REVIEW OF: Wilens TE et al, J Addict Med2024;18(2):180–184

STUDY TYPE: Retrospective quality assurance examination

Methamphetamine use has surged dramatically, with a 460% increase in stimulant-related overdose deaths from 2016 to 2021. Unlike opioids or alcohol, methamphetamine withdrawal does not cause severe medical symptoms such as elevated blood pressure, seizures, or delirium, which has led to a lack of specific treatment protocols. Nevertheless, individuals withdrawing from methamphetamines often experience significant irritability, agitation, depression, and intense drug cravings, making it a challenging condition to manage.

In this study, the authors aimed to develop a standardized approach for treating psychiatrically hospitalized patients with methamphetamine withdrawal that minimized the need for constant physician intervention. The protocol, outlined in the table, starts with a full physical exam and a large dose of ascorbic acid, which might protect against methamphetamine neurotoxicity (Huang YN, Toxicol Appl Pharmacol 2012;265(2):241–252). The protocol then centers on behavioral interventions, with additional medications available as needed. Focus groups assessed the feasibility and staff perceptions of the approach.

Unit staff received training on the effects of methamphetamine, withdrawal symptoms, and protocol specifics. They enrolled 23 participants, all single men with recent methamphetamine use admitted to the inpatient unit. There was no control group, meaning all participants received the protocol. Most participants (87%) had comorbid opioid use disorder (OUD), and a majority (91%) were experiencing homelessness. Behavioral interventions alone sufficed for about half of them (48%), while the other half (52%) required medication, the most common of which was quetiapine. An impressive 83% of the patients completed the protocol, with a mean withdrawal symptom duration of 2.6 days. Staff feedback was positive regarding both the behavioral and pharmacologic components, and they found the pre-implementation educational material particularly beneficial.

The study’s biggest limitations are its small size and lack of a control group. The adherence rate of 83% is notable and exceeds the 70% adherence rates reported in other studies (Lappan SN et al, Addiction 2020;115(2):201–217). However, it is unclear how much of this success is attributable to the protocol itself versus other factors. Another potential confounding variable is that most participants had comorbid OUD and all of them were started on medication for OUD (MOUD). While comorbid OUD is common among methamphetamine users, the impact of MOUD on the study’s outcomes remains uncertain.

CARLAT TAKE

This small, non-controlled study introduces a novel clinical approach for managing methamphetamine withdrawal, an increasingly prevalent and challenging clinical scenario. Despite the study’s significant limitations, its approach is valuable in light of the absence of widely accepted protocols for methamphetamine withdrawal treatment.