State of the Evidence Review on Best Practices in the Prevention, Treatment and Healing of Methamphetamine Use in Youth Final Report Submitted to Alberta Centre for Child, Family, and Community Research Prepared by Alberta Research Centre for Child Health Evidence August 2006 Final Report to Alberta Centre for Child, Family, and Community Research State of the Evidence Review on Best Practices in the Prevention, Treatment and Healing of Methamphetamine Use in Youth August 31, 2006 Partner: Alberta Research Centre for Child Health Evidence, University of Alberta Research Team: Kelly Russell, Carol Friesen, Carlynne Greidanus, Tamara Durec, Kathleen O’Gorman, Yuanyuan Liang, Donna M Dryden, Terry P Klassen (Principal Investigator) Steering Committee: Yvonne Allan (Rural Alberta/Parent Representative), Kathy Collins (Alberta Solicitor General), David Cook (Pharmacology, University of Alberta), Pat Knoll (Law, University of Calgary), Marilyn Mitchell (AADAC), Harold Trupish (RCMP), Cam Wild (Addiction Research, University of Alberta), Wadieh Yacoub (Health Canada/First Nations) For further information please contact: Dr. Terry P Klassen Professor of Pediatrics and Chair Department of Pediatrics University of Alberta Aberhart Centre One, Room 8213 11408 University Avenue Edmonton, Alberta T6G 2J3 CANADA email: [email protected] phone: 780-407-7084 fax: 780-407-8538 State of the Evidence Review on Risk Factors, Policy, Prevention, Treatment and Healing of Methamphetamine Use in Youth Executive Summary Introduction Methamphetamine (MA), also known as crystal meth, crank, ice, speed and jib, is a potent stimulant that acts on the central nervous system. It is easy to produce using readily available ingredients and equipment. MA produces sensations of euphoria, lowered inhibitions, feelings of invincibleness, heightened sexual experiences, and hyperactivity resulting in increased energy for extended periods of time. MA can be addictive and withdrawal symptoms include depression, exhaustion, headaches, irritability, reduced concentration, and a craving for more MA. Long-term use of MA is associated with neurotoxicity and neurodegeneration. It is difficult to determine the true prevalence of MA use because of different definitions of MA, the contamination of MA and other drugs, and the tendency of MA users to be polydrug users. In Alberta, a school-based survey of youth enrolled in Grades 7-12 found that 2.4% of respondents reported using MA (speed) and 1.4% reported using the crystalline form of MA. In Vancouver, 71% of street youth aged 14-30 years reported using amphetamine-type stimulants. The objectives of this review were to: 1) Identify factors at the individual, family, and community level that influence the likelihood of MA use among children and youth; 2) Describe best practices in legislation and policy targeted to eliminate the production and supply of MA; 3) Identify best practices aimed at the individual, family, and community level to reduce exposure to and prevent the use of MA; 4) Identify best practices targeted at the individual, family, and community level that influence the likelihood of recovery and healing among children, youth, and families. Methods We conducted a comprehensive search of electronic databases, grey literature, and key journals and conferences. We developed a list of inclusion and exclusion criteria for each objective; decisions to include studies were made independently by two reviewers with disagreements resolved through consensus. For Objectives 1 and 3, we considered experimental and observational studies with children ≤18 years; for Objective 2 (legislation), we considered experimental and observational studies for all age groups. We excluded studies that did not include a comparison group or intervention. For Objective 4 (treatment), we considered experimental studies for all age groups. For each included study, we extracted information on study design, study population, and details of interventions and outcomes. We assessed the quality of studies and graded the strength of the body of evidence for each outcome. For each objective, we performed a narrative synthesis. Standard meta-analytical techniques were employed where the evidence permitted. Results Risk Factors. Five studies assessed risk factors associated with MA use among MA-users and low-risk youth (did not use illicit drugs). Factors associated with MA use included history of alcohol use, history of heroin/opiate use, smoking, family history of drug use, fewer years of education, any psychiatric disorder, adjustment disorder, conduct disorder, ADHD, State of the Evidence Review on Crystal Methamphetamine Executive Summary homosexuality/bisexuality, having peers who use or provide MA, and engaging in unprotected sex. Seven studies examined risk factors associated with MA among high-risk youth (i.e., used illicit drugs other than MA or in juvenile detention). Factors associated with MA use included female sex, family history of crime, alcohol abuse or drug use, psychiatric treatment, >2 admissions to a juvenile home, and a history of violence. Strict parental monitoring was protective. Policy. Two studies examined the impact of four US federal MA precursor regulations – three targeted large-scale MA producers; one targeted small-scale producers. MA-related hospital admissions decreased in Arizona and Nevada after the implementation of two of the regulations targeting large-scale producers. In California, MA-related hospital admissions and arrests decreased following implementation of all of the regulations targeting large-scale producers. The regulation targeting small-scale producers had little or no effect on hospital admissions or arrests. In all three states, hospital admissions and arrests began to rise within 6 months to 2 years of implementation of the regulations. Prevention. One study evaluated the effectiveness of 30 drug prevention public service announcements (PSA). Four PSAs were specific to MA and focused on the negative outcomes associated with MA use. For comparison purposes, children also viewed a video about news production that included vague references to drugs. All four MA videos were significantly more effective in increasing knowledge about MA than the comparison video. Treatment. Six studies compared five different anti-depressants (isradipine, amlodipine, bupropion, paroxetine, and selegiline) to placebo for treating various MA-related symptoms. Isradipine was not effective in treating the MA-related decreases in cognitive performance. Bupropion reduced MA cravings and cravings for any drug or high; it also reduced MA- associated increases in heart rate. Paroxetine may reduce MA craving; however, the high attrition rate for participants in this study precluded formal statistical analysis. The remaining drugs were not significantly different than placebo at improving MA-related outcomes or symptoms. Five studies compared a combination pharmacological and psychological intervention to placebo/no treatment and a psychological intervention: 1) dexamphetamine and weekly counselling vs. placebo and weekly counselling; 2) gabapentin and relapse prevention vs. baclofen and relapse prevention vs. placebo and relapse prevention; 3) buproprion and Matrix model vs. placebo and Matrix model; 4) high-dose imipramine and group counselling vs. low- dose imipramine and group counselling; and 5) sertaline and contingency management vs. sertaline (alone) vs. contingency management and placebo vs. placebo (alone). Overall, the addition of a pharmacological intervention to a psychological intervention did not improve any MA-related outcomes. However, in a subgroup of low to moderate MA users, the combination of Matrix model and bupropion significantly reduced MA use. Four studies assessed the effectiveness of psychological therapy in the treatment of MA- related symptoms. Among gay and bisexual men, a combination of contingency management (CM) and relapse prevention had a greater impact on MA use than CM alone. In the same population, both CM alone and the combination of CM and cognitive behaviour therapy (CBT) were more effective than CBT alone. When compared to “usual treatment”, the Matrix model is a promising intervention for the treatment of MA use among young adults. A combination of the Matrix model and CM was effective in initiating MA abstinence and State of the Evidence Review on Crystal Methamphetamine Executive Summary reducing relapse. Different reinforcement schedules for CM showed various levels of effectiveness. One study assessed the effectiveness of acupuncture when added to the regular treatment protocol. Those who received acupuncture were more likely to stay in their treatment program than those who did not receive acupuncture. Summary • There is limited high-quality evidence to guide policy-makers in developing policies related to MA prevention, treatment, harm reduction, or enforcement. • Precursor legislation targeted at large-scale producers reduced MA-related arrests and hospitalizations in the short term; however, the impact appears to dissipate over time. • No studies assessed the effectiveness of prevention programs targeted at MA use. • No studies evaluated the effectiveness of treatment programs specifically for youth. • Pharmacological interventions for adults do not reduce MA use or depressive symptoms. Furthermore, adding drugs to a psychological intervention does not improve the effectiveness of the intervention. • Contingency management may be effective in reducing MA use among