Treatment of Methamphetamine Use Disorder

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                             HAND THE PATIENT NARCAN BEFORE DISCHARGE!

                            Document using autotext  .ednaloxoneEDdistribution

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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).

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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.  

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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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