Substance Abuse Bruce L Houghton MD Division of

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 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

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 19 th century US Civil War heavy use Multiple ‘tonics’ and patent medicines late 1800 s

Heroin Use* Use Peaked 1960 s, decreased slightly in 1970 s and 1980 s and increased 1990 s 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 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 Five Substances of Abuse Accounted for 96% of all TEDS Admissions 2003 – Alcohol – Opiates (primarily heroin) – Marijuana/hashish – Stimulants (primarily Methamphetamine) Increase from 2% in 1993 42% 18% 15% 7%

Heroin Street Names Dope Horse Smack Tar Chemical name: diacetylmorphine

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 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 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 Respiratory depression, aspiration, pneumonitis, pulmonary edema Decreased mental status, miotic pupils, absent bowel sounds HIV, Hepatitis, cellulitis, abscesses

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 Naloxone – Pure opioid antagonist – 0. 1 to 0. 4 mg IV (or SQ or IM) – May repeat if needed

Opioid Withdrawal

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 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 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 Serious complications No benefit long term from other detoxification protocols Not recommended

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

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 – – – 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? Methamphetamine is synthesized by converting ephedrine or pseudoephedrine into methamphetamine via a series of steps usually involving additions of phosphorous and iodine

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

Equipment Needed 2 L. Pyrex vessel 2 L. 2 -neck round bottom flask Glass condenser (coil best) Steam distillation splashhead Pressure cooker and hot plate Buchner funnel & filter paper Glass stoppers & pvc tubing Oil bath & thermometer

Synthesis Steps Extract pseudo-ephedrine/ephedrine pills to purify. React with iodine + red P under heat Change the p. H to 14 with Na. OH 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 White Odorless Bitter-taste Easily dissolves in water or alcohol

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 Social issues – children Contamination – Law enforcement Explosions

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: A 576

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

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

METH Awareness And Prevention Project of South Dakota

Swat Team in Colorado Removing a child from A Meth House

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’ NEBRASKA Products 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 Medicine’ IOWA Products 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 Medicine’ FEDERAL The recently reauthorized USA Patriot Act creates a nationwide requirement for buyers of pseudoephedrine to show identification and sign a logbook Beginning Sept. 30 th 2006

OWH story March 20 th, 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 Le. Master, unit supervisor for the Southwest Iowa Narcotics Task Force.

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

Anhydrous Ammonia

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 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 1960 s and 1990 s Worldwide Epidemic: 180 million people consuming drugs 1990 s – 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 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) Social and health concern for 50 years Most popular illicit drug for the last 10 years

Annals NY Academy of Science 1025: 279 -287 (2004)

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

Why is it called Crank? Smuggled in crankcases of vehicles

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 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) 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 Five Substances of Abuse Accounted for 96% of all TEDS Admissions 2003 – Alcohol – Opiates (primarily heroin) – Marijuana/hashish – Stimulants (primarily Methamphetamine) Increase from 2% in 1993 42% 18% 15% 7%

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 2003 Sex – Male 55. 3% – Female 44. 7% Race – White (non-Hispanic) 72. 7% – Black (non-Hispanic) 2. 6% – Hispanic origin 15. 8%

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

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 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 Nucleus Accumbens Stimulated By Dopamine Major Reward Center of the Brain

Dopamine Receptors

Methamphetamine and Brain Chemistry Reuptake of Dopamine

Methamphetamine and Brain Chemistry Methamphetamine (and other Stimulants) block reuptake of Dopamine at the synapse. HIGH LEVELS of dopamine persist

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 “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

Some recovery Of dopamine Activity possible Volkow The Journal of Neuroscience December 1, 2001

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

Mayo Clinic Proceedings January 2006

Health Consequences Daily use Binge use – 24 to 72 hours – No sleep – High risk sexual activity Agitation, anxiety, acute paranoia Mimic schizophrenia

Re-calibrate your clinical suspicion

“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. ) 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

METH Awareness And Prevention Project of South Dakota

Health Consequences (cont. ) Dental Decay – Bruxism and clenching – Soft drink use – Dry mouth – Residual product of methamphetamine – Failure to floss

Drink of Choice

METH Awareness And Prevention Project of South Dakota

American Dental Association Website

Dr. Chris Heringlake, a dentist at the St. Cloud Correctional Facility in Minnesota Photo from NPR story online

American Dental Association Website

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

MSNBC story from August 2005 Series of mug shots of a methamphetamine user Over a 10 year period

Facesof. Meth. us Multnomah County Sheriff’s Department in Oregon Corrections Divisions Classification Unit, Deputy Bret King Mug shots and photos ‘before and after’

Eight Years of Meth Use

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

Mayo Clinic Proceedings January 2006

Acute Presentation of Methamphetamine Patient Acute paranoia and agitation Chest Pain Trauma Burns from explosion Shock Hyperthermia – Rhabdomyolysis, acute renal failure

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) – Med. Gen. Med. 2004 Dec 29; 6(4): 6 Delayed ischemic stroke associated with methamphetamine use (Japan) – J Emerg Med. 2005 Feb; 28(2): 165 -7

Hierarchy of Strength of Evidence for Treatment Decisions

Cardiac Chest pain Tachycardia Hypertension Pulmonary edema Dilated cardiomyopathy Endocarditis Aortic dissection Sudden Cardiac Death

Cardiac Pathophysiology High catecholamine state (similar to cocaine) – Norepinephrine and epinephrine Coronary vasoconstriction Hypertension Tachycardia

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 Dilated Cardiomyopathy ACEI or ARB Standard therapy for CHF *Avoid Beta Blockers if patient continues to use Methamphetamine

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 Hyperthermia Rhabdomyolysis Seizures Paranoia/psychosis/agitation/antisocial personality CVA Pulmonary from smoking Infections

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 BENZODIAZEPINES Haloperidol

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 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 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 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 139 HIV-negative heterosexual meth users Majority were male, Caucasian, highschool educated, never married, unemployed, and living with other adults Average 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 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 unprotected sexual 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 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 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 “. . . 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 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 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? 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 One of the most difficult drugs to maintain abstinence Only at the 5 yr clean and sober point does the relapse rate drop near zero

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

Treatment Paroxetine shown to decrease methamphetamine cravings in an eightweek study – An exploratory study: the use of paroxetine for methamphetamine craving. J Psychoactive Drugs. 2002 Jul. Sep; 34(3): 301 -4.

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

Treatment Psychotherapies are best option: - Cognitive-behavioral - Recovery Support Groups - 12 Step programs

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 W Editorial

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?

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? 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 How many of you saw this episode?

A single death is a tragedy; a million deaths is a statistic. – Joseph Stalin – Georgian Soviet politician (1879 - 1953)

Questions or Comments? Thank you for your attention

Online Resources http: //www. whitehousedrugpolicy. gov/ www. methresources. gov http: //www. samhsa. gov/ http: //www. facingthedragon. org

Online Resources www. drugabuse. gov http: //www. mappsd. org

National Institute on Drug Abuse http: //www. nida. nih. gov/Meth. Alert/Meth. Ale rt. html

METH Awareness And Prevention Project of South Dakota MAPP-SD http: //www. mappsd. org/Index. htm

Methamphetamine and Addiction www. drugabuse. gov http: //www. drugabuse. gov/pubs/teaching/T eaching 4. html

Recommended Sources M. Holley, M. D.

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

http: //www. oas. samhsa. gov/nsduh/2 k 4 nsd uh/2 k 4 results. htm#5. 1

Methamphetamine Statistics TEDS 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 There are 4448 hits on the word methamphetamine in our archive since 1983. – Ann Walding-Phillips Researcher Library. Link – Omaha World-Herald 809 hits over the last 2 years – Lexis-Nexis search 4 15 06

http: //www. decodog. com/default. html

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. ”