PAC 330 Module 5 Stimulants and Other Substances Example

Wide Awake for Double Shifts: Methamphetamine's Harms and the Evidence for Incentives and Medication

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 330: Substance Abuse

Instructor Name

Month Day, Year

Wide Awake for Double Shifts: Methamphetamine's Harms and the Evidence for Incentives and Medication

Tina is thirty-four and works as a home care aide, often covering double shifts to support her two children. Three years ago a coworker offered her methamphetamine to stay awake through a sixteen-hour day. It worked, and she began using on long days, then on most days. She now smokes methamphetamine daily, sleeps about three hours a night and has lost twenty pounds. Last week she told her sister that she heard voices saying she was being watched through the vents. Her sister brought her to Prairie Hope Recovery, the composite Omaha program in these papers. This paper profiles methamphetamine and other stimulants and plans her treatment. Tina is invented for teaching, as is the program, and the research is real.

How Stimulants Act

Stimulants, including methamphetamine, amphetamine and cocaine, increase the activity of dopamine and norepinephrine in the brain. Cocaine blocks the reuptake of these neurotransmitters, prolonging their action. Methamphetamine both blocks reuptake and causes neurons to release large amounts of dopamine, producing a stronger and much longer effect; a methamphetamine high can last many hours, compared with less than an hour for smoked cocaine. Users experience energy, alertness, confidence, reduced appetite and euphoria. With repeated use, the brain's dopamine systems adapt, and stopping produces a crash of exhaustion, low mood, increased sleep and appetite and intense craving.

The Harms of Methamphetamine

Darke et al. (2008) reviewed the major physical and psychological harms of methamphetamine use. Cardiovascular harms were prominent: methamphetamine raises heart rate and blood pressure and is associated with heart rhythm problems, damage to heart muscle and heart attacks, even in young users. Cerebrovascular harms included strokes. Psychological harms included dependence, depression and anxiety, and psychosis, with paranoia and hallucinations, which can occur during use and sometimes persist. Users also experienced dental problems, skin lesions, weight loss and, for those who inject, infections. The authors noted evidence that heavy use may damage dopamine and serotonin nerve terminals, with effects on memory and thinking that may partly recover with abstinence.

Tina's symptoms map onto this review: weight loss, severe sleep loss and the auditory hallucinations and paranoia of methamphetamine psychosis, which require prompt assessment.

Contingency Management

Higgins et al. (1994) tested contingency management for cocaine dependence. Outpatients receiving an intensive behavioral treatment based on the community reinforcement approach were randomly assigned to receive vouchers for cocaine-negative urine tests or no vouchers. The vouchers, exchangeable for goods and services, increased in value with consecutive negative tests and were reset after a positive one. Patients receiving vouchers stayed in treatment much longer, with most completing the full twenty-four weeks compared with fewer than half of those without vouchers, and they achieved substantially longer periods of continuous abstinence. Later research extended contingency management to methamphetamine and found similar benefits, and lower-cost prize-based versions were developed for community programs. Contingency management is now regarded as the most effective treatment for stimulant use disorders.

A Medication Trial

No medication is approved for methamphetamine use disorder. Trivedi et al. (2021) reported the ADAPT-2 trial, which tested a combination of injectable extended-release naltrexone every three weeks and daily oral bupropion in adults whose methamphetamine use disorder was rated moderate or severe. The trial used a two-stage design to account for placebo response. A response was defined as at least three of four urine tests negative for methamphetamine at the end of each stage. Response rates with the medication combination were low but clearly higher than with placebo: across the trial, the medications produced a response in about one in six participants in the first stage and about one in nine in the second, compared with only a few percent on placebo. The authors concluded that the combination had a modest but meaningful effect, the first such positive result for a medication in a large trial of methamphetamine use disorder.

Harms and Treatments

Other Substances

Prairie Hope also sees clients using cocaine, prescription stimulants not as prescribed, benzodiazepines and hallucinogens. Cocaine shares methamphetamine's mechanism and contingency management evidence. Benzodiazepine dependence requires medically supervised tapering, because withdrawal can cause seizures. Hallucinogens rarely produce dependence but can produce dangerous intoxication. A growing concern across all these drugs is contamination with fentanyl, which has been found in methamphetamine, cocaine and counterfeit pills. Tina, who has never used opioids, has no tolerance and would be at high risk if her supply were contaminated.

Tina's Plan

Tina's first step will be a same-day psychiatric assessment of her psychosis and a medical exam, including her heart. If her symptoms are safe to manage as an outpatient, she will begin twice-weekly urine testing with prize-based contingency management, in which negative tests earn draws for prizes of increasing chances. She will attend weekly counseling using cognitive-behavioral methods, with attention to her work schedule. Because she began using to work double shifts, her counselor will help her plan how to manage her finances and schedule without them, including a referral to a social worker. Her prescriber will discuss the naltrexone and bupropion combination, explaining its modest effect. She and her sister will receive naloxone and fentanyl test strips, and her counselor will explain her risk from contaminated supply. Sleep and nutrition recovery will be part of the plan, since both take weeks to return.

Conclusion

Methamphetamine raises dopamine powerfully and harms the heart, brain and mind, as Darke and colleagues document, and Tina's psychosis and weight loss show those harms clearly. Higgins and colleagues show that rewarding abstinence works, and the ADAPT-2 trial shows that a medication combination now offers modest help. A plan that addresses her psychosis first, rewards abstinence, considers medication, protects her from fentanyl and solves the double-shift problem that started her use gives Tina the best evidence-based care available.

References

Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2008). Major physical and psychological harms of methamphetamine use. Drug and Alcohol Review, 27(3), 253-262. https://doi.org/10.1080/09595230801923702

Higgins, S. T., Budney, A. J., Bickel, W. K., Foerg, F. E., Donham, R., & Badger, G. J. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51(7), 568-576. https://doi.org/10.1001/archpsyc.1994.03950070060011

Trivedi, M. H., Walker, R., Ling, W., dela Cruz, A., Sharma, G., Carmody, T., Ghitza, U. E., Wahle, A., Kim, M., Shores-Wilson, K., Sparenborg, S., Coffin, P., Schmitz, J., Wiest, K., Bart, G., Sonne, S. C., Wakhlu, S., Rush, A. J., Nunes, E. V., & Shoptaw, S. (2021). Bupropion and naltrexone in methamphetamine use disorder. New England Journal of Medicine, 384(2), 140-153. https://doi.org/10.1056/NEJMoa2020214