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Substance Abuse. Bruce L. Houghton, MD Division of General Medicine Department of Internal Medicine Creighton University School of Medicine. Acknowledge. Dr. Nipper Dr. Malin Dr. Hunter Dr. Siefert Dr. Wilwerding. Cover. Heroin Methamphetamine. Objectives.

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substance abuse

Substance Abuse

Bruce L. Houghton, MD

Division of General Medicine

Department of Internal Medicine

Creighton University School of Medicine

acknowledge
Acknowledge
  • Dr. Nipper
  • Dr. Malin
  • Dr. Hunter
  • Dr. Siefert
  • Dr. Wilwerding
cover
Cover
  • Heroin
  • Methamphetamine
objectives
Objectives
  • Describe the history of methamphetamine in the Midwest
  • Discuss the pathophysiology of methamphetamine’s effect on the brain in addiction
  • Recognize common physical findings and features of patients who use methamphetamine
  • Describe treatment options for acute methamphetamine intoxication and complications
heroin definitions
Heroin (Definitions)
  • Opioids
    • Natural and synthetic substances with morphine like activity
  • Opiate
    • subclass of opioids consisting of alkaloid compounds extracted from opium
    • Morphine and Codeine
  • Heroin
    • Derivative of morphine
    • Most commonly abused opiate
opium derived from poppy plant
Used as early as 4000 BC

Morphine was purified from opium in 19th century

US Civil War heavy use

Multiple ‘tonics’ and patent medicines late 1800s

Opium derived from poppy plant
heroin use
Heroin Use*
  • Use Peaked 1960s, decreased slightly in 1970s and 1980s and increased 1990s
  • 2.4 million people used heroin at some point during their lives
  • 130,000 used sometime in last month
      • 1998 National Household Survey on Drug Abuse
treatment episode data set teds 2003
Treatment Episode Data Set (TEDS) 2003
  • Admission based system
  • Facilities that receive federal or state funding
  • Facilities that are licensed or certified by the State substance abuse agency to provide treatment
    • Does NOT include all admissions to substance abuse treatment
methamphetamine statistics teds 2003
Methamphetamine StatisticsTEDS 2003
  • Five Substances of Abuse Accounted for 96% of all TEDS Admissions 2003
    • Alcohol 42%
    • Opiates (primarily heroin)18%
    • Marijuana/hashish 15%
    • Stimulants7%
      • (primarily Methamphetamine)
      • Increase from 2% in 1993
heroin street names
Heroin Street Names
  • Dope
  • Horse
  • Smack
  • Tar
  • Chemical name: diacetylmorphine
heroin routes of administration
Heroin Routes of Administration
  • Snort (“snorting or sniffing”)
  • IV (“shooting up or mainlining”)
    • Most overdoses
    • Infection Risks
    • “Skin Popping”
  • Smoke “Chasing the Dragon”
    • More common in Asia
    • “Once Upon a Time in America”
purity
Purity
  • Often ‘cut’ with ASA or talc or sugar powdered milk
  • May only be 10 to 40% pure on the street
  • Deaths occur with increased purity of the heroin
heroin history and physical
Heroin History and Physical
  • Be direct
  • Amount of drug used
    • Dependent patients use 2 to 6 times per day
  • When last used
  • Route of administration
  • Previous attempts at treatment
  • Problems from the drug
  • Other drugs (alcohol, benzos, stimulants)
heroin effects
Heroin Effects
  • Respiratory depression, aspiration, pneumonitis, pulmonary edema
  • Decreased mental status, miotic pupils, absent bowel sounds
  • HIV, Hepatitis, cellulitis, abscesses
physical exam
Physical Exam
  • Track Marks (easily accessible veins)
    • Breast veins, dorsal vein penis, axilla, under fingernails, toes, fingers (to hide use)
  • Nasal Septum (snorting—perforation)
  • Cardiac murmur (endocarditis)
  • Cervical lymphadenopathy (HIV/AIDS)
  • Hepatic enlargement (hepatitis)
intoxication heroin
Intoxication Heroin
  • Naloxone
    • Pure opioid antagonist
    • 0.1 to 0.4 mg IV (or SQ or IM)
    • May repeat if needed
opioid withdrawal2
Opioid Withdrawal
  • Methadone
    • Tapering protocols available
    • CANNOT be used by physician for maintenance (outside of a licensed program)
    • May use for MAX of 3 days while patient waits to get into a program
    • OK to use for pain control
    • OK to use in acute hospital setting for detoxification for ‘non opioid addiction’ admission (infection, etc)
opioid withdrawal3
Opioid Withdrawal
  • Clonidine
    • alpha-2 adrenergic receptor agonist, reduces catecholamine release in the sympathetic nervous system and may decrease withdrawal symptoms in patients taking low doses of opioids
    • Up to 1.2 mg per day in divided doses used
    • 0.1 mg doses to 0.2 mg generally
opioid withdrawal4
Opioid Withdrawal
  • Rapid Detoxification
    • Protocols with opioid antagonists such as naloxone plus,clonidine with or without adjunctive medications such as benzodiazepines, antiemetics, and NSAIDs.
  • Ultrarapid Detoxification
    • General anesthesia while given large doses of naloxone to induce withdrawal and diuretic to remove narcotics
ultrarapid detoxification
Ultrarapid Detoxification
  • Serious complications
  • No benefit long term from other detoxification protocols
  • Not recommended
amphetamine history
Amphetamine History
  • Synthesized in 1887
  • 1920’s used as a stimulant
  • 1930’s abuse began
    • Marketed as Benzedrine nasal inhaler
  • Used in WWII for combat fatigue and for pilots
footnotes
Footnotes
  • Adolf Hitler reported to use amphetamines by injection
  • Japanese Kamikaze Pilots in WWII
  • James Bond used Benzedrine in Ian Fleming novels
  • Judy Garland given at an early age for weight control
  • James Ellroy (author of LA Confidential) used stimulants
  • 1959 the FDA made it a prescription drug in the United States
        • Wikipedia
how is meth made
How is “Meth” Made?
  • Methamphetamine is synthesized by converting ephedrine or pseudoephedrine into methamphetamine via a series of steps usually involving additions of phosphorous and iodine
materials needed
Materials Needed
  • Iodine crystals
  • Red Phosphorous (may replace with anhydrous ammonia)
  • Pseudo-ephedrine or ephedrine
  • Methanol
  • Toluene
  • Acetone
  • NaOH
  • Ice
equipment needed
Equipment Needed
  • 2 L. Pyrex vessel
  • 2 L. 2-neck round bottom flask
  • Glass condenser (coil best)
  • Steam distillation splash-head
  • Pressure cooker and hot plate
  • Buchner funnel & filter paper
  • Glass stoppers & pvc tubing
  • Oil bath & thermometer
synthesis steps
Synthesis Steps
  • Extract pseudo-ephedrine/ephedrine pills to purify.
  • React with iodine + red P under heat
  • Change the pH to 14 with NaOH
  • Steam distill using pressure cooker as a steam source
  • Extract the meth oily layer with toluene and crystallize the pure methamphetamine
  • Should be done in hood behind safety glass!
characteristics
CHARACTERISTICS
  • White
  • Odorless
  • Bitter-taste
  • Easily dissolves in water or alcohol
equipment
Equipment
  • Fits into a car trunk or closet
  • Recipes found on internet easily
  • Most ‘cookers’ learn from other cookers
    • One reference cited an average cooker teaches 10 other people over a year the technique
  • Over 80% of Methamphetamine comes from Mexico and other countries
meth lab concerns
Meth Lab Concerns
  • Social issues
    • children
  • Contamination
    • Law enforcement
  • Explosions
meth lab concerns1
Meth Lab Concerns
  • Toxins
    • Each pound of Meth produced yields 6 pounds of toxic waste*
    • Lye, acid, phosphorus in rivers/lakes
    • Methamphetamine residue on house interior
      • Who is going to rent the house next?
  • Crime
    • Booby traps in labs
    • Trip wires, hidden sticks with nails or spikes, and light switches or electrical appliances wired to explosive devices
          • *Holton WC.  Unlawful lab leftovers. Environ Health Perspect. 2001;109:A576
slide43

Number of US methamphetamine lab incidents in 2004 from the

National Clandestine Laboratory Database. Total number was 17,033

slide44

A Meth cook found dead in a Southern California motel room, overcome by

phosphrine gas - created when red phosphorus is overheated.

METH Awareness And Prevention Project of South Dakota

slide50

Swat Team in Colorado

Removing a child from

A Meth House

smurfs
Smurfs
  • Little gatherers in the cartoon
  • Pseudo-Smurfing
    • The phenomenon of drug dealers crossing state lines to buy pseudoephedrine -- sometimes known as "pseudo smurfing"
    • Cross state lines when OTC cold medication laws passed in one state.
legislation about otc cold medicine
Legislation about OTC ‘Cold Medicine’
  • NEBRASKAProducts containing pseudoephedrine must be behind store counters or in locked cabinets; purchases limited to 1,440 milligrams, or 48 adult doses, in any 24-hour period, unless a doctor prescribes more
  • Took effect in September 2005
legislation about otc cold medicine1
Legislation about OTC ‘Cold Medicine’
  • IOWAProducts containing pseudoephedrine must be sold only by licensed pharmacists; purchases limited to 7,500 milligrams in a 30-day period, unless doctor calls for more; buyer must show ID and sign logbook
  • Took effect in May, 2005
legislation about otc cold medicine2
Legislation about OTC ‘Cold Medicine’
  • FEDERALThe recently reauthorized USA Patriot Act creates a nationwide requirement for buyers of pseudoephedrine to show identification and sign a logbook
  • Beginning Sept. 30th 2006
owh story march 20 th 2006
OWH story March 20th, 2006
  • "It's one of the few laws in my 22 years in law enforcement that I've seen make an impact so quick…"
  • Iowa has seen an 80 percent decrease in labs, and in Pottawattamie, Mills and Harrison Counties, the number has dropped 27 percent,
  • Nebraska reported a 70 percent decrease in the first four months after its law took effect.
    • Terry LeMaster, unit supervisor for the Southwest Iowa Narcotics Task Force.
80 of meth comes from i 80 from large labs mexico and in california
80% of Meth comes from I-80 from large labs Mexico and in California

A ditch in

Mexico with boxes of

Cold Medicine from a

Methamphetamine Lab

how to decrease theft
How to Decrease Theft
  • Take delivery of tanks just before you expect to use them and return them as soon afterward as possible
  • Place tanks in easily observed areas
  • Bleed pressure and remove tank hoses when not in use
    • one hose contains enough ammonia to make a batch of meth
  • If you own your own nurse tank, add a lock and cover
      • http://extension.unl.edu/Meth/index.html
profile of methamphetamine users
Profile of Methamphetamine Users
  • 1.2 million used stimulants
    • including 583,000 methamphetamine users
    • Similar to 2003 data.
    • (National Survey on Drug Use & Health) NSDUH 2004 data
methamphetamine epidemics 1960s and 1990s
Methamphetamine Epidemics1960s and 1990s
  • Worldwide Epidemic:
  • 180 million people consuming drugs 1990s
    • 29 million use amphetamine-type stimulants
    • More than cocaine and opiates combined
        • United Nations Office for Drug Control, Crime Prevention (UNODCCP). World Drug Report 2000
japan
Japan
  • After World War II, intravenous Methamphetamine abuse reached epidemic proportions.
  • This was due to the fact that the Japanese military had large amounts of Methamphetamine stock piled and after the war, made it available to the public.
japan annals ny academy of science 1025 279 287 2004
Japan Annals NY Academy of Science 1025: 279-287 (2004)
  • Social and health concern for 50 years
  • Most popular illicit drug for the last 10 years
methamphetamine street names
Speed

Meth

Chalk

Ice

Crystal

Crank

Glass

Poor Man’s Cocaine

Zip

Tina

Stove Top

Oz

Hillbilly Crack

Peanut Butter

Lemon drop

Cinnamon

Tick tick

Methamphetamine Street Names
why is it called crank
Why is it called Crank?
  • Smuggled in crankcases of vehicles
production history
Production History
  • During the 1970’s and the 1980’s, the biker gangs such as the Hell’s Angels were responsible for 90% of the methamphetamine produced in the United States.
distribution
Distribution
  • This changed in the late 80’s because the Mexican gangs/mafia began manufacturing Meth in Mexico and smuggling it into the U.S.
  • The biker gangs then began purchasing Meth from Mexico because it was cheaper and easier than manufacturing their own.
treatment episode data set teds 20031
Treatment Episode Data Set (TEDS) 2003
  • Admission based system
  • Facilities that receive federal or state funding
  • Facilities that are licensed or certified by the State substance abuse agency to provide treatment
    • Does NOT include all admissions to substance abuse treatment
methamphetamine statistics teds 20031
Methamphetamine StatisticsTEDS 2003
  • Five Substances of Abuse Accounted for 96% of all TEDS Admissions 2003
    • Alcohol 42%
    • Opiates (primarily heroin) 18%
    • Marijuana/hashish 15%
    • Stimulants7%
      • (primarily Methamphetamine)
      • Increase from 2% in 1993
treatment episode data set teds 20032
Treatment Episode Data Set (TEDS) 2003
  • Average Age of Admission
    • Methamphetamine age 31 years
    • Marijuana 23 years
    • Cocaine (smoked 37 years) (non-smoked 34)
    • Heroin 36 years
  • Route of Methamphetamine administration reported
    • 56% smoking
    • 22% injection
    • 15% inhalation
methamphetamine statistics teds 20032
Methamphetamine StatisticsTEDS 2003
  • Sex
    • Male 55.3%
    • Female 44.7%
  • Race
    • White (non-Hispanic) 72.7%
    • Black (non-Hispanic) 2.6%
    • Hispanic origin 15.8%
objectives1
Objectives
  • Describe the history of methamphetamine in the Midwest
  • Discuss the pathophysiology of methamphetamine’s effect on the brain in addiction
  • Recognize common physical findings and features of patients who use methamphetamine
  • Describe treatment options for acute methamphetamine intoxication and complications
cocaine vs methamphetamine
Plant-Derived

50% removed from the body in 1 hour

Duration 8 minutes

Man-made

50% removed from the body in 12 hours

Duration 8 hours

Cocaine vs. Methamphetamine
methamphetamine forms and time to effect
Methamphetamine Forms and Time to Effect
  • Intravenous
    • 15 to 30 seconds
  • Smoked
    • Immediate
  • Snorted
    • 3 to 5 minutes
  • Ingested
    • 15 to 20 minutes
street prices
Street Prices
  • Methamphetamine*
    • One ‘hit’ (about a quarter gram) $25
  • Cocaine**
    • $80 to $100 per gram
    • One Rock $40
        • *www.pbs.com
        • **http://www.clarkprosecutor.org/index.htm
methamphetamine and brain chemistry
Methamphetamine and Brain Chemistry

Nucleus

Accumbens

Stimulated

By

Dopamine

Major Reward

Center of the

Brain

methamphetamine and brain chemistry2
Methamphetamine and Brain Chemistry

Methamphetamine (and other

Stimulants) block reuptake of

Dopamine at the synapse.

HIGH LEVELS of dopamine persist

slide87

These PET scans

show that dopamine

receptor levels are

lower in

methamphetamine

abusers than

in control subjects.

High dopamine

receptor levels

appear red,

while low levels

appear

yellow/green.

Volkow

American Journal of Psychiatry

December 2001

neurologic effects of methamphetamine
Neurologic Effects of Methamphetamine
  • “Rush” follows methamphetamine use
    • Dopamine, serotonin, epinephrine
  • Increase levels of dopamine
    • Inhibits reuptake and increase release at synapse
  • Nucleus Accumbens---stimulated by dopamine
    • Major ‘reward’ center in the brain (addictive behaviour)
  • Prolonged use results in chronically depressed dopaminergic activity
slide89

Some recovery

Of dopamine

Activity possible

Volkow

The Journal of

Neuroscience

December 1, 2001

objectives2
Objectives
  • Describe the history of methamphetamine in the Midwest
  • Discuss the pathophysiology of methamphetamine’s effect on the brain in addiction
  • Recognize common physical findings and features of patients who use methamphetamine
  • Describe treatment options for acute methamphetamine intoxication and complications
health consequences
Health Consequences
  • Daily use
  • Binge use
    • 24 to 72 hours
    • No sleep
    • High risk sexual activity
  • Agitation, anxiety, acute paranoia
  • Mimic schizophrenia
tweaking
“Tweaking”
  • Term for psychosis from Methamphetamine
  • Sleep deprived
  • Extremely irritable and paranoid
  • Higher risk for violent behavior
    • Especially if confronted
    • User will sometimes ingest alcohol (which can make violence more likely)
        • National Drug Court Practitioner Fact Sheet, April 2000, Vol. II, No. 2
health consequences cont
Health Consequences (cont.)
  • Rapid weight loss
    • Sympathomimetic effects
  • Skin lesions
    • Obsessive/excessive picking and scratching
      • “Meth Mites” or “Meth Bugs”
    • May become infected
      • Cellulitis
      • Abscesses
    • MRSA infections reported
      • Clin Infect Dis 2005 May 15;40(10):1529-34
slide97

METH Awareness

And Prevention

Project of

South Dakota

health consequences cont1
Health Consequences (cont.)
  • Dental Decay
    • Bruxism and clenching
    • Soft drink use
    • Dry mouth
    • Residual product of methamphetamine
    • Failure to floss
slide103

Dr. Chris Heringlake, a dentist at the St. Cloud Correctional Facility in

Minnesota

Photo from NPR story online

health consequences cont2
Health Consequences (cont.)
  • Rapid ‘aging effect’ seen in heavy methamphetamine users
    • Weight loss
    • Skin lesions
    • Dental decay
    • Decline in overall appearance
      • Socioeconomic factors
      • General hygiene
slide106

MSNBC story from August 2005

Series of mug shots of a methamphetamine user

Over a 10 year period

facesofmeth us
FacesofMeth.us
  • Multnomah County Sheriff’s Department in Oregon
  • Corrections Divisions Classification Unit, Deputy Bret King
  • Mug shots and photos ‘before and after’
objectives3
Objectives
  • Describe the history of methamphetamine in the Midwest
  • Discuss the pathophysiology of methamphetamine’s effect on the brain in addiction
  • Recognize common physical findings and features of patients who use methamphetamine
  • Describe treatment options for acute methamphetamine intoxication and complications
acute presentation of methamphetamine patient
Acute Presentation of Methamphetamine Patient
  • Acute paranoia and agitation
  • Chest Pain
  • Trauma
  • Burns from explosion
  • Shock
  • Hyperthermia
    • Rhabdomyolysis, acute renal failure
selected case reports
Selected Case Reports
  • Many case reports and series from Hawaii
    • Cardiology cases
  • Methamphetamine toxicity secondary to intravaginal body stuffing (Arizona)
    • J Toxicol Clin Toxicol. 2004;42(7):987-9
  • Methamphetamine-associated shock with intestinal infarction (Nebraska)
    • MedGenMed. 2004 Dec 29;6(4):6
  • Delayed ischemic stroke associated with methamphetamine use (Japan)
    • J Emerg Med. 2005 Feb;28(2):165-7
cardiac
Chest pain

Tachycardia

Hypertension

Pulmonary edema

Dilated cardiomyopathy

Endocarditis

Aortic dissection

Sudden Cardiac Death

Cardiac
cardiac pathophysiology
Cardiac Pathophysiology
  • High catecholamine state (similar to cocaine)
    • Norepinephrine and epinephrine
  • Coronary vasoconstriction
  • Hypertension
  • Tachycardia
acute therapy for chest pain with methamphetamine
Acute Therapy for Chest Pain with Methamphetamine
  • Benzodiazepines
  • Calcium Channel Blockers for heart rate
  • IV Nitrates
    • Maybe Nipride for hypertension?
  • AVOID BETA BLOCKERS
    • Unopposed alpha constriction
    • Similar to cocaine-associated MI therapy
    • ?Labetalol?
      • Weak alpha and beta blocker???
long term meth use
Long Term Meth Use
  • Dilated Cardiomyopathy
  • ACEI or ARB
  • Standard therapy for CHF
  • *Avoid Beta Blockers if patient continues to use Methamphetamine
cardiomyopathy tip of the iceberg
Cardiomyopathy: “Tip of the Iceberg”
  • Retrospective review of medical records of 21 crystal methamphetamine users.
  • RESULTS: Nineteen (84%) underwent echocardiography with consistent findings of dilated cardiomyopathy and global ventricular dysfunction
      • Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg?J Toxicol Clin Toxicol. 2003;41(7):981-6.
      • Department of Medicine, University of Hawaii, Honolulu, Hawaii
meth patient presentation
Meth Patient Presentation
  • Hyperthermia
  • Rhabdomyolysis
  • Seizures
  • Paranoia/psychosis/agitation/antisocial personality
  • CVA
  • Pulmonary from smoking
  • Infections
much is supportive care and deal with the complications
Much is supportive care and deal with the complications
  • Head CT if altered mental status
  • CBC, Basic Metabolic Profile
  • CPK
    • Rhabdomyolysis
    • Troponin if cardiac damage concern
  • EKG
  • Pregnancy test
  • LOW threshold for STD testing
  • Calm, quiet environment
agitation from methamphetamine
Agitation from methamphetamine
  • BENZODIAZEPINES
  • BENZODIAZEPINES
  • BENZODIAZEPINES
  • BENZODIAZEPINES
  • Haloperidol
methamphetamine and burn units
Methamphetamine and Burn Units
  • 17,033 Meth Lab Seizures by Law Enforcement in 2004
  • Increased costs and time in treating Meth lab burn patients
    • Require more sedation (withdrawals) and pain medication than others
    • More trauma from projectiles (glass, etc)
    • Thermal and Chemical Burns
        • JAMA October 26, 2005 Vol 94 No 16
methamphetamine and sexual risk behavior
Methamphetamine and Sexual Risk Behavior
  • Men who have sex with men (MSM)
    • Methamphetamine use 10 times higher than general population
    • High among both HIV-uninfected and HIV-infected MSM
      • 10% to 20% reporting recent methamphetamine use
        • Medscape Colfax 10 17 05
        • Purcell DW, Parsons JT, Halkitis PN, Mizuno Y, Woods WJ. Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. J Subst Abuse. 2001;13:185-200.
        • Stall R, Paul JP, Greenwood G et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men's Health Study. Addiction. 2001;96:1589-1601.
        • Morin SF, Steward WT, Charlebois ED, et al. Predicting HIV Transmission Risk Among HIV-Infected Men Who Have Sex With Men: Findings From the Healthy Living Project. J Acquir Immune Defic Syndr. 2005;40:226-235.
methamphetamine and sexual risk behavior1
Methamphetamine and Sexual Risk Behavior
  • Circuit parties (weekend-long dance party events) attended by MSM participants
    • 43% reported methamphetamine use in a 72-hour period
      • Medscape Colfax 10 17 05
      • Purcell DW, Parsons JT, Halkitis PN, Mizuno Y, Woods WJ. Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. J Subst Abuse. 2001;13:185-200.
      • Stall R, Paul JP, Greenwood G et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men's Health Study. Addiction. 2001;96:1589-1601.
      • Morin SF, Steward WT, Charlebois ED, et al. Predicting HIV Transmission Risk Among HIV-Infected Men Who Have Sex With Men: Findings From the Healthy Living Project. J Acquir Immune Defic Syndr. 2005;40:226-235.
the context of sexual risk behavior among heterosexual methamphetamine users
The context of sexual risk behavior among heterosexual methamphetamine users
  • Descriptive study (interviews)
  • Explored context of sexual risk behavior in HIV-negative, heterosexual meth-using men and women
    • Drug use history
    • Motivation for drug use
    • Relationship types
    • Social-sexual context of meth use
        • Addict Behav. 2004 Jun;29(4):807-10
sample characteristics san diego ca
Sample CharacteristicsSan Diego, CA
  • 139 HIV-negative heterosexual meth users
  • Majority were male, Caucasian, high-school educated, never married, unemployed, and living with other adults
  • Average age 38.6 years
  • 29% reported having one or more STDs in the past 2 months
    • *This may be why patients present to access healthcare system*
the context of sexual risk behavior among heterosexual methamphetamine users1
The context of sexual risk behavior among heterosexual methamphetamine users
  • Primary motivations for current meth use
    • Get high, get more energy, and to party
  • Participants reported an average number of 9.4 sex partners over 2 months
  • Mean number of unprotectedsexual acts over a 2-month period
    • Vaginal 21.5
    • Anal 6.3
    • Oral 41.7
        • Addict Behav. 2004 Jun;29(4):807-10
methamphetamine and hiv
Methamphetamine and HIV
  • Methamphetamine use is independently associated with HIV infection
    • Even after controlling for
      • Sexual partners
      • Unprotected sex
        • Colfax G. Confronting the methamphetamine epidemic: an HIV prevention priority. Program and abstracts of the 2005 CDC HIV Prevention Conference. Atlanta, Georgia; June 12-15, 2005.
methamphetamine and hiv1
Methamphetamine and HIV
  • Adherence to Antiretroviral Therapy (ART)
    • Probably the largest risk factor---emergence of resistance
  • Methamphetamine increases replication of feline immunodeficiency virus (related to HIV)
    • ?clinical significance but interesting
  • Neurotoxicity of methamphetamine and HIV are synergistic (may both affect dopamine receptors)
        • Medscape Colfax G 10 17 05
methamphetamine and sexual activity
Methamphetamine and Sexual Activity
  • “...sexual episodes during which methamphetamine is used are far more likely to be associated with high-risk sexual behavior compared with episodes during which methamphetamine is not used…”
      • Medscape Colfax G 10 17 05
      • Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men. Am J Epidemiol. 2004;159:1002-10
methamphetamine and stds
Methamphetamine and STDs
  • Increased risk-taking with methamphetamine use
  • Condom breakage with methamphetamine use
  • Aggressive sex with more fissures, bleeding
  • Immunosuppressive factors
  • Changes in blood flow with methamphetamine use
        • Medscape Colfax G 10 17 05
meth and hiv www lifeormeth com
Meth and HIVwww.lifeormeth.com
  • Meth makes users feel hypersexual and uninhibited, heightened orgasm
  • L.A., 2004: 1 out of 3 HIV+ men reported using meth
  • % of HIV+ men using meth has tripled since 2001
meth withdrawal
Meth Withdrawal?

Mixed evidence....

  • No physical manifestations of a withdrawal syndrome is recognized by experts at this time

Rather, appears majority of symptoms are psychiatric and emotional…

  • Depression
  • Anxiety
  • Fatigue
  • Paranoia
  • Aggression
  • Intense drug cravings
treatment
Treatment
  • One of the most difficult drugs to maintain abstinence
  • Only at the 5yr clean and sober point does the relapse rate drop near zero
psychiatric issues
Psychiatric Issues
  • Psychiatric disorders accompany methamphetamine abuse (preexist the methamphetamine use)
    • Rule more than the exception
    • Poor impulse control
    • Childhood trauma
      • Mayo Clinic Proceedings
      • January 2006
treatment1
Treatment
  • Paroxetine shown to decrease methamphetamine cravings in an eight-week study
    • An exploratory study: the use of paroxetine for methamphetamine craving.J Psychoactive Drugs. 2002 Jul-Sep;34(3):301-4.
treatment2
Treatment
  • No pharmacologic options available to assist for meth abstinence as no single agent has been proven efficacious in clinical studies
  • Some studies with buproprion show ↓craving
  • Antidepressants, antipsychotics, and anxiolytics are utilized wide-spread for both acute intoxication and residual psychiatric sequelae
treatment3
Treatment
  • Psychotherapies are best option:

- Cognitive-behavioral

- Recovery Support

Groups

- 12 Step programs

united states drug abuse awareness
United States Drug Abuse Awareness
  • If a US drug abuse epidemic fails to include a major east coast city, can it be called an epidemic?
    • J Addict Dis. 2002;21(1):1-4
      • Rawson RA, Simon SL, Ling WEditorial
epidemic
Epidemic?
  • If a tree falls in a forest and no one is there to hear it, does it make a sound?
  • If a US drug abuse epidemic fails to include a major east coast city, can it be called an epidemic?
slide148

Methamphetamine

Treatment

Admission

Rates

Per 100,000

RED 50+

Grey 10 to 50

Green less than 10

Office of

National

Drug

Policy

Control

why the slow recognition of methamphetamine epidemic
Why the Slow Recognition of Methamphetamine Epidemic?
  • National News Media
    • Greater attention to East Coast public health concerns
  • Hawaii and California are a ‘long way’ from Washington, DC
saturday night live good morning meth skit november 12 th 2005
Saturday Night Live “Good Morning Meth” SkitNovember 12th, 2005
  • How many of you saw this episode?
slide151
A single death is a tragedy; a million deaths is a statistic.
    • Joseph Stalin
    • Georgian Soviet politician (1879 - 1953)
questions or comments
Questions or Comments?
  • Thank you for your attention
online resources
Online Resources
  • http://www.whitehousedrugpolicy.gov/
  • www.methresources.gov
  • http://www.samhsa.gov/
  • http://www.facingthedragon.org
online resources1
Online Resources
  • www.drugabuse.gov
  • http://www.mappsd.org
national institute on drug abuse
National Institute on Drug Abuse
  • http://www.nida.nih.gov/MethAlert/MethAlert.html
meth awareness and prevention project of south dakota
METH Awareness And Prevention Project of South Dakota
  • MAPP-SD
  • http://www.mappsd.org/Index.htm
methamphetamine and addiction
Methamphetamine and Addiction
  • www.drugabuse.gov
  • http://www.drugabuse.gov/pubs/teaching/Teaching4.html
recommended sources
Recommended Sources

M. Holley, M.D.

M. Holley, M.D.

recommended websites
Recommended Websites

For the health care professional:

  • nida.nih.gov

- covers each drug of abuse

- contains several links to more specific sites

- recently published articles

For the patient:

  • Crystalrecovery.com
  • Mamasite.net
  • Methamphetamineaddiction.com
slide160
http://www.oas.samhsa.gov/nsduh/2k4nsduh/2k4results/2k4results.htm#5.1http://www.oas.samhsa.gov/nsduh/2k4nsduh/2k4results/2k4results.htm#5.1
methamphetamine statistics teds 20033
Methamphetamine StatisticsTEDS 2003
  • Proportion of admissions increase from 2% (1993) to 7% (2003)
  • Criminal Justice System as Source of Referral to Treatment Program
    • Primary marijuana (57%)
    • PCP (52%)
    • Methamphetamine (51%)
methamphetamine and omaha world herald stories
Methamphetamine and Omaha World Herald stories
  • There are 4448 hits on the word methamphetamine in our archive since 1983.  
    • Ann Walding-Phillips
      • Researcher
      • LibraryLink
    • Omaha World-Herald
  • 809 hits over the last 2 years
    • Lexis-Nexis search 4 15 06
meth lab clean up
Meth Lab Clean-up
  • http://www.hhs.state.ne.us/enh/riskasse/exposchem.htm
  • “There is currently no official federal guidance or regulations on how to clean up a former meth lab for reoccupation. Utilizing an environmental company trained in hazardous substance removal and cleanup is the safest way to deal with the property but may be cost prohibitive. Often property owners choose to remove and cleanup a former meth lab themselves. These guidelines are designed to assist with the cleanup.”