# Presentation: 046589

## Methamphetamine Use:  Addiction and Mental Health Crisis

**Kathleen Masis M.D**
** ****Indian Health Service**
**San Diego**
**June 28, 2005**

## Tragedies 

- People with co-occurring MH and Addictive Disorders often seen in emergency rooms, jails, homeless shelters, on the streets, and in the obituaries.

## Methamphetamine causes severe mental illness (DSM-IV)

- Amphetamine-Induced Psychotic Disorder, with Delusions
- Amphetamine-Induced Mood Disorder
- Amphetamine-Induced Anxiety Disorder
- Amphetamine-Induced Sleep Disorder
- Amphetamine-Induced Psychotic Disorder, with Hallucinations

## Methamphetamine causes psychiatric symptoms

- Amphetamine intoxication with perceptual disturbances
- Amphetamine withdrawal

## How can we deal with this epidemic?

**Our CD recovery programs were not designed to treat addiction to methamphetamine, heroin, and prescription drugs.**
**Our mental health programs are overwhelmed and often limited to crisis intervention only.**

## Now that everything is changing, is it not up to us to change ourselves?             Rilke, Letters to a Young Poet

## Co-occurring MH and Addictions

**27 yo male in ER**
**Brought by police**
**Combative, hallucinating**
**Intact reality testing**
**Treated with Haldol and Ativan**
**Calms down **
**Drug screen + meth and morphine**

## Co-Occurring Mental Health and Addictive Disorders

**42 yo female**
**Discharged from acute psych hospital**
**3 days after suicide attempt**
**Drug screen was positive for methamphetamine**

## Sound Familiar?

**Male from the ER is referred to the CD/Addiction counselor**
**Doesn’t keep appointment**
**Female from psych hospital is seen in follow up by the mental health provider**
**She is referred to the CD Program**
**Doesn’t keep appointment**

## Characteristics of Co-Occurring

**Clients don’t keep appointments**
**They have many treatment and living situation needs**
**Their treatment providers fail to communicate**
**It’s easy for them to fall through the cracks**
**They don’t have a lot of success**
**They tend to get blamed for not doing well**

## Shall we dare to try something new?

**One definition of insanity is doing the same thing over and over and expecting different results. (Al-Anon)**

## No single therapist, health care provider, or counselor can successfully treat clients with both severe mental illness and addiction.

## What is required of ourselves is to love the difficult and learn to live with it.             Rilke, Letters

## Integrated Treatment Model for Methamphetamine Treatment

- “Resolve to be always beginning....”

## Our Guides will be:

- Kim Fox, Douglas Noordsy, Robert Drake, and Lindy Fox from Dartmouth Medical School and Psychiatric Research Center, New Hampshire, 2003
- Consensus Panel on Treatment of Stimulant Use Disorders, Center for Substance Abuse Treatment, SAMHSA, 1999
- American Psychiatric Association, DSM IV, 1994

## Stages of Treatment compared to Stages of Change

**Engagement              (Precontemplation)**
**Persuasion                 (Contemplation,  **
**                                        ****Preparation)**
**Active Treatment       (Action)**
**Relapse Prevention    (Maintenance)**
-                                         Mueser, 2003

## Engagement

**26 yo male with paraplegia, depression, and methamphetamine dependence**
**Stage:  Not engaged in treatment**
**Goal:  Establish working alliance with client**
**Interventions:  Outreach, practical assistance, crisis intervention**
-                                           Mueser, 1999

## Engaging the meth user in treatment

**Ambivalence is expected**
**Make treatment accessible**
**Provide support for being in treatment (food vouchers, transportation, onsite child care)**
**Respond quickly and positively when user makes contact with program**
**Convey empathic concern**
-                                      CSAT, 1999

## Persuasion, Motivation

**14 yo  female came in for pregnancy test, has needle marks.  Mother is in clinic waiting room.**
**Stage: Not aware that substance abuse is a problem for her.**
**Goal: Safety**
**Intervention: Urine drug test, interview mother. Social worker comes to clinic.**

## Active Treatment Stage

**46 yo male with Hepatitis C, one month off meth, depressed**
**Stage: Motivated to reduce substance use**
**Goals: Help client develop plan for abstinence. Instill hope.**
**Interventions: Working relationship between MH and CD program is evident to client.  Therapists and counselors are confident in ability to assist him.**

## Stages in Methamphetamine Treatment

**1.  Get started**
**2.  Get clean**
**3.  Stay clean**
**4.  Long-term abstinence support plan**
-                                      adapted from CSAT, 1999

## Getting Started

**Stop using.**
**Feel bad:  depression, fatigue, poor memory, trouble concentrating, irritability, craving for drug, paranoia**
**Lasts 10 days-2 weeks**
-                                      CSAT, 1999

## What helps (first 2 –3 weeks)

**Frequent, brief, supportive visits**
**Urine drug testing: mandatory, vigilant, frequent, and record of results protected by  42CFR regulations**
**Client is not kicked out of treatment for positive drug test**
**Instead, they are rewarded for clean urines (vouchers, etc.)**
**Assess co-occurring mental health disorders**
**Initiate treatment of MH disorders, including meds if needed**
-                                             CSAT, 1999

## Primary Care Can Help

**Depression/fatigue is a powerful motivation to resume use**
**Antidepressants have been shown useful in treatment of individuals who have discontinued stimulants (cocaine and amphetamines)(NIDA, 1998)**
**It helps for the healthcare providers to be on the same page/same team**
**CD and Clinic need to ask client for consent to discuss their case (sign release forms)**

## Relapse Prevention Stage

**35 yo female with diagnosis of amphetamine-induced psychosis with delusions**
**Stable on meds at home**
**Last use of meth was six months ago**
**Stage:  Relapse prevention**
**Goal: Extend recovery to other areas of life. Maintain awareness that relapse can happen. Stay on meds.**
**Interventions: Cultural/traditional program, peer groups, stress management**

## MH and CD programs have to engage each other

**Outreach—visit each other’s programs**
**In-services—offer to teach each other**
**Support—Ask clients for consent to consult with the other program whenever they are going to both programs**
**Speak the same language—bring trainers in, go to the same training.  **
**Doesn’t matter exactly what language you speak, as long as you understand each other!**

##  Step One: Agree that every client is unique.   Step Two:  Agree on terminology to describe client’s current status. Step Three:  Get permission from client to consult about his/her case.Step Four:  Meet and/or discuss the case.Step Five:  Support each other.  This is hard work.

## No one knows more about how to address the treatment needs of the meth-addicted Indian people on your reservation/city than you and your colleagues do.

## Summary

**Our systems weren’t designed for today’s drug problems.**
**Our clients are sicker and have more psychiatric problems than ever before.**
**We want to do the right thing for our clients/tribes.**
**We can start with simple, (not easy) steps to integrate treatment for clients with co-occurring mental health and addictions.**
**We don’t need to wait to be told what to do.**
**We can start now.**