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A New Epidemic:

The Rise of Methamphetamine Use in

Patients with OUD

Gloria Miele, PhDUCLA Integrated Substance Abuse Programs

Aiden Clarke, MDRiverside-San Bernardino Indian Health

Jasmine Marozick, RNSanta Cruz County Health Services Agency

CPCA 2019 Region IX Clinical Excellence ConferenceNewport Beach, CA

June 25, 2019

Objectives

Discuss three clinical challenges experienced by patients with

co-occurring opioid and stimulant use disorders

Describe three empirically-based interventions for stimulant use

disorders

List two clinical strategies to address stimulant use disorders in

MAT treatment in community health settings

Identify how health center leadership can support providers and

augment the system of care for patients with co-occurring

stimulant and OUD?

History Repeats

In the late 1980s and 1990s, the cocaine epidemic seriously damaged

the treatment progress of many patients on methadone

In many Opioid Treatment Programs (OTPs), 70% + of urinalyses were

positive for cocaine

The treatment progress for many patients on methadone and who had

not used illicit drugs for years was seriously degraded by high levels of

cocaine use. This was particularly true once crack became available.

Dramatic increases in injection drug use, HIV, Hep C and drug-related

crime were associated with the elevated cocaine use. Premature

treatment termination/drop-out rates increased dramatically.

Many OTPs became locations for cocaine dealing and associated

behaviors

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Methamphetamine Today

Twin Epidemics: The surging rise of

methamphetamine use in chronic opioid users. Ellis, M. Kasper, A., Cicero, T. (2018)

Drug and Alcohol Dependence, 2018, 14-20

Past month use of methamphetamine significantly increased

among treatment-seeking opioid users (+82.6%, p < .001), from

18.8% in 2011 to 34.2% in 2017.

Methamphetamine use Among Patients

with Chronic Opioid Use is on the Rise

Ellis, MS, Kasper, ZA, Cicero, TJ (2018). Twin epidemics: The surging rise of methamphetamine use in chronic

opioid users. Drug and Alcohol Dependence, v193, 1 Dec 2018, 14-20.

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Methadone vs Buprenorphine: Is there a

different response to stimulant use?

Don’t know. We do not have good data on rates of stimulant use

comparing patients on methadone with those on buprenorphine.

Preclinical and laboratory research in the 80s and 90s suggested

that buprenorphine may be useful in reducing stimulant use.

Several studies (Strain et al 1994; Schottenfeld et al 1997)

compared methadone and buprenorphine for the treatment of

individuals who used opioids and cocaine. Results of both

studies showed that both medications reduced opioid use but did

not affect cocaine use.

Ling et al 2016 reported mixed results when buprenorphine was

used to treat cocaine dependent individuals. Some measures

indicated a reduction of cocaine use, other measures concluded

no effect. The jury is still out.

Clinical Considerations

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Clinical Challenges for Patients with

Stimulant Use Disorder

Limited understanding of stimulant use disorder

Ambivalence about need to stop use

Cognitive impairment and poor memory

Anhedonia

Powerful Pavlovian trigger-craving response

Poor retention in outpatient treatment

Elevated rates of psychiatric co-morbidity

CRAVING

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“And then it hit me: I’m salivating over a damn bell.”

Insight is not enough…

Treatments for Individuals with

Stimulant Dependence

Motivational incentives/Contingency management

Focused CBT

Motivational Interviewing

Exercise

Mindfulness

Medications – off-label indications

Contingency Management

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Why talk about contingency management?

It has been “endorsed” by NIDA (1999)

It appears on most every list of evidence-based practices for treating substance use disorders (e.g., ADAI, 2005)

It has been singled out, along with CBT and MI as being an effective psychotherapy for treating substance use disorders (Carroll & Onken, 2005)

A meta-analysis reports that Contingency

Management results in a successful

treatment episode 61% of the time while

other treatments with which it has been

compared result in a successful treatment

episode 39% of the time

(Prendergast, Podus, Finney, Greenwell & Roll, 2005)

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Rawson, R.A., Huber, A., McCann, M.J, Shoptaw, S., Farabee, D., Reiber, C., & Ling, W. (2002). A comparison of contingency

management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Archives

of General Psychiatry, 59(9), 817-824.

160 patients on methadone who were cocaine dependent randomly assigned to one of 4

conditions, each 16 weeks long:

1. Methadone maintenance treatment as usual (MMTP-only)

2. MM with 3X weekly CBT groups (CBT)

3. MM with 3X weekly UAs and contingency management (CM)

4. MM with 3x weekly CBT and CM (CBT+CM)

All patients completed batteries of assessments at 17 weeks (end of study, 26 weeks and 52

weeks

Research with cocaine using patients

on methadone. Rawson, et al 2002

19.8

30.326.1

11

0

8

16

24

32

40

48

CBT CM CBT+CM MMTP-only

Group (F = 6.8, df = 3, P < 0.0001)

Mean

# C

ocain

e-f

ree U

rin

e

Sam

ple

s

36.7

60 56.7

23.3

0

20

40

60

80

100

CBT CM CBT+CM MMTP-only

Group (X2 = 10.9, df = 3, P < 0.01)

Percen

t C

ocain

e-f

ree f

or 3

Con

secu

tive W

eek

s

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0

14

28

42

56

70

17 Week 26 Week 52 Week

Group (F = 2.85, df = 3, P = 0.0423)

Percen

t C

ocain

e-f

ree U

rin

es

CBT

CM

CBT+CM

MMTP-only

0

2

4

6

8

10

CBT CM CBT+CM MMTP only

Group (F = 1.94, df = 3, P = n.s.)

Days

Cocain

e U

se i

n P

ast

30

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Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy & Relapse

Prevention

Cognitive Behavioral Therapy (CBT) (also referred to

in the addiction field as “Relapse Prevention

Therapy”) is a form of talk therapy that emphasizes

modification of cognitions and behaviors as a strategy

to reduce drug use.

CBT involves coaching and teaching patients about the

cognitions and behaviors critical to reducing drug and

alcohol use.

CBT can be delivered in individually, in groups, and

online

Cognitions and Behaviors

Behaviors

Setting a schedule to promote engagement in behaviors that are inconsistent with substance use

Recognizing and avoiding “high risk” situations

Facilitating positive coping skills

Cognitions Psychoeducation regarding

addiction

Teaching clients about triggers and cravings

Teaching clients cognitive skills (e.g., “thought stopping” and “urge surfing”)

Identifying “red flag thoughts”

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Summary

Behavioral strategies in CBT include scheduling

and avoiding high risk situations.

Cognitive strategies include recognizing triggers

and cravings, thought stopping, recognizing “red

flag thoughts,”and analysis of the chain of events

that result in a “slip” or “lapse.”

Optimally, CBT strategies can be used while

practicing a style of interaction that is consistent

with M.I.

CBT effects are robust across substances of abuse.

Motivational Interviewing

Motivational Interviewing: Definition

A directive, client centered counseling style

for eliciting behavior change by helping

clients explore and resolve ambivalence.

Designed to produce rapid, internally

motivated change.

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Five Principles of Motivational Interviewing

1. Express empathy through reflective listening.

2. Develop discrepancy between patients’ goals

or values and their current behaviors.

3. Avoid argument and direct confrontation.

4. Adjust to client resistance.

5. Support self-efficacy and optimism.

By contrast…

“Why are you still using”?

“Are you serious about this program”?

“Why aren’t you working harder at recovery”

“I don’t think you’re ready for treatment”

“The “my way or the highway” approach

Exercise

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Exercise Study (Rawson et al, 2015)

Health Education Group:1h, 3 days/wk

Assessments: cardiopulmonary exercise test, body

composition, muscle strength & endurance

Exercise Group:1h, 3 days/wk

N=69 N=66

Change Scores in Anxiety (BAI)

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

12.0

13.0

1 2 3 4 5 6 7 8

Ch

ange

Sco

re in

BA

I

Week

Exercise

Education

Change Scores in Depression (BDI)

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1 2 3 4 5 6 7 8

Ch

ange

Sco

re in

BD

I

Week

Exercise

Education

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Brain Imaging Data

Health Education Group:1h, 3 days/wk

D2-like receptor binding assessed with 18F-fallypride and PET: before & after 8-wk intervention

Exercise Group:1h, 3 days/wk

N=8 N=6

Exercise Results

Lower severity methamphetamine users had

significantly fewer positive urine results at the 3

follow-up points

Exercise group participants had significantly lower

scores on a measure of depression compared to

the ED group over the 8-week treatment period.

Exercise group participants had significantly lower

scores on a measure of anxiety compared to the

ED group over the 8-week treatment period.

Summary of Clinical Management Issues

Treat agitation or withdrawal symptoms if indicated

Provide/refer to evidence-based behavioral

interventions

Treat psychiatric comorbidity

Consider medications with some evidence base

• Think about comorbidities when selecting options (e.g. ADHD,

depression, anxiety)

• Consider severity of use (e.g. frequency, duration)

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Mindfulness

Other Considerations for Treatment

Planning

Injection drug use

Daily or high dose stimulant use

Housing status, chronic mental illness

Men who have sex with men (MSM)

Individuals under the age of 21

People on medication treatment for OUD

Summary

Methamphetamine use has increased significantly in patients in

treatment for Opioid Use Disorder

Among a number of behavioral interventions tested, Contingency

Management shows the strongest effect in reducing stimulant

use

Focused CBT, MI, exercise, and mindfulness can also be helpful

in addressing stimulant use

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METHAMPHETAMINE

AIDAN M. CLARKE, MD

Crystal ("shards") METH--$40/3gm

SMOKED--0.01--0.05gm++

SNORTED—0.01-0.05gm ++

SWALLOWED—0.06-0.15gm

INJECTED--.03--.1gm

Heavy users 1gm +/day

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METH BINGE & CRASH

SEVERAL DAYS IN A row—a "run"

Redoseing q1-4 hours

"Tweeking" to no effect

Dysphoria then etoh—heroin--benzodiazepines

PHARMACOLOGY

Stimulates catecholamine release and blocks reuptake

Dopamine, norepinephrine, serotonin

Centrally and peripherally

Converges with endogenous opiate system

?Cravings?

Depletion of monoamines

Neurotoxicity

NEUROTOXICITY-STRIATUM, PFC,

HIPPOCAMPUS

Oxidative stress on neurons

Cognitive decline across multiple domains

Memory, impulsivity, motor skills, learning

Depression, anxiety, paranoia, psychosis, agressiveness

Parkinsonism

Long-term

Variable phenotypes?

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WITHDRAWAL—14 DAYS (maybe)

Depression

Craving

Sleep

Anxiety

Irritability

WITHDRAWAL MANAGEMENT

Benzodiazepines

Anti-psychotics

Anti-depressants

Little literature support on details; symptom

management

Pharmacotherapy

MODAFINIL

neurocognitive?

BUPROPRION

neurocognitive?

NALTREXONE

neurocognitive?

MIRTAZEPINE?

TOPIRAMATE?

SUBSTITUTION--dextroamphetamine

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Comorbid Substance Use

Alcohol

Marijuana

Cocaine

Heroin

Benzodiazepines

METHAMPHETAMINE + HEROIN USE

PREDICT POORER LONG-TERM

RECOVERY FROM MOUD

(methadone)

Summary of Evidence – Pharmacotherapy for

Methamphetamine Underpowered studies, high attrition

Bupropion (300 mg/day) may be more effective in

individuals with lower use disorder severity

May be better in individuals with depression, males

Low strength evidence that methylphenidate and

topiramate may facilitate reduction in use

Topiramate better if negative urine screen at baseline

Standard dosing ranges generally studied

Chan B, Kondo K, Ayers C, Freeman M, Montgomery J, Paynter R, and Kansagara D.

Pharmacotherapy for Stimulant Use Disorders: A Systematic Review of the Evidence.

VA ESP Project #05-225; 2018.

Contingency

Management

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Our MAT Team

• Joey Crottogini, Health Clinic Manager of HPHP

• Danny Contreras, Health Services Manager over MAT

• Jasmine Marozick, MAT Nurse,

• Angelica Torres, Bilingual SUD CM

• 5 prescribers

Homeless Person Health Project (HPHP)

• Marion Brodkey, MAT Nurse

• Greg Goldfield, SUD CM

• Marissa Torres, Bilingual SUD CM

• Adam Echols, SUD CM

• 8 prescribers

Santa Cruz Health Center

(EMELINE)

• This could be you, Bilingual MAT Nurse

• Alejandro Monroy, Bilingual SUD CM

• This could be you, Bilingual SUD CM

• 6 prescribers

Watsonville Health Center

(WHC)

Contingency

Management

“Simply stated, it involves providing tangible and concrete reinforcers or incentives to patients for evidence of objective behavior change.” (Petry, 2012)

https://www.careinnovations.org/resources/contingency-management-treatments-for-stimulant-and-other-substance-use-disorders-what-they-are-and-how-they-work/

We already use CM in our daily lives ( children, employees, pets, etc.)

This Photo by Unknown Author is licensed under CC BY-SA

Why Contingency Management?

IT WORKS! BETTER OUTCOMES HIGHER RETENTION RATES

INCREASE IN PATIENT SELF-ESTEEM AND EMPOWERMENT

STAFF MORALE

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Basic

Principles

Frequently monitor the behavior that you are trying to change.

Provide tangible, immediate (increasing) positive reinforcers each time that the behavior occurs.

When the behavior does not occur, without the positive reinforcers.

Methods

Fishbowl

Vouchers

Prize cabinets

Santa Cruz County- What We Do

Contingency Management for Medication Assisted Treatment Program (MAT) – Homeless Persons Health Project (HPHP)

Background: Contingency management (CM) is the application of tangible positive reinforcers to change behavior, and specifically substance-using behavior. This evidenced based practice is effective in medication-assisted treatment programs that target stimulant use for patients being treated for opioid use disorder. At HPHP, the contingency management pilot program will broaden patient selection to include all MAT patients who have positive urine drug screens (UDS), with the exception of buprenorphine and THC, and are in tiers two and three. The CM program at HPHP will be lead by the MAT Clinic Nurse III, with eligible patients participating for a duration of 12 continuous weeks. The total supplies budget for the 12 week pilot is $1,500. The pilot will be evaluated and presented to MAT Steering Committee as well as Quality Management Committee using a Plan, Do, Study, Act (PDSA) format.

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Prizes

Fishbowl method with 150 winners and 150 positive affirmations

Gift cards ranging from $5-$50

Santa Cruz Coffee Roasters, McDonalds, Burger King, Dollar Tree, Subway, Regal Cinemas, Ross

Tier 2

(weekly

requirement)

• Earn one prize drawing from the fishbowl for the first UDS negative for any substances, with the exception of THC and buprenorphine.

• Earn two additional entries for the second UDS negative for any substances, with the exception of THC and buprenorphine.

Submit Urine Drug Screens 2X per week. (Tuesdays and Fridays)

• If patient does not show up, there will be no prize drawing awarded for that day.

• If patient has a positive UDS, no prize drawing will be awarded for that day.

Each week there will be a total possible of three prize drawings.

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Tier 3 (bi-

weekly

requirement)

Submit Urine Drug Screen 1x every other week as

required (Tuesday MAT group)

Earn one prize drawing from the fishbowl for the

negative UDS, with the exception of THC and

buprenorphine.

Patient who is on Tier 3 is only required to come bi-

weekly. Patient will only have one chance to test and

draw at their required group. Tier 3 timeframe is 12

weeks which will allow for 6 group attendances max. If

patients on Tier 3 come outside their group or every

week they still will only get to participate according to

their bi-weekly requirement.

Process (SMA and individualized)

Patients are seen during a shared medical appointment as well as individually depending on patient needs.

Patients provide UDS before MAT group.

MAT team huddles regarding all patients

MAT RN compiles list of eligible CM drawings.

Drawings performed during MAT group.

Any gift cards won given after group or 1 on 1 session

Tuesdays: Patients Check in 30 min before Group. MAT TEAM: Nurse, MA, SUDCM collects and results UDS,

BUP/Naltrex check in sheetMAT team

huddles before group to go over

patients

SUDCM starts Psychoeducation

al 60 minute group

Provider and Nurse come to

group. Fishbowl draw done

Provider provides medication refill

Patients that need more time with provider will be seen after group an a individual

basis with Provider and Team or Nurse and Team

Patient will return for next scheduled SMA visit. CM patients

return Friday 10-11am

HPHP’s Shared Medical Appointments for MAT

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February 2019, Pre Weeks

February 2019, CM Weeks

Comparison

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Issues/Barriers

Did not require second weekly UDS (was made optional)

Second UDS was not during a set time

Did not include Tier 4-5

Did not award draws for attendance

Did not replace draw slips to keep odds 50/50

Small sample size

Short duration of study

Only one staff member with access to gift cards

Not all 15 people were consistent in program for 12 weeks

Successes

Patient empowerment

Patients testing negative more then positive

Staff morale

Increased attendance

Patients excited to come to group or show up on a extra day

Decrease substance use

Including Contingency Management in Grant funding

Plan for next 12 week study

Split scriptsReplace slips to keep odds 50/50

Add attendance reward

Add escalating drawing for each

consecutive negative UDS

Require twice weekly UDS

testing

Dispense split script from clinic

by RN

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Questions and Discussion

References

Strain, E., Stitzer, M., Liebson, I., and Bigelow, G. (1994)

Buprenorphine versus methadone in the treatment of opioid-

dependent cocaine users. Psychopharmacology, 116, 401-406

Schottenfeld, R., Pakes, J., Oliveto, A. et al

(1997). Buprenorphine vs methadone maintenance treatment for

concurrent opioid dependence and cocaine abuse. Archives of

General Psychiatry, 54, 713-720.

Ling W., Hillhouse, et al. Buprenorphine/naloxone plus naltrexone

for the treatment of cocaine dependence. Addiction, 45, 1-12

References

Rawson, R.A., Huber, A., McCann, M.J, Shoptaw, S., Farabee, D.,

Reiber, C., & Ling, W. (2002). A comparison of contingency

management and cognitive-behavioral approaches during methadone

maintenance treatment for cocaine dependence. Archives of General

Psychiatry, 59(9), 817-824.

Petry, Nancy M.,Martin, Bonnie (2002) Low-cost contingency

management for treating cocaine- and opioid-abusing methadone

patients. Journal of Consulting and Clinical Psychology, Vol 70(2), Apr

2002, 398-405.

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Research on CBT for SUD

Carroll, K. M., Rounsaville, B. J., Gordon, L. T., Nich, C., Jatlow, P.

M., Bisighini, R. M., et al. (1994). Psychotherapy and

pharmacotherapy for ambulatory cocaine abusers. Archives of

General Psychiatry, 51, 177-197.

Carroll, K. M., Rounsaville, B. J., Nich, C., Gordon, L. T., Wirtz, P. W.,

& Gawin, F. H. (1994). One year follow-up of psychotherapy and

pharmacotherapy for cocaine dependence: Delayed emergence of

psychotherapy effects. Archives of General Psychiatry, 51, 989-997.

Carroll, K.M., Ball, S.A., Martino, S., Nich, C., Babuscio, T. A. &

Rounsaville, B.J. (2009). Enduring effects of a computer-assisted

training program for cognitive behavioral therapy: A six-month follow-

up of CBT4CBT. Drug and Alcohol Dependence, 100, 178-181. PMCID:

PMC2742309

REFERENCES

Courtney & Ray; Methamphetamine: An update on epidemiology, pharmacology, clinical phenomenon, and

treatment literature. Drug & Alcohol Dependence 143 (2014); 11-21

Moszcznska & Callan. Molecular, Behavioral, and Physiological Consequences of Methamphetamine

Neurotoxicity: Implications for Treatment. J Pharm Exp Ther 362; 474-488; Sept. 2017

Wang, et al. Polydrug use and its association with drug treatment outcomes among primary heroin,

methamphetamine and cocaine users. Int J Drug Pol. 2017 Nov; 49: 32-40.

Winkelman, et al. Evaluation of amphetamine-related hospitalizations and associated clinical outcomes and

costs in the United States. JAMA Net Open. Oct 19, 2018; 1 (6)

NIDA: Common Comorbidities with Substance Use Disorders. February 2018

Anderson, et al. Modafinil for the Treatment of Methamphetamine Dependence . Drug Alcohol Depend. 2012

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