Editorial to Methamphetamine (“Crystal meth”) and New Psychoactive Substances

Since 2010 the use of methamphetamine (“crystal meth”) and a multitude of previously unknown, so-called “new psychoactive substances” considerably increased in several European countries [1], often with the intention to increase mental performance (“neuroenhancement”) [2]. Cross-sectional surveys conducted in Australia, the US and Germany found that 0.2 to 0.4% of respondents used methamphetamine during the last 12-months, and that prevalence rates are highest at age 20–25 years. Epidemiological data derived from wastewater analysis suggest that methamphetamine use markedly differs between countries and between regions of the same country ([Fig. 1]).The clinical consequences, even in these young users, are often as bad as with opiate dependence. They include dental decay and cardiac complications which, together with acute intoxication, put users at risk for sudden death. This disquieting development prompted the editors of Pharmacopsychiatry to dedicate a special issue to this topic. It contains 4 review papers describing core clinical problems caused by methamphetamine use, one research letter alerting clinicians to heed an ultra-high risk population, and 2 expert commentaries taking a broader and international perspective.

Fig. 1 Mean daily amount of consumed methamphetamine in European cities in 2015, calculated from wastewater analysis. Data are from the European Monitoring Centre for Drugs and Drug Addiction, see: http://www.emcdda.europa.eu/topics/pods/waste-water-analysis#panel2.

Methamphetamine differs from the mother compound by its N-methylation, which markedly increases lipophilicity, duration of action, and, most importantly, neurotoxicity. Intoxicated patients often present as an emergency due to paranoid and hallucinatory psychoses, likely with aggressive behavior, or due to medical complications affecting the heart, lungs or central nervous circulation. As intoxication abates, withdrawal may occur; displaying predominantly with psychiatric symptoms of drug craving, depression, tiredness, and possibly suicidal ideation; while sympathetic hyperarousal or other physical manifestations of withdrawal do not occur. Once abstinence is achieved, treatment efforts to prevent relapse are often complicated by specific long-term sequelae of methamphetamine toxicity. These manifest as a persistent lack of psychomotor drive, inattention, distractibility, and impulsivity, together with impairments when learning new information, of executive functioning, and in reduced speed of information processing. The pathophysiology of this syndrome is unclear and probably heterogeneous, including effects such as compromised functioning of dopaminergig or serotonergic neurotransmission, disseminated white matter lesions due to microinfarctions, or even ischemic/ hemorrhagic strokes. This syndrome also considerably overlaps with the symptoms of attention deficit/ hyperactivity disorder (ADHD) extending into adulthood, which occurs quite frequently comorbid with substance use disorders. It is difficult but important to make this differentiation, since treatment and patient counselling is fundamentally different.

The rapidly growing prevalence of methamphetamine dependence in some German areas prompted its federal government to initiate the development of methamphetamine-specific treatment guidelines, which were published in German language in June 2016 [3]. In order to make their recommendations available to an international readership, this issue of Pharmacopsychiatry features 2 articles summarizing the guideline’s core insights regarding pharmacological treatment strategies. Wodarz et al. describe how pharmacotherapy can effectively and safely help managing acute methamphetamine-related disorders and toxicity. Härtel-Petri et al. summarize the clinical trials testing medications to treat the dependence syndrome and typical psychiatric comorbidity. Their results are quite dissatisfying, since they could not recommend any pharmacotherapy at all that effectively helps patients to abstain, or at least reduce their methamphetamine use. More research is urgently needed, particularly since the evidence for the published psychotherapeutic interventions is also very weak [3]. According to the U.S. National Library of Medicine’s registry of clinical trials, there are trials with at least 11 drugs underway, studying whether they can improve treatment outcome, alter subjective and physical effects of concomitantly administered methamphetamine, or reduce methamphetamine self-administration in behavioral lab studies. Ongoing trials investigating the psychotherapeutic methods of “intensified motivational interviewing”, “functional family therapy” and “cognitive behavior therapy-based text messaging” are also registered. Studies trying to identify subgroups of patients who do or do not respond to a specific treatment are still entirely lacking.

Methamphetamine use in both males and females is associated with behavioral changes which increase the risk for unintended pregnancy. In this issue, Dinger at al. describe the serious health risks of continued methamphetamine use during pregnancy with respect to the mother, the fetus and the newborn. Of note, they also emphasize that pregnancy invariably and strongly motivates women to quit their substance use. Finally, they describe how collaborative multidisciplinary treatment programs can help women and their partners to successfully make use of this unique opportunity to regain control over their lives, and provide adequate care for their child.

Although methamphetamine is a relatively new drug in many countries, it is unfortunately not the last one. Over the recent few years, hundreds of chemically defined new psychoactive substances (NPS) emerged, confronting clinicians with new intoxication syndromes and challenging authorities to define legal regulation to stop their trading. Scherbaum et al. give an overview on chemical categories of NPS, their mechanisms of action, associated health hazards, and resources to keep up to date with this new challenge to the health care system.

In summary, this special issue of Pharmacopsychiatry provides comprehensive and up-to-date advice how to manage methamphetamine and NPS toxicity, dependence, and associated problems.

May 2017

• References

• 1 EMCDDA. European Drug Report 2016: Trends and developments. Lisbon: EMCDDA; 2016. http://www.emcdda.europa.eu/publications/edr/trends-developments/2016 last accessed on 12/30/2016
• 2 Franke AG, Northoff R, Hildt E. The case of pharmacological neuroenhancement: medical, judicial and ethical aspects from a german perspective. Pharmacopsychiatry 2015; 48: 256-264
• 3 Die Drogenbeauftragte der Bundesregierung, Bundesministerium für Gesundheit (BMG), Bundesärztekammer (BÄK), Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN). S3-Leitlinie Methamphetamin-bezogene Störungen – Kurzfassung. 1. Auflage. Version 1. 2016. Available from: www.crystal-meth.aezq.de doi:10.6101/AZQ/000292 Last accessed on 12/30/2016