June 16, 2025 • 37 mins
Dr. Casey Grover explores the history, neuroscience, and treatment approaches for methamphetamine use disorder, highlighting how methamphetamine releases more dopamine than any other known substance.
• Methamphetamine was widely used during World War II by German, Japanese, and Allied forces to enhance performance
• Modern meth production shifted from ephedra to P2P method, creating cheaper, more potent meth with worse psychiatric effects
• Meth causes dopamine release up to 1,400 ng/dL of dopamine compared to cocaine (400), sex (200), and food (150), severely damaging reward centers
• Many methamphetamine users have undiagnosed ADHD and are inadvertently self-medicating
• Effective medications include bupropion, topiramate, atomoxetine, viloxazine, guanfacine, and mirtazapine
• Contingency management (reward-based incentives) shows significant efficacy for methamphetamine addiction treatment
• Combination therapies using bupropion with naltrexone show promise for reducing meth use
• Treating underlying mental health conditions and providing housing/social support remains essential for recovery
To contact Dr. Grover: ammadeeasy@fastmail.com
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Episode Transcript
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Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
I am really excited about thisepisode.
(00:43):
Today we are going to be talkingabout methamphetamine use
disorder.
We will start with a history ofmethamphetamine and move on to
treatment of methamphetamine usedisorder, with a specific focus
on how medications can reducethe desire to use meth.
I gave this lecture last weekto my colleagues who work at a
residential drug and alcoholtreatment program and I wanted
(01:04):
to share it with all of you.
Here we go All right.
So today we're going to betalking about methamphetamine
use and I'm going to go throughthe history of methamphetamines
and then we're going to talkabout treatment.
And one of the reasons thislecture came up is I get
referred patients for MAT formeth and there really isn't an
(01:30):
official set of meds formedications for addiction
treatment for meth.
But there are some medicationsthat help.
They're not nearly as effectiveas, say, methadone or suboxone
for opioid use disorder, butthey can help.
So we're going to go throughhow I approach the medications
to treat methamphetamine use andwe'll get started.
(01:52):
I always love to start withhistory.
I'm a total history geek.
If you did not know, manysoldiers in World War II used
methamphetamine to stay awake,to improve performance and go on
long missions.
It was used by Japanesesoldiers, german soldiers and
Allied Forces soldiers.
(02:14):
It was pharmaceutical, the drugname at the time was called
Pervitin and it was actuallyvery extensive through the
German army, really really alllevels of the German military
during World War II, all the wayup to Adolf Hitler himself.
Incredible amounts ofmethamphetamine were used during
(02:36):
the war.
And there's more to the historyof methamphetamine, but I find
it so interesting that it reallyfueled one of the biggest human
conflicts in human history.
So this is a graphic that Ifound that provides an overview
of the history ofmethamphetamine.
And they were first synthesizedin the late 1800s and we
(02:57):
weren't really sure what to dowith them.
Stimulants are helpful forthings like boosting our
metabolism.
Stimulants are helpful forthings like boosting our
metabolism, dilating our lungsduring asthma attacks and
causing wakefulness.
So the very first uses wereactually in Japan for asthma and
(03:19):
to promote wakefulness andnarcolepsy.
As I mentioned, they were veryextensively used during World
War II and interestingly and Ididn't know this after the war
Japan, whose country was bothphysically and financially
decimated, japan, experienced arise in recreational
methamphetamine use, and itmakes sense right.
People were emotionallydistraught after what they had
(03:43):
been through.
The country had to rebuild.
It's not surprising at all thata substance like meth would take
hold.
It was used medically in theUnited States in the 1950s,
particularly around obesity,sinusitis and again to promote
wakefulness with narcolepsy.
Into the 1970s it was finallymade a controlled substance by
(04:08):
the federal government and inthe 1980s we began to see it
uniquely as a problem drug inthe population of men who have
sex with men, and this wasaround the time that AIDS and
HIV began to come about.
In the 1990s we saw increasingproduction of methamphetamine To
combat this.
(04:28):
In 1996, congress passed theComprehensive Methamphetamine
Control Act, which we will talkabout, and into the 2000s
methamphetamine has justabsolutely flooded the market,
particularly here on the WestCoast.
And I think it's important tounderstand the history because,
like many drugs, methamphetaminehas evolved over time and it's
(04:51):
currently being produceddifferently than it used to be
and we can learn from how thataffects our patients.
So this is a slide that outlinesone of the traditional ways of
producing methamphetamine.
And methamphetamine used to bemade from a plant-based
substance called ephedra and ithad a related chemical called
(05:12):
pseudoephedrine which was incold medicines to help with
sinus congestion, and most methwas made using the ephedra
method.
And in the middle of the screenhere you can see a reference to
the so-called shake-and-bakemethod.
This was a very common way thatmethamphetamine was made in
small batches and you took coldmedicine containing
(05:34):
pseudoephedrine, put it into awater bottle with some common
household chemicals and a stripfrom a battery, and over several
hours you were able to makemethamphetamine.
And you can see on the righthere that's a pile of the
packets, the blister packetsthat cold medicine would come in
along with some propane tanks,and this likely represents the
(05:56):
remnants of someone cooking upmethamphetamine using the
so-called shake-and-bake method,where they would use
pseudoephedrine to makemethamphetamine.
Where they would usepseudoephedrine to make
methamphetamine and that'sactually the reason why Congress
passed the act in 1996 is itreally restricted cold medicine?
Because they were trying tochoke out the supply to make
methamphetamine.
And at the time.
(06:16):
I remember hearing the termsmurfing, which was a reference
to going into a pharmacy buyinglarge amounts of cold medicine
and blister packs and thenpopping them out to be able to
buying large amounts of coldmedicine and blister packs and
then popping them out to be ableto give large quantity of pills
to somebody who was going tomake methamphetamine.
Now it turns out that there's asecond way to make
methamphetamine and that methodis called the P2P method for the
(06:38):
chemical phenyltupropanone, andit turns out that most of meth
was being made via the ephedramethod, and in the 1980s some
biker gangs tried the P2P method, but there were a lot of nasty
chemicals and it smelled reallybad, and so into the 80s, 90s
and into the 2000s, the ephedramethod was still the dominant
(06:59):
method.
But that changed here on theWest Coast in the mid-2010s.
And this is an article from theAtlantic called I Don't Know
that I Would Even Call it MethAnymore, and it's written by the
author, sam Quinones, who isfantastic, and he outlines in
this article the transition fromephedra meth to P2P meth and
(07:22):
P2P meth.
It's made differently, usingdifferent chemicals, many of
which are common industrialchemicals, and it allows
drastically larger quantities ofmethamphetamine to be made of a
higher potency compared to theephedra method, and so what we
found in the mid 2010s is thatthe amount of methamphetamine
(07:43):
that was being brought into theUS from drug cartels was through
the roof and it was a lotcheaper because there was so
much of it and, again, it wasmore potent.
So in California, you know,over the 2010s the price of
methamphetamine dropped by about90%.
So what we found, unfortunately, is that P2P meth and ephedra
(08:05):
meth were different.
People who used meth from theephedra method talked about it
being something that was verysocial and you wanted to party
all night and it kept you awakeand it was a very social thing.
But the P2P meth was different.
People got a lot more mentalhealth side effects.
They got more psychosis.
They were more isolated.
It was.
They got more psychosis, theywere more isolated.
(08:25):
It was associated with morepeople becoming homeless, and
there's probably two reasons forthat.
One is because it was cheaper.
People were using more of it.
Two, it was more potent.
And then, three, the p2p methodwas associated with all sorts
of chemical residues being lefton the meth, and so it's just a
(08:47):
different drug now, and we beganseeing a lot of
methamphetamine-inducedpsychosis coming into emergency
departments around this time.
Now, one of the other thingsthat makes amphetamines, and
particularly methamphetamine,such a unique addiction is how
it affects the reward centers ofour brain.
So in the reward centers of ourbrain we release the chemical
(09:11):
dopamine and that tells us thatwe feel good.
And traditionally we release itfrom three things Human
connection, intimacy or sex andfood.
And those are really survivalright.
So you have to eat to survive.
We need human connection tocreate villages for protection,
and then we need babies to growour villages.
(09:35):
And the normal levels ofdopamine in the reward centers
of the brain are between about140, 40 being the lowest, 100
being the highest, nanograms perdeciliter.
So that's the actual numbers ofthe dopamine levels in the
brain.
Addictive chemicals orbehaviors take that dopamine
(09:56):
level above 100.
So on the graphic here you cansee alcohol, nicotine, morphine
and cocaine.
All take dopamine above 100nanograms per deciliter, but
they only take it up a smallamount somewhere between maybe
150 and 300 nanograms perdeciliter.
Take a look at methamphetamine.
That takes the dopamine levelsup to 1,000 nanograms.
(10:20):
Here's another graphic fromUCLA Dopamine goes again from 40
to 100 nanograms per deciliterin the pleasure centers of the
brain.
Addictive food like McDonald'stakes it up to 150.
Sex takes it up to 200.
Nicotine to 200.
Cocaine to 400.
And methamphetamine takes it upto 1100.
(10:41):
And I've even heard some reportsthat methamphetamine takes the
dopamine in our brain all theway up to 1,400 nanograms per
deciliter.
It releases more dopamine thanany other substance that we know
of on planet Earth, and so,unfortunately, it really damages
the reward center of our brain,which is one of the reasons why
(11:02):
methamphetamine is fairly hardto quit, because people feel so
flat.
They feel that there is such anabsence of pleasure and joy in
their life because they'vereally just broken their reward
system.
And I love this graphic.
I think this is funny.
Somebody is comparing thelevels of dopamine that you
release from differentactivities and they compare it
to meth and they say don't ruinpizza, don't take meth.
(11:23):
And they compare it to meth andthey say don't ruin pizza,
don't take meth.
And there's probably somevalidity here.
People lose interest in humanrelations, food, seeing, family
when they're on methamphetamine,because the dopamine levels are
so off the charts.
Nothing else feels good.
Now we've talked about thehistory of methamphetamine and
(11:43):
how it works.
Let's talk about how to treatmethamphetamine addiction.
So this is my three-leggedstool of addiction treatment.
We have three basic ways thatwe treat addiction.
We have medications, counselingand therapy and mutual support
groups.
I like my patients to do allthree and, following following
the stool analogy, if you have astool with three legs it's
(12:05):
going to be very stable.
If you take away one of thelegs, it's going to begin to be
less stable.
It's going to teeter-totterback and forth and if you only
have one of the legs, it's goingto be very unstable.
And so I hope all of mypatients will do all three.
And I'm going to focus on themedications for this lecture,
because I'm a doctor and that'swhat I do I prescribe meds.
(12:27):
That's the core of addictionmedicine.
So let's talk about medicationsthat can be used to treat
methamphetamine use disorder.
So the first step in what I dowhen I treat patients with
methamphetamine addiction is Ilook for comorbid mental illness
.
Most of my patients tend to bedual diagnosis.
(12:49):
They have addiction and mentalhealth issues and I need to
treat both.
So if they're depressed, I wantto put them on an
antidepressant.
If they're bipolar, we need toput them on a mood stabilizer.
If they have PTSD, we need toaddress that we don't use
anything different or specialfor mental health conditions
when people have methamphetamineaddiction.
(13:10):
We just treat their mentalhealth condition and then we
also consider other medicationsthat are methamphetamine
specific.
So again, step one treatwhatever underlying mental
health condition that they have.
Treat whatever underlyingmental health condition that
they have.
(13:32):
Now step two is there arecertain medications that can be
specifically used to reducemethamphetamine use and promote
sobriety from methamphetamine.
So we'll go through them.
The first one is bupropion andthe other name for this is
Welbutrin.
I'll do my best to use genericnames, but I often forget and
use the brand name.
So what is bupropion?
So it is a very activatingantidepressant and it increases
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levels of dopamine andnorepinephrine in the brain.
That's how it works to treatdepression and many years ago,
when I was a little baby doctorthat didn't understand anything
about addiction, I was juststarting to learn about
addiction and I was learningabout dopamine and I was
learning that the addictivesubstances raise the dopamine
(14:14):
beyond normal levels and so whenpeople are trying to get sober,
their dopamine levels are lowbecause the brain has spent a
lot of the dopamine because ofthe addictive substance, causing
more release than normal.
And I remember thinking, gosh,if we could only find a medicine
that would increase dopaminelevels, wouldn't that help for
addiction?
And really, one of the onlymeds that increases dopamine
(14:37):
levels is bupropion, and that'sone of the reasons why it works
for smoking cessation.
The way my patients who usemethamphetamine and find
bupropion to be helpful, the waythey describe it to me, is that
it's very activating.
In other words, they feel awakeand alert and ready to go, and
that's probably from a couple ofthings.
(14:58):
One is is that's how it works.
It affects dopamine and thattends to be very activating.
It makes us feel good.
It also works for ADHD, so ifthey have ADHD, they feel more
able to focus, and for somepeople, unfortunately, it's too
stimulating.
So somebody who has bad anxiety, I usually shy away from this
(15:20):
because it can be too activating.
The main reason why we don't useit is if somebody has a history
of seizures.
Bupropion increases thelikelihood of them having a
breakthrough seizure, and weusually avoid antidepressants in
people with bipolar because itcan trigger mania.
If we do use it, we usuallycombine it with a mood
(15:42):
stabilizer and formethamphetamine addiction we use
bupropion at higher doses.
I usually start everybody on300 milligrams a day, as long as
they tolerate 150.
So my first prescription willbe 150 milligrams extended to
release a day and if theytolerate it, I take them up to
300.
The vast majority of mypatients are on 300.
You can go up to 450, but ittends to be too overstimulating
(16:05):
for folks.
Okay, the next medication istapiramate, also known as
Topamax, and this is a medicinethat we use to prevent seizures
and migraines, but it turns outas a positive side effect.
It reduces cravings for alcoholand stimulants.
We don't fully know why itworks for stimulants.
(16:30):
We know why it works foralcohol.
It appears to mimic some of thechanges that happen in the
brain when alcohol is consumed,but at a very low level.
But it does.
It works and I have a case thatwe'll go through a little bit
later to describe one patient'sexperience with it.
Unfortunately, tapiramate isnotorious for side effects.
You can get paresthesias, liketingling in the hands and feet.
(16:52):
It causes taste changes.
Because of the taste changes itactually is associated with
weight loss, so I do have somefolks that are worried about
gaining weight after stoppingmeth and this can be a good
medication.
And then it can make peoplementally cloudy.
And my experience because Itook it.
I wanted to see what wouldhappen is that I was very
(17:13):
mentally cloudy.
I struggled to remember martialarts.
My family does taekwondo and Ikept forgetting my forms in
taekwondo.
And with taste changes, I keptthinking that the sparkling
water had gone bad.
I would open a can of LaCroixand taste changes.
I kept thinking that thesparkling water had gone bad.
I would open a can of LaCroixand taste it and it tasted weird
.
So I'd tell my daughter youknow, sweetheart, I think the
LaCroix went bad and she wasjust dad, what's wrong with you?
(17:37):
And it was the Topamax.
In terms of dosing, we usuallystart at very low, at 25 to 50
milligrams, to avoid sideeffects, and then we taper up
over several weeks to avoid sideeffects all the way to 300
milligrams daily.
Okay, now there is some realsignal around patients with
stimulant addiction havinguntreated ADHD.
Now many of my patients tell methat they use methamphetamine
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to calm down, and for years Ijust couldn't figure it out.
They must be lying or theydon't know what's going on,
except if you think about ithyperactive children with ADHD
that are restless and irritableand distractible.
We give them pharmaceuticalamphetamines and they calm down,
(18:21):
and so there is significantoverlap between ADHD and
stimulant use disorder.
Let me give an example.
I was in clinic this week and awoman came in.
She was about six months soberfrom meth and I asked her what
did meth do for her?
And she said, oh, I would useit during the day as my thinking
cap and I went okay, what wereyou like in school?
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And she said, oh, I reallystruggled.
I had to be in special learningand I couldn't finish high
school because I couldn't focus.
And I asked her what class washer worst?
Because folks with ADHD tend tostruggle with math and science
and she was just oh, dr Grover,math was so hard and science.
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And she was just oh, dr Grover,math was so hard.
And she was self-medicating herADHD with meth.
And if you didn't know, we asdoctors can prescribe
pharmaceutical methamphetaminefor ADHD.
The brand name is calledDesoxyn.
I've only done it once.
A patient actually tricked me.
I will never forget it.
But yes, most psychiatristsdon't use it just because
methamphetamine is so euphoric,but many of my patients with
(19:31):
stimulant use disorder have ADHD, and so I am very liberal with
the non-addictive ADHD meds inmy patients with stimulant use
disorder who have or I suspectthey have ADHD, and those meds
are bupropion or Welbutrin.
We already talked about thatand we're going to go through
the rest.
The first one is calledadamoxetine, also known as
(19:53):
Stratera, and this one works byincreasing norepinephrine levels
in the brain, similar tobupropion, and it works pretty
well.
The main side effects is thatpeople get GI upset, like nausea
or upset stomach, and so weusually start it again pretty
low, around 25 milligrams.
We start them at a low dose,like 25 milligrams a day, and we
(20:17):
bring them up to somewherebetween about 50 and 100
milligrams a day if we can.
Its cousin is called viloxzineor Kelbree and this one
increases norepinephrine levelsin the brain and I think of it
like adamoxetine 2.0.
It does very similar effects toadamoxetine but it doesn't have
(20:39):
the same stomach upset sideeffects.
The only issue is that it's onpatent and is expensive, so most
insurance companies require aprior authorization which takes,
you know, my time and I have tofill out some forms, but it can
be very effective.
The dosing we usually startpeople again low dose, about a
hundred milligrams, and then webring them up to usually between
(21:00):
400 and 600 milligrams daily,usually between 400 and 600
milligrams daily.
The next one is guanfacine, andguanfacine is a cousin of
clonidine.
Clonidine can be used for ADHD,but guanfacine appears to work
a little bit better, and the wayguanfacine works is it makes
the nerve cells in the front ofthe brain work better, more
(21:23):
efficiently, and the front ofthe brain is the part of the
brain work better, moreefficiently, and the front of
the brain is the part of thebrain that is the most human,
that helps us with ourdecision-making, and we all know
that people who have addictionstruggle with decision-making
and people with ADHD.
It's very similar they'reeasily distractible, they're
impulsive.
So guanfacine seems to be veryhelpful for people who have
(21:45):
stimulant addiction and alsoADHD.
The side effects is that it cancause sedation and it lowers
blood pressure.
I usually dose it at bedtime.
Because of this and then thedosing, I prefer the extended
release form called Intuniv, andI usually start at one
milligram a night and increaseto four milligrams If tolerated.
(22:07):
Most of my patients do prettywell on about two milligrams and
this is something that I willoften combine with one of the
other meds so that they have adaytime med and a nighttime med.
Now there are stimulantmedications for ADHD and here
are some examples Mixedamphetamine salts and that one's
Adderall, methylphenidate,known as Ritalin or Concerta,
and lisdexamphetamine also knownas Vyvanse.
(22:29):
And I am really careful withthese meds in my patients who
have ADHD and stimulantaddiction because it can be
triggering because they're, youknow, pharmaceutical
amphetamines.
These amphetamine medicationscome in two forms instant
release and extended release.
The instant release issomething that people will take
(22:50):
a dose, the drug levels go up,they peak fairly quickly and
they wear off fairly quickly.
So people will be veryfunctional for just a few hours
and then crash and it's hard toget through the school day or
work day when your focus goesaway around you know 1 or 2 pm,
the school day or work day whenyour focus goes away around you
know 1 or 2 pm.
So it's recommended that peoplebe on the extended release
because it avoids peaks andtroughs.
(23:10):
So, for example, extendedrelease Adderall would be the
product of choice for someonewho needs Adderall for their
ADHD because it lasts throughoutthe day and then it wears off
before bed so they can go tosleep.
And it's probably a good timeright now for us to talk about
the rhythm of ADHD medicationsas it relates to symptoms.
(23:31):
So I mentioned, I'll oftencombine a morning med like
adamoxetine with an evening medlike guanfacine, and here's why.
So when people wake up in themorning and their ADHD is really
going, they're distractible,it's hard to get motivated, it's
hard to get going.
So if I give them a nighttimemed like guanfacine, it's in
(23:52):
their system and effective.
When they wake up in themorning they feel better.
In the morning they're able toprepare for work, prepare for
school, and then they remember,because their ADHD is managed,
to take their morning med likeadamoxetine and then that med
works through the day and thenthey come back and they take the
nighttime med and it justreally sets them up for success.
So again, they don't have thesebig peaks and troughs of where
(24:14):
they have medication that'sworking and when they don't.
Now you might be wondering okay,well, we use suboxone and
methadone for opioid addiction.
Could we use prescriptionstimulone and methadone for
opioid addiction?
Could we use prescriptionstimulants for stimulant
addiction?
So this is a website calledOpen Evidence and I use it all
the time.
It uses the power of artificialintelligence to rapidly search
(24:37):
the National Library of Medicineto give doctors answers to
questions.
So I asked Open Evidence canyou use prescription stimulants
to treat stimulant use disorder,and the answer is prescription
stimulants are not currentlyrecommended as a routine
treatment for stimulant usedisorder.
Now, that being said, ifsomeone has ADHD and a history
(24:59):
of stimulant use disorder, wecould use one of these, but
there's no evidence that givingpeople who use stimulants
stimulants works to keep themsober.
And because of the addictivepotential of prescription
stimulants, I am extremelycareful when I give someone a
prescription stimulant for theirADHD.
(25:19):
When they have stimulant usedisorder, I make them sign a
special contract, I shorten theinterval between their
appointments and I do veryregular urine drug testing to
make sure that they're able totake the medication as
prescribed.
Now, I was always taught thatstimulants do not have a
withdrawal syndrome, but thatwas before I learned how to
(25:42):
practice addiction medicine, andstimulant withdrawal is
absolutely a thing, and itprobably comes from the fact
that stimulants mess with oursleep-wake cycle and release so
much dopamine that when we comeoff of it, our brain doesn't
know how to feel good, becausethe dopamine is depleted and our
sleep-wake cycle is totally off.
(26:03):
So here are some symptoms ofstimulant withdrawal Dysphoric
mood, fatigue, abnormal dreams,changes in sleep, changes in
appetite and agitation.
And that brings us to the nextmedication that can be used for
stimulant use disorder, and thatis mirtazapine, also known as
(26:23):
Remeron.
So mirtazapine is anantidepressant.
It increases appetite, it'svery sedating and can help reset
the sleep-wake cycle.
So let's think about thisYou're coming off of
methamphetamine, your sleep-wakecycle.
So let's think about thisYou're coming off of
methamphetamine, your sleep-wakecycle is totally disrupted,
you're depressed, your appetiteis totally off.
(26:45):
It makes perfect sense thatmirtazapine would be a
medication that would make theprocess of getting off of meth
less unpleasant.
So we actually use it and ithelps people maintain their
sobriety, particularly early intheir recovery from
methamphetamine.
Main side effects, like manyantidepressants dry mouth and
(27:09):
grogginess, because it's verysedating.
We use it as a sleep med, soyou can guess people are going
to be fatigued if they take itduring the day.
Sometimes people feel the sleepeffects into the day and they
can be groggy in the morning,and we dose it at 15 to 30
milligrams at bedtime.
There are some other studieslooking at treatments for
(27:30):
methamphetamine use disorder.
This is one from the NewEngland Journal of Medicine in
2021, bupropion and naltrexonein methamphetamine use disorder.
In 2021, bupropion andnaltrexone in methamphetamine
use disorder, and this looked atusing bupropion taken orally
and naltrexone as an injection.
The brand name is Vivitrol totreat methamphetamine use
disorder, and the idea is isthat when we do things that are
(27:52):
pleasurable, our brain releasesdopamine, but it also releases
some of the naturally occurringopioids in our body called
endorphins.
And so naltrexone works foralcohol and binge eating because
it suppresses those extrapleasure chemicals, the
endorphins, when we indulge infood or drink alcohol, and so
(28:16):
there's a thought that maybethere's a little bit of that
endorphin release withmethamphetamine too, and this
was actually a very positivestudy.
They found that it was reallyable to reduce the prevalence of
methamphetamine positive urinedrug tests in the study
population.
So here's another potentialcombination to treat
(28:37):
methamphetamine use disorder.
So here's another potentialcombination to treat
methamphetamine use disorder.
This was another study lookingat lisdexamphetamine for
methamphetamine use disorder.
This is the ADHD med.
That is a stimulant calledVyvanse and on the screen you
can see the podcast AddictionMedicine Journal Club.
Those are my friends, drs JohnKeenan and Sonia Deltredici.
(28:58):
They have their addictionmedicine podcast and we
collaborate and they coveredthis study I believe it was out
of Australia on using veryhigh-dose lisdexamphetamine for
methamphetamine use disorder andit was essentially a negative
study.
It didn't really help.
So that goes back to the factthat we don't yet have evidence
(29:18):
that giving people stimulantsfor their stimulant use disorder
works.
Again, if they have ADHD,that's totally different.
But for pure stimulantaddiction, stimulants are not
yet found to be effective.
Now, shameless plug, this is mypodcast Addiction Medicine Made
Easy.
I met a doctor, dr Miller, inIndiana, who is a general
(29:40):
surgeon, turned pain managementdoctor, turned addiction doctor,
and he came on my podcast totell me that he has a treatment
that reduces meth use by 86%.
That is insane.
There is nothing else that Ihave heard of that reduces meth
use by anywhere close to that.
So he and I talked about it andat the time I didn't really
(30:03):
know much about ADHD and thevast majority of the patients
he's treating with Stimulant UseDisorder who are using
methamphetamines have ADHD andby treating them with some
combination of adamoxetine orvioxazine or guanfacine or
bupropion he was really able tomanage their methamphetamine use
(30:24):
.
He did have another patientsubset that really struggled
with fatigue and motivation andhe had a little bit of a
different pathway there, but thevast majority of the successes
that he was making were fromjust treating people's comorbid
ADHD.
Now, before we wrap up, I wantedto ask the question does
(30:47):
contingency management work forstimulant use disorder?
And we're going to talk aboutit.
So I went back to Open Evidenceand I asked AI to search the
National Library of Medicine andthe answer I got was yes.
Contingency management is themost effective and
evidence-supported behavioralintervention for stimulant use
disorder and it is stronglyrecommended as a primary
(31:10):
treatment approach.
So what is contingencymanagement?
Contingency management isoperant conditioning management.
Contingency management isoperant conditioning, basically,
where we create rewards topromote the behavior that we
want to take root and besuccessful.
And here's a common way thatit's used around methamphetamine
(31:31):
use.
So we know that methamphetaminereally brings up levels of
dopamine in the brain and partof what we need to do is give
people dopamine back to helptheir brain recover from how
damaging methamphetamine is tothe reward system.
So the idea is is that peopleare told you're going to give us
(31:52):
a urine drug test and if it'snegative for methamphetamine,
you get a prize.
So what does that entail?
Negative for methamphetamine,you get a prize.
So what does that entail?
They have something to lookforward to, kind of like with
drug cravings.
When you use the drug, itreleases dopamine.
But we also know theanticipation of the drug
releases a little tiny bit ofdopamine and that's probably
(32:13):
where cravings come from.
So the idea that I'm going toget a reward, I'm going to get a
reward, I'm going to get areward releases a little bit of
dopamine.
And then when they do the urinedrug test and it's negative,
they're there with their drugand alcohol counselor.
That's positive humanconnection, that's dopamine.
And then they get to reach intoa prize bucket or a fishbowl.
The reward itself gives themdopamine, and it's not always
(32:38):
the same prize.
It might be a sticker, it mightbe an Amazon gift card, it
might be a $100 bill, it mightjust be a handwritten note
saying you're killing it, you'redoing a great job.
And because the reward isn'tthat predictable and there's the
potential for a big reward, itreally gets the dopamine going
in anticipation of a big reward.
(32:58):
And we actually do it in myoffice and it's something that
we're starting to see used moreand appears to be uniquely
helpful in methamphetamineaddiction, among other
addictions.
In other words, it works foraddiction in general, but it's
uniquely useful inmethamphetamine addiction.
Okay, let's go through a coupleof cases and I'll talk about how
(33:21):
it actually looks when I'mtreating patients with some of
these meds.
So case number one is a68-year-old female.
History of opioid use andstimulant use and she came to me
using fent and meth and shecouldn't get on suboxone.
So I sent her to the methadoneclinic and they stabilized her
on 90 milligrams of methadone aday.
I put her in therapy and shewas able to stop using fentanyl
(33:42):
but was really struggling withmeth.
So I put her on tapiramate at50 milligrams daily and I
titrated her up.
Over about four weeks I got herup to 300 milligrams and she
had some side effects.
I brought her back down to 250.
And she came to me the nextweek and she said, dr Grover,
that medicine is a miracle, Ihave no desire to use meth.
(34:03):
And I'm thinking, wow, this isamazing.
Except her urine drug testsshowed that she was still using
meth.
So I dug into it with her andshe said, well, it's more than I
don't think about meth all thetime.
But you know, sometimes thatfriend comes around and, yeah, I
really don't want to use meth,but sometimes I get really bored
(34:26):
.
So essentially I was able toreduce her methamphetamine use
very significantly, but itdidn't eliminate it.
And I bring up this casebecause you know we put people
on Suboxone for opiate usedisorder and they do amazing.
We can really extinguishcravings and furthermore,
suboxone blocks other opioids.
So medications for meth use aredifferent.
(34:48):
They don't quite have the sameintensity of their effects in
reducing cravings, but for thispatient she was able to
drastically reduce her use andnow I'm focusing on positive
human connection, away from theusing friends and trying to keep
her busy.
So I'm working on it.
Okay, case number two46-year-old male was referred
(35:10):
for using methamphetamine.
He was unhoused and he told methat he used meth to chill out.
So I got the vibe maybe this isa patient with ADHD.
So I asked him about his schoolhistory.
He really struggled withlearning, didn't complete high
school, and then he actuallytold me, doctor, I have ADHD.
So it really fit together.
(35:30):
I started him on guanfacine atbedtime and adamoxetine in the
morning.
We titrated his dose up overabout three to four weeks and he
came to me and he said you know, dr grover, I can finally think
clearly and I I don't want touse meth.
And again I went wow, this isamazing.
And then unfortunately, werealized that he had sexual
(35:51):
assault that he had never reallyaddressed and he was homeless
and so now he didn't really havethe desire to use meth, but he
was really fearful and wasunhoused and was just I don't
know how to do this sober and so, yeah, I was able to suppress
his methamphetamine cravings,but then we had to address all
the other parts of his life thathad led to his addiction.
(36:12):
So I got him to stop usingmethamphetamine by managing his
ADHD.
I got him to stop usingmethamphetamine by managing his
ADHD, but he still continued touse, actually until we got him
housing and counseling.
So he actually ended up goingto residential treatment and
then they eventuallytransitioned him to sober living
.
Okay, so I am going to stopthere and that is the end of
(36:35):
what I prepared and we will stopand we'll have a conversation
and do some questions Before wewrap up.
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenonprofit Central Coast Overdose
Prevention for teaming up withme on this podcast.
(36:58):
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
(37:19):
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
I'll see you next time.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
I am really excited about thisepisode.
(00:43):
Today we are going to be talkingabout methamphetamine use
disorder.
We will start with a history ofmethamphetamine and move on to
treatment of methamphetamine usedisorder, with a specific focus
on how medications can reducethe desire to use meth.
I gave this lecture last weekto my colleagues who work at a
residential drug and alcoholtreatment program and I wanted
(01:04):
to share it with all of you.
Here we go All right.
So today we're going to betalking about methamphetamine
use and I'm going to go throughthe history of methamphetamines
and then we're going to talkabout treatment.
And one of the reasons thislecture came up is I get
referred patients for MAT formeth and there really isn't an
(01:30):
official set of meds formedications for addiction
treatment for meth.
But there are some medicationsthat help.
They're not nearly as effectiveas, say, methadone or suboxone
for opioid use disorder, butthey can help.
So we're going to go throughhow I approach the medications
to treat methamphetamine use andwe'll get started.
(01:52):
I always love to start withhistory.
I'm a total history geek.
If you did not know, manysoldiers in World War II used
methamphetamine to stay awake,to improve performance and go on
long missions.
It was used by Japanesesoldiers, german soldiers and
Allied Forces soldiers.
(02:14):
It was pharmaceutical, the drugname at the time was called
Pervitin and it was actuallyvery extensive through the
German army, really really alllevels of the German military
during World War II, all the wayup to Adolf Hitler himself.
Incredible amounts ofmethamphetamine were used during
(02:36):
the war.
And there's more to the historyof methamphetamine, but I find
it so interesting that it reallyfueled one of the biggest human
conflicts in human history.
So this is a graphic that Ifound that provides an overview
of the history ofmethamphetamine.
And they were first synthesizedin the late 1800s and we
(02:57):
weren't really sure what to dowith them.
Stimulants are helpful forthings like boosting our
metabolism.
Stimulants are helpful forthings like boosting our
metabolism, dilating our lungsduring asthma attacks and
causing wakefulness.
So the very first uses wereactually in Japan for asthma and
(03:19):
to promote wakefulness andnarcolepsy.
As I mentioned, they were veryextensively used during World
War II and interestingly and Ididn't know this after the war
Japan, whose country was bothphysically and financially
decimated, japan, experienced arise in recreational
methamphetamine use, and itmakes sense right.
People were emotionallydistraught after what they had
(03:43):
been through.
The country had to rebuild.
It's not surprising at all thata substance like meth would take
hold.
It was used medically in theUnited States in the 1950s,
particularly around obesity,sinusitis and again to promote
wakefulness with narcolepsy.
Into the 1970s it was finallymade a controlled substance by
(04:08):
the federal government and inthe 1980s we began to see it
uniquely as a problem drug inthe population of men who have
sex with men, and this wasaround the time that AIDS and
HIV began to come about.
In the 1990s we saw increasingproduction of methamphetamine To
combat this.
(04:28):
In 1996, congress passed theComprehensive Methamphetamine
Control Act, which we will talkabout, and into the 2000s
methamphetamine has justabsolutely flooded the market,
particularly here on the WestCoast.
And I think it's important tounderstand the history because,
like many drugs, methamphetaminehas evolved over time and it's
(04:51):
currently being produceddifferently than it used to be
and we can learn from how thataffects our patients.
So this is a slide that outlinesone of the traditional ways of
producing methamphetamine.
And methamphetamine used to bemade from a plant-based
substance called ephedra and ithad a related chemical called
(05:12):
pseudoephedrine which was incold medicines to help with
sinus congestion, and most methwas made using the ephedra
method.
And in the middle of the screenhere you can see a reference to
the so-called shake-and-bakemethod.
This was a very common way thatmethamphetamine was made in
small batches and you took coldmedicine containing
(05:34):
pseudoephedrine, put it into awater bottle with some common
household chemicals and a stripfrom a battery, and over several
hours you were able to makemethamphetamine.
And you can see on the righthere that's a pile of the
packets, the blister packetsthat cold medicine would come in
along with some propane tanks,and this likely represents the
(05:56):
remnants of someone cooking upmethamphetamine using the
so-called shake-and-bake method,where they would use
pseudoephedrine to makemethamphetamine.
Where they would usepseudoephedrine to make
methamphetamine and that'sactually the reason why Congress
passed the act in 1996 is itreally restricted cold medicine?
Because they were trying tochoke out the supply to make
methamphetamine.
And at the time.
(06:16):
I remember hearing the termsmurfing, which was a reference
to going into a pharmacy buyinglarge amounts of cold medicine
and blister packs and thenpopping them out to be able to
buying large amounts of coldmedicine and blister packs and
then popping them out to be ableto give large quantity of pills
to somebody who was going tomake methamphetamine.
Now it turns out that there's asecond way to make
methamphetamine and that methodis called the P2P method for the
(06:38):
chemical phenyltupropanone, andit turns out that most of meth
was being made via the ephedramethod, and in the 1980s some
biker gangs tried the P2P method, but there were a lot of nasty
chemicals and it smelled reallybad, and so into the 80s, 90s
and into the 2000s, the ephedramethod was still the dominant
(06:59):
method.
But that changed here on theWest Coast in the mid-2010s.
And this is an article from theAtlantic called I Don't Know
that I Would Even Call it MethAnymore, and it's written by the
author, sam Quinones, who isfantastic, and he outlines in
this article the transition fromephedra meth to P2P meth and
(07:22):
P2P meth.
It's made differently, usingdifferent chemicals, many of
which are common industrialchemicals, and it allows
drastically larger quantities ofmethamphetamine to be made of a
higher potency compared to theephedra method, and so what we
found in the mid 2010s is thatthe amount of methamphetamine
(07:43):
that was being brought into theUS from drug cartels was through
the roof and it was a lotcheaper because there was so
much of it and, again, it wasmore potent.
So in California, you know,over the 2010s the price of
methamphetamine dropped by about90%.
So what we found, unfortunately, is that P2P meth and ephedra
(08:05):
meth were different.
People who used meth from theephedra method talked about it
being something that was verysocial and you wanted to party
all night and it kept you awakeand it was a very social thing.
But the P2P meth was different.
People got a lot more mentalhealth side effects.
They got more psychosis.
They were more isolated.
It was.
They got more psychosis, theywere more isolated.
(08:25):
It was associated with morepeople becoming homeless, and
there's probably two reasons forthat.
One is because it was cheaper.
People were using more of it.
Two, it was more potent.
And then, three, the p2p methodwas associated with all sorts
of chemical residues being lefton the meth, and so it's just a
(08:47):
different drug now, and we beganseeing a lot of
methamphetamine-inducedpsychosis coming into emergency
departments around this time.
Now, one of the other thingsthat makes amphetamines, and
particularly methamphetamine,such a unique addiction is how
it affects the reward centers ofour brain.
So in the reward centers of ourbrain we release the chemical
(09:11):
dopamine and that tells us thatwe feel good.
And traditionally we release itfrom three things Human
connection, intimacy or sex andfood.
And those are really survivalright.
So you have to eat to survive.
We need human connection tocreate villages for protection,
and then we need babies to growour villages.
(09:35):
And the normal levels ofdopamine in the reward centers
of the brain are between about140, 40 being the lowest, 100
being the highest, nanograms perdeciliter.
So that's the actual numbers ofthe dopamine levels in the
brain.
Addictive chemicals orbehaviors take that dopamine
(09:56):
level above 100.
So on the graphic here you cansee alcohol, nicotine, morphine
and cocaine.
All take dopamine above 100nanograms per deciliter, but
they only take it up a smallamount somewhere between maybe
150 and 300 nanograms perdeciliter.
Take a look at methamphetamine.
That takes the dopamine levelsup to 1,000 nanograms.
(10:20):
Here's another graphic fromUCLA Dopamine goes again from 40
to 100 nanograms per deciliterin the pleasure centers of the
brain.
Addictive food like McDonald'stakes it up to 150.
Sex takes it up to 200.
Nicotine to 200.
Cocaine to 400.
And methamphetamine takes it upto 1100.
(10:41):
And I've even heard some reportsthat methamphetamine takes the
dopamine in our brain all theway up to 1,400 nanograms per
deciliter.
It releases more dopamine thanany other substance that we know
of on planet Earth, and so,unfortunately, it really damages
the reward center of our brain,which is one of the reasons why
(11:02):
methamphetamine is fairly hardto quit, because people feel so
flat.
They feel that there is such anabsence of pleasure and joy in
their life because they'vereally just broken their reward
system.
And I love this graphic.
I think this is funny.
Somebody is comparing thelevels of dopamine that you
release from differentactivities and they compare it
to meth and they say don't ruinpizza, don't take meth.
(11:23):
And they compare it to meth andthey say don't ruin pizza,
don't take meth.
And there's probably somevalidity here.
People lose interest in humanrelations, food, seeing, family
when they're on methamphetamine,because the dopamine levels are
so off the charts.
Nothing else feels good.
Now we've talked about thehistory of methamphetamine and
(11:43):
how it works.
Let's talk about how to treatmethamphetamine addiction.
So this is my three-leggedstool of addiction treatment.
We have three basic ways thatwe treat addiction.
We have medications, counselingand therapy and mutual support
groups.
I like my patients to do allthree and, following following
the stool analogy, if you have astool with three legs it's
(12:05):
going to be very stable.
If you take away one of thelegs, it's going to begin to be
less stable.
It's going to teeter-totterback and forth and if you only
have one of the legs, it's goingto be very unstable.
And so I hope all of mypatients will do all three.
And I'm going to focus on themedications for this lecture,
because I'm a doctor and that'swhat I do I prescribe meds.
(12:27):
That's the core of addictionmedicine.
So let's talk about medicationsthat can be used to treat
methamphetamine use disorder.
So the first step in what I dowhen I treat patients with
methamphetamine addiction is Ilook for comorbid mental illness
.
Most of my patients tend to bedual diagnosis.
(12:49):
They have addiction and mentalhealth issues and I need to
treat both.
So if they're depressed, I wantto put them on an
antidepressant.
If they're bipolar, we need toput them on a mood stabilizer.
If they have PTSD, we need toaddress that we don't use
anything different or specialfor mental health conditions
when people have methamphetamineaddiction.
(13:10):
We just treat their mentalhealth condition and then we
also consider other medicationsthat are methamphetamine
specific.
So again, step one treatwhatever underlying mental
health condition that they have.
Treat whatever underlyingmental health condition that
they have.
(13:32):
Now step two is there arecertain medications that can be
specifically used to reducemethamphetamine use and promote
sobriety from methamphetamine.
So we'll go through them.
The first one is bupropion andthe other name for this is
Welbutrin.
I'll do my best to use genericnames, but I often forget and
use the brand name.
So what is bupropion?
So it is a very activatingantidepressant and it increases
(13:54):
levels of dopamine andnorepinephrine in the brain.
That's how it works to treatdepression and many years ago,
when I was a little baby doctorthat didn't understand anything
about addiction, I was juststarting to learn about
addiction and I was learningabout dopamine and I was
learning that the addictivesubstances raise the dopamine
(14:14):
beyond normal levels and so whenpeople are trying to get sober,
their dopamine levels are lowbecause the brain has spent a
lot of the dopamine because ofthe addictive substance, causing
more release than normal.
And I remember thinking, gosh,if we could only find a medicine
that would increase dopaminelevels, wouldn't that help for
addiction?
And really, one of the onlymeds that increases dopamine
(14:37):
levels is bupropion, and that'sone of the reasons why it works
for smoking cessation.
The way my patients who usemethamphetamine and find
bupropion to be helpful, the waythey describe it to me, is that
it's very activating.
In other words, they feel awakeand alert and ready to go, and
that's probably from a couple ofthings.
(14:58):
One is is that's how it works.
It affects dopamine and thattends to be very activating.
It makes us feel good.
It also works for ADHD, so ifthey have ADHD, they feel more
able to focus, and for somepeople, unfortunately, it's too
stimulating.
So somebody who has bad anxiety, I usually shy away from this
(15:20):
because it can be too activating.
The main reason why we don't useit is if somebody has a history
of seizures.
Bupropion increases thelikelihood of them having a
breakthrough seizure, and weusually avoid antidepressants in
people with bipolar because itcan trigger mania.
If we do use it, we usuallycombine it with a mood
(15:42):
stabilizer and formethamphetamine addiction we use
bupropion at higher doses.
I usually start everybody on300 milligrams a day, as long as
they tolerate 150.
So my first prescription willbe 150 milligrams extended to
release a day and if theytolerate it, I take them up to
300.
The vast majority of mypatients are on 300.
You can go up to 450, but ittends to be too overstimulating
(16:05):
for folks.
Okay, the next medication istapiramate, also known as
Topamax, and this is a medicinethat we use to prevent seizures
and migraines, but it turns outas a positive side effect.
It reduces cravings for alcoholand stimulants.
We don't fully know why itworks for stimulants.
(16:30):
We know why it works foralcohol.
It appears to mimic some of thechanges that happen in the
brain when alcohol is consumed,but at a very low level.
But it does.
It works and I have a case thatwe'll go through a little bit
later to describe one patient'sexperience with it.
Unfortunately, tapiramate isnotorious for side effects.
You can get paresthesias, liketingling in the hands and feet.
(16:52):
It causes taste changes.
Because of the taste changes itactually is associated with
weight loss, so I do have somefolks that are worried about
gaining weight after stoppingmeth and this can be a good
medication.
And then it can make peoplementally cloudy.
And my experience because Itook it.
I wanted to see what wouldhappen is that I was very
(17:13):
mentally cloudy.
I struggled to remember martialarts.
My family does taekwondo and Ikept forgetting my forms in
taekwondo.
And with taste changes, I keptthinking that the sparkling
water had gone bad.
I would open a can of LaCroixand taste changes.
I kept thinking that thesparkling water had gone bad.
I would open a can of LaCroixand taste it and it tasted weird
.
So I'd tell my daughter youknow, sweetheart, I think the
LaCroix went bad and she wasjust dad, what's wrong with you?
(17:37):
And it was the Topamax.
In terms of dosing, we usuallystart at very low, at 25 to 50
milligrams, to avoid sideeffects, and then we taper up
over several weeks to avoid sideeffects all the way to 300
milligrams daily.
Okay, now there is some realsignal around patients with
stimulant addiction havinguntreated ADHD.
Now many of my patients tell methat they use methamphetamine
(18:01):
to calm down, and for years Ijust couldn't figure it out.
They must be lying or theydon't know what's going on,
except if you think about ithyperactive children with ADHD
that are restless and irritableand distractible.
We give them pharmaceuticalamphetamines and they calm down,
(18:21):
and so there is significantoverlap between ADHD and
stimulant use disorder.
Let me give an example.
I was in clinic this week and awoman came in.
She was about six months soberfrom meth and I asked her what
did meth do for her?
And she said, oh, I would useit during the day as my thinking
cap and I went okay, what wereyou like in school?
(18:45):
And she said, oh, I reallystruggled.
I had to be in special learningand I couldn't finish high
school because I couldn't focus.
And I asked her what class washer worst?
Because folks with ADHD tend tostruggle with math and science
and she was just oh, dr Grover,math was so hard and science.
(19:07):
And she was just oh, dr Grover,math was so hard.
And she was self-medicating herADHD with meth.
And if you didn't know, we asdoctors can prescribe
pharmaceutical methamphetaminefor ADHD.
The brand name is calledDesoxyn.
I've only done it once.
A patient actually tricked me.
I will never forget it.
But yes, most psychiatristsdon't use it just because
methamphetamine is so euphoric,but many of my patients with
(19:31):
stimulant use disorder have ADHD, and so I am very liberal with
the non-addictive ADHD meds inmy patients with stimulant use
disorder who have or I suspectthey have ADHD, and those meds
are bupropion or Welbutrin.
We already talked about thatand we're going to go through
the rest.
The first one is calledadamoxetine, also known as
(19:53):
Stratera, and this one works byincreasing norepinephrine levels
in the brain, similar tobupropion, and it works pretty
well.
The main side effects is thatpeople get GI upset, like nausea
or upset stomach, and so weusually start it again pretty
low, around 25 milligrams.
We start them at a low dose,like 25 milligrams a day, and we
(20:17):
bring them up to somewherebetween about 50 and 100
milligrams a day if we can.
Its cousin is called viloxzineor Kelbree and this one
increases norepinephrine levelsin the brain and I think of it
like adamoxetine 2.0.
It does very similar effects toadamoxetine but it doesn't have
(20:39):
the same stomach upset sideeffects.
The only issue is that it's onpatent and is expensive, so most
insurance companies require aprior authorization which takes,
you know, my time and I have tofill out some forms, but it can
be very effective.
The dosing we usually startpeople again low dose, about a
hundred milligrams, and then webring them up to usually between
(21:00):
400 and 600 milligrams daily,usually between 400 and 600
milligrams daily.
The next one is guanfacine, andguanfacine is a cousin of
clonidine.
Clonidine can be used for ADHD,but guanfacine appears to work
a little bit better, and the wayguanfacine works is it makes
the nerve cells in the front ofthe brain work better, more
(21:23):
efficiently, and the front ofthe brain is the part of the
brain work better, moreefficiently, and the front of
the brain is the part of thebrain that is the most human,
that helps us with ourdecision-making, and we all know
that people who have addictionstruggle with decision-making
and people with ADHD.
It's very similar they'reeasily distractible, they're
impulsive.
So guanfacine seems to be veryhelpful for people who have
(21:45):
stimulant addiction and alsoADHD.
The side effects is that it cancause sedation and it lowers
blood pressure.
I usually dose it at bedtime.
Because of this and then thedosing, I prefer the extended
release form called Intuniv, andI usually start at one
milligram a night and increaseto four milligrams If tolerated.
(22:07):
Most of my patients do prettywell on about two milligrams and
this is something that I willoften combine with one of the
other meds so that they have adaytime med and a nighttime med.
Now there are stimulantmedications for ADHD and here
are some examples Mixedamphetamine salts and that one's
Adderall, methylphenidate,known as Ritalin or Concerta,
and lisdexamphetamine also knownas Vyvanse.
(22:29):
And I am really careful withthese meds in my patients who
have ADHD and stimulantaddiction because it can be
triggering because they're, youknow, pharmaceutical
amphetamines.
These amphetamine medicationscome in two forms instant
release and extended release.
The instant release issomething that people will take
(22:50):
a dose, the drug levels go up,they peak fairly quickly and
they wear off fairly quickly.
So people will be veryfunctional for just a few hours
and then crash and it's hard toget through the school day or
work day when your focus goesaway around you know 1 or 2 pm,
the school day or work day whenyour focus goes away around you
know 1 or 2 pm.
So it's recommended that peoplebe on the extended release
because it avoids peaks andtroughs.
(23:10):
So, for example, extendedrelease Adderall would be the
product of choice for someonewho needs Adderall for their
ADHD because it lasts throughoutthe day and then it wears off
before bed so they can go tosleep.
And it's probably a good timeright now for us to talk about
the rhythm of ADHD medicationsas it relates to symptoms.
(23:31):
So I mentioned, I'll oftencombine a morning med like
adamoxetine with an evening medlike guanfacine, and here's why.
So when people wake up in themorning and their ADHD is really
going, they're distractible,it's hard to get motivated, it's
hard to get going.
So if I give them a nighttimemed like guanfacine, it's in
(23:52):
their system and effective.
When they wake up in themorning they feel better.
In the morning they're able toprepare for work, prepare for
school, and then they remember,because their ADHD is managed,
to take their morning med likeadamoxetine and then that med
works through the day and thenthey come back and they take the
nighttime med and it justreally sets them up for success.
So again, they don't have thesebig peaks and troughs of where
(24:14):
they have medication that'sworking and when they don't.
Now you might be wondering okay,well, we use suboxone and
methadone for opioid addiction.
Could we use prescriptionstimulone and methadone for
opioid addiction?
Could we use prescriptionstimulants for stimulant
addiction?
So this is a website calledOpen Evidence and I use it all
the time.
It uses the power of artificialintelligence to rapidly search
(24:37):
the National Library of Medicineto give doctors answers to
questions.
So I asked Open Evidence canyou use prescription stimulants
to treat stimulant use disorder,and the answer is prescription
stimulants are not currentlyrecommended as a routine
treatment for stimulant usedisorder.
Now, that being said, ifsomeone has ADHD and a history
(24:59):
of stimulant use disorder, wecould use one of these, but
there's no evidence that givingpeople who use stimulants
stimulants works to keep themsober.
And because of the addictivepotential of prescription
stimulants, I am extremelycareful when I give someone a
prescription stimulant for theirADHD.
(25:19):
When they have stimulant usedisorder, I make them sign a
special contract, I shorten theinterval between their
appointments and I do veryregular urine drug testing to
make sure that they're able totake the medication as
prescribed.
Now, I was always taught thatstimulants do not have a
withdrawal syndrome, but thatwas before I learned how to
(25:42):
practice addiction medicine, andstimulant withdrawal is
absolutely a thing, and itprobably comes from the fact
that stimulants mess with oursleep-wake cycle and release so
much dopamine that when we comeoff of it, our brain doesn't
know how to feel good, becausethe dopamine is depleted and our
sleep-wake cycle is totally off.
(26:03):
So here are some symptoms ofstimulant withdrawal Dysphoric
mood, fatigue, abnormal dreams,changes in sleep, changes in
appetite and agitation.
And that brings us to the nextmedication that can be used for
stimulant use disorder, and thatis mirtazapine, also known as
(26:23):
Remeron.
So mirtazapine is anantidepressant.
It increases appetite, it'svery sedating and can help reset
the sleep-wake cycle.
So let's think about thisYou're coming off of
methamphetamine, your sleep-wakecycle.
So let's think about thisYou're coming off of
methamphetamine, your sleep-wakecycle is totally disrupted,
you're depressed, your appetiteis totally off.
(26:45):
It makes perfect sense thatmirtazapine would be a
medication that would make theprocess of getting off of meth
less unpleasant.
So we actually use it and ithelps people maintain their
sobriety, particularly early intheir recovery from
methamphetamine.
Main side effects, like manyantidepressants dry mouth and
(27:09):
grogginess, because it's verysedating.
We use it as a sleep med, soyou can guess people are going
to be fatigued if they take itduring the day.
Sometimes people feel the sleepeffects into the day and they
can be groggy in the morning,and we dose it at 15 to 30
milligrams at bedtime.
There are some other studieslooking at treatments for
(27:30):
methamphetamine use disorder.
This is one from the NewEngland Journal of Medicine in
2021, bupropion and naltrexonein methamphetamine use disorder.
In 2021, bupropion andnaltrexone in methamphetamine
use disorder, and this looked atusing bupropion taken orally
and naltrexone as an injection.
The brand name is Vivitrol totreat methamphetamine use
disorder, and the idea is isthat when we do things that are
(27:52):
pleasurable, our brain releasesdopamine, but it also releases
some of the naturally occurringopioids in our body called
endorphins.
And so naltrexone works foralcohol and binge eating because
it suppresses those extrapleasure chemicals, the
endorphins, when we indulge infood or drink alcohol, and so
(28:16):
there's a thought that maybethere's a little bit of that
endorphin release withmethamphetamine too, and this
was actually a very positivestudy.
They found that it was reallyable to reduce the prevalence of
methamphetamine positive urinedrug tests in the study
population.
So here's another potentialcombination to treat
(28:37):
methamphetamine use disorder.
So here's another potentialcombination to treat
methamphetamine use disorder.
This was another study lookingat lisdexamphetamine for
methamphetamine use disorder.
This is the ADHD med.
That is a stimulant calledVyvanse and on the screen you
can see the podcast AddictionMedicine Journal Club.
Those are my friends, drs JohnKeenan and Sonia Deltredici.
(28:58):
They have their addictionmedicine podcast and we
collaborate and they coveredthis study I believe it was out
of Australia on using veryhigh-dose lisdexamphetamine for
methamphetamine use disorder andit was essentially a negative
study.
It didn't really help.
So that goes back to the factthat we don't yet have evidence
(29:18):
that giving people stimulantsfor their stimulant use disorder
works.
Again, if they have ADHD,that's totally different.
But for pure stimulantaddiction, stimulants are not
yet found to be effective.
Now, shameless plug, this is mypodcast Addiction Medicine Made
Easy.
I met a doctor, dr Miller, inIndiana, who is a general
(29:40):
surgeon, turned pain managementdoctor, turned addiction doctor,
and he came on my podcast totell me that he has a treatment
that reduces meth use by 86%.
That is insane.
There is nothing else that Ihave heard of that reduces meth
use by anywhere close to that.
So he and I talked about it andat the time I didn't really
(30:03):
know much about ADHD and thevast majority of the patients
he's treating with Stimulant UseDisorder who are using
methamphetamines have ADHD andby treating them with some
combination of adamoxetine orvioxazine or guanfacine or
bupropion he was really able tomanage their methamphetamine use
(30:24):
.
He did have another patientsubset that really struggled
with fatigue and motivation andhe had a little bit of a
different pathway there, but thevast majority of the successes
that he was making were fromjust treating people's comorbid
ADHD.
Now, before we wrap up, I wantedto ask the question does
(30:47):
contingency management work forstimulant use disorder?
And we're going to talk aboutit.
So I went back to Open Evidenceand I asked AI to search the
National Library of Medicine andthe answer I got was yes.
Contingency management is themost effective and
evidence-supported behavioralintervention for stimulant use
disorder and it is stronglyrecommended as a primary
(31:10):
treatment approach.
So what is contingencymanagement?
Contingency management isoperant conditioning management.
Contingency management isoperant conditioning, basically,
where we create rewards topromote the behavior that we
want to take root and besuccessful.
And here's a common way thatit's used around methamphetamine
(31:31):
use.
So we know that methamphetaminereally brings up levels of
dopamine in the brain and partof what we need to do is give
people dopamine back to helptheir brain recover from how
damaging methamphetamine is tothe reward system.
So the idea is is that peopleare told you're going to give us
(31:52):
a urine drug test and if it'snegative for methamphetamine,
you get a prize.
So what does that entail?
Negative for methamphetamine,you get a prize.
So what does that entail?
They have something to lookforward to, kind of like with
drug cravings.
When you use the drug, itreleases dopamine.
But we also know theanticipation of the drug
releases a little tiny bit ofdopamine and that's probably
(32:13):
where cravings come from.
So the idea that I'm going toget a reward, I'm going to get a
reward, I'm going to get areward releases a little bit of
dopamine.
And then when they do the urinedrug test and it's negative,
they're there with their drugand alcohol counselor.
That's positive humanconnection, that's dopamine.
And then they get to reach intoa prize bucket or a fishbowl.
The reward itself gives themdopamine, and it's not always
(32:38):
the same prize.
It might be a sticker, it mightbe an Amazon gift card, it
might be a $100 bill, it mightjust be a handwritten note
saying you're killing it, you'redoing a great job.
And because the reward isn'tthat predictable and there's the
potential for a big reward, itreally gets the dopamine going
in anticipation of a big reward.
(32:58):
And we actually do it in myoffice and it's something that
we're starting to see used moreand appears to be uniquely
helpful in methamphetamineaddiction, among other
addictions.
In other words, it works foraddiction in general, but it's
uniquely useful inmethamphetamine addiction.
Okay, let's go through a coupleof cases and I'll talk about how
(33:21):
it actually looks when I'mtreating patients with some of
these meds.
So case number one is a68-year-old female.
History of opioid use andstimulant use and she came to me
using fent and meth and shecouldn't get on suboxone.
So I sent her to the methadoneclinic and they stabilized her
on 90 milligrams of methadone aday.
I put her in therapy and shewas able to stop using fentanyl
(33:42):
but was really struggling withmeth.
So I put her on tapiramate at50 milligrams daily and I
titrated her up.
Over about four weeks I got herup to 300 milligrams and she
had some side effects.
I brought her back down to 250.
And she came to me the nextweek and she said, dr Grover,
that medicine is a miracle, Ihave no desire to use meth.
(34:03):
And I'm thinking, wow, this isamazing.
Except her urine drug testsshowed that she was still using
meth.
So I dug into it with her andshe said, well, it's more than I
don't think about meth all thetime.
But you know, sometimes thatfriend comes around and, yeah, I
really don't want to use meth,but sometimes I get really bored
(34:26):
.
So essentially I was able toreduce her methamphetamine use
very significantly, but itdidn't eliminate it.
And I bring up this casebecause you know we put people
on Suboxone for opiate usedisorder and they do amazing.
We can really extinguishcravings and furthermore,
suboxone blocks other opioids.
So medications for meth use aredifferent.
(34:48):
They don't quite have the sameintensity of their effects in
reducing cravings, but for thispatient she was able to
drastically reduce her use andnow I'm focusing on positive
human connection, away from theusing friends and trying to keep
her busy.
So I'm working on it.
Okay, case number two46-year-old male was referred
(35:10):
for using methamphetamine.
He was unhoused and he told methat he used meth to chill out.
So I got the vibe maybe this isa patient with ADHD.
So I asked him about his schoolhistory.
He really struggled withlearning, didn't complete high
school, and then he actuallytold me, doctor, I have ADHD.
So it really fit together.
(35:30):
I started him on guanfacine atbedtime and adamoxetine in the
morning.
We titrated his dose up overabout three to four weeks and he
came to me and he said you know, dr grover, I can finally think
clearly and I I don't want touse meth.
And again I went wow, this isamazing.
And then unfortunately, werealized that he had sexual
(35:51):
assault that he had never reallyaddressed and he was homeless
and so now he didn't really havethe desire to use meth, but he
was really fearful and wasunhoused and was just I don't
know how to do this sober and so, yeah, I was able to suppress
his methamphetamine cravings,but then we had to address all
the other parts of his life thathad led to his addiction.
(36:12):
So I got him to stop usingmethamphetamine by managing his
ADHD.
I got him to stop usingmethamphetamine by managing his
ADHD, but he still continued touse, actually until we got him
housing and counseling.
So he actually ended up goingto residential treatment and
then they eventuallytransitioned him to sober living
.
Okay, so I am going to stopthere and that is the end of
(36:35):
what I prepared and we will stopand we'll have a conversation
and do some questions Before wewrap up.
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenonprofit Central Coast Overdose
Prevention for teaming up withme on this podcast.
(36:58):
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
(37:19):
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
I'll see you next time.
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