What are the best practices for managing psychosis associated with methamphetamine use?

From the Guidelines

Managing psychosis associated with methamphetamine use requires a comprehensive approach that prioritizes antipsychotic medications, supportive care, and long-term treatment planning, with a focus on contingency management (CM) and community reinforcement approach to achieve sustained abstinence and improved outcomes. The treatment of methamphetamine-induced psychosis typically involves antipsychotic medications such as olanzapine, risperidone, or haloperidol to address acute psychotic symptoms like paranoia, hallucinations, and agitation 1. Benzodiazepines like lorazepam may be added for severe agitation or anxiety. These medications should be administered in a controlled environment, preferably an inpatient setting, where vital signs and mental status can be closely monitored.

Key considerations in managing methamphetamine-induced psychosis include:

• Hydration, nutrition, and a quiet, low-stimulation environment as essential supportive measures
• The use of contingency management (CM) and community reinforcement approach to potentiate the effect of purely behavioral interventions and enhance sustained abstinence 1
• The importance of long-term abstinence from methamphetamine to prevent recurrence, as repeated episodes may lead to persistent psychotic symptoms even after drug cessation
• The potential of interventions that focus on improving goal-directed behavior and positive reinforcement rather than punishment in people with substance use disorders 1

After acute stabilization, which typically takes 3-7 days, patients should transition to a comprehensive recovery program that includes substance use disorder treatment, cognitive behavioral therapy, and possibly maintenance antipsychotic medication for 2-4 weeks with gradual tapering. This approach is effective because methamphetamine-induced psychosis results from dopamine dysregulation, which antipsychotics directly address by blocking dopamine receptors. The combination of CM and community reinforcement approach has been shown to achieve the best outcomes in terms of abstinence and acceptability 1.

From the Research

Best Practices for Managing Psychosis Associated with Methamphetamine Use

• The management of psychosis associated with methamphetamine use is challenging due to its similarity to primary psychiatric disorders, such as schizophrenia 2.
• Current best practices involve the use of antipsychotic medication, which can alleviate psychotic symptoms but may produce debilitating adverse effects and fail to address methamphetamine use 2.
• Psychosocial therapies should be explored to address co-occurring substance use and psychosis in the treatment of methamphetamine-associated psychosis (MAP) 2.
• Clozapine may be effective in treating methamphetamine-induced psychosis, particularly in cases resistant to other antipsychotics 3.
• Differential diagnosis of primary vs. substance-induced psychotic disorders among methamphetamine users is crucial, and can be optimized through careful assessment of the temporal relationship of symptoms to methamphetamine use, aided by state-of-the-art psychodiagnostic assessment instruments and objective indicators of recent substance use 4.

Treatment Approaches

• Pharmacological treatment of acute methamphetamine-induced psychosis may include the use of antipsychotic medications, such as Risperidone and Olanzapine, as well as benzodiazepines 4, 5.
• Psychosocial treatment for methamphetamine dependence has a strong evidence base and is the optimal first-line treatment approach to reducing rates of psychosis among individuals who use methamphetamines 4.
• Electroconvulsive therapy (ECT) may be effective in treating methamphetamine-induced psychosis, particularly in cases with persistent psychotic symptoms 5.

Clinical Features and Course

• Methamphetamine-induced psychosis is often characterized by violent behavior, delusions, hallucinations, and suicidal thoughts 5.
• Recovery from psychotic symptoms can take more than a month in some cases, and persecutory delusion and auditory hallucination are common persistent psychotic symptoms 5.
• Individuals with methamphetamine use disorder and co-occurring psychotic disorders have high rates of acute care utilization, suggesting a high degree of disease burden and the need for targeted treatment interventions 6.