And welcome. I'm Dr. Rob Cotez, Director of the Clinical and Research Program for Psychosis at Grady Health System and Associate Professor at Emory University School of Medicine. I'm so pleased that you're joining us for today's SMI Advisor webinar, exploring the relationship between stimulant use and serious mental illness. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit IV physicians, one Nursing Continuing Professional Development Contact Hour, one Continuing Pharmacy Education Credit Hour, one Continuing Education Credit for Psychologists, and one Continuing Education Credit for Social Workers. Credit for participating in today's webinar will be available until February 13th. Next slide. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Next slide. Captioning for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Then click the arrow and select View Full Transcript to open captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. And now I'd like to introduce you to the faculty for today's webinar, Dr. Debra Pinals and Dr. Charles Scott. First, Dr. Debra Pinals serves as the Director of the Program in Psychiatry, Law, and Ethics, and as a Clinical Professor of Psychiatry at the University of Michigan Medical School. She is Clinical Adjunct Professor at the University of Michigan Law School. She also is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. Dr. Charles Scott is a Professor of Psychiatry and Behavioral Sciences at UC Davis School of Medicine. He also serves as Chief of Division of Psychiatry in the Law, and is also the Forensic Psychiatry Fellowship Director. Thank you both for leading today's webinar, and now I'll hand it over to you all. All right, thank you very much for that nice introduction and overview. Neither Dr. Pinals nor myself have any relationships or conflicts of interest related to the subject matter of this presentation. And so with no further ado, let's begin and review our learning objectives. First, after completion of this activity, we expect that you will be able to distinguish really different forms of stimulants, for example, cocaine versus methamphetamine, versus methamphetamine. Recognize some unique characteristics of stimulant-induced psychosis, if you're trying to differentiate that between schizophrenia. And finally, and very importantly in our society right now, we're looking at emerging potent forms of methamphetamine known as M2P methamphetamine, and the relationship of that to really more emergence and overdose-type presentations. And then finally, we're going to highlight some evidence-based treatments for stimulant use disorders. So when you look at the stimulant use disorder in the DSM-5 TR criteria, it's really rather kind of nonspecific. I mean, there are different intoxication syndromes that we're very used to as psychiatrists, but I found it interesting that some of the criteria, for example, say you can present with either high or low blood pressure. And you can have either psychomotor agitation or retardation, so very broad. And likewise, the withdrawal criteria also have some very nonspecific criteria. So that could include insomnia or hypersomnia, and again, psychomotor agitation or retardation. So let's delve into a little bit further what additional signs of stimulant intoxication we should be prepared to recognize. Oftentimes, people who are actively using stimulants have a rambling speech. They have these transient ideas of reference. They'd be worried or paranoid or suspicious of those around them. You can also have a tinnitus, like a ringing in the ear. Again, the sense of paranoia, and both auditory but also tactile hallucinations. And you'll hear me say this several times during this presentation, when trying to differentiate stimulant use or intoxication from schizophrenia, this additional sense of tactile hallucinations is one unique discriminating factor. And all of this occurs in the sense, typically, of a clear sensorium, where they may be oriented to person, place, time, and situation. Now, again, when we think about stimulant withdrawal, it usually has these kind of physiologic changes that are opposite to the intoxication phase. So typically, more of a fatigue versus kind of an agitated, being up for several hours or days. And if you open up your DSM-5, there are many different mental disorders related specifically to stimulant use. Now we get into one of our key objectives, which is what is some perhaps differentiating factors between stimulant psychosis versus schizophrenia? Well, a lot of the psychiatric effects of both are very similar. So you might think of a person who may have kind of anxiety and panic in both schizophrenia and stimulant psychosis, the sense of searching out, looking, hypervigilant, paranoia, fear of others. But again, if someone presents with this additional hallucination of tactile hallucination where they may feel something that's crawling on their skin or they're scratching themselves, oftentimes they may even describe it's like ants that are crawling on their hand. All of these would be more unique to methamphetamine or a stimulant. When we think about behavioral effects, many of the behavioral effects also overlap with both of these disorders, restlessness, agitation, but with stimulants, you're more likely to have a tremor. So on physical exam, you would look for that. And this particular behavior unique to stimulants in this setting, which is kind of a repetitive behavior. So a person may be opening and closing something over and over or having what we call skin picking. And you don't typically see that if it's uniquely a schizophrenic presentation. In addition, there are physiologic changes. So if you get an EKG and you see a rapid heartbeat or tachycardia, obviously you're gonna be thinking stimulant use as a main contributor. And then finally, dilated pupils are much more commonly seen as a physiologic result from using stimulants. When we think about cognitive impairment, does the stimulant use cause permanent cognitive impairment? And there are several studies that indicate that it can have long lasting problems in cognition. And one interesting study that we've listed the reference at the bottom of the slide, they did really just a general review of methamphetamine and other disorders such as cannabis use, alcohol use and opioid use. And they administered the MOCA, the Montreal Cognitive Assessment to outpatients who are seeking treatment for a substance use disorder. And overall, 31% of all substance users did have on the MOCA impairment as defined by a score of less than 24. 27% of stimulant users had a cognitive impairment and about 39% for opioid users. And there are other studies that look at long-term impact and for methamphetamine and stimulants, you can have more sustained cognitive impairment as well. Let's look at some specific types of stimulants and see if we can even differentiate how they may present. So cocaine, which is in the stimulant category, just to remind you, it's a Schedule II drug, about 20% of users, so one out of every five will progress to a cocaine use disorder. And cocaine use has been increasing since 2019. You know, we had that dip in the 80s and 90s after there was that kind of crack epidemic, there was a crackdown, but sadly it's coming back and it's rising back. So don't be surprised if you see elevated cocaine use in ER presentations. And when you look at some of the results from the SAMHSA study, looking at the rate of ED visits per 100,000 population, what you see here again is cocaine is highly presented, in fact, the highest in this study of those who present to the ER. Now, cocaine comes from this beautiful- And just to jump in, Dr. Scott, as you said we were going to do, so sorry to interrupt, but I want people to see that. And remember, that's 2013 data, and we know that there's a whole, you know, as this has evolved post-pandemic, we're still seeing high numbers of stimulant use in these data. Yeah, thank you. And please, Dr. Pinals, jump in any time. I might take a deep breath and let you jump in at the end of each slide. No problem. Okay, so this green and red is not meant to represent the holiday season, but the coca berry from which cocaine is derived. And there are different forms of cocaine. So the base is really the more direct pure form from the berry. It has a low melting point. We think of this more as sort of a crack cocaine. And then when there are additives to convert that to a salt, this has a higher melting point, and it's more consistent with the powdered version. It's water soluble, and therefore much more easy to inject. Cocaine in general has a relatively short half-life compared to some of the other stimulants, anywhere between 40 to 90 minutes. And how you use it may impact how quickly you have an effect. So smoking, people can have a sensation from it fairly briefly, within six to eight seconds. Intravenously, it may have quick, but also a sustained effect, four to seven minutes. And then snorting it intranasally may also have a more sustained impact, 30 to 45 minutes. And when we're testing for cocaine use, typically in the urine, you're testing for a metabolite known as benzoyle echnogene. And so not directly testing cocaine, but a by-product in the body. Now, one of the things you may want to counsel your patients but also be aware of in your clinical practice is there's a high co-occurring use of alcohol and cocaine, but it's even more dangerous with this stimulant than you might think because of the unique combination of these two substances known as cocaethylene. And this is important because it has a higher toxicity level. It remains in the body three times longer. And this use of alcohol and cocaine with this metabolite is associated with sudden deaths and cardiovascular events. Poly-drug use is also very common, not just alcohol, but other substances with cocaine. It can very much resemble mania. These higher doses and duration, even though we typically think of this as in a clear sensorium, when you have this higher usage, it can actually produce a delirium-like picture. And certainly cocaine also is known to produce psychosis. Now, there's a particular substance known as levomysol, and this is a veterinary drug typically used to treat parasitic infections in animals. And why would it be added to cocaine? Well, it looks and feels, if you will, like cocaine, and so it adds bulk and weight. So for the drug dealer, they can get kind of an increased financial revenue by adding it to the cocaine. The problem is one of the side effects is it suppresses white blood cells, results in neutropenia, and it's been linked to skin necrosis in those who use it. So again, if you're in the ER setting, or if you have a patient who unfortunately has had this type of necrotic reaction, you should strongly suspect that they may have been using cocaine with this additive to it, which is a known side effect. When we think about treatments for cocaine use disorder, there's really no FDA-approved treatment. There's a 2022 study that looked at what oral progesterone in women perhaps help reduce their use. What they did here is they had a 10-week double-blind randomized treatment trial, and you had to be abstinent from cocaine a week before. So a small number of women, 11 to be exact, got randomized to progesterone, and 10 got randomized to the placebo use. In this study, the majority of women in both placebo and progesterone relapsed in less than four days with no differences between the group. There have been other studies though, for example, in postpartum women that have shown some improvement with oral progesterone 12 weeks postpartum. So there is perhaps some promising use here. There was a lot of great hope several years back that perhaps we could have a vaccine that could be used to aid in cocaine addiction. I really think its efficacy is still being evaluated. The purpose of a vaccine would be to create an antibody, if you will, that would stimulate the immune system to produce antibodies that would attach themselves to the cocaine molecule in the blood and therefore prevent this antibody-cocaine combination from passing through the blood-brain barrier. And then therefore you couldn't get all the positive euphoric effects. So there has been at least some research that indicates that there's a slight improvement using this vaccine and measuring cocaine-free samples. But I think the overall efficacy is still being evaluated and it's not yet approved by the FDA. Behavioral therapies therefore are probably the most important component. And cocaine users compared to other addictions, there's something particularly challenging in keeping them in treatment as they have higher dropout than other addictions. And Dr. Pinos, I was curious your thoughts on, we're talking about cocaine use and serious mental disorders combined and your thoughts about behavioral therapies and kind of the co-occurring group. Yes, I think that's something that we talked about in preparing for this and for the audience to be aware of that the behavioral therapies that we know of, there haven't been a lot of studies or any real significant studies looking at serious mental illness in combination with cocaine use disorders and the impact of different behavioral therapies. We do use them, but we really want to think about making sure that when we're treating psychotic disorders and serious mental illness in combination that we're also treating those serious mental illness symptoms so that people can be as receptive as possible to the behavioral therapies. Yeah, thank you. So now let's move on to meth use in the United States. Again, like the return of cocaine, we're seeing also an increase in methamphetamine use. And with that, there's been a 300% increase in methamphetamine overdose deaths from 2015 through 2020. And this is disproportionately impacting people experiencing homelessness or who've recently been placed in permanent supportive housing, sort of indicating the need to have intense continued follow-up, even if placed in housing. And this graphic really shows you the impact of deaths involving stimulants. So the blue bars are just the overview of deaths from 2000 to 2018. The red line represents how many of those deaths involved the combination with an opioid and the green bar are stimulants without opioid use, but with other drugs. So what I want you to think from this is a lot of the deaths using a stimulant are also combined with opioids. So have a heavy screening and evaluation for treatment for both. Now, stimulants in general, I'm not talking about cocaine, but I'm talking about prescribed stimulants certainly can be obtained through prescription and then subsequently diverted into an illegal market. And like cocaine, the use of stimulants such as methamphetamine or prescribed stimulants can have a feeling of wellbeing and euphoria. Dramatic behavioral changes can develop and even aggressive behavior and sexual dysfunction or increased sexual aggression can occur as well. Unlike cocaine, it has a much longer duration of action that oftentimes exceeds six hours. And again, how you use it can make a difference. So here smoking it, for example, can have an onset of action within five minutes. Whereas if you take an oral form, it can be much longer to have the onset even up to 20 minutes. And I just want to throw in one other thing about the behaviors is we often see people with this combination of serious mental illness and stimulants or stimulants alone, really getting involved in the criminal system as well. And that's in terms of behaviors, they may engage in behaviors that, throwing a rock in a store window or other things that are more aggressive, but this is one of the challenges. And we have other webinars as an SMI advisor about working with people in the criminal legal system as well. Yeah, thank you, Dr. Pinal. I would say, I know certainly out here in Northern California, Sacramento, when we look at arrests for people who are referred for a competency in trial or sanity at the time of the act, we probably have 60 to 80% of those have a co-occurring disorder, usually a stimulus disorder. Yeah, so that's a very good point. Now, the opposite of meth intoxication, obviously, is that they come off with meth withdrawal. So you might see people with depression, fatigue, a lack of energy. And as I mentioned earlier, sometimes they can have cognitive impairment, slowing and dulling that exceeds the period of intoxication alone. I'm gonna really focus now on this relatively new emerging form of methamphetamine and how devastating this is to our patient population. And so you might remember the day when methamphetamine was made from over-the-counter prescription or non-prescriptive substances such as Sudafed and nasal congestion. And that was so prominent that in 2006, there was legislation that really required ephedrine and Sudafedrine to be placed behind the counter. And as a result, clever drug dealers and makers had to make a different form of meth. So now we have the welcoming or unwelcome use of super meth. And here's an example of what this compound could look like. And in contrast to using ephedrine, it now uses phenyl acetone, which is much cheaper and much easier to obtain. And you don't have to worry about being tracked through signing out all the different banned stimulants. And when you just look at the development of super meth in the history, my gosh, you know, you had the 2006 act that banned over-the-counter stimulants. And what we see is even by 2012, most of the domestic samples of meth were using the phenyl acetone method. And now today, most of the overdose using stimulants are also combined with opioids, but also this new super meth. So why is super meth or PTP meth so worrisome for us and our patients? Well, first of all, it's a lot cheaper. It's more potent with more side effects and more stimulant use. High level of purity, readily more available. And to top it all off, the effects are much longer lasting. So bad on all fronts. And this graph shows you how much cheaper it is. So in 2002, if you needed a crystal meth dose, it could be up to $125. And now it's $25 or less with this new formulation. And when we look at the seizures of meth, also you can see the potency is increasing and this heavily relates to PTP meth. With this increased potency of methamphetamine, you also would expect to see an increased risk of methamphetamine-induced psychosis. So let's talk about trying to differentiate methamphetamine-induced psychosis versus a primary psychosis. Well, first of all, the meth ongoing use can really resemble schizophrenia like we talked about in describing intoxication. And about 13 to 24% of methamphetamine users will actually have psychotic symptoms. But most of these psychotic symptoms are transient and they resolve in less than one month. And I think that's in part why the DSM-5 uses a one month cutoff timeframe for duration of psychotic symptoms to help distinguish between a drug-induced psychosis versus an underlying primary psychosis. That being said, you can certainly get a prolonged meth psychosis. And although the DSM-5 says one month is a cutoff period, in reality, other research indicates up to 30% can have symptoms that last six months. And I've clinically seen even longer sustained symptoms that seem to be related to the methamphetamine. And some of the work coming out of Japan shows that they can remain psychotic for even up to three years in their follow-up. So we know that meth not only can precipitate, but also can exacerbate psychosis. So if you have an individual with schizophrenia and they have a meth use disorder, this is really a worrisome combination. And we've talked about the one month duration criteria for the DSM-5, but again, sometimes meth, and I think you probably have seen this in your practice, can have symptoms that last beyond a month. So let's go over a vignette and just sort of see if we could potentially differentiate from what we've learned so far, what might likely be due to meth versus an underlying true psychosis. So imagine you're seeing Mike. He comes into your clinic and he's 42 years old. He presents with severe paranoia, agitation, lack of sleep, obviously common symptoms of both disorders. He has paranoid delusions. He believes that the FBI is planning to kill him. And so he's in a local grocery store and he becomes very paranoid about this clerk who was just trying to help him, but he believes that she's about to murder him. And so now he's obviously gonna be referred at some point for a forensic evaluation. And one of the questions might be, was this meth or was this a primary psychosis? And for those of you who work in forensics, this can be a really important question for purposes of evaluating sanity. And he does have meth use on the drug screening that comes out. So what are some factors, if you were asked, that would predict if he will develop from his meth use an ongoing long chronic psychosis? Well, in culling all the literature, there are several factors that play a role if you're trying to determine the long-term outcome from a meth-induced psychosis to having this develop more than a month and into a chronic phase. And these could include the intensity of use, high dosage, frequency over time, if they had a prior history of a psychotic disorder. Please ask if there's a family history of psychosis. This is also predictive of chronic meth psychosis of the individual, as any other family history of another mental illness, other psychiatric comorbidities. And this one kind of surprised me, but there is literature on this. Having an adverse child event, what we know as a childhood ACE events, which are 10 factors prior to the age of 18, is also a risk factor for someone if they use meth, become psychotic, to have a long-term chronic methamphetamine-induced psychosis. So I don't know if I've helped you. And we know, you know, trauma can cause some impairments in social and emotional development. So it's interesting to see that data, that it can also put people at risk for a psychotic illness later on. Yeah. Dr. Pinellas, I think that's a good point because we know even with schizophrenia, having adverse childhood life events and trauma can be a risk factor. And so for chronic meth use, developing into chronic psychosis seems to be also a factor. And we know that, you know, the whole issue of which comes chicken and egg, you know, is it the psychosis or the substance use or the substance use, and then the psychosis. Sometimes we see just risk factors overall that make that co-occurring condition more likely too. And so it's really important as we think about it, and we'll talk more about this, you know, as we talk about treatments, is really just looking at trying to treat both conditions and trying to mitigate risk for the future. Great. Thank you. So have I helped with meth use versus schizophrenia? I don't know. You might be a little confused right now because as Dr. Pinos said, it's the chicken or egg phenomenon. Does meth induce schizophrenia or is it a distinct syndrome altogether? And for those of you who do forensics, this can be a unique legal question that I may leave to another day, but it is important sometimes to distinguish. So one author who's written on this as McKeaton with her co-authors, and they are looking at transient methamphetamine-induced psychosis, and that doesn't last. So their definition from this study of a transient methamphetamine-induced psychosis would be if they have some symptoms of psychosis during the month they're using methamphetamine, but they do not have symptoms of psychosis when they're not using methamphetamine, so it's transient. And it was characteristic for this transient group, again, to have persecutory delusions and tactile hallucinations, and for that to be just a transient psychosis. So again, really check in for those tactile hallucinations. In contrast, persistent methamphetamine psychosis, and they defined it in this study as having psychotic symptoms that occurred while using methamphetamine, but also continuing and being present during a month when not using methamphetamine. And this more persistent group had more symptoms similar to schizophrenia, but also a range of hallucinations in a variety of domains. So their questioning or result from the study was, is persistent methamphetamine psychosis just really a precipitated primary psychosis? So again, if you're reviewing in a vignette, a chart to try to look at a diagnosis, imagine that you have a guy, he's called Joe, he murdered his wife and was found not guilty by reason of insanity for this, and the court evaluator made a diagnosis of schizophrenia, but he also has this history of meth and alcohol use. For treatment purposes, not forensic purposes, but if he's now on your unit and you're really trying to determine what were some of the primary issues, if you wanted to look at his prior records, I would challenge you to really dig deep for some possible signs to help distinguish was this a drug use disorder versus primary psychosis related to the murder. So if you're looking at the record history and you see that there were dilated pupils at the time of the offense, sometimes you can get these from the arrest records when they go to the jail and the physical exam. Sometimes if they're sweating at the time of the arrest and that's noted by the arresting officer, they have an obvious tremor, they're picking at their skin, or they tell someone about tactile hallucinations, this is gonna lean you much more as far as an acute drug-induced psychosis, particularly when it has a clear sensorium. Also in his case, his symptoms cleared without medications in five days and he had no sustained psychotic symptoms. So although the court evaluator diagnosed him with schizophrenia, I would really challenge that diagnosis with all of this evidence and have this primary focus then on a methamphetamine-induced psychosis. We're gonna conclude in the last eight to 10 minutes looking at treatments. And when we think about medication management, for those who've really used high doses of ongoing chronic stimulant use, sometimes they just don't respond as well to the antipsychotics in the same way that individuals with schizophrenia may. And for acute psychosis, and I would say this is primarily related to acute cocaine psychosis. In cocaine psychosis, you have to be concerned with certain antipsychotics that you may develop neuroleptic malignant syndrome. However, there's a good bit of literature for methamphetamine-induced psychosis that you can use antipsychotics to help treat the active psychotic symptoms. So I don't wanna suggest by the slide that you would not use antipsychotics in an acute psychosis stage, but just be mindful if there's a cocaine positive, the risk of neuroleptic malignant syndrome, and oftentimes the cocaine clears up pretty quickly. In one study that's fairly recent, comes out of the New England Journal of Medicine, and they're trying to look at for methamphetamine use, would there be a medication combination that might be helpful? So they've had 403 persons with moderate to severe methamphetamine use disorder. And so they had a combination of this naltrexone and bupropion, and then they compared this to a placebo, obviously no medication. And the dose of naltrexone in the study was 380 milligrams every three weeks, and the dose of the bupropion in the study was 450 milligrams per day. So what was the outcome when they followed them over 12 weeks? And they defined success as three of four negative urine drug screens, indicating that they were not using. Here are the results. The medication group, 13.6% had three of four negative urine drug screens, whereas the placebo group only 2.5% did. So, I mean, there's some mixed thoughts about this. I mean, certainly this isn't a high response rate. It's not over 50%, but there is at least some improvement compared to the placebo. And Dr. Pinos, I don't know if you had any thoughts about this study and what it might mean in our population. Yeah, I mean, you could look at it as it's five times better than placebo, but your overall response rate is not great. And three out of four negative screens doesn't mean perfect sobriety. So there's lots of ways to look at this. We're really trying hard. I think the research is trying hard to advance what we can do to even make some improvements. And I think that's where we're really at. And these aren't FDA approved for the treatment of methamphetamine use disorder. We have to keep that in mind. But clinically, clinicians are trying to try to mitigate the risk of this very difficult substance and substance use disorder. And again, this wasn't a study of people with co-occurring serious mental illness. So it's not clear what the success rate would have been with those medications or whether there would have been other things to think about in terms of the underlying mental illness. Yeah, I'm curious, Dr. Pinos, have you seen individuals who sometimes may snort or crush bupropion to get a stimulant-like effect? That is something, and we see that in carceral settings. That's why it's often difficult to obtain in carceral settings. It does have that potential as well. Okay, yeah, so it was interesting that it was used as one of the treatments, whereas in some carceral settings, there may be caution for its use with individuals with a stimulant use disorder. But that may be similar to what we do with opioids, where we use something that affects the same neurotransmitter system in an effort to manage the cravings, because sometimes the snorting use is trying to deal with intense cravings and hit that dopamine receptor in a way that helps reduce the pain of withdrawal. And I don't think the methamphetamine withdrawal is the painful type of withdrawal as opioids, but it is uncomfortable. And so it may be a similar thing of using a stimulant to treat a stimulant use disorder. Good point. All right, when we think about behavioral therapies for methamphetamine use, there's something known as the matrix model, which really combines many different approaches, such as cognitive behavioral therapy, family education, motivational interviewing, and then 12-step facilitation, which is not exactly the same thing as going to AA and going through the 12 steps, but it's a particular approach where caregivers can help facilitate them understanding the benefits potentially of a 12-step program. And with the matrix model, this is sort of just a summary point. It has shown from a behavioral standpoint to decrease methamphetamine use over a 16-week period of its structured intervention. And let me just comment on that. For first episode psychosis, coordinated specialty care is something that's really an important intervention that allows for kind of similar, very wraparound types of services. And so it would be interesting in the future to see how models like a matrix model might look with coordinated specialty care for somebody with co-occurring conditions. Contingency management is examining, can you use certain rewards that a person could have and based on if they had negative urines, suggesting strongly that they were not using the substance, they would get a voucher contingent on that negative urine. And I've heard some concerns expressed by people really not familiar or as familiar with the research on contingency management. Why would you just give rewards to someone should they just stop using the substance on their own? Typically the vouchers, you're not giving them like cash because I think the concern could be that they would go out and just buy more drugs. It can be a voucher for something that could be useful in their life, like to a store for clothing or some other item that would reward them. So they're getting positively reinforced in a contingent way for abstinence. And typically many of these approaches that have increased points with each negative test and the more points you have, you might get a bigger prize if you will, or voucher. And again, when combined with counseling for stimulant use disorders, contingency management has been one of the most important interventions to help improve long-term outcome. And Dr. Higgins, who's written about this, published a book about this, has been a big leader in the field of contingency management. One type of contingency management is something known as the fishbowl approach. You might've used this, or maybe not have used this with your kids over time, but the point of this is unlike just a known defined point system, and this system, if you have a negative urine, you can put your hand in a fishbowl. I don't think it has to technically be a fishbowl. It can be any kind of large bowl, but you put your hand down and you're gonna randomly draw. And maybe you get the prize of the day that's really a super good voucher, or maybe it's something sort of minor, but this is also shown to be efficacious because it reinforces that they may have, if they have a negative urine screen, a really good prize. Now, that being said, having talked about the use of contingency management, only about 55% of publicly funded programs use this. So this speaks to the need for much more training in addictions and in these types of interventions. One of the last things I'm gonna talk about is something known as the community reinforcement approach. And this is a behavioral strategy that can oftentimes be combined or used with contingency management. It really is focusing on reducing use. And so you have individuals in the community, could be their families, support people, help them meet their social and emotional needs. Other than using substances, oftentimes this approach uses something known as a functional analysis. So you're looking at the function served by the use of substances and also a functional analysis of the positive of having pro-social behavior such as being sober. It's individualized and collaborative as well. All right, you probably have heard at least this is a significant approach here out in California. It's something known as the harm reduction hypothesis. A lot of this work initially came from some studies looking at opioids in Portugal, but other all around the world as well. And the point here is you're trying to lessen the negative social and or physical consequences of human behavior. So perhaps the person is never gonna be able to have a complete abstinence approach. So if you say never use again, go to AA, get a sponsor and you can never use, that may not fit the needs of many people. So the goal is less use is better than higher use. One of the concerns some folks have is, well, it doesn't require abstinence. Can you really, for example, with these P2P forms of meth that are highly potent, highly addicting, can you control your addiction just using less of it or not? But the overall goal is to decrease the totality of adverse consequences. So if you're injecting less than you have a less risk of, for example, sharing a needle that might have hepatitis or other diseases involved as well. So we've covered a whirlwind of topics related to meth use and SMI. I think we all know that stimulants certainly can mimic schizophrenia. It can result in a chronic psychosis picture and they're increasingly potent forms of methamphetamine. And these do contribute to serious mental illness and also continuing the presentation of SMI such as schizophrenia. And then we concluded talking about some interventions such as contingency management. There's several references in your slide set that we quoted during this presentation that you can review on your own. And then I turn it over now to our wonderful SMI advisor team. Great, thank you so much, Dr. Scott and Dr. Pinals. Really great, great presentation. Before we go into the Q&A, I just wanted to let you know that SMI Advisor is available via your mobile device. Use SMI Advisor app to check out resources, education and upcoming events, complete mental health rating scales and even submit questions directly to our team of SMI experts. And a fair bit of questions have come to us on methamphetamine induced psychosis. Download the app now at smiadvisor.org slash app. Okay, now let's jump into the Q&A. It's interesting, I was given a grand rounds actually last week on SMI Advisor. And the first question that came up was what resources do you have for methamphetamine induced psychosis? And I said, you need to tune into this webinar. So I hope that some of those folks are here today watching that. So a couple of questions came up. You know, one thing I was kind of wondering about some great questions from the audience and then also a couple of things that I was wondering about as well. So I was really interested in this idea about treating people with antipsychotics who have had methamphetamine induced psychosis. And what's your all's thought about, let's say somebody has had a history of having psychosis after using methamphetamine. They have this kind of chronic ongoing psychosis type picture. And I guess the question is, these folks may even sometimes be continuing to use. What is your thought about how to incorporate antipsychotic medications, even particularly long acting injectables for this population? Yeah, Deb, I'll let you start off and I'm happy to jump in. Yeah, I mean, I think we still have to treat in the best way we can. The data on why, you know, whether these medications will work. I mean, I think we run the risk of trying to, you know, it's not really clear that you need higher doses to impact or whether you need to switch medications to maybe newer generation medications, less focus on the dopamine receptor, that sort of thing as a strategy around thinking about what will work with this population. And so even though we know that traditional antipsychotics may not be as effective, especially if the person is still using methamphetamine, that's the other thing is you're often dealing with somebody who not only has a psychotic condition, but is actively using and is having a very hard time not using. So you want to combine all of the techniques we can, antipsychotics, motivational interviewing, toxicology screens to see what's going on, all of that to try and inform your thinking around treatment planning. I don't know, Dr. Scott, what your thoughts are. Yeah, I agree. And I think with a shorter acting stimulant, such as cocaine, I mean, if a person is hospitalized, if you're lucky enough, you know, to have the opportunity to observe them and they rapidly clear, I mean, that's the cleanest, best situation where they may not need ongoing. I think the question for those who have that co-occurring, I remember of schizophrenia, 60% plus will have some co-occurring substance use disorder. So it is common to have that comorbidity, really trying to look at to what degree, if they have acute psychotic episodes that were related to meth use, trying to differentiate between some of the physical signs and symptoms. So treat those symptomatically as well, if they're having a medical response to the stimulant use. And also if they're actively psychotic, you may have to, I agree with you, Dr. Pinos, treat them symptomatically also with an antipsychotic because there's harm if they're untreated from their psychosis. So that involves also a risk assessment. It's gonna be a risk benefit analysis for your patient about when and if you should continue to intervene. Okay, sounds good. Another sort of follow-up question about antipsychotic use for people with methamphetamine-induced psychosis. I guess that one of the questions is, how long are antipsychotics necessary and should antipsychotics be continued after the psychosis clears for people with methamphetamine-induced psychosis, particularly the ones who have longer lasting episodes of psychosis, like some of the three-year group you were talking about. Is there any way you can know whether to continue the antipsychotic with them or how do you kind of conceptualize that? Yeah, since I may take the first round, I'm happy to jump in on this one. And Dr. Pinos, please add your wisdom. I'm fortunate to work in a system where we've had many people who were found not guilty by reason of insanity. It's a 1,500-bed hospital, about 500 to 600 people who have been found criminally insane and a large number of those, years and years of evaluation and treatment, the thinking was primarily a methamphetamine-induced psychosis misdiagnosed by the court evaluator. Not that they're bad, but they didn't have all the information we had. And so what we do typically, we look at all the evidence and then we'll do a very slow taper. We have the advantage of following them, though oftentimes for months, if not years, to see if they have a recurrence. But if someone really doesn't have, in my opinion, a independent or persistent psychosis and you can observe them for months to years without the antipsychotic, you have to do that risk-benefit analysis of the risk of continuing on the antipsychotic with all the potential side effects if they really don't have an underlying psychosis and their methamphetamine psychosis is cleared. So we would do that on an individual case basis and we do taper, monitor slowly, and then closely observe these people if we don't think they have a primary psychosis. I don't know, Dr. Pinus, what do you think? Yeah, I mean, I think that's fair. I don't think there's any clear, you need at least six months of this or eight months of that. I think it's a case-by-case analysis. I think it's always wise, going slow, observing for recurrence of symptoms when you're wondering whether the diagnosis was correct in the first place. The other thing is in community-based settings, especially is the person at risk of ongoing use, has their, you have to understand in a hospital setting where there still could be substances, but in large part their methamphetamine or stimulant use disorder is not active. It's often in remission due to the controlled environment. In a community setting, that's not as easy to obtain. And so you want to understand what's happening with their substance use disorder. And you're really trying to balance both conditions at the same time. Okay, sounds good. And one other question, I'm curious about your all's experience with the prospect, albeit fairly statistically low, of antipsychotic medications reducing the seizure threshold. And then how do you kind of incorporate that with treating people with methamphetamine-induced psychosis who the methamphetamine can potentially reduce the seizure threshold? Dr. Pinals, what do you think? I mean, I think it's, you got to understand what those risks are. You got to do a good history, a neurological history. You got to look at other substances. A lot of people with methamphetamine psychosis also have significant alcohol use disorder and are using. We also know that there's been prescription or non-prescription benzodiazepine in a lot of these fatalities. So you're looking at multiple things that might impact seizure threshold, both lowering it and raising it. And you're going to need history and monitoring and vigilance and helping the patient understand what a seizure could mean and what it looks like as you're thinking about how to balance those things. This is all very ginger, step-by-step, really working with the patient and remembering. I mean, this is one of the things I spend a lot of time talking about. A lot of these people, especially when they have early developmental traumas and all of that, they had reactive attachment disorders. Their personalities are sometimes challenging to work with. Their resistance to connection is understandable, but difficult. We talk about patients that are treatment resistant, but systems and treaters that are patient resistant because they may be demanded, you know, they're stimulus bound, they want what they want, they're agitated. So working with this population can be very challenging. Some of them have antisocial traits or borderline traits. And what we know is that even getting them in treatment is a huge opportunity, but keeping people in treatment is very, very difficult. So continuing to work with them on alliance and engagement so that you can do this gentle work, helping see what their goals are to help them get to their goals is really where we want to go to get people motivated for their own recovery. And that is really hard when you're dealing with people with the cognitive limitations that we see and the psychosis and all of the things and probably some limited family supports because they may have burnt out some family connections. So it's a lot of work. And that's why some of these wraparound models, some of the matrix model really helps to try and shore up so that it's a team approach of who's helping this person. Yeah, and just to add on briefly to that, if someone has a known seizure disorder, you could also consider getting a neurology consult to look at a second opinion to be super safe about whether options from both neurology and yourself might be warranted. Great. I thought it was really interesting when you all were talking about some of the wraparound services and sort of CSC-like type programs. I'm kind of curious what you all think from a health policy standpoint about like, what does states need to do to help address folks with cocaine-induced psychosis, methamphetamine-induced psychosis? Do you have any recommendations from a policy standpoint? Yeah, I have some thoughts. Deb, you're the guru of public policy. So- Yeah, I mean, I definitely have thoughts and we're looking at this as we look at states that are applying for 1115 waivers to do re-entry services. We're gonna see a lot of these individuals in the community. And I'm a firm believer in people helping people. So those kinds of wraparound supports, healthcare workers, peer support, in addition to medical interventions as being the way to foster engagement and continuity of care, and really developing policies that help with that type of coordination. I know coordinated specialty care is evidence-based for first episode psychosis, but similar models like critical time intervention, the matrix model with methamphetamine, those are all models that kind of take the same principles of intensive human supports, providing structured interventions to help people move to better places in their recovery. Yeah, and I live here in San Francisco. So the issue of methamphetamine and how serious mental illness public policy, I mean, certainly San Francisco has been in the national news and they are changing certain approaches. We have a very progressive mayor, Mayor London Breed, and Mayor Breed now has announced that for those who are substance users, whereas in the past, certain just general cash payments may have just been given to help them live and support, that that may be more closely tied to negative urine drug screens. So in some way it's like a public policy contingency model. The other thing that we're finding is, there's the housing first model, which I really didn't discuss much today, but that premise is before people can have adequate response to their serious mental illness and or substance use who are unhoused, you've got to get them to housing first because otherwise they're just not gonna have effective treatments on the street. And we've had plus minus with that and that if there's no requirement for any treatment access, any treatment follow-up, any medication whatsoever, even if they do get permanent supportive housing, is their outcome for their SMI and substance use impacted in a positive way? And so I do think because of the P2P and the fentanyl and the stronger forms of drugs, there's gonna be some augmentation of the housing first model, which is going to encourage more strongly, you have to participate to some degree. And so we're having a statewide legislation that's been passed called the CARE Court, which is for those with schizophrenia, looking at more strong public policy connection to treatment, not just being placed in housing with no treatment. Yeah, and the only thing I would add on a note is that there are ways to inspire, motivate engagement beyond court mandates. And I do think we wanna be careful to not assume that a court mandate will solve all these problems either. A lot of data around rep payees and money monitoring and things like that as a way, family supports, family kind of positive pressures, if you will, to help people get to yes in a way. I don't think we have data on the use of courts per se as the single intervention to ensure sobriety, stability and all of that. So it may be one arm, one tool, but it's only one tool. And we wanna think broadly, we wanna think about psychiatric advanced directives, all the things we can to get upstream from those interventions. And then also what other models can be used in that sort of contingency management framework. Great point. Really helpful. Thank you so much to both of you, Dr. Scott, Dr. Pinal. It's really, really wonderful webinar, great discussion. Maybe now we can go into a couple of the outro slides. So if we could just go to the next slide and the next slide and the next slide. Okay. So if there are topics covered in this webinar that you would like to discuss with colleagues in the mental health field, feel free to post a question or comment on SMI Advisors Discussion Board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of our SMI Advisors National Experts. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals with SMI. It's completely free and confidential. All right, next slide. SMI Advisor offers more evidence-based guidance on stimulant use disorder, such as the basics on substance use and serious mental illness, stimulants, This fact sheet provides an overview of relevant background details and reviews the basics on screening, interventions, and treatment. Access the fact sheet by clicking on the link in the chat or by downloading the slides. Next slide. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for the credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and the usage of the Zoom platform. All right, so please feel free to join us next week on December 21 as Dr. Edgar Woznika presents major depressive disorder, marijuana, and cannabinoids, disentangling the research to help you guide your patients. Again, this free webinar will be December 21st from 3 to 4 p.m. Eastern on Thursday. So thanks so much for joining us and until next time, take care.

Dr. Rob Cotez

stimulant use

serious mental illness

webinar

stimulant-induced psychosis

evidence-based treatments

cocaine

methamphetamine

behavioral therapies

antipsychotic medications