Methamphetamine:Who Really Gets Burned

Nathan Kemalyan, MD FACS

Medical Director, Oregon Burn Center

Credits:

Kelli Salter, M.D.

Surgical Resident, OHSU

Methamphetamine Drug Pharmacology

• A central nervous system stimulant that promotes the release of neurotransmitters (dopamine, norepinephrine, and serotonin) which control the brain’s messaging system for reward and pleasure, sleep, appetite and mood

• 1500% more potentthan cocaine

• Purely a syntheticcompound

Faster, Faster untilthe thrill of speedovercomes the thrillof death

Hunter S Thompson

"Appalachian Methamphetamine Lab"Pieter Boggle VIII

Methamphetamine: Historical Aspects

Adolf Hitler

JF Kennedy

Methamphetamine: Historical Aspects

• 1887: Amphetamine synthesized in Germany

• 1919: Methamphetamine synthesized in Japan

• 1930-40: Performance enhancer in WWII

• 1930s: Treatment for nasal passage inflammation, narcolepsy,attention deficit disorder, obesity and fatigue

• 1960s: First recreational use

• 1970s: Legal production > 10 billion tablets ( ~1000X legitimatemedical use)

• 1970: Amphetamine/Methamphetamine classified as aSchedule II drug

• 1980s: Illegal street forms popularized(injected, inhaled or taken orally)

Methamphetamine Historical Aspects

• 1988: Smokable form (ice or glass) introduced from Hawaii

• Prior to 1990s: Manufacture controlled by the “White MotorcycleGangs” using phenyl-2-propanone (P2P)

• 1998: Federal Chemical Diversion and Trafficking Act placedP2P under federal control

• 2003: Ephedrine (precursor) banned in its pure form in US(increased restriction on

pseudoephedrine)

• 2004: Identification required (in many states) to purchaseover-the-counter cold medications that

contain pseudoephedrine

• Today: 90% of the Methamphetamine available in United Statestransported from Mexico

Current Methamphetamine Statistics

• The second most common illicit drug used worldwide• 35 million regular users

• 12 million Americans have tried Methamphetamine• 40% from 2000; 156% from 1996• 1.5 million regular users

• 2003 National Survey: 5% of 8th graders and 15% of 12th graders have tried Methamphetamine once in their lifetime

• > 17000 clandestine labs seized in United States in 2004 (100% from 2002 and ~ 600% from previous decade)

• Over 50 recipes extracted from Internet Search

Oregon Statistics

• Number of Methamphetamine lab seizures in Oregon increased from 67 in 1995 to 591 in 2001

• Oregon was third in the nation for number of children (241) found at Methamphetamine labs during 2001-2002

• 2001: 2750 children (> half of all foster cases) were taken from parents using or making Methamphetamine

• Between 4300 and 5350 children retrieved from Methamphetamine homes have circulated in foster homes since 2001

• 2005: 472 labs and ~ 35 Kg Methamphetamine seized in state of Oregon (7,000,000 dosage units)

Methamphetamine Addiction Statistics

• 100 people: alcoholic drink/day X 3 weeks = 8/100 addicted

• 100 people: oral or snort Methamphetamine or Cocaine daily X 3 weeks = 14/100 addicted

• 100 people: smoke or inject Methamphetamine twice = 90/100 addicted

• Methamphetamine addict that wants to quit: After 11 months of not using, 100% of recovering addicts will use Methamphetamine if offered

Methamphetamine AssociatedHospital Admissions (2002)

General Impact on Burn Centers

• Need for decontamination (treat chemical and thermal burns)

• Clandestine production (“cooking”) of Methamphetamine involves > 30 different chemicals

• Increased incidence of trauma from explosions/projectiles• Emergency medical personnel injury• Withdrawal (higher sedation/narcotic use)• Majority of patients uneducated and uninsured• Extended length of stay• Greater excision and graft failure• Increased cost of treatment

Users and Cooks

• Cooks– Adult Male– Undernourished– Paranoid ideation– Agitated, impulsive– Vague, Implausible history of injury– Big burns, lots of critical care

Legitimate Organic Chemistry Production

• Highly Educated, Sober Operator

• Safety-Designed Facility

• Personal Protective Equipment

• Process Control

• Safety Practice

• Decontamination Facility and Emergency Response Plan

Methamphetamine Production Facility

• Hotel Room, Rental Apartment, Trailer, Tent• High School Dropout• Judgment is Impaired-High on Methamphetamine,

Cannabis, etc.• Agitated, impulsive, impatient• Smoking a Cigarette• Garbage Cans, Dry Ice and Kitchen Utensils• No Ventilation, No Plexiglas Shield, No PPE

Users and Cooks

• Cooks– Adult Male– Undernourished, poor dentition– Paranoid ideation– Agitated, impulsive– Vague, Implausible history of injury– Big burns, lots of critical care

• Users– All ages– Males and Females– Uneducated– Poly-substance users– Poor social/family resources– Difficult to discharge– Erratic follow-up, rehabilitation

Burn Center behavior patterns

• Recreational User– Goes to sleep, awakens 2-3 days later

• Hard Core User/Cook– Tachycardia, Hypertension, Agitation– Weeks in duration

Methamphetamine Associated Solvents

• Absorbed after ingestion, inhalation or dermal contact

• Associated Pathologies:• Pneumonitis; Respiratory depression

• CNS depression

• Hepatotoxicity

• Renal toxicity (pyuria, hematuria, acute renal failure)

• Ventricular arrhythmias

Methamphetamine Associated Caustics (Acids and Alkalis)

• Chemical Burns: Direct contact, ingestion, inhalation

• Associated Pathologies:• Pneumonitis; Respiratory depression• CNS depression• Hepatotoxicity• Renal toxicity (pyuria, hematuria, acute renal failure)• Ventricular arrhythmias

Methamphetamine AssociatedMetals and Salts

• Multiorgan toxicity• Skin burns

• Eye and Respiratory tract irritations

• Nervous system: Headache and seizures

• Gastrointestinal irritations (nausea, vomiting, diarrhea)

• Renal

• Hematological

Methamphetamine-Associated Burn Injuries:A Retrospective Analysis

• Retrospective review of medical records (507 burn patients)• 34 patients (6.7%) identified

• Mean Age: 31.9 7.65 years; 92% male• 41% tested positive for other illicit drugs (excluding alcohol)• Mean % TBSA: 18.9 % 20.72 % (range: 1.5-90%)

70.6% flame injury; 20.6% chemical injury• Drug withdrawal: 44.1% (agitation and hypersomnolence)• Average length of stay: 15.9 19.2 days (range 0-72)• Mean cost/patient: $77,580 (range: $112-$426,386)

• 69.6% unemployed• 11.8% with third-party insurance• 44.1% uninsured without government assistance• 44.1% supplemented with Medicaid or Medicare• 96.8% of cost related to length of stay, %TBSA and total days

on ventilator

Danks, R. R., Wibbenmeyer, L.S., Faucher, L.D., et al. J Burn Care Rehabil 2004; 25: 425-429

The Methamphetamine Burn Patient

• Retrospective study• 15 (2%) Age-matched and TBSA-matched patients

• Mean Age: 30 6 years• 10 male; 5 female

• Results:• Methamphetamine patients required at least 2-3X the

calculated volume of resuscitation, irrespective of burn size• All Methamphetamine patients with 40% TBSA burn died

(estimated 60% survival without Methamphetamine)

Warner, P., Connelly, J.P., Gibran, N.S., et al. J Burn Care Rehabil 2003; 24: 275-278

Methamphetamine Laboratory Explosions: A New and Emerging Burn Injury

• Retrospective study• 15 (4%) patients: Age-matched and TBSA-matched

patients to 45 patients• Mean Age: 35.5 years (range 21-48)• Mean burn size 36% TBSA

Methamphetamine Laboratory Explosions: A New and Emerging Burn Injury

• 87% Men• 93% Caucasian• 73% unemployed• 73% uninsured• 87% no college education

Methamphetamine Laboratory Explosions: A New and Emerging Burn Injury

• Tox Screen• 100% Methamphetamine• 66% two or more drugs (opiates,

benzodiazapines, cannabis)

Methamphetamine Laboratory Explosions: A New and Emerging Burn Injury

• Results:• Methamphetamine patients required at least 1.5-2X the

calculated volume of resuscitation, irrespective of burn %• 73% with inhalation injury: Mean 33 days on ventilator (17

days for control) • Skin graft loss 33% (12.5% for control)• Higher predicted need for sedation/pain control• Longer hospital stay: Mean 30 days (21 for control)• Higher mean cost/patient: $228,732 ($74,799 for control)

Santos, A.P., Wilson, A.K. Hornung, C.A., et al. J Burn Care Rehabil 2005; 26: 228-232

The Faces of Methamphetamine

“Meth Mouth”Source: New York Times, June 11, 2005

3 years, 5 months later

“Methamphetamine: You wished it would have

killed you the first time”- unknown author