See Article by Zhao et al

The rapid growth of the methamphetamine epidemic is well-documented in the United States and globally. According to the United Nations World Drug Report, between 2017 and 2018, methamphetamine use increased dramatically in the United States from 0.7% to 1.9% of the population (1.9 to 5.1 million people). To contextualize this number, in 2018, 3.7% of Americans (10.3 million people) reported opioid misuse within the last year.¹ However, currently, the meth epidemic does not seem to command the same or at least proportional national attention relative to the opioid crisis. This inattention may be due in part to a lower risk of immediate death caused by methamphetamine overdose as compared with opioids.¹ But, this is a different drug with its own M.O., equally dangerous and costly to society but more insidious in nature, its effects potentially causing decades of mental and physical debilitation before ending in premature death. Methamphetamine-associated cardiomyopathy/heart failure (MethHF) is just one disease entity that engenders the long-term human and economic costs of methamphetamine use. In this issue of Circulation: Cardiovascular Quality and Outcomes, Zhao et al² help to elucidate the magnitude and extent of these socioeconomic costs and refocus attention on the methamphetamine epidemic.

The sharp uptick in publications related to MethHF in recent years suggests its growing relevance to clinicians. MethHF is a severe form of dilated cardiomyopathy often afflicting younger males who present with biventricular failure or Takotsubo-like pattern.^3,4 Their hospital course is often complicated by consequences of heavy methamphetamine use such as hyperthermia, rhabdomyolysis, peripheral or coronary vasospasm, tachycardia, and hypertension.⁵ Management of these patients can be resultingly complex and costly, potentially entailing admission to an intensive care unit with longer length of stay and more procedures. Several case series characterizing the clinical severity and rising prevalence of MethHF have been reported throughout the western United States and Pacific Islands but they exist in isolation, both in time and space—retrospective, single-center experiences spanning variable time periods. A birds-eye perspective on the extent of the MethHF epidemic has remained elusive until now.

Zhao and colleagues set out to catalog where we were, where we are, and where we are going with MethHF. In an effort to determine geographic and temporal trends in hospitalization for MethHF between 2008 and 2018, the group queried heart failure admission data maintained by the State of California Health and Human Services Agency’s Office of Statewide Health Planning and Development (OSHPD), then cross-referenced cases with methamphetamine-related diagnostic codes. To further color the issue at hand, they abstracted data pertaining to health care costs, that is number of hospitalizations, length of stay, number of procedures, and charges made to the patients.

Population-level data from this study corroborates signals of increasing burden seen in prior MethHF studies. The data show clearly, and for the first time on such a large scale, a stable upward trend in age-adjusted rate of hospital admission for MethHF on a background of decreasing non-methHF admissions between 2008 and 2018. Cases were found to be rising uniformly across the state with geographic hotspots in rural areas—a not unexpected finding given that methamphetamine use is more prevalent, per capita, in rural areas of the United States.¹ The group also found the economic burden of rising MethHF admissions to be further saddled by higher rates of repeat hospitalization and more procedures compared with the average non-MethHF admission. But while the increasingly hot geographic map of cases and steady upward trajectory of costs is alarming, it still does not capture the whole picture of what is lost by society to the methamphetamine epidemic and MethHF.

The authors allude to an uncaptured cost of MethHF; many men and women afflicted with MethHF in this study were within their most productive years of life (35–64 years of age)—in stark contrast to those with non-MethHF (65–84 years of age). The World Drug Report quantifies this type of cost to society as disability-adjusted life years, which encompasses years of healthy living lost due to drug-related disability and years lost to premature death.¹ It is a useful measure to help grasp what is truly lost by both the individual and community and is particularly apt in the case of methamphetamine addiction given its tendency to debilitate over longer periods of time, by means of psychiatric and cardiac sequela, rather than by killing instantly. A monetary value for disability-adjusted life years is difficult to estimate as it is a loss of opportunity rather than an upfront cost, but can be expected be substantial given the young age at which patients develop MethHF. Zhao et al offer insight into another aspect of total costs related to MethHF, which is health care expenditure. They report that in 2018, $390.2 million was spent on MethHF admissions, 6.1% of all HF admission costs in California that year. A broader analysis of total cost was offered by the Rand Corporation in 2005, in their last national assessment of costs related to methamphetamine. They estimated the cost of excess health care use associated with use and dependence, productivity losses, methamphetamine-associated crime, production of methamphetamines, the intangible burden borne by those addicted, and child endangerment to be between $16.2 and 48.3 billion—a number that has likely increased exponentially at this time given the current prevalence of methamphetamine use and MethHF.⁶

What can we do to help these patients and reduce costs to our health care system? First, clinicians should understand that management of MethHF cannot end with volume optimization and must include efforts to avoid repeat hospitalization. The current study showed high rates of readmission; we can speculate that this is related to patients’ ongoing use of methamphetamines after discharge which not only exacerbates hemodynamics but also portends poor medication compliance, ultimately circling back to readmission. To provide real, durable benefit to the patient, while at same time reducing cost to the health care system and tax payer, engagement with substance use recovery services must be a priority of care. Importantly, cardiac dysfunction in MethHF may be recoverable in certain cases where replacement fibrosis is limited.⁷ Thus, achieving abstinence at an early stage of disease could have exponential lifetime returns for the patient and health care system.

Hospitals are often the first point of medical contact for patients with MethHF and therefore their presentation is an opportunity to alter the predetermined fate of recurrent HF admissions. However, studies have shown that, unfortunately, brief interactions such as emergency room encounters are unlikely to change the course of substance use.⁸ More effective and cost efficient results are seen within integrated systems of care, that is, primary care settings where medical and mental health providers can readily collaborate with substance abuse specialists to deliver comprehensive, long-term care.⁹ These models are becoming more common but are still underutilized due to issues of reimbursement, workforce shortages, stigma, and differences in treatment cultures.¹⁰ A concerted effort is still by health care administration, public health officials, and government to establish the infrastructure needed to properly address methamphetamine addiction and curb rising health care costs.

The rising prevalence of MethHF should ring alarm bells but also signals an opportunity. Until recently, MethHF was highlighted only in the form of isolated case reports but is now seen regularly in high usage areas. Although this study makes strides in underscoring the potential societal impact of this protracted illness, prospective data from larger cohorts may help clarify questions left unanswered by the current study. Importantly, we do not know which risk factors predispose to the development of MethHF, which prognostic factors may predict cardiac recovery or which medical therapies may benefit patients. Additional understanding may simultaneously benefit the patient and alleviate spiraling health care costs.

The work by Zhao et al has turned a spotlight on a public health crisis that has grown unfettered for over 2 decades. Now, it is up to the medical community to recognize and manage cases of MethHF with a comprehensive approach that addresses both mental and physical illness. Only then can we hope to properly help these patients and with that, reduce the socioeconomic burden of MethHF.

Disclosures None.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

For Disclosures, see page 803.

见赵等人的文章

甲基苯丙胺流行的快速增长在美国和全球都有充分的记录。根据联合国世界毒品报告，2017 年至 2018 年期间，美国的甲基苯丙胺使用量从占人口的 0.7% 大幅增加至 1.9%（1.9 至 510 万人）。将这个数字与这个数字联系起来，2018 年，3.7% 的美国人（1030 万人）报告了去年滥用阿片类药物的情况。¹然而，目前，与阿片类药物危机相比，冰毒流行似乎并没有引起同样或至少成比例的全国关注。这种疏忽可能部分是由于与阿片类药物相比，甲基苯丙胺过量引起的立即死亡风险较低。¹但是，这是一种不同的药物，有自己的 MO，对社会同样危险和昂贵，但本质上更阴险，其影响可能导致数十年的身心衰弱，然后导致过早死亡。甲基苯丙胺相关的心肌病/心力衰竭 (MethHF) 只是一种导致长期使用甲基苯丙胺的人力和经济成本的疾病实体。在本期《循环：心血管质量和结果》中，Zhao 等人²帮助阐明了这些社会经济成本的规模和程度，并将注意力重新集中在甲基苯丙胺流行病上。

近年来与 MethHF 相关的出版物急剧增加表明它与临床医生的相关性日益增加。MethHF 是一种严重的扩张型心肌病，常折磨年轻男性，表现为双心室衰竭或 Takotsubo 样模式。^3,4他们的住院过程常常因大量使用甲基苯丙胺的后果而变得复杂，例如体温过高、横纹肌溶解、外周或冠状血管痉挛、心动过速和高血压。⁵对这些患者的管理可能会因此变得复杂和昂贵，可能需要入住重症监护病房，住院时间更长，程序更多。在美国西部和太平洋岛屿上已经报道了几个描述 MethHF 临床严重程度和患病率上升的病例系列，但它们在时间和空间上都是孤立存在的——跨越不同时间段的回顾性单中心经验。到目前为止，对 MethHF 流行程度的鸟瞰仍然难以捉摸。

赵和同事开始编目我们在哪里，我们在哪里，以及我们将与 MethHF 一起去哪里。为了确定 2008 年至 2018 年间 MethHF 住院的地理和时间趋势，该小组查询了由加利福尼亚州卫生与公共服务局全州健康规划与发展办公室 (OSHPD) 维护的心力衰竭入院数据，然后交叉具有甲基苯丙胺相关诊断代码的参考案例。为了进一步说明手头的问题，他们提取了与医疗保健费用有关的数据，即住院次数、住院时间、手术次数和向患者收取的费用。

这项研究的人口水平数据证实了先前 MethHF 研究中看到的负担增加的信号。数据显示，在 2008 年至 2018 年非甲基HF 住院人数减少的背景下，甲基HF 的年龄调整住院率呈稳定上升趋势，这是首次如此大规模的数据显示。病例数呈上升趋势整个州的地理热点均位于农村地区——鉴于甲基苯丙胺使用在美国农村地区的人均使用率更高，这一发现并不出人意料。¹该小组还发现，与平均非 MethHF 入院率相比，更高的重复住院率和更多的手术进一步加重了 MethHF 入院率上升的经济负担。但是，虽然日益火爆的病例地理地图和成本稳步上升的轨迹令人担忧，但它仍然没有捕捉到社会因甲基苯丙胺流行病和甲基氢氟酸而损失的全貌。

作者提到了 MethHF 的未捕获成本；在这项研究中，许多患有 MethHF 的男性和女性都处于生命最富有成效的年龄（35-64 岁）——与非 MethHF 患者（65-84 岁）形成鲜明对比。《世界毒品报告》将这种社会成本量化为残疾调整生命年，其中包括因与毒品有关的残疾而损失的健康生活年数和因过早死亡而损失的年数。¹这是帮助了解个人和社区真正失去的东西的有用措施，并且特别适用于甲基苯丙胺成瘾，因为它倾向于通过精神和心脏后遗症而不是通过精神和心脏后遗症在更长的时间内使人虚弱瞬间杀人。残疾调整生命年的货币价值难以估计，因为它是机会的损失而不是前期成本，但考虑到患者发生甲基HF 的年轻年龄，可以预期它是可观的。Zhao 等人深入了解了与 MethHF 相关的总成本的另一个方面，即医疗保健支出。他们报告说，2018 年，3.902 亿美元用于 MethHF 入学，占当年加州所有 HF 入学费用的 6.1%。兰德公司在 2005 年对总成本进行了更广泛的分析，在他们对与甲基苯丙胺有关的成本的最后一次全国评估中。他们估计与使用和依赖、生产力损失、甲基苯丙胺相关犯罪、甲基苯丙胺生产、成瘾者承担的无形负担以及儿童危害相关的过度医疗使用成本在 16.2 到 483 亿美元之间——这个数字已经鉴于目前甲基苯丙胺使用和 MethHF 的流行率，此时可能呈指数增长。⁶

我们可以做些什么来帮助这些患者并降低我们医疗保健系统的成本？首先，临床医生应该明白 MethHF 的管理不能以容量优化结束，必须包括努力避免重复住院。目前的研究表明再入院率很高；我们可以推测，这与患者出院后继续使用甲基苯丙胺有关，这不仅会加剧血流动力学，而且预示着药物依从性差，最终会回到再入院。为了为患者提供真正、持久的利益，同时降低医疗保健系统和纳税人的成本，参与药物滥用康复服务必须是护理的优先事项。重要的是，在某些替代纤维化有限的情况下，MethHF 的心脏功能障碍可能是可以恢复的。⁷因此，在疾病的早期阶段实现禁欲可以为患者和医疗保健系统带来指数级的终生回报。

医院通常是 MethHF 患者的第一个医疗接触点，因此他们的介绍是一个机会，可以改变复发性 HF 入院的预定命运。然而，研究表明，不幸的是，急诊室遭遇等短暂的互动不太可能改变物质使用的过程。⁸在综合护理系统中可以看到更有效和更具成本效益的结果，即在初级保健环境中，医疗和心理健康提供者可以很容易地与药物滥用专家合作，以提供全面的长期护理。⁹这些模式正变得越来越普遍，但由于报销、劳动力短缺、污名化和治疗文化差异等问题，仍未得到充分利用。¹⁰卫生保健管理部门、公共卫生官员和政府仍在共同努力，建立必要的基础设施，以妥善解决甲基苯丙胺成瘾问题并遏制不断上涨的医疗保健成本。

MethHF 的日益流行应该敲响警钟，但也预示着一个机会。直到最近，MethHF 仅以孤立病例报告的形式突出显示，但现在经常出现在高使用率区域。尽管这项研究在强调这种长期疾病的潜在社会影响方面取得了长足进步，但来自更大队列的前瞻性数据可能有助于澄清当前研究未解决的问题。重要的是，我们不知道哪些风险因素易导致 MethHF 的发展，哪些预后因素可以预测心脏恢复或哪些药物治疗可能使患者受益。额外的理解可以同时使患者受益并减轻不断上升的医疗保健成本。

赵等人的工作使人们关注了一场持续了 20 多年的公共卫生危机。现在，医学界需要通过综合方法识别和管理 MethHF 病例，同时解决精神和身体疾病。只有这样，我们才能希望妥善帮助这些患者，从而减轻 MethHF 的社会经济负担。

披露无。

本文中表达的观点不一定是编辑或美国心脏协会的观点。

有关披露，请参阅第 803 页。