Rehabilitation Programs

Effective treatment of methamphetamine-dependent patients poses many challenges, some of which are unique. For instance, poor treatment engagement and high treatment dropout rates, severe or ongoing paranoia or psychotic symptoms, high relapse rates, and intense protracted cravings, dysphoria (unease or dissatisfaction with life), and anhedonia (inability to feel pleasure) are among the commonly cited obstacles to success in this population.⁵¹ Many of the challenges of meth addiction treatment stem from the effects of the drug itself. Meth abuse results in cognitive impairment such as deficits in attention, impulse control and task performance. These deficits make it difficult or impossible for the abuser to benefit from programs that focus on motivations for abstinence, strategies for avoiding drug use or promoting relapse prevention as these require the patient to attend sessions, comprehend information and remember skills presented. In addition, determining the most effective treatment components is further complicated by the special needs of methamphetamine-using subgroups such as women and gay or bisexual men. Special needs of female meth addicts include high frequency of personal and social disadvantage, psychiatric illness, and a history of sexual and/or physical abuse. Failure to address these issues and related disorders (for instance, post-traumatic stress from sexual abuse) may contribute to resumption of meth use. For gay or bisexual men, meth use is deeply intertwined with sexual and social behavior and rates of abuse can be as high as 20 times the general population.⁶¹ Meth use is known to increase the frequency and duration of sexual encounters and result in the abandonment of safe sex practices. Group treatment sessions that cover such topics as sexual risk reduction, sexual behavior and recognizing meth use in sexual partners yet include heterosexual men could increase the likelihood of poor treatment engagement and early dropout for both groups.

The admissions rates for treatment of methamphetamine-related disorders have ballooned alarmingly in some areas, particularly in rural or frontier areas, causing public health concerns. Data from the National Institute on Drug Abuse National Drug Early Warning System indicate that treatment admissions for methamphetamine use were less than 1% in sites east of the Mississippi River (with the exception of Atlanta GA) but ranged from 12% to 29% in sites west of the Mississippi.³

Facts About Meth Addiction Recovery¹⁹

• 93 percent of those in treatment end up relapsing, either back to a meth or a different drug that can add stimulation to the body.

• The national rate of meth addiction recovery is between 16 and 20 percent.

• Meth addiction is very difficult to treat because of the constant cravings for the drug.

• The chances of a recovery happening without some form of addiction therapy: 3%

• The average is 7 to 13 relapses before success in quitting takes hold.

• Meth has been known to cause addiction in nearly half of first-time users and almost 75% of second-time users.

• A SAMHSA report states the life expectancy of an addict is 7 years.²⁹

Although meth abuse has been an issue for more than 70 years, it is only recently that treatment approaches have been investigated and are therefore in the early stages of development and evaluation. Most are borrowed from successful cocaine dependence therapy programs.⁶¹

The first step in treatment is detoxification. Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances. Detoxification provides specialized medical supervision and safety for the user as they experience withdraw symptoms.⁸⁰ The treatment plan for meth addiction often involves more than one type of treatment on the continuum of care. These could include:

Inpatient or residential treatment: This treatment option involves the user staying at a 24-hour facility with intensive professional care, including medical supervisions, educational sessions, individual and group counseling and behavior therapies.

Outpatient treatment: This treatment provides the same professional care as residential treatment but allows the user to live at home or in a sober living environment. The patient would travel to the treatment facility to attend counseling and therapy sessions.

Aftercare or ongoing treatment: This treatment provides an opportunity to avoid future relapse. This could include community-based and family-based support systems, mutual-help groups, alumni events, and 12 step groups.

The recommended treatment for methamphetamine abuse is cognitive-behavioral intervention in an intensive outpatient setting.⁹ This type of treatment teaches clients to recognize the conditioned cues that lead to methamphetamine use and the subsequent cravings produced. Once clients understand and identify their personal cues, they may use the following strategies to avoid meth use: extensive relapse-prevention activities, participation in 12-step programs, urine testing, individual therapy, family therapy and social support groups. The typical treatment protocol lasts 8-16 weeks, and uses a chronic illness model, where monitoring and management is provided for long periods of time, perhaps a lifetime. Shorter treatment intervals show less positive outcomes. Longer treatment times are more successful.^17,42

A cognitive-behavioral intervention program, The Matrix Model, was developed by Richard Rawson, a leading expert on meth addiction. It is specifically designed for those addicted to stimulants such as meth. The Matrix Model is a 16-week comprehensive behavioral treatment approach that combines behavioral therapy, family education, individual counseling, 12-step support, drug testing and encouragement for non-drug-related activities.⁴⁰ Methamphetamine recovery support groups also appear to be effective adjuncts to behavioral interventions that can lead to long-term, drug-free recovery.^18,40

Twelve-step facilitation therapy such as Crystal Meth Anonymous (CMA) is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence. Three key ideas predominate:

1. Acceptance, which includes the realization that drug addiction is a chronic, progressive disease over which one has no control, that life has become unmanageable because of drugs, that willpower alone is insufficient to overcome the problem, and that abstinence is the only alternative;

2. Surrender, which involves giving oneself over to a higher power, accepting the fellowship and support structure of other recovering addicted individuals, and following the recovery activities laid out by the 12-step program; and

3. Active involvement in 12-step meetings and related activities

While the efficacy of 12-step programs (and 12- step facilitation) in treating alcohol dependence has been established, the research on its usefulness for other forms of substance abuse is more preliminary, but the treatment appears promising for helping drug abusers sustain recovery.⁴²

Contingency Management/Motivational Incentives uses behavioral principles to reinforce the occurrence of the targeted behavior. It is effective in rates of abstinence, completion of recovery-related activities, and treatment completion.⁵⁹ The ‘fishbowl’ version uses a variable ratio reinforcement schedule instead of a fixed ratio. Each time the desired behavior occurs, the participant draws a prize voucher. The longer the behavior continues, the more vouchers are drawn. Although each voucher may not equal a tangible prize (much less expensive to do) the chance to collect enough vouchers to exchange for a desired prize is still motivating.^57,92 Vouchers can be exchanged for non-cash goods and services that promote a drug-free lifestyle such as food, clothes, housing, electronics and sports equipment.⁴²

Research has verified that frequent 15-minute sessions are more effective for meth treatment than the longer, less frequent sessions commonly employed for treating other addicts. This is due to the short attention span of most meth addicts.²¹

Another rehabilitation concept is a meth boot camp. In Minnesota, addicts spend 6 months detoxifying prior to spending an additional 6 months in a regimented schedule of exercise, literacy, education and military drills followed by reintroduction to the community. A version of this program called Challenge Incarceration Program (CIP) is being used by prison systems. The goal of CIP is to help the inmate gain the resources needed to return to the community drug- and crime-free. Results are promising and costs are less than or equal to non-CIP participants.

All treatment programs should provide testing for HIV/AIDS, hepatitis B and C and other infectious diseases. Counseling can help patients adjust behaviors to reduce the risk of infection for themselves or others. Those already infected should be treated.

The use of technology – computers, websites, mobile devices – has the ability to enhance the power, reach and cost-effectiveness of behavioral treatment.⁴¹ Patients who live in remote areas or have limited mobility will have easier access to treatment. Patients who cannot or will not attend live sessions may benefit from computer programs designed to teach relapse-avoidance skills, for example. Supplement or emergency support can be provided via telephone or the web.

Currently, there are no specific pharmacological treatments that counteract the specific effects of meth or that prolong abstinence from and reduce the abuse of meth by an addicted individual.⁴⁰ Strategies for effective pharmacotherapy include targeting the depressed mood and drug cravings associated with withdrawal, using drugs that elicit an aversive response when meth is ingested, using agents that block the positive effects of meth, treating the co-morbid conditions, and providing agonist therapy. The agonist approach attempts to substitute a drug with less negative side effects that targets the same receptors in the brain, in an attempt to gradually eliminate drug dependence.⁶¹ The existing pharmacological approaches are borrowed from experiences with treatments of cocaine and opioid dependence. Unfortunately, these approaches have provided minimal success since no single agent has proven effective in controlled clinical studies. Antidepressant medications are helpful in combating the depressive symptoms frequently seen in meth users who recently have become abstinent. Bupropion, commonly known as Wellbutrin is showing some promise in meth recovery of low to moderate users. It is hypothesized that it reduces the methamphetamine induced “high” as well as drug cravings elicited by drug-related cues. In a small study, bupropion helped the user feel better as well as prolonging periods of drug abstinence. Fluoxetine (Prozac^®) has decreased drug cravings in short-term treatment. Imipramine (Tofranil^™) has increased the duration of adherence to treatment in medium-term treatment. Modafinil (Provigil^®) is a drug indicated for use in patients with excessive daytime sleepiness secondary to narcolepsy or sleep apnea. Modafinil (Provigil) acts as a dopamine agonist and may help normalize brain dopamine function and improve abstinence rates in meth abusers. Naltrexone (Revia^®) is an opiate receptor antagonist commonly used to treat alcohol and opiate dependence. In a small study, naltrexone was shown to reduce cravings and relapse in meth addicts. These treatment options need further research to verify efficacy in meth addiction treatment.^12,61

Novel treatment approaches are being researched and tested. Under study is the idea of using the body’s immune system to neutralize the drug in the bloodstream before it reaches the brain.^40,47 This approach includes injecting the meth user with antimeth antibodies, such as monoclonal antibody mAb7F9, or a vaccine that would stimulate the body to produce its own antimeth antibodies. A second approach centers on the glial cells which function in the brain like the immune system functions in the body. A drug, AV411 or ibudilast suppresses the neuroinflammatory actions of glial cells and has been shown to inhibit meth self-administration in rats. Research is promising and is being fast-tracked to establish its safety and efficacy in humans. A third approach is looking at the role of gamma-aminobutyric acid (GABA) neuron whose function is to decrease dopamine transmission, possibly decreasing the reinforcing effects of meth. In a small study, recipients of the GABA agonist baclofen (Gablofen^®) exhibited great numbers of meth-negative urine samples suggesting a small but positive effect in reducing meth use.⁴⁷

Emergency department treatments focus on the immediate symptoms including control of agitated, hyperactive or violent behavior; airway maintenance; management of cardiac conditions such as ischemia and tachycardia; using ice baths to bring down the dangerous hyperthermia; treating heavy metal toxicity; and administration of anticonvulsants. Patients are then referred for methamphetamine abuse treatment.