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Methamphetamine-associated psychosis: a new health challenge in Iran Alam mehrjerdi, Zahra; Barr, Alasdair M; Noroozi, Alireza Apr 11, 2013

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EDITORIAL Open AccessMethamphetamine-associated psychosis: a newhealth challenge in IranZahra Alam mehrjerdi1*, Alasdair M Barr2 and Alireza Noroozi3AbstractThe rapidly growing popularity of methamphetamine use in Iran has posed a new health challenge to the Iranianhealth sector. Methamphetamine-associated psychosis (MAP) has been frequently reported in Iran in recent years.Although methamphetamine use and MAP are considerable health problems in Iran but there is still a need toconduct epidemiological studies on the prevalence of MAP and its health-related problems. The present paperemphasizes that health policy makers should consider the immediate needs of drug users, their families and thecommunity to be informed about the detrimental health effects associated with MAP. Although MAP could bemanaged by prescribing benzodiazepines and psychiatric medications but the most effective regime for stabilizingpatients with MAP still needs to be studied in Iran. Constant collaborations among psychiatric services andoutpatient psychotherapeutic services should be established to successfully manage MAP in Iran. Iranian cliniciansespecially emergency medicine specialists should be informed about the differences between the two forms oftransient and recurrent MAP in order to implement appropriate pharmacological therapies to manage MAP. It ishoped that special training courses are designed and implemented by health policy makers to inform clinicians,health providers and especially emergency medicine specialists to effectively deal with MAP.EditorialFor centuries, opium and opium residues have been usedby Iranians but in recent years, methamphetamine (MA)use has emerged as an epidemic health concern amongIranian substance users [1]. Methamphetamine is knownas a synthetic derivative of amphetamine, but due to theaddition of a methyl group in its chemical structure, ithas lipid solubility, allowing more rapid transport of thedrug across the blood–brain barrier [2].Methamphetamine use and abuse can result inmethamphetamine-associated psychosis (MAP) which hasa recurrent nature [3]. MAP is characterized by auditoryor visual hallucinations, ideas of reference, persecutorydelusions, thought reading, strange or unusual beliefs,delusions of reference and thought insertion [4]. Theincidence and severity of MAP are related to high dosesof methamphetamine use, the routes of administration,and duration of regular use [5,6]. MAP is more likely tooccur in methamphetamine patients even after adjustingwith psychotic disorders [7,8]. The presence of MAP isgenerally transient and normally abates in a few days.However, susceptibility to psychotic episodes could prolongfor years after prevention from methamphetamine use [3].Studies show that methamphetamine use [3], using otherdrugs [9] and psychosocial stressors [10] could trigger therelapse of MAP. MAP is also associated with considerablehealth service utilization and increased psychiatricsymptoms over time [11]. Chronic MAP is persistent andso similar to those of schizophrenia. Studies show thatsusceptibility to MAP could last for years after preventingfrom methamphetamine use [5].Currently, methamphetamine use has rapidly emergedand developed in Iran [12,13]. A recent rapid situationalassessment (RSA) of substance use showed that only asmall group of Iranian substance users (3.6%) reportedmethamphetamine as their main drug of abuse [14] butin the past several years, the price of methamphetaminehas dramatically decreased. Current nonofficial estimatessuggest that methamphetamine is the second or thirdillicit drug in Iran [14] and an increasing number ofpatients with MAP are admitted to Iranian psychiatrichospitals [15].In a study on the symptoms and treatment of MAPduring one-year follow-up, researchers studied a 38* Correspondence: a.mehrjerdi@gmail.com1Iranian National Center for Addiction Studies (INCAS), Tehran University ofMedical Sciences, No.669, South Karegar Ave, Tehran, IranFull list of author information is available at the end of the article© 2013 Alam mehrjerdi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Alam mehrjerdi et al. DARU Journal of Pharmaceutical Sciences 2013, 21:30http://www.darujps.com/content/21/1/30year-old man who was admitted to the emergencydepartment setting of Iranian educational and therapeuticcenter of psychiatry because of suicide attempts, auditoryhallucinations and persecutory delusions. The patient wastreated with prescribing antipsychotic medications andexperienced a short recurrence of MAP during abstainingfrom methamphetamine use, as well as a MAP episodealthough he was receiving antipsychotic medications [16].Omidvar and Sharifi (2012) examined a patient whowas diagnosed with MAP and eye autoenucleation. Thepatient had delusions of being in control and believedthat others were using his eyes. He was diagnosed with afirst episode of MAP and did not report MAP symptomsin the absence of methamphetamine use but he wastreated with six sessions of electroconvulsive therapy(ECT) and prescribing psychiatric medications [17]. Astudy on 50 methamphetamine abusers recruited fromthe Iranian legal medical organization in Tehran showedthat delusion, mood instability, disorientation, andself-mutilation were prevalent among the patients [18].In another study, the clinical files of 111 metham-phetamine patients who had been admitted to a centralhospital in Tehran from April 2008 to April 2010 werereviewed. The study results showed that the most prevalentpsychotic symptoms were persecutory delusions (82%),auditory hallucinations (70.3%), reference delusions (57.7%),visual hallucinations (44.1%), grandiosity delusions (39.6%)and jealousy delusions (26.1%). The mean duration ofadmission and psychotic episodes were 21.43 and 17.37days respectively. In seven cases (8.75%), MAP continuedfor more than one month [19]. Methamphetamine-relatedhealth problems such as MAP have changed the profile ofpatients who utilize psychiatric services in Iran [20].Because of heavy use, many of such cases are characterizedby delusions, hallucinations, anxiety, insomnia, mooddisturbances, suicide, violent behaviors and homicidalideations [20]. This is consistent with some studies inother countries which indicate that heavy use of metham-phetamine contributes to a variety of severe psychiatricproblems including MAP [21].It should be noted that the rapidly growing popularity ofmethamphetamine use has posed a new health challengeto the Iranian health sector. MAP is associated with arange of acute and chronic health and social problems thatneed to be considered during the course of treatmentespecially in emergency department settings, and psychi-atric and general hospitals. In order to effectively deal withMAP in Iran, several issues should be considered byhealth policy makers. Although MAP is prevalent amongmethamphetamine users in Iran, epidemiological studieson the prevalence of MAP and its health-related problemsshould be conducted.The negative effects of MAP on methamphetaminepatients, and the community should be considered byhealth policy makers. Nationwide drug education shouldbe designed and implemented to inform drug users, theirfamilies and the community about the harms associatedwith MAP and the necessity of immediate referrals of suchcases to emergency department settings of psychiatrichospitals. MAP could be treated with prescribing psychi-atric medications and benzodiazepines in a supportivenon-judgmental relationship. Atypical antipsychoticshave become first line treatments for psychotic disorders,especially first episode psychosis [22]. Recently, casereports of successful MAP treatment with atypicalantipsychotics such as Olanzapine [23], Risperidone[24] and Quetiapine [25] have been reported. Suchstudies have been conducted in other countries such asUSA and Australia. There is an immediate need for Iranto devise a treatment protocol to pharmacologically manageMAP according to its health and medical-relatedconditions.Little is known about the pharmacological therapies ofpatients with MAP in Iran. Moreover, the most effectiveregime for stabilizing patients with MAP still needs tobe studied in Iran. Once, the pharmacological therapy ofMAP is implemented in a psychiatric hospital, referringpatients to outpatient drug use treatment clinics isimplemented. In many instances, the involvements of suchservices include outpatient psychotherapeutic services andthere is still a need to establish constant collaborationsamong psychiatric services and outpatient psychothera-peutic services to successfully manage MAP.Methamphetamine users are vulnerable to MAP, eitherfrom exacerbation of symptoms of underlying psychoticdisorders [26] or emerging new psychotic symptoms duringintoxication and withdrawal stages [27] and recurrencecan occur in response to psychological stressors even inthe absence of methamphetamine use [28].Iranian clinicians should know that psychotic symptomstend to persist in some patients. Therefore, the distinctionbetween persistent MAP and a primary transient MAPhas grown increasingly important. Iranian cliniciansespecially emergency medicine specialists should beinformed about the differences between these two formsof MAP and recurrence of MAP in order to implementappropriate pharmacological therapies to manage MAP.Primary and emergency health care providers, mentalhealth and substance abuse treatment service providersneed to be trained to distinguish between MAP, otherforms of toxic psychosis, and primary psychosis. A furtherchallenge to primary and emergency health care serviceproviders lies in the detection and management of transientMAP and persistent MAP. This issue needs attention byhealth policy makers.To sum up, as MAP negatively influences Iran, newnationwide and research-oriented strategies should bedesigned and implemented to meet the increasing needsAlam mehrjerdi et al. DARU Journal of Pharmaceutical Sciences 2013, 21:30 Page 2 of 3http://www.darujps.com/content/21/1/30of the community, and health care providers especiallyemergency medicine specialists to effectively deal withMAP. Given the challenges that MAP has posed tohealth professionals and the community, the role of thehealth sector in the provision of evidence-based treatmentfor MAP is emphasized. In order to fulfill this role, it isimportant that the health sector such as the medicalschools also provides health care professionals withevidence-based information and training related to thediagnosis and management of MAP.Authors’ contributionsZAM wrote the manuscript. AMB and AR N provided editorial assistance andscientific advice. All authors read and approved the final manuscript.Financial disclosureNone.Author details1Iranian National Center for Addiction Studies (INCAS), Tehran University ofMedical Sciences, No.669, South Karegar Ave, Tehran, Iran. 2Department ofAnesthesiology, Pharmacology & Therapeutics, University of British Columbia,Vancouver, BC, Canada. 3Iranian National Center for Addiction Studies(INCAS), School of Advanced Technologies in Medicine (SATM), TehranUniversity of Medical Sciences, Tehran, Iran.Received: 5 March 2013 Accepted: 6 April 2013Published: 11 April 2013References1. Mehrpour O: Methamphetamine abuse a new concern in Iran. Daru 2012,20:73. doi:10.1186/2008-2231-20-73. PMID:23351837.2. Barr AM, Panenka WJ, MacEwan GW, Thornton AE, Lang DJ, Honer WG,Lecomte T: The need for speed: An update on methamphetamineaddiction. J Psychiatr Neurosci 2006, 31:301–313. PMID: 16951733, PMCID:PMC1557685.3. 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Aust N Z J Psychiatry 2005, 39:1–30. PMID: 15660702.23. Misra LK, Kofoed L, Oesterheld JR, Richards GA: Olanzapine treatment ofmethamphetamine psychosis. J Clin Psychopharmacol 2000, 20:393–394.24. Misra L, Kofoed L: Risperidone treatment of methamphetamine psychosis.Am J Psychiatry 1997, 154:1170.25. Dore G, Sweeting M: Drug-induced psychosis associated with crystallinemethamphetamine. Australas Psychiatry 2006, 14:86–89.26. Curran C, Byrappa N, McBride A: Stimulant psychosis: Systematic review.Br J Psychiatr 2004, 185:196–204.27. Zweben JE, Cohen JB, Christian D, Galloway GP, Salinardi M, Parent D,Iguchi M: Psychiatric symptoms in methamphetamine users. Am J Addict2004, 13:181–190.28. Sato MA: Lasting vulnerability to psychosis in patients with previousmethamphetamine psychosis. Ann N Y Acad Sci 1992, 654:160–170.doi:10.1186/2008-2231-21-30Cite this article as: Alam mehrjerdi et al.: Methamphetamine-associatedpsychosis: a new health challenge in Iran. DARU Journal of PharmaceuticalSciences 2013 21:30.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitAlam mehrjerdi et al. DARU Journal of Pharmaceutical Sciences 2013, 21:30 Page 3 of 3http://www.darujps.com/content/21/1/30

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