Methamphetamine Brain and Behavior Research Findin

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Methamphetamine: Brain and Behavior: Research Findings: 

Methamphetamine: Brain and Behavior: Research Findings Richard. A. Rawson, Ph.D. UCLA Integrated Substance Abuse Programs Los Angeles California Rrawson@mednet.ucla.edu www.uclaisap.org Missouri, March 2004 Supported by National Institute on Drug Abuse and the Pacific Southwest Technology Transfer Center

Methamphetamines A Brief History: 

Methamphetamines A Brief History 1887 1919 1932 Amphetamine developed Methamphetamine developed Amphetamine & methamphetamine used as decongestant

Methamphetamines A Brief History: 

Methamphetamines A Brief History WW II Extensive use by: - RAF fighter pilots - German Panzer troops - Japanese workers - Led to Kamikaze fever

Methamphetamines A Post-War Epidemic: 

Methamphetamines A Post-War Epidemic FACTORS Large quantities Disorganization “Work pills” 500,000 addicts Reduced supply Increased heroin JAPAN

Methamphetamines Speed in Sweden: 

Methamphetamines Speed in Sweden FACTORS Large supply 3% are users Preludin widespread Mostly oral use “Speed clinics” Clinics closed SWEDEN

Methamphetamines A Previous U.S. Epidemic: 

Methamphetamines A Previous U.S. Epidemic FACTORS More legal speed Base is legal Easy to make Large market Many IV users Law enforcement Rural areas

Methamphetamines Factors Related to Epidemic: 

Methamphetamines Factors Related to Epidemic Over supply Opportunity to experience Widespread knowledge A reliable market Non-parenteral methods Many “speed labs”

California Department of Justice Bureau of Narcotics Enforcement Clandestine Lab Seizures: 

California Department of Justice Bureau of Narcotics Enforcement Clandestine Lab Seizures *DEA still calculating statistics **CA statewide seizures, state and local combined SOURCE: www.stopdrugs.org/images/1999nationallabstat.jpg

Methamphetamine admissions per 100,000 population: 

Methamphetamine admissions per 100,000 population

Toxic Effects of Methamphetamine: 

Toxic Effects of Methamphetamine Manufacturing Abuse Fetal exposure

Slide17: 

Clandestine Meth Lab

Slide18: 

Clandestine Meth Lab Equipment

Meth Lab Seizures: 

Meth Lab Seizures A small percentage of labs seized are labeled “Super Labs” and are capable of producing over 10 lbs per batch. Super Labs are operated by Mexican National Drug Trafficking Organizations (MNDTO’s), and supply the majority of meth to the market.

Lab Seizure Locations: 

Lab Seizure Locations Most common meth lab facilities were single-family houses, followed by apartments, mobile homes, vehicles in traffic stops, garages, trailers, motels/hotels, businesses, desert, and storage.

Stove top labs: 

Stove top labs Small, stove top labs comprise the bulk of clandestine laboratory seizures. Cookers make small amounts using household chemicals and equipment.

Stove Top Labs: 

Stove Top Labs The active ingredient in making methamphetamine is ephedrine or pseudoephedrine, commonly found in over the counter cold remedies.

Chemical Ingredients: 

Chemical Ingredients Trichloroethane (Gun Scrubber) Ether (Engine Starter) Toluene (Brake Cleaner) Methanol (Gasoline Additive) Gasoline Kerosene

Chemical Ingredients: 

Chemical Ingredients Lithium (Camera Batteries) Anhydrous Ammonia (Farm Fertilizer) Red Phosphorus (Matches) Iodine (Veterinarian Products) Muriatic Acid Campfire Fuel Paint Thinner

Chemical Ingredients: 

Chemical Ingredients Acetone Sulfuric Acid (Drain Cleaner) Table Salt/Rock Salt Sodium Hydroxide (Lye) Sodium Metal (Can be made from Lye) Alcohol (Rubbing/Gasoline Additive)

Household Equipment: 

Household Equipment Coffee Filters Rubber gloves Tempered Glass Baking Dishes Glass or Plastic Jugs Bottles Measuring Cup

Household Equipment: 

Household Equipment Glass Jars Funnels Blender Plastic Jugs Tape Turkey Baster Clamps Hotplate Strainer

Household Equipment: 

Household Equipment Rubber Tubing Paper Towels Gasoline Can Plastic Tote Box Aluminum Foil Propane Cylinder (20-lb) Books/internet (Meth lab Instruction)

Toxicity: 

Toxicity Detrimental effects of meth labs reach further than increase in drug supply. For each quantity of methamphetamine manufactured, five times that amount is produced toxic wastes.  Due to illegal nature of meth production, these toxic wastes are not disposed of lawfully (including heavy metals and flammable chemicals like mercury and phosphorus that should be transported to hazardous waste facilities.

Toxicity: 

Toxicity Instead they are dumped into streams, rivers, fields, and sewage systems, and buried illegally, allowing the toxins to seep into groundwater. This contaminates the environment and ground water, putting communities at risk.

Toxicity: 

Toxicity Gases created during the manufacturing process permeate walls and carpets of houses and buildings, making them uninhabitable. The cost of cleaning these sites ranges from $2,000 to $4,000 taxpayer dollars.

Toxic Effects of Methamphetamine Manufacturing: 

Toxic Effects of Methamphetamine Manufacturing Fires Explosions Toxic gases Toxic wastes

Toxic Effects of Methamphetamine Manufacturing: 

Toxic Effects of Methamphetamine Manufacturing Cooking hydrochloric acid mixing / heating red phosphorous straining sodium hydroxide Extraction solvents conversion to base extracting Salting drying

Toxic Effects of Methamphetamine Manufacturing: 

Toxic Effects of Methamphetamine Manufacturing Manufacturers Law enforcement officers Bystanders

Toxic Effects of Methamphetamine Manufacturing: 

Toxic Effects of Methamphetamine Manufacturing Air (immediate vicinity) Water supply Soil

Organ Toxicity from MA Abuse: 

Organ Toxicity from MA Abuse Central nervous system toxicity Cardiovascular toxicity Pulmonary toxicity Renal toxicity Hepatic toxicity

CNS Toxicity from MA Abuse: 

CNS Toxicity from MA Abuse Acute psychosis Chronic psychosis Strokes Seizures

Cardiovascular Toxicity from MA Abuse: 

Cardiovascular Toxicity from MA Abuse Arrhythmic sudden death Myocardial infarction Cardiomyopathy

Pulmonary Toxicity from MA Abuse: 

Pulmonary Toxicity from MA Abuse Acute pulmonary congestion Chronic obstructive lung disease

Renal / Hepatic Toxicity from MA Abuse: 

Renal / Hepatic Toxicity from MA Abuse Renal failure Hepatic failure

Fetal Toxicity from MA Abuse: 

Fetal Toxicity from MA Abuse Early effects: fetal death small for gestational age Late effects: learning disability poor social adjustment

Children: 

Children Children who live in and around the area of the meth lab become exposed to the drug and its toxic precursors and byproducts. 80-90% of children found in homes where there are meth labs test positive for exposure to meth. Some are as young as 19 months old.

Children: 

Children Children can test positive for methamphetamine by: Having inhaled fumes during the manufacturing process Coming into direct contact with the drug Through second-hand smoke

Children: 

Children Hundreds of children are neglected by parents who are meth cooks. Nationally, over 20% of the seized meth labs in 2002 had children present. In Washington State, the counties of Grays Harbor, Spokane, Thurston, and Klickitat all reported that children were found at half the labs seized in 2002. In Lewis County, children were found at 60-70 %, and in Clark-Skamania, 35%.

Children: 

Children In 2002, a total of 142 children were present at lab seizures in Riverside and San Bernardino Counties. Most children reported as being present during a seizure were school age.

Children: 

Children Social workers now accompany law enforcement during lab seizures with children involved. Parents are often charged with second-degree criminal mistreatment, along with manufacturing charges. Allowing children to live in a toxic environment where additional risks of explosion and fire are high is considered to be neglect at best to child abuse.

Children: 

Children Children have a greater skin surface area per pound than do adults, making them more susceptible to environmental contaminants. They also eat, drink, and breathe faster, and are more likely to put hands and other objects in their mouths.

Children: 

Children Inquisitive nature of young children makes them more prone to accidentally consuming toxic chemicals that are sometimes kept in unmarked containers in the refrigerator.

Children: 

Children Children are uniquely susceptible to neurological contamination in the environment because their brains are still developing.   Lead poisoning is an example of what the child is exposed to in these meth labs. A small amount of lead that may not affect an adult can cause neurological damage in a child.

What Does Child Welfare Field Need in Context of Meth & Labs?: 

What Does Child Welfare Field Need in Context of Meth & Labs? Support from Auxiliary Agencies and Departments Policies that Protect their Safety Policies that Appropriately Safeguard Children Resources to Support Meth-dependent parents in treatment & recovery in the context of reunification efforts Training for Caregivers and Treatment Staff to implement best practices for parents & kids

Slide52: 

CHILD PROTECTIVE SERVICES (24/7) MEDICAL & PUBLIC HEALTH PERSONNEL (24/7) LAW ENFORCEMENT (24/7) (If Lab) DISTRICT ATTORNEY’S OFFICE (24/7) (If Lab) (CORE DEC RESPONSE TEAM MEMBERS) ADDITIONAL INVOLVEMENT FROM: MENTAL HEALTH & THERAPEUTIC PERSONNEL CHILD CARE PROVIDERS: FOSTER FAMILIES DRUG & ALCOHOL TREATMENT PROVIDERS ENVIRONMENTAL SERVICES & HAZARDOUS MATERIALS TEAM PERSONNEL (If Lab) Drug Endangered Children: Who Should be Involved?

Drug Endangered Children Response Teams: 

Drug Endangered Children Response Teams Multi-Need Families; Multi-Need Individuals Multi-Disciplinary Approach Spirit of Cooperation Sharing of Information Case Coordination for Best Family and Individual Outcome Why the Team Concept Is Needed and Works...

Brain metabolism in newly abstinent methamphetamine users: 

Brain metabolism in newly abstinent methamphetamine users

Slide64: 

x = -12 mm Perigenual ACC Infragenual ACC x = 10 mm Medial Orbital Gyrus z = 11 mm Insula

Slide65: 

z = -14 mm x = 6 mm y = 6 mm Amygdala V. Striatum Mid- Cingulate

Triggers and Cravings Human Brain: 

Triggers and Cravings Human Brain

Cognitive Process During Addiction: 

Cognitive Process During Addiction Relief From Depression Anxiety Loneliness Insomnia Euphoria Increased Status Increased Energy Increased Sexual/Social Confidence Increased Work Output Increased Thinking Ability AOD Introductory Phase May Be Illegal May Be Expensive Hangover/Feeling Ill May Miss Work

Conditioning Process During Addiction: 

Conditioning Process During Addiction Introductory Phase Triggers Parties Special Occasions Responses Pleasant Thoughts about AOD No Physiological Response Infrequent Use Strength of Conditioned Connection Mild

Development of Obsessive Thinking Introductory Phase: 

Development of Obsessive Thinking Introductory Phase

Development of Craving Response: 

Development of Craving Response Introductory Phase Entering Using Site Use of AODs  Heart/Pulse Rate  Respiration  Adrenaline  Energy  Taste AOD Effects

Slide71: 

Cognitive Process During Addiction Maintenance Phase Depression Relief Confidence Boost Boredom Relief Sexual Enhancement Social Lubricant Vocational Disruption Relationship Concerns Financial Problems Beginnings of Physiological Dependence

Slide72: 

Conditioning Process During Addiction Maintenance Phase Strength of Conditioned Connection Triggers Parties Friday Nights Friends Concerts Alcohol “Good Times” Sexual Situations Responses Thoughts of AOD Eager Anticipation of AOD Use Mild Physiological Arousal Cravings Occur as Use Approaches Occasional Use Moderate

Slide74: 

Development of Craving Response Maintenance Phase Entering Using Site Physiological Response Use of AODs AOD Effects  Heart  Breathing  Adrenaline Effects  Energy Taste  Heart  Blood Pressure  Energy

Slide75: 

Cognitive Process During Addiction Disenchantment Phase Social Currency Occasional Euphoria Relief From Lethargy Relief From Stress Nose Bleeds Infections Relationship Disruption Family Distress Impending Job Loss

Slide76: 

Conditioning Process During Addiction Disenchantment Phase Strength of Conditioned Connection Triggers Weekends All Friends Stress Boredom Anxiety After Work Loneliness Responses Continual Thoughts of AOD Strong Physiological Arousal Psychological Dependency Strong Cravings Frequent Use STRONG

Slide77: 

AOD

Slide78: 

Thinking of Using Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Powerful Physiological Response Use of AODs AOD Effects  Heart Rate  Breathing Rate  Energy  Adrenaline Effects  Heart  Blood Pressure  Energy

Slide79: 

Cognitive Process During Addiction Disaster Phase Relief From Fatigue Relief From Stress Relief From Depression Weight Loss Paranoia Loss of Family Seizures Severe Depression Unemployment Bankruptcy

Slide80: 

Strength of Conditioned Connection Triggers Any Emotion Day Night Work Non-Work Responses Obsessive Thoughts About AOD Powerful Autonomic Response Powerful Physiological Dependence Automatic Use OVERPOWERING

Slide81: 

Development of Obsessive Thinking Disaster Phase

Slide82: 

Development of Craving Response Disaster Phase Thoughts of AOD Using Place Powerful Physiological Response  Heart Rate  Breathing Rate  Energy  Adrenaline Effects

Roadmap for Recovery: 

Roadmap for Recovery Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Cravings Return Irritability Abstinence Violation Protracted Abstinence

Memory Difference between Stimulant and Comparison Groups: 

Memory Difference between Stimulant and Comparison Groups

Differences between Stimulant and Comparison Groups on tests requiring perceptual speed: 

Differences between Stimulant and Comparison Groups on tests requiring perceptual speed

Summary: 

Summary Actively using MA addicts demonstrate impairments in: the ability to manipulate information the ability to make inferences the ability to ignore irrelevant information the ability to learn the ability to recall material

Longitudinal Memory Performance: 

Longitudinal Memory Performance test number correct

Summary (cont.): 

Summary (cont.) Some deficits are resolved after a period of 12-weeks of abstinence: The ability to ignore irrelevant information The ability to manipulate information

Summary (cont.): 

Summary (cont.) Some abilities get worse in the early periods of abstinence: Recall and recognition both show more impairment at 12 weeks of non-use than is evident in current users

Methamphetamine Acute Physical Effects : 

Methamphetamine Acute Physical Effects - Increases -Decreases Heart rate Appetite Blood pressure Sleep Pupil size Reaction time Respiration Sensory acuity Energy

Methamphetamine Acute Psychological Effects: 

Methamphetamine Acute Psychological Effects Increases Confidence Alertness Mood Sex drive Energy Talkativeness Decreases Boredom Loneliness Timidity

Methamphetamine Chronic Physical Effects : 

Methamphetamine Chronic Physical Effects - Tremor - Sweating - Weakness - Burned lips; sore nose - Dry mouth - Oily skin/complexion - Weight loss - Headaches - Cough - Diarrhea - Sinus infection - Anorexia

Methamphetamine Chronic Psychological Effects: 

Methamphetamine Chronic Psychological Effects - Confusion - Irritability - Concentration - Paranoia - Hallucinations - Panic reactions - Fatigue - Depression - Memory loss - Anger - Insomnia - Psychosis

Methamphetamine Psychiatric Consequences: 

Methamphetamine Psychiatric Consequences Paranoid reactions Permanent memory loss Depressive reactions Hallucinations Psychotic reactions Panic disorders Rapid addiction

Typical Day of MA Use: 

Typical Day of MA Use Amount -- 1 gram Route -- Smoke First Use -- “When I wake up” Other uses -- “Every few hours” Amount each use -- 1/5 gram

Typical Day of MA Use: 

Typical Day of MA Use Amount -- 3/4 gram Route -- Shoot First Use -- “When I get up” Other uses -- “Noon and Afternoon” Amount each use -- 1/4 gram

MA Treatment Issues: 

MA Treatment Issues Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

Acute MA Overdose: 

Acute MA Overdose Slowing of Cardiac Conduction Ventricular Irritability Hypertensive Episode Hyperpyrexic Episode CNS Seizures and Anoxia

Acute MA Psychosis: 

Acute MA Psychosis Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

Treatment of MA Psychosis: 

Treatment of MA Psychosis Typical ER Protocol for MA Psychosis Haloperidol - 5mg Clonazepam - 1 mg Cogentin - 1 mg Quiet, Dimly Lit Room Restraints

MA “Withdrawal”: 

MA “Withdrawal” - Depression - Paranoia - Fatigue - Cognitive Impairment - Anxiety - Agitation - Anergia - Confusion Duration: 2 Days - 2 Weeks

Treatment of MA “Withdrawal”: 

Treatment of MA “Withdrawal” Hospitalization/Residential Supervision if: Danger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from Clinic. Otherwise Intensive Outpatient Treatment

Treatment of MA “Withdrawal”: 

Treatment of MA “Withdrawal” Intensive Outpatient Treatment No Pharmacotherapy Available Positive, Reassuring Context Directive, Behavioral Intervention Educate Regarding Time Course of Symptom Remission Recommend Sleep and Nutrition Low Stimulation Acknowledge Paranoia, Depression

Initiating MA Abstinence: 

Initiating MA Abstinence Key Clinical Issues Depression Cognitive Impairment Continuing Paranoia Anhedonia Behavioral/Functional Impairment Hypersexuality Conditioned Cues Irritability/Violence

Initiating MA Abstinence: 

Initiating MA Abstinence Key Elements of Treatment Structure Information in Understandable Form Family Support Positive Reinforcement 12-Step Participation No Pharmacologic Agent Currently Available

Treatment of MA Disorders: 

Treatment of MA Disorders Traditional Treatments Therapeutic Community Minnesota Model Outpatient Counseling Psychotherapy

Treatment of MA Disorders: 

Treatment of MA Disorders State of Empirical Evidence No Information on TC or “Minnesota Model” Approaches No Pharmacotherapy with Demonstrated Efficacy Results of Cocaine Treatment Research Extrapolated to MA Treatment

A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine Dependence     Richard A. Rawson, Ph.D. and The Methamphetamine Treatment Project Corporate Authors* Addiction (2004, In Press): 

A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine Dependence     Richard A. Rawson, Ph.D. and The Methamphetamine Treatment Project Corporate Authors* Addiction (2004, In Press)

Project Goals:: 

Project Goals: To study the clinical effectiveness of the Matrix Model To compare the effectiveness of the Matrix model to other locally available outpatient treatments To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments To explore the replicability of the Matrix model and challenges involved in technology transfer

Matrix Model An Integrated, Empirically-based, Manualized Treatment Program: 

Matrix Model An Integrated, Empirically-based, Manualized Treatment Program

Manuals in Psychosocial Treatment: 

Manuals in Psychosocial Treatment Reduce therapist differences Ensure uniform set of services Can more easily be evaluated Enhance training capabilities Facilitate research to practice

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Program components based upon scientific literature on promotion of behavior change. Program elements and schedule selected based on empirical support in literature and application. Program focus is on current behavior change in the present and not underlying “causes” or presumed “psychopathology”. Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change.

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Non-judgmental, non-confrontational relationship between therapist and patient creates positive bond which promotes program participation. Therapist as a “coach” Positive reinforcement used extensively to promote treatment engagement and retention. Verbal praise, group support and encouragement other incentives and reinforcers.

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Accurate, understandable, scientific information used to educate patient and family members Effects of drugs and alcohol Addiction as a “brain disease” Critical issues in “recovering” from addiction

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Behavioral strategies used to promote cessation of drug use and behavior change Scheduling time to create “structure” Educating and reinforcing abstinence from all drugs and alcohol Promoting and reinforcing participation in non- drug-related activities

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Cognitive-Behavioral strategies used to promote cessation of drug use and prevention of relapse. Teaching the avoidance of “high risk” situations Educating about “triggers” and “craving” Training in “thought stopping” technique Teaching about the “abstinence violation effect” Reinforcing application of principles with verbal praise by therapist and peers

Matrix Model of Outpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Involvement of family members to support recovery. Encourage participation in self-help meetings Urine testing to monitor drug use and reinforce abstinence Social support activities to maintain abstinence

Elements of the Matrix Model: 

Elements of the Matrix Model Engagement/Retention Structure Information Relapse Prevention Family Involvement Self Help Involvement Urinalysis/Breath Testing

The Matrix Model: 

The Matrix Model Urine or breath alcohol tests once per week, weeks 1-16

Slide121: 

  Table 1. Sites participating in the MTP (from Herrell et al, 2000)

Slide122: 

Table 4. MTP Participant Characteristics (taken from baseline ASI)

Slide123: 

Table 7. Comparison of retention between groups within sites, with Matrix truncated to the length of TAU at each site

Slide124: 

Figure 3. Participant retention throughout treatment, by site and treatment group

Slide125: 

Figure 4. Percent completing treatment, by group

Slide126: 

Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition