Amphetamines-Ice

Cardiac sequelae are the second most common cause of death (behind overdose) in patients who use methamphetamines (“meth”). Like cocaine use, use of methamphetamines can produce both acute and chronic cardiovascular disease. Acute intoxication with methamphetamines produces a hyperadrenergic state, not unlike having a pheochromocytoma. The hypertension and tachycardia that result can lead to myocardial ischemia and infarction, aortic dissection, malignant arrhythmias, Takotsubo’s (stressinduced) cardiomyopathy, and cardiac arrest. Chronic methamphetamine use can lead to hypertrophic cardiomyopathy (due to persistent severe hypertension) or dilated cardiomyopathy (due to the drug’s toxic effects on myocardium), and the clinical syndrome of heart failure. In addition, chronic meth use can also cause pulmonary arterial hypertension (PAH). Meth-associated PAH is a devastating disease, with five-year mortality rates above 50%.

Diagnosing and managing acute methamphetamine intoxication:

Patients who present with suspected acute methamphetamine intoxication should undergo a full physical exam, electrocardiogram, and basic lab work (including basic metabolic panel, blood counts, clotting times (prothrombin time and international normalized ratio), liver function tests, creatine phosphokinase (CPK), urinalysis, and urine and serum toxicology screens). Amphetamine intoxication or toxicity is ultimatelydiagnosed by confirming the presence of amphetamines in urine or serum. However, if patients present with signs and symptoms which raise concern for amphetamine intoxication—including hyperthermia, agitation, hypertension, and tachycardia—treatment should not be delayed while waiting for these test results to return.

If there is concern for myocardial ischemia or infarction (for example, if the patient complains of chest discomfort or shortness of breath or the ECG shows ischemic changes), then cardiac biomarkers should be checked as well (i.e. troponin I or T). Acute methamphetamine intoxication with secondary sequelae (i.e. agitation, hypertension, tachycardia) should be managed initially with sedatives (benzodiazepines and 2nd generation atypical antipsychotics).

Hyperthermia should be managed aggressively by controlling core body temperature with sedatives and, if necessary, with paralysis and intubation (but antipyretics should not be used).

Rhabdomyolysis is common, and a CPK level should always be checked in patients who are acutely intoxicated with meth. If the hypertension is refractory to treatment with an adequate trial of sedation, then nitrates and/or phentolamine should be used. Calcium channel blockers can also be used, and are effective agents for managing tachycardia that persists despite sedation. Beta-blockers should be avoided in the acute setting to avoid precipitating unopposed alpha-mediated vasoconstriction (via identical mechanisms to those described above). If beta blockers are necessary for chronic management of a different disease process (e.g. cardiomyopathy or coronary artery disease), then labetalol or carvedilol are the preferred agents due to their partial alphaantagonism. Myocardial infarction in the setting of methamphetamine intoxication should be managed per evidence-based guidelines for the management of heart attacks, and as described above (for cocaine). The one exception is that, if heart rate control is needed, calcium channel blockers, not beta blockers, should be used. Interestingly, monoclonal antibodies against methamphetamine have been developed and are currently in clinical trials.

Chest pain in the setting of acute methamphetamine intoxication should raise concern not only for myocardial infarction, but also for acute aortic dissection. Methamphetamine abuse is the second most common cause of acute fatal aortic dissection in the US, after hypertension. Unlike chest discomfort due to myocardial ischemia, which often starts as mild or moderate discomfort and worsens progressively over minutes-hours, chest discomfort due to aortic dissection is typically extreme from the outset.

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Chronic methamphetamine use causes neuroadaptive/pathological changes in the brain, including numerous cognitive deficits plus mood, thought and behavioral disorders, the worst of which is psychosis. Research by Wang et al, (2015) found similar patterns of delusions common in patients with schizophrenia among those with methamphetamine-induced psychoses. Moreover, when compared with schizophrenic patients, those with methamphetamine-induced psychosis present a higher prevalence of visual and tactile hallucinations but less cognitive disorganization, blunted affect and motor retardation.

Additional investigations are needed to identify biological differences between schizophrenia and methamphetamine-induced psychosis in order to develop therapeutic targets and potential medications for methamphetamine addiction and co-occurring mental illness.

Why Does This Matter?

Because of the high toxicity of meth, the debilitating effects often persist after extended periods of abstinence. As a result, the cognitive deficits (which are not easy to detect in abstinence) affect how individuals respond to treatment, which is a highly didactic and educational experience. Therefore, treatment modalities and interventions must be tailored to address the individuals’ unique cognitive and emotional deficits and co-occurring psychiatric and medical disorders.

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Abstract

Background Amphetamine abuse is becoming more widespread internationally. The possibility that its many cardiovascular complications are associated with a prematurely aged cardiovascular system, and indeed biological organism systemically, has not been addressed.

Methods Radial arterial pulse tonometry was performed using the SphygmoCor system (Sydney). 55 amphetamine exposed patients were compared with 107 tobacco smokers, 483 non-smokers and 68 methadone patients (total=713 patients) from 2006 to 2011. A cardiovascular-biological age (VA) was determined.

Results The age of the patient groups was 30.03±0.51–40.45±1.15 years. This was controlled for with linear regression. The sex ratio was the same in all groups. 94% of amphetamine exposed patients had used amphetamine in the previous week. When the (log) VA was regressed against the chronological age (CA) and a substance-type group in both cross-sectional and longitudinal models, models quadratic in CA were superior to linear models (both p<0.02). When log VA/CA was regressed in a mixed effects model against time, body mass index, CA and drug type, the cubic model was superior to the linear model (p=0.001). Interactions between CA, (CA)2 and (CA)3 on the one hand and exposure type were significant from p=0.0120. The effects of amphetamine exposure persisted after adjustment for all known cardiovascular risk factors (p<0.0001).

Conclusions These results show that subacute exposure to amphetamines is associated with an advancement of cardiovascular-organismal age both over age and over time, and is robust to adjustment. That this is associated with power functions of age implies a feed-forward positively reinforcing exacerbation of the underlying ageing process.

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Drug Culture Can be Changed

A recent study has found that life skills training early intervention programs can be cost effective in turning off youths from using ICE (methamphetamines).

The skills training program aimed at parents and schools were assessed to return ten times the cost of the program.

The longitudinal study of 667 families looked at prevention of use of ICE and alcohol and has the potential to save enormous sums of money in preventative health and community costs.

(Source: Iowa State University Partnerships in Prevention Science Institute paper at the United Nations Office on Drugs and Crime/World Health Organization conference in Vienna Austria December 2008).

DRUG ADVISORY COUNCIL COMMENTS-

Australia NEEDS effective early intervention illicit drug resistance programs to avoid the trauma and costs of dealing with the early drug use influenced by our culture.

We need to use world's best practice in early intervention life skills training to prevent illicit drug use promoted by the culture.

ICE (methamphetamines) is a significant problem in Australia.

ICE causes permanent brain damage, violence, aggression, paranoia, hallucinations, psychosis and irrational behavior and other mental illness.

The way forward is to provide Australian children with the ability to resist drug pressure at a young age so they will not use illicit drugs.

These studies show that resistance is ten times more effective than rehabilitation of ICE users.

Speed use Higher than Heroin

The number of people in New South Wales dependent on methamphetamine, such as speed far exceeds dependent heroin users.

The reason for this is that the number of dependent speed users has increased.

This increase in speed dependency has placed pressure on drug and health services as well as emergency workers.

A recent study by the National Drug and Alcohol Research Centre has found that the use of speed in Australia is at an all time high with one in ten people having reported as having taken the drug.

Most of the users inject speed so the transmission of blood borne disease such as Hepatitis C and HIV is a strong risk.

Prolonged use of speed causes psychosis and violence so that emergency and health workers are most at risk.

Another form of methamphetamine called ice is also increasing in use in Australia with increasing incidents of psychosis and violence.

The research found that in New South Wales alone there were 19000 regular heroin users and 36900 regular methamphetamine users.

The 2004 National Drug Strategy household survey found that 3.2 per cent of people had used methamphetamine in the last year compared to 1.4 per cent who had used heroin.

(Source: Sydney Morning Herald 28 July 2005 Page 3)

DRUG ADVISORY COUNCIL COMMENTS-

Speed and Ice use in Australia is increasing because there are not enough efforts to reduce the number of users.

Also worrying is the increasing violence our health and emergency workers are facing as they deal with this increased use.

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THE DRUG ADVISORY COUNCIL OF AUSTRALIA SUPPORTS

More detoxification & rehabilitation that gets illicit drug users drug free.
Court ordered and supervised detoxification & rehabilitation.
Less illicit drug users, drug pushers and drug related crimes.

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