Treating Substance Use Disorder: Stimulants & How to Get Addiction Histories

Psych

Aug 8

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Show notes:

I’m THRILLED to share a second episode from our last guest Shelby Pope, an addiction medicine nurse practitioner who started out in primary care and LOVES her work. First of all, Shelby is brilliantly smart, but second of all, she imparted SO much wisdom in our last episode together, I just knew I needed to bring her back to talk more about addiction medicine essentials.

I wanted to acknowledge how challenging and scary addiction can feel to new nurse practitioners (or even experienced NPs when they don’t feel confident in their knowledge 🙋🏻). So we got into how to talk to patients about addiction in a way that feels accessible and less intimidating.

We also covered the essentials of stimulant use disorders - how to assess them, manage them, and educate & support patients.

This is a must-listen - SO many patients in our practices have addictions, and there’s so much bias against patients who have addictions.

We have so much power to contribute to patients’ lives and reduce morbidity and mortality, and it’s way easier than it seems.

Key Takeaways From This Episode:

Open and non-judgmental conversations are essential when discussing substance use with patients.
Screening practices, such as using screeners like PHQ-2, SBIRT, and DAST, can help identify substance misuse or struggles.
Taking a comprehensive history of substance use, including the type, amount, frequency, and motivation, is crucial for providing appropriate care.
Healthcare providers should be aware of the different routes of administration and the potential risks associated with each.
Stimulant use disorder, particularly cocaine and methamphetamine use, can have significant adverse effects and poor outcomes. Cocaine and methamphetamine are both monoamine neurotransmitter reuptake inhibitors, increasing serotonin, norepinephrine, and dopamine levels in the brain.
There is a withdrawal syndrome associated with stimulant use disorder, characterized by depression, fatigue, and sleep disturbances.
In managing patients with stimulant use disorder, primary care providers should consider triage based on severity and acuity, and refer patients to appropriate resources such as rehab or the ER.
Psychosocial interventions, such as cognitive behavioral therapy and contingency management, are the mainstay of treatment for stimulant use disorder.
Off-label pharmacologic treatments for stimulant use disorder include mirtazapine, bupropion, injectable naltrexone, topiramate, and psychostimulants.
It is important for healthcare providers to be aware of state regulations and their own comfort level in prescribing off-label medications for stimulant use disorder.

Resources mentioned in this episode:

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Liz Rohr 00:00
Liz, Hey there. Welcome to the real world. NP, Podcast. I'm Liz Rohr family nurse practitioner, educator and founder of real world NP, an educational company for nurse practitioners in primary care. I'm on a mission to equip and guide new nurse practitioners so that they can feel confident, capable and take the best care of their patients. If you're looking for clinical pearls and practice tips without the fluff, you're in the right place, make sure you subscribe and leave a review so you won't miss an episode, plus you'll find links to all the episodes with extra goodies over at Real WorldNP.com/podcast,
Liz Rohr 00:47
hey there. So I have another interview for you. So I'm having Shelby Pope again on the podcast. She is a family nurse practitioner who is now dual certified as a psychiatric nurse practitioner who specializes in addiction medicine and formerly used to work in primary care. So our last episode together, if you missed it, was about substance use disorder, specifically opiates use disorder, like talking about triage and management and things like that. It was really fantastic episode, and in this episode, we wanted to focus more specifically on, first, the topic of how to get a history when it comes to substance use disorder, because I know there's a lot of sticking points for people of feeling like uncomfortable and not sure how to ask and things like that. So we kind of walk you through that piece. And then also, after that, we touch on ambulance use disorder, specifically, different types assessment, what are the treatment options and things like that. So it's a really wonderful episode again. I hope I get to have her on again. Actually, she is. She just has such a wealth of knowledge. So I hope you enjoy this interview with myself and Shelby Pope. Thank you so much for being here again. I'm so excited. I guess maybe do like a little intro, because I'll link back to the previous episodes. Yeah, episode that we did together, but just like a brief intro, if somebody hasn't watched or listened to the previous episode that we did, who are you? I'm
Shelby Pope 02:17
Shelby. I am a family nurse practitioner, and actually just passed my psych and P Boards last week. So dual certified. I am a DNP. I've been a nurse practitioner for going on four years now. I've done rural primary care, fell in love with treating substance use disorders, and ended up getting recruited to work at the clinic that I currently work at, which we primarily do Addiction Medicine and quite a bit of behavioral health, because those you know kind of align with one another, and we sprinkle in some primary care services. So yeah,
Liz Rohr 02:49
that beautiful. And so I loved our last recording. And so this time, what we're going to focus on is talking about getting a history for substances that people use and and maybe into. Like, I can also share a little bit too, because I kind of, like, threw this at you last minute, but kind of like, the screening practices and like, because you've worked in both primary care and addiction medicine, so it's like, maybe just like, I think the thing that I'm really trying to get at with this piece of the conversation is that so many people feel really uncomfortable either asking the questions in the first place, or they don't know, like, what to say or how to say it, or they're worried about, like, offending somebody, or how do I like, know what to ask for, if I like, don't know what the different drug names are that are out there, the different options, right? So I think that's like, the main focus of that. And then after that, we'll transition into talking about stimulant use disorder, which I'm very, I'm very excited to hear, but I'm excited to hear about all of it, but especially that, because I don't feel comfortable at
Shelby Pope 03:46
all with that. So no, I'm excited. I'm definitely excited about it. Yeah, so as far as history goes, Yeah, it's so essential. And I think I mentioned before the camera like, I think I take that a little bit for granted, so I'm gonna let you kind of lead the way, and I'll just kind of tell you what I do and how it goes.
Liz Rohr 04:01
Okay, perfect. Yeah. So when you, when you So, for example, like, I guess, and maybe you can also pull back on your experience from primary care. So like, for example, like, if I, if you have a patient that's there, and somebody comes in and they're like, so, okay, so here's how, here's how it worked in primary care before, depending on the clinic, they would do, like, a screener. PHQ two. Sorry, not PHQ two. SBIRT screening. And the DAST, I think, is the other one that I'm thinking of. So the DAST is like screening for drug misuse or struggles with drugs, and then the SBIRT was more specific to alcohol use disorder. And so typically, that's what we would see, is like, hopefully we were screening people as we, you know, as we ideally screen them at the frequency that we want to. We don't always get in that, into that screening. But like, I think that there's kind of like two entry points. And one is, you have some sort of screener where you, like, look at the answers and then you kind of ask them, versus, like, they're a brand new patient, they come in and you're kind of like, you know, do you do use alcohol? Yeah. Do you use smoke? Do you use drugs? Like, I think that's where people go. But like, Do you have any thoughts about, especially from your experience, going from primary care to into addiction medicine? Like, if they're there, they're already, if they're in addiction medicine already, they're like, ready an open platform, yeah. Like, you're already talking about it. But like, if you're in thinking about primary care, especially, I'm really, I think you have such a beautiful vantage point to share with people, because you're on the other side of like, somebody is already recognizing that they are using substances and it's getting in the way of their livelihood and their quality of life. And then you have people in primary care where they're like, either there could be in any spectrum of situation where it's they're struggling with alcohol use disorder or stimulant use disorder, and they don't like, haven't talked to any providers yet. Or they like, actively use, and they like, like, we just need to know these things. And I think that's like, what you're saying before the recording started, is like, I think we make assumptions about people of whether, like, oh, like, they're not, they're not doing this or not, they're not using this or whatever. Like, you just have no idea, behind closed doors. If somebody is totally and like, you can make any old assumption, you can learn some wild things that you never expected. And so it's like, I guess maybe that's a place to start. Is like, if you had a brand new patient, thinking back to your time in primary care, because I'm sure it's influenced now by how you ask questions in addiction medicine, like, what does that look like for you if somebody comes in say you haven't done a screener on them, but it's just like, do you like? How does that go for you? Your brand new patient, physical, something like that.
Shelby Pope 06:26
I think so. In primary care, the the screeners were definitely essential, specifically because of the limited time frame. So depending on the workflow and how, how the intro into clinic kind of was set up. But for me, when I was working in primary care, it wasn't uncommon to have kind of a set intake form that I could go through and look at and kind of highlight, Oh, these are the red flags, like this person reported problematic drinking or something, so that obviously would would start the conversation. But there's always those outliers, right, like of so the conversation needs to be had, especially on an initial appointment. And for me, anecdotal experience was I was a like, brand new baby nurse practitioner. I think, I think maybe three months into the thing, like I barely knew anything, I had a mid 30 year old male that had advanced cardiomyopathy, had never seen a primary care provider? Really, really sweet guy, and he was there with a significant other, not the like you said before, like you cannot judge a book by the by its cover, right? Like you just never know, and never in a million years, would I have expected that he had an underlying substance use disorder, but with the advanced cardiomyopathy, like, things were not adding up, and it was, and he honestly ended up passing away from the cardiomyopathy and complications and but during that initial visit, we were going through things, and his significant significant other was like, going through this, like, whole Deal, like, I've put them on a plant based diet. We are exercising. We're only drinking water. I've cut out sugar. And I'm like, God, Lee, this is just, this is strange. You know that you the way, like, and I was looking through the hospital records, and nothing was really adding up. And I'm, like, any like, substance use at all? Like, like, stimulant specifically, oh yeah, we smoke meth. And I'm like, oh, okay, so I'm, I'm like, stoked that you're doing plant based exercise is wonderful, but maybe let's work on, on cutting back on the meth, because that's probably the catalyst to the cardiomyopathy. And she was like, Oh, you think so? And I'm like, this, oh, she
Liz Rohr 08:42
didn't know. She didn't know. And this didn't
Shelby Pope 08:45
even come up with cardiology. So I'm like, wow. So it was like, mind blowing to me. And that's really, that really started my interest. And because I had no idea, I'm like, What do you even offer somebody that is a daily meth user? Like, I have no I have absolutely no clue what I'm supposed to do here. So that really was kind of an awakening point for me of how it needs to be an open conversation with everyone, no matter how uncomfortable it is. I've seen people on all ends of the spectrum, especially in the setting, but even in primary care, CEOs of large corporations making multi million dollars a year, actively using substances, struggling with their use, going to rehab. And then I've also seen, you know, the opposite end of the spectrum, generational substance use. But I think across the board, the conversation needs to be had without a doubt. And I think just being open about it, most common screeners that you mentioned, a couple. There's also cage and audit. Those are a co
Liz Rohr 09:42
audit. That's what I was trying to remember. Things, yes,
Shelby Pope 09:45
those, those come up a lot, but I find anecdotally, in the in the primary care setting, it's wonderful, because for the most part, you can build a rapport, and you can have these conversation points multiple times. So even if. You suspect it, but you're uncomfortable initially, you can kind of build yourself up for the follow up, you know, like, obviously I would recommend discussing it each time, but if you don't have the confidence to pursue it, like, remind yourself, like this is for the greater good, like, I can have the conversation and then just bring it up next time. Be like, Hey, you know your vitals every time I see you, or, like, for alcohol specifically, or just a little bit concerning, like, you appear to be hypertensive. You're a little bit diaphoretic during the appointment. Heart rates high, you look uncomfortable. Some of these things could be signs of withdrawal from either opiates or alcohol. Or, you know, if you you appear agitated and really restless. Sometimes that's a side effect of stimulants. So I just kind of want to have that conversation, like, Do you struggle at all, or do you currently, actively use if you want to have a conversation about we can talk about options and a lot of time, especially in this setting, most people want help. So it's, yeah, it's an open platform. Most of my patients don't have any issues talking about it. But in primary care, I think just doing it, you just got to do it, yeah?
Liz Rohr 10:58
So I think, yeah. I think that's like, bottom line is just like, having those conversations and not making assumptions, like, I love that like, I hate that story, and I love that story as an illustrative point, because, like, what a tragedy,
Shelby Pope 11:10
right? But, yeah, I
Liz Rohr 11:11
think it's like, one of those things that goes under the radar of, like, how, how did this get missed by so many providers, you know? Like, that's just so heartbreaking. I think something. I guess thinking about some specifics of like, when I think about especially like, hopefully we're encouraging people to feel more confident managing addiction in house. But if we're going to be referring to addiction medicine, like, I want to make sure, as a primary care provider, I've provided an adequate enough history as much information as I can present to that person. And so if you're looking for like, in terms of next steps, of like, so say, I open the door with this patient and I'm like, you know, or like, on the desk or on like, any of those screeners, something came up like, what? Like, what substances are you using? Like, how does that conversation go? From there, it's like, what are they using? How much are they using? How frequently? Like, what are their what is, is that all the information, typically, are there other questions that you're asking about? Like, again, like, I don't feel like I had the fund of knowledge to know what all the different street street names are for different substances. So, like,
Shelby Pope 12:10
and I don't think, I don't think they expect that, you know, like, to be honest with you, I think we I would appear more foolish if I was, like, trying to be like, hey, throwing out all these different words. What about your ice, you know, like, I think there's a point where they, like, they know that I'm, like, very basic and I'm pretty lame, so I just call it for what it is, you know. And it's fine, totally. I have a great rapport with my patients, and they know that I'm dorky. So it's, I think I just have to accept it more than anything, and we laugh at each other, and it all works out. But you kind of hit the nail on the head, honestly, asking about I ask about everything. I ask about nicotine, I ask about caffeine, I ask about alcohol. I ask about stimulants, whether it be I mentioned caffeine, but like cocaine, methamphetamine, opiates, obviously, I ask when they started, and kind of what the catalyst to use was, Oh, that's interesting. Or for a lot of people in this setting, it specifically for opiates, that it was a lot of a lot of times prescribed pain medicine, and it just kind of spiraled out of control. For stimulants, I have a ton, a ton of patients that had ADHD in childhood or adolescence, and they aged out of their pediatrician, and they could not find a primary care provider that was willing to prescribe them Adderall. And for anyone listening to this that may struggle with ADHD not having
Liz Rohr 13:38
gonna say, not really functional without medication. And
Shelby Pope 13:41
it gets to a point where, like, people become desperate. And if you've ever been a place in a place of desperation, and if you're in the right setting around the right people or wrong people, and they say, Hey, this is a great replacement. Like, you can smoke a little meth, and you can focus and and then again, it spirals, you know. So it's in a lot of cases that I experience it seems like self treatment for lack of appropriate treatment for ADHD, which we can get into that here in a bit, anyways. And then there, a lot of it too is depending on the population of people. Sometimes it's just like an energy aspect. Like, people do too much. People need to pay the bills, and they can't do it all. People that some of my my gentlemen that work in really, really like labor intensive jobs, working 13, 14, 16 hour days, like they physically cannot keep up with that, and they have a household to support and to them, it's like, I'll, I would rather kill myself on this substance and do it from day, like, be able to do these things, then stop. And then I have other patients that who it's it literally is a survival thing, like people that are unsheltered or unhoused or housing vulnerable. I. Um, they flat out tell me like, Shelby, meth is not my drug of choice, but if I don't do it every night, someone's gonna stab me and rob me and take all my possessions in this world. And it's like, okay, well, um, let's work on your, uh, social determinants of health, you know, let's, let's start there and kind of, and kind of go down that route. Um, I don't like just, I
Liz Rohr 15:21
want to pause you for a sec. I love that again, like, I just, I love the specific anecdotes, because, I think especially for students, but even, like, experienced nurse practitioners, it's like, nice to see what happens kind of in the real world. But I think, like, especially, like, I think what popped in my mind as you were talking about, like, the history taking in your patients is like, there are people who don't want to stop, right? And it's for a variety of reasons that we could not imagine, right? And so I just love hearing you share that, because, again, horrible situation, but it's important to hear that. It's like, just because someone has substance use, like, what is that? I'm losing the name of it. But what is that, like, the motivation, like, where they are in that, like, motivation scale. It's like they're pre cognitive. It's
Shelby Pope 16:03
like contemplation, like pre contemplation, pre contemplation, action, yes, yes,
Liz Rohr 16:07
yes, totally, totally. And so like, there are people who are like, yeah, there's like, I have no interest of going down on that, because this is a literally survival thing. And so I think it's so I just want to put in there that I think it's so important for us, especially even if we feel like, so goofy, like doing this wrong, quote, unquote, of like, as long as we're trying, we're asking the questions we're like, coming from a non judgmental place of any answer is appropriate. Like, you need to manage your face now, your face responds right in terms of creating a psychologically safe space for somebody. But if you expect so many options, and you expect that that's also an option that, like, no, they don't want help right now, it's not, we're not judging them, we're not pushing them. We're like, how do we do some harm reduction to keep you as safe as possible? And how do we also help with the underlying reasons for the challenges, right? Like you said, the social determinants of health?
Shelby Pope 16:57
No, absolutely. And I think, I mean, you hit some really strong points, because this is not a space for our bias or our expectations. We can't help people that are dead. So we need to create a therapeutic space that allows individuals to feel safe and able to come back, come here, and be transparent about what they're using, why they're using, and all I tell people every day, all I'm doing is educating you on the tools that are available, and I want to give you access to them. I am not here to shove them down your throat. I am not here to force you, because more times than not, people that are forced to pursue sobriety. Oh, yeah, sobriety, yeah, absolutely. So that's I think the key is understanding the motivations and then understanding what all they use, because they're like specifically for stimulants, a lot of people will use opiates as a downer if they're too amped up. And honestly, a lot of the supply around this area, I'm in Oklahoma, around the Tulsa area, and it's not uncommon for us to see a contaminated supply with fentanyl. And there's different theories on that. Some people just say it's a dirty supply, or they got a dirty bag. But some there's some assumption that maybe fentanyl is actually being placed in the methamphetamine to create a higher physical dependence. And then then there's another argument that maybe the methamphetamine is getting placed in the fentanyl because it's killing everyone, and they need to amp it up a little bit. They need to not make that nod so hard. So it's kind of like so that's where the baseline urine drug screen is really beneficial. In my setting, which obviously I know in primary care, it was very rare we did a urine drug screen unless somebody was being prescribed something controlled. So that's where it's like essential that you have to have the open conversation. You have to ask specifics. And if people are guarded while open ended questions are, you know, obviously the most therapeutic, it's okay to ask specific, close ended questions if it gets the conversation going. So, yeah, do you use methamphetamine? Yeah, yes, or no. Like, yeah, it makes them less uncomfortable. And then, you know, you can kind of go that way, but yeah,
Liz Rohr 19:08
especially when you're volunteering it, or, like, how often do you use meth? You know, it's like, it's just like, that's like, I'm ready for that answer. I'm not going to be surprised. I'm not, I'm not leading you to a specific answer. Of, like, Oh, of course, I don't use meth. I never right. And then it's like, right, if we open that door in that psychologically safe space, like it's going to help us get those answers sooner than later, which is going to help us take better care of them? Exactly.
Shelby Pope 19:29
Another specific question would be, you know, preferred route I always ask amount to because that kind of helps in terms of, like, drug purchasing. Most people do like, like, specifically, since we're gonna talk about methamphetamine, I'll just stick to that. Just for revenue sake, Methamphetamine is a usually bought in. People talk about grams a lot in most people around here, like, pay like, $20 a gram, and then there's a. Which is like three and a half grams. So, like, those are just like terms that a lot of them use. I always ask, like I said about route, do you smoke? Do you snort, which is insufflation? Do you inject, specifically because they have an increased risk? You know of infectious disease, hepatitis C, HIV, as well as cardiovascular issues related to infections like septicemia and bacteremia. And then I there's also other routes too. There's parachuting, which is where they put methamphetamine and toilet paper and swallow it. I get mixed reports on that. Some people just prefer it that way, but some of my some of my my, I call them old school stimulant users. They're like, I have no idea why anybody would want to do that, so I'm not sure what the experience is. But some that's some people's preference. And then there's also something called booty bumping, where people will take the crystal meth and kind of break it down and dissolve it in water, almost like granulated sugar, and kind of do an enema. So, so that's kind of important to like, like, I just have to, I just open up, like, Okay, do you do booty bumping? You know, I love that. And you just kind of lead at that. It's like, yeah. And it also gives an opportunity, because there's people that have no idea what that is, and then I can educate them and show them that I'm not uncomfortable with talking about their rectum. And then it's like, okay, this isn't so uncomfortable. She's cool with talking about weird stuff. So totally. Um, so, yeah, so we that's, that's the most common routes. I think I covered everything. Um, most commonly, what I see is snorting or insufflation, smoking and injection or IV use, yeah, that's the that's the most common that I encounter. And then obviously you need to consider, you know, the comorbidities that go with those, and specific targeting harm reduction with that. Yeah. And then I think that's trying to think about history, about if there's anything other specific things that I ask, I think we kind of covered a lot of it, the catalyst to use the different things that they're using, how often, how much, and specifically what their motivation for use is. I think that's the key. Because if you don't know what motivates their use, then you're it's the cart before the horse. Yeah, you gotta know why
Liz Rohr 22:26
I love that. That's so, so helpful. And I think, like, in terms of the amounts, like, I think that's still, like, a learning curve for people, like, that's, I don't think that there's an expectation that you know what all the amounts are. So like, how much math they're using? Like, I don't, yeah, I don't use math. I don't know people who use math. So like, I don't know, but that's something I'm sure that we can all learn as we go in terms and there's nothing.
Shelby Pope 22:46
There's nothing. As far as the DSM five criteria that says someone has to be using a gram a day to qualify for having a stimulant use disorder or any substance use disorder, it's very subjective. It's the amount that they feel is inappropriate. So like, are you using more than would you like to cut back, or has it taken more than what you previously took to get what you need out of it? You know, talking about tolerance and talking about withdrawal, like there's no specific quantity or amount to be measured. So if that part really doesn't matter too much. It's just like, common language of how people describe it. I remember when I first started, I'm like, I'm gonna have to go Google what a gram is, because I don't know what that means. So totally. But, you know, the whole time sitting there with poker face on, like, okay, yeah, no problem, three grams a day. Got it
Liz Rohr 23:36
totally, totally so hard, yeah? So like, it sounds like, over time, you'll get a sense of like, how much is one compared to the other kind of thing? Yes, absolutely. I
23:45
love that. Well,
Liz Rohr 23:46
do you want to transition into substance use disorder or, sorry, stimulant use disorder?
Shelby Pope 23:50
Yeah, let's do it. I think I kind of started off by mentioning, you know, the different types of stimulants. So usually, yeah, if you want to recap that caffeine, nicotine, are the really common, but really the ones that are most problematic and have the most what appears to be adverse effects and poor outcomes are cocaine use and methamphetamine use, and those are the most common things that I experience in this setting.
Liz Rohr 24:15
Do you see any people who are who are using like street, Adderall, dextromethorphan? What? No, no,
Shelby Pope 24:24
yes, and no. I do see some people that will buy it off of the street and don't have a formal prescription, but it's actually really rare. I don't, I don't know if it's just a geographical thing, but it seems difficult for patients to get it and around here, so the people that I think are getting it prescribed are like, got their claws dug in. They're like, I'm not selling my supply, you know.
Liz Rohr 24:50
So I guess that's just helpful. I love I wanted to ask that because I think that there's a lot of discomfort that providers can have about prescribing, and I hate using Adderall, but the name is too long. The generic. So I think that, yeah, I think that some providers feel really uncomfortable with that, so they I think it's just nice to hear that. It's like, no, actually, at least in your anecdotal experience, right? It's
Shelby Pope 25:10
like, yeah, yeah.
Liz Rohr 25:11
Those are not the things, no,
Shelby Pope 25:12
those are not the things that we I don't think that's how we should start care. You know, like if in that's very much practicing defensively, and I urge people to educate themselves, specifically nurse practitioners, on on what that impact looks like whenever we're constantly practicing defensively, because there's going to be a lot of marks missed in terms of high quality care if we're constantly doing things because we're afraid of the bad outcome. But ultimately, what ends up happening when you withhold, which, in this in the state of Oklahoma, I can't prescribe a stimulant so that it's not it's a schedule two. It's not even option for me. And most nurse practitioners may experience that as well, but I see the poor outcomes that come from patients not having access to appropriate treatment for ADHD, and I can confidently say this is just a personal opinion, but I can confidently say that I well, many of those patients would be better off being appropriately prescribed Adderall instead of being on methamphetamine and exposed to fentanyl. So, yeah, so don't do that. Don't practice defensively. Yeah, thank you for that. When you can thank you for that.
Liz Rohr 26:18
But sorry, so cocaine, methamphetamine, those are kind of like the main ones that you're seeing.
Shelby Pope 26:25
Yes, so cocaine, obviously, is a natural substance. Comes from coca leaves. There could be coca paste, but what we see primarily is cocaine hydrochloride, and most of it is in a powder. But there's also a kind of a a rock form, or crack cocaine powder, tends to be snorted or injected. But the crack cocaine same way it can be smoked, because it's it's very water soluble, and it it sublimates and fairly low temperatures. So most people that I encounter smoke it methamphetamine, same, almost exact same. As far as benefits from it, people experience a lot of euphoria, increased energy, a lot of motivation, both cocaine and methamphetamine, just as far as like mechanism of action and how they work in the brain. I don't know if we want to get that deep into it just, but just sure people kind of understand why people love it so much. Yeah, they are mono amine neurotransmitter. I'm so sorry. Mono. Am mono amine neurotransmitter reuptake inhibitors, so and they're non selective, so they increase serotonin, they increase norepinephrine, and they increase dopamine. Methamphetamine is a little bit more intense because it also it has like an efflux as well. So it's just far more saturated and way more potent. So you have this enormous rush of dopamine and norepinephrine and serotonin. And it's important to realize that, because I I've heard a lot of conversations as far as case reports about there not being a withdrawal from stimulants, but there definitely is, if somebody is is, if you ask any patient that's coming off methamphetamine, they do not feel well, they're very depressed. They have no energy. They want to sleep all the time. So there's, without a doubt, a withdrawal to that, and that's why, because they're the synapses of their brain, have just gotten so used to being saturated with all these, you know, dopamine, norepinephrine and serotonin, and then we've just taken all that away. So that's the the addictive component of it. And then what else? What else do you want to you want to talk about, like, so experience? Yeah,
Liz Rohr 28:49
so I think if you have a patient coming in that's like, I am using meth, I'm using Coke, cocaine, like it more than I want to. It's disrupting my life. Like, what are the kind of like next steps that you would recommend for primary care people to think about like in the in the last episode that we did, we talked about like a triage component of like, especially like with opiates specifically, of like, can you be off of this for at least, you know, 20 is, can you not handle being off of this for more than 24 hours? Then, like, those people maybe need to go to more of like, a rehab versus, you know, so, like, what is, is there, like, a triage specific process for stimulant use disorder, after you've done that assessment and you're thinking about, like, how to assist this person in their next steps?
Shelby Pope 29:29
I think, if anything, I think it could happen with cocaine, but more so in terms of like, like, severity, in terms of acuity, I think it would be more common to encounter over amping with methamphetamine, specifically, and that's very subjective. So patients may come in and they're having a lot of palpitations, they're having chest pain, they're having shortness of breath, but that can even go into like people are having seizures. There they can be in Frank psychosis. So people may. Love. Nurse practitioners that are working in urgent care settings may experience this a bit more where, like somebody's coming in, and if they're in Frank psychosis, it can be very difficult, I will say that to know if it's an underlying mental health issue or if it's a stimulant, and obviously in those cases, we just need to refer the patient to the ER for triage and appropriate management. Typically, though, if somebody is like, alert and oriented and able to make sound decisions or have a discussion, but they're just like, really, really overstimulated into panicking. It's honestly kind of similar to what you would do with someone having a panic attack. You just lower your voice, you can turn down the lights, calm down stimulation, just kind of like, you know, create the therapeutic environment for them, and just kind of let them write it out in in acute care settings, it's more so like, you can do some low doses of benzodiazepines, and then, for the psychosis part, pull in psychiatry for sure, because you kind of have to tease out, is this active stimulant, you know, overdose or over amping, or is it schizophrenia or some other psychotic presentation? And then, if that's the case, then obviously an antipsychotic needs to be brought into the treatment plan the in terms of primary care setting, I think it's just, I love a good algorithm when it's appropriate, and kind of following that following, following the steps. So I think the most important part is diagnosing correctly. Because if somebody comes to you and they say, I, I, I do a little coke on the weekends with friends at a party. I don't think it's an issue. I don't have any issues stopping. It hasn't affected my daily living. I'm not doing I haven't experienced any legal issues. Then that really doesn't meet the criteria for a stimulant dependency or stimulant use disorder. So you really kind of have to go off of the DSM five criteria, which are very easy to find. The big things are like, you know, taking larger amounts over longer periods than intended, persistent desire to use cravings, I mentioned the tolerance earlier, withdrawal symptoms, legal issues, it's affecting your daily life. And I think there's 11 in total, and then depending on how many yeses you get. So if memory serves me, well, two to three is mild, four to five is moderate, and anything greater than six yeses is considered severe. So you can kind of go off that and decide, you know, if you're in that severe route, and you're just, like, really nervous about treating this person, hook them up with an addiction medicine clinic, you know. But if, if you're not afraid to kind of dip your toes in and give it a go, I think stimulant use disorder is a good one, honestly, to to affect change ultimately, because really the best evidence that we have in terms of treatment are psychosocial interventions. There's different types of therapy that you can refer people to. There's cognitive behavioral therapy. Obviously, most of us know what that is, the Matrix Model, which a lot of group therapy sessions follow, and then, but specifically, one that I want to mention is something called contingency management. Have you ever heard of that? Most people haven't. It's kind of what I called, and this might take away from a little bit, but it's just how I remember. It the Gold Star effect, and it's a little bit controversial, but it really does work, and it's where it's not really your goals that you set, it's the patient's goals, is what I typically recommend. So it could be that you, the patient, sets a goal of like, I just want to show up to my appointments every other week. I just, I want to be consistent with that first, and then, if they show up twice in a row, you give them a gas card, or you literally give them a gold star, like, something along those lines. And it really, it really does work. It affects the dopamine in the brain. And they're just like, This is great, and I see it work all the time. I typically use appointment frequency as my contingency management. Like, Listen, you won't have to come every week if we can work on cutting down cocaine use if you want to do that and it works, they're like, Okay, yeah, I want to go to two week appointments. I'm going to use cocaine once this week instead of twice this week. So it's just, it's an easy thing to do, and you could do that in any setting. It doesn't cost a lot to implement something like that. When I was in primary care, I did a contingency management with, I'm gonna use a brand name, Long John Silver's, you know the bell? Yeah? Okay, yep. I did it with diabetes and weight management. If you met your a 1c goal, or you lost your weight you got to ring the bell on your way out, and then the entire office would cheer for you. So. Um, it worked, and it was exciting for us. You know, if the bell rang like the whole office would, like, shout and cheer, like it was just, it was good, it was good. So, so that's my plug. Get a bell. It really works. I love that. No, it was good. So
Liz Rohr 35:16
I So, I guess, like just to paint the picture. So if you have a person, you've done your history, you've done the triage of, like, how severe are we talking in terms of, like, the addiction, and using that DSM criteria to support us in terms of the criteria, and then when you're talking about setting up the treatment plan, like, what does that kind of concretely look like? I mean, is it just kind of a negotiated conversation of, like, you know what? I just really want to cut, I really want to stop using cocaine, but I'm using meth all the time. Like, where do, what do you kind of concretely guide them to? Like, okay, how much are you using? Do they kind of come up with like, Okay, I'll use less. I'll use once less this week, or something like that. Like, what does that kind of concretely look like, especially if you don't have like, maybe you refer them to a therapist to start with, CBT, concrete cognitive behavioral therapy. But yeah, can you give any sort of insight into, like, the how often do you meet with them? What kinds of conversations are you having? Are there any sort of other pharmacologic, you know, supports for them, or sort of, like, life style behavior, things especially to help with that, like fact that they don't really have those neurotransmitters that they did before? Like, are there any other sort of supports for them, absolutely.
Shelby Pope 36:22
So typically, so kind of like what we learn in nursing school, ABCs. So I always start with the harm reduction, obviously, if and understand the comorbidity. So if somebody is using specifically in the setting opioids, including the methamphetamine, I really focus on the opioids. And I can and I talked to them about therapies that we talked about in the previous podcast. And I start there, and I make sure that they have Narcan and anyone that's using fentanyl, or, sorry, anyone that's using methamphetamine, we provide fentanyl test strips so that they can test their supply to prevent overdose, because there are more and more overdose and death related to overdose on methamphetamine because of opioid contamination. So it's really, really important that we reduce harm because, like I said, we can't treat dead people. It doesn't, it doesn't work. So, and then we give Narcan to everyone. Obviously, that doesn't seem silly, you know, because it's methamphetamine, but it's because of the cross contamination. So that's first and foremost comorbidities, figure out what the other like, their risk factors are, and kind of try to modify those in a way that keeps them as safe as possible so they can continue pursuing treatment. And then the social determinants of health, like we mentioned earlier, because if somebody came into my office and they were unsheltered or vulnerably housed and they were using methamphetamine to stay awake at night. If I said, Hey, let's try contingency management. Okay, at best, at best, that's me missing the mark and not providing a therapeutic environment. At worst, it's highly offensive. So obviously, be self aware and understand social determinants of health and impact those like get case management involved, see where you can help. And then the next step would be the non pharmacologic obviously, because, you know, we're trying to be most therapeutic and least invasive. So that would be really do research on contingency management and see how you could implement something like that, or refer to some form of therapy. And then the pharmacologic treatments, while there's not really any FDA approved medications for stimulants, there are quite a few that we use off label. You just have to be really good about documenting and educating the patient about, hey, this is a non FDA approved medication for stimulus disorder. But anecdotally, I find that it does help, or there's been such and such study that shows that it's effective for this. For the most, I'm just gonna throw them out there. The most is that? Okay, yeah, okay. Mirtazepine at 30 milligrams per day, it has some norepinephrine stimulation at that high of a dose, it's kind of it's one of those meds that, at lower doses, it could be more sedating,
Liz Rohr 39:02
so like, lower doses is more sedated,
Shelby Pope 39:04
yes, and that's been and I used to think it was another med, and I'm maybe getting them confused, but I had recently looked this up because I was having a patient who was started on 7.5 of mirtazepine, and they just could not tolerate it because it's so sedating, so then it's, like, really not helping because, yeah, They want to use more methamphetamine, but I learned, in terms of the data that the norepinephrine stimulation specifically happens more so at the 30 milligram dose. And there was this study done, and I want to give credit to who it was, but I am losing I cannot recall, but it was done, I believe, in San Francisco, and it was a 24 week long study of individuals using stimulants, and they found that there was an increase in abstinence and a stimulant cessation after starting mirtazepine at 30 milligrams. So that's one that I do. I try to do quite a bit. I also really like Bupropion. I. Um, the extended release. There's the 150 dose, there's 300 but really, 450 tends to work best in this population. And just an anecdotal thing, the 450 doesn't get covered well by insurance. So I typically have to send in two scripts, the 300 and the 150 in order to get it covered, the most important things to consider is history of seizures with Bupropion prescribing and a history of eating disorder. And it's another one of those things where while a lot of people say it's a contraindication to prescribe Bupropion with someone with a history of seizures, you have to consider the risk that these people are putting themselves in by continuing methamphetamine use and potential fentanyl exposure. So I've had cases where it's not it doesn't happen very often, but a person says I had a seizure because I overdosed on this thing, and they don't have a seizure disorder that's documented. I'll talk to them about the risk, like, hey, if we start this like, this will lower seizure threshold. We know that to be a fact, so I'm it's potentially going to put you at risk, but they'll be like, Shelby, I'm shooting at meth every day. So okay, yes, that's fair, totally. So 450 on the Bupropion, anecdotally, what I find, though, with the Bupropion, it primarily helps with abstinence once someone has detoxed off of methamphetamine, I've started it in a few cases where they're actively using, but I don't know that I've noticed any measurable reduction in methamphetamine use. Primarily, it seems like people will subjectively report less cravings and less use. Nothing as far as you're in drug screens show that it's completely stopped. My patients that have gone to detox or some sort of rehab and were completely quit methamphetamine on their own, and I started Bupropion, they they respond really well to it. They like it. They say that it gives them energy. They they're able to focus, and they, they seem to do well the other, another common one, Vivitrol, or injectable naltrexone, and in shorter frequencies. So there was a study that showed doing that every three weeks instead of every four weeks, showed a reduction, and that's a good one to consider for people using opiates as well, as long as they're not on buprenorphine or on method methadone, to consider trying, because it's kind of a double whammy, or even a triple whammy, if they're drinking alcohol as well. The only downfall of that is it's very, very expensive, so insurance coverage can be a booger. And if, if they're only have stimulant use disorder, I have not experienced getting it covered under stimulant use disorder, because it's not FDA approved for that, but if they have those other comorbidities, it potentially could be, but if you're dosing it every three weeks, you're potentially going to hit a month where it's not covered, so you can have to be careful. And then there's some argument that you can put them on oral naltrexone, high dose, 50 milligrams a day, and that might be beneficial, but I haven't seen a lot of data that really supports it. And then lastly, I know I'm forgetting one. Oh, I'm forgetting to actually, Topiramate. I feel like, did you experience this in primary care? What's kind of becoming the umbrella drug? Like, yes, you've got, you've got some evening binge eating. I'm gonna give you Topiramate headaches to pyramid like, like, Topiramate everyone. And so Topiramate is one that was that's been studied in a couple of times, that shows potentially a less risk of relapse, but not a whole lot of like, I quit meth because I started Topiramate. Like, yeah, it's more so reduction in relapse rate. But number one, actually recently released in the ASAM guidelines was prescribing psychostimulants, and the guidelines specifically say, think I actually put a note on here, and I'm just going to read that, yes. So the ASAM guidelines specifically said physician specialists who are board certified in addiction medicine or addiction psychiatry and physicians with the training competencies and capacity for close patient monitoring, they specifically recommended Dextroamphetamine, methylphenidate, Adderall were most promising, but higher doses, the 20 to 30 milligrams a day did not seem to be effective, but 60 milligrams a day did show some some decent outcomes. So those are the pharmacologic interventions, and we covered non farm. Yeah, what am I missing?
Liz Rohr 44:38
No, I think that sounds great, and I guess I just wanted to put in a little like disclaimer that probably doesn't need to be said, because most of the people in the real world, np community, are very cautious, like, overly cautious, as as we are when we're new grads. But yeah, just like, these are just like, reinforce, these are off label. FDA, which depends on your state. Also, like, if you are allowed to prescribe, quote, unquote, off label. Things, it depends under state regulations, but also the like, I wouldn't, I would not feel comfortable myself starting a stimulant, pharmacologic stimulant, without right, more advanced training. So, right? But it's really, I think it's really important for us to hear like, what all the options are, and especially if we're motivated to do more Addiction Medicine, like, what are the what are the training and skills that we need to feel comfortable prescribing those things in addition to like, the other measures that we've done for people.
Shelby Pope 45:25
Exactly, yeah, and I think any type, I think having the conversation, at least opening the conversation, and getting people into that pre contemplation, contemplation phase, like we talked about earlier, is really essential, because people start considering, like, what the landscape could look like without this thing in their life that's potentially a barrier to them being successful in one form or another, if it is, you know, causing a negative outcome. And then they're more willing to come back and have a discussion about, okay, all right, Shelby, what can I do? What's my options? And it just kind of goes from there. But no, you're absolutely right. I and I think it's probably the culture of the state that I that live and work in. I do not feel comfortable prescribing stimulants. Yeah, my but I will say my perception of stimulants has completely changed. I'm not anti stimulant prescribing. I'm just not comfortable. I don't know Well, I can't legally. But I think it is very important for people to know what state they work in, what those regulations are, and know that while the guidelines do say that you know it's, it's, could be a treatment for stimulant use disorder, it's very important to know that the guidelines specifically say that physician specialist, so it we first and foremost, we can't help people if we lose our license. So it's really important to be mindful of that, but totally
Liz Rohr 46:52
I guess, I guess what's coming to mind also is, like, in the conversation for somebody who is, like, pre contemplative, for example, like, yeah, and I just really want to second what you said about like, it really just having conversations. Plants a seed that you would just have no idea what impact it can have for people, right? So I guess it occurred to me also, like, do you have like, a set kind of spiel that you give people when you're talking about, like, like reasons, like, the kind of, like education for people, of like, why they might not want to continue using meth if they're like, I'm chilling, kind of thing. Like, what are the kind of like, risks, benefits? Conversations, like, Do you have any sort of, like, set thing that you say for people, or is it any, any sort of guidance on that piece?
Shelby Pope 47:30
No, that's a great question, because I think it's, like we said earlier, it's really important to know what motivates them, because if you can't, if you can't address that motivation, then are you being therapeutic? It's a little bit arguable, you know, I think that there. I think I primarily try to plant the seed of, what does the landscape look like without it? Like, what could that mean for you? I have a lot of individuals that desire more, but, like, can't pass a urine drug screen to get a different type of job, you know? And so we just talked about that. Like, okay, What? What? What What would be your dream job? If you could wake up tomorrow and you had your dream job, what would it be? And a lot of conversations very similar to that, like people that have a lot of turmoil in their marriage because of impulsivity or because of, like, aggressive behavior or fighting a lot like, how might like Jim, how might that stimulant use impact that? Do you feel like that, like when you're actively using stimulants, or on the day that you're smoking that it's making you more aggressive? What would the landscape look like if you weren't fighting with your wife every day? Like, would that make you happier? Obviously, I can't define that. It's a subjective thing that you have to define for yourself, but I just kind of wonder what the stimulant plays in this. And then I think that's primarily it is just knowing, trying to tease out what what their motivation is, and kind of meet them where they are, so that you know how to help
Liz Rohr 48:53
totally. That reminds me of I did like a almost like the SBIRT, the brief intervention thing. I can link to these down below. But we did, like, a practice thing script when we they did the like in service training for it, and it was like, I remember two of the questions being like, and being on the receiving end as the quote, unquote patient. It just felt really nice where it was just like, Well, what do you like about your meth use and what don't you like about it? Because it's like, it just gives that possibility of, like, just seeing things as they are. And then I just really love how you just have that vision casting for patients. Because I like, makes me excited thinking about it's like, what, how is life different? Like, how could things be different? Because then you can hold that vision for them, and you can believe in them, and, like, right? And like, that can help them believe in their own, like, self efficacy. So, yeah, that's really beautiful.
Shelby Pope 49:38
It makes me, like, like, honestly, choke up because it, it's, it's just really devastating in this setting, like the amount of people that come in and they have no self worth, like they do not recognize the things that they deserve. And I feel like that's like 90% of my patient appointments. Like, I just got a letter, actually, yesterday, from a patient who just talked about his sobriety and how much the treat. It has changed his life. And he just wanted to thank me for being his friend and and making him recognize that he was worthy of being sober and having these good outcomes. And he just finished an HVAC program, and he's gonna, and he got hired by his teacher like he's gonna do great things, you know? And it's, it's like a lot of times, it's just reminding people like you deserve this, and I also tell people like my I share my experiences too. So I I encouraged any nurse practitioner that has anecdotal rapport or an empathetic opportunity to pursue that when it's appropriate. Of like, yeah, I come from generational substance use. Yes, I'm the first person to pursue a college education in my family, or I have such and such in the system, like you talk about these things like, and I tell people all the time, Listen, I'm not judging you. I could be sitting on that stretcher tomorrow. So I'm I see it enough to know that none of us are above this. So I think again, meeting people where they are,
Liz Rohr 51:01
that's so awesome. Well, thank you so much again for being here. This is so fun. It's been good
Shelby Pope 51:07
. I'm glad, and I'm really, I really hope that people hear it and just are more comfortable. And that was the whole goal, right? Is just making our primary care peeps comfortable with having the discussion. Because Absolutely, you guys are home for them absolutely well. Thank you.
Liz Rohr 51:21
You're welcome. That's our episode for today. Thank you so much for listening. Make sure you subscribe, leave a review and tell all your NP friends, so together, we can help as many nurse practitioners as possible give the best care to their patients. If you haven't gotten your copy of the ultimate resource guide for the new NP, head over to real world np.com/guide, you'll get these episodes sent straight to your inbox every week with notes from me, patient stories and extra bonuses I really just don't share anywhere else. Thank you so much again for listening. Take care and talk soon.

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Liz Rohr