Case 1: The need for speed

A 16-year-old girl is referred to your office by her school guidance counsellor. The patient has complained of being in a depressed mood for the past three to four weeks, interspersed with periods of irritability. She has been unable to sleep at night despite feeling excessively fatigued. She has denied any suicidal behaviour, although her teachers note increased absenteeism and feel she has become more isolated in class. She has lost weight in recent weeks, and attributes this to a decreased appetite. The counsellor notes that a telephone call to her parents revealed that she has been spending more and more time outside of the home. They too have become quite concerned with her behaviour and suspect she is using drugs. She did not return home from school the previous Friday but, instead, arrived home on Sunday morning looking quite disheveled and acting ‘wired'. She has denied drug use previously, but has admitted to regular alcohol use with friends. You meet with the teenager who confirms the above information. A psychosocial screening (obtained using the HEADSS interviewing strategy) reveals that she has recently started dating a new boy at school. She admits to feeling depressed and being unable to sleep, but cannot identify any obvious stressor or trigger. Further questioning reveals that her boyfriend has a ‘drug problem’, and she eventually discloses information that provides an explanation for the recent changes in her medical and psychological status. The patient admitted to regular use of ‘crystal meth’ in the weeks leading up to her presentation. She acknowledged that the timing of her drug use correlated with her recent change in mood. Crystal meth is the crystalline form of methampheta-mine. It is a highly potent, inexpensive and addictive stimulant that is typically manufactured in clandestine laboratories. Methamphetamine also commonly goes by the street names speed, ice, tweak, tina and crank. It can be taken orally, snorted, smoked or injected with onset of action occurring immediately (in the case of smoking or injection), or taking as long as 20 min to 30 min when ingested orally (1). The mechanism of action involves blockade of presynaptic reuptake and displacement of stores of various neurotransmitters, including dopamine (most pronounced), noradrenaline and serotonin, resulting in hyperstimulation of postsynaptic neurons with secondary excitatory effects (2). The first noted effect is usually a characteristic ‘rush’, which is believed to be the result of rapid dopamine release (1). The drug's extended half-life allows a sustained euphoria, or ‘high’, often followed by a profound crash, which leaves the user desperate to regain the high (2). This predisposes to runs or binges, during which the user may go for days to weeks without sleeping and with minimal nutrition, often resulting in weight loss. Methamphetamine abuse has the potential for both acute and chronic health consequences. Acute effects of methamphetamine use parallel those of other stimulants and include euphoria, increased energy, heightened alertness, tachycardia, increased blood pressure, hyperthermia, increased libido, as well as central nervous system effects (eg, insomnia, anxiety, inability to focus, tremors, hallucinations and paranoia) (2). The addictive nature of methamphetamine makes long-term abuse of the drug common. Chronic abuse can result in permanent central nervous system consequences, including confused states, paranoia, hallucinations (auditory and tactile are most common), psychosis and memory loss. Patients are also at risk for the development of cardiomyopathies, stroke, dermatological lesions due to injection site infection or from picking at the skin, poor dentition (meth mouth) and weight loss (2). From a psychosocial standpoint, metham-phetamine abuse may also increase the risk of other adverse health consequences, including depression, violent behaviour, blood-borne viruses (HIV, hepatitis B and C) from shared injection equipment and secondarily acquired sexually transmitted infections (2). The United Nations Office on Drugs and Crime estimated that close to 25 million people worldwide consumed amphetamines in 2005 (two-thirds of whom consumed methamphetamine), surpassing both cocaine and heroin use (3). Globally, amphetamine-type stimulant production appears to have stabilized in recent years, a trend, at least partially influenced by increased monitoring and control measures, although there are suggestions that the number of production laboratories are on the rise (3). The Canadian Addiction Survey 2004 (4) showed that 6.4% of Canadians reported using speed at least once in their lifetime, with less than 1% having used it in the preceding 12 months. This survey, however, did not include high-risk groups, such as street youth and Aboriginal communities in remote areas. Anecdotal information, such as reports of increased hospital admissions, police contacts, numbers of individuals seeking treatment and clandestine laboratories producing methamphetamine point to an increased prevalence of methamphetamine use in the Western provinces (5). Treatment of methamphetamine ingestion is primarily supportive. Routine laboratory workup should be performed in all patients with methamphetamine intoxication including measurement of electrolytes and creatine kinase levels, to rule out rhabdomyolysis. Patients with acute mood and other psychiatric disturbances may initially be managed nonpharmacologically by decreasing environmental stimuli; although agitated patients may require treatment with a benzodiazepine or an antipsychotic agent (2). Once stable, adolescent patients should be interviewed, assessed and screened (when appropriate) for other high-risk activity. The HEADSS interviewing strategy can facilitate this process because it involves a graduated exploration of psychosocial parameters aimed at identifying specific risk and protective factors in a nonthreatening manner (6). All at-risk youth should be screened for sexually transmitted or injection-acquired infections. Referrals to substance abuse counsellors and other appropriate programs should also be encouraged in cases of ongoing suspected substance abuse. In the above case, the patient's recent mood disturbance, history of weight loss and sleep disturbance were each believed to be a consequence of her stimulant abuse. The patient was motivated to change her pattern of use and was subsequently referred to a substance abuse program that offered intensive day program support in both an individual and group setting. Adolescent patients presenting with depression should undergo a complete history and physical examination, with specific attention paid to psychosocial functioning, substance use history, and recent behavioural changes and/or stressors. Methamphetamine is an extremely potent stimulant with an extremely high addictive potential that can cause significant short- and long-term morbidity. Patients who present with amphetamine-type stimulant toxicity should be monitored closely, both from a medical (specific attention paid to vital signs and biochemical parameters) and a psychiatric standpoint (agitation and aggression should be treated as needed).

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