WellsandWrightpresen tation

Idaho Drug Endangered Children Conference – Medical Summit: 

Idaho Drug Endangered Children Conference – Medical Summit September 14, 2004 Post Falls, ID Kathryn Wells, MD Wendy Wright, MD

Who are Drug Endangered Children?: 

Who are Drug Endangered Children? Children under 18 years of age Suffer physical harm or neglect from direct or indirect exposure to illegal drugs or alcohol Live in a house where illegal drugs are used and/or manufactured

Who are Drug Endangered Children?: 

Who are Drug Endangered Children? Children who are exposed to or ingest illegal drugs in the home Children exposed to the toxic chemicals of home drug labs Children being cared for by a caregiver under the influence of illegal drugs or intoxicated by alcohol Infants exposed to illegal drugs in utero

Who are Drug Endangered Children?: 

Who are Drug Endangered Children? Most importantly: Infants/Children who suffer abuse or neglect because of their caretaker’s substance abuse

Slide5: 

Children of Parents with Substance Abuse Problems Have poorer developmental outcomes (physical, intellectual, social and emotional) than other children Are at (an eight-fold) increased risk of substance abuse themselves

Slide6: 

Substance Abuse Affects Parenting [Blending Perspectives and Building Common Ground, A Report to Congress on Substance Abuse and Child Protection, April 1999] Impaired judgment and priorities Inability to provide the consistent care, supervision and guidance children need Substance abuse is a critical factor in child welfare

Slide7: 

Substance Abuse and Child Abuse and Neglect In the U.S., more than 3 children die each day as a result of child abuse and neglect In 2000, just under 3 million reports were made for child abuse and neglect concerning 5 million children In 2000, 879,000 children were found by child protection agencies to have been victims of child abuse and neglect

Slide8: 

Substance Abuse and Child Abuse and Neglect 88% of respondents named substance abuse as one of the top two problems presented by families reported for child abuse

Substance Abuse and Child Abuse and Neglect: 

Substance Abuse and Child Abuse and Neglect Substance abuse causes or exacerbates 7 out of 10 cases of child abuse and neglect Children whose parents use drugs and alcohol are: 3x more likely to be abused More than 4x more likely to be neglected

Methamphetamine – The Drug: 

Methamphetamine – The Drug Speed, Ice, Meth, Crystal, Crank Clandestine labs Easily synthesized Readily obtainable Sold through networks Abusers range widely in age, educational level, socioeconomic status and ethnic background

Methamphetamine Facts: 

Methamphetamine Facts [National Household Survey on Drug Abuse] An estimated 9.6 million people (aged 12 years and older) have tried methamphetamine 338,000 individuals aged 12 to 17 1.5 million individuals aged 18 to 25

Direct Meth Effects: 

Direct Meth Effects Adults Short term Long term Pregnancy Children Clinical experience suggests pervasive exposure, but not well studied

Immediate Effects of Methamphetamine Use: 

Immediate Effects of Methamphetamine Use Powerful stimulant CNS effects: Induce euphoria Intensify emotions Alter self-esteem Increase alertness, aggression, and sexual appetite

How is Methamphetamine Used?: 

How is Methamphetamine Used? May be smoked, snorted, orally ingested, injected or used rectally or vaginally Alters moods in different ways depending on how it is taken

Effects of Methamphetamine: 

Effects of Methamphetamine “Flash” or “rush” immediately after smoking or injecting - described as extremely pleasurable Euphoria only with snorting or oral ingestion Snorting – effects within 3-5 minutes Oral ingestion – effects in 15-20 minutes Effects last up to 24 hours

Slide16: 

The Cycle of Use Rush (smoking or injecting) High Binge Tweaking - most dangerous stage due to the potential for violence Crash - time for severe neglect of children

Meth vs. Cocaine: 

Meth vs. Cocaine Man-made Daily use Longer binges Smoking produces a high that last 8-24 hours 50% of the drug is removed from the body in 12 hours Plant-derived Recreational use Intermittent binges Smoking produces a high that lasts 20-30 minutes 50% of the drug is removed from the body in 1 hour

Effects of Methamphetamine Use on the Brain : 

Effects of Methamphetamine Use on the Brain Direct dopamine effects: Changes in mood Excitation Intensification of emotions Elevation of self esteem Sensory perception Decreased appetite Elevation of libido Unusual motor movements Suspected serotonin effects: Increase feelings of empathy Feelings of closeness Bizarre mood changes Psychotic behavior Aggressiveness Bruxism

Slide19: 

Meth vs. Cocaine Effects on the Brain Cocaine Methamphetamine

Slide20: 

Brain Changes with Meth Use Baboon study N=90 Given meth doses equivalent to humans PET scan, decreased dopamine transporter activity in the caudate, 3 weeks after meth (Villemagne 1997)

Reduction of Dopamine Transporters: 

Reduction of Dopamine Transporters Rate of dopamine transporter loss with age is 6 – 7% per decade Losses in meth users equivalent to 40 years of aging (Dr. Nora Volkow, Director of NIDA)

Slide22: 

Brain Changes with Meth Use Rhesus and Vervet monkey studies Given 3-6 months meth doses equivalent to humans Decreased dopamine levels in the caudate by 80% immediately after stopping meth and up to 6 months later (Seiden 1975, Woolverton 1989, Melega 1996 and 1997)

Slide23: 

Depleted dopamine transporter levels in methamphetamine abusers show recovery after prolonged abstinence. In these brain scans, high dopamine transporter levels appear as red, while low levels appear as yellow/green. Dr. Nora Volkow, Director of NIDA (National Institute on Drug Abuse)

Slide24: 

Brain Changes with Meth Use PET scans comparing control, Meth users with 6 mo-5 years abstinence, and patients with Parkinson’s Disease, showing decreased dopamine transporter activity in the caudate and putamen. 25% decrease for Meth users, and 60% for PD. (McCann 1998)

Slide25: 

Cognitive Deficits Axons don’t always grow back correctly Different parts of brain recover at different rates Impairment of word and picture recall Impaired ability to manipulate information Ignore information Inability to filter irrelevant information Studies show impairment worse at 12 weeks of non-use than is evident in current user Word recall gets worse, picture recall gets better

Slide26: 

Clinical Symptoms of Meth Use Dilated pupils/dry mouth Elevated blood pressure, tachycardia (increased heart rate) Decreased oxygenation to extremities/poor circulation/skin lesions Dental decay Increase temperature of organs Decreased appetite/increased libido Damage to organs, loss of body fat, muscle damage due to elevated temps

Long-Term Effects of Methamphetamine Use: 

Long-Term Effects of Methamphetamine Use Behavior changes Association with trauma Systemic effects Addiction Tolerance Withdrawal The Children

Effects of Methamphetamine Use - Behavior Changes: 

Effects of Methamphetamine Use - Behavior Changes Violent behavior Bizarre behavior Anxiety Confusion Insomnia

Behavior Changes – Psychotic Features: 

Behavior Changes – Psychotic Features Paranoia Visual and auditory hallucinations Mood disturbances Delusions (ex. The sensation of insects creeping on the skin) Homicidal thoughts Suicidal thoughts Out of control rages Can persist for years after use discontinued

Effects of Methamphetamine Use - Violence and Trauma: 

Effects of Methamphetamine Use - Violence and Trauma Trauma accounted for two-thirds of the victims in meth-related deaths – often results from bizarre violent behavior “Hyperviolence syndrome” - the victim is frequently a part of the perpetrator’s delusional belief system Weapon used most commonly (ie: gun, knife) Frequently there are multiple wounds inflicted, many postmortem and sometimes days after death

Slide31: 

Heightened Sexuality Continue to attempt feeling of first orgasm on meth Bizarre behavior Sexual photos can trigger use even after long term abstinence Many babies Increased HIV, STD’s Increased child sexual abuse

Effects of Methamphetamine Use – General Medical Complications: 

Effects of Methamphetamine Use – General Medical Complications Hyperthermia (elevated body temperature) Sudden cardiac death Convulsions Death Acute lead poisoning or other toxin exposure Systemic effects Fetal complications

Effects of Methamphetamine Use - Cardiovascular System Complications: 

Effects of Methamphetamine Use - Cardiovascular System Complications Sudden cardiac arrest Tachycardia Arrhythmia Hypertension Aneurysm rupture Heart attack Damage to heart muscle Inflammation of the heart lining Damaged blood vessels

Effects of Methamphetamine Use - Central Nervous System Complications: 

Effects of Methamphetamine Use - Central Nervous System Complications Neuron loss Seizures Chronic psychosis – “withdrawal” or “abstinence psychosis” Movement disorders Strokes Spontaneous cerebral hemorrhaging Cerebral artery spasm and occlusion “Kindling” phenomenon or “reverse tolerance”

Effects of Methamphetamine Use - Respiratory System Complications: 

Effects of Methamphetamine Use - Respiratory System Complications Pulmonary edema Pulmonary hypertension Chronic obstructive lung disease

Effects of Methamphetamine Use - Other Organ System Complications: 

Effects of Methamphetamine Use - Other Organ System Complications Renal failure Muscle breakdown Liver damage Giant gastrointestinal ulcers Ischemic colitis

Effects of Methamphetamine Use - Addiction: 

Effects of Methamphetamine Use - Addiction Chronic, relapsing disease Characterized by compulsive drug-seeking and drug use Functional and molecular changes in the brain Stronger potential for addiction of the rapid-acting routes of administration

Effects of Methamphetamine Use - Tolerance: 

Effects of Methamphetamine Use - Tolerance Take higher doses Dose more frequently Change their method of drug intake “Run” - forego food and sleep while binging No tolerance for effects on judgment, impulsivity, aggression, and susceptibility to paranoia, delusions, and hallucinations – opposite reaction

Effects of Methamphetamine Use - Withdrawal: 

Effects of Methamphetamine Use - Withdrawal Physical: Polyphagia (excessive hunger) Hypersomnolence (sleepiness) Psychological: Depression Anxiety/agitation Fatigue/malaise Paranoia Aggression Intense craving for the drug

Special Issues for Women and Methamphetamine: 

Special Issues for Women and Methamphetamine Affordable Available Appetite suppressor Energy enhancer Mood elevator Libido enhancer The growing illicit drug of choice among young women

Meth Use During Pregnancy: 

Meth Use During Pregnancy Mother Poor prenatal care, nutrition Ruptured placenta Preterm labor, breech delivery STDs (HIV, Hepatitis) Baby Low birthweight, birth defects Drug withdrawal Developmental disabilities

Methamphetamine Use in Pregnancy: 

Methamphetamine Use in Pregnancy Fetal anomalies CNS abnormalities Cardiovascular abnormalities Intestinal abnormalities Urogenital system abnormalities Malformations of extremities May have periods of extreme heart rate variability Transfer of methamphetamine to fetal blood where - remains in fetal circulation longer than in maternal blood

Slide43: 

Methamphetamine – Effects on the Newborn Intrauterine growth delay May have some withdrawal symptoms First few weeks - sleepy and lethargic (often don’t wake to feed) After the first few weeks - behave similar to cocaine-exposed infants - jittery, cry shrilly, startle at even the slightest stimulation

Methamphetamine – Effects on the Newborn: 

Methamphetamine – Effects on the Newborn Abnormal sleep, poor feeding, tremors and increased muscle tone Poor ability to habituate or self-regulate, especially under stressful conditions Increased risk of SIDS

Slide45: 

FEBRUARY 3, 1997 VOL. 149 NO. 5 SPECIAL REPORT FERTILE MINDS FROM BIRTH, A BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING CONNECTIONS THAT MAY SHAPE A LIFETIME OF EXPERIENCE. THE FIRST THREE YEARS ARE CRITICAL BY J. MADELEINE NASH  

Overview:Meth/Drug effects on Kids: 

Overview: Meth/Drug effects on Kids Direct physical effects of Methamphetamine/drugs Substance abuse and child abuse and neglect Direct physical effects of Meth Lab toxicity and dangers

Children Who Ingest Illegal Drugs: 

Children Who Ingest Illegal Drugs Children pick up pieces of the raw drug or carry the drug powder on their hands and put their hands in their mouth Most identified cases are Cocaine and Methamphetamine Few cases reported in the literature

Children Who Ingest Illegal Drugs: 

Children Who Ingest Illegal Drugs Few cases reported in the literature 11 month old boy with irritability and blindness found to have urine + for meth. Symptoms resolved after 12 hours. (Gospe, 1995) 10-month-old infant died from “crack” cocaine ingestion. 2-year-old brother fed him “crack” found on floor and crib. (Havlik, 2000)

Children Who Ingest Illegal Drugs: 

Children Who Ingest Illegal Drugs Few cases reported in the media Arizona 2002 – breastfeeding infant died from Methamphetamine overdose California 2003 – breastfeeding infant

Slide50: 

Parenting Issues with Meth Involvement Neglect during long periods of sleep Inconsistent, paranoid behavior Irritability, short fuse, potentially leading to physical abuse Exposure to violence, unsavory characters Generally poor parenting skills Mental health issues

Slide51: 

Hazards - Neglect by Caretakers Lack of essential food Lack of grooming Inappropriate sleeping conditions Lack of medical/dental treatment Lack of supervision

Slide52: 

Hazards - Emotional Abuse Lack of support Lack of encouragement Lack of discipline Lack of guidance

Slide53: 

Physical Abuse Sexual Abuse Domestic Violence

Chemicals Used:: 

Chemicals Used: Organic Solvents Benzene Acetone Chloroform Ethylether Toluene

Acids Bases  : 

Acids Bases Formic Hydriodic Hydrochloric Muriatic Phosphoric Sulfuric Lye

Other: 

Other Ephedrine Iodine Red Phosphorus Anhydrous Ammonia Lithium/Heavy Metals

Non-Chemical Dangers: 

Non-Chemical Dangers Environment- garbage, infestation Animals (used to protect labs) Needles Firearms

Protective Issues: 

Protective Issues Neglect Domestic Violence Physical Abuse Sexual Abuse General Risk of Danger/Harm (fires, explosions, exposure to chemicals and drugs)

Chemical Dangers: 

Chemical Dangers Ingestion Inhalation Contact

Consequences of Drug Lab Exposure: 

Consequences of Drug Lab Exposure Immediate Social Health

Dangers - Immediate: 

Dangers - Immediate Explosion Fires “Booby Traps” Toxic Fumes

Reported Toxicities: 

Reported Toxicities JAMA 12/6/00: events reported to the Hazardous Substances Emergency Events Surveillance system from 1996-1999 noted 112 methamphetamine-associated events with 155 persons injured. 51 % were first responders: police officers, EMTs, firefighters, and hospital employees. 54.1 % had respiratory irritation (cough), difficulty breathing, throat irritation. 10.8 % had eye irritation.

Reported Toxicity: 

Reported Toxicity 77.2 % were treated and released. Of the 84.8 % of first responders whose personal protective equipment status was known, 85.1 % had not worn PPP at the time of injury. Of the 36 events causing these injuries, 33.3% involved anhydrous ammonia 30.6% involved hydrochloric acid.

Reported Toxicity: 

Reported Toxicity In 33 of the 36 events for which the type of release was known: 57.6% involved air emissions 30.3% involved fires 7 involved explosions

Social Consequences: 

Social Consequences Delinquency School Problems School absenteeism Criminal Behavior Homelessness Isolation Poor peer relations Unemployment Poverty Addictions

Health Consequences: 

Health Consequences

Children Are NOT Small Adults : 

Children Are NOT Small Adults Different diet Growing & developing (brain, liver, kidney, lungs); still vulnerable to damage Higher metabolic rate: absorb & metabolize toxins at a higher rate Developing nervous system Unusual habits (i.e. hand-to-mouth behaviors; eating strange things; close to ground/floor; unknowingly imitating; etc.)

Even more about the kids: 

Even more about the kids Children breathe faster than adults Children have a faster heart beat than adults Children are smaller and closer to the ground than adults They have a heavier exposure to the chemicals due to the above

Medical Problems: 

Medical Problems Acids/Bases burns inhalation Solvents liver kidney bone marrow Iodine/Red Phosphorus burns Ephedrine/Meth death seizures tachycardia severe irritability

CDC Sub-analysis: 8 events with 13 injured children: 

CDC Sub-analysis: 8 events with 13 injured children Most common methods of injury to child: Volatilization/spill or fire/explosion 4 exposures involved anhydrous ammonia with respiratory symptoms in 3 Horton, KD et al J. Of Children’s Health Vol. 1 No. 1 2003

CDC Sub-analysis: 8 events with 13 injured children: 

CDC Sub-analysis: 8 events with 13 injured children Other chemical exposure: toluene, lye solves with headache, GI, chemical burns, skin/eye irritation 1 chemical burn from acid exposure Ether explosion led to trauma & respirator irritation Horton, KD et al J. Of Children’s Health Vol. 1 No. 1 2003

Medical Evaluation: 

Medical Evaluation

DECONTAMINATION: 

DECONTAMINATION Controversial as to amount Maximal – Undress and rinse/wash at scene, all new clothes Medium – Undress and wipe off and put on new clothes Do nothing or transport with a covering blanket or suit Toys/Objects left at scene

Medical Exam: 

Medical Exam Comprehensive Exam good lung exam respiratory rate O2 saturation Developmental Exam Vision/Hearing Screening Urine Tox Screen at exposure level Blood Tests - CBC, LFT’s, RFT’s

Blood Tests: 

Blood Tests Complete blood count (CBC) anemia (solvents, nutrition) cancers (solvents) Liver function tests (LFT’s) solvents Kidney function tests (BUN, Cr) Solvents

Toxicology Screening: 

Toxicology Screening Urine Hair testing Oral fluids Sweat

Urine Tox Screens: 

Urine Tox Screens NIDA levels - work place screening 300 ng/dl Exposure levels Usually done by lab Reported out only if asked Level down to 50 to 100 ng/dl

Urine Tox Screens: 

Urine Tox Screens Collect first urine after leaving scene (when possible as we all know 2 year olds don’t urinate on command!) Consider keeping chain of evidence

Hair Analysis: 

Hair Analysis Advantages longer exposure period easier to collect Disadvantages less precise in timing possible racial bias newer technology

Oral Fluid Testing: 

Oral Fluid Testing 0.4 ml of oral fluids Collection takes about 2 minutes Confirmed by ELISA and GC/MS Not tested in children younger than 15 yrs Amphetamine, methamphetamine, MDA, MDMA, and MDEA, codeine, morphine, heroin, oxycodone, cocaine, marijuana, and PCP

Cost of tox testing: 

Cost of tox testing Urine - $13 Oral fluids - $25 Hair - $40

Other Medical Issues: 

Other Medical Issues Asthma Obesity Anemia Dental caries Developmental delay Dermatitis Hyperglycemia