Treatment for amphetamine psychosis

 

Abstract

Background

Chronic amphetamine users may have experience of paranoia and hallucination. It has long been believed that dopamine antagonists, such as chlorpromazine, haloperidol, and thioridazine, are effective for the treatment of amphetamine psychosis.

Objectives

To evaluate risks, benefits, costs of treatments for amphetamine psychosis.

Search methods

MEDLINE (1966-2007), EMBASE (1980-2007), CINAHL (1982-2007), PsychINFO (1806-2007), CENTRAL (Cochrane Library 2008 issue 1), references of obtained articles.

Selection criteria

All randomised controlled and clinical trials (RCTs, CCTs) evaluating treatments (alone or combined) for people with amphetamine psychosis

Data collection and analysis

Two authors evaluated and extracted the data independently. Dichotomous data were extracted on an intention-to-treat basis in which the dropouts were assigned as participants with the worst outcomes. The Relative Risk (RR) with the 95% confidence interval (95% CI) was used to assess the dichotomous data. The Weighted Mean Difference (WMD) with 95% CI was used to assess the continuous data.

Main results

The comprehensive searches found one randomised controlled trial of treatment for amphetamine psychosis meeting the criteria for considering studies. The study involved 58 participants and compared the efficacy and tolerability of two antipsychotic drugs, olanzapine (a newer antipsychotic) and haloperidol (a commonly used antipsychotic medication used as a control condition), in treating amphetamine-induced psychosis. The results show that both olanzapine and haloperidol at clinically relevant doses were efficacious in resolving psychotic symptoms, with the olanzapine condition showing significantly greater safety and tolerability than the haloperidol control as measured by frequency and severity of extrapyramidal symptoms.

Authors' conclusions

Only one RCT of treatment for amphetamine psychosis has been published. Outcomes from this trial indicate that antipsychotic medications effectively reduce symptoms of amphetamine psychosis, the newer generation and more expensive antipsychotic medication, olanzapine, demonstrates significantly better tolerability than the more affordable and commonly used medication, haloperidol.

There are other two studies that did not meet the inclusion criteria for this review. The results of these two studies show that agitation and some psychotic symptoms may be abated within an hour after antipsychotic injection.

Whether this limited evidence can be applied for amphetamine psychotic patients is not yet known.

The medications that should be further investigate are conventional antipsychotics, newer antipsychotics and benzodiazepines. However, naturalistic studies of amphetamine psychotic symptoms and the prevalence of relapse to psychosis in the presence of amphetamine, are also crucial for advising the development of study designs appropriate for further treatment studies of amphetamine psychosis.

 

Plain language summary

Treatment for amphetamine psychosis

A minority of individuals who use amphetamines develop full-blown psychosis requiring care at emergency departments or psychiatric hospitals. In such cases, symptoms of amphetamine psychosis commonly include paranoid and persecutory delusions as well as auditory and visual hallucinations in the presence of extreme agitation. More common (about 18%) is for frequent amphetamine users to report psychotic symptoms that are sub-clinical and that do not require high-intensity intervention. Clinical reports suggest the development of amphetamine psychosis and of sub-clinical psychosis symptoms is related to the individual's lifetime history of amphetamine use, i.e., cumulative quantity and frequency of exposure to amphetamines. In one of the only randomised trials of antipsychotic medications for treating amphetamine psychosis, Leelahanaj (2005) reported that olanzapine and haloperidol delivered at clinically relevant doses both showed similar efficacy in resolving psychotic symptoms (93% and 79%, respectively), with olanzapine showing significantly greater safety and tolerability than haloperidol as measured by frequency and severity of extrapyramidal symptoms. These outcomes are consistent with treatments for schizophrenia indicating equivalent efficacy between atypical anti-psychotics and conventional anti-psychotics, mostly haloperidol with older drugs causing more severe side effects (Leucht 1999).While anti-psychotic medications demonstrate efficacy in providing short-term relief when a heavy user of amphetamines experiences psychosis, there is no evidence to guide decisions regarding long-term clinical care using these medications for preventing relapse to psychosis.

 

摘要

背景

治療安非他命引起之精神病症狀

長期的安非他命使用者也許會有妄想及幻覺的經驗。長久以來相信dopamine antagonists，如chlorpromazine， haloperidol，及thioridazine可以有效治療安非他命引起之精神病症狀。

目標

評估治療安非他命引起之精神病症狀的風險，效益，成本。

搜尋策略

MEDLINE (1966 – 2007)，EMBASE (1980 – 2007)，CINAHL (1982 – 2007)，PsychINFO (1806 – 2007)，CENTRAL (Cochrane Library 2008 issue 1)，已取得文章之參考文獻。

選擇標準

評估所有用來治療安非他命精神病患者之療法(單一或合併治療)的隨機對照及臨床試驗(RCTs，CCTs)。

資料收集與分析

兩名作者分別獨立評估並摘錄資料。在意圖治療分析的基礎上摘錄類別資料，其中退出研究的人被分配到相當於具有最壞結果的參與者中。使用相對風險(Relative Risk (RR))之95%信賴區間(confidence interval (95% CI))以評估類別資料。加權平均差(Weighted Mean Difference (WMD))的95%信賴區間用以評估連續性資料。

主要結論

全面性檢索後發現一篇治療安非他命引起之精神病症狀的隨機對照試驗符合標準。研究包含58名參與者，並比較兩種抗精神病藥物對於治療安非他命引起之精神病症狀的功效及耐受性，包括olanzapine (一種新的抗精神病藥物)及haloperidol (一種普遍使用的抗精神病藥物作為對照)。結果顯示olanzapine及haloperidol在臨床相關的劑量下可以有效緩解精神病症狀，且測量錐體外徑症狀(extrapyramidal symptoms)的頻率及嚴重度時，相較於對照haloperidol，olanzapine顯示有明顯較佳的安全性及耐受性。

作者結論

僅一篇有關治療安非他命引起之精神病症狀的隨機對照試驗已發表。這篇試驗的結果指出，抗精神病藥物可以有效地減少安非他命引起的精神病症狀，相較於較易取得且普遍使用的藥物haloperidol，新一代且較昂貴的抗精神病藥物olanzapine證實有顯著較佳的耐受性。有其他兩篇不符合這篇回顧的納入標準的研究。這兩篇研究的結果顯示在注射抗精神病藥物一小時內也許會緩解煩躁及部分的精神病症狀。這項有限的證據是否可以應用於安非他命精神病患者尚未知曉。慣用的抗精神病藥物，新的抗精神病藥物及benzodiazepines應進行進一步的研究。然而，安非他命精神病症狀之自然觀察研究(naturalistic studies)與精神病症狀復發的盛行率對於指引發展適當的研究設計以進行安非他命精神病症狀的進一步治療研究也是很重要的。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

少數使用安非他命引起全面發作之精神症狀者需要在急診部門或精神病醫院接受照護。在這類的病例中，安非他命引起的精神病症狀通常包括偏執及被害妄想症，以及存在極度煩躁的幻聽和視幻覺。對於經常使用安非他命者較常見的(約18%)為臨床前的精神病症狀，且不需要密集的介入措施。臨床報告認為安非他命引起的精神病症狀及無臨床精神病症狀的發展與個人使用安非他命的病史有關，如安非他命的累積量及暴露頻率。在唯一一篇抗精神病藥物治療安非他命引起的精神病症狀之隨機試驗中，Leelahanaj (2005)報告olanzapine及haloperidol在臨床相關的劑量下顯示兩者對於解決精神病症狀具有相似的功效(分別為93%及79%)，且測量錐體外徑症狀(extrapyramidal symptoms)的頻率及嚴重度時，相較於對照haloperidol，olanzapine顯示有明顯較佳的安全性及耐受性。這些結果與治療精神分裂症的結果一致，其指出非典型的抗精神病藥物及慣用的抗精神病藥物間有相同的功效，大部分haloperidol伴隨其他較舊的藥物會導致嚴重的副作用(Leucht 1999)。當一個重度安非他命使用者經歷精神病症狀時，抗精神病藥物可以提供短期的緩解功效，但沒有證據可以指引有關長期臨床照護採用這些藥物可以預防精神病復發的結論。