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After reading the article you should be able to:

1. Describe prevalence of methamphetamine addiction.
2. Identify routes of ingestion and symptoms of intoxication.
3. Discuss nursing and medical management for a patient with methamphetamine addiction.

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By JASON CLARK, RN, CEN, PHRN

JASON CLARK is a flight nurse for Life Lion Aeromedical Service, Penn State Milton S. Hershey Medical Center, Hershey, PA. He is also a flight nurse for Life Flight, Geisinger Medical Center, Danville, PA. He has no financial relationships to disclose. EDITOR: KATHLEEN A. MOORE, RN, BS.

Crystal, glass, crank, ice, Tina. Patients who abuse methamphetamine add another dimension to nursing care. Here’s making sure you’re up to the challenge.

After marijuana, methamphetamine and other amphetamine-type stimulants are the most widely used illicit drugs worldwide.¹ In the United States, approximately 5% of adults have admitted to using methamphetamine at least once.² The drug's use in this country declined between 2002 and 2005. Yet, in 2005, an estimated 1.3 million people—741,000 males and 556,000 females—12 years of age and older admitted to using methamphetamine during the past year.³ Approximately 600,000 people are weekly users.²

A patient I'll call Tiffany Smither was one of them. I met her when the police summoned our aeromedical transport team to the scene of a single-vehicle accident. The 17-year-old had driven her car into a tree. In the back seat, the police found spray paint, plastic bags, a glass pipe, and other drug paraphernalia.

Ms. Smither was conscious when we arrived at the scene. Upon impact, her chest had hit the steering wheel; fortunately, she'd been wearing a seatbelt. In her pockets, we found syringes and an odorless, white powder, later confirmed to be methamphetamine. Her boyfriend, the unrestrained passenger, had been thrown from the car. We rushed the two victims to the nearest trauma center, where both were eventually admitted.

According to an analysis of hospital admission rates among adults and children age 12 and older, inpatient treatment related to methamphetamine/amphetamine use increased from 10 per 100,000 in 1992 to 68 per 100,000 in 2005.⁴ To help you safely care for patients admitted for trauma, medical conditions, or other problems associated with methamphetamine use, I'll share what I've learned about this form of substance abuse during my years as an emergency department (ED) and critical care nurse, and in my present job as a flight nurse first responder.

The good and bad of methamphetamine

Methamphetamine is a psychostimulant used to treat attention-deficit disorder, narcolepsy, and morbid obesity. It's a federal Drug Enforcement Administration schedule II drug, which means it has safe and accepted medical uses, but the potential for abuse is high. The drug is legally obtainable only by prescription, but is available illegally on the street. In its crystallized form, it's known as "crystal," "glass," "Tina," and "ice." For many, methamphetamine is the street drug of choice because it's less expensive and has longer-lasting effects than crack cocaine. While cocaine is metabolized, broken down, and removed from the body quickly, methamphetamine has a longer duration of action. It remains unchanged in the body, staying in the brain longer than cocaine and producing extended stimulated effects.

The drug has had a variety of uses over the decades. In the 1930s, it was used in nasal decongestants and bronchial inhalers for the treatment of bronchial asthma. Twenty years later, physicians used methamphetamine to treat alcoholism, Parkinson's disease, and depression. During World War II, the Korean and Vietnam Wars, and even Operation Desert Storm, amphetamine-type stimulants helped keep soldiers and pilots alert and combat ready.

The 1980s and '90s brought great surges both in the drug's recreational use and in its illegal production in clandestine laboratories. Recipes for the drug became readily available and production was—and still is—easily accomplished with the use of household chemicals and basic chemistry lab instruments. With these surges, the United States—as well as the international community—has witnessed a new "Ice Age." In the United States alone, there were 5,080 "methamphetamine lab incidents" just in 2007. Such incidents included the seizure of labs, equipment, and dump sites.⁵

Methamphetamine is a versatile drug. Users can ingest it, smoke it, snort it, insert it into the anus or urethra, or mix it with water and inject it intravenously—Ms. Smither's route of choice. Because of rapid absorption, which ensures an immediate "rush" or "flash," smoking and injecting are the most popular ways of using the drug. When injected, the rush lasts only a few minutes but produces extremely pleasurable sensations.

When the drug is snorted, its effects appear within five minutes. It produces a high but not an intense rush. For a more immediate response, hard users may grind glass into microscopic shards and mix it with the methamphetamine. When inhaled, the shards produce microscopic lacerations in the lining of the nose, allowing more rapid passage of the drug into the bloodstream. This practice predisposes the user to infection and causes irritation to the lining of the airways and potential bleeding.

Oral ingestion produces a high in approximately 20 minutes. The effects are not as pronounced as with other routes, but they last much longer—up to 12 hours.

How the drug affects the nervous system

Like cocaine, methamphetamine targets the central nervous system (CNS). It stimulates the release of dopamine and, in smaller amounts, norepinephrine and serotonin, and inhibits their reuptake. The neurotransmitter dopamine causes CNS excitation. It elevates mood, creates pleasurable feelings or euphoria, and enhances body movement and reflexes. Small doses of methamphetamine increase wakefulness, decrease appetite, and trigger the need for physical activ-ity. A single, high dose of methamphetamine will damage nerve terminals in areas of the brain containing the dopamine and serotonin neurotransmitters.

Life-threatening medical complications can occur with a dose of any size. Tachycardia, hypertension, and increased metabolism commonly occur, but more serious effects, such as hyperthermia, seizures, MI, stroke, and even death, are possible. For a list of the signs and symptoms of methamphetamine intoxication, see at end of this article.

Upon arrival in the ED, Ms. Smither was alert, tachycardic, hypertensive, restless, and at times, agitated. She had a heart rate of 140 beats per minute and a blood pressure of 166/94. Her temperature and oxygen saturation were near normal. The ED nurses were unsure if her restlessness, elevated BP, and rapid heart rate were signs of methamphetamine intoxication, or clues to a trauma-related condition yet to be determined. Computed tomography (CT) scans and X-rays of her head, limbs, chest, abdomen, and pelvis would help solve the puzzle.

Young adults, like Ms. Smither and her boyfriend, make up the largest group of recreational methamphetamine users.⁶ Recreational use can lead to addiction after a single dose, if the dose is high enough. As one user described it, the feeling produced by methamphetamine is intense and euphoric, "with the strength of 10 orgasms."

The drug is a powerful aphrodisiac. It enhances the user's sex drive and confidence, reduces inhibitions, raises adrenaline levels, and increases sexual stamina. These effects make sexual intercourse more likely, which in turn, significantly raises the risk of acquiring or spreading a sexually trans-mitted disease.¹ Indeed, HIV infection rates are higher in communities with significant methamphetamine use, primarily because of unprotected sex and the sharing of syringes.¹

Ironically, "meth with sex" eventually leads to impotence and sexual apathy, as the user requires higher and higher doses of the drug to maintain sexual stamina. As one patient revealed to me, "Meth became my sex partner, my life."

Changes in body image are inevitable

Methamphetamine abuse, particularly if chronic, leads to changes in physical appearance. Users may develop "meth bugs," which is slang for the wounds, infected wounds, scabs, and scars that result from obsessive picking at the skin. Patients feel as if their skin is crawling, or that a bug is tunneling under their skin. Even though they may know that nothing is there, they'll scratch, pick, and sometimes use needles, glass, or other sharp objects to "dig out," or get rid of, the sensation. This practice may reduce the distress, but puts the user at risk for disease, infection, and altered body image.

Chronic methamphetamine use damages the teeth and gums, a condition that users and healthcare providers call "meth mouth." One of the reasons meth mouth develops is because the chemicals used to make illicit methamphetamine—lithium, lye, ammonia, and red phosphorus, for example—cause xerostomia, or dry mouth, which promotes dental caries and periodontal disease. Other factors contributing to meth mouth include poor oral hygiene; tooth grinding and clenching; consumption of sugary, carbonated drinks; and inadequate protein nutrition.⁷

Other ingredients used to make methamphetamine—such as household chemicals, brake fluid, antifreeze, and paint thinner—are toxic to the skin and mucous membranes, as are the vapors created in the production process. These chemicals and fumes are also explosive. Meth users and clandestine manufacturers are often admitted to hospitals for blast-related trauma, chemical and thermal burns, and inhalation injury.

When responding to a methamphetamine lab explosion, emergency personnel will typically remove the victim's clothes and carefully decontaminate him before moving him into the transport helicopter or ambulance. Decontamination, which includes rinsing or flushing the affected areas of the body with water, removes as much of the toxic material as possible, slows the acceleration of chemical burning, and protects the rescuers from fume inhalation and chemical exposure.

Treating "meth burns" can be problematic because the exact chemicals used in the clandestine manufacture of the drug may not be known. Depending on the severity of the burns, victims of methamphetamine lab explosions may require care on specialized burn units, and may need even more aggressive fluid resuscitation than patients with other types of burns.⁸

The long-term effects of meth abuse

As addiction to methamphetamine worsens, users develop tolerance to the drug. To achieve the desired "high," depending on their personal sensitivity, they may need to increase the amount of methamphetamine used or change the route of administration. Users may embark on a "binge and crash" cycle, in which they try to maintain the euphoria for as long as they can, for one continuous episode. As soon as they feel the previous dose wearing off, they smoke or inject some more. Some users have reported that these episodes, or "runs," have lasted two weeks or longer.

The lack of sleep and nourishment that accompanies such episodes can lead to paranoia, psychosis, and unpredictable, violent, or risk-taking behavior. The user may turn to crime to pay for his drugs, or act in ways that contribute to acute medical problems, traumatic events, or life-threatening crises. Methamphetamine-induced paranoia and hallucinations can lead to rage, domestic violence, child abuse, murder, and suicide.

Women who use methamphetamine during pregnancy risk harming themselves and their fetuses. The drug can cause placental abruption, premature birth, fetal growth restriction, and congenital anomalies.^9-11 The newborn of a meth-addicted mother may exhibit withdrawal symptoms, including irritability, jitteriness, tremors, hypertonia, sleep pattern disturbances, and poor feeding. Children who were exposed in utero to methamphetamine may be more likely to experience cognitive and neurobehavioral disorders than other children.^9-11

Methamphetamine abuse damages neurons, causing long-term effects in the user. Even when users enter a drug rehabilitation program, anxiety, depression, insomnia, fatigue, memory loss, slowed thinking, decreased reflexes, and paranoia frequently occur during recovery. Because of their constant craving for the drug, recovering addicts typically encounter social, occupational, and economic hardships as well. Long-term psychological therapy is therefore essential.

Nursing care has an added dimension

As you can see, caring for the methamphetamine user can be challenging. In Ms. Smither's case, the ED nurses followed their trauma protocol and also monitored the patient for adverse effects and complications of methamphetamine use. They obtained a 12-lead EKG, which revealed sinus tachycardia but no evidence of myocardial ischemia or infarction. In addition to the necessary X-rays and imaging studies, they sent blood and urine for routine lab work, toxicology screening (for drugs of abuse, including amphetamine), and pregnancy testing. They also secured the forensic specimens requested by the state police, per protocol.

Ms. Smither's X-rays and scans revealed pulmonary contusions and a broken leg, but no other injuries. Her head CT and pregnancy test were negative. After ruling out other reasons for her agitation and elevated vital signs, the staff attributed these signs to pain and methamphetamine intoxication, a suspicion later confirmed by the lab. The nurses administered fentanyl (Sublimaze) for pain and midazolam (Versed) for sedation, bearing in mind that, because of drug tolerance, methamphetamine users often need higher doses of sedatives and pain medication.

Once her pain and agitation subsided, Ms. Smither's blood pressure and heart rate also began to normalize. The staff continued to monitor her, paying particular attention to her cardiovascular and neurological status, since the CNS and heart are the primary targets of meth's effects.

Ms. Smither was admitted for further observation and for pinning of her broken leg. She received lorazepam (Ativan) to prevent withdrawal symptoms, which typically include anxiety, restlessness, and agitation. She also received zolpidem (Ambien) to help her sleep at night.

With the help of social services and psychiatry, the young woman was discharged home to her mother, 10 days after admission, with arrangements for physical therapy and outpatient drug and psychological counseling. Her boyfriend, a mere 19 years old, didn't fare as well. After three days in the ICU, he died as a result of multisystem trauma and toxic ingestion.

Illicit methamphetamine wreaks havoc on individuals, families, and entire communities. It increases crime rates and risk-taking behaviors, and its production yields toxic waste that damages the environment, threatens public health, and requires costly clean up. The seizure of clandestine labs, along with laws restricting the sale of products containing ephedrine and other ingredients used to make methamphetamine, may be helping to curb the availability and use of this popular street drug. Education, by nurses and other professionals, to increase public awareness of the dangers of methamphetamine may also help reduce the number of "Ice Age" casualties.

References

1. Urbina, A., & Jones, K. (2004). Crystal methamphetamine, its analogues, and HIV infection: Medical and psychiatric aspects of a new epidemic. Clin Infect Dis, 38(6), 890.

2. Roehr, B. (2005). Half a million Americans use methamphetamines every week. BMJ, 331, 476.

3. Substance Abuse and Mental Health Services Administration. "The National Survey on Drug Use and Health (NSDUH) Report." 2007. www.oas.samhsa.gov/2K7/meth/meth.htm (15 Feb. 2008).

4. Substance Abuse and Mental Health Services Administration. "The DASIS Report: Geographic differences in substance abuse treatment admissions for methamphetamine/amphetamine and marijuana: 2005." 2008. www.oas.samhsa.gov/2k8/stateMethamphetamineTX/methamphetamines.cfm (15 Feb. 2008).

5. United States Department of Justice. "Maps of methamphetamine lab incidents (2007)." 2008. www.usdoj.gov/dea/concern/map_lab_seizures.html (16 Feb. 2008).

6. Substance Abuse and Mental Health Services Administration. "The National Survey on Drug Use and Health (NSDUH) Report." 2006. www.oas.samhsa.gov/2K5/meth/meth.htm (5 March 2008).

7. American Dental Association. "Methamphetamine use (meth mouth)." 2007. www.ada.org/prof/resources/topics/methmouth.asp (16 Feb. 2008).

8. Warner, P., Connolly, J. P., et al. (2003). The methamphetamine burn patient. J Burn Care Rehab, 24(5), 275.

9. Wouldes, T. LaGasse, L., et al. (2004). Maternal methamphetamine use during pregnancy and child outcome: What do we know? N Z Med J, 117. U118.

10. Smith, L. Yonekura, M. L., et al. (2003). Effects of methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr, 24, 17.

11. Smith, L. M., LaGasse, L. L., et al. (2006). The infant development, environment, and lifestyle study: Effects of prenatal methamphetamine exposure, polydrug exposure, and poverty on intrauterine growth. Pediatrics, 118(3), 1149.

Methamphetamine intoxication

Methamphetamine primarily affects the cardiovascular and central nervous systems, but an overdose can damage virtually any organ system. Some of the signs and symptoms of methamphetamine intoxication are listed below.

• Hyperthermia
• Euphoria
• Hallucinations
• Hyperreflexia
• Increased alertness
• Increased body movement/physical activity
• Insomnia
• Loss of appetite
• Paranoia
• Tachycardia
• Restlessness
• Tremors

Sources: 1. Derlet, R. "Toxicity, methamphetamine." 2006. www.emedicine.com/EMERG/topic859.htm (1 March 2008). 2. Malay, M. E., & Campbell, P. (2001). Unintentional methamphetamine intoxication. J Emerg Nurs, 27(1), 13. 3. Winslow, B. T., Voorhees, K. I., & Pehl, K. A. (2007). Methamphetamine abuse. American Family Physician, 76(8), 1169.

Clandestine meth labs

Citizens and law enforcement officials discover illegal methamphetamine labs every day, all across the United States, in apartments, motel rooms, vacant buildings, barns, the backs of trucks, the trunks of cars, and camouflaged in open fields. The operators of these illegal labs use household chemicals, brake fluid, antifreeze, batteries, matches, ammonia, paint thinner, and OTC cold medication to make methamphetamine, often adding other chemicals to increase the potency of the end product.

The chemicals used in the manufacture of methamphetamine are flammable, toxic, and highly volatile, as are the vapors produced when methamphetamine is "cooked" from a liquid to a crystal. Toxic inhalation, lab fires, and explosions often occur, particularly when the makeshift meth labs are located in closed, poorly ventilated spaces.

The illegal manufacture of methamphetamine also produces a large amount of toxic waste—an estimated five pounds for every pound of crystal meth that's made.¹ In rural areas, producers can easily pour the waste onto the ground and cover it with soil. In urban areas, they usually dump it down drains and into the sewer system. Toxic meth waste contaminates vast areas, posing health threats to those who come into contact with it. Cleanup of these sites is dangerous, time consuming, and expensive.

Source: 1. United States Drug Enforcement Agency. "Environmental impacts of methamphetamine." 2008. www.dea.gov/concern/meth_environment.html (5 March 2008).