27 April 2009

Comparative Pharmacology

I wrote earlier this month on the regional variations between the different types of heroin we see out west vs back in the midatlantic region. One interesting thing that I would note is that we just don't see much heroin use out where we are, at least not on a comparable basis. Nor, now that I think of it, do we see much cocaine use. I think part of this is that we are in a suburban location -- not the affluent suburbs by any means, more of a gritty, blue-collar exurb -- but a suburb nonetheless. When I do see someone who admits to cocaine use in particular, they are quite commonly "visiting" from the Big City directly to the south of where we work.

This, by the way, is not some sort of racial code. The Pac NW is a very different mix, ethnically, than anywhere I have ever worked in the past. Mostly white, with a lot of Asians and Pacific Rim folks, Ukranian & middle easterners (lotsa Iraqis), some Hispanics, many Native Americans, and only a small amount of African-Americans. In sharp contrast to the highly segregated drug use patterns I have seen elsewhere, there does not seem to be much racial differentiation in the patterns of drug use here. There is, of course, a high degree of economic correlation with drug use, which I suspect is more of a universal pattern, but I still see an urban-suburban local pattern too.

But I digress. Again. What we do see it lots and lots of methamphetamine use. One of the small towns near here was once dubbed the "meth capital of the US" and meth lab busts used to be a daily occurrence. That's not the case any more, since the severe restrictions on sudafed sales went into place. Sudafed is a key ingredient in the manufacture of meth. This really drove a reduction in the home manufacture of meth, most of which, I am now informed, is imported from mexico, where sudafed is available in mass quantities and industrial, high-grade meth can be manufactured on a large scale. Ironically, this is partly a good thing, since meth is made with anhydrous ammonia, which is quite dangerous. Decontamination is a big problem both for the ER and for the police when they do have a meth lab bust; explosions/fires were also fairly common. Score one for globalization!

The acute issues with meth are very different and more intractable than heroin. With heroin, folks come in with infectious complications of injection, which are straightforward enough to manage. Sometimes they come in with withdrawals which are miserable but not dangerous, and most commonly treated with anti-emetics and time. Sometimes they come in with overdoses which can be tragic but are very straightforward in their management. There are detox centers which are comfortable and familiar with heroin withdrawal, so if there happens to be funding and availability, it's easy to get them into treatment.

Not so with meth. The most common meth presentation is a patient commonly described as "tweaking." They are the folks who have been using heavily and represent a real challenge in the department. They are jittery and nervous, hyperkinetic and very talkative. If they're really been on a bender, they may not have slept for several days and they may be getting paranoid, confused, and delusional. Often, the reason that they were brought into the ER is that they have started to come apart at the seams, mentally and have crossed the line into full-blown psychosis. There is absolutely nothing you can do to calm them down or reassure them. Trying to redirect a restless paranoid tweaker is an exercise in futility, and a constant struggle.

So what do you do? No psychiatric facility will take them for admission, since their psychosis is purely due to the drugs (and psychiatry's ability to treat that is minimal). Most detox facilities won't take them either on the theory that a) there's no withdrawal syndrome from amphetamines and b) they require so much personal attention while tweaking that the detox places simply can't handle them. Families are also reluctant to take a tweaker home, either because they've burnt their bridges or, again because they're such a handful.

So that leaves me in the position of streeting them or keeping them. If the symptoms are mild and there's no cognitive impairment, then it's perfectly OK to discharge them back to their own recognizance. It's frustrating, but we all know there's nothing else to do. On the other hand, most people don't come to the ER because their symptoms are mild. So I get to play policeman and restrain them for their own safety until they are back to their normal selves. That gets real fun. Four-point restraints are the first line, while we check them out medically to make sure there's nothing else going on. Oh boy, that can be a real rodeo! Put a tweaker in restraints and the volume of the department goes up by 400%. And worse, it's dangerous, because the typical person high on meth will not stop struggling against the restraints no matter what. I've seen docs who just shut the door and ignored the hollering tweaker until the next shift came in to find the patient dehydrated and in rhabdomyolysis. Not a good idea, and though I have never seen it, this has been thought to be the cause of deaths in some police cases, due to "excited delerium." And like the PCP guys of yore, they don't feel pain like normal people do, which makes them dangerous when they try to escape. I've a black belt in karate, and many's the time I've had to utilize it to help restrain a tweaker (note: joint locks have their uses!) who was trying to get away before security could get there.

So you wind up sedating them in most cases. You have to be careful in how you dose the ativan (haldol works too, but is harder to titrate). If they are full-bore tweaking, it may take many doses to get them calm. On the other hand, if they've been high for a few days and are ready to crash, just a little bit can put them in a deep, deep sleep. Once they go to sleep, it's possible for them to be nearly unarousable for 24 hours as their bodies repay their sleep debt.

Meth is an evil, evil drug. I used to think that heroin was the most evil drug ever created. Heroin has a way of getting a hold on your soul in a way that, once an addict, you can never be free. One of the most searing books I ever read was The Corner (amzn) which told the story of a year in the life of an inner-city neighborhood ravaged by heroin, and the people whose lives were ruled by that drug. Understand that I am not minimizing the impact of heroin. But it is possible to live a normal, productive life despite being a heroin addict. I have seen sixty-five year old grandparents who got hooked as GIs in Vietnam and have used daily ever since. It's uncommon -- you need to avoid jail, getting shot, overdosing, HIV, tachyphylaxis, withdrawal and more. But it is possible.

Not so with meth. Meth destroys the mind in a way distinctly different from other drugs. The chronic users who come in are awful to see. When not high, they shamble, vacant-eyed and apathetic. Their speech is simple and sparse of content. Their affect is blunted. It's like something happened to their frontal lobes -- whether they have been destroyed, or just turned off I can't say, but they look and act like people who have had frontal lobotomies. It's hard to imagine how a meth user could ever be rehabilitated into a functional member of society again. I say this not to be judgmental or prejudicial, but to emphasize the degree of intellectual impairment these folks exhibit. And it's so sad, to think that this young person was just a couple of years ago a typical high-school sophomore. And the transformation into the cadaverous specimen is appalling.

Because meth is as hard on the body as it is on the mind -- the relentless expenditure of energy, physical and mental, strips fat from the body, followed by muscle mass, until all that is left is skeletal.

The above photo series is entirely consistent with what I see in the ED. Actually, if anything it understates the physical devastation that meth brings. The phenomenon of "meth mouth" is amazing to see. Nobody really knows why -- whether it's a drug-related toxicity, or due to the incessant grinding of teeth, but meth users have the most astonishing dentition. 20-year olds with all their teeth broken off at the gum line. They're uninsured, practically unemployable, so no dentist will touch them, and as a result they much come to the ER repeatedly for dental pain. It's hard to blame them when you look into their mouths, but what do you do? Write weekly scripts for vicodin for people who are already addicted to one drug? Talk about a catch-22. Also, for some reason, maybe hygiene though I don't really know, but MRSA flourishes in our meth-head population. Facial lesions are common due to nervous picking at the skin, and their faces, already hollow-cheeked and sunken-eyed, become pockmarked and scabrous to boot.

I don't have a conclusion here -- there's no simple, neat, pat answer to this new epidemic. It's a scary thing, which reminds me more of the onslaught of the crack epidemic in the '80s. That seems to have peaked and I hope that out here the same can be said for meth. I see less of it than I did two years ago. But it's a scary glimpse into the dystopian future of designer drugs. Blade Runner had nothing on this stuff.

I seem to have a talent for waxing prolific about the drugs we see in the ER. I'll try to finish my trilogy with some comments on the other popular drug of abuse in our ER -- Oxycodone -- tomorrow. And if history is to be any guide, by "tomorrow" I mean "on our about May 22."


  1. Meth taught me a valuable psychosis differential: the meth psychotic takes a nice long nap with the droperidol, the non-meth psychotic just starts talking to you intelligibly.

    The meth psychotic wakes up in 12 hours and goes home, the other goes to the psych ward, much calmer.


  2. Anonynonymous.4/28/2009 12:14 AM

    very very very good article. Please never stop.

  3. I gave this series of pictures and a couple of choice shots of meth mouth to a vain young man with amphetamines on his tox screen and mrsa on his leg. We spoke of the evils of meth, his response, "Oh ____!"

  4. What saddens me most greatly about meth are the kids whose parents are caught up in it.

    I grew up with an alcoholic parent and that was bad enough.... I can't get my mind around the horribleness that a meth-addicted parent can inflict.

  5. Tweaking is a situation for which Zyprexa Zydis is VERY effective. You get the anxiolytic +antipsychotic effect+enough sedating effect to slow them waaay down--->sleep. They will smooth out and sleep it off. Titrate the dose, of course on how far out they are and size/wt and any history of previous neuroleptic use. It of course helps that the Zydis form tastes good and disolves rapidly in the mouth.

  6. I live in another NW meth center and provide some coverage for the psych ER.
    I'll second the nomination for Zyprexa (Zydis or otherwise.) If they have methadone on board with their amphetamine of choice, you don't get into fun benzo-methadone interactions, and the titration problems are pretty much moot. Around here, my cranked-up folks usually have all kinds of other things on board, and by the time they come to the ER in extremis, their not-logical brain has often come to the conclusion that "methadone is used for heroin addiction and withdrawal; I'm withdrawing from *something*; maybe I should try some methadone?" [look, it's pretty shaky-sounding to me, too, but, then, I'm not on meth, am I?]
    But it's damned expensive, and I hate giving the money to Pharma.
    But it works really, really well.
    The Zydis isn't any faster but has amazing placebo powers - "look! it melts on your tongue! like Pop Rocks!"

    When you get to oxycodone... please feel free to spare some unkind words for Soma on the side.

    I dunno, though; meth still doesn't strike me as more evil than cocaine. Stimulants are just bad news all around when we try to self-regulate them. Mammals love to light up that reward pathway...

  7. A couple of really good books involving meth, from the perspective of the father of a meth addict and the addict himself: Beautiful Boy (father) and Tweak (son). They really helped me to understand about the drug and also about addiction and what it does to families and the addicts themselves.


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