Addiction Medicine Made Easy | Fighting back against addiction

Breaking the Ice: Treating Methamphetamine Use Disorder

• Casey Grover, MD, FACEP, FASAM

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Dr. Casey Grover explores the history, neuroscience, and treatment approaches for methamphetamine use disorder, highlighting how methamphetamine releases more dopamine than any other known substance.

• Methamphetamine was widely used during World War II by German, Japanese, and Allied forces to enhance performance
• Modern meth production shifted from ephedra to P2P method, creating cheaper, more potent meth with worse psychiatric effects
• Meth causes dopamine release up to 1,400 ng/dL of dopamine compared to cocaine (400), sex (200), and food (150), severely damaging reward centers
• Many methamphetamine users have undiagnosed ADHD and are inadvertently self-medicating
• Effective medications include bupropion, topiramate, atomoxetine, viloxazine, guanfacine, and mirtazapine
• Contingency management (reward-based incentives) shows significant efficacy for methamphetamine addiction treatment
• Combination therapies using bupropion with naltrexone show promise for reducing meth use
• Treating underlying mental health conditions and providing housing/social support remains essential for recovery

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. I am really excited about this episode.

Speaker 1:

Today we are going to be talking about methamphetamine use disorder. We will start with a history of methamphetamine and move on to treatment of methamphetamine use disorder, with a specific focus on how medications can reduce the desire to use meth. I gave this lecture last week to my colleagues who work at a residential drug and alcohol treatment program and I wanted to share it with all of you. Here we go All right. So today we're going to be talking about methamphetamine use and I'm going to go through the history of methamphetamines and then we're going to talk about treatment. And one of the reasons this lecture came up is I get referred patients for MAT for meth and there really isn't an official set of meds for medications for addiction treatment for meth. But there are some medications that help. They're not nearly as effective as, say, methadone or suboxone for opioid use disorder, but they can help. So we're going to go through how I approach the medications to treat methamphetamine use and we'll get started.

Speaker 1:

I always love to start with history. I'm a total history geek. If you did not know, many soldiers in World War II used methamphetamine to stay awake, to improve performance and go on long missions. It was used by Japanese soldiers, german soldiers and Allied Forces soldiers. It was pharmaceutical, the drug name at the time was called Pervitin and it was actually very extensive through the German army, really really all levels of the German military during World War II, all the way up to Adolf Hitler himself. Incredible amounts of methamphetamine were used during the war. And there's more to the history of methamphetamine, but I find it so interesting that it really fueled one of the biggest human conflicts in human history. So this is a graphic that I found that provides an overview of the history of methamphetamine. And they were first synthesized in the late 1800s and we weren't really sure what to do with them.

Speaker 1:

Stimulants are helpful for things like boosting our metabolism. Stimulants are helpful for things like boosting our metabolism, dilating our lungs during asthma attacks and causing wakefulness. So the very first uses were actually in Japan for asthma and to promote wakefulness and narcolepsy. As I mentioned, they were very extensively used during World War II and interestingly and I didn't know this after the war Japan, whose country was both physically and financially decimated, japan, experienced a rise in recreational methamphetamine use, and it makes sense right. People were emotionally distraught after what they had been through. The country had to rebuild.

Speaker 1:

It's not surprising at all that a substance like meth would take hold. It was used medically in the United States in the 1950s, particularly around obesity, sinusitis and again to promote wakefulness with narcolepsy. Into the 1970s it was finally made a controlled substance by the federal government and in the 1980s we began to see it uniquely as a problem drug in the population of men who have sex with men, and this was around the time that AIDS and HIV began to come about. In the 1990s we saw increasing production of methamphetamine To combat this. In 1996, congress passed the Comprehensive Methamphetamine Control Act, which we will talk about, and into the 2000s methamphetamine has just absolutely flooded the market, particularly here on the West Coast. And I think it's important to understand the history because, like many drugs, methamphetamine has evolved over time and it's currently being produced differently than it used to be and we can learn from how that affects our patients.

Speaker 1:

So this is a slide that outlines one of the traditional ways of producing methamphetamine. And methamphetamine used to be made from a plant-based substance called ephedra and it had a related chemical called pseudoephedrine which was in cold medicines to help with sinus congestion, and most meth was made using the ephedra method. And in the middle of the screen here you can see a reference to the so-called shake-and-bake method. This was a very common way that methamphetamine was made in small batches and you took cold medicine containing pseudoephedrine, put it into a water bottle with some common household chemicals and a strip from a battery, and over several hours you were able to make methamphetamine. And you can see on the right here that's a pile of the packets, the blister packets that cold medicine would come in along with some propane tanks, and this likely represents the remnants of someone cooking up methamphetamine using the so-called shake-and-bake method, where they would use pseudoephedrine to make methamphetamine. Where they would use pseudoephedrine to make methamphetamine and that's actually the reason why Congress passed the act in 1996 is it really restricted cold medicine? Because they were trying to choke out the supply to make methamphetamine. And at the time. I remember hearing the term smurfing, which was a reference to going into a pharmacy buying large amounts of cold medicine and blister packs and then popping them out to be able to buying large amounts of cold medicine and blister packs and then popping them out to be able to give large quantity of pills to somebody who was going to make methamphetamine.

Speaker 1:

Now it turns out that there's a second way to make methamphetamine and that method is called the P2P method for the chemical phenyltupropanone, and it turns out that most of meth was being made via the ephedra method, and in the 1980s some biker gangs tried the P2P method, but there were a lot of nasty chemicals and it smelled really bad, and so into the 80s, 90s and into the 2000s, the ephedra method was still the dominant method. But that changed here on the West Coast in the mid-2010s. And this is an article from the Atlantic called I Don't Know that I Would Even Call it Meth Anymore, and it's written by the author, sam Quinones, who is fantastic, and he outlines in this article the transition from ephedra meth to P2P meth and P2P meth. It's made differently, using different chemicals, many of which are common industrial chemicals, and it allows drastically larger quantities of methamphetamine to be made of a higher potency compared to the ephedra method, and so what we found in the mid 2010s is that the amount of methamphetamine that was being brought into the US from drug cartels was through the roof and it was a lot cheaper because there was so much of it and, again, it was more potent. So in California, you know, over the 2010s the price of methamphetamine dropped by about 90%. So what we found, unfortunately, is that P2P meth and ephedra meth were different.

Speaker 1:

People who used meth from the ephedra method talked about it being something that was very social and you wanted to party all night and it kept you awake and it was a very social thing. But the P2P meth was different. People got a lot more mental health side effects. They got more psychosis. They were more isolated. It was. They got more psychosis, they were more isolated. It was associated with more people becoming homeless, and there's probably two reasons for that. One is because it was cheaper. People were using more of it. Two, it was more potent. And then, three, the p2p method was associated with all sorts of chemical residues being left on the meth, and so it's just a different drug now, and we began seeing a lot of methamphetamine-induced psychosis coming into emergency departments around this time.

Speaker 1:

Now, one of the other things that makes amphetamines, and particularly methamphetamine, such a unique addiction is how it affects the reward centers of our brain. So in the reward centers of our brain we release the chemical dopamine and that tells us that we feel good. And traditionally we release it from three things Human connection, intimacy or sex and food. And those are really survival right. So you have to eat to survive. We need human connection to create villages for protection, and then we need babies to grow our villages.

Speaker 1:

And the normal levels of dopamine in the reward centers of the brain are between about 140, 40 being the lowest, 100 being the highest, nanograms per deciliter. So that's the actual numbers of the dopamine levels in the brain. Addictive chemicals or behaviors take that dopamine level above 100. So on the graphic here you can see alcohol, nicotine, morphine and cocaine. All take dopamine above 100 nanograms per deciliter, but they only take it up a small amount somewhere between maybe 150 and 300 nanograms per deciliter.

Speaker 1:

Take a look at methamphetamine. That takes the dopamine levels up to 1,000 nanograms. Here's another graphic from UCLA Dopamine goes again from 40 to 100 nanograms per deciliter in the pleasure centers of the brain. Addictive food like McDonald's takes it up to 150. Sex takes it up to 200. Nicotine to 200. Cocaine to 400. And methamphetamine takes it up to 1100.

Speaker 1:

And I've even heard some reports that methamphetamine takes the dopamine in our brain all the way up to 1,400 nanograms per deciliter. It releases more dopamine than any other substance that we know of on planet Earth, and so, unfortunately, it really damages the reward center of our brain, which is one of the reasons why methamphetamine is fairly hard to quit, because people feel so flat. They feel that there is such an absence of pleasure and joy in their life because they've really just broken their reward system. And I love this graphic. I think this is funny. Somebody is comparing the levels of dopamine that you release from different activities and they compare it to meth and they say don't ruin pizza, don't take meth. And they compare it to meth and they say don't ruin pizza, don't take meth. And there's probably some validity here. People lose interest in human relations, food, seeing, family when they're on methamphetamine, because the dopamine levels are so off the charts. Nothing else feels good.

Speaker 1:

Now we've talked about the history of methamphetamine and how it works. Let's talk about how to treat methamphetamine addiction. So this is my three-legged stool of addiction treatment. We have three basic ways that we treat addiction. We have medications, counseling and therapy and mutual support groups. I like my patients to do all three and, following following the stool analogy, if you have a stool with three legs it's going to be very stable. If you take away one of the legs, it's going to begin to be less stable. It's going to teeter-totter back and forth and if you only have one of the legs, it's going to be very unstable. And so I hope all of my patients will do all three.

Speaker 1:

And I'm going to focus on the medications for this lecture, because I'm a doctor and that's what I do I prescribe meds. That's the core of addiction medicine. So let's talk about medications that can be used to treat methamphetamine use disorder. So the first step in what I do when I treat patients with methamphetamine addiction is I look for comorbid mental illness. Most of my patients tend to be dual diagnosis. They have addiction and mental health issues and I need to treat both. So if they're depressed, I want to put them on an antidepressant. If they're bipolar, we need to put them on a mood stabilizer. If they have PTSD, we need to address that we don't use anything different or special for mental health conditions when people have methamphetamine addiction. We just treat their mental health condition and then we also consider other medications that are methamphetamine specific. So again, step one treat whatever underlying mental health condition that they have. Treat whatever underlying mental health condition that they have.

Speaker 1:

Now step two is there are certain medications that can be specifically used to reduce methamphetamine use and promote sobriety from methamphetamine. So we'll go through them. The first one is bupropion and the other name for this is Welbutrin. I'll do my best to use generic names, but I often forget and use the brand name. So what is bupropion? So it is a very activating antidepressant and it increases levels of dopamine and norepinephrine in the brain. That's how it works to treat depression and many years ago, when I was a little baby doctor that didn't understand anything about addiction, I was just starting to learn about addiction and I was learning about dopamine and I was learning that the addictive substances raise the dopamine beyond normal levels and so when people are trying to get sober, their dopamine levels are low because the brain has spent a lot of the dopamine because of the addictive substance, causing more release than normal. And I remember thinking, gosh, if we could only find a medicine that would increase dopamine levels, wouldn't that help for addiction? And really, one of the only meds that increases dopamine levels is bupropion, and that's one of the reasons why it works for smoking cessation.

Speaker 1:

The way my patients who use methamphetamine and find bupropion to be helpful, the way they describe it to me, is that it's very activating. In other words, they feel awake and alert and ready to go, and that's probably from a couple of things. One is is that's how it works. It affects dopamine and that tends to be very activating. It makes us feel good. It also works for ADHD, so if they have ADHD, they feel more able to focus, and for some people, unfortunately, it's too stimulating. So somebody who has bad anxiety, I usually shy away from this because it can be too activating.

Speaker 1:

The main reason why we don't use it is if somebody has a history of seizures. Bupropion increases the likelihood of them having a breakthrough seizure, and we usually avoid antidepressants in people with bipolar because it can trigger mania. If we do use it, we usually combine it with a mood stabilizer and for methamphetamine addiction we use bupropion at higher doses. I usually start everybody on 300 milligrams a day, as long as they tolerate 150. So my first prescription will be 150 milligrams extended to release a day and if they tolerate it, I take them up to 300. The vast majority of my patients are on 300. You can go up to 450, but it tends to be too overstimulating for folks.

Speaker 1:

Okay, the next medication is tapiramate, also known as Topamax, and this is a medicine that we use to prevent seizures and migraines, but it turns out as a positive side effect. It reduces cravings for alcohol and stimulants. We don't fully know why it works for stimulants. We know why it works for alcohol. It appears to mimic some of the changes that happen in the brain when alcohol is consumed, but at a very low level. But it does. It works and I have a case that we'll go through a little bit later to describe one patient's experience with it.

Speaker 1:

Unfortunately, tapiramate is notorious for side effects. You can get paresthesias, like tingling in the hands and feet. It causes taste changes. Because of the taste changes it actually is associated with weight loss, so I do have some folks that are worried about gaining weight after stopping meth and this can be a good medication. And then it can make people mentally cloudy. And my experience because I took it. I wanted to see what would happen is that I was very mentally cloudy. I struggled to remember martial arts. My family does taekwondo and I kept forgetting my forms in taekwondo. And with taste changes, I kept thinking that the sparkling water had gone bad. I would open a can of LaCroix and taste changes. I kept thinking that the sparkling water had gone bad. I would open a can of LaCroix and taste it and it tasted weird. So I'd tell my daughter you know, sweetheart, I think the LaCroix went bad and she was just dad, what's wrong with you? And it was the Topamax.

Speaker 1:

In terms of dosing, we usually start at very low, at 25 to 50 milligrams, to avoid side effects, and then we taper up over several weeks to avoid side effects all the way to 300 milligrams daily. Okay, now there is some real signal around patients with stimulant addiction having untreated ADHD. Now many of my patients tell me that they use methamphetamine to calm down, and for years I just couldn't figure it out. They must be lying or they don't know what's going on, except if you think about it hyperactive children with ADHD that are restless and irritable and distractible. We give them pharmaceutical amphetamines and they calm down, and so there is significant overlap between ADHD and stimulant use disorder.

Speaker 1:

Let me give an example. I was in clinic this week and a woman came in. She was about six months sober from meth and I asked her what did meth do for her? And she said, oh, I would use it during the day as my thinking cap and I went okay, what were you like in school? And she said, oh, I really struggled. I had to be in special learning and I couldn't finish high school because I couldn't focus. And I asked her what class was her worst? Because folks with ADHD tend to struggle with math and science and she was just oh, dr Grover, math was so hard and science. And she was just oh, dr Grover, math was so hard. And she was self-medicating her ADHD with meth.

Speaker 1:

And if you didn't know, we as doctors can prescribe pharmaceutical methamphetamine for ADHD. The brand name is called Desoxyn. I've only done it once. A patient actually tricked me. I will never forget it. But yes, most psychiatrists don't use it just because methamphetamine is so euphoric, but many of my patients with stimulant use disorder have ADHD, and so I am very liberal with the non-addictive ADHD meds in my patients with stimulant use disorder who have or I suspect they have ADHD, and those meds are bupropion or Welbutrin. We already talked about that and we're going to go through the rest.

Speaker 1:

The first one is called adamoxetine, also known as Stratera, and this one works by increasing norepinephrine levels in the brain, similar to bupropion, and it works pretty well. The main side effects is that people get GI upset, like nausea or upset stomach, and so we usually start it again pretty low, around 25 milligrams. We start them at a low dose, like 25 milligrams a day, and we bring them up to somewhere between about 50 and 100 milligrams a day if we can. Its cousin is called viloxzine or Kelbree and this one increases norepinephrine levels in the brain and I think of it like adamoxetine 2.0. It does very similar effects to adamoxetine but it doesn't have the same stomach upset side effects. The only issue is that it's on patent and is expensive, so most insurance companies require a prior authorization which takes, you know, my time and I have to fill out some forms, but it can be very effective. The dosing we usually start people again low dose, about a hundred milligrams, and then we bring them up to usually between 400 and 600 milligrams daily, usually between 400 and 600 milligrams daily.

Speaker 1:

The next one is guanfacine, and guanfacine is a cousin of clonidine. Clonidine can be used for ADHD, but guanfacine appears to work a little bit better, and the way guanfacine works is it makes the nerve cells in the front of the brain work better, more efficiently, and the front of the brain is the part of the brain work better, more efficiently, and the front of the brain is the part of the brain that is the most human, that helps us with our decision-making, and we all know that people who have addiction struggle with decision-making and people with ADHD. It's very similar they're easily distractible, they're impulsive. So guanfacine seems to be very helpful for people who have stimulant addiction and also ADHD. The side effects is that it can cause sedation and it lowers blood pressure. I usually dose it at bedtime. Because of this and then the dosing, I prefer the extended release form called Intuniv, and I usually start at one milligram a night and increase to four milligrams If tolerated. Most of my patients do pretty well on about two milligrams and this is something that I will often combine with one of the other meds so that they have a daytime med and a nighttime med.

Speaker 1:

Now there are stimulant medications for ADHD and here are some examples Mixed amphetamine salts and that one's Adderall, methylphenidate, known as Ritalin or Concerta, and lisdexamphetamine also known as Vyvanse. And I am really careful with these meds in my patients who have ADHD and stimulant addiction because it can be triggering because they're, you know, pharmaceutical amphetamines. These amphetamine medications come in two forms instant release and extended release. The instant release is something that people will take a dose, the drug levels go up, they peak fairly quickly and they wear off fairly quickly. So people will be very functional for just a few hours and then crash and it's hard to get through the school day or work day when your focus goes away around you know 1 or 2 pm, the school day or work day when your focus goes away around you know 1 or 2 pm. So it's recommended that people be on the extended release because it avoids peaks and troughs. So, for example, extended release Adderall would be the product of choice for someone who needs Adderall for their ADHD because it lasts throughout the day and then it wears off before bed so they can go to sleep.

Speaker 1:

And it's probably a good time right now for us to talk about the rhythm of ADHD medications as it relates to symptoms. So I mentioned, I'll often combine a morning med like adamoxetine with an evening med like guanfacine, and here's why. So when people wake up in the morning and their ADHD is really going, they're distractible, it's hard to get motivated, it's hard to get going. So if I give them a nighttime med like guanfacine, it's in their system and effective. When they wake up in the morning they feel better. In the morning they're able to prepare for work, prepare for school, and then they remember, because their ADHD is managed, to take their morning med like adamoxetine and then that med works through the day and then they come back and they take the nighttime med and it just really sets them up for success. So again, they don't have these big peaks and troughs of where they have medication that's working and when they don't.

Speaker 1:

Now you might be wondering okay, well, we use suboxone and methadone for opioid addiction. Could we use prescription stimulone and methadone for opioid addiction? Could we use prescription stimulants for stimulant addiction? So this is a website called Open Evidence and I use it all the time. It uses the power of artificial intelligence to rapidly search the National Library of Medicine to give doctors answers to questions. So I asked Open Evidence can you use prescription stimulants to treat stimulant use disorder, and the answer is prescription stimulants are not currently recommended as a routine treatment for stimulant use disorder. Now, that being said, if someone has ADHD and a history of stimulant use disorder, we could use one of these, but there's no evidence that giving people who use stimulants stimulants works to keep them sober. And because of the addictive potential of prescription stimulants, I am extremely careful when I give someone a prescription stimulant for their ADHD. When they have stimulant use disorder, I make them sign a special contract, I shorten the interval between their appointments and I do very regular urine drug testing to make sure that they're able to take the medication as prescribed.

Speaker 1:

Now, I was always taught that stimulants do not have a withdrawal syndrome, but that was before I learned how to practice addiction medicine, and stimulant withdrawal is absolutely a thing, and it probably comes from the fact that stimulants mess with our sleep-wake cycle and release so much dopamine that when we come off of it, our brain doesn't know how to feel good, because the dopamine is depleted and our sleep-wake cycle is totally off. So here are some symptoms of stimulant withdrawal Dysphoric mood, fatigue, abnormal dreams, changes in sleep, changes in appetite and agitation. And that brings us to the next medication that can be used for stimulant use disorder, and that is mirtazapine, also known as Remeron. So mirtazapine is an antidepressant. It increases appetite, it's very sedating and can help reset the sleep-wake cycle. So let's think about this You're coming off of methamphetamine, your sleep-wake cycle. So let's think about this You're coming off of methamphetamine, your sleep-wake cycle is totally disrupted, you're depressed, your appetite is totally off. It makes perfect sense that mirtazapine would be a medication that would make the process of getting off of meth less unpleasant. So we actually use it and it helps people maintain their sobriety, particularly early in their recovery from methamphetamine. Main side effects, like many antidepressants dry mouth and grogginess, because it's very sedating. We use it as a sleep med, so you can guess people are going to be fatigued if they take it during the day. Sometimes people feel the sleep effects into the day and they can be groggy in the morning, and we dose it at 15 to 30 milligrams at bedtime.

Speaker 1:

There are some other studies looking at treatments for methamphetamine use disorder. This is one from the New England Journal of Medicine in 2021, bupropion and naltrexone in methamphetamine use disorder. In 2021, bupropion and naltrexone in methamphetamine use disorder, and this looked at using bupropion taken orally and naltrexone as an injection. The brand name is Vivitrol to treat methamphetamine use disorder, and the idea is is that when we do things that are pleasurable, our brain releases dopamine, but it also releases some of the naturally occurring opioids in our body called endorphins. And so naltrexone works for alcohol and binge eating because it suppresses those extra pleasure chemicals, the endorphins, when we indulge in food or drink alcohol, and so there's a thought that maybe there's a little bit of that endorphin release with methamphetamine too, and this was actually a very positive study. They found that it was really able to reduce the prevalence of methamphetamine positive urine drug tests in the study population. So here's another potential combination to treat methamphetamine use disorder. So here's another potential combination to treat methamphetamine use disorder.

Speaker 1:

This was another study looking at lisdexamphetamine for methamphetamine use disorder. This is the ADHD med. That is a stimulant called Vyvanse and on the screen you can see the podcast Addiction Medicine Journal Club. Those are my friends, drs John Keenan and Sonia Deltredici. They have their addiction medicine podcast and we collaborate and they covered this study I believe it was out of Australia on using very high-dose lisdexamphetamine for methamphetamine use disorder and it was essentially a negative study. It didn't really help. So that goes back to the fact that we don't yet have evidence that giving people stimulants for their stimulant use disorder works. Again, if they have ADHD, that's totally different. But for pure stimulant addiction, stimulants are not yet found to be effective. Now, shameless plug, this is my podcast Addiction Medicine Made Easy.

Speaker 1:

I met a doctor, dr Miller, in Indiana, who is a general surgeon, turned pain management doctor, turned addiction doctor, and he came on my podcast to tell me that he has a treatment that reduces meth use by 86%. That is insane. There is nothing else that I have heard of that reduces meth use by anywhere close to that. So he and I talked about it and at the time I didn't really know much about ADHD and the vast majority of the patients he's treating with Stimulant Use Disorder who are using methamphetamines have ADHD and by treating them with some combination of adamoxetine or vioxazine or guanfacine or bupropion he was really able to manage their methamphetamine use. He did have another patient subset that really struggled with fatigue and motivation and he had a little bit of a different pathway there, but the vast majority of the successes that he was making were from just treating people's comorbid ADHD.

Speaker 1:

Now, before we wrap up, I wanted to ask the question does contingency management work for stimulant use disorder? And we're going to talk about it. So I went back to Open Evidence and I asked AI to search the National Library of Medicine and the answer I got was yes. Contingency management is the most effective and evidence-supported behavioral intervention for stimulant use disorder and it is strongly recommended as a primary treatment approach. So what is contingency management? Contingency management is operant conditioning management. Contingency management is operant conditioning, basically, where we create rewards to promote the behavior that we want to take root and be successful.

Speaker 1:

And here's a common way that it's used around methamphetamine use. So we know that methamphetamine really brings up levels of dopamine in the brain and part of what we need to do is give people dopamine back to help their brain recover from how damaging methamphetamine is to the reward system. So the idea is is that people are told you're going to give us a urine drug test and if it's negative for methamphetamine, you get a prize. So what does that entail? Negative for methamphetamine, you get a prize. So what does that entail? They have something to look forward to, kind of like with drug cravings. When you use the drug, it releases dopamine. But we also know the anticipation of the drug releases a little tiny bit of dopamine and that's probably where cravings come from. So the idea that I'm going to get a reward, I'm going to get a reward, I'm going to get a reward releases a little bit of dopamine. And then when they do the urine drug test and it's negative, they're there with their drug and alcohol counselor. That's positive human connection, that's dopamine. And then they get to reach into a prize bucket or a fishbowl. The reward itself gives them dopamine, and it's not always the same prize. It might be a sticker, it might be an Amazon gift card, it might be a $100 bill, it might just be a handwritten note saying you're killing it, you're doing a great job. And because the reward isn't that predictable and there's the potential for a big reward, it really gets the dopamine going in anticipation of a big reward. And we actually do it in my office and it's something that we're starting to see used more and appears to be uniquely helpful in methamphetamine addiction, among other addictions. In other words, it works for addiction in general, but it's uniquely useful in methamphetamine addiction.

Speaker 1:

Okay, let's go through a couple of cases and I'll talk about how it actually looks when I'm treating patients with some of these meds. So case number one is a 68-year-old female. History of opioid use and stimulant use and she came to me using fent and meth and she couldn't get on suboxone. So I sent her to the methadone clinic and they stabilized her on 90 milligrams of methadone a day. I put her in therapy and she was able to stop using fentanyl but was really struggling with meth. So I put her on tapiramate at 50 milligrams daily and I titrated her up. Over about four weeks I got her up to 300 milligrams and she had some side effects. I brought her back down to 250. And she came to me the next week and she said, dr Grover, that medicine is a miracle, I have no desire to use meth. And I'm thinking, wow, this is amazing. Except her urine drug tests showed that she was still using meth. So I dug into it with her and she said, well, it's more than I don't think about meth all the time. But you know, sometimes that friend comes around and, yeah, I really don't want to use meth, but sometimes I get really bored. So essentially I was able to reduce her methamphetamine use very significantly, but it didn't eliminate it. And I bring up this case because you know we put people on Suboxone for opiate use disorder and they do amazing. We can really extinguish cravings and furthermore, suboxone blocks other opioids. So medications for meth use are different. They don't quite have the same intensity of their effects in reducing cravings, but for this patient she was able to drastically reduce her use and now I'm focusing on positive human connection, away from the using friends and trying to keep her busy. So I'm working on it.

Speaker 1:

Okay, case number two 46-year-old male was referred for using methamphetamine. He was unhoused and he told me that he used meth to chill out. So I got the vibe maybe this is a patient with ADHD. So I asked him about his school history. He really struggled with learning, didn't complete high school, and then he actually told me, doctor, I have ADHD. So it really fit together.

Speaker 1:

I started him on guanfacine at bedtime and adamoxetine in the morning. We titrated his dose up over about three to four weeks and he came to me and he said you know, dr grover, I can finally think clearly and I I don't want to use meth. And again I went wow, this is amazing. And then unfortunately, we realized that he had sexual assault that he had never really addressed and he was homeless and so now he didn't really have the desire to use meth, but he was really fearful and was unhoused and was just I don't know how to do this sober and so, yeah, I was able to suppress his methamphetamine cravings, but then we had to address all the other parts of his life that had led to his addiction. So I got him to stop using methamphetamine by managing his ADHD. I got him to stop using methamphetamine by managing his ADHD, but he still continued to use, actually until we got him housing and counseling. So he actually ended up going to residential treatment and then they eventually transitioned him to sober living.

Speaker 1:

Okay, so I am going to stop there and that is the end of what I prepared and we will stop and we'll have a conversation and do some questions Before we wrap up. A huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives. I'll see you next time.