I remember telling medical students that despite seeing patients every day who have substance use disorders, they probably wouldn't see a patient on meth while rotating with me. It was the one substance that stayed out of the office and, most of the time, out of the hospital, too.

In the past year, those patterns have changed -- a lot. Not only do I see an overall increase in meth use, I see it as a chronic medical problem.

West Virginia has the highest rate of opioid overdose deaths in the country and continues to find ways to stay at the top despite efforts at state and local levels to address the problem. And although we have some success stories to tell, we are nowhere near solving this complicated epidemic.

I think we are starting to do the right type of research that recognizes this isn't simply a case of overdiagnosing pain and overprescribing opiates, which is how the birth of the epidemic is often framed. There are heavy economic precursors to substance use in West Virginia, and people are starting to connect the dots of jobs, depression and drugs. And thankfully, we are starting to explore new treatment options as we understand the pathology of this process.  

I've never met a patient who is or was proud of their substance use, even those who were still using with no interest in cessation. Patients regret the first time they used, regardless of the substance, but heroin and meth are always at the top of that list. Patients tell me they wish they had never used the first time because they've not felt the same since.

Last week, as I started to think about writing this post, I realized I hadn't seen a positive drug screen for heroin in my patient population in approximately two years, but I have been keenly aware of the increasing frequency of tests that show meth. Unfortunately, patients often start using meth as a treatment for opiate withdrawal, which may be why we are seeing this trend.

As with any illicit substance use or other sensitive topics that a patient may not want their doctor to know about, the ways I find out about methamphetamine abuse are varied. I often get an ER note that includes a urine drug screen. My office has a rigorous and mandatory program for managing controlled substances, which includes random and scheduled urine drug screens even for medications like gabapentin. I obtain a urine drug screen before even placing a pain management referral.

It's not that I didn't see any drug screens positive for meth a few years ago, it's that I am seeing a significant increase now. And accompanying that increase is a more open dialogue with my patients.

Initially, I thought the problem simply was an increase in access. I've spoken to colleagues in other parts of the state (from both outpatient and inpatient perspectives), and they all agree that meth is currently the top substance being used based on their patient encounters. Data shows there is an increase in use dating back to 2017, when meth overdose deaths in West Virginia were seen to have risen 500% in four years.

But the overall increase in use isn't all that has changed. I now find myself counselling patients about their meth use more aggressively than I do about tobacco use, but with a similar approach. They know it is dangerous, they know it causes irrational behavior, but they also know it makes them feel amazing.

Unfortunately, the pharmacology of meth causes dopamine, serotonin and norepinephrine releases and even acts as a reuptake inhibitor, similar to antidepressant medications. But then, similar to opiates, the brain changes the way it responds to normal physiologic levels of neurotransmitters after the substance isn't available. The only way for the patient who has been using meth to feel "normal" is to use more meth. Euphoria comes with use, but depression, apathy and withdrawal follow.

There are similarities here to the cycle we see with opiates, but the irrational and often psychotic effects that come with meth intoxication are what has kept it out of the mainstream medical care setting. Law enforcement officers are the real experts on the acute phase, and they find meth more difficult to manage and are often forced to interact with dangerous patients to protect the patient and the public. My hometown made the news in September when a couple using meth hallucinated that they were being held hostage and created an explosive device to escape. It detonated.  

Another quality that makes meth use its own crisis is the drug's inherent variability. It is not a consistent substance because it is often homemade with different ingredients in each batch, or it can be purchased and cut with other substances. Heroin poses this same challenge, and it is this unknown ingredient list that gives these two substances high risks for overdose deaths.

Meth is also notorious for causing explosions and creating dangerous environmental exposures. During residency, the house next to mine exploded in the middle of the night and meth-making materials were strewn all over the yard the next morning.

Despite all I've said above about meth and its destructive forces, I feel something has changed, and it isn't just the increase in prevalence. My patients are going to the ER for chest pain when they use meth, then they see me for their follow-up visit. Maybe it's because I've been in the same small town long enough that I have a solid rapport with my patients or maybe it's because the stigma related to using meth has decreased as it has become more common. I am talking about managing stroke recovery from meth use, arranging for cardiology procedures due to ischemic damage and heart failure, and treating anxiety and depression. One of my patients was using meth in an attempt to lose weight initially and now he can't stop.

Occasionally, a patient is not happy when I confront them at an ER follow-up visit about a drug screen result that maybe they didn't even know was positive for meth. I've had patients leave the exam room before I'm finished seeing them during an acute meth intoxication, and the same thing happens in hospitals. But I also see cases where the hospital team had plenty of opportunity to realize the patient tested positive for meth but didn't discuss the result with the patient. I view these uncomfortable situations in two ways: 1) I owe patients full disclosure about the cause of their symptoms, and 2) meth use comes with significant modifiable risks that are my responsibility to address.

My approach to a patient who had a stroke due to meth use is no different than my approach to a patient whose diabetes contributed to stroke. They've had a stroke, and now my job is to help prevent the next one, to decrease the risk and to help the patient make changes. Honesty is paramount to the role we play as family physicians, but it must be mutual to be effective.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.

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