A decade ago I was traveling on behalf of a rehab facility in Rocky Mountain, where the rich and famous run dry and grapple with their drug habits. It offered every imaginable therapy to its well-heeled clientele and claimed strong results. But I’ll never forget what the director of operations told me about the clinic’s biggest failure: “Our results with methane addicts are bleak,” he admitted.
Poor results remain all too typical of what is known as a methamphetamine use disorder. Approximately one million people in the US are addicted to meth, a powerful stimulant that – smoked, sniffed, injected or swallowed – ruined lives and contributed to more than 12,000 overdose deaths in 2018 from the Covid pandemic. Unlike people who struggle with alcoholism or opioid abuse, meth users don’t have approved drugs to shake their habit with. And most behavioral therapies fail.
But this tragic picture could finally change. A recent study found that taking two drugs helped some users stay away from the drug. Additionally, a psychosocial intervention called Contingency Management (CM) has been shown to be particularly effective and, while not widely available, is now the first-line therapy for people seeking treatment for meth or cocaine addiction in the U.S. Department of Veterans system.
All addictions are difficult to defeat, but methamphetamine is a particular challenge. One important way that researchers measure the addictive level of a substance is to conduct animal studies to determine how much dopamine (a neurotransmitter associated with pleasure) flows into the brain’s main reward center during use. “Methamphetamine is the drug that produces the greatest release,” says Nora Volkow, director of the National Institute on Drug Abuse. “An animal goes crazy when it pulls a lever to get the drug,” she adds. Another metric involves real human experience: if you try a new substance, what is the likelihood of becoming addicted? “In this regard, methamphetamine, along with heroin, is one of the top addictive substances,” says Volkow.
Two substances aimed at withdrawal were used in the drug study. Bupropion, an antidepressant also prescribed for smoking cessation, increases dopamine levels in the brain and can thus cushion the plight of steep drops that occur when people stop using meth. Naltrexone, the second drug, is an opioid blocker that “has an effect on the reward cycle and potentially relieves cravings,” said lead study author Madhukar H. Trivedi, a psychiatrist at Southwestern Medical Center, University of Texas. In a study of 403 heavy meth users, a regimen of the two drugs helped 13.6 percent stay away from the drug and tested meth-free at least three-quarters of the time over a six-week period. Only 2.5 percent of the placebos achieved this level of abstinence.
Business continuity management works on behavior by increasing abstinence with prices. At VA clinics, addicted veterans provide urine samples twice a week. If the sample is meth-free, you can pull a slip of paper out of a fishbowl. Half of the receipts show various amounts of dollars that can be spent in VA stores and the rest are words of encouragement. Two clean samples in a row bring two fishbowl draws, three in a row three draws, and so on, up to a maximum of eight. But drug positive urine means no price. The key “is the immediacy of reinforcement,” says Dominick DePhilippis, a clinical psychologist at Corporal Michael J. Crescenz VA Medical Center in Philadelphia. This is important, he notes, because the meth rush also intensifies immediately, be it the “euphoric feeling that substance use brings with it or the flight from fatigue or uncomfortable moods” of withdrawal.
A 2018 study of 2,060 VA patients led by DePhilippis found that participants completed an average of 56 percent of their 24 sessions and 91 percent of their urine samples were free of the target drug over a 12-week period. According to a 2018 analysis of 50 studies involving nearly 7,000 patients with meth or cocaine habits, one person for every five patients treated will benefit from CM.
The DePhilippis team is collecting data on the long-term effectiveness of CM for drug users. If the results are good, more health insurers may be able to overcome concerns about using financial rewards in treatment and cover therapy. Volkow hopes meth users will ultimately receive a variety of treatments, including some that combine drugs with behavioral therapy. This, she says, treats illnesses from depression to diabetes. But “we stigmatize addiction,” says Volkow, “and the insurance company is willing to pay much less than for any other disease. There is a double standard. “