear and are fine the next morning (though sometimes now, which is why they need to stay somewhere). But I don't think there's any problem with "pscyhiatricizing" them. If the patient is having A/VH or delusions that are distressing the patient, I disagree with the sentiment some have of just letting the patient suffer, since it's drug-induced. If a patient's in pain, I can't think of an ethical argument for not treating.

I don't mind when the ED wants med recs for treating meth-induced psychosis. But I'm with you if they want us to admit any patient whose meth intoxicated.

 

[michaelrack]

"Phenelzine has also been shown to metabolize to phenethylamine (PEA).[11] PEA acts as a releasing agent of norepinephrine and dopamine, and produces effects very similar to those of amphetamine, though with markedly different pharmacokinetics such as a far shorter duration of action" (from Wikipedia)

 

[AnnTaylor]

"Phenelzine has also been shown to metabolize to phenethylamine (PEA).[11] PEA acts as a releasing agent of norepinephrine and dopamine, and produces effects very similar to those of amphetamine, though with markedly different pharmacokinetics such as a far shorter duration of action" (from Wikipedia)

Well this explains why at least one of the suspected axis II folks in my nardil seekers/former meth users subset is always so melodramic in my office, "Doc, I can oonly describe my depression as a deep ache from within..." and then pt becomes a dramatically bright social butterfly by the elevator immediately after leaving my office. Spying pays.