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Clandestine Meth Labs 2015

Medical Effects and Consequences of

Methamphetamine Use

ACMT / BIA Meth Lab Working Group

Jennifer Lowry, MD American College of Medical Toxicology Associate Professor, Pediatrics University of Missouri-Kansas City Children’s Mercy – Kansas City, MO

The Faces of Meth How Did We Get There?

2.5 Years Later Clandestine Meth Labs 2015

Objectives

l  Where Meth Works l  Routes of Abuse l  Phases and Patterns

of Abuse l  Short Term and

Long Term Effects


●  Methamphetamine is a central nervous system stimulant.

●  It interferes with neurotransmission. ●  It increases the release of the

neurotransmitters dopamine, norepinephrine and serotonin.

What is Methamphetamine?


●  Methyl group is key –  Amphetamine is a metabolite of methamphetamine –  Greater CNS penetration –  ~10X Longer duration of action than amphetamine

CH3

HN

H

CH3

CH3N

H

Methamphetamine Amphetamine

Toxicokinetics / dynamics

Pseudoephedrine Clandestine Meth Labs 2015

Dopamine is manufactured in nerve cells within the ventral tegmental area and is released in the nucleus

accumbens and the frontal cortex.

Why People Use Meth


What Happens in the Brain

l  Dopamine –  Responsible for enjoyment/pleasure –  Responsible for reinforcement

l  Frontal Cortex –  Behavior

l  Movement –  Substantia Nigra


Medicinal Use

l  Started with benzadrine (amphetamine) l  Military use - Pervitin l  Methedrine (Methamphetamine)

l  Now is a Schedule II agent


● Oral forms – The prescribed form ● Onset 20-60 min

Oral Administration

Desoxyn (methamphetamine) Clandestine Meth Labs

2015

● Sniffed powder ● Onset of action: 5-10 min

Intranasal methamphetamine


●  Inhalational form ● Onset of action: Less than 2 min

Crystal Meth (aka Ice)


● Onset of action: Less than 2 min

Intravenous Administration


What It Feels Like To Use Meth

l  Rush (5-30 min) - due to adrenal gland release of epinephrine putting the body into “fight or flight” mode and the explosive release of dopamine; –  effects are tachycardia, increased metabolism,

hypertension, palpitations; euphoria likened to the intensity of 10 orgasms (sexual rush)

l  High (4-16 hrs) - follows the rush and sometimes called the shoulder; feelings of aggression and “heightened intellect”


Short-term Effects of Meth Abuse

●  Increased wakefulness and physical activity and decrease appetite.

●  A brief, intense sensation, or rush, is reported by those who smoke or inject methamphetamine.

●  Oral ingestion or snorting produces a long-lasting high instead of a rush.

●  Both the rush and the high are believed to result from the release of very high levels of the neurotransmitter dopamine into areas of the brain that regulate feelings of pleasure.


●  Low intensity –  Casual use / often task-oriented –  Tend to swallow or snort –  Not addicted

●  Binge –  Psychological dependence –  May develop physical dependence –  Tolerance during binges (2 - 15 days) –  “Speed Runs” –  Develop Medical Problems

Meth Use Patterns


l  Binge (2-15 days) - continuation of the high but due to tolerance larger doses required to achieve same intensity until no rush or high felt; physical and mental hyperactivity

l  Tweaking - at the end of the binge when nothing will

take away the feelings of emptiness and dysphoria; often alcohol and heroin used during this time to ease the bad feelings; Irritable, psychotic symptoms, paranoid, violence more likely –  Myoclonic, jerking movements

A binge goes through several stages


When the binge is over

●  Crash (1-3 days) –  Follows binge or long period of high-intensity use –  Suffers from sleep deprivation and

neurotransmitter washout –  Similar to other stimulants (cocaine)

l  Post-binge – relatively normal –  Physical and psychological state slightly

deteriorated compared to pre-binge –  May depend on length of usage


When the binge is over

●  Withdrawal (30-90 days) –  No acute, immediate symptoms. Psychological

element strongest –  Depression (suicidal), lethargy, drug craving –  Relieved by

return to drug use

Volkow et al. J of Neuroscience 2001;21:9414-18.


Meth Use Patterns (cont)

● High intensity – Psychological and physical dependence – Tend to smoke or inject

l Rush – Entire life aimed at preventing crash -->Life dysfunction


High Intensity Use

●  Extreme Weight Loss (50-100 lbs.), Malnutrition ●  Belligerence, Aggression, Violence ●  Toxic Psychosis

–  Paranoia –  Hallucinations –  Hysteria –  Sleep Deprivation

●  Multiple medical complications ●  e.g. Stroke, Heart Failure


Classes of Clinical Effects

Early – during binge l  Adrenaline excess

–  Tachycardia –  Hypertension –  Tachypnea –  Dilated pupils –  Psychomotor

agitation l Hyperthermia

Late – at the end l  Adrenaline Depletion

–  Lethargy –  Unresponsive –  Normal vital signs –  Depression


Depends on Route

Chronicity of Use


Abstinence

●  Anergia: –  Decreased energy.

●  Anhedonia: –  Inability to experience pleasure, boredom: –  in contrast to the intense euphoria of the

drug experience, sharpens the users dissatisfaction with the current state.


Abstinence

●  Craving: –  Endogenous:

● "comes from within" or background craving, feelings of dysphoria.

–  Environmentally Cued: ● Craving stimulated by objects, persons

and situations associated with prior use


l  Vitals –  Tachycardia –  Hypertension –  Fast Respiratory Rate –  Hyperthermia

l  Neurological –  Stroke –  Seizures –  Tremors

l  Cardiovascular –  MI –  Dysrhythmias –  Necrotizing Angiitis –  Aortic Dissection

l  Pulmonary –  Wheezing –  Chemical Pneumonia –  Pulmonary edema

Clinical Features of Sympathomimetic Toxicity


Clinical Features of Symptomatic Meth Patients

l  Musculoskeletal –  Muscle Spasms –  Rigidity –  Rhabdomyolysis

l  Psychiatric –  Insomnia –  Anxiety –  Impulsive –  Irritability

l  Psychiatric –  Tremors –  Aggressiveness –  Paranoia –  Confusion –  Hallucinations –  Psychosis


l  Skin –  Sweating –  Lesions –  Formication

l  Mouth –  Dry mouth –  Bruxism –  Extensive tooth

decay

l  Gastrointestinal –  N/V –  Diarrhea –  Malnourished

l  Genito-urinary –  STDs (HIV) –  Dehydration –  Renal Failure –  Rhabdomyolysis

Clinical Features of Symptomatic Meth Patients


Other Meth Related Problems

–  Smoking-Related –  IV-Related –  Trauma –  Medico-legal –  Lab / Chemical

Exposures


Long-term Effects of Meth Abuse

●  Addiction ●  Tolerance for methamphetamine ●  Violent behavior, anxiety,

confusion, and insomnia ●  Psychotic features ●  Physical Appearance


Specific to Methamphetamine

l  Cardiovascular –  Stroke (Hypertension, Tachycardia, Vasculitis) –  Cardiomyopathy (Infarction, Catecholamine Use) –  MI, arrhythmias less likely

l  Neurologic –  Acute psychosis –  Kindling Effect –  Seizures Less Likely –  Movement Disorders

l  Neuropsychiatric Changes Clandestine Meth Labs

2015

Meth Mouth


The Faces of Meth

4 YEARS LATER Clandestine Meth Labs 2015

The Faces of Meth

3 MONTHS LATER Clandestine Meth Labs 2015

Chronic Effects


Meth & Pregnancy

●  Methamphetamine use and/or abuse during pregnancy can be fatal to the mother and result in spontaneous abortion of the fetus.

●  Methamphetamine has been shown to cause placental vasoconstriction and interfere with placental monoamine transporters.

●  Neonatal drug withdrawal symptoms requiring treatment have been reported.


Summary

l  Meth is a stimulant drug whose abuse has both acute and chronic effects

l  Various use patterns are known (low / high intensity, tweaking, etc.)

l  Acute effects are generally due to adrenergic excess l  Adrenergic depletion in the crash phase l  Chronic effects involve neurologic, psychiatric, and

dental deterioration plus much more


Questions?


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