Good afternoon, and thank you for coming to our workshop. Today we'll be presenting evidence-based practice of treatment of methamphetamine dependency, a review. And beside me, let me just introduce everyone at the same time, Dr. Chang Tong. Beside him is Dr. Mohamed Adil. Dr. Daniel Souter could not be here. And on the left side of Mohamed is Dr. Itzaz Munir and myself, Anil Thomas. We have no financial disclosures. So we thought we would start with a case, keeping in mind that this is not a case conference. It is just to keep it in context on the evidence that will be presented by my colleagues here. So the learning objectives. At the conclusion of this session, you should be able to know how to establish diagnosis, build rapport with a patient who used methamphetamine, review the latest research and practice guidelines for the treatment and management of patients with methamphetamine dependence, and discuss harm reduction approaches. So the clinical case. This is something that this is an individual that came to our hospital, Bellevue, about a month ago. And so we thought we would start with his case and then move on from there. It was a 35-year-old man, identifies as gay, single, no children, unemployed currently, but he was an architect in his native country. He's seeking asylum here in the US. And currently he's domiciled in a shared accommodation in the city of New York. Past medical history, none reported, but he's on PrEP. Past psychiatric history, he denied any prior hospitalization. He denied any prior treatment for anxiety, depression, PTSD. However, when a PTSD PCL-5 was done in his native country, he scored about 27. That was about December 2020. After that, the patient's brother attempted to have him killed because he found out that he was gay. Subsequently, he moved to the US and filed for asylum. In terms of going further, in 2020, his BDI was three. When he came here in 2021 to one of the services, not our hospital, but another service, his PTSD PCL-5 was about 44. The cutoff is about 33 for PTSD. And his BDI was about 17, indicating depression. Other things were part of his diagnostics was that rule-out character pathology. He also had one self-aborted suicide attempt hanging in his native country after a breakup. And he self-aborted because he did not want to traumatize his mother. And also, he had one recent suicidal ideation in the US while he was here. And current with hospitalization. And he was hospitalized because he wanted to jump out of the window. After that, in the residence that he was staying, the nurse practitioner put him on Lexapro and propranolol. With questionable effect as a result of his questionable compliance with the medication. Social history, he was born and raised in the Middle East. He's an architect by education, but currently unemployed here. In contact with his mother, a few other siblings, cousins in the Middle East. And he's seeking asylum here. Denied any incarcerations or any sort of pending legal issues. In terms of his substance abuse history, he experimented with MDMA, cocaine, ketamine, GHB, and of course crystal meth in his 20s while he was in college. Crystal meth more regularly since 03-21. He initially started using small amounts for weight loss. About 0.1 gram, or as he put it, a point. Inhaling daily, used for a week or so, and then stops for a month or so. However, currently he uses about 0.5 grams, one to two times maybe more per day, IV for extended periods with minimal time off. Cannabis, he admitted to smoking about one blunt per day regularly for anxiety. Denied any other substance, including tobacco. And he denied any sort of addiction treatment history. Mental status, when he came to our clinic, appeared as stated age. He was dressed in street clothes, well-developed, well-nourished, good hygiene and grooming. No significant increase or decrease in the psychomotor activity. No tremors or abnormal movements. Eye contact appropriate, maintained. His speech was normal. However, there was a flare for a little anxiety, excitement in that. Mood, he stated it was better. Effect was reasonable. Denied any sort of suicidal ideation or anything like that. Thought process was linear. Perception, denied any sort of hallucinations. Attention was intact. Attention and concentration was intact. Memory, grossly intact. Insight and judgment was good. His labs on admission to our outpatient clinic was positive for amphetamine. As he had admitted. And of course, eutox was positive also for cannabis. His vitals mildly elevated in terms of his body temperature. It was about 99.9. Elevated blood pressure about 160 over roughly about 100, 105. On time of the interview, he denied any sort of shortness of breath or chest pain. But he had claimed that he has a history of shortness of breath as well as periods of chest pain. Pupils were mildly dilated. And of course, there was a mild increase in activity on the interview. No history of any sort of diarrhea or nausea, vomiting was noted. Oh, I'm missing a slide. So he was admitted and then we continued with treatment. The reason for the clinical cases is as the gentlemen beside me, as they present treatment and the course of the illness, hopefully we can have a more rich discussion in terms of how to manage this individual in terms of coming up with a proper diagnosis, treatment, and of course, a long-term outcome for this individual. With that, let me introduce Dr. Tom. Thank you, Dr. Thomas. Hi, this is Chun. I am a addiction fellow from the Mount Sinai West Morningside Fellowship Program. I'll be presenting some slides that were prepared by one of my attending, Dr. Sridhar, before my slide. He wasn't able to make it today, unfortunately. So I will quickly go through some of the information here. So he really wanted to bring us attention to how we screen for methamphetamine use disorder. Very often, patients will come to us letting us know they use. And very obviously, we will probably see in the UTOCS as well. But there are definitely a few evidence-based screening, too, that we can use just to make sure we cover all our bases. So a couple of ones that you may or may not be familiar with already could be the TABs, Tobacco Alcohol Prescription Med, and Other Substance Use Screening Instrument. There's the DAST, the 10-Item Drug Abuse Screening Task. And SODU, Screening of Drug Use, which is a two-question screening tool. They ask, say, two questions. One is about how many days in the past 12 months have you been using crystal meth or whatever substance you're inquiring. And then the second question is how many days in the past 12 months have you used a drug more than you want to. And a positive response will be seven or more days for the first question and two or more days for the second question. And this two-question instrument has a sensitivity of 100% and a specificity of 93.73% for methamphetamine use, which is a very quick and easy way to sort of keep your practice within an evidence-based parameter if you want to screen for methamphetamine use. And it's very easy for you to use. The four Ps is also very interesting. It really covers other parts of the screenings. The four Ps stands for parents, which means asking for the family history. Does any of your parents have problems with drug use? The second P is partner. Does your partner have any substance use? And then the last two Ps is past and present. You're asking about past use, a problem related to use and present use as well. And also, you ask for the fifth P if pregnancy or a woman of childbearing age is coming to your clinic. And you want to ask about any use during pregnancy as well. So in terms of risk factor or maybe things you can find in your patient's family, they'll prompt you to think about crystal meth use. It is definitely not a lot of data. And the ones that we know about are not too surprising. History of opioid use, family history of drug use, risky sexual behavior, and partners that use meth. They are very much a risk factor for methamphetamine use. And we'd see methamphetamine use more in younger, especially male population. And there's not that many specific risk factor research being done in adult population as well. Let me see. How do I go to the next slide? There you go. So there are some physical findings related to methamphetamine use. Some of these pictures, and I'm sure many social medias and popular shows, Netflix and whatnot, has depicted people who have methamphetamine use in a very dramatic way. But nonetheless, we do see them presented like this. So some of the findings include weight loss due to catecholamine surge, and increased metabolism due to leading to decreased appetite, and just the fact that they're not taking care of themselves. And this can lead to wasting of fat and muscle stores, which can then lead to significant changes appearance. And then you also can, crystal meth can also cause decreased saliva production in the mouth. And that can cause problems with your dental hygiene and other problems. And then if you can see in the picture, you see all this lesion over the face. It's been termed the meth mite, which is kind of similar to a severe skin picking disorder. The mechanism is not entirely well understood, but we believe it's related to the sensory hallucination coming from the substance use. And obviously, there is many, many serious medical consequences to methamphetamine abuse as well. Some are listed here. Cardiomyopathy, malignant hypertension, aortic dissection, et cetera. Diagnosis of methamphetamine use following a stimulant use disorder, section in the DSM-5, is very much the same as the other substance use disorder. The 11 criteria that we saw is exactly the same. And the modifier is with early and sustained remission, also the same, three months and one year. Nothing too surprising here. So we'll move on. And if you want to diagnose someone with stimulant intoxication, these are the clinical signs and symptoms you can look for. Not too surprising. I'm pretty sure we're all familiar with them. So I just want to point out one thing, is that the intoxication effect can vary greatly. And you can see some of these words are almost like the opposite of each other. Some people can have euphoria, while some may experience effect blunting. So you can have all these changes in different people. So not everybody who use crystal meth will present exactly the same. But they will all have some of these stuff here. Change in sociability, have vigilance, hallucination, things like that. And then the withdrawal is very much what we predicted, which is most usually the opposite of the intoxication effect, or whatever the intoxication effect may be for the patient. And again, you may see some contracting words being used here, because everyone presents slightly differently. But nothing too surprising. Since it's a stimulant, when people are withdrawing from it, they get fatigued, they can slow down, they can appear very depressed, they have craving, et cetera. And there are some medication, obviously none FDA approved, but has been looked at for treating stimulant withdrawal. As listed up here, remeron, metazapine, mabufanil. So this is my session. I thought it would be interesting to learn about a substance from a bit of a historical context. So I just throw in a couple of slides with a bit more picture, so it's to stimulate more interest into the topic. So ephedermine was invented by Romanian scientists, you know, I'll forget. I'm not even going to try to say it. In 1887, but methamphetamine was actually invented by Japanese scientists. And that, I can say, is Nagai Nagayoshi. I'm Chinese, by the way, so. So he's a scientist, and this is the guy here. That's his face. And in 1919, Akira Okada also turned the methamphetamine compound into the actual crystal compound that we know today, which contained both of the isomer and 50-50. And that compound still lingered around, but it wasn't really popularized in medicine until the first appearance in 1933. It's marked as a decongestant in Helen. And we used a lot of very interesting substance back in the day for different types of medication, and this crystal meth was being used for one of them. And not just five years later, this substance enters a really large field and a very prominent role as a pervitin, which is called the pilot salt. It is used by a soldier during World War II as a stimulant to enhance the combat performance. That is great and all, except the drug has a lot of terrible effect, and Germans take advantage of it and use it for their pilot, and so does the Japanese. And later on, there are some other prominent figures, such as JFK, even Adolf Hitler. They have been found to have been using this substance for one reason or another. And I include a little picture here for this Dr. Max Jacobson, which is known as Dr. Feelgood at the time, who prescribed this medication as a cocktail of a bunch of substance to many very famous figures at the time as a remedy for their low mood and energy, which we now know that those remedies were primarily because of the meth. And there's the kamikaze, which is the Japanese suicide pilot using this medication to kind of hype themselves, to commit those acts. So in America, now moving on from the World War, in the 50s, it was at one point looked at as an antidepressant and diet aid. And even as ADHD treatment in the 60s, but very soon it fell out of favor due to neurotoxicity. And the substance keep getting very bad press from many big events, such as the high aspirin incidents in San Francisco. There was an incident when many young people go to study at the utopian community. And these people are also using methamphetamine at the time. And they were trying to live a very idealized life. But that soon fall apart very quickly. And it leads to a lot of paranoia and violence within the community. And a lot of things broke out. The Altamonte disaster, that was a concert that happens in the 60s, hoping to become the next Woodstock. But a lot of meth was being used at the time by both the security and the participant. And eventually led to some death that happens due to the violence that broke out. Methamphetamine, hydrochloride, a.k.a. crystal meth and ice was being popularized in the 80s. And today we have this thing called P2P meth, which is a type of isomer that has more potency. And it can be synthesized with P2P, which is the chemical that's used as an ingredient. And that will increase the potency of the drug. And that is what the crystal would have looked like. And the identity of this substance may popularize by a very famous show, which I just listed here. So a quick bit of a view of history and epidemiology. Based on the data from the NIH National Survey, over 14.7 million people in America, or 5.4% of the population, has tried meth at least once. And overdose death has overall increased within the past eight years, 2015 to now. And the use has increased as well, not too surprising. They look into genders as well. There's a threefold increase in female among heterosexual female, two times increase among heterosexual male. They also noted 10 times increase in black individuals and nearly triple among white individuals. And through the data, they identify some risk factor. And if you were to summarize them into one line, it would be very much social determinants of health. If you have low education, low income, low housing stability, all these things, and mental health that is not being addressed correctly, then you're at risk of using these substances. Just to iterate that the data does not include children, people go incarcerated, hospitalized, and nursing home. And another interesting way to look at crystal meth epidemic outside of the medical field is to look at the criminal justice side. And this is a map of the 2018 methamphetamine laboratory incident, which is how many labs they busted in that year. And where I'm from, New York, definitely wins the kick at 220, and right along with Michigan, the same number. And where we are right now, Florida, which is still top 10. And I will pass this along to my colleague, Dr. Izzaz Munir. Hello, everyone. I'm Dr. Izzaz Munir. I'm currently a fellow at NYU for addiction psychiatry. So I'll be talking about some interesting part of the workshop today, the treatment, current emerging treatments. First of all, the factors that are related to treatment outcome mainly is the duration of the drug use, the frequency, the route, and the time of abstinence when they are in the treatment. So as you can see, there are a few factors that can improve the outcome of the treatment, and there are a few that can make it worse. So things that can improve are low level of use before admission, short history of meth use, more detainment in the treatment, mostly like more than 90 days. Factors that can make it worse are like IV use, less education, other comorbidities, including the disability, multiple drug use, childhood trauma, and other psychiatric diagnoses like depression, anxiety, and other diagnoses. As we know, a lot of our patients, they usually don't remain abstinent in their relapse, so it is very important to teach them the harm reduction practices, along with the treatment options we have. So the most common thing that you can teach your patients include testing the drugs before they use, because nowadays a lot of drugs are coming laced with a lot of other stuff that can lead to overdose and deaths. Avoid using alone, so that there's somebody there to help you out in case of overdose or some adverse event happens. Use of sterile syringes if using IV, switch to a safer method of use if you're using IV. We can switch it to something else if they are not trying to stay abstinent. And strategies for safer chem sex. So moving on to the psychosocial treatments. It includes contingency management, CBT, Medix model, 12-step facilitation therapy, and there's a mobile medical application in RESET. There's the most evidence on contingency management and we can talk about in the later slide. There are other non-pharmacological treatment that are emerging but we don't have much data on it but it is there and we can try that. That includes the translinear magnetic stimulation and direct current stimulation therapy. Others are like exercise and music therapy. So contingency management is an intervention in which we use small gifts or in terms of money. We can give small badges, small stickers, anything that makes a patient being rewarded when they are presenting with negative utoxis and showing abstinence from the drug use. It has multiple benefits along with just being abstinent. It results in increased utilization of treatments, more going to the groups and the therapy practices and decrease in risky sexual behavior. You can see dramatically decrease number to three, like only five is NNT for contingency management and it has very broad evidence. Like there are 27 studies in a systemic review I reviewed recently and there was only one that showed that it did not effectively reduce methamphetamine use but all others showed like significant reduction in methamphetamine use among these patients. Moving on that well-known therapy is CBT that we use for a lot of drug use. The main concept behind the CBT is like see the substance use is a learned behavior which we can unlearn. We can teach different techniques to the patients when they are doing the therapy and to learn and identify the addictive behavior and how to correct them. Explore the positive and negative effects of the drugs, recognize the cravings early and developing coping skills to cover control. Usually they are like weekly session lasting up to 60 minutes and they can last from 12 to 20 weeks moving on every weekly. Next is the matrix model. It is a model in which we integrate a lot of different techniques all at once. It also includes CBT, we include family as like to help them with the therapy, group therapy, we can educate the family as well and the patient and we also incorporate the peer support group that can help being remaining abstinent and decrease in methamphetamine use. Moving on other psychosocial treatments that have evidence include the 12-step facilitation therapy. It is similar to the Alcoholic Anonymous 12-steps, the basic steps that include our acceptance of one's addiction, surrender and acceptance to fellowship and support structure and last active involvement in the 12-step meetings. Another recent application that has been approved by FDA, it's like it can be downloaded on any cell phone and you can prescribe to your patient to download it. It has multiple skill training videos and other techniques that can help patient learn about different skills in their everyday life along with it has contingency management incorporated in this application where you can give a small, because there's a clinician dashboard as well, you can give small rewards over the phone and that can serve as contingency management for this patient. It has shown that it has caused increased attention in outpatient programs where this application was utilized. Now the most emerging treatments are like transcolinear magnetic stimulation and direct current stimulation. There are not much research done on it but only, for example, RTMS at five RTCs that showed significant improvement for meth cravings and withdrawal symptoms and direct current stimulation was like only four RCTs that showed this kind of improvement in this patient. Obviously we need more research and more details on how these technologies help in the use of methamphetamine use disorder and other drug use disorders. Moving on, last but not the least, this is the community reinforcement approach in the patients once they are abstinent and for the long term they can stay abstinent in the society. So we have to start it while they are in outpatient programs. There are like coping skills, you can train them like including a CBT, we can help them solve the, teach them the skills for problem solving, drug refusal training. Because the drug uses a learned behavior and it gives them reward, we can replace it with something that is more rewarding or like that is healthy rewards in place of the drugs. For example, like spending time with the family, playing, doing some sports, something like that that can replace their drug use. We can also include family in this treatment intervention. It's known as CRAFT. It's like community reinforcement approach for family training. We can treat families to identify the markers when the patients are on the edge to go and relapse and when they are withdrawing or there are other signs that they can see and seek help. Other things we can use are recreational activities and vocational trainings after they are abstinent to help them get a job. Having a stable job, stable housing definitely help improve the abstinence in the long run. Next I will ask Dr. Adil to tell us about the pharmacological treatment options for the amphetamine use disorder. Thank you. Hi, my name is Mohammed Adil. I'm one of the addiction psychiatry fellow at Yale School of Medicine and I would be reviewing the pharmacological options for methamphetamine use disorder. So as we know it's unfortunate that we still don't have any FDA approved medication and in the last 10 years there has been a huge desperate attempt to find something that can be helpful and there are many medications that have been studied that includes antidepressants, anticonvulsants, muscle relaxants, mood stabilizer, stimulant-based medication. But except for these four medications that are highlighted here, none of the other medications had any clinically significant effect for the treatment of methamphetamine use. And these four medications include topiramide, mirtazapine, bupropion, and naltrexone. There's also now an effort to find a combination of these medications and bupropion and naltrexone has been studied recently and the study was published last year which is very remarkable which we will go a bit in detail and it has some promising outcomes there. In terms of mirtazapine use, there are multiple studies done and we have found that it is somewhat helpful in reducing methamphetamine use but overall it doesn't help much with the retention and it didn't help with the depression symptoms. It's a safe medication to use overall but the biggest challenge remains that it didn't help with the retention and you can see in the graph that it was somewhat helpful compared to the placebo. Topiramide, so there are two studies that were done. One of them didn't show any significant effect on the methamphetamine use but there was the other study which is a bit low-powered but it did show a reduction in the use of methamphetamine and it did show a decrease in the cravings. This medication is something you know I would like to explore further and I would like to see more data on it because right now the data is very limited but it's something to consider for patients who have severe craving. Lastly, velbutrin and naltrexone injectable is a combination that has recently been studied published last year in New England Journal of Medicine and what they did is they used 450 milligrams of velbutrin with naltrexone that was given every three weeks instead of four weeks and the study design is also very interesting. They divided the patients into two groups that would later go into into another stage and they looked at the consumption of methamphetamine through urine drug testing and they found that the methamphetamine use was decreased and the medication combination was helpful in decreasing the cravings in improving the depression score. It did not have a lot of impact on the retention of the patients but still really the data looks really promising though there are a lot of limitations in the study that include that you know the result cannot be generalized to all the patients. There was a lot of financial incentive for the patients as well to be participant in the study but still something that you know we can consider in combination with the psychosocial interventions. So I will just end here and say that you know we have very limited medication options but I think with the combination of contingency management and community outreach it can be a good option to consider. Thank you. Hi, so this is also my session. I want to include this session because I found that treating patients with methamphetamine use disorder, stimulant use disorder, I think there's a, since like Dr. Mohamed Adel was saying that a lot of good FDA approved medication which is none to treat the patient, I really want to try to approach the care for this patient in a more personalized sort of way that I can interact with them like two individuals trying to get to the same goal. I find it helpful to understand my patient perspective and one way for me to do that is to try to see where they get their information from. That's why we are very familiar with using PubMed and all these other evidence-based data to support our understanding of the substance use and how we treat them. Our patient don't necessarily do the same thing. So I just want to put together a few slides to sort of address that. So one of the first thing I do besides reading books and reading papers about the substance use is that I go on Reddit Reddit is a online forum that everybody has access to on the internet and there are many sub forum within Reddit that people will post about any information related substance use, either the experience of using it, how they approach about getting treatment for themselves, how did they feel when they are on those treatment, etc. And I think since the patient go to there for information, we should all to be familiar what patient can find in those places. So I want to put a slide up here. You can see these names. These are names of the sub forum like our drugs, MDMAs, psychonaut, reagent testing, stims, etc. These are all Reddit that could contain information related to methamphetamine use and your patient wouldn't take five minutes to find this link so you should know what they are about to as well. So I found some very good long posts that are very well thought out and well written out by both clinicians and patients. And one of the things about online forum is that it is that the identity is never revealed and people feel very comfortable sharing what they think about a substance, where in a clinical setting, face-to-face, there's always this concern about, you know, ego and things. So people may not be absolutely upfront about their thoughts, but on Reddit you can trust that they will write everything very bluntly. And so I want to say I definitely will believe almost everything that they put in here. And don't try to read this text, it's unreadable on the screen, but they didn't say anything too unsurprising in terms of approaching the patient with substance use disorder. This patient asked the counselor or clinician who are reading the post to be real and to be genuine about their care and to uphold the boundary and set it firm because they know that as a substance use user themselves they have problem with boundaries in the past and they're looking for clinician and counselor to make sure that boundary is tight and so that they can actually learn to live with boundaries. And some other tips as well that is not unfamiliar to us, but this is from what the patient feel and say and I think it's very helpful for us to read that and understand that. And then another website, this is something Dr. Suda showed me, it also contains a lot of information related to all kinds of substance use. They have like every substance that are known to men and I know about like 5% of what's listed on this very long web page that are being used and misused and abused by other people. And if you click into it, there are many articles and things that people write posts about the experience of using, how to use it safely, or how they think they can use it safely, how to get treatment, etc. And then that patient are writing their account as well. And some people are having very positive experience and some people have very negative experience. Since it's more aware to have positive outcome, sometimes I like to read this just to make myself feel a little better. And this person say my life is awesome after they achieve sobriety. It makes me believe that people do get better if they can get the treatment. This is a book that I recently got recommended by a colleague as well. It is written by this very wonderful clinician on his experience treating people with methamphetamine use in the LGBT community. Where I'm training right now at Mount Sinai in the city, we do see a huge overlap between methamphetamine use and LGBT men. So this helps me sort of get their perspective on how to approach it as well. I'm about halfway through the book and I think it was really helpful for me. It explains a lot of the sexuality, sexual symptoms related to crystal meth uses, and how as a clinician you need to be comfortable and ready to address these as they will cause relapses if you don't, if you ignore them, or if you show the patient that you're not comfortable talking about them. I'm almost getting the treatment part, so eventually I'll know what to do. But this is a very interesting book. A bit of an advertisement if you want to call it that. In where I'm doing training as well, we have a program called Crystal Clear. It started in 2008 initially by city funding, but later it's just run by the hospital. We have patients coming in for crystal methamphetamine use disorder treatment, and they can get either like one to two times a week of individual session to up to like five times a week, almost like an intensive outpatient program. And then we have psychiatrists there and therapists to help with doing groups and family therapy as well. And this is just one of those programs out there that is providing support, and I'm sure there are many others. The reason I put this up here is to say that there are definitely resources where you're practicing, and knowing what those resources are, how to get the referral, and what type of patient they're looking for is going to be important because patients will come to you and ask you what they can do next, and having those information on hand is most important. And so that's what I do whenever I start working in a new place. So I believe this is the last slide, and we will begin the question and answer right now. So thank you very much for being here for the first part. I had a question about the naltrexone. So quite often my patients will ask me a perfectly reasonable question, which is, how does this medication do what it does? And I'm having a hard time wrapping my head around how a mu-opiate blocker would kind of play into what I normally think of just as a dopamine and norepinephrine thing. So how does the naltrexone help with amphetamine? Well, I think that there's still a need to do more research on this. But I think it has something to do with the reward pathway and with the dopamine release. I'm not fully aware exactly what mechanisms are involved and how it is helpful. But there's a lot of literature that shows it is helping patients with methamphetamine and even with other stimulant use. And it looks like it's one of the most promising medication that is going to be used in the future for methamphetamine use disorder. Yeah, and we use it a lot. And I can definitely wrap my head around how it plays into alcohol, certainly opiates, obviously. But it'd be nice to have some little spiel that I could give to a patient that made sense to me so it seemed believable to the patient. Other than, hey, we've tried this. It seems to work a little bit. Hi, I'm Alona Balasanova, I'm an addiction psychiatrist in academic practice in Omaha, Nebraska at the University of Nebraska Medical Center, where we see a lot of methamphetamine use disorder in the state of Nebraska and the Midwest in general. And with regard to contingency management, it's something that we've really tried to look at, and yet there are federal restrictions on Medicaid recipients of how much money they're able to receive as a contingency management bonus, so to speak. Can you comment on the state of that and how to work around some of those things? Because that's been our biggest barrier. So we don't have to use the money to give the award. It can be like a small sticker, a small award, kind of like that. Not very expensive. You can just, like, a small sticker, whoever shows up at the NAC review talks, you can just give them, and that will also show a good benefit in the treatment. So people will stop using meth for stickers? No, it's not stickers. It's like your Starbuck, where if you get enough points, they can get, like, movie tickets. But then who buys the movie tickets, right? Where does the funding come from? Yeah, so that's the most difficult part about implementing contingency management. So I work at the VA West Haven in Connecticut, and we have a program there, and we can give, I think, up to $400 of the cash award through CM. I have seen a lot of benefits for the patients who get enrolled in that program. I think this is the biggest challenge, because even politically, I see, you know, the debates are why are we rewarding patients with cash? And we have to advocate a lot to explain that this isn't so much helpful for the patients, and it kind of also helps decrease hospitalization, which is also very expensive. But this is a struggle we are having as well, trying to explain to the people that this is so effective. And implementing a CM program, finding funding for that is the biggest challenge right now. Outside of the VA, right? Because the VA has a closed system and does not have to abide by CMS requirements, and so that's the major issue, right? I think it's like $75 that somebody can receive if they have Medicaid maximum per year, which is not sufficient based on the studies that have been done on contingency management. Yeah. Hi, my name's Sophia. I'm a psychiatry resident here in Florida, and it seems like meth is everywhere, so I really appreciate your presentation. I was wondering, what are your thoughts on treating someone with modafinil? I saw it on one of your first slides, and I wonder, you know, are there any things we need to be careful of when considering treating with modafinil about potential to cause relapse or increase the rate of relapse, as you would think maybe would happen if you were treating a patient with a methamphetamine use disorder with like amphetamine or something? There were some studies that they did find it to be somewhat helpful in decreasing the methamphetamine use, but the latest literature that I have looked up, there was no significant impact compared to a placebo. I don't see, like Mudafinil, there were initially a lot of emphasis on stimulant medication use, but the latest literature doesn't show any significant effects on the patients in helping decrease the use of it. And I don't see any new studies that are going into it as well, so I don't think that's a very viable option in the long run. Okay, thank you. Hi, I have two questions. One is that if the patient is using cocaine and methamphetamine, and considering no contraindication, anything else, which medication would you, what's your go-to medication? That's the first question. The second question is that if the patient has methamphetamine use disorder and bipolar and nothing else to consider, what's the medication? What's your first choice? Those are the two questions. Sorry, can you repeat the first question? I couldn't understand. Yes, the first question is that patient has the cocaine use, methamphetamine use. Second question, methamphetamine use and bipolar. No other contraindication. If there is an option for contingency management or community reinforcement, I think those intervention are right now the most effective goal-centered intervention that can be used for both of them. The problem with medication is that not only they are not effective, they also doesn't improve the retention rate in the clinic. And they come with certain side effects that a lot of patients are not interested in. So I think psychosocial interventions remains the most effective one. For patients who have methamphetamine use and bipolar disorder, do you want to comment on? Let me just open it up to the audience. I mean, because there are no FDA-approved medications, in terms of non-pharmacological treatment, we know a couple of them do have effect on it. If anyone else has experience with medications that they have tried on individuals, novel treatments that they would like to share. Hi, I'm Kate Reen, I'm a psychiatrist at the Seattle VA. I can comment on that. My initial go-tos are bupropion or mirtazapine. I think they have the least risk of side effects, so it's pretty easy to give it a shot and see if it's helpful. Have you had success with it on individuals with crystal? Not a lot for mirtazapine, but some for bupropion. I think that's been a little bit more helpful for some. And I'll assume that there is the non-pharmacological treatment that's applied with it. Ideally, yes, but not everyone wants to do that, so we do what we can. I don't know if you have other comments on that. Matt? So, based on my personal experience with patients, it's an N of three, small sample size. Two patients with comorbid bipolar disorder, one of them bipolar I, the other, wasn't clear, bipolar I, bipolar II. The third, just methamphetamine use disorder. The methamphetamine use in all three of them was impressive. Daily, heavy use for, in one case, 17 years. The other, shorter duration, but extensive. What's the secret? Nothing worked in all three. I did naltrexone, Adderall even, high doses, nothing. To the point, you know when a patient doesn't even bother taking Adderall, it's not really doing anything. All three of them had a full resolution of cravings with Asenapine, Safras. So, it was such a robust response in all three cases. Something worth considering. Dose? The dose in one, in one of them, and again, I was using it as a mood stabilizer as well, so that was a full dose, like 20 milligrams. The other two, dose range from 2.5 to 10 milligrams. But impressive, impressive. Safras, Asenapine, Safras, Asenapine. I don't know if other people wanna comment on that, but my other question was gonna be, there does seem to be some signal that using prescription stimulants can be helpful for stimulant use disorder, whether or not that's just, we're not dosing it high enough to where we're getting a response, or the dropout rate, or whatever other factors might come into play. But I'm wondering if anyone's seen any studies or knows of anything in the works in terms of combining maybe contingency management with some of these medications that have shown some promise, and seeing if you can kind of get more robust results. Sorry, I wasn't listening to the question fully, but I think your question is that use of stimulant for methamphetamine, right? So my question is more so about combining contingency management with a medication, like a stimulant or something else that maybe hasn't shown promise individually. In my clinical experience so far, the biggest challenge is, so we have an option for CM, but it's so difficult to recruit people for CM alone. So I have to do both medication management and try to motivate them to join CM program. My favorite medications are mirtazapine and velbutrin. The problem with CM often is that patients will say it's difficult to come twice every week. They have some problem with the transportation, or they have some job they have to go to. They cannot come that frequently to this program. So I often use these medication. But there's one patient that I had that has shown significant improvement that is on mirtazapine and is going to CM. And he has won up to $200 and he's very motivated. So that combination was very helpful for me personally. But I think that a combination of these two is going to be the most effective one for helping our patients. Okay, great, thanks. Hello, my name's Justin. I'm a psychiatry resident from Calgary, Canada. Routinely we'll see in hospital patients with repeated admissions with methamphetamine-induced psychosis. And there's no evidence of a primary psychotic disorder as far as we can tell based on history. What is routine practice in some hospitals will be to put these patients with this recurrent history on long-acting injectables of antipsychotics, like invegasistana? I'm just curious, in your understanding of the literature, is there any evidence to support long-acting injectables to prevent recurrence of methamphetamine-induced psychosis or reduce hospital admissions or anything else? Chang, do you want to take this one? Hi, so I'll just speak from what I understand personally. I have not come across any literature. Oh, hi. I have not come, oh, you can't hear me, okay. I have not come across any specific evidence supporting the use of long-acting injectable for simulin-induced psychosis. Obviously, if you're giving it for any comorbid psychotic disorder, as people with psychotic disorder are more likely to have a psychotic break if they are also taking stimulant, then it can be justified for that reason. And I don't think there'll be, those evidence were easy to come by, but if you want to think very clinically and worry that if this patient is using and continue using and has no sign of stopping, then at some point in the next 30 days within the medication duration, they will be using crystal meth again and they have psychosis. And if you want to rationalize that having the medication on board while the patient's using substance so that they will have less intensive psychosis and less chance of returning to the hospital, I guess you can try to justify it that way. But honestly, this is kind of stretching it, really stretching it. So no, I don't think there's any formal evidence to support the use of that. Okay, yeah. Yeah, in terms of long-acting injectables, I mean, yeah, I've not heard of that being used solely for psychosis as a result of crystal, unless they have a dual diagnosis and then that's another story. Yeah, and just to add further context, like this is a practice I see in a few cities where there's usually like a homeless population that's engaging in recurring crystal meth use, like high, high usage of the hospital system with repeated admissions, sometimes violence involved and ultimately lost to follow up. And so I think some folks take the harm reduction approach of trying to add on an LAI to prevent further psychosis, but it's helpful to know that this is not an evidence-based practice whatsoever. Yeah, I mean, I would be a little uncomfortable putting someone on an LAI solely based on that, like the homelessness and repeated use. Thank you. Hello, my name is Jared. I'm a fourth year psychiatry resident at Zucker Hillside Hospital in Queens, New York. More of a comment than a question, responding to the earlier inquiry about barriers to the contingency management. So as part of my training and now in a moonlighting capacity, I work at an outpatient dual diagnosis treatment program called Project Outreach. So two small things. We use the RESET software that you referenced in your presentation. That software and there are a small handful of others in the digital therapeutic space. Many are not evidence-based, have any authorization approval, whatever, but some do including the RESET. It's not FDA authorization. They use a different term for devices and things of this nature, but it's been okayed by the FDA. And because of that, it is covered for our Medicare and Medicaid patients. And that entails contingency management as part of that. So that's one consideration. The other is we have groups, obviously as part of our program, what some of our groups do on a weekly basis is they have like at the end of each meeting, they like spin a wheel for each attendee on the way out the door. And you can either get an affirmation or you have a one in eight chance or two in eight chance, I don't know what it is exactly, of getting a $5 gift card to Subway, whatever. So if you're not getting funding from somewhere else and you think that this is a useful strategy for keeping people coming back, I would have to think that the fairly nominal sums of gift card money weighed against the increased reimbursements just for the care by retaining people in the treatment might justify that from a budgetary standpoint. I think that just comes out of the clinic's budget. I can't swear to that, but that's another consideration. I think that's where the challenge is. Do departments give that readily? Right, if the evidence is there that it's helpful, and it keeps more people in care, maybe more should. At Bellevue Hospital, we have an auxiliary group that provides us with minimal funding for contingency purposes for some of the programs. Yeah, I just want to make a comment that a lot of time we think the CM is about giving some sort of reward, but it's also a lot about the social connection, and that's the part that a lot of patients find very helpful, the social aspect of it. The affirmation. Yes, thank you so much for that comment. I realize I didn't introduce myself before. Matthew Rotnick, NYU School of Medicine and Private Practice in New York City. The N of three that I was thinking about before, this is a separate point. Two of them were gay men, and the third was identified as heterosexual, but his methamphetamine use was commingled with sex with male to female transsexual prostitutes. And I realize Petros isn't here, otherwise he would be making this comment. Unless things have changed dramatically, I think that methamphetamine use, you have to think, is this the gay male urban population or the non-gay male urban population, right? That really polarizes into two groups, and they're very, very different groups. What was striking about these, well, two of these three patients, was their use was pervasive, and it wasn't just commingled with sexual or compulsive sexual behavior, however you want to describe it. So my point is this, and just in treatment approach, if this is methamphetamine use slash sex, again, gay urban population, you really, really have to treat the whole thing, or else there's absolutely no way it's going to. So in my experience, again, now I'm going on my mostly Private Practice, the pornography use has to be addressed, the sexual compulsivity has to be addressed, the profound narcissistic injury underlying the use. You take a drug that gives you like a Superman cape in the sexual realm, it's a great antidote to narcissistic injury. Take it away, what are you left with? So I think it's a really important point, and again, this is Petros' area. You guys, Addiction Institute, the Crystal Clear program, that's like the epicenter of this kind of work. Take a minute and talk it up some. It's an important program. Yeah, what you mentioned is absolutely correct. The Crystal Clear program, since it's founded in 2008, has seen that more than, basically 98% of the patients there are LGBT men, male-conscious men, and they definitely present many unique sort of challenges doing the treatment of the substance use disorder, primarily the sexual behavioral symptoms that you're talking about. A lot of these men's associated use with sex and using the crystal meth was kind of the first time they ever felt belong to a community of people who use crystal meth. It makes them feel empowered. It makes them feel like they're free and be themselves, even though that self that we're talking about is not really them, it's them being intoxicated. And then later down the line, when the consequences catch up, they really truly feel lost. And then very often you hear them talking about like they couldn't even enjoy having sex just because it's also associated with the substance use. The actual neurotoxicity causing all this collapses in the brains and the receptors and the connection truly do happen, and this takes a very, very long time for them to recover from that. And ignoring that part will result in treatment failure almost guaranteed, so it must be addressed, like Matt was saying earlier. In crystal clear programs, you know, right now seeing an average 70-something patient, and they're all basically gay men in the city. That is for a good reason. This drug use, along with GHB, also a very commonly seen comorbid use substance, they all need to be talked about. And then, yeah, Dr. Lavounas will be definitely the person to talk to, but crystal clear is in, right now running by Monsanto, is definitely the epicenter of it. So if any trainees interested to reach out and take a look at the program, glad to have you. But yes, I think that's a great comment. Yeah, the individual that started that is Dr. Joseph Ruggerio. Yeah, I still get that deck with him every week, so he cannot stop talking about it, it's great. Hi, Jim Halicus. I find it useful to ask all stimulant abusers what it does for them. And if I find a sweet spot where they say at a certain level I'm more functional, I clean the apartment or I get things done, and I'm not particularly high from it, I think that's ADD, that's been untreated. And I think they respond to the stimulant medications preferentially. And that associates with one of the early slides where you mentioned RDCS. Is RDCS the brain stimulation that is now being studied for ADHD? Yes, yes, that's the one. So it connects. Dr. Gallanter. Yeah, hi. There are 1,800 narcotics anonymous programs in the United States groups. And we surveyed 2,000 NA members. 10% of them had a primary drug problem of methamphetamine. If you speak to a lot of clinicians, they'll say, well, we do this and that and so on. And if we're lucky, they'll go to NA. And NA is a resource that's widely available. When we asked the people in that survey how many came because of recommendation from addiction professionals, it's a small minority. So there's really a gulf between the recovery, if you want to call it, that community and the medical community, which bespeaks an issue of whether we should have more orientation to introducing 12-step participation in the programs that we're talking about. And absent that orientation, people are not likely to go to NA because of anything we've done. And I think that a lot of rehab programs have a 12-step orientation, and it's well worth considering that as an option. In fact, we just published a study in the American Journal on Addictions, this is like a week ago, in which we have the data on that. But it's really worth considering how programs can be structured to have an option for people being encouraged to go to 12-step programs. Thank you. Last question. Hi, this is more a comment, maybe a couple of comments. My name is Maria Petrova, I'm the Addictions Clinical Director for Pair Therapeutics that actually manufactures RESET. And really very insightful comments in the room. I just wanted to mention that RESET actually has several different protocols. We are current, one that is non-monetary, CM. Another one is CM75 that a lot of Medicaid programs reimburse for, and then CM500. We're also working on a gamified version, and in an initial study it's showing us really, really high engagement, and it's a non-monetary program. We're also working on a lot of data, really to compare these different protocols and see which one is giving patients really positive results. One thing that I wanted to also share with you, I think you rightfully pointed out that engaging patients in contingency management is really challenging because of the fact that you have to test them, drug test them. I'm a faculty member at University of Miami, and I just currently got a grant funded implementing RESET within HIV care, specifically with men who have sex with men who are HIV positive. We're implementing a virtual CM protocol where we're sending cups, urine, drug screens to the home of the patient, and then they're providing us with the sample via Zoom, and then we read the cup via Zoom so the patient doesn't actually have to physically go to the clinic, and that's really making it much easier for people to adhere and to participate in a contingency management program. I'd be happy to share the protocol with anybody that's interested, so thank you. Yeah, thank you. Can I ask for the non-monetary CM, is it difficult to engage or recruit patients for that or compared to the monetary version? So what we are learning is the onboarding is really important, so if there is a peer advocate or a staff member in the clinic that helps the patient to onboard on the app, and if they, in fact, even within the first clinic visit, they take the first lesson, they're much more likely to stay engaged, and with that gamified version that I shared with you, we're really seeing very high engagement that is actually higher in some of the monetary programs that we have. Yeah, that's very interesting. Thank you so much. Yeah. Thank you. Okay. Thank you.

evidence-based practice

methamphetamine dependency

psychosocial treatments

pharmacological options

Topiramate

Mirtazapine

Bupropion

naltrexone

LGBT community

Crystal Clear program