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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: street names include 'meth', 'crystal meth', 'ice', 'glass', 'Tina', 'Christine', 'crank', 'tik', 'yaba' and 'crazy medicine'
Methamfetamine (METH) is an amfetamine-type stimulant. Within the central nervous system (CNS), it blocks presynaptic catecholamine reuptake, causing hyperstimulation at the post-synapse. See also separate article Amfetamine Abuse and Intoxication.
It is most commonly smoked in its crystal form ('ice') in a pipe or in aluminium foil, heated by a flame below; however, it can also be snorted, injected, swallowed in pill form ('yaba') or inserted rectally. Smoking the drug increases its bioavailability compared with an oral formulation and decreases plasma half-life. Mean plasma half-life after smoking is about 11 hours. Smoking approaches the bioavailability of injecting. Its effects are compared to those of crack cocaine (euphoria, heightened arousal and increased energy) but longer-lasting due to the longer half-life. It is also highly addictive.
It can be made easily in clandestine home laboratories and is often adulterated with the chemicals used in its synthesis.
Over the 1990s, there was an epidemic of METH use in some parts of America. Whilst amfetamine and ecstasy have been widely used across the UK and Europe, crystal METH use has been and remains to date uncommon, although rates may be increasing. It has been reclassified as a Class A drug so as better to control emergent problems associated with its use.
In the USA, rates of METH use grew steadily over the 1990s but are thought to have stabilised, with 2.8% of 18- to 26-year-olds reporting use. Its popularity spread from Hawaii and California and use is now highest in western and north central states, presenting significant medical and social problems in rural as well as urban populations. METH abuse has spread throughout the world - with high rates in countries such as Thailand, South Africa, Australia, Pacific island states and Mexico.
In the UK, epidemiological data have tended to look at amfetamine and METH use together. However, the 2013/14 Crime Survey for England and Wales asked individuals specifically about METH use. 0.9% of adults aged 16-59 years reported ever using and 0.1% reported use in the previous month.
Abusers typically self-administer the drug in 'runs' of several days, with intervening periods of abstinence. Whilst on a 'run', an individual may stay awake continuously for up to 10 days with little food or drink. Prolonged sleep and mild dysphoria occur as the drug wears off. Immediate subjective effects include:
- Increased alertness.
- Increased energy.
- Increased libido and enhanced sexual pleasure.
- Decreased inhibition.
- Decreased appetite.
- Decreased need for sleep.
Peripheral actions arise due to the indirect sympathomimetic effects of the drug:
- Sweating and hyperthermia.
- Dry mouth.
- Decreased gastrointestinal (GI) motility.
- Dilated pupils.
Central actions may account for some of the other typical behaviours and movement disorders seen such as:
- Jaw clenching.
- Repetitive jerking and choreoathetoid movements.
- Compulsion with repetitive tasks ('punding').
- Formication (sensation of flesh crawling with bugs with associated compulsive picking and infected sores).
Repetitive movements, hyperactivity and difficulty focusing thought are sometimes referred to as 'tweaking'.
- Diarrhoea and nausea.
- Restlessness, agitation and irritability.
- Chest pain due to myocardial infarction or dissecting aortic aneurysm.
- Panic attacks.
- Renal failure.
- Sexually and parenterally transmitted infections.
METH use is associated with high-risk behaviours and serious injury. In one Californian trauma series, METH overtook cannabis as the most common drug used by the trauma population between 2003-2005. Use of METH increased the risk of:
- A violent mechanism of injury.
- Gun and stab wounds.
- Attempted suicide.
- Domestic violence.
- Death from injuries.
Aside from the risks associated with the use of METH, there are hazards associated with the production of METH and toxic waste exposure. Those indirectly involved (neighbours, family members, children and emergency personnel) as well as users and producers may present with:
- Serious burns due to explosions (METH laboratories explode due to volatile substances used in production).
- Symptoms of environmental exposure (eg, headache, nausea, dizziness, dyspnoea and eye irritation).
- Heavy metal poisoning.
The differential is wide and includes:
- Hypertensive crisis.
- Toxicity from other stimulant/sympathomimetic/hallucinogen.
Be aware that many patients will not only have used METH - polydrug use (including alcohol) is the norm, so consider whether there is a mixed picture.
- Diagnostic testing:
- Urine - METH is detectable for 48 hours after use.
- Hair analysis.
- Meconium testing - the most accurate method in neonates.
- Other laboratory tests should be directed towards symptoms:
- Blood tests - FBC, U&Es, creatine kinase (CK), cardiac enzymes.
- CXR - where there are pulmonary symptoms.
- CT scan - where there is altered mental status.
- Sexual health promotion - offer sexually transmitted infection (STI) and pregnancy testing.
- Consider staff safety - patients may be highly agitated and unpredictable. Call for security/police back-up where necessary. Sedation with neuroleptics (eg, haloperidol) may be required.
- Management is largely supportive.
- Activated charcoal is only helpful where there has been oral ingestion.
- Benzodiazepines are indicated for seizures.
- Cooling measures may be necessary where there is hyperthermia.
- Treatment of hypertension may require intravenous beta-blockers.
- The use of olanzapine and risperidone to treat amfetamine-related psychosis is also under investigation.
- Before discharge, consider additional needs and referrals. For example, drug and alcohol team, psychiatry, social services (consider child protection issues) and genitourinary medicine (GUM) clinic.
- Symptoms include:
- Problems with concentrating
- Psychomotor slowing
- Increased appetite
- Withdrawal from stimulants is considered less dangerous than from alcohol, opioids or sedatives; however, seizures are possible.
- Compared with cocaine withdrawal, METH withdrawal is considered to produce more severe and prolonged depression so careful monitoring for suicidal ideation is important.
Treatment of abuse and dependence
- There is no effective treatment currently. Research into pharmacological treatment for METH dependence is ongoing - candidate drugs have included bupropion, mirtazapine, baclofen and topiramate.However, medication is considered primarily an adjunct to the use of psychosocial interventions.
- Outpatient behavioural therapies are the standard treatment currently in the USA. The use of cognitive behavioural therapy and contingency management have been borrowed from the treatment of cocaine addiction and applied to METH and have been shown to be effective in reducing use in the short-term, although longevity has yet to be proven. Contingency management gives rewards to patients who provide drug-free urine specimens although recent research suggests this effect may last as little as 6 months.
- Support groups and 12-step treatment programmes may also offer benefit.
For METH users
The morbidity associated with METH use is considerable:
- Myocardial infarction, dissecting aortic aneurysm, cardiomyopathy.
- Hypertensive crises and stroke.
- Rhabdomyolysis and kidney failure.
- 'Crystal cock' (erectile dysfunction).
- GI ulcers and ischaemic colitis.
- Pulmonary hypertension.
- Skin abscesses and lesions.
- Premature ageing.
- Cognitive impairment - confusion, memory loss, motor slowing and learning impairment.
- 'Meth mouth' (dental decay).[17, 18]
- Psychiatric disorders:
- Suicidal ideation and behaviour,
- Malnutrition and weight loss.
- Dependence and withdrawal-related symptoms.
- Trauma-related injuries.
- Placental insufficiency and abruption.
- Intrauterine growth restriction.
- Cleft palate defects.
- Cardiac anomalies.
- Miscarriage and stillbirth.
For children of METH users
- Neonatal withdrawal (usually milder than with opiate withdrawal) - abnormal sleep, poor feeding, decreased movement and arousal, increased stress response.
- Long-term effects of intrauterine exposure are unclear - possible developmental delay.
- Neglect and abuse.
- Inadvertent poisoning and trauma.
Public health issues
- Environmental health risk from illicit laboratories and illegal toxic waste.
- Increased rate of STI transmission - in particular, HIV.
- Increased levels of crime and violence.
METH use is associated with rapid dependence and sharp physical decline, often accompanied by criminality. Cases of acute uncomplicated toxicity treated rapidly and appropriately have a good prognosis but outcome associated with chronic use is much less positive. Relapse rates following treatment for dependence are high (one study suggesting 36% under 6 months and a further 15% between 7-19 months). Anecdotal evidence in areas with high METH use suggests significant drug-related death rates, either direct (related to toxicity) or more often indirect (eg, road traffic accidents, homicide, suicide).
Efforts in North America have centred around education (including high-profile, 'shock' advertisements), targeted interventions to those considered high-risk (eg, pregnant women users) and law enforcement strategies such as limiting the availability of precursor substances - for example, pseudoephedrine (found in cold remedies and decongestants). This has limited success at the expense of limiting access to the public to effective medicines.
Further reading and references
Drugfucked; Terrence Higgins Trust
Schifano F, Corkery JM, Cuffolo G; Smokable ("ice", "crystal meth") and non smokable amphetamine-type stimulants: clinical pharmacological and epidemiological issues, with special reference to the UK. Ann Ist Super Sanita. 200743(1):110-5.
Winslow BT, Voorhees KI, Pehl KA; Methamphetamine abuse. Am Fam Physician. 2007 Oct 1576(8):1169-74.
Haile CN, Kosten TR, Kosten TA; Pharmacogenetic treatments for drug addiction: cocaine, amphetamine and methamphetamine. Am J Drug Alcohol Abuse. 200935(3):161-77.
Liu SW, Lien MH, Fenske NA; The effects of alcohol and drug abuse on the skin. Clin Dermatol. 2010 Jul-Aug28(4):391-9. doi: 10.1016/j.clindermatol.2010.03.024.
Wako E, LeDoux D, Mitsumori L, et al; The emerging epidemic of methamphetamine-induced aortic dissections. J Card Surg. 2007 Sep-Oct22(5):390-3.
Swanson SM, Sise CB, Sise MJ, et al; The scourge of methamphetamine: impact on a level I trauma center. J Trauma. 2007 Sep63(3):531-7.
Spann MD, McGwin G Jr, Kerby JD, et al; Characteristics of Burn Patients Injured in Methamphetamine Laboratory Explosions. J Burn Care Res. 2006 July/August27(4):496-501.
Brensilver M, Heinzerling KG, Shoptaw S; Pharmacotherapy of amphetamine-type stimulant dependence: an update. Drug Alcohol Rev. 2013 Sep32(5):449-60. doi: 10.1111/dar.12048. Epub 2013 Apr 25.
Lee NK, Rawson RA; A systematic review of cognitive and behavioural therapies for methamphetamine dependence. Drug Alcohol Rev. 2008 May27(3):309-17.
Roll JM, Petry NM, Stitzer ML, et al; Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry. 2006 Nov163(11):1993-9.
Benishek LA, Dugosh KL, Kirby KC, et al; Prize-based contingency management for the treatment of substance abusers: a meta-analysis. Addiction. 2014 Sep109(9):1426-36. doi: 10.1111/add.12589. Epub 2014 May 23.
Donovan DM, Wells EA; 'Tweaking 12-Step': the potential role of 12-Step self-help group involvement in methamphetamine recovery. Addiction. 2007 Apr102 Suppl 1:121-9.
Yeo KK, Wijetunga M, Ito H, et al; The association of methamphetamine use and cardiomyopathy in young patients. Am J Med. 2007 Feb120(2):165-71.
Chin KM, Channick RN, Rubin LJ; Is methamphetamine use associated with idiopathic pulmonary arterial hypertension? Chest. 2006 Dec130(6):1657-63.
Scott JC, Woods SP, Matt GE, et al; Neurocognitive effects of methamphetamine: a critical review and meta-analysis. Neuropsychol Rev. 2007 Sep17(3):275-97.
Shetty K; "Meth Mouth", Medical Journal of Australia, 2006 185 (5): 292
Saini T, Edwards PC, Kimmes NS, et al; Etiology of xerostomia and dental caries among methamphetamine abusers. Oral Health Prev Dent. 20053(3):189-95.
Smith LM, Lagasse LL, Derauf C, et al; Prenatal methamphetamine use and neonatal neurobehavioral outcome. Neurotoxicol Teratol. 2008 Jan-Feb30(1):20-8. Epub 2007 Oct 3.
Smith LM, LaGasse LL, Derauf C, et al; The infant development, environment, and lifestyle study: effects of prenatal methamphetamine exposure, polydrug exposure, and poverty on intrauterine growth. Pediatrics. 2006 Sep118(3):1149-56.
Garofalo R, Mustanski BS, McKirnan DJ, et al; Methamphetamine and young men who have sex with men: understanding patterns and correlates of use and the association with HIV-related sexual risk. Arch Pediatr Adolesc Med. 2007 Jun161(6):591-6.
Hillhouse MP, Marinelli-Casey P, Gonzales R, et al; Predicting in-treatment performance and post-treatment outcomes in methamphetamine users. Addiction. 2007 Apr102 Suppl 1:84-95.
Eccles R; Substitution of phenylephrine for pseudoephedrine as a nasal decongestant. An illogical way to control methamphetamine abuse. Br J Clin Pharmacol. 2007 Jan63(1):10-4. Epub 2006 Nov 20.