What are the guidelines for monitoring withdrawal from methamphetamine (methamphetamine hydrochloride)?

From the Guidelines

Monitoring methamphetamine withdrawal should be undertaken in a supportive environment, focusing on relief of symptoms such as agitation, sleep disturbance, depression, or psychosis, without specific medication recommended for the treatment of withdrawal itself. This approach is based on the World Health Organization's guidelines for managing substance use disorders, as outlined in a study published in PLoS Medicine 1. The management of methamphetamine withdrawal involves a comprehensive assessment of both physical and psychological symptoms, which can include significant cardiovascular fluctuations, depression, suicidal ideation, psychosis, and severe cravings.

Key aspects of monitoring methamphetamine withdrawal include:

• Regular checks of vital signs, such as blood pressure, heart rate, temperature, and respiratory rate
• Psychological assessment focusing on depression, suicidal ideation, psychosis, and severe cravings
• Monitoring for complications arising from dehydration, malnutrition, or severe depression
• Consideration of supportive medications for specific symptoms, such as bupropion for depression and cravings, mirtazapine for insomnia and appetite stimulation, and short-term benzodiazepines for severe agitation, although these should be used with caution due to their potential for addiction

The neurochemical basis for methamphetamine withdrawal symptoms, including dopamine depletion and dysregulation of other neurotransmitters like serotonin, norepinephrine, and glutamate, underlines the importance of a supportive environment and symptom management 1. Regular assessment of hydration status, nutritional intake, and sleep patterns is also crucial, given the common deficits in these areas among methamphetamine users. Overall, the goal of monitoring methamphetamine withdrawal is to provide a supportive environment that addresses the physical and psychological symptoms associated with withdrawal, minimizing the risk of complications and promoting the individual's overall well-being.

From the FDA Drug Label

Methamphetamine hydrochloride tablets may produce physical dependence. Physical dependence is a state that develops as a result of physiological adaptation in response to repeated drug use, manifested by withdrawal signs and symptoms after abrupt discontinuation or a significant dose reduction of a drug Withdrawal signs and symptoms after abrupt discontinuation or dose reduction following prolonged use of CNS stimulants including methamphetamine hydrochloride tablets include dysphoric mood; depression; fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation.

Monitoring withdrawal from methamphetamine should focus on the following key areas:

• Withdrawal signs and symptoms: Monitor for dysphoric mood, depression, fatigue, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation.
• Dose reduction: Gradually reduce the dose to minimize the risk of withdrawal symptoms.
• Physical dependence: Be aware that methamphetamine hydrochloride tablets may produce physical dependence, and monitor for signs of dependence 2.

From the Research

Monitoring Withdrawal from Methamphetamine

• Methamphetamine withdrawal symptoms can be challenging to manage, and there is a lack of protocols addressing these symptoms, resulting in difficulties in inpatient management and premature discharges 3.
• A novel treatment protocol comprising behavior-targeted and pharmacological components has been developed to reduce the intensity and duration of methamphetamine intoxication and withdrawal-related symptoms during early treatment 3.
• The protocol includes pharmacological interventions such as ascorbic acid, antipsychotics, and other sedatives, as well as behavior-based orders, and has shown feasibility, tolerability, and preliminary evidence of effectiveness 3.

Factors Associated with Methamphetamine Withdrawal Symptoms

• Methamphetamine withdrawal symptoms are common among people who inject drugs (PWID), with 53% reporting symptoms in the past 6 months, and 25% reporting weekly withdrawal symptoms 4.
• Factors associated with methamphetamine withdrawal symptoms include more frequent methamphetamine use, non-injection tranquilizer use, and receptive syringe sharing 4.
• Female sex is associated with more frequent withdrawal symptoms, and very or extremely painful withdrawal symptoms are associated with being in residential treatment 4.

Pharmacological Treatment for Methamphetamine Withdrawal

• There is insufficient evidence to indicate that any medication is effective for the treatment of methamphetamine withdrawal, with most studies having a low to very low quality of evidence 5.
• Amineptine may reduce discontinuation rates and improve global state compared to placebo, but this medication is no longer approved 5.
• Bupropion has been tested for efficacy in increasing weeks of abstinence in methamphetamine-dependent patients, with mixed results, and may be effective in combination with behavioral group therapy for participants with low-to-moderate methamphetamine dependence 6, 7.

Treatment Outcomes

• Patient completion of a novel methamphetamine withdrawal treatment protocol was 83%, and the protocol's utility was supported by nursing staff 3.
• Bupropion did not increase abstinence in dependent participants who were using methamphetamine less-than-daily, and medication non-adherence was a limitation in this trial 7.
• Psychosocial therapy remains the mainstay of treatment for methamphetamine dependence, and further research on subgroups who may respond to bupropion may be warranted 7.