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Meth & Cocaine
Treatment of Methamphetamine Use Disorder
HAND THE PATIENT NARCAN BEFORE DISCHARGE!
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1. Treat agitation in the ED with benzodiazepine +/- antipsychotic
2. Contact Clinical Social Work for patients experiencing homelessness and consult Substance Use Counselor.
3. Ask about co-occurring opioid like heroin use. "Many people use opioids like heroin to come down off meth. Does that happen to you?"
a. Offer buprenorphine 8mg/2mg tablets, one tab BID, #60-90
4. Ask about co-occurring alcohol use
a, If + alcohol use disorder and NO OPIOID USE DISORDER, offer naltrexone 50mg qday or naltrexone 360mg IM (see Alcohol use disorder for other naltrexone contraindications).
5. Offer clean needles if using IV. Write "for harm reduction" to pharmacy.
6. Tell patients to snort instead of using IV. Less risk of infection, transmission of HIV, hepatitis.
7. Offer medication for stimulant use. Best for patients using meth at least weekly for > 3 months.
a. Mirtazapine 30mg PO qHS #30, 0-1 refill
i. Helps with cravings, and the insomnia and depression experienced when stopping or reducing meth or patient lacks of access to meth
ii. Caution with the following.
-- Hx MAOI inhibitors in the last 2 weeks
--Severe liver or renal disease (GFR <40)
-- Elderly, >65 yrs old - start lower dose Mirtazapine 15mg qHS
-- Hx Bipolar disorder*
Screening for bipolar disorder:
-- "Have you been diagnosed as bipolar?"
-- "What were you like before you started using meth? Would you stay up all night? Did you ever have racing thoughts, unable to control your thoughts? Were you ever on a 5150 or placed in a psych facility for?"
-- "Do you ever have racing thoughts, stay up for days at a time when you aren't using Meth?"
*Very low risk of Mirtazapine causing mania in a patient with bipolar disorder. Truth is Meth has a MUCH HIGHER risk of causing mania in patients with bipolar disorder compared to Mirtazapine. Much safer to have the patient start Mirtazapine even if you miss the diagnosis of bipolar disorder.
8. Educate about Contingency Management (CM) - rewarding patients for remaining abstinent. Has been shown to very successful for patients with substance use disorder.
--LAC+USC has a grant funded CM program. Have patient call LAC+USC CM program themselves to show interest. Phone number also on patient. handout listed below. 323-409-6623.
9. Patient Handout - Meth Use Disorder Patient Handout in Cerner.....Patient Education......Departmental....SUD
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