Methamphetamine – the devil’s dandruff
Methamphetamine (meth, ‘p”, ice) is the drug causing arguably the most problems in NZ at present. Marcus Lush refers to it as “the devil’s dandruff” and the animation comedy Brotown calls it “upside down ‘b’”. While alcohol is still the drug causing most social harm, the recent surge in methamphetamine use has created severe disruption for the user and for society. The highly publicized horror stories abound – financial ruin/job loss, marriage destruction, health decline, legal consequences etc…. the old addiction quartet- liver, lover, livelihood and law.
But the difference between this drug and others is what is causing most concern for GPs. The typical cliché addict profile- someone who looks a bit down and out and disheveled- does not fit meth abusers, who will look completely normal and display few symptoms to permit detection, in the early stages of use. I asked a group of GPs last week if there were any “tells” of meth abuse – “you would never know” was what one GP said. The surprising thing about meth abusers, is how long they can use meth without their GP ever knowing. I see mostly GP referred patients in my private practice. I am astounded at the number of patients who disclose to me in therapy, for the first time, that they have been abusing meth.
So how does a GP recognize the signs of meth abuse? The patient may appear a bit animated or restless, if they are under the influence, or tired and anxious if they have been using it and they have not used it for a few days. The patient on meth may be reporting sleeping problems, weight loss, skin irritation, anxious or low mood. So if they are requesting sleep medication, benzos and hydrocortisone cream – that trifecta may be a hint, but not necessarily so! I would suggest always ask the question, in a ‘matter of fact’ manner, ie normalize the experience enabling the patient to answer without fear of judgment – the way I ask is, after the tobacco and alcohol and pot questions, I say “Have you ever used any of the ‘alphabet’ drugs such as a p e ghb…”
As most GPs have come to see, meth addicts come from all socio-economic stratum – I have seen teachers, housewives, lawyers, property magnates, beauticians, nurses and even a doctor, who are abusing meth. It is a drug that instantly creates its own market due to the ease of use, the performance enhanced state it initially endows the user with and it is relatively cheap and easily available. The use is widespread and almost socially acceptable now, despite the fact this is a Class A drug ie a drug that poses a very high risk of harm. The product is sold in $100 “points” – 20cmx20cm plastic bags containing powder or a few crystals– and its use is so simple and efficient- a small crystal in a piece of tinfoil, a rolled up $5 note and a lighter and its done. No syringes to clean up, no bags of smelly product to hide, no residue,- as if it didn’t happen. It is almost the “perfect” drug in this regard. Until it isn’t….
The intoxication associated with alcohol, marijuana and narcotics would render most users incapable of, normal functioning eg work, driving, etc. Meth has no immediate disabling effects The meth user can do normal functioning better in the initial stages of use. While they report a “high” feeling, this is not intoxicating, ecstatic or hallucinogenic to the extent normal transmission is interrupted. Due to the performance enhancing effects, most users have a “eureka” experience ie why didn’t I find this sooner, now I can do my life – with more energy and efficiency. This is due to the drug’s massive dopamine release. The percentage of basal release of dopamine produced by meth in the first hour after use is almost double that of cocaine and four times that of ethanol, with no marked effects on performance. The person feels great and can function seemingly as normal and the effects can endure for up to 5 days. This is the reason the drug is so addictive. A person can use it just once, but after the drug has left their system in 5 days, they will feel depressed and desperately need to feel good again. After a period of continued use for anything over a month, a person will no longer be experiencing the dopamine “lift” to anything like the same extent as when they first used it, but will be taking the drug to avoid the depression and anxiety they will endure when they have not had any for a few days.
While the early signs of abuse are less obvious- dry mouth, skin disorders, mood instability, sleep issues, etc, the long-term effects become more easily detectable. These include irritability, temper tantrums, aggression, weight loss, sores around the mouth, and the symptoms associated with sleep deprivation, including psychosis, paranoia, confusion, visual/auditory hallucinations, out of control rages and delusions. In rare cases, a GP may need to involve Mental Health services for an assessment for drug induced psychosis. The GP will certainly be involved in long-term mood management issues after a meth addict commences abstinence. Due to the massive dopamine surge meth produces, up to 50% of dopamine cells can be damaged after 6-12 months use. Brain scans have shown that even after 24 months abstinence, meth users dopamine mechanisms are still not at normal functioning.
I have worked as a psychologist for over 20 years, with many years in the Alcohol and Drug sector. I have seen the effects of most drugs across the lifespan of those who abuse them. Meth use has shocked me in 2 aspects- the spread of it through all walks of life and socio-economic sectors and the speed in which it wrecks peoples’ lives. An alcoholic or marijuana or opiate user can continue use for decades before the consequences ie the “rock bottom” is reached. Meth users seem to arrive at this place in 6 months to a year.
When people attempt to stop using meth, the most commonly reported symptom is exhaustion- Anne Carroll is a detox nurse specialist at Higher Ground Drug and Alcohol Rehab in Te Atatu, Auckland. She states that seldom do meth addicts require a medical detox- in most cases this would only be indicted where alcohol, benzos and meth use are combined. The reason for this is the increased risk of stroke. Anne Carroll states that, in most cases, a meth addict coming off long term use will be hungry and tired – they will eat anything and sleep for a week! She also states, because the drug speeds up bowel movement. they also become constipated when they stop using.
But detox is seldom the hardest part of giving up meth. GP assistance with withdrawal, after that initial exhaustion, is in the management of the irritability and low mood, which can endure, as stated, up to 24 months after abstinence. While many recovering meth addicts may benefit from a course of SSRIs, exercise, sleep and diet form the mainstay of mood management. Rachel Arthur, an Australian naturopath and expert in nutritional rehabilitation to aid the recovery of homeostasis in mood neurotransmitter functioning of recovering addicts, has suggestions for supplements- Melatonin, omega 3, B6, B12 and magnesium are among her recommendations. Meth abusers seem incapable of empathy, happiness, pleasure, etc, long after they stop use and it is this aspect that draws them back to use. The cravings are long lasting and repetitive. This drug calls its users for a long time.
So, in summary, GPs need to ask the question about Meth- don’t make assumptions abut the “type of person” who uses meth. its use is widespread now, so sleep issues, mood issues, skin conditions, erratic bowels, all could indicate this drug is being abused. Motivational Interviewing – a form of outcome-informed, client-directed therapy devised by Scott Miller, suggests advice-giving or ”lecturing” on harms, will be unlikely to achieve insight to stop drug use. He suggests the types of questions that are more likely to increase motivation to change require a more Socratic approach eg “What are the good things and not so good things about using drugs” or “When you started using meth, it was probably fun, but you probably didn’t think it would get like this” and “ how will you know when its time to stop? Do you still want to be doing this in 1 year, 5 years, 10 years time?” etc In initial stages of withdrawal, exhaustion and increased appetite are most common symptoms. After the first week of withdrawal, anxiety and depression are common and SSRIs can be useful to stabilize these symptoms. Following chronic meth use, the low/anxious mood component is often long-lasting so CADS and/or Narcotic Anonymous self help/support meetings – one addict can best help another- may be the best option for meth users after they stop use to prevent relapse.
Rachel Arthur naturopath advice http://rachelarthur.com.au
Motivational Interviewing scottdmiller.com
Narcotics Anonymous www.nzna.org
CADS www.cads.org.nz
Higher Higher Ground Drug Rehabilitation Trust www.higherground.org.nz