Artist Riley Stolte grew up in Seattle around family members who struggled with substance use disorders.
By age 14, Stolte had started using drugs herself, and for the next 16 years battled heroin and methamphetamine addictions. That was until Stolte started taking Suboxone, an opioid-treatment medication that removed her desire for heroin.
But there wasn't any medication like that for meth. And because meth helped Stolte focus on her art, she struggled to stop using it -- even though, she says, it made her "psychotic."
"I told myself in my head, 'I can't do my art or paint without a little meth,'" Stolte said. "And I believed that, too."
Medications like Suboxone, which partially bind to the same opioid receptors in the brain as heroin without the high, are now considered a best practice for treating opioid-use disorder. But addiction to methamphetamine, which has rapidly overtaken heroin as the most common drug associated with overdose deaths in King County, has no equivalent drug treatment -- conclusive research on it simply doesn't exist.
Data from overdose deaths in King County shows that most involve a combination of opioids and stimulants, but deaths that involved methamphetamine hit a recorded high last year -- 204, more than quadruple the number in 2013 when it began to rise. Local research shows that it's harder for patients to get help and remain in treatment for opioid use disorder alone if they also struggle with methamphetamine.
The deaths are disproportionately striking King County's Black, Indigenous and homeless populations. Nearly 20% of all King County overdose deaths involving stimulants in 2019 were among people reported to be homeless. Nearly 16% of people who died were Black, even though Black people represent less than 7% of King County. American Indians and Alaska Natives represented more than 3% of the deaths, though they make up less than a percentage point of the overall King County population.
Coronavirus has made the search for an effective treatment for methamphetamine use disorder even more urgent. Restrictions on travel have disrupted global drug production and supply chains, according to a United Nations report on drug trafficking trends published in May.
As some users in the United States find methamphetamine more expensive or harder to come by, a new report from health care workers and advocates argues now might be a prime opportunity to get people into treatment -- and that it's time for cities to fund the research looking for solutions, specifically to see whether drug-based treatment for methamphetamine use disorder could help people.
But not everyone is optimistic.
Promising signals, but nothing conclusive — yet
The lack of treatment options for methamphetamine users is frustrating for Dr. Richard Waters, medical director of Neighborcare Health's Housing and Street Outreach Team. Nine years ago, when he started his residency in Seattle, meth use wasn't widespread. But in the past six years, it's skyrocketed alongside the West Coast's homelessness crisis, during which some people living on the street have reported using meth as a survival tool to stay awake and protect themselves at night.
According to a 2019 survey of clients at syringe exchange programs across Washington, nearly half who used methamphetamine said they were interested in reducing or stopping their use.
"I've had patients come to my office and cry because they want to stop using meth, but ... despite their strong desire to stop, they keep falling back in that cycle of craving use and then withdrawal," Waters said.
International research has given some signs of hope for a meth treatment medication.
In Australia, where 1.4% of people over age 14 have reported using methamphetamine or amphetamine within the past year, finding treatments for methamphetamine addiction has become a government priority.
Dr. Krista Siefried, a clinical researcher with The National Centre for Clinical Research on Emerging Drugs (NCCRED), published an Australian government-supported study in March reviewing the evidence for drug treatment in methamphetamine and amphetamine use disorder. The study looked at 43 different clinical trials testing 23 different medications, and found that five studies using a class of drugs known as psychostimulants showed "promising signals" for possible treatment, Siefried said.
The two psychostimulants that had research available to look at were methylphenidate, known as Ritalin in the United States, and dextroamphetamine, a stimulant used to treat ADHD and narcolepsy.
While the trials didn't show these drugs were successful at getting people to cut off their meth use completely, some studies had subjects who reported that they used meth less frequently or had fewer withdrawal symptoms.
Researchers' findings weren't particularly conclusive. Results were mixed and the studies measured and selected their outcomes differently, making them more difficult to analyze.
"We haven't yet struck that medication substitute that we can say really works," Siefried said. "We need more research."
To that end, a group of Seattle-based researchers, advocates and health care workers have put together a report asking local government to invest in the kind of research that would further investigate stimulant substitution therapy.
Dr. Judith Tsui, one of the authors of the report and an associate professor at the University of Washington Department of Medicine, has proposed a clinical trial to look at whether long-acting methylphenidate could be effective for people who are already prescribed methadone to treat their opioid addiction.
Her interest in finding a potential drug treatment stemmed from her own experience as a primary care provider at a methadone clinic, where patients would show up with various medical complications associated with their meth use, like heart problems, dental problems and psychosis.
"I think as a physician I felt helpless not having more options to have to offer more patients who were struggling with their methamphetamine use disorder," Tsui said.
Waters, of Neighborcare Health's Housing and Street Outreach Team, supports the idea of a randomized controlled trial like the one Tsui is proposing.
"I think that would be perfect for what needs to happen," Waters said. "There have been studies on methylphenidate before and the results offer a glimmer of hope."
But some in the addiction medicine community are skeptical -- including the doctor who treated Stolte's meth use with ADHD medicine, Dr. Richard Ries.
Ries, founder of the Mental Health and Addiction Services Department at Harborview Medical Center, said that from years of working with patients and conducting and reviewing research, he's only seen a very specific group of people benefit from medication: people with ADHD who are very committed to quitting their meth use and whose lives are otherwise relatively stable.
When Ries prescribed Stolte methylphenidate, or Ritalin, for her ADHD, she stopped using methamphetamine quickly.
"I noticed it right away pretty much. My thoughts slowed down, I felt kind of peaceful a little bit more -- and less running around and creating ruckus in the psych ward," Stolte said, laughing.
That was a year ago. On June 11, she woke up before 5 a.m. with a huge smile on her face. She'd been sober for a whole year, the first time since she was 14.
But people with ADHD are most likely a minority among meth users, although percentages vary widely study to study, Ries said.
One of the reasons Ries doesn't expect a substitute to work is because the high from methamphetamine is so much more powerful and releases so much more dopamine than heroin or prescribed ADHD meds, Ries said.
"To put it in alcohol terms, you've got a person who's drinking two fifths a day, and you say, 'OK, we're going to give you ... two shots of alcohol,'" Ries said. "If you're going to prescribe it and think that you're going to substitute it, you're going to have to find doctors somewhere who are willing to prescribe astonishing amounts."
Dr. Caleb Banta-Green, a principal research scientist at the UW's Alcohol and Drug Abuse Institute, convened a "meth summit" last year in Seattle to discuss interventions like the one Tsui has proposed studying. Banta-Green believes "there is some evidence for some medications that have had some benefits for some populations," such as prescribing Ritalin for meth users with ADHD or mirtazapine for users with depression. Banta-Green says it deserves more research.
"Pinning all your hopes on one particular medication doesn't make sense to me," Banta-Green said. "There's something there (with methylphenidate) ... but it's not as convincing, nearly, as what we've been seeing for opioids. And we've been looking for a long time."
A more favored approach among research scientists doesn't involve medicine at all. Called "contingency management," it's a system where patients get rewards for using drugs less frequently or stopping completely. But while multiple studies have reported the approach's success, it's not as effective for people living homeless, who are eight times more likely than housed participants to drop out of the treatment, one of the leading researchers told The Seattle Times last year.
British Columbia is trying a different tack. In late March, fearing that the pandemic would make the street drug supply even more dangerous, British Columbia started allowing health care workers to provide prescriptions of replacement drugs to users of street drugs. The strategy, called "safe supply," is intended to cut down on the number of overdoses for vulnerable people on the street, and for people who would be at risk of greater exposure to coronavirus through drug use.
Providence Healthcare's Crosstown Clinic, in Vancouver, B.C., had already been prescribing long-acting dextroamphetamine to a small group of meth users since 2016.
"Many who have tried it have cut down on their use," said Crosstown Clinic's physician lead, Dr. Scott Hanson. "We think it's effective, [but] it doesn't work for everybody in our population."
People looking for energy throughout the day tend to do better with the sustained-release dextroamphetamine tablets, Hanson said, rather than people looking for an immediate effect.
But while policymakers and health care workers debate treatments, Tsui stresses that the progress made in treating opioid use disorder could be undercut by failure to address co-occurring meth addictions.
“We have made great strides in improving access to opioid use disorder treatment,” Tsui said. “But if we cannot adequately address concurrent methamphetamine use, it may stand in the way of allowing patients to achieve their best treatment outcomes.”