What works for meth addiction?

[Long Dong]

Here's the story when I was in med school one of my good friends (a lawyer) was doing party drugs e.g. ecstacy as the gateway that lead him eventually to meth. Long story short he lost his license to practice law, lost his job, and accused his GF of cheating on him (wasn't true) and eventually put a .38 to his chest. I felt pretty useless as a med student having just learned SIGE CAPS and couldn't pick it up or do anything about it. Felt like what more could I have done to prevent this, it still haunts me to this day.

About 4 years later now have another friend similar story, car salesman starts with party drugs now on meth. Lost his job, GF, and most of his friends cause he accuses them of scheming against him. What can I do to get this guy some help? Do I have to wait for him to hit bottom before he seeks help? I'm afraid he might go to jail, and then develop SI/HI. As of now he doesn't have that and denied SI/HI. But when I visited him last time he was so parinoid and talked about SI/HI but said he'd never actually do it. Should I 5150 him? I don't even know if I can cause my license isn't even in Calif, but I go home to visit and that's the state he is in. I did a uptodate search but nothing was specific for meth. Please advise how should I proceed since I'm not a psych res. Might ask an addiction specialist at my hospital but wanted to get your guys ideas first. My friend again is unemployed and has no insurance, what can be done? I don't want to have the feeling of what more could I have done. Thanks in advance.

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[dianamd]

Here's the story when I was in med school one of my good friends (a lawyer) was doing party drugs e.g. ecstacy as the gateway that lead him eventually to meth. Long story short he lost his license to practice law, lost his job, and accused his GF of cheating on him (wasn't true) and eventually put a .38 to his chest. I felt pretty useless as a med student having just learned SIGE CAPS and couldn't pick it up or do anything about it. Felt like what more could I have done to prevent this, it still haunts me to this day.

About 4 years later now have another friend similar story, car salesman starts with party drugs now on meth. Lost his job, GF, and most of his friends cause he accuses them of scheming against him. What can I do to get this guy some help? Do I have to wait for him to hit bottom before he seeks help? I'm afraid he might go to jail, and then develop SI/HI. As of now he doesn't have that and denied SI/HI. But when I visited him last time he was so parinoid and talked about SI/HI but said he'd never actually do it. Should I 5150 him? I don't even know if I can cause my license isn't even in Calif, but I go home to visit and that's the state he is in. I did a uptodate search but nothing was specific for meth. Please advise how should I proceed since I'm not a psych res. Might ask an addiction specialist at my hospital but wanted to get your guys ideas first. My friend again is unemployed and has no insurance, what can be done? I don't want to have the feeling of what more could I have done. Thanks in advance.

Whoa, I read your Step 1 posts way back in the day, and so had to reply.

Although I am just a fourth year med student, I did spend a month in California and learned some of the rules about 5150 (a 72-hour hold in CA, for those who don't know). One thing is that if you attempt (or a california psychiatrist attempts) to 5150 your friend, and he denies SI/HI in the ED, they will probably let him go. You have to prove that the guy is a real danger to self and if he is denying it and you have no proof, it is going to be hard to keep him in house.

Furthermore, a 5150 is merely 72 hours, and while that may serve as a "wake up call" to your friend, it could also do him little benefit and perhaps even make him upset.

Just my two cents: I would try hard to convince him to see an addiction specialist (of which there are many in California). That way, he will be in the "psych system," and there will be someone who knows his story that can 5150 him at a later date if need be. And I would guess, that is going to be the best chance he has to get proper therapy and get clean -- more importantly, to prevent him from doing something he/you regrets.

If you can get him to admit that he has a problem and convince him that a psychiatrist can help him, that he can be happier, healthier, have a job and a life again -- and let him know that you are there for him -- it can set the stage for a psychiatrist actually making an impact.

it is a terrible feeling to have regret over a medical decision that you didn't make (especially one when you didn't know any better) -- but you can only do so much from afar and you can't hold yourself responsible (blameworthy) for your friend from back in med school or your friend now. good luck.

 

[Rapunzel]

People don't recover from addiction until they make the choice to do so. There is no way to force them to get better. You can lock them up for a while, but the greatest risk period for suicide is after release from the hospital, if I am remembering correctly.

As a friend, you could tell him how scared you are for him and what you see happening and how it would impact people who care, like you. And ask him to get help. It is out there.

 

[OldPsychDoc]

Here's the story when I was in med school one of my good friends (a lawyer) was doing party drugs e.g. ecstacy as the gateway that lead him eventually to meth. Long story short he lost his license to practice law, lost his job, and accused his GF of cheating on him (wasn't true) and eventually put a .38 to his chest. I felt pretty useless as a med student having just learned SIGE CAPS and couldn't pick it up or do anything about it. Felt like what more could I have done to prevent this, it still haunts me to this day.

About 4 years later now have another friend similar story, car salesman starts with party drugs now on meth. Lost his job, GF, and most of his friends cause he accuses them of scheming against him. What can I do to get this guy some help? Do I have to wait for him to hit bottom before he seeks help? I'm afraid he might go to jail, and then develop SI/HI. As of now he doesn't have that and denied SI/HI. But when I visited him last time he was so parinoid and talked about SI/HI but said he'd never actually do it. Should I 5150 him? I don't even know if I can cause my license isn't even in Calif, but I go home to visit and that's the state he is in. I did a uptodate search but nothing was specific for meth. Please advise how should I proceed since I'm not a psych res. Might ask an addiction specialist at my hospital but wanted to get your guys ideas first. My friend again is unemployed and has no insurance, what can be done? I don't want to have the feeling of what more could I have done. Thanks in advance.

All YOU can do is tell him what he already knows--that he has a problem.
You might be fortunate enough to catch him in a moment of lucidity in which he can rationally consider how much it has cost him to be on this drug vs. what it benefits him. To be honest there's not much you can do from out of state except let him know that you know that there is a problem, and you'd really like to help--even if it's just to call 911 for him when he's talking SI/HI. (And don't hesitate to make that call--it could be what gets him into an ER where a referral to appropriate help can be made. Sometimes having the police show up at the door is what it takes to convince a guy that he is an addict.)

You are right that there is nothing specfic for meth dependence. Those of us in the field do use some antidepressants (specifically bupropion) and antipsychotics to assist in symptomatic treatment in early sobreity, but meth in particular takes some time to get back to baseline normal brain functioning--especially if they've been using to the point that they are paranoid. He's also going to have some pretty major psychosocial needs--job, home, friends, potentially legal issues--so it can be tough. I don't know what programs are available for the uninsured in CA.

Bottom line--best thing you can do is prevent the next one. If you have other friends who are convinced that "party drugs", even MJ, are "harmless fun", you now have an N=2 for what can potentially come later...maybe, just maybe it can be a wake-up call for someone else.

 

[whopper]

One factor I've picked up from my own clinical experience is if you have someone who is addicted to stimulants--rule out ADHD.

There is a fine line between someone with ADHD & someone who is addicted to stimulants, faking their problems for more stimulants. One approach I tried is to give non abuse ADHD meds such as Atomoxetine, Bupoprion, or Venlafaxine.

I had a few cases where after the person felt like their ADHD was treated, they didn't feel as much of a need to take a stimulant that was a substance of abuse.

 

[futureapppsy2]

This is not really that helpful (likely), but Beautiful Boy by David Sheff gives a pretty depressing (but likely realistic) account of dealing with a loved one who is addicted to meth.

 

[OldPsychDoc]

One factor I've picked up from my own clinical experience is if you have someone who is addicted to stimulants--rule out ADHD.

There is a fine line between someone with ADHD & someone who is addicted to stimulants, faking their problems for more stimulants. One approach I tried is to give non abuse ADHD meds such as Atomoxetine, Bupoprion, or Venlafaxine.

I had a few cases where after the person felt like their ADHD was treated, they didn't feel as much of a need to take a stimulant that was a substance of abuse.

Yeah, it always kind of bugs me when a meth or crack addict says "I used to bounce off the walls in elementary school, but my mom didn't want them to give me any drugs." Then of course they start smoking weed at 14, and discover meth a couple of years later... As a rule of thumb, if one of these folks tells you that crack calmed them down--they probably had ADHD. It's interesting that actual evidence is mounting that bupropion can improve abstinence from cocaine and methamphetamine in these folks. I like atomoxetine for the really restless, hyperactive, anxious ones too. Had a nice result this week in a 26 yr old ADHD/meth dependent pt. I make it REAL clear that they're not getting Adderall from me, though! I won't rule out using some methylphenidate (especially a slow release) after maybe a year of sobreity--but most of them have moved on from me by the time they make that time point....

 

[Therapist4Chnge]

It's interesting that actual evidence is mounting that bupropion can improve abstinence from cocaine and methamphetamine in these folks.

I know bupropion is often used as an alternative for ADHD Tx if the person can't have a stimulant, so it isn't surprising that the above holds water.

 

[whopper]

I make it REAL clear that they're not getting Adderall from me, though!

I remember a nightmare day in outpatient, had a guy who was trying to get Adderall (or any other amphetamine based ADHD med). The guy was a meth addict, & was placed on an amphetamine based ADHD med by his PCP, who then referred the guy to psychiatry.

So we then got him, and he demanded we give him that same med or one just as potent. I told the guy that I wanted to entertain the possiblity that he had ADHD, but I couldn't just do it based on his meth history. I told him I wanted to do some testing on him, have off of meds for at least a week, and try him on Wellbutrin, Modafanil, Effexor or Strattera.

The guy flipped. He brought his mother along who also begged we put him on an amphetamine. Well, I was hoping the mother could shed some light, and the only symptom she could tell me that improved with his ADHD med was that he was more polite and would start saying "thank you".

OK well yeah, she's not a clinician, maybe there was more to it than she could elucidate, but heck, that could also be someone addicted to stimulants, who since he was being prescribed a stimulant is less irritable because his dependence symptoms are now put at bay.

Well now the mother's flipping out, and I had to call the attending in. That appointment started 3pm--and didn't end to 6pm because we kept trying to explain to them that we just can't give out a possible substance of abuse until there was some verification & non-abusive alternatives were tried. I was thinking "dude, I'm in outpatient and there's no staff to give haldol"--that's how bad it got. There was a lot of screaming going on from that guy & his mother.

 

[kugel]

call 911 for him when he's talking SI/HI. (And don't hesitate to make that call--it could be what gets him into an ER where a referral to appropriate help can be made. Sometimes having the police show up at the door is what it takes to convince a guy that he is an addict.)

You know the adage that you can't help until he hits bottom...
MAKE this this bottom. Do everything you can to put a stop to this.

You lost one friend and wish you could have done more. Don't make it two. You compare calling 911 in order to put him in front of a police officer and, hopefully, a psychiatrist vs. worrying about whether it "might make him upset?"...... you see where I'm going.

If/when you call 911 (with a complaint of SI that same day), make sure the officer contacts you for collateral information, so he can put your quotes on the 5150 (makes it much stronger). If the officer doesn't call YOU in a few minutes, call back to 911 and tell the dispatcher that you need to talk with the officer assigned IMMEDIATELY. Don't give them the chance to dismiss the call because your friend denied the statements, or didn't answer the door, etc. Make your statements as clear as possible, and TELL THEM if you believe he IS suicidal - despite his denials.

Also, ask the dispatcher for the # to the psych emerg service where your friend would be taken, so that you can tell your story directly to the doc evaluating your friend. Again, it helps to assure it doesn't all get dismissed as a "misunderstanding." Don't assume the police will pass along your statements or your phone #. If the doc doesn't have your info, he/she has nothing besides your friend's word.

If a friend told you over the phone that he's having crushing chest pain radiating down his left arm, beginning to get SOB, diaphoretic, etc. but "didn't think it was a problem," could you live with yourself if you didn't make the call and he died? You'd call 911, and then you'd probably follow-up with a call to the ER doc so they know everything you know.

I know I'm being a hardass here, but feel free to tell your friend to hate ME for giving you this advice - - after this is all behind him.

 

[OldPsychDoc]

I remember a nightmare day in outpatient, had a guy who was trying to get Adderall (or any other amphetamine based ADHD med). The guy was a meth addict.....
Well now the mother's flipping out, and I had to call the attending in. That appointment started 3pm--and didn't end to 6pm because we kept trying to explain to them that we just can't give out a possible substance of abuse until there was some verification & non-abusive alternatives were tried. I was thinking "dude, I'm in outpatient and there's no staff to give haldol"--that's how bad it got. There was a lot of screaming going on from that guy & his mother.

Oh G-d, I had one like that too--just substitute the word "girlfriend" for "mother".
And, Oh yeah, there was no attending to call in, because now that's ME.
Did any of the screaming include the lines: "Well if you don't prescribe it for him, I guarantee you he'll be out buying meth on the street in 20 minutes", or "If it's a legal prescription drug, then why won't you just prescribe it for him?"

 

[whopper]

Well if you don't prescribe it for him, I guarantee you he'll be out buying meth on the street in 20 minutes", or "If it's a legal prescription drug, then why won't you just prescribe it for him?"

Yeppers. Not with the same exact qoutes, wait a minute, maybe they actually were the same exact qoutes. I'm sure what happened to you was pretty much almost the same that happened to me.

Funny, now that I'm an attending, had the resident called me in, I would've been just as scared, frustrated and not knowing what to do too-because it was an outpatient office, and I can't haldol the guy if he attacked me.

I thought about that case long & hard because I did wonder if this guy really did have ADHD, what could've been done better & why it went so bad.

IMHO, I think the PCP giving this guy an amphetamine without doing some preliminary testing really upped this guy's expectations. When we told him he wasn't going to get it--it dropped his expectations, so much that it lead to him being agitated.

If the guy came in, told us he had a meth problem, and I told him that I need to treat his meth dependence, while trying to rule out ADHD, and the guy never got an amphetamine to begin with, I think the guy would've been more amenable, and he would've probably felt better being on Welbutrin since there would've been some increased dopamine, and at least it would've been better than nothing had he not been given an amphetamine in the first place. Telling a guy something to the effect of -the amphetamine stops here- was probably interpreted as a crushing blow instead of a ray of hope.

So I kept trying to tell the guy that there were other things that could be tried--and it didn't seem to help. I actually did think the guy was being sincere, but that didn't convince me he had ADHD. He could've been a meth addict who was so down on his luck that he convinced himself he had ADHD, that was further solidified by a PCP who told him he might have it without going through the DSM criteria or testing.

I think in the future, if I do get a case similar to this, where someone is given an amphetamine without proper documented testing for ADHD, I need to tell the person upfront, before the interview even begins that amphetamines will likely not be given. That might've defused the problem before it blew up.

 

[Abram Hoffer]

I remember a nightmare day in outpatient, had a guy who was trying to get Adderall (or any other amphetamine based ADHD med). The guy was a meth addict, & was placed on an amphetamine based ADHD med by his PCP, who then referred the guy to psychiatry.

So we then got him, and he demanded we give him that same med or one just as potent. I told the guy that I wanted to entertain the possiblity that he had ADHD, but I couldn't just do it based on his meth history. I told him I wanted to do some testing on him, have off of meds for at least a week, and try him on Wellbutrin, Modafanil, Effexor or Strattera.

The guy flipped. He brought his mother along who also begged we put him on an amphetamine. Well, I was hoping the mother could shed some light, and the only symptom she could tell me that improved with his ADHD med was that he was more polite and would start saying "thank you".

OK well yeah, she's not a clinician, maybe there was more to it than she could elucidate, but heck, that could also be someone addicted to stimulants, who since he was being prescribed a stimulant is less irritable because his dependence symptoms are now put at bay.

Well now the mother's flipping out, and I had to call the attending in. That appointment started 3pm--and didn't end to 6pm because we kept trying to explain to them that we just can't give out a possible substance of abuse until there was some verification & non-abusive alternatives were tried. I was thinking "dude, I'm in outpatient and there's no staff to give haldol"--that's how bad it got. There was a lot of screaming going on from that guy & his mother.

That's why I love psych; if you don't like the way someone is behaving, your instinctive thought tells you to sedate them.

 

[Chrismander]

I make it REAL clear that they're not getting Adderall from me, though! I won't rule out using some methylphenidate (especially a slow release) after maybe a year of sobreity--but most of them have moved on from me by the time they make that time point....

OPD, can you elaborate on this for us newbies? I'm on the adult inpatient wards this year so I don't treat a lot of ADHD. What's the Adderall/methylphenidate distinction with regards to drug-seeking or potential abuse?

 

[whopper]

That's why I love psych; if you don't like the way someone is behaving, your instinctive thought tells you to sedate them

While I know you're joking, I've seen some attendings get very very over the top with haldolling/thorazining patients.

Chrismander--OPD may be able to add more & answer better, but I'll answer your question with what I know.

ADHD increases the odds of substance abuse. There's several reasons as to why, the impulsivity, comorbid disorders, etc. Also, some with ADHD may abuse stimulants because it may be somewhat therapeutic for them.

Several of the meds to treat ADHD are potential substances of abuse, e.g. methylphenidate or Adderall. They in short are pretty much amphetamines pure & simple.

So if you have someone claiming to have ADHD, and wanting an amphetamine, how are you to know if this person truly has it, or if the person is simply just someone trying to get pharmaceutical grade amphetamines for the purposes of getting high?

Often times one cannot tell. Add to the problem is that if the person truly has ADHD, and they're not treated-they are more likely to abuse illicit substances. The issue becomes especially suspicious in the case I mentioned above--the guy came in demanding amphetamines, had a history of drug abuse, had no formal testing, could not give me any school records, and unfortunately, his PCP already started him off on some amphetamines & gave him the impression that I as a psychiatrist would continue it without asking me my opinion--> all of which lead to that patient blowing up in my office.

There are methods however to tell, and to treat ADHD without being duped by those intending to abuse stimulants. Several medications which are not substances of abuse such as Buproprion, Venlafaxine, & Atomoxetine among others have been found to treat ADHD without giving the person a buzz. You might be able to successfully treat one's ADHD without amphetamines.

There are also formal methods of testing such as the Conners scale (though IMHO the tests are too easy to fake).

I personally very much agree with OPD's take on this--avoid giving the amphetamines unless there's strong reason to believe someone is not abusing the medication.

The guy in the case I mentioned above thought his PCP & his mother's endorsement would've been good enough. Not to me. I've seen several PCPs give out psychotropic meds without following DSM criteria, and that's not good enough for me. As for the mom, heck, I've seen mother son drug dealing operations. For all I know the mother wanted some amphetamines for herself as well. I don't believe in my gutt that this was what was really going on, but I don't practice medicine or give out substances of potential abuse simply based on my gutt.

 

[Therapist4Chnge]

There are also formal methods of testing such as the Conners scale (though IMHO the tests are too easy to fake).

ADHD assessment was just being discussed on a psychology listserv I frequent, and the rub involve what insurance will reimburse for vs. what is needed. There are more brief batteries that can be done (1 hr), though a more comprehensive battery (3-4 hr) will help eliminate other neuro and related issues. It is important to note that screeners are meant to flag for further assessment, and not meant for Dx, as they are often too simplistic and easily manipulated (which we both seem to agree with).

 

[Abram Hoffer]

While I know you're joking, I've seen some attendings get very very over the top with haldolling/thorazining patients.

Yeah, drooling and hibernation are sort of bad. Shining bright lights at them also doesn't work. Dexedrine combined with atypicals sometimes has decent results.

 

[whopper]

OT, but I've had 3 situations in 2 years in outpatient where patients were doing behavior that could've gotten them committed.

But in outpatient, all you can do is call the cops who don't show up for 15 minutes.

In the above case, the guy eventually calmed down on his own. In the other 2 cases, I had to get someone to open the samples bin, and give some Zyprexa Zydis samples to calm that agitated person down. (Case 1-person was manic & left the day program and was walking up & down the street with busy traffic, case 2, the guy had bipolar & PTSD, had a flashback & went manic all at the same moment). Yay, JACHO wants all samples removed. Thanks JACHO, you're really helping us in your attempts to give better care. Next time, I'll just have to lay on my hands & hope that helps.

If I ever develop an outpatient practice, I'm going to create a panic button situation, where if a clinician feels they're in danger, a press of the button will cause all the staff to go to that person's room, and 9-1-1 will be called immediately. I'm surprised how little I see that in outpatient.

 

[billypilgrim37]

Thanks JACHO, you're really helping us in your attempts to give better care. Next time, I'll just have to lay on my hands & hope that helps.

Since no office could possibly PURCHASE a few doses of heavy tranquilizers as part of a safety plan...

 

[whopper]

Since no office could possibly PURCHASE a few doses of heavy tranquilizers as part of a safety plan...

Hey, they ought to, but no outpatient office I've seen had ready supplies of haldol, nor orderlies, TPWs (as they are called in Ohio, MHAs, in NJ), or security guards.

I'm sure some of them do, just not any of the ones I've seen. JCAHO wanted to get rid of samples, but didn't advise offices to fill up with anything else.

 

[billypilgrim37]

Hey man, the market abides. We should get financing to produce a psychiatric utility belt, including a B52 in an epi-pen, and some tootsie-pops wrapped in M-tabs...

 

[kugel]

I'm Marlin Perkins from Mutual of Omaha's "Wild Kingdom." I'll keep on eye on the rest of the herd from up here in the helicopter while Jim Fowler, down on the ground, wrestles the angry schizophrenic to the ground and injects him with a sedative, while awaiting the arrival of the police some time in the next hour.

 

[OldPsychDoc]

I'm Marlin Perkins from Mutual of Omaha's "Wild Kingdom." I'll keep on eye on the rest of the herd from up here in the helicopter while Jim Fowler, down on the ground, wrestles the angry schizophrenic to the ground and injects him with a sedative, while awaiting the arrival of the police some time in the next hour.

What's that sound? Another helicopter approaches. It's billypilgrim37, rappelling down to the rescue! In a single smooth motion, he draws a patented double-barrel B-52 dart gun from his psychiatric utility belt, aims and fires! The patient goes down! The day is saved! As they wait for the medivac chopper, our hero expertly debriefs Jim, and supplies propranolol lollipops to stave off PTSD...

On our next episode--will billypilgrim's portable TMS unit simultaneously treat depression as it snatches the razor blades from the wild borderline's hand? Tune in next week for more...

 

[Faebinder]

Hey, they ought to, but no outpatient office I've seen had ready supplies of haldol, nor orderlies, TPWs (as they are called in Ohio, MHAs, in NJ), or security guards.

I'm sure some of them do, just not any of the ones I've seen. JCAHO wanted to get rid of samples, but didn't advise offices to fill up with anything else.

Which is why I am serious about hiring a large male as my office assistant and having a pepper spray handy.

 

[Faebinder]

Here's the story when I was in med school one of my good friends (a lawyer) was doing party drugs e.g. ecstacy as the gateway that lead him eventually to meth. Long story short he lost his license to practice law, lost his job, and accused his GF of cheating on him (wasn't true) and eventually put a .38 to his chest. I felt pretty useless as a med student having just learned SIGE CAPS and couldn't pick it up or do anything about it. Felt like what more could I have done to prevent this, it still haunts me to this day.

About 4 years later now have another friend similar story, car salesman starts with party drugs now on meth. Lost his job, GF, and most of his friends cause he accuses them of scheming against him. What can I do to get this guy some help? Do I have to wait for him to hit bottom before he seeks help? I'm afraid he might go to jail, and then develop SI/HI. As of now he doesn't have that and denied SI/HI. But when I visited him last time he was so parinoid and talked about SI/HI but said he'd never actually do it. Should I 5150 him? I don't even know if I can cause my license isn't even in Calif, but I go home to visit and that's the state he is in. I did a uptodate search but nothing was specific for meth. Please advise how should I proceed since I'm not a psych res. Might ask an addiction specialist at my hospital but wanted to get your guys ideas first. My friend again is unemployed and has no insurance, what can be done? I don't want to have the feeling of what more could I have done. Thanks in advance.

The first step to making sure he gets better is to make sure he knows he has a problem. Follow that by sending him to an addiction specialist. Unfortunately, most do not think they have a problem and need to hit rock bottom in life style and social support for them to realize this is a problem...that's when it potentially gets dangerous. You can't blame yourself for your friend's lack of insight but you can blame yourself for not trying to make point about this lack of insight.