Current TEAP Issues: Methamphetamine and Legal Drug Abuse

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Current TEAP Issues Methamphetamine and Legal
Drug Abuse

• Pat Jackson RN
• Drew Alexander MD
• Winton King MD

Emerson Robinson DDS Magdalena Montes CADC I
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Overview

• Prescriptions Hit the StreetsOur Role
• Legal Drug Abuse Prevention on Center
• Methamphetamine Overview
• The Impact of Methamphetamine on the Oral
  Cavity
• Methamphetamine Prevention on Center

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Prescriptions Hit the StreetsOur Role

• Drew Alexander MD
• Regional Medical Consultant
• Region IV Job Corps

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Definitions

• Use Taking medication as prescribed or approved
  by the FDA (over the counter)
• Misuse Taking medication outside the prescribed
  or FDA approved label
• Diversion Sharing ones prescribed medication
  with another person
• Abuse DSM IV documented habituation or addiction
  or unauthorized distribution

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Use

• Professional dialogues with a patient or
  responsible party regarding purpose of the drug
• Verify the patient can read labels
• Educate regarding the wanted and unwanted
  medication effects
• Monitor the patients appropriate use
• Follow up to review the drugs continuing effect
  and treatment outcome

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Misuse

• The patient or responsible party does not
  understand or intentionally misuses drug
• A person in authority promotes misuse
• Patient or responsible party stands to gain by
  misuse such as getting high
• Health workers must ask how drug is used and
  manage misuse

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Prescriptions Often Misused

• Albuterol Inhalers for wheezing
• Dextromethoraphan for cough (2006 4
  to 7 abuse of 8th to 12th)
• Tylenol PM and Nyquil for sleep
• Pain Medications Tranquilizers and Sedatives
  like Oxycotin and Vicotin
• Alcohol-based preparations to get high like
  Nyquil and Cough Syrups ()

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Diversion

• Person named on drug label offers the
  prescription to help others
• Benefits are derived by offering a drug such as
  control of another or sales profit
• Health Workers must ask about diversion in
  particular with dispensing irregularity

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Prescriptions Often Diverted

• Tylenol PM
• Dextromethorpham
• Pseudoephedrin
• OxyContin (2006 increase 8th/10th) and Vicotin
• Alcohol-based preparations

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Manufacture and/or Sales

• Unauthorized preparation of experimental and
  creative drug formulations that provide people
  euphoria and pleasure
• Health workers must ask about the use of these
  drugs

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Heroin-Like Combinations

• Blue Velvet 60s
• Ts and Blues 70s
• Green Hornet 90s
• Cheese 2006 Dallas

• Tripelennamineelixir terpin hyrate codeine
• Tripelennamine and talwin
• Diphenylhydramine Dextromethorphan
• Diphenhydramine acetaminophen black tar heroin

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The Latest Craze

• Cheese Tylenol PM ground and mixed with heroin

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Summary/Recommendations

• On the street Rxs have many uses misuses
  diversions and abuses
• Health workers must take history in all four
  categories when assessing use
• Health workers must review the log or chart for
  dispensing regularity
• Health workers must minimize dispensing elixirs
  and inhalers that are psychoactive

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Summary/Recommendations (continued)

• Dispense in small increments like daily or
  weekend quantities
• Be aware of the psychoactive properties of the
  medications you prescribe
• Be aware of the current street formulary and how
  you may be supplying it

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Legal Drug Abuse Prevention on Center

• Magdalena Montes CADC 1
• Tongue Point Job Corps Center
• Astoria Oregon

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Abuse of Rx and OTC Medications In Job Corps

• Recent studies have highlighted medicine
  abuseboth prescription and over-the-counteras
  an alarming trend among young people. One of
  these is discussed here.

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Dextromethorphan (DXM)

• Approved by FDA in the 1950s
• Safe and effective
• Found in over 100 cough and cold medicines
• Most widely used cough suppressant in the U.S.
• DXM abuse involves taking extreme-well beyond the
  recommended does-amounts of cough medicine to get
  high

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Sample of Products with DXM

• Alka-Seltzer Plus Cold Cough Medicine
• Coricidin HBP Cough and Cold
• Robitussin cough products
• Dimetapp DM
• Sudafed cough medicines
• Triaminic cough syrups
• Vicks 44
• Vicks NyQuil and DayQuil Medicine

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Code Names for DXM or Specific Products

• Dex
• DXM
• Robo
• Triple Cs or CCC
• Skittles
• Syrup
• Tussin
• Velvet

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Code Names for Abusing DXM-Containing Cough
Medicines

• Roboing
• Robo-tripping
• Robo-fizzing
• Smurfing
• Skittling
• Syrup heads or robtards

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The High

• Similar to an ecstasy high
• Experience mild distortions of color and sound
• Strong visual hallucinations
• Out-of-body sensations
• Confusion
• Slurred speech
• Loss of motor control

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The Lows

• Delusions
• Panic attacks
• Memory problems
• Blurred vision
• Stomach pain nausea and vomiting
• High BP and rapid heart beat
• Numbness of fingers and toes
• Drowsiness and dizziness
• Fever and headaches
• Rashes and itchy skin
• Loss of consciousness

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What to Look for at JC

• Bottle/pill packs backpack locker etc.
• Arrival of unexpected packages
• Disappearance of cough and cold medicines from
  RAs office
• Unusual chemical or medicinal smells in bedroom
• Changes in eating or sleeping patterns declining
  grades loss of interest in friends and activities

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Prevention in Job Corps

• Control all prescription drugs taken by students
• Increase number of dose given to students as they
  show compliance and dependability
• Provide residential staff with information
  regarding the behaviors that may indicate use
  misuse and abuse of all drugs
• Provide student education regarding the
  consequences of inappropriate use of legal drugs

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Prevention (Continued)

• Conduct luggage inspections and package
  inspections when students arrive on center or
  return to center
• Provide students with a single does of legal
  prescription medications or OTC medications and
  send the remainder to the HWC directing the
  student to go to HWC in the morning to discuss
  medications
• Tell all staff to refer to the wellness center
  for an evaluation when in doubt
• Prevention/educationearly intervention can save
  lives

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Methamphetamine Overview

• Winton King MD
• Regional Medical Consultant
• Atlanta Region

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Common Slang Street Names

• Speed
• Crystal
• Chalk
• Ice
• Tina
• Glass
• Crank
• Uppers

• Most widely abused illicit drug in the world
  after marijuana

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Methamphetamine Types

• 3 types
• Dextro most potent and widely abused fewer side
  effects associated w/ drug traffic in Mexico
• Dextro-levo more difficult to make 2-3x less
  potent side effects (shakes stomach cramps)
  assocated w/ U.S. motorcycle gangs
• Levo found in OTC cold medicines least active
  effects cardiovascular system

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What is Meth

• Highly addictive stimulant
• Odorless bitter-tasting white crystalline
  powder
• Smoked snorted injected taken orally
• Sympathetic nervous system stimulant
• It can produce a high lasting anywhere from two
  to 16 hours
• Meth is very addictive and can produce severe
  withdrawal symptoms

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The Method of Use

• Smoking or injecting the drug is described as
  extremely pleasurable and considered more
  dramatic then cocaine. The user experiences a
  rush of euphoria almost immediately and the high
  lasts for about five minutes.
• Snorting or oral ingestion also produces a
  euphoria state but the high is not as intense.
  The effect of snorting begins within 3 to 5
  minutes and oral ingestion within 15 to 20
  minutes.

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History of Methamphetamines
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First Uses of Methamphetamine

• One of the earliest use of meth was during World
  War II
• Germans used chocolate dosed methamphetamies know
  as flyers chocolate and tankers chocolate.
  This was used to maintain prolonged wakefulness
  during the long stressful hours of sleeplessness.
• Hitler used methamphetamine as a treatment for
  depression and fatigue.
• Japanese especially Japanese suicide pilots
  used an injectable more potent form of
  methamphetamines to fuel their courage and
  stamina.

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Origin of Methamphetamines

• Methamphetamine commonly referred to as meth
  was first synthesized from ephedrine in Japan in
  1893
• The related compound amphetamine was first
  synthesized in Germany in 1887

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Methamphetamines Post-War

• 1950s
• Legally manufactured pills like dextroamphetamine
  (Dexedrine) and methamphetamine (Methedrine)
  became legally available to the American public
• The drug was prescribed for narcolepsy weight
  gain and mild depression
• The use and abuse of meth spread to college
  students truck drivers and athletes during
  these years

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Methamphetamines Post-War (Continued)

• 1960s
• The injectable form of the drug was manufactured
  clandestinely in home for personal use
• 1970s
• Amphetamines became illegal with the passage of
  the US Drug Abuse Regulation and Control Act of
  1970s

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Methamphetamines Post-War (Continued)

• 1980s
• With the increase of recreational use of meth
  San-Diego California was described as the
  methamphetamine capital of North America
• In the mid 80s the U.S government passed the
  Federal Controlled Substance Analogue Enforcement
  Act in an attempt to stop the use of meth and
  other drugs

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Methamphetamines Post-War (Continued)

• 2000s
• Methamphetamis is classified as a schedule II
  (Psychotropic substance) substance by the Drug
  Enforcement Administration.
• Currently it is only available as a prescription
  drug.
• In 2005 the Combat Methamphetamine Epidemic Act
  was passed putting restriction on the sale of
  methamphetamine precursors such as
  pseudoephedrine. This is because meth was being
  produced in home labs by purchasing over the
  counter precursors such as pseudoephedrine.

Home Meth Lab
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How does it work
Note the orange area here. This is called the
reward pathway it makes us feel good and as a
result we want to do whatever it is that made us
feel good again and again and again.
Methamphetamine acts on the brain reward
pathway by affecting a neurotransmitter called
dopamine neurotransmitters are the chemical
messenger which allow different parts of the
brain to communicate
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Dopamine
Dopamine is important for us to feel pleasure.
Too little dopamine can lead to depression and
too much dopamine can lead to mania.
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Whats the Downside

• Meth users suffer severe effects and
• consequences
• Depression
• Binge and crash pattern of use
• Crash phasetweakingoften includes feelings of
  anxiety and emptiness
• Addiction
• Brain damage

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What Comes After the High

• Irritability/aggressiveness/frustration
• Anxiety
• Depression
• Fatigue
• Paranoia
• Hallucinations or delusions
• Intense cravings for the drug
• Tremors
• Aggression
• Convulsions

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Long-term Effects

• Brain damage
• Memory problems
• Insomnia
• Decreased appetite and anorexia
• Increased heart rate and blood pressure
• Breathing problems
• Increased risk of stroke
• Increased risk of HIV/AIDS hepatitis B and C
  and other diseases from shared needles.
• Violent and aggressive behavior
• Behavior resembling paranoid schizophrenia
• Decreased social life
• Poor coping abilities

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Binge and Crash
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Withdrawal Symptoms

• Severe craving
• Insomnia
• Impatience
•  Mental confusion
•  Depression
• As a user practices abstinence from the drug they
  will have several symptoms ranging from
  depression anxiety fatigue paranoia
  aggression and an intense craving for the drug.
  A user may also experience anergia (decreased
  energy) anhedonia (find no pleasure in
  anything) or environmental cues (things/objects
  in your surroundings that create instant cravings
  or urges).

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Characteristics of Methamphetamine Psychosis

• Extreme paranoid ideation
• Emotional instability panic extreme fearfulness
• Aggression high potential for violence
• Well formed delusions
• Insomnia
• Hyperactivity disorder
• Lack of focus

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Special Concerns

• ADHD
• Youth with untreated ADHD are extremely
  susceptible to methamphetamine addiction
• Methamphetamine addicts with concurrent ADHD have
  even more severe problems with memory learning
  abstract thinking attention focus and verbal
  fluency
• Psychiatric Medications
• Regular methamphetamine use can also interfere
  with and have harmful interactions with
  prescribed psychiatric medications

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The Impact Of Methamphetamine On The Oral Cavity
Emerson Robinson DDS MPH Regional Dental
Consultant Philadelphia and Chicago Regions
Somes Provided By Joy Jordan DDS Cleveland
Job Corps Center
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Meth Mouth Harm Reduction 2006
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Meth Mouth

• Unaccounted for and accelerated tooth decay in
  teenagers and young adults
• Distinctive pattern of decay on the buccal smooth
  surface of the teeth and the interproximal
  surfaces of the anterior teeth
• Malnourished appearance in heavy users because
  methamphetamine acts as an appetite suppressant

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Meth Mouth
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Meth Mouth Symptoms

• Meth mouth is an informal name for advanced tooth
  decay attributed to heavy methamphetamine use.
  According to the American Dental Association
  Meth Mouth is probably caused by a combination
  of drug-induced psychological and physiological
  changes resulting in Xerostomia (dry mouth)
  extended periods of poor oral hygiene frequent
  consumption of high-calorie carbonated beverages
  and tooth grinding and clenching.

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Characteristics include

• Xerostomia (dry mouth) Methamphetamine use may
  decrease the production of saliva. A lack of
  salivas natural protective effects directly
  leads to increased tooth decay particularly at
  the GUMLINE.
• Many users consumer highly sugared soft drinks
  worsening the problem.
• Cracked teeth Methamphetamine induces clenching
  and grinding of the teeth leading to wear or
  cracks.
• Neglect of oral hygiene This is likely among
  the most important causes of poor oral health
  among methamphetamine users. After a prolong
  binges users may sleep for a day or more with
  their mouths open exacerbating the problems of
  poor saliva supply

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Meth Mouth
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Periodontal Disease

• Gum Disease - Teeth and gums need blood to stay
  healthy
• Meth causes the vessels that supply blood to oral
  tissues to shrink up
• Reduced blood supply causes tissues to break down
  
• With repeated shrinking the blood vessels dont
  recover and tissues die

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Meth Mouth

• The toxic and caustic ingredients involved in the
  making of the Meth including anhydrous ammonia
  (farm fertilizer lithium from batteries) and
  lighter fluid among other ingredients are very
  acidic and cause very aggressive erosion of
  enamel and decay formation. This is caused by
  acidic nature of the drug and dry mouth.

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Methamphetamine and Its Impact on Dental Care
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Methamphetamine and Its Impact on Dental Care

• The oral effects of methamphetamine use can be
  devastating. A distinctive caries pattern can
  often be seen on the buccal smooth surface of the
  teeth and the interproximal surfaces of the
  anterior teeth. Reports have described rampant
  caries that resemble early childhood caries. This
  is referred to as METH MOUTH.

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Radiograph Dental Caries
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Radiograph of Patient Before/After Meth Use
8 months later

• Before

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Caries Associated with Methamphetamine Abuse
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Caries Associated with Methamphetamine Abuse

• Rampant caries are one of the hallmarks of
  chronic methamphetamine abuse. The rampant
  caries associated with meth use are attributed to
  the following
• The acidic nature of the drug
• The drugs xerostomic (dry mouth) effect
• Its propensity to cause craving for high calorie
  carbonated beverages
• Tooth grinding and clenching
• Its long duration of action leading to extended
  periods of poor oral hygiene

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Ways Meth is Used

• If injected intravenously it causes no dental
  problems
• Nasal snorting causes some enamel problems
  because the substance goes down to the posterior
  nasal pharynx drains in the back of the throat
  and bathes the teeth with corrosive substances
• Chronic Meth smokers have teeth rotted to the gum
  line. Ether benzene freon and paint thinner
  are extremely dangerous materials used in Meth
  that affect dental health

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Meth Inhalant

• When a person smokes Meth these substances are
  heated vaporized and swirl throughout the users
  mouth. 
• They irritate and burn the sensitive skin inside
  the mouth create sores and lead to infection. 
• Chronic Meth smokers have teeth rotted to the gum
  line from the continuous affect of the vapors on
  tooth enamel.

it is not polite to turn a good smoke down.
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Xerostomia - Dry Mouth

• Saliva acts as a buffer against acidic substances
  in the mouth neutralizing it and protecting
  teeth against acidic foods like lemons acid from
  the gut or acidic plaque
• The average person creates around one liter of
  saliva a day 
• If saliva production is reduced oral bacteria
  levels can increase ten times over normal levels 

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Xerostomia (Continued)

• Meth dries out the salivary glands
• Without saliva the acidic substances can eat
  away at the minerals in tooth enamel causing
  holes or weak spots that turn into cavities
• Other medications dry the mouth but Meth is
  especially bad 

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Caries - Tooth Decay

• Meth users crave high sugar carbonated sodas
• The bacteria that feed on the sugars in the mouth
  secrete acid which leads to more tooth decay
• Also Meth users arent likely to brush rinse
  and floss when high 

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Harm Reduction Recommendations for the Dental
Practitioner

• Educate users about the risks associated with
  methamphetamine or any illicit drug use
• The speed and extent of decay from meth use is
  largely dependent on the users habits and the
  frequency of dental visits
• A lot of times our only choice is to extract the
  teeth and replace them with full upper and lower
  dentures

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What Are Our Obligations

• Your dental office should encourage a medical
  evaluation and referral to TEAP
• You dont have a legal responsibility to report
  drug use but the patient will benefit if you try
  to facilitate an intervention

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MethamphetaminePrevention on Center

• Magdalena Montes CADC 1
• Tongue Point Job Corps Center
• Astoria Oregon

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Identifying Meth Use in Job Corps Students

• Common complaints may include
• Difficulty sleeping
• Agitation or aggression
• Decreased motivation or ability to maintain usual
  activities
• Symptoms of depression and anxiety
• Decreased concentration or memory
• Psychotic symptoms such as paranoia and
  hallucinations

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Intervention for Methamphetamine

• Individual Assessment of
• Drug use history
• Medical and psychological state
• Social and family situation
• Medical and Psychological Detoxification
• Cognitive/Behavioral Chemical Dependency
  Treatment (as part of a continuum of services)
• Inpatient or
• Supervised/Structured Outpatient
• Step-Down to
• Halfway house or very structured independent
  living
• Aftercare

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Suggestions for Job Corps Centers

• Team Assessment by TEAP Specialist CMHC and
  Physician
• Consider MSWRs with assistance in finding
  treatment facility
• Increased 11s with TEAP Specialist
• Train ALL staff on recognition of methamphetamine
  behavior and the centers referral process
• Test when suspicious behavior is identified
• Provide ALL students with factual information
  about methamphetamine

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Treatment Challenges

• Methamphetamine addiction and withdrawal can
  resemble bipolar disorders and other mental
  illnesses
• Methamphetamine effects can last up to six
  months for this reason it takes much longer to
  treat a person with a meth addiction

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Resources

• SAMHSAs National Clearinghouse for Alcohol and
  Drug Information at 1-800-729-6686
  www.SAMHSA.gov.
• Informational Web sites
• www.whitehousedrugpolicy.gov
• www.nida.nih.gov
• www.preventiondss.org
• www.clubdrugs.org
• www.cadca.org
• www.usdoj.gov/dea/agency/domestic.htm
• www.usatoday.com/news/health