What is the best management approach for a 61-year-old patient with methamphetamine withdrawal, bilateral hip pain due to severe osteoarthritis and avascular necrosis, hypertension, hypercholesterolaemia, and iron deficiency anaemia, who is currently experiencing fatigue and mood swings, and has a history of smoking and financial difficulties?

Management of Methamphetamine Withdrawal with Complex Comorbidities

This patient requires structured psychosocial intervention with contingency management plus community reinforcement approach for methamphetamine withdrawal, aggressive pain management for bilateral hip osteoarthritis with consideration for urgent orthopedic referral, immediate blood pressure control with felodipine, and resumption of statin therapy for cardiovascular risk reduction.

Methamphetamine Withdrawal Management

Psychosocial Interventions (Primary Treatment)

• Combined contingency management (CM) plus community reinforcement approach is the most effective intervention for methamphetamine addiction, achieving superior abstinence rates at 12 weeks (NNT 2.1), end of treatment (NNT 4.1), and longest follow-up (NNT 3.7) compared to treatment as usual 1
• CM alone shows efficacy during treatment but effects are not sustained at follow-up, whereas the combined approach addresses the biological, psychological, and behavioral complexity of addiction 1
• Brief motivational interviewing should be employed using the "elicit-provide-elicit" technique rather than direct confrontation, as telling patients to change generates resistance 1
• Focus on understanding the patient's own motivations for change (divorce stress, financial difficulties) and reflect these back to support self-efficacy 1

Pharmacotherapy Considerations

• No medication is currently approved for methamphetamine withdrawal, and evidence quality is very low to low for all studied agents 2
• Amineptine showed promise in reducing discontinuation rates (RR 0.22) but is no longer approved 2
• Consider symptomatic management with behavior-targeted protocols including ascorbic acid, antipsychotics for agitation, and sedatives as needed during acute withdrawal 3
• The fatigue and mood swings at 3 weeks post-cessation are expected withdrawal symptoms that typically improve with time and supportive care 3, 2

Critical Pitfalls

• Avoid restricting treatment only to patients whose goal is complete abstinence—reductions in use frequency have important health benefits 1
• Light versus heavy users respond differently to pharmacotherapy; this patient's 10-year history suggests heavy use requiring intensive psychosocial intervention 4
• Early treatment response and medication compliance are strong predictors of success 4

Bilateral Hip Pain Management

Immediate Pain Control

• Continue Celebrex 150mg but consider increasing to 200mg daily given inadequate pain control (pain waking at night despite medication) 5, 6
• NSAIDs are the primary pharmacologic intervention for hip osteoarthritis pain, used at the lowest effective dose 5, 6
• Paracetamol is first-choice for mild-moderate pain but this patient has severe pain requiring stronger intervention 5
• Avoid opioids given methamphetamine addiction history—opioids are inferior to NSAIDs for musculoskeletal pain and cause significantly more side effects 6

Surgical Planning

• This patient requires urgent orthopedic referral for bilateral hip replacement given severe osteoarthritis with avascular necrosis, refractory pain despite medication, and functional disability 5
• Total hip replacement is specifically indicated for patients with radiographic hip osteoarthritis who have refractory pain and disability despite conservative management 5
• Joint-preserving procedures (periacetabular osteotomy) are reserved for younger patients with dysplasia before significant osteoarthritis develops—this patient has advanced disease 5
• The left hip with sciatica and worse pain should be prioritized, though bilateral surgery may be considered 5

Conservative Measures During Surgical Wait

• Weight reduction is essential if patient is overweight/obese, as obesity is a specific hip risk factor 5
• Exercise therapy is recommended with high-strength evidence, though must be tailored to pain tolerance 5
• Intra-articular steroid injections may be considered for flares unresponsive to NSAIDs 5, 6
• Do not recommend glucosamine, chondroitin, or intra-articular hyaluronic acid—these lack evidence for hip osteoarthritis 5

Methamphetamine and Avascular Necrosis Connection

• While avascular necrosis is typically associated with corticosteroids and alcohol, intravenous drug use including heroin has been reported to cause bilateral femoral head avascular necrosis through decreased blood flow 7
• The mechanism involves disruption of blood supply leading to bone ischemia, though heroin's systemic vascular effects remain incompletely understood 7
• This patient's 10-year methamphetamine history may have contributed to or accelerated the avascular necrosis process 7

Hypertension Management

Immediate Intervention

• BP 186/80 requires immediate treatment—initiate felodipine as planned per discussion with provider 8
• Felodipine is a calcium channel blocker appropriate for hypertension management 8
• Target BP should be <140/90 mmHg in this 61-year-old patient 1

Monitoring

• Monitor for excessive peripheral vasodilation, marked hypotension, or bradycardia with felodipine initiation 8
• If severe hypotension occurs, place patient supine with legs elevated and administer IV fluids 8
• Recheck BP within 1-2 weeks of starting felodipine to assess response and titrate dose 8

Hypercholesterolemia Management

Statin Resumption

• Resume atorvastatin 40mg immediately—this patient has multiple cardiovascular risk factors (hypertension, hypercholesterolemia, smoking, age 61) requiring aggressive lipid management 9
• Atorvastatin 40mg significantly reduces total cholesterol, LDL-C, triglycerides, and apolipoprotein B 9
• Address barriers to adherence: counsel on importance for cardiovascular risk reduction, assess financial concerns given patient's financial difficulties 9

Monitoring and Safety

• Order baseline lipid panel (already planned) and repeat in 4-6 weeks to assess response 9
• Monitor liver enzymes given atorvastatin can cause elevations—advise patient to report fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice 9
• Counsel on myopathy risk: report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever 9
• Inform patient that HbA1c and fasting glucose may increase; optimize lifestyle measures including exercise and healthy diet 9

Iron Deficiency Anemia Management

Investigation and Treatment

• Proceed with ordered FBC and iron studies to confirm iron deficiency and assess severity 10
• Investigate etiology: given GI upset with oral iron and need for NSAIDs, evaluate for gastrointestinal bleeding as potential cause 10
• Consider intravenous iron given patient's history of GI upset with oral iron tablets and need for ongoing NSAID therapy 10
• Iron deficiency beyond anemia causes fatigue, which may be compounding methamphetamine withdrawal symptoms 10

Smoking Cessation

• All patients should be encouraged to stop smoking regardless of cardiovascular risk 1
• Current 2-3 cigarettes daily represents opportunity for intervention during this period of substance use recovery 1
• Offer pharmacotherapy (varenicline, bupropion, or nicotine replacement) combined with behavioral counseling 1

Care Coordination and Follow-Up

Multidisciplinary Approach

• Utilize multidisciplinary model with identified primary provider to support long-term patient-provider relationship 1
• Coordinate care between addiction services, orthopedics, and primary care 1
• Address financial difficulties as barrier to care—connect with social services for assistance with medication costs and treatment programs 1

Depression and Mood Monitoring

• Evaluate for depression given mood swings, fatigue, recent divorce, and substance use history 1
• Depression management should be integrated with addiction treatment, as these conditions commonly co-occur 1
• Consider antidepressant therapy if depression persists beyond acute withdrawal period 1

Adherence Support

• Schedule frequent follow-up visits (weekly initially) to monitor methamphetamine abstinence, medication adherence, and treatment response 1
• Use objective measures (urine drug screens) to monitor abstinence 4
• Early treatment response is a strong predictor of long-term success 4