# Presentation: 243679

## Methamphetaminean MCH perspective

- Diana Hu, MD
- February 26, 2005

## Case presentation 1

- 22 yo presents to ED with low back pain
- no prior history of trauma
- sudden onset that day
- no other symptoms

## Case 1

- past med history: known history of past drug abuse (“skin popping”) and alcohol abuse
- LMP not noted, hx irreg menses
- dx: low back strain
- rx: ativan

## Case 1

- < 24 hours later, patient delivers 35 week gestation infant in her car en route to health center
- transferred to OB unit
- mother’s urine tox screen positive for meth, THC, benzodiazapines
- infant urine tox (+) for meth

## Case 1

- because of no prenatal care and history of injectable drug use, baby given HepB vaccine/HBIG at birth
- rapid RPR negative, HIV negative
- discussed with DSS, child removed from custody of mother

## Case presentation 2

- 35 yo paraplegic G4 P2 SAB 1 presents in 1st trimester with urinary tract infection
- PMHx remarkable for paraplegia in adulthood secondary to T5-6 spinal cord injury post  MVC
- neurogenic bladder with frequent UTI

## Case 2

- SAB at 31 weeks gestation when mother had Serratia urosepsis 1 year ago
- known meth and alcohol abuse for many years, (+) meth at the time of last SAB
- history of depression and suicidal ideation in past
- FHx- boyfriend (+) meth, mother (+) EtOH abuse

## Case 2

- unplanned but desired pregnancy
- patient agrees to inpatient treatment of resistant UTI
- patient refuses counseling for known substance abuse or depression

## Case 2- progression 

- hospitalized x 2 for extended periods of time for treatment of recurrent UTI- E. Coli, pseudomonas
- allowed to go on pass during hospitalizations, (+) urine tox screen for meth both times immediately post home pass

## Case 2

- no consistent prenatal care in between hospitalizations
- confronted at 34 weeks gestation about need for rehab or possible DSS intervention-mother will not accept any services
- patient removes herself from hospital AMA

## Case 2

- presents in labor at 38 weeks
- uncomplicated vaginal delivery
- mother’s urine tox screen (+) for meth
- infant screen (+) for meth
- FOC and mother both confronted- refuse intervention
- infant removed from home by DSS

## Case 2

- mother has 2x week visitation with infant
- court ordered substance abuse treatment
- mother has not complied in 1st 6 weeks of baby’s life
- infant is thriving in foster care

## 2004 meth related crimes- Tuba City

-  4 cases resulting in assault (serious bodily injuries)
-  3 cases of assaults with a deadly weapon
-  1 assist with another agency
-  1 case of 1st degree murder (2 suspects/1 victim)
-  1 case of 2nd degree murder (1 suspect/1 victim)
-  10 cases involving meth/other narcotics (13 suspects)
-  1 suicide

## meth related crimes

- 38 individuals arrested for meth related crimes
- 9.5 lbs. of meth confiscated
- 350.5 lbs of marijuana
- 12  grams “heroin like substance”
- 16 meth dealers prosecuted
- 6 are also bootleggers
- 10% of all TC case load is related to drug use

## TC stats-2004

- 1/3 of all tox screens run in 2004 were (+) for meth
- 20% of HS students in TC admit to trying meth

## Methamphetamine:Physiology

- Average dose 50 – 200 mg
- Onset of action
- Oral: 30-60 min
- Nasal: 15-20 min
- Inhaled or injected: 1-3 min
- Canine LD-50 = 11 mg/kg
- Elimination half-life  and duration of action: 4 – 6 hours

**Notes:**
Half – life is dose-dependent, and also lasts longer with alkalinization of the urine

## Methamphetamine:Physiology

- Potent systemic sympathomimetic, α- and β-adrenergic direct and indirect effects

## Methamphetamine:Physiology

- Dopamine receptor stimulation and reuptake inhibition effects
- Serotonin receptor stimulation and reuptake inhibition effects

## Methamphetamine:Pathophysiology

- CENTRAL NERVOUS SYSTEM
- Hyperthermia/Hyperpyrexia (up to 108 F)  DIC
- Seizures
- Intracerebral hemorrhage
- Headache
- Choreoathetoid movements
- Hyperreflexia
- Cerebral vasculitis (chronic use)

## Methamphetamine:Pathophysiology

- PSYCHOLOGICAL
- 	Acute psychosis
- Hallucinosis
- Formication
- Homicidal/suicidal ideation
- Paranoia
- Anxiety
- Agitation
- Anger and aggression
- Euphoria
- Stereotypy

## Methamphetamine:Pathophysiology

- RESPIRATORY SYSTEM
- Tachypnea
-  Pulmonary edema

## Methamphetamine:Pathophysiology

- CARDIOVASCULAR SYSTEM
- Chest pain
- Hypertension
- Tachycardia
- Dysrhythmias (mostly ventricular)
- Myocardial ischemia/infarction
- Cardiomyopathy
- Vasospasm

## Methamphetamine:Pathophysiology

- GASTROINTESTINAL SYSTEM
- Nausea
- Vomiting
- Anorexia
- Diarrhea
- Constipation
- Xerostoma
- Unpleasant taste

**Notes:**
Well-described phenomenon  in cocaine toxicity is spontaneous duodenal perforation 

## Methamphetamine:Pathophysiology

- CUTANEOUS
- Diaphoresis
- Urticaria
- Erythematous painful rashes
- Ecthyma (infected deep ulcerations)
- Psoriatic symptoms

## Methamphetamine:Pathophysiology

- HEENT
- Mydriatic, sluggish pupils
- Bruxism

## Methamphetamine:Pathophysiology

- GENITOURINARY
- Rhabdomyolosis in overdose
- Difficult micturition

## Methamphetamine:Pathophysiology

- OBSTETRETIC
- Intrauterine growth retardation
- Placental abruption
- stimulation of premature labor

## Methmaphetamine- fetal effects

- thought to have similar effects to cocaine
- vasoconstriction related anomalies
- intrauterine CVA
- gut atresia secondary to mesenteric artery vasoconstriction
- ? Gastroschisis
- withdrawal syndrome
- jittery, difficult to console
- ?long term developmental consequences

## Methamphetamine- fetal effects

- meth DOES cross in significant amounts in breast milk
- but are the short term risks outweighed by the long term benefits of breast feeding if baby stays with mom?
- meth is volatilized in second hand smoke

## Methamphetamine:Pathophysiology

- LABORATORY ABNORMALITIES
- Leukocytosis
- Hyperglycemia
- Elevated CPK
- Elevated LFTs
- Myoglobinuria (or acellular hematuria)

## Methamphetamine:Clinical Presentation

**Rush** (5-30 min) –
- Adrenal gland release of epinephrine
- Explosive release of dopamine
- Intensely euphoric
- BP spike, dysrhythmias

## Methamphetamine:Clinical Presentation

**High **(4-16 hrs)
- “The shoulder”
- Feelings of aggression and heightened intellect
**Binge** (3-15 days)
- Continuation of the high
- Larger doses required to achieve same intensity
- Little or no rush or high felt
- Physical and mental hyperactivity

## Methamphetamine:Clinical Presentation

- “**Tweaking**”
- Follows a binge
- Feelings of emptiness and dysphoria
- Often alcohol and heroin used self-medicate
- Most dangerous state of cycle for law enforcement and medical personnel

## Methamphetamine:Clinical Presentation

- “**Crash**” or “**Washou**t” (1-3 days)
- Total excitatory neurotransmitter depletion
- No threat posed, lifeless and sleepy
**Withdrawal** (30-90 days) –
- Slow progression to depression, lethargy, cravings, suicidal thoughts
- MAP use during this period can alleviate dysphoria

## Treatment

- no medical antagonist/adjunct to treatment
- “cognitive behavioral model”
- 12 step program models
- success rates similar to alcohol treatment
- 10 individuals referred from TC in 2004

## So- the big question- DO WE SCREEN?

- If we screen
- universal?
- Targeted-
- with consent
- without consent
- If positive- what do we do?
- law enforcement role?
- DSS role?
- DBHS role?

## UNM policy

_**Guidelines for obtaining maternal and neonatal UDM **_
- 1) UDM should only be ordered for specific indications and should be sent on all patients with these indications:
- _Maternal UDM in OB triage or L and D _
- History of substance abuse in this pregnancy
- Preterm labor (Not POOC)
- Placental abruption
- Behavior consistent with acute intoxication

## UNM policy (cont.)

- _Neonatal UDM at newborn nursery _
- History of substance abuse in this pregnancy
- Preterm labor (Not POOC)
- Placental abruption
- Unexplained neonatal depression, seizures, jitteriness or possible neonatal
- abstinence syndrome

## UNM policy (cont.)

-  Informed consent
- Pregnant woman and postpartum mothers are to be informed that a UDM will be sent based on our standard guidelines. Written consent is not required. If they refuse to send a maternal UDM that request should be noted and honored. Parents do not have a legal right to decline a medically indicated infant UDM