Methamphetamine has devastated the gay community for decades. A new treatment offers hope.

“Do you want to be a 50-year-old meth addict?”

For Roger, the enormity of what he had lost during his nearly two decades of intermittent methamphetamine use, and what he had the most to lose, hit hard when a man he was dating asked him that question.

Roger, who was 47 at the time, had already suffered a major ischemic stroke thanks to methamphetamine, the powerfully addictive stimulant that had long gripped his life.

So when Roger, who is from Dallas and asked not to have his last name published for fear that the stigma of methamphetamine could damage his career, he learned that a study was looking for people like him to test a treatment for use disorder. of methamphetamine, jumped on the opportunity.

“I woke up one day and had no cravings,” Roger, now 50, recalled of the life-changing change he experienced just weeks after the clinical trial.

Much like the National Institute on Drug Abuse, or NIDA, has released a report detailing the rising rate of methamphetamine-related overdose deaths in the U.S., a national research team has reached a milestone by developing his recent double-blind, placebo-controlled clinical trial. has established that it is the first safe and effective drug-based treatment for stimulant addiction, often ruinous.

While the treatment success rate, 14 percent, is modest and important questions remain about its potential for real-world use, the study’s publication in The New England Journal of Medicine last month has raised hopes in the field of addiction that further research could be based on their findings. In particular, researchers hope that the benefits of the two-drug combination of daily bupropion treatment (the antidepressant Wellbutrin) and three-week injections of naltrexone (used to treat alcohol and opioid use disorder) may be magnified. if combined with evidence-based psychosocial support, such as cognitive behavioral therapy.

The study’s lead author, Dr. Madhukar Trivedi, a psychiatrist at the University of Texas Southwestern Medical Center in Dallas, described methamphetamine addiction as “a very serious disease that affects health, employment, quality of life, marriage and the person’s self-esteem – and it’s fatal. “

“For those people who benefit from this treatment, it is highly likely that it will have a positive impact on their lives as well as on society,” Trivedi said.

Methadone and buprenorphine have long been used to treat opioid use disorder, though sadly underused. But when it comes to treating people whose neural reward circuits have been hijacked by methamphetamine, there is no comparable approved prescription therapy. That gaping hole in addiction medicine has left the country uniquely prepared to deal with a burgeoning methamphetamine use crisis that, as the opioid epidemic becomes concentrated and funded, has taken small towns and rural communities in particular by surprise. .

‘The next drug epidemic’

The estimated national population of people with methamphetamine use disorder increased by more than 45 percent from 2016 to 2018, from 684,000 to more than 1 million, according to the Substance Abuse and Mental Health Services Administration. NIDA researchers estimated in a letter published in JAMA Psychiatry last month that from 2012 to 2018, the national methamphetamine-related overdose death rate increased nearly fivefold.

“We have to find something to help these people, because methamphetamine is becoming the next drug epidemic,” said Dr. Michael Mancino, a psychiatrist and addiction specialist at the University of Arkansas for Medical Sciences.

Once rebuffed by major government efforts to crack down on domestic methamphetamine lab production in the mid-2000s, the national methamphetamine scourge is on the rise today, fueled by cheap imports that are funneled from Mexico, the Administration has determined. of Drug Control. NIDA Director Dr. Nora D. Volkow said that a substantial part of the growing methamphetamine use appears to be among people who also use drugs such as heroin or fentanyl, who may seek stimulant drugs, a category that includes the cocaine, to balance opioids. depressive effects, or who can take them when they cannot access opioids.

“It’s a major problem that makes the opioid crisis so much more deadly than before,” Volkow said of the convergence of drug epidemics.

In 2019, about 16,000 of the more than 70,000 estimated overdose deaths in the US involved methamphetamine, and about half of those deaths also included opioids as a factor, according to the Centers for Disease Control and Prevention.

The national drug crisis has only worsened during the coronavirus pandemic. Research published in JAMA in September documented an increase after the first wave of government shutdowns in methamphetamine, cocaine, fentanyl and heroin use among people diagnosed with or at risk of substance use disorders.

Methamphetamine and the gay community

Methamphetamine has thrown a heavy cloud over the gay community in particular for decades. The National Survey on Drug Use and Health estimated that in 2015, the prevalence of methamphetamine use last year was more than four times higher among gay men compared to heterosexual men: 4.1 percent versus 0.9 percent. Research has found that the drug is closely related to sexual risk-taking among men who have sex with men and that it has been an important factor in the transmission of HIV among this population.

In November, researchers from the City University of New York published the findings in the Journal of Acquired Immune Deficiency Syndrome from an ongoing study of nearly 5,000 sexual and gender minorities who have sex with men and are considered to be at risk for HIV infection. . The study authors found that participants’ chances of contracting the virus during the study were four times higher among those who reported recent methamphetamine use and seven times higher among those who reported persistent use of the drug.

Research also suggests that for people living with HIV, like Roger, methamphetamine exacerbates the virus’ damage to the body.

Roger, who said he started taking methamphetamine at gay “circuit” parties, said his use of the drug led him to stop going to the doctor and stop taking his HIV treatment a decade ago. His immune health plummeted, and while he’s been back on antiretrovirals since 2014, his T-cell count has yet to return to the completely healthy range.

‘A tremendous sign of hope’

The new methamphetamine treatment study was funded by NIDA, a division of the National Institutes of Health, and was conducted within the network of clinical trials overseen by the institute. The study, which ran from 2017 to 2019, enrolled 403 adults who had used methamphetamine in at least 18 of the previous 30 days and expressed a desire to reduce or quit smoking.

The study authors defined the regimen as effective if at least three-quarters of a participant’s urine tests for methamphetamine were negative during the last two weeks of each six-week phase of the trial.

To reinforce adherence to the daily pill regimen, participants were paid $ 3 each time they logged into a video app and recorded themselves taking their daily bupropion. Study co-authors said in interviews that the method was likely a determining factor in the success of the study, considering that previous studies reported lower adherence to bupropion and it may be difficult to replicate in real-world practice.

Overall, 13.6 percent of the treatment group met the definition of response, compared with 2.5 percent of the placebo group.

“He had a pipe in the house, he had methamphetamine in the house, and after two weeks he wasn’t even looking at it,” Roger recalled of how well the treatment worked for him. “I have been a daily user for years and years and years.”

Trivedi called the findings “very definitive” and emphasized that the treatment multiplied the success by five.

Mancino was more moderate in his assessment, saying, “It’s certainly a start, but the important thing is that we don’t jump to conclusions and say, ‘Oh, here’s the answer.”

Linda Dwoskin, a professor of pharmacy education at the University of Kentucky College of Pharmacy who is researching a novel compound intended to mitigate methamphetamine-taking and seeking behaviors, called the results a “tremendous sign of hope” for families who they have been devastated by the use of the drug by their loved ones.

Trivedi hopes that a future study that includes people who use methamphetamine less than daily will yield a greater benefit. For now, Volkow said, the goal is to work with the Food and Drug Administration to design a trial that would seek to replicate the results of the recent study while providing the FDA with data to consider approval of the bupropion-naltrexone regimen for the disorder. use of methamphetamine.

Dr. W. Brooks Gentry, medical director of InterveXion Therapeutics in Little Rock, Arkansas, which is investigating a monoclonal antibody designed to bind methamphetamine and mitigate its effects, praised the study’s finding that the treatment was also associated with a overall reduction in the percentage of positive methamphetamine urine samples.

Additionally, those who received bupropion and naltrexone reported fewer cravings for methamphetamine and improvements in their quality of life.

“If you can get some kind of reduction and you can make people’s lives better, that should be considered a success,” Gentry said.

Jessica Hulsey, founder and CEO of Addiction Policy Forum, a nonprofit organization that advocates for people with substance use disorders and their families, said the study sends a powerful message to researchers and drug companies that “This is an area where drug development is possible.”

Trivedi and his colleagues speculated that bupropion, which acts on the neurotransmitters dopamine and norepinephrine, may have cushioned the emotional and neurological hit of methamphetamine withdrawal. And theoretically, naltrexone reduced the euphoric effects and cravings for methamphetamine.

However, Dr. Melissa Zook, a family and addiction physician in London, Kentucky, said that the use of naltrexone would be problematic in her practice, because it cannot be combined with buprenorphine. All of their patients who report taking methamphetamine also use opioids, and they have a strong preference for buprenorphine over naltrexone to treat opioid use disorder, so treating patients with both substance use disorders would present a contraindication.

Also, the new study was unable to determine how the bupropion-naltrexone regimen might benefit people for periods longer than six to 12 weeks.

But three years after the trial, Roger has been in good health, became a vegetarian, and got a coach. While still taking bupropion, last summer she stopped taking the off-label naltrexone her doctor had prescribed after the study ended.

“Methamphetamine,” Roger said, “is not part of my plan.”

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