By Rick Moldenhauer; MS,LADC, ICADC, LPC, treatment services consultant, Chemical Health Division, DHS, State of Minnesota

In working with addicts newly engaged in abstinence from methamphetamine use, I have found similarities to those not exhibiting a pattern of addiction, rather a symptom cluster often associated with traumatic brain injury (TBI), Symptoms can be mild, moderate, or severe, depending on the extent of the damage to the brain, regardless of it’s etiology (blunt force trauma or methamphetamine induced neuro-chemical alterations), Some symptoms are evident immediately, while others do not surface until a period of time has passed after the injury/termination of chemical use.

A person with a mild TBI may remain conscious or may experience a loss of consciousness for a few seconds or minutes. The person may also feel dazed or not like himself for several days or weeks after the initial injury. Other symptoms of mild TBI include headache, confusion, lightheadedness, dyskinesia, blurred vision or tired eyes, tinnitus, lethargy, insomnia, behavioral or mood changes (anhedonia), and trouble with memory, concentration, attention, or thinking.

A person with a moderate or severe TBI may show these same symptoms, but may also complain of a headache that gets worse or does not go away, repeated nausea and/or emesis, convulsions or seizures, hypersomnia, mydriasis, slurred speech, weakness or parethesia, dyskinesia, and/or increased confusion, restlessness, or agitation.

The DSM-4R lists among its criteria for amphetamine intoxication (292.89) papillary dilation (mydriasis), nausea and vomiting, psychomotor agitation, muscular weakness, confusion, seizures, dyskinesia, dystonia, or coma. While the “high” of methamphetamine lasts an average of 8-10 hours, continued assaults on the brain and body bring about a variety of medical conditions found in malnourishment and dehydration.

Methamphetamine addicts tend to be awake for days (4-5 days continuous is not uncommon) and “crash” for 2-3 days of fitful sleep. Repeated cycles circumvent the circadian rhythm, bring about symptoms commonly
found in mood disorders (flat affect, constricted range of emotions, various difficulties with executive functions of the frontal lobe, etc.). Given these similarities, a successful method of dealing with methamphetamine addicts is approaching them from the stance one works with a TBI. In this article, I suggest methods of intervention based on I) difficulty with concentration (time on task), 2) working with reduced impulse control, 3) constricted range of emotion and flattened affect and 4) deficits with executive functioning.

Difficulties with concentration

Many addicts enter treatment with noted decrease in short term memory and concentration, or time on task. This is especially prominent in traditional treatment where there is a large amount of reading and written assignment work. This will quickly overwhelm the client, increasing already underlying anxiety and agitation, potentially resulting in elopement or request of discharge. Programs can consider a number of options here. The written assignments can be reduced in volume and re-written if necessary, using mono-syllabic vocabulary and short, closed ended questions allowing for simple, uncomplicated answers. Rather than asking “what chemicals have you regularly used in the past six months?” ask “did you use ______ in the last six months” allowing for binary answers of “yes” or “no”. Follow with graduated scales of use: “1-2 times a week” or “3-4 times a week” and so on. Make written assignments a set of talking points rather than an end unto themselves. With the reading component, consider smaller assignments. Rather than “read chapter one by Friday” it would be “read the first five pages by tomorrow, pages 6-10 the following day, pages 11-16, etc”. The end product is the same - completion of the task - but it is in smaller portions allowing for shorter attention span and decreased concentration span. For those with more severe impairment, consider having assignments read to the client and staff write brief responses. Or verbally complete the assignment and denote it as such. The flow of therapy conducting a recent training, during interaction allows for far more expression than forcing someone to try to write down answers in a vacuum.

Working with reduced impulse control

Walking hand in hand with increasing anxiety and agitation is lack of impulse control. This will be demonstrated in somewhat tolerable methods, such as verbal interruptions of others during group process, attempts to dominate discussion during family work, etc. It may also take more objectionable and disruptive behaviors in a program; shouting obscenities, sexual acting out, etc. Management of the behavior and its often underlying etiology (anxiety) are both achieved by control of the environment and guidance of the situation. Environmentally, stimulus reduction is a long known successful method of reducing acting out behaviors (e.g. indirect lighting; soft colored walls (blue); calm, background music; staff walking calmly rather than hurrying and frantic to get somewhere). The program has control of the physical environment, which sets much of the mood for both staff and client. If you work in a community mental health center or locked residential unit, you do have some control over the physical environment/structure of the facility.

Behavior of clients is a bit more difficult, but not impossible. Clients are willing to allow the therapist to do the work if they want, and are also willing to engage in battle with the therapist whenever allowed. Both must be avoided. Therapists need to be aware when they are working harder than the client. Impulsive behavior is often a by product of being overwhelmed. Just as assignments need to be fairly closed ended and direct, so are goals and objectives on treatment plans and expectations of daily milieu. Concrete, black and white goals and objectives are easier to understand and follow. “Client will…” rather than “Client should….” Initial goals will need to be more behavioral, and as faculties begin to return (either initial treatment or in following aftercare) more tradition insight oriented methods can be employed.

Constricted range of emotion and flattened affect

Both mood and affect are often altered in the methamphetamine addict during initial abstinence. During initial abstinence, emotions will present more intensely, escalate and transition’ erratically. Neuro-vegetative signs of depression (anhedonia, sleep disturbance, decreased libido, etc.) are common. Rapid cycling between little affective presentation and acute anxiety (overwhelmed) or aggression are not uncommon.

The therapist must initially be aware that these are common symptoms during initial abstinence from methamphetamine, and may not necessarily be an indication of a co-morbid disorder. While medication is a form of assistance, it is not the only form of assistance. These swings do seem to abate with time. Much of the non-medication management of these symptoms is also found in management of the environment. Controlling cues and stimulus are key to avoiding external stimulus for cycling. Also important is how the program is presented to the client. Strong confrontation raises anxiety, producing quick and intense transitions, usually toward defensiveness, anger and outright aggression. Consistent re-assurance of hope for ongoing abstinence is vitally important, especially in the face of much of what the media presents (inaccurately) about methamphetamine.

Deficits of executive functioning

Some of this has already been mentioned, but noted deficits of executive functioning are more the norm than the exception with methamphetamine addicts. This is present in a range based on amount of use, length of time, last period of use, etc. Difficulty with concentration, inability to perform mathematics or logical trains of thought, memory (short term retention) will present with varying degrees of inhibition. Method of achieving goals and objectives should involve recognition rather than recall. Consistent repetition of smaller goals are essential. As mentioned above in the example of drug history, recognizing that drugs you may have ingested in the last 30 days from a list is easier then trying to remember them and write them down on blank paper. This is also important in relapse prevention planning. Asking someone what they can do different to be safe and sober is going to be difficult because most of their life has recently been spent doing the exact opposite. In other words, they don’t know.

Provide a list of ideas/activities, assist the client in choosing a few and plan out who, what, when, where and how. Assist the client in doing it; don’t do it for them. Recovery is not a spectator sport. In summary, the method you present your programming seems to have a greater effect than the philosophical orientation of it. Traditional, abstinence based 12 Step programs, harm reduction, medication assisted therapies, and TEl interventions all share a common goal: to help the client heal from the damage that has occurred. Using smaller portions of programming, simplified behavioral goals, repetition of key concepts, and consistent reinforcement over a long period of time seem the most effect method of intervention for both TBI and methamphetamine addiction.

Tags: intervention methods, Methamphetamine, traumatic brain injury, treatment

This entry was posted on Friday, March 14th, 2008 at 10:57 pm and is filed under Drugs, Methamphetamine. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.