‘We're a meth city, not an opioid city” is what I tell new residency grads looking for a job in San Francisco. I read about how opioids have decimated cities and towns, especially in the Midwest and on the East Coast, particularly in the Rust Belt, but I don't see it much. News anchors announce that a small town in Ohio or Pennsylvania had 11 opioid overdoses in one night, and I can't imagine it because I haven't even seen 11 opioid overdoses in one year where I practice. But 11 patients with acute or chronic sequelae of methamphetamine? That seems like my normal night shift.
Opioids have rightfully received a lot of attention: The health care system deserves most, if not all, of the blame. The number of deaths from opioids and overdoses is difficult to fathom, and the hundreds of thousands of overdoses managed by police, firefighters, paramedics, EMTs, EPs, and now friends and family members, thanks to intranasal naloxone, are staggering.
It is an absolute public health disaster. We prescribed too many opioids, patients became dependent, and heroin made a comeback, especially as people started to crack down on the Norcos and Percocets. Fentanyl became even easier to produce at scale, and its potency makes it (and now acetyl fentanyl and other synthetics) economically sound to manufacture abroad, ship to the United States, dilute here, and sell on the streets. (Who cares if half of your postmarked fentanyl gets seized when it's so potent and you can easily dilute a pound of it for millions of dollars?)
According to data from government agencies like the Drug Enforcement Administration, Centers for Disease Control and Prevention, and others, meth use is back after previously reaching a nadir in the late 2000s when pseudoephedrine restrictions became common. If you're in western or southwestern United States like me, you might find articles warning that meth is on the rise laughable like I do because it never left!
And over the past 11 or so years, I've seen several disturbing trends:
- Methamphetamine use and addiction are really tough to treat. There's no suboxone for meth, no partial agonists that help people get clean.
- Methamphetamine use leads to major psychologic sequelae. Addiction of all types runs along with mental health issues, but meth seems to permanently affect the brain. One study of chronic methamphetamine users found that more than a third had psychosis or schizophrenia syndromes, and many also had depression or bipolar or anxiety disorders. (Front Psychiatry. 2018;9:551; http://bit.ly/2CMfscJ.) Those of us who work in meth cities know this quite well. The majority of my patients with mental health emergencies are intoxicated with or are prior users of methamphetamine, and most patients with severe psychiatric symptoms like psychosis, hallucinations, and paranoia have had a prior run-in with meth.
- Methamphetamine does not kill people the way that opioids do, through overdose, nor as easily. Sadly, a whole cohort of opioid-addicted patients have died, while meth users have become chronically ill with the physical, mental, and social sequelae of chronic meth use. That said, deaths from methamphetamine use are also on the rise, tripling since 2011. (NIDA. January 2019; http://bit.ly/34RTvVY.)
Most disturbing, however, is the crossover I'm now seeing. Active and former opioid users are now starting to use meth as well, with several papers in the substance use literature referring to this as the new twin epidemic. Opioid use is starting to fall in some parts of the country, but methamphetamine use is rising, especially among current or former opioid users. It also looks like some methamphetamine users are starting to use opioids as well.
Fentanyl and its synthetic cousins now seem so cheap that they seem to be cross-contaminating other drugs too. In fact, all of the opioid overdose patients I've seen in the past three months (three total) have been attempting to use a different drug (cocaine, cocaine, meth) and have been sold fentanyl by a “friend of a friend” or “a guy in the club.” Intending to get high on meth or cocaine can easily kill you from opioid overdose too.
I'm proud of our specialty for its rallying cry to make changes in the larger health care system to address opioid overdoses, but sadly, our work will never be done. I worry that even if the opioid epidemic finally ends, we'll need to advocate for treatment protocols and a new and better way to manage our patients with meth-induced psychiatric illness. San Francisco recently announced plans to open a meth sobering center, a place to stabilize patients with meth-induced psychosis and provide mental health services outside of the emergency department.
Thank you to Eric Funk, MD, for the inspiration for this column on Twitter. (http://bit.ly/2NC0wUO.) He hypothesized that meth is destroying communities 10 times worse than heroin, and I worry he may be right.
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Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.