Results and Discussion
General recommendations
In the case of methamphetamine intoxication, the following symptoms may occur to varying
degrees:
-
medical-somatic symptoms, such as sympathoadrenergic symptoms (high blood pressure,
tachycardia, hyperthermia, diaphoresis, mydriasis, or agitation) and complications
such as uncontrolled hypo-/hypertension, cardiac arrhythmia, circulatory problems,
seizures, respiratory depression, chest pain, strokes, brain hemorrhage, and disorders
of consciousness.
The level of tachycardia or hypertonus usually is a good indication of the degree
of methamphetamine intoxication [5].
-
mental symptoms such as expansive-aggressive states, agitation with poorly controllable
fits of rage, stereotyped behavior, and anxious-agitated, delirious, or psychotic
states with hallucinations and delusions.
-
psychosocial complications such as aggressive behavior, traffic offences, and criminal
offences.
Severity of intoxication symptoms depends on dose and duration of methamphetamine
intake. The symptoms may persist for several hours. The risk for aggressive behavior
is particularly high in the case of a psychotic disorder and/or when methamphetamine
intake is coupled with drinking of alcohol [6].
During the acute intoxication, it may be difficult to take the medical history from
the person affected. Therefore, information from a third party and consideration of
the social environment of the patient are important for making a diagnosis. The possibility
of methamphetamine intoxication should be considered in every patient presenting with
diaphoresis, hyperthermia, hypertonia, tachycardia, severe agitation, or psychosis.
Initially, the amount and type of substance (or substances) involved are mostly unknown.
Hence, it is difficult to predict the clinical course. The management of any sympathoadrenergic
syndrome including methamphetamine intoxication follows a syndrome-oriented approach.
Monitoring the autonomic nervous system and psychopathological symptoms is crucial.
A positive result from a qualitative urine test (“tox screening”) increases the probability
of methamphetamine intoxication. However, a negative test cannot rule out life-threatening
methamphetamine intoxication.
A person suffering from a methamphetamine intoxication ought to be treated in a quiet,
low-stimulus environment if possible (LoE 5; ⇑) [2].
The emphasis is on care and calming of the affected individual and on attending to
or preventing secondary harm due to panic or expansive and aggressive behavior. According
to clinical experience, a quiet, protective space and talking down the patient is
crucial. As far as possible, the patient should be attended to by the same member
of staff. Family or friends of the patient, who might help to calm him or her down,
can also be involved. Doctors and nursing staff should listen to the patient and try
to explain to him or her the situation and their acts in simple, short sentences.
Their basic attitude should be empathic and accepting (no reproaches or confrontations!).
Any potentially irritating or misleading forms of behavior such as abrupt movements
or approaching the patient rapidly should be avoided. When these principles are respected,
clinical experience shows that sedating medication may not be required [7].
In an emergency situation with aggressive patients, it is essential for helpers to
always keep their own safety and health in mind (keep an exit route open, high level
of staffing, at least a second person who can intervene or go for help). There are
established and, in some cases, evaluated de-escalation management concepts for staff
in health care and social services (e. g., www.prodema-online.de).
As far as possible, physical restraints (fixation) should be avoided, as they will
almost always promote further escalation of agitation and aggression. Of note, physical
restraints are associated with increased risk of life-threatening conditions (e. g.,
rhabdomyolysis, hyperthermia, etc.) and sudden death. Nevertheless, temporary use
of restraint may be unavoidable in exceptional situations (e. g., aggressive attacks
by the patient). In this case, a standard procedure and high staffing are needed (usually
5 people). Given the risk for the patient, attendance by a qualified professional
nurse is recommended throughout restraint (1:1 care).
After a methamphetamine intoxication, a psychiatric evaluation for substance-use disorders
and, if appropriate, further addiction treatment should be recommended (LoE 5; ⇑⇑).
Once the intoxication has abated, many patients are receptive to psychoeducation and
recommendations for diagnostics and treatment. Diagnostic procedures should include
a psychiatric evaluation for addiction and comorbid psychiatric disorders. If appropriate,
contacts to the professional support system should be establishment in order to promote
further treatment (e. g., psychiatrist, specialist outpatient addiction treatment
center, counselling facility).
Pharmacological interventions in acute methamphetamine intoxication
No evidence is available on pharmacological interventions in acute methamphetamine
intoxication. Recommendations reflect the consensus of the working group based on
their clinical experience (see Acknowledgment). The systematic search for guidelines
came up with consensus-based guidelines of moderate methodological quality on the
emergency management of patients with psychostimulant intoxication syndrome [7]. Overall, the level of evidence of recommendations is weak.
In the case of an intoxication with several (unknown) substances, no medication ought
to be given, unless sufficient monitoring of cardiovascular parameters can be provided
(LoE 5; ⇑).
In an acute situation, it is often unclear which substance or combination of substances
is involved. In this case, it is advisable to be reticent with the administration
of medication if or as long as no adequate monitoring of cardiovascular parameters
is provided. Possible interactions can exacerbate disorienting and respiratory depression
(e. g., benzodiazepines in the case of a mixed intoxication with alcohol, liquid ecstasy,
or certain natural hallucinogens [fly agaric toadstools, angel’s trumpets, etc.]).
Resuscitation equipment must be available, and monitoring of cardiovascular parameters
(e. g., heart rate, blood pressure, blood oxygen) must be ensured for the duration
of action of the medication given, especially outside emergency wards.
In the case of methamphetamine intoxication with severe agitation, aggressiveness,
or psychotic symptoms requiring pharmacological treatment, benzodiazepines should
be given as first-line medication (LoE 5; ⇑⇑).
Table 4 Grades of Recommendation.
|
Strong recommendation
|
Should/should not
|
⇑⇑/⇓⇓
|
|
Recommendation
|
Ought to/ought not to
|
⇑/⇓
|
|
Open recommendation
|
May be considered/no specific recommendation
|
⇔
|
Fast-acting benzodiazepines are the first choice in the case of severe agitation,
threatening or manifest aggressive behavior towards the patient himself/herself or
others, or psychotic symptoms. [Table 5] gives some typical doses and dosage intervals. Sedation should not be so deep that
the patient becomes unconscious. In most cases, no other medication apart from benzodiazepines
is needed.
Table 5 Psychopharmacological treatment of methamphetamine intoxication.
|
First choice: benzodiazepines
|
|
Substance
|
Typical doses and dosage intervals
|
|
Diazepam
|
10 mg orally, if necessary repeat after 30 min; alternatively, 2.5–5.0 mg i. v. bolus,
if necessary repeat after 5–10 min
|
|
Midazolam
|
5–10 mg orally (tablets or drops), if necessary repeat after 30 min; alternatively,
2.0–2.5 mg i. v. bolus or i.m., if necessary repeat after 5–10 min
|
|
Lorazepam
|
1.0–2.5 mg orally, if necessary repeat after 60 min; alternatively, 2–4 mg i. v. bolus,
repeat after 5–10 min
|
|
Add-on treatment, if neccessary: antipsychotics
|
|
Substance
|
Typical doses and dosage intervals
|
|
Olanzapine
|
10 mg orally (orally dissolving tablets), if necessary repeat after 60 min; alternatively,
5–10 mg i.m., if necessary repeat after 120 min
|
|
Risperidone
|
2 mg orally (orally dissolving tablets), if necessary repeat after 60 min
|
|
Second choice: Haloperidol
|
5 mg orally (tablets or drops), if necessary repeat after 60 min; alternatively, 5–10 mg
i.m., if necessary repeat after 5–10 min
|
|
In most cases, high cumulative doses are to be expected
|
|
ECG monitoring with i. v. application required
|
In the case of methamphetamine intoxication, an additional medication with an antipsychotic
may be considered if the administration of benzodiazepines is not sufficient (LoE
5; ⇔).
In the case of hallucinations and delusions, it may be appropriate to administer an
add-on antipsychotic medication. Based on clinical experience, second-generation antipsychotics
such as olanzapine are the first choice. First-generation antipsychotics, like butyrophenones
(haloperidol), may be an alternative choice; however, they have a high risk for acute
side effects (in particular acute dystonia). Furthermore, butyrophenones may worsen
symptoms of dysphoria and anxiety [8]
[9]. [Table 5] gives some typical doses and dosage intervals.
Epileptic seizures are a frequent complication of methamphetamine intoxication. Here,
too, benzodiazepines are the first choice. In contrast, antipsychotics usually lower
the threshold for seizures.
Once there is no further intake of methamphetamine, the ingested methamphetamine has
been excreted, and normal sleep patterns have been reestablished, psychotic symptoms
from methamphetamine intoxication mostly ease within hours or 1–2 days. The need for
continuation of antipsychotic medication should be reviewed continuously during the
course of treatment of methamphetamine intoxication and at the latest after 3 days
[7]
[8] ([Table 6]).
Pharmacotherapy of methamphetamine-induced psychosis
The use of an antipsychotic medication is indicated in case of psychosis following
methamphetamine use and extending beyond the period of the pharmacologic action of
the drug. According to ICD-10 criteria, (meth)amphetamine-induced psychosis (F15.5x)
evolves during intoxication or within a few days of last use and lasts for several
days to weeks. Some lighter (residual) symptoms may persist for up to 6 months.
An antipsychotic ought to be administered as first-choice medication for the treatment
of methamphetamine-induced psychosis. Within 6 months, the indication ought to be
reviewed. Given the more favorable side-effect profile, preference ought to be given
to a second-generation antipsychotic drug (LoE 2; ⇑).
Olanzapine and haloperidol were equally effective in an RCT involving 58 patients
with amphetamine psychosis. Haloperidol use was associated with a higher rate of acute
extrapyramidal motor side effects, resulting in an increased rate of therapy discontinuations.
In contrast, weight gain was more frequent on olanzapine [10]. In another RCT enrolling 80 patients with methamphetamine-induced psychosis, low
doses of quetiapine and haloperidol were equally effective and accepted by the patients
[11]. In another RCT, risperidone proved superior to aripiprazole in reducing positive
symptoms [12]. In contrast, another RCT with 42 patients with a methamphetamine-induced psychosis
showed similar efficacy of risperidone and aripiprazole. However, the acceptance of
risperidone was better, and a higher number of therapy discontinuations was observed
on aripiprazole [13]. Overall, given the limited evidence, no specific recommendation for a specific
second-generation antipsychotic medication can be given for the treatment of methamphetamine-induced
psychosis.
No trials have investigated the optimum duration of antipsychotic medication for methamphetamine-induced
psychosis. Antipsychotic medication should be reviewed after 6 months at the latest,
and if possible, it should be tapered off. If there are persisting psychotic symptoms
after 6 months of methamphetamine abstinence, the diagnosis of a schizophrenic disorder
must be considered.
A benzodiazepine may be considered temporarily as an add-on treatment to an antipsychotic
medication of a methamphetamine-induced psychosis (LoE 5; ⇔).
No evidence is available on the use of benzodiazepines in the treatment of methamphetamine-induced
psychosis. According to the clinical experience of the experts, add-on benzodiazepines
may be helpful in the case of ongoing psychotic symptoms if antipsychotic medication
is not sufficient. Add-on benzodiazepines may attenuate the acute threat to the patient
himself/herself or others (e. g., due to pronounced depressive mood swings or acute
anxiety symptoms). Benzodiazepines themselves are addictive. Therefore, the dose should
be as low as possible with limited treatment duration.
General treatment of methamphetamine withdrawal
The main goals of physical detoxification are alleviation of withdrawal symptoms and
prevention of complications. The goals also include diagnostic evaluation, counselling,
and, where appropriate, commencement of treatment of physical and psychiatric disorders.
Moreover, social counselling and the introduction of the first steps towards socio-rehabilitative
procedures may be appropriate. The special feature of qualified withdrawal treatment
is to integrate somatic, psychiatric, psychotherapeutic, and social work [8].
According to clinical experience, the need for treatment in methamphetamine-dependent
users is similar to heroin and cocaine addicts. Withdrawal symptoms include craving,
exhaustion, cognitive impairments, sleep disorders, irritability, agitation, depressive-anxious
moods, and sometimes even suicidal ideation. Withdrawal symptoms may be very heavy
for at least 1 week and somewhat milder for at least another 2 weeks [14]. Craving lasts far longer and presents a high risk of relapse, particularly in outpatient
treatment [15]
[16]
[17].
Given the high risk of relapse, the duration of qualified withdrawal treatment should
consider the needs of the individual patient and extend beyond the abatement of acute
withdrawal symptoms in order to achieve sufficient, mental, somatic, and social stability
for further treatment. However, up to now, there is no clear evidence concerning which
patients do better with in- or outpatient treatment.
Treatment of a methamphetamine withdrawal should be at least 3 weeks, particularly
in the case of high and regular substance consumption (LoE 5; ⇑⇑) [14]
[18].
Pharmacotherapy of methamphetamine withdrawal
Fifty-eight publications on pharmacotherapy of withdrawal from amphetamine-type stimulants
were identified. However, only a few studies focused on methamphetamine-dependent
patients. Furthermore, they had considerable methodological limitations (small sample
sizes, high drop-out rates), and only a few studies addressed specifically withdrawal
treatment. Hence, only findings of limited reliability are available for methamphetamine
withdrawal, and many of the recommendations are extrapolations from studies with cocaine-
and other amphetamine-type-stimulant-dependent patients.
Only 2 RCTs were available on the use of antidepressants for withdrawal of methamphetamine-dependent
users. A study with 20 participants showed that bupropion reduced methamphetamine-induced
subjective effects (“high”) and cue-induced craving, but it had no effect on depressive
mood or anxiety [19]. Another study (n=31) failed to show any effect of mirtazapine on retention rate
or withdrawal symptoms such as sleep disorders, anxiety, and depression [20]
[21]
[22].
There was no evidence to support the efficacy of selective serotonin reuptake inhibitors
(SSRI) in alleviating methamphetamine withdrawal symptoms. In fact, there is a risk
of a serotonergic syndrome and a higher rate of side effects with SSRI in methamphetamine
users [23].
There were no studies on tricyclic antidepressants (TCAs) in the acute treatment of
methamphetamine-dependent users [24]. However, TCAs like desipramine are effective against withdrawal symptoms in cocaine
addicts [25]. As both the pharmacology and the withdrawal symptoms of methamphetamine are quite
comparable to those of cocaine, TCAs might be helpful for methamphetamine withdrawal,
too.
Overall, the evidence concerning antidepressants during methamphetamine withdrawal
is poor, in some cases contradictory, and probably very much dependent on the random
sample examined (especially consumption duration and pattern) and the treatment setting
[22]
[26].
If, in the case of methamphetamine withdrawal, the prevailing signs are depressive-anxious
symptoms, exhaustion, and/or hypersomnia, bupropion or a TCA with activating properties
such as desipramine may be considered (LoE 5; ⇔).
If insomnia and/or agitation prevail, an antidepressive medication with more sedative
properties may be considered (LoE 5; ⇔).
These recommendations refer to symptoms during acute withdrawal. Reference is made
here to the publication by Härtel-Petri et al. in the same journal for the treatment
of a comorbid depressive disorder.
First-generation antipsychotic medication with high potency ought not to be used to
alleviate withdrawal symptoms in the acute treatment of methamphetamine patients (LoE
2; ⇓).
There is neither a rationale nor evidence for the use of first-generation antipsychotic
medication to alleviate withdrawal symptoms.
For second-generation antipsychotics, RCTs on aripiprazole are available that show
no or only marginal effects compared to placebo [20]
[27]
[28]
[29]. In 1 study, an exacerbation of methamphetamine craving was described on aripiprazole
[28]. There are no studies on other antipsychotic medications for the treatment of withdrawal
symptoms. According to clinical experience, olanzapine or quetiapine might be helpful
in the management of agitation, tension, or insomnia during methamphetamine withdrawal.
Benzodiazepines may be considered in inpatient withdrawal treatment of methamphetamine-dependent
users to attenuate an acute threat of harm to the patient himself/herself or others
or to treat pronounced anxiety symptoms (LoE 5; ⇔). Given the addictive potential,
benzodiazepines should be administered at the lowest possible dose and should be tapered
off as soon as possible (LoE 5; ⇑⇑).
No evidence is available on the use of benzodiazepines for the treatment of methamphetamine
withdrawal. The general use of benzodiazepines in conjunction with uncomplicated methamphetamine
withdrawal does not seem appropriate. However, add-on benzodiazepines may be helpful
in the case of ongoing psychotic symptoms if antipsychotic medication is not sufficient.
Add-on benzodiazepines may attenuate the acute threat to the patient himself/herself
or others (e. g., due to pronounced depressive mood swings or acute anxiety symptoms).
Nevertheless, benzodiazepines should be tapered off as soon as possible.
In justified individual cases and if previous withdrawal attempts have failed, sustained-release
dexamphetamine may be considered in inpatient withdrawal treatment to alleviate withdrawal
symptoms in methamphetamine-dependent users (LoE 2; ⇔)
When sustained-release dexamphetamine is used in inpatient withdrawal treatment to
alleviate withdrawal symptoms, the dose should be individually titrated and then tapered
off no later than the time of discharge (LoE 5 based on [20]
[24]
[30]; ⇑⇑).
Sustained-release dexamphetamine should not be given to treat methamphetamine withdrawal
in an outpatient setting (LoE 5; ⇓⇓).
A small RCT with 49 methamphetamine-dependent users investigated reduction of use
after 3 months on sustained-release dexamphetamine versus placebo. At the end of the
“stabilization phase” (corresponds to the withdrawal phase), the average dose was
80 mg/day. Although there was no significant difference to placebo for the primary
endpoint, a reduction in withdrawal symptoms in the stabilization phase was demonstrated
as a secondary endpoint. The study had several limitations (secondary endpoint, small
sample size, high drop-out rate of 53%) [20]
[24]
[30]. In another small RCT, which enrolled 60 methamphetamine-dependent users, 60 mg/day
of sustained-release dexamphetamine were tolerated as well as placebo (primary endpoint:
tolerance) and the drop-out rate was 13% in both treatment arms [31]. Regarding the secondary endpoints, there was no reduction in the level of use,
but a reduction in withdrawal symptoms (Amphetamine Withdrawal Questionnaire) and
craving (measured using a visual analogue scale). The clinical relevance of these
effects seems to be limited; for instance, the difference in severity of withdrawal
of around 3 points (score of 15 vs. 12) was seen for only 2 of the 8 withdrawal severity
scorings. Similarly, the reduction in craving was demonstrated in only 2 out of 8
craving scorings during withdrawal. This trial, too, has several limitations (secondary
endpoint, small sample size).
Due to the limited evidence, no specific recommendation can be made. Given the high
drop-out rate amongst methamphetamine users during withdrawal, inpatient treatment
with dexamphetamine may be justified (e. g., when patients have already dropped out
from previous withdrawals). Sustainable-release dexamphetamine should be titrated
individually and should be tapered off within 2 weeks and no later than at the time
of discharge from the inpatient setting. Needless to say, dexamphetamine is a narcotic
and has potential for abuse. Hence, the patient should not be supplied with any of
this medication on discharge from inpatient treatment, nor should it be prescribed
for outpatients.
For other stimulants, either no evidence was available for the acute treatment of
methamphetamine-dependent users (methylphenidate), or the available studies did not
show any effects or they only showed marginal benefits compared to placebo [32]
[33]
[34]
[35]
[36]. Hence, several small RCTs with modafinil failed to demonstrate clinically relevant
improvements [32]
[33]
[34]
[35]
[36].
N-acetylcysteine may be considered for alleviating methamphetamine craving during
withdrawal (LoE 2; ⇔).
A small (n=32), but otherwise methodologically sound, randomized, placebo-controlled
study with a cross-over design showed a favorable effect of N-acetylcysteine on craving
in the acute treatment phase coupled with very good tolerability. The dose was 600 mg
in the first week and 1 200 mg in the second to fourth week followed by wash-out over
3 days [37].
Another randomized, placebo-controlled study with 18 participants demonstrated an
attenuation of some subjectively positive methamphetamine-induced effects (agitation,
drive, energizing effects) by the calcium antagonist israpidine. However, israpidine
was not well tolerated during methamphetamine withdrawal [38]. Another small, placebo-controlled RCT (n=30) revealed a weakening of cue-induced
craving and reduction of a few subjectively pleasant effects of methamphetamine by
naltrexone. However, in addition to the small number of participants, this study had
further methodological limitations [39]. Other RCTs showed that topiramate, ondansetron, and a combination of 2 pharmacological
agents (flumazenil and gabapentin or N-acetylcysteine and naltrexone) were not superior
to placebo [40]
[41]
[42]
[43].
In a small placebo-controlled RCT (n=26), varenicline enhanced the information processing
speed of patients during methamphetamine withdrawal. Moreover, varenicline attenuated
the subjectively positive methamphetamine-induced effects. Apart from this, no positive
effects on other symptoms of methamphetamine withdrawal or on craving were observed
[44]
[45]. Given the considerable methodological flaws (small sample size, not double-blinded,
conflicts of interest), the validity of this study is very limited. Two other small
placebo-controlled RCTs failed to demonstrate any improvement of cognitive functions
on rivastigmine. However, cognitive impairment was not seen in patients included [46]
[47].
Based on the available evidence, N-acetylcysteine may be considered for the treatment
of methamphetamine craving during withdrawal treatment. This substance is usually
well tolerated. There is also preliminary evidence that N-acetylcysteine might have
a favorable impact on craving and the risk of relapse in other substance-use disorders
[48]
[49]
[50]
[51]. The effect of N-acetylcysteine is thought to be linked to a modulation of glutamatergic
transmission; however, the exact mechanism of action has still to be elucidated [52].
Table 6 Basic guidelines for the management of an acute methamphetamine intoxication (based
on [8]).
|
|
|
|
|
|
|
|
|
|
Synopsis: Symptom-oriented approach
[Table 7] gives a synopsis of the recommendations for the pharmacological treatment of acute
complications of methamphetamine use. The recommendations are grouped according to
the target symptoms (symptom-oriented approach).
Table 7 Synopsis of symptom-oriented pharmacological treatment.
|
Symptom
|
Treatment options
|
Strength of recommendation
|
|
Methamphetamine-intoxication with acute agitation or pronounced fluctuation of symptoms
with reactions that are difficult to predict
|
After exhaustion of psychotherapeutic de-escalation actions, preferably benzodiazepines,
as soon as an adequate monitoring of cardiovascular parameters is available
|
⇑⇑
|
|
Methamphetamine-induced psychotic symptoms
|
Second-generation antipsychotics
If necessary, concomitant benzodiazepines for a limited period of time
Review of indication and, if possible, tapering-off attempt after 6 months at the
latest
|
⇑
⇔
|
|
Pronounced craving during methamphetamine withdrawal
|
If necessary, N-acetylcysteine with 600–1 200 mg/day
|
⇔
|
|
Sleep disorders and/or agitation during methamphetamine withdrawal
|
Sedating antidepressants or sedating antipsychotics
Avoid hypnotics!
|
⇔
|
|
Acute depressive and/or anxious symptoms with risk of harm to patient or others during
methamphetamine withdrawal
|
If necessary, benzodiazepines for a limited period of time
|
⇔
|
|
Depressive-anxious symptoms with exhaustion and/or hypersomnia during methamphetamine
withdrawal
|
Bupropion or TCAs, especially desipramine
|
⇔
|
|
In the case of repeated failed withdrawal attempts in the past
|
Dexamphetamine (individual cases, only in an inpatient setting), wash-out of the dose
after 2 weeks at the latest
|
⇔
⇔
|
Taken together, the available evidence for the acute pharmacological treatment of
methamphetamine-related disorders is limited. The recommendations are based mainly
on clinical expert consensus. Benzodiazepines are first-choice medication for methamphetamine-induced
intoxication syndromes, particularly if they present with acute agitation. There is
no evidence-based medication for the treatment of methamphetamine-related withdrawal
symptoms and craving. When treating methamphetamine-induced psychosis, second-generation
antipsychotic drugs ought to be favored, given the more favorable side-effect profile.
The indication for continuation of antipsychotic medication must be reviewed regularly.
In most cases, the antipsychotic should be tapered off within 6 months. Overall, further
research is warranted.
The complete guidelines (in German) can be downloaded at www.crystal-meth.aezq.de.
The Working Group (Co-Authors) of the S3 Guidelines
-
Wolf-Dietrich Braunwarth, Klinikum Nürnberg
-
Roland Härtel-Petri, Psychotherapeutische Praxis, Bayreuth
-
Heribert Fleischmann, Bezirksklinikum Wöllershof
-
Euphrosyne Gouzoulis-Mayfrank , LVR-Klinik Köln
-
Willem Hamdorf, AHG Klinik Mecklenburg
-
Ursula Havemann-Reinecke, Universitätsklinik Göttingen
-
Peter Jeschke, Neurologische Gemeinschaftspraxis, Halle
-
Josef Mischo, Kreiskrankenhaus St. Ingbert
-
Bernd Mühlbauer, Institut für Klinische Pharmakologie am Klinikum Bremen Mitte
-
Stephan Mühlig, Technische Universität Chemnitz
-
Timo Harfst, Bundespsychotherapeutenkammer
-
Ingo Schäfer, Sascha Milin, Universitätsklinikum Hamburg-Eppendorf/Zentrum für interdisziplinäre
Suchtforschung der Universität Hamburg
-
Norbert Scherbaum, LVR-Klinikum Essen
-
Katharina Schoett, Ökumenisches Hainich Klinikum
-
Frank Schulte-Derne, Landschaftsverband Westfalen-Lippe (LWL)
-
Frank Vilsmeier, Psychiatrisches Krankenhaus Rickling
-
Winfried Looser, LVR-Klinik Düren
-
Norbert Wittmann, Benjamin Löhner, Mudra Drogenberatung
-
Willem Hamdorf, AHG Klinik Mecklenburg
-
Ursula Havemann-Reinecke, Universitätsklinik Göttingen
-
Norbert Wodarz, Klinik und Poliklinik für Psychiatrie und Psychotherapie der Universität
am Bezirksklinikum Regensburg
