Substance Abuse

1. Substance Abuse Bruce L. Houghton, MD Division of General Medicine Department of Internal Medicine Creighton University School of Medicine

2. Acknowledge • Dr. Nipper • Dr. Malin • Dr. Hunter • Dr. Siefert • Dr. Wilwerding

3. Cover • Heroin • Methamphetamine

4. 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

6. HEROIN

7. 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

8. 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

10. 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

11. 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

12. 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

13. Heroin Street Names • Dope • Horse • Smack • Tar • Chemical name: diacetylmorphine

14. 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”

15. 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

16. 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)

17. Heroin Effects • Respiratory depression, aspiration, pneumonitis, pulmonary edema • Decreased mental status, miotic pupils, absent bowel sounds • HIV, Hepatitis, cellulitis, abscesses

18. 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)

19. Intoxication Heroin • Naloxone • Pure opioid antagonist • 0.1 to 0.4 mg IV (or SQ or IM) • May repeat if needed

20. Opioid Withdrawal

21. Opioid Withdrawal

22. 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)

23. 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

24. 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

25. Ultrarapid Detoxification • Serious complications • No benefit long term from other detoxification protocols • Not recommended

28. How many have seen a patient with methamphetamine problems? • Outpatient • Inpatient

29. 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

32. 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

33. 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

34. Materials Needed • Iodine crystals • Red Phosphorous (may replace with anhydrous ammonia) • Pseudo-ephedrine or ephedrine • Methanol • Toluene • Acetone • NaOH • Ice

35. 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

36. 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!

38. CHARACTERISTICS • White • Odorless • Bitter-taste • Easily dissolves in water or alcohol

40. 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

41. Meth Lab Concerns • Social issues • children • Contamination • Law enforcement • Explosions

42. 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

43. Number of US methamphetamine lab incidents in 2004 from the National Clandestine Laboratory Database. Total number was 17,033

44. 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

45. METH Awareness And Prevention Project of South Dakota

46. METH Awareness And Prevention Project of South Dakota

47. METH Awareness And Prevention Project of South Dakota

48. METH Awareness And Prevention Project of South Dakota

49. METH Awareness And Prevention Project of South Dakota

50. Swat Team in Colorado Removing a child from A Meth House