Amphetamine & Methamphetamine

We can expect a growing number of patients to be admitted to treatment with methamphetamine dependence.  This problem is growing and has reached epidemic proportions in Hawaii and Northern California.  Methamphetamine or “ice” is commonly synthesized in an illicit laboratory using pseudoephedrine or common cold remedy and other chemicals including acids and nail polish remover. Pure methamphetamine in crystalline form is essentially tasteless and odorless.  Less pure forms of taste associated with the manufacturing process and range from yellow and brown in color up to white or powder.

Usual routes of administration include inhaled via combustion (smoking) ingestion orally or intravenous administration.  In our patients, smoking and injection are the most common routes of administration of the illicit use of methamphetamine.  Other sources of methamphetamine include psycho stimulant medications (medications used to treat ADD) such as Adderall and Ritalin.  A patient with a valid prescription for one or more of these medications may in fact be abusing them.  It is safe to assume neither abuse nor dependence on admission with a prescription but careful evaluation should be undertaken to determine whether the patient is benefiting or being harmed by the medication prescribed.

Methamphetamine Detox Considerations

Detoxification for methamphetamine is usually accomplished without difficulty.  Patients presenting intoxicated with methamphetamine are another matter.  Evidence for intoxication includes patient history, urine drug screen results, and stereotyped behavior associated with methamphetamine intoxication.  Classic findings of methamphetamine intoxication include increased agitated movements, paranoid delusions, pressured rapid speech, sweating, picking at the skin, dilated pupils (midriasis) and in general an inability of the patient to sit still.

Normal (above) and Dilated (below)

One problem which must be assessed as soon as possible is the status of the patient’s mental processes.  A condition known as the “amphetamine psychosis” may be present.  Amphetamine psychosis is the mind affected long-term by amphetamine use.  Patients retain a condition of thought disturbance after amphetamine detox.  Such disturbances closely mimic schizophrenia.  Patients often have delusions of persecution, paranoia, and a variety of physical complaints.  They frequently report auditory hallucinations with visual hallucinations less common.

Patients acutely intoxicated with methamphetamines are also at risk of autonomic overdrive.  Their hearts beat so fast and their blood pressure can be so high that they are at risk for acute heart attack and stroke.  Another concern is dehydration.  Along with high heart rate and blood pressure, temperature and respiratory rate may be as well, all of which increase rate of water loss from the body.  Because of this, patients must be monitored for hydration status quite closely.  Fluids should be encouraged and the patient should need to void at least every hour or two.

Their vital signs should be monitored frequently. Attention should be paid to the trend of vital signs. In general, a staff member should stay with a patient who is acutely intoxicated with amphetamines.  As a consequence of their substance induced thought disorder they may try to walk off the property or enter areas where they shouldn’t be such as the kitchen or go into staff areas.  Occasionally while the patient is intoxicated with amphetamines, sedatives may be necessary.  Good choices include Klonopin and Ativan.

Try to ascertain when the last time a patient used methamphetamine.  This will guide your expected course.  If it has been at least 12 hours since the patient used methamphetamine, you can anticipate a gradual autonomic slowing and post-amphetamine depression.  It has been fewer than 12 hours in the lookout for acute amphetamine intoxication and acute substance induced psychosis.  Detox appearance in the days following methamphetamine intoxication are somewhat predictable as well.

Dopamine Transport

Dopamine Transporter Mechanism

Dopamine causes a reversal of the reuptake transporter mechanism in neurons.  As a result of this dopamine excess is present at synaptic junctions.  There is of course, a price to pay.  In the days following methamphetamine use, dopamine depletion is evident.  Symptoms include profound lethargy, severe fatigue, and somnolence.  Oftentimes the somnolence will have an agitated quality in the patient a difficult time finding a comfortable position in which to sleep.  Mild sedatives here again may be helpful such as Klonopin or Ativan.

The duration of time to anticipate the patient remaining in this sedated drowsy depressed state are in proportion to the intensity and duration of prior methamphetamine use.  An occasional user will recover in a day or two more frequent heavy users may take a number of days before he is able to function normally.  In general they should be allowed to sleep.

They still need close monitoring as the first two or three days following amphetamine use as cravings to resume use may be the highest.  Patients should be advised of this and encouraged to stay despite some of their thoughts.  They typically will have thoughts prompting them to leave prematurely.  They should be encouraged to stay and reminded that these thoughts are normal part of the brain’s crying out for methamphetamine which is now gone.

Patients using methamphetamine may also have underlying psychosis not caused by the amphetamine.  In general these patients are extremely difficult both to diagnose and treat. Homeless methamphetamine users have a higher rate of schizophrenia.  Whether the schizophrenia was caused by the methamphetamine or patient uses methamphetamine to relieve their symptoms of schizophrenia may not be known in up to two thirds of cases.


Category: Drugs

About the Author: Dr. Jason Giles is certified by the American Board of Addiction Medicine and the American Board of Anesthesiology. He is a physician specializing in the treatment of drug, alcohol, and behavioral addictions. He is the founder of Haywire.

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