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Smoking Out Meth Use


 

With methamphetamine use spreading across the country like a flu epidemic, hospitalists see more meth addicts and deal increasingly with the physical and psychiatric conditions common in these individuals. In overcoming the challenges and frustrations of working with these patients, hospitalists in regions where meth use is rampant have become experts of sorts, and they have messages for their colleagues nationwide: Learn our lessons, because you could be next.

The Meth Evolution

Methamphetamine has become popular for obvious reasons. The drug is cheap, and because it is manufactured using common and easily obtained ingredients, it is accessible anywhere.

The meth epidemic is not a new phenomenon. It started in the 1970s in the American heartland—Iowa and parts of Missouri. Since then, it has spread from West to East—hitting California and Hawaii in the ’80s and moving to Southeastern states such as Georgia and South Carolina in the late ’90s.

According to Richard A. Rawson, PhD, associate director and professor-in-residence for the Integrated Substance Abuse Programs at the Semel Institute for Neuroscience and Human Behavior in the David Geffen School of Medicine at the University of California at Los Angeles, “The spread of meth in the U.S. looks much like that of an infectious disease. It has spread in a very systematic way.”

It is a particular problem in rural communities, where it’s easily accessible and cheap. In fact, Dr. Rawson suggests that the drug doesn’t really present a major problem in urban areas—with the exception of cities that have a concentration of gay men. “Meth use in this population is a unique phenomenon that doesn’t follow the same homogenous spread from west to east,” he says.

Compounding this problem is the fact that HIV and sexually transmitted diseases often accompany meth use. “The drug is uniquely connected to sexual behavior because it increases sex drive, sexual performance, and pleasure,” observes Dr. Rawson. At the same time, hepatitis C is a broad concern in communities in which users inject the drug instead of smoking it. In fact, he says, about 50% of meth injectors are hepatitis-C-positive.

Ohio BCI Agent Gary Miller and Montgomery County Sheriff's Detective Dean Miller, suited up in protective gear, inspect a large amount of “lab trash” found in a horse trailer behind a residence where a drug raid was conducted, Feb. 16, 2006, in New Lebanon, Ohio.

Meth Addicts: Routine for Some Hospitalists

For those hospitalists who see many meth users, working with these patients is fairly routine. As Emory University, Atlanta, assistant professor of medicine and hospitalist J. Allen Garner, MD, says, “As many as 30% of the patients I deal with on any given day are addicted to something—cocaine, alcohol, meth. I can’t say it’s a greater burden than anything else.”

Establishing rapport with these patients can be challenging. “Some say, ‘I’m really strung out and need help.’ Many come in with some physical complaint and don’t tell me that they’re high on meth and haven’t slept for 72 hours,” says Dr. Garner. “Basically, this has to do with the denial that goes along with chemical dependency.

Even patients who readily admit that they have a problem are often in denial about the depth of their addiction. “They’ll say that they have it under control, that they only did it once, or that someone slipped them the drug—all ‘party lines’ that take the heat off of them,” he says.

Gaining the trust of meth addicts is a major challenge, “because the drug produces paranoia, agitation, and nervousness,” says Dr. Rawson, noting that “quick urine tests” can be used to identify meth users, and drug use shows up for hours. These tests are great because they only cost $5-$10 each.

Many meth patients come into the hospital because of a physical ailment. “They present with chest pain, palpitations, and/or shortness of breath, although these conditions clear up pretty quickly,” says Dr. Garner.

Tip-offs that the problem might be drug related include poor hygiene, disheveled appearance, and edgy, antsy behavior. Additionally, says Dr. Rawson, “Weight loss, skin sores and scabs, dental disorders, nervous behavior, and paranoid ideation are blue-ribbon signs of meth use. In places where users inject meth, look for needle marks. In regions where users smoke meth, pulmonary disease and coughing are common.”

In the patients Dr. Garner sees, meth’s lasting effects affect their physical health less than their mental health and quality of life. “Meth deteriorates them to the point that they can’t work, and they detach themselves from family, friends, and society as a whole,” he explains. “They require a lot of deep-seated [psychiatric] therapy to deal with multiple issues.”

While most of the meth users Dr. Garner sees are poorly educated and come from the working class, meth is increasingly popular among college students and professionals. In fact, he says, “I know of several doctors for whom meth was the drug of choice.” It is important for hospitalists to remember that addiction knows no socioeconomic boundaries. Many clinicians view meth addicts in an unsympathetic light and as people who have caused their own problems. This is a barrier that needs to be overcome, stresses Dr. Garner.

Meth and the Pediatric Hospitalist

Pediatric hospitalists are not immune to meth problems. “We see a lot of meth use among expectant and new mothers,” says Dr. DiRenzo-Coffey. Few of these women admit to their drug use, but Dr. Di-Renzo-Coffey suggests that the signs are pretty clear. “If I see a mom with no teeth who is underweight, my radar goes up,” she explains.

One of the biggest challenges she faces with these patients is that she has to get permission from the parents to test a baby for meth exposure. “You can only do drug testing on the baby if you have good reason,” she explains. “If we want to test and the mother says no, that only increases our suspicion. If the baby has symptoms, we can say that we have to test the baby to determine the cause. Sometimes, the mother will confess at that point.”

Another challenge to the hospitalist is that symptoms of meth exposure may not appear in a newborn for weeks, and the symptoms are hard to detect. “You just may see a fussy, irritable baby for the first eight weeks,” says Dr. DiRenzo-Coffey. “Once these babies become irritable, they also are hypersensitive to light and touch.”

Most meth babies go into the foster care system. Foster parents need extensive education and support to help control these babies’ responses to stimulation and help them adjust to become normal infants. “These babies need a quieter, calmer environment to sleep, and they need to be on a solid routine,” explains Dr. DiRenzo-Coffey. This is especially important in the first three months. “If these things aren’t addressed, they [these children] can become socially isolated as they grow.”

Pediatric hospitalists also are likely to see poor nutrition in some meth babies. “Many are poor eaters from day one. Others may have problems later because they are hyperactive and burn off all the calories they take in,” states Dr. DiRenzo-Coffey. “Later in life, the incidence of attention deficit disorder in school is high with these children, and this is something pediatric hospitalists are likely to see.”

When it comes to meth babies, hospitalists generally face the same challenges as any pediatrician dealing with newborns. “But as a hospitalist, you don’t have a relationship with the parents. You have to ask a lot of questions,” she explains. “I do this casually, and I tell them that I ask all moms these questions.” If she has strong suspicions about drug use, it is mandatory that she report it to Child Protective Services (CPS).

As for working with meth babies, Dr. DiRenzo-Coffey admits, “My contact is brief. I do detective work up front, but I’m not involved in follow-up until it’s time to go to court if it comes to that. As a pure hospitalist, there is only so much you can do. But if you bring the situation to the attention of the authorities, that’s a good start.”—JK

What Hospitalists Can Do

Meth users often aren’t even admitted to the hospital. “Treatment is mostly supportive. There is no drug you can give them to bring them down,” says Dr. Garner. “Withdrawal is a terrible thing—a sensation like Satan is crawling up their chest. We give them valium, but they basically have to weather it out.”

Even if the hospitalist addresses the physical effects and discusses treatment options with the meth user, it’s common for these patients to go back to their drug use when they leave the hospital. “Because meth doesn’t have life-threatening withdrawal symptoms—although you feel like you’re going to die—it’s easy for them to keep going back and using. Detox centers generally won’t touch these people,” says Dr. Garner. As a result, many patients end up in a catch-22, repeatedly going back to meth use.

While Dr. Garner does everything he can to help these patients, “they already are slaves to the drug by the time I see them,” he says. “Meth is highly addictive, and many people get hooked after using it just once or twice.”

This lack of available treatment for meth addicts is one of the greatest frustrations Dr. Garner faces as a hospitalist. “We keep putting resources into catching addicts as criminals and not getting them treatment and help before they become burdens on society,” he says.

He is pleased to note that this is changing in some states. “A few of the courts in our locale are starting to incorporate treatment programs through the court systems,” he explains.

Meth and Youth

While meth has become a popular drug among all age groups, “very few teens end up in the hospital because of meth,” says Wendy Wright, MD, a hospitalist at Rady Children’s Hospital in San Diego. “If kids are high on meth, they generally aren’t admitted when they are coming down. And, unlike many adults, they don’t have physical or medical issues that require hospitalization,” she explains. “Kids tolerate meth really well from the physical standpoint. We don’t see the arrhythmias or heart attacks that we see in adult addicts.”

When teen addicts do come in with medical conditions, Dr. Wright suggests, hospitalists often see problems such as skin or urinary tract infections. Teen meth users more frequently come to the hospital with psychiatric problems. “They have paranoid delusions, and some are fairly aggressive,” says Dr. Wright.

While hospitalists dealing with teens face the usual challenge of establishing rapport quickly, Dr. Wright observes that teens tend to be much more open than adults about their drug use. “They are pretty up front; they tell me right off the bat what drugs they use,” she says. “Of course I’m mostly seeing kids [who] aren’t living in an upper-class environment, and they’re not trying to hide things from their parents. The kids I see are streetwise and no nonsense. They have a sense of what their medical needs are and think nothing of asking for HIV or STD testing.”

Because of their youth and general good physical health, teens don’t necessarily create a burden for the hospitals and professionals who care for them. The biggest burden of meth-using teenagers, she suggests, “has to do with social issues. These kids often don’t grow into productive adults. They also have a lot of mental health issues such as bipolar disorder or severe depression, and these are the biggest burdens on the community as a whole. We also see a lot of chlamydia and gonorrhea in our kids.”

Although Dr. Wright strictly sees young patients, she acknowledges intergenerational meth use in families. Her facility sees many children who are brought into protective custody because their parents are meth users and unfit to care for them.

“These kids end up staying in the system, which is a bad place for them to be,” says Dr. Wright. “They grow up with a lot of insecurities and mental health issues, and many go on to be users themselves. While she sees many kids whose grandmothers and mothers are addicts, she believes the problem is situational and not hereditary. Nonetheless, “We’re not sure how to break this cycle,” she says.

Some kids are hospitalized because they are hurt or sick as a result of being in an unsafe environment where parents are meth users. These children are often malnourished or sick because of neglect.

Helping Hospitalists Manage Meth

It helps hospitalists if their facility has clear protocols for handling meth intoxication. “It is especially good to establish a procedure in the emergency department,” advises Dr. Rawson. He stresses that these procedures should address ways to de-escalate aggressive behavior. There are also clinical training techniques and brief interventions used to treat alcoholics that can be useful for dealing with meth addicts. These interventions involve efforts to change behaviors. Specifically, helping patients understand that their substance abuse is putting them at risk and encouraging them to reduce or stop their drug use altogether. The elements of brief interventions for substance abuse have been summarized in the acronym “FRAMES,” which stands for feedback, responsibility, advice, menu of options, empathy, and self-efficacy.

“These tools can help get people to talk about their meth problem[s] and deal with [them],” says Dr. Rawson. “Some of these brief interventions can be amazing in terms of deferring further drug use.”

Burdens of Meth

What hospitalists see in their meth-using patients depends on the maturity of the problem in their community. “In communities where the problem is newer, you are likely to see younger users and fewer physical problems,” says Dr. Rawson.

In areas where the problem has existed for years, hospitalists can expect to see older addicts with physical problems that range from heart conditions to widespread tooth decay (a condition known as “meth mouth”). The longer a community has had a meth problem, the more likely the epidemic is placing a financial burden on the healthcare system.

Dr. Garner urges his colleagues to learn about meth. “A couple of years ago, this was a nonexistent problem,” he says. “Now it has reached crisis proportions in many communities.”

Gina DiRenzo-Coffey, MD, director of inpatient pediatrics and a pediatric hospitalist at Alegent Health/Bergan Mercy Medical Center in Omaha, Neb., agrees: “You can lull yourself into believing that this can’t happen in your community. But no one has been able to stop meth use [among members of their community], and it keeps spreading. It is our job to learn everything we can about this drug and help meth addicts as much as we can.” TH

Joanne Kaldy also writes about a day in the life of a pediatric hospitalist in this issue.

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