Journal of Substance Abuse Treatment (2003) 24:267-277
Cretzmeyer M, Vaughan Sarrazin M, Huber DL, Block RI, Hall JA. Treatment of methamphetamine abuse: research findings and clinical directions.
Dear Colleagues,
This 'review article' looks at the modern stimulant epidemic from a clinical standpoint. On searching the literature, these authors found some treatment protocols, each of limited if any proven value in stimulant addiction, but each describing some 'promise' for methamphetamine dependency. Unlike the treatment of opioid and nicotine dependency, none involved prescribing of stimulants as either maintenance or reduction regimens as is used in the UK and in trials in Australia.
Amphetamine analogues are regularly prescribed by doctors and, unlike in the case of opioids for pain, there seems to be no 'grey area' between this and 'recreational' use despite some similarities in the expectations of both types of consumer. Like alcohol, opiates and other drugs, it is clear that stimulants have benefits and risks. Indeed, they are apparently dispensed to US Air Force pilots to increase attention and reduce fatigue. Yet current bans have never stopped many long-haul truck drivers claiming the same benefits from regular but completely unsupervised and unresearched stimulant use.
The first treatment protocol quoted by these authors, remarkably, involves the almost completely discredited 'aversion therapy'. It was used in the most clumsy and misguided manner using stand-in drugs for the stimulants and emetics or low voltage electrocution as the 'punishment'. Despite the absence of a control group and no valid scientific outcome data, these authors accept the treatment as 'promising'. And this was not in Abu Graid prison, but America in the 1990s.
The second was using first-generation antidepressants which the authors claim were successful or 'promising' based upon an improvement from 17 to 34 days retention with active imipramine over placebo, proving little except that these drug-users could detect placebos. 34 days in the life of a drug user is not exactly long-term.
The Californian 'Matrix' program is a psychosocial treatment model funded by the US drug agency, NIDA. It may be that the name 'matrix' is the most important component of its 'success' or 'promise'. The quoted trial here, with or without desipramine, only had 13 subjects who were amphetamine dependent. They were randomised three ways and ethnic differences confounded the already insignificant outcomes at 6 and 12 months. Why such a trial was quoted in a scientific paper I cannot tell.
'Case management' is examined next and it was found, unsurprisingly, that giving high quality vocational counselling improved employment outcomes and decreased depression levels. Case management did not reduce drug use compared with controls and thus it cannot be considered a 'treatment' for stimulant dependency on this evidence.
This review by a group of eminent experts seems to indicate an unwillingness on their part in the current US political climate to examine medical dependency problems from a purely scientific viewpoint. If patient outcome is paramount, it is essential to look beyond our own jurisdiction to see what is being done elsewhere. No promising modality should be 'off limits'. Substitute prescribing is not mentioned by these researchers for unstated reasons and when I wrote to them, I was asked to explain what I meant! As long as US researchers feel unable to write freely about harm reduction measures, and while needle services are not available in most areas, American citizens, including non-drug users, will continue to be exposed to high risks of HIV/AIDS, hepatitis C and the enormous social costs of unchecked non-medical drug use.
comments by Andrew Byrne ..
Citations:
Cooper D, Souther L, et al. Public Health Consequences Among First Responders to Emergency Events Associated With Illicit Methamphetamine Laboratories - Selected States, 1996-1999. JAMA (2000) 284; 21
Volkow ND, Chang L et al. Association of Dopamine Transport Reduction With Psychomotor Impairment in Methamphetamine Abusers. Am J Psychiatry 2001;158:377-382
