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Methamphetamine use in Indian Country: Discussion Below are some issues worth discussion about Methamphetamine use in Indian Country. Let us here your thoughts on these, or other issues
-How common is meth use in your area? -Should all mothers be screened at delivery for meth use or only if medically indicated? -What is the disposition of an infant born to a mother with known meth use? -Do you think this is or should be different than use of other drugs? -What resources are available for teenagers and adults who are meth users? -What programs have shown success in treating meth addiction? -Do you know of any successful prevention programs? -In your tribal area are there laws that make meth production and use a crime? Are there penalties for possession?
Here is a little background: Methamphetamine (meth) has become an increasing drug of abuse in many rural areas, including Indian reservations, in the past two years. Primary care physicians see patients with meth issues in emergency departments, clinics, delivery suites, domestic violence episodes and child neglect cases. Diagnosis of meth abuse with the use of urine toxicology screens is easy; successful treatment appears to be hard.
Clinicians need to be aware of this drug and its ramifications.
The two presentations below can serve as primers about methamphetamine and as background for discussion.
The methamphetamine
"Word" document was written by Thomas Drouhard, MD, a longtime general
surgeon at
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf
This PowerPoint
presentation was prepared by Drs. Harrison Alter of emergency medicine and
Diana Hu of pediatrics who also work in
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt
A special thanks to Steve Holve MD for providing this material and moderating this discussion
Grenier, Denise (OIT-Tucson) [Denise.Grenier@IHS.GOV]
Thu 3/31/2005 7:53 AM
In light of burn injuries associated with the production of Methamphetamines (an interesting piece on this ran on NPR 03/30/05 citing an increase in visits to EDs and increased burn unit admissions in Iowa due to burns received secondary to the production of Methamphetamines), I wonder if we might also want to ask:
-Are you seeing an increase of burn injuries secondary to the production of Methamphetamines? -Are victims of suspicious burn injuries being screened for meth use?
Stuart, Peter [Peter.Stuart@IHS.GOV]
Fri 4/1/2005 5:01 PM
Hard to know where to start but here’s a mixed bag of responses and questions – first, while meth has ‘arrived’ on the res (at least here in Navajo) and the alarm raised that does not equate in any manner or form to the level of impact meth has had in many other communities – we still appear to be in the beginning stages of its distribution and widespread use – again referring to Navajo. Whether or not the aggressive prevention and education efforts will save the day remains to be seen but I think we need to be honest in how it is portrayed and discussed. Alcohol still by far causes the most damage and disease and should remain in the forefront of addiction prevention/treatment.
Second, many of the problems and violence related to meth use are related to its manufacture and distribution and only partially due to its direct effects as a drug. This will be an ongoing issue and begs the question of whether a focus on closing down labs over targeting individual users should be the strategy. Cleaning up lab sites, preventing/reducing exposure of children and unwitting adults to the toxic chemicals involved in manufacture and the manifold problems with gang-based distribution chains (in a community with 50% unemployment it’s not a bad way to make some cash) will need ongoing attention outside of standard prevention and treatment approaches. We do have advantages out here because as compared to some rural parts of the country setting up a lab in our remoter regions will be noticed by someone – because everyone is family. This may be an effective leverage point in preventing long-term establishment of its manufacture here but only with aggressive education and prosecution by local tribal police and federal officers. Health care providers can assist in this process by willingness where appropriate to get involved in the rough and tumble of tribal politics.
Third, age-wise meth appears to have a more significant impact on our local adolescent and young adult population – related to its marketing by pushers as a diet aid, wt loss agent, fatigue fighter etc. Alcohol is perceived as the drug of the older generation and while used does not have the cachet meth has with our teens. This has meant for us focusing more attention on younger women as we have seen increasing numbers becoming pregnant while on meth and who continue meth use during their pregnancies. Drug screening in pregnancy and of newborn infants has raised interesting issues about consent given the consequences of positive screens (reporting to CPS, child removal, etc.). I personally believe we need to move with great caution here making sure women in crisis see us as supports and not as police agents while at the same time not enabling continued drug use. Screening should be connected with good, sound addiction treatment interventions and not done in isolation – and preferably with the full consent of the mother. The process also needs to focus on the interaction part of the screening and assessment process and not rely on urine screens as the sole indicators of risk. Negative drug screens are not sensitive for the absence of a drug or alcohol problem.
Finally, meth is an addiction plain and simple. Treatment success rates, relapse rates, etc. are not dissimilar from the other drugs of abuse. It is not thus per se more intractable or problematic than other addictions such as our old friend alcohol. We should avoid thinking in rural areas with limited resources and populations that we’re somehow missing treatment programs just because we don’t have a “meth” program. What is different with meth is that it’s effect during intoxication are different than alcohols, and it’s delivery methods have their own particular risks (HIV, endocarditis, etc.) that our local counselors need to be aware of and educate clients on. But getting off of it requires similar skills and approaches to those needed by people struggling with alcohol dependence. Our message should be “If you’re addicted to meth – there is help” not “oh my god you’re on meth you’re doomed”. Primary care providers have a role to play in that even fairly simple interventions such as identifying use as a problem, discussing consequences of use, and connecting patients to resources make a difference. Asking about use regularly and predictably also sets the stage for later revelations of use. Here in Chinle over the years I have often noticed a general sense of despair when it comes to dealing with addictions among primary care providers – this is despite the fact that more people here than elsewhere with histories of drinking problems end up being teetotalers for the rest of their lives! That despair is readily appreciated by our patients and no doubt contributes to a lack of optimism by both providers and patients as it regards the patient’s addiction. This need not be – primary care level interventions can and do make a difference! – but a long term and realistic perspective definitely helps carry the provider through the inevitable valleys of caring for patients with addictions. Motivational interviewing is a technique readily learned and applied in the primary care setting and has a good empirical base for interventions with drug and alcohol dependencies.
We’re working locally on helping the local tribal drug and alcohol treatment program develop a “Matrix”-based treatment program. This is a tested, manual based cognitive-behavioral treatment program that has been used to treat both specifically meth dependent and alcohol dependent patients and generally groups of patients with mixed drug and alcohol dependencies. There is growing experience with NA/AN populations. More information is available at www.matrixinstitute.org
Holve, Steve (TCRHCC)
Fri 4/1/2005 6:55 PM
The issue of screening pregnant women is particularly difficult. Meth is clearly a dangerous drug to use in pregnancy and likely has permanent effects on offspring. On the other hand, given the potential legal and social service ramifications of testing positive, do patients need consent to be tested? Will universal testing drive some women away from prenatal care? How can we make testing a positive intervention? What is done at the service unit level?
N.
Mon 4/4/2005 12:05 AM
I do perinatal hospital reviews for an organization here, and have been amazed in that usually we in OB seek consent for testing moms, but it is rare for testing to ever be consented in the nursery, although the newborn is in reality a proxy for the mom (and it is the mom who will be the one reported to authorities). This has been considered an ethical issue in ACOG's drug testing policy, but apparently does not carry over to other disciplines. When I brought the issue up here, it even got to a special committee at the Governor's Office.
Matthew A. Clark, MD, FAAP
Thu 4/7/2005 7:38 PM
Meth use is
quite prevalent in the local community.
N.
Fri 4/8/2005 2:17 AM
This follows on my comments about ignoring the fact that testing of the child is a proxy test of the mom, yet consent is never requested for such testing. This is also the usual procedure with other drug testing, and conflicts with ACOG's ethical guidelines on drug testing.
Neufeld, Brenda G (TUC) [Neufeld@IHS.GOV]
Fri 4/8/2005 12:28 PM
As a family doctor doing prenatal care, I'd like to echo Dr. Stuart's comments. I feel that we should proceed very cautiously with drug screens, although on occasion patients have readily agreed to them as an adjunct to counseling, especially when CPS is already involved. Our clinic is lucky to have a behavioral health counselor present in the clinic on prenatal morning; all patients are encouraged to see her for education and screening regarding substance abuse. Providers also screen patients for substance abuse at the time of the first prenatal visit. We have found it very helpful to use the ACOG database for prenatal visits rather than the IHS form, as it has more space for additional comments. We have made some stamps to add to the ACOG form so that we are certain to ask additional questions about substance abuse, as well as about past and present domestic violence, whether the pregnancy was planned, educational level, etc.
Bunt, Clayton [Clayton.Bunt@IHS.GOV]
Fri 4/8/2005 3:59 PM
I've got to admit I don't have a real sophisticated perspective on this, but I really don't find the need to wring my hands over the consent issue. We need to remember that there is a child protection issue involved. Would you hesitate to order a skeletal survey if you suspect physical abuse? I don't. At our hospital, we set screening criteria such as less than 4 prenatal visits, obvious clinical signs of intoxication, etc. Those get at minimum a meconium drug screen, and often a maternal urine screen in labor. I believe we wrote consent for testing into our admission consent, although I don't have one handy to check.
If we get a positive, we then interview the mom. Most, even if they have previously denied drug use, then admit to using. Social Services are notified and we offer referrals to treatment. This really can become a positive therapeutic intervention if you approach it right. I find that reminding me of my own frailties and failings before addressing the mom with a positive screen really helps in having a successful interaction with her!!!
I don't have time in my practice to stew over the fine distinctions, so I proceed from the premise I learned in the ER: "When in doubt, Protect the Child"
Byron, Lori [Lori.Byron@IHS.GOV] Sat 4/9/2005 10:28 PM
I am only addressing the
delivering mother’s issue. Many years ago, we adopted a policy in Crow
Agency that all babies with s/s of possible drug exposure would be screened
and that INCLUDED poor prenatal care.
Disposition of a drug positive baby varies, unfortunately. Some are allowed to go home with mom; others are placed with a relative. Most of the mom's are then required to do drug assessment/treatment. And meth is a bad problem here - is there anywhere that it is NOT currently? Our child protection list seems full of meth+ parents. It is not a crime on our res. Lori Byron
17 years on the Crow Res,
Manning, Thomas [tmanning@WSP.PORTLAND.IHS.GOV]
Sun 4/10/2005 3:48 PM
I think there would be great interest in the Crow policy that has passed legal muster that allows screening of infants without having to obtain parental consent.
Holve, Steve (TCRHCC) [steve.holve@TCIMC.IHS.GOV]
Mon 4/11/2005 7:56 AM
Yes, can you share with us your screening policy?
Clark, Donald [dclark@ABQ.IHS.GOV]
Mon 4/11/2005 6:30 AM
Only slightly off the subject: Prenatals should have already been screened for domestic violence by delivery. But if they haven't - or even if they have - <4 prenatal visits = (another) DV screen.
Holve, Steve (TCRHCC) [steve.holve@TCIMC.IHS.GOV]
Mon 4/11/2005 7:54 AM
An important point here is if screening is done, how to make sure that the information is used in a positive way( intervention and treatment) as opposed to purely punitive (arrest and jail time). A report to social services is probably mandatory, does this lead unintentionally to judicial proceedings in any tribal jurisdictions?
Racehorse, Ann [aracehorse@ABQ.IHS.GOV]
Mon 4/11/2005 8:22 AM
Is this why Dr. Hsi, a pediatrician, left Indian Health - there was no real follow up and treatment for prenatal, women and infants for substance abuse? He is now at UNMH and has grants for programs such as Milagro and Select which provide case management, treatment, residential programs etc. for not only substance abuse but domestic violence as well as other social issues that impact this client population. Ann Racehorse, LMSW
Lindsey, Catharina [Catharina.Lindsey@IHS.GOV]
Tue 4/12/2005 10:43 AM
I think that medical
consent to procedures and basic medical ethics might be a great topic for
our next group forum. Practicing medicine on the reservation does not give
providers a license to practice paternalism or disregard a client's basic
rights. I wonder if we are guilty of 'racial profiling' in providing
'screening' labs for our own population. Some of the comments voiced give
me flashbacks to
Taking care of patients and client safety is certainly the central goal. However, I am not sure if the current practice of taking children away from parents and placing them in the care of social services crippled by an overwhelming case load is the best answer to this issue.
I utterly agree with the provider who stated that we need to look at our own motivations in providing care before providing care.
I work in
Catharina
Stuart, Peter [Peter.Stuart@IHS.GOV]
Tue 4/12/2005 1:40 PM
Well said. I understand the sentiment behind the idea of uninformed drug screening but I'm not sure the evidence supports that it prevents what it is intended to prevent. A very recent article (2005, Mar 31) in the Journal of Pediatric Psychology at least suggests (though there are different ways of interpreting the outcomes) that cocaine-exposed children who are in foster care are more symptomatic than cocaine-exposed children in maternal or relative care. Screening only to have kids end up in problematic foster care settings is hardly a solution. I believe a balance between informed consent and taking appropriate action on the behalf of abused children is needed - and this balance may vary due to prevailing concerns in specific localities. If there was an excellent specialized foster care system in place, and if there was active support for aggressive, outreach-oriented drug treatment interventions (drug court, TX programs oriented to caring for mothers with children, etc.) and if the intervention at the hospital/clinic level was one of collaboration and support for pregnant mother, or the new mother and her child(ren) then the downsides of screening would be considerably less. Unfortunately, while most of us may have one or sometimes two of the above, I would be surprised by programs having all three.
The plus side of informed consent is that it is establishing an atmosphere of trust and support between provider and patient - something that may not pay off immediately but in our systems people are often life-time members and the care they receive and how it is approached will be remembered.
Finally, why not do informed consent? My experience is that if handled appropriately most people consent anyway - and if they don't they are deserving of increased attempts at outreach and support in many cases. There is a cost to the system in time but the benefits of respectful care are life long.
Holve, Steve (TCRHCC) [steve.holve@TCIMC.IHS.GOV]
Tue 4/12/2005 11:43 AM
How to best come down on the side of treatment as opposed to punishment? How can we identify patients who are using meth and endangering themselves and infants while not having a negative judicial outcome?
Mon 4/18/2005 1:11 PM
I strongly disagree with
any accusation of racial profiling.
The majority of our moms are NOT removed from their babies, but they are monitored and offered/given services. When I know a mom is positive and the mom knows that I know that she is a drug user, we actually have a more honest well child visit, and we can talk about the elephant in the room; if I did not know, she likely would not tell me, and we would waste the visit on more mundane topics.
Most hospitals, ours included, do certain tests when signs/symptoms point to an important problem, ie, doing a glucose as well as a drug screen on a jittery baby, and talking to mom about the reasons/results when you get the time. The regional attorney (Gary Falstaff) for IHS thought that with Jan's research, the meconium screens could be obtained without parental permission (we do tell the families) in the best interest of the child.
Comparing this to sterilization is a little far-fetched.
Lori Byron
Olson, Richard D. (HQE) [Richard.Olson@IHS.GOV]
Tue 4/12/2005 11:41 AM
See attachment. Meth use reported through RPMS by Area.
Stuart, Peter [Peter.Stuart@IHS.GOV]
Tue 4/12/2005 3:16 PM
These numbers should be used cautiously as they reflect things other than actual incidence or prevalence. Some Areas report limited RPMS data and are thus underrepresented in the numbers, others have more specific treatment resources and thus may appear to have higher levels of activity (i.e. one of the adolescent RTC's uses RPMS as an electronic health record - and thus would regularly be entering visits with "methamphetamine dependence" as the POV inflating the frequency of meth POV's compared to areas who are not reporting RTC numbers). Somewhat more representative numbers (though still not readily interpretable without further information about reporting activity) would be prevalence numbers - how many distinct patients were seen for a POV of methamphetamine abuse, dependence or intoxication in the last year.
From Judy Thierry on Behalf of Suzan Murphy, PIMC Lactation Consultant
Thu 4/14/2005 12:37 PM
Meth pops in many conversations We have a Pharm.D student addressing medications and drug exposure in breastfeeding moms:
A format will be available at the breastfeeding web site - user friendly info, categories for different issues like hypertension, dm, mental health, colds/flu, gi distress, etc. OTCs will be listed also and the links to up-to-date and other resources. Hopefully she will have a chance to do some in depth looking at street drugs. The use of methamphetamines has increased in many communities - with not clear guidelines on what/how/if with bf. One of the local big hospital groups now prevents moms from bf if they were UDS + for anything (including marijuana) in the last 3 months of pregnancy or at delivery. We are planning to continue with case by case treatment. Info about street drugs - esp. meth, will be helpful and time saving. Dr. Hale et al have indicated that moms with a +UDS for meth at delivery may still be able to breastfeed safely because the amount of meth that gets into the colostrum is small, and the amount colostrum that the baby receives is also small, making the meth dose negligible. Unfortunately, as the baby grows, the subsequent use and feedings may be a problem. There has been newspaper publicity about meth user’s breastfeeding and their babies dying. It is not yet a clearly understood issue.
John Ratmeyer, GIMC
Fri 4/15/2005 2:32 PM
What is fairly clear, however, is that breastfeeding is more than just nutrition, something lost on those who would bar any woman from nursing solely on the basis of a positive urine toxicology screen. Breastfeeding develops a bond between parent and child which may serve as a motivator for positive change on the part of drug-abusing parents while decreasing the risk of future child maltreatment. That information has to be considered along with concerns about the likelihood and degree of drug exposure the newborn has if breastfed. If it's predetermined in whatever system one works that newborns will be separated from their drug-abusing mothers, I would agree not to allow breast-feeding to begin as a practical matter, but many social work agencies are opting to send these infants home with their parents while social work monitors the situation and puts a treatment plan in place. Those treatment plans include frequent visitation by SWer's, the parent's attendance at 12-step programs, frequent parental urine drug tests, and links with financial resources. I think it's actually fortunate when discharge disposition is not predictable. That at least suggests that some individualized care planning is possible. I share the concern that it may also mean that there is inconsistency within the designated social service agency; that different workers approach similar situations differently, with little or no supervisory oversight to rectify these inconsistencies. We seem to have been spared the overwhelming problems meth has brought to the reservation and remote rural areas. As a border town, EtOH still seems to be our drug of choice.
Do I correctly understand
that isolated poor prenatal care (defined as 4 or fewer visits) prompts
urine drug screening of expectant or newly-postpartum mothers in Crow
Agency? I don't believe we have a written guideline used by our
What are other people doing? Do other people have written protocols/guidelines for such testing of either mothers or their newborns? Thanks!
John Ratmeyer, M.D., FAAP Medical Consultant to the Child Protection Team
Mon 4/18/2005 12:01 PM
John, Poor prenatal care - the main identifiable risk factor for drug use in pregnancy is used to obtain a meconiun drug screen. Maternal and infant urine drug screens are used when there are s/s of drug use/withdrawal.
Lori Byron, Crow Agency
Murphy, Neil
Mon 4/18/2005 1:58 PM
#1 I would like to welcome Andrew Hsi to the discussion. Dr Hsi has worked in Indian Health and now is on staff at UNM in ABQ “Good Evening, Neil,
Thanks for sending me the
documents. I'm on the road at the moment, but from my first look, the
documents have a wealth of information. I'd be happy to participate in the
discussion on list serve. I told Judy that the
Looking forward to further communications, and thanks for including me,
Andrew Hsi, MD, MPH, FAAP Professor Director, Division of General Pediatrics UNM Health Sciences Center phone (505) 272-3142 fax (505) 272-6847 “
#2 I think we may want to be a little clearer about the distinction between ‘clinical testing’ and ‘screening’. The following is an excerpt from answer to the Frequently Asked Questions that I have posted on the MCH website on this topic
“Different indications for drug testing NB: Not all drug ‘testing’ is ‘screening’
First, let us not confuse overlapping issues, e.g., there are at least 4-5 separate issues
A.) Clinically indicated drug testing of pregnant mother - this is not drug ‘screening’, it is testing the mother because she bleeding, changing her cervix, need to know for anesthesia and medications, etc....
B.) Targeted Drug testing - this is performed after the verbal 5 P’s or 4 P’s, IHS No. 866, or a CAGE-like screen. The verbal screens may be confirmatory, qualitative, or quantitative. If the pregnant patient answers yes to the questions, then you ask her to submit a biochemical test. If she says No, then you document that fact, as well.
C.) Universal screening - screening all pregnant patient based on some common characteristic, e.g., all patients presenting to this clinic, or that L/D unit. This type of testing is reserved for areas where the Native Board has approved it. As it is, exposures may be hidden, or clinically obvious. This modality would only be indicated if there were good treatment modalities and referral systems in place when one obtains a positive result.
D.) Clinically indicated drug testing of an infant - this is not drug screening of the infant; this is testing of an infant because he/she is sick. Yes this last method also secondarily implies something about the mother, but the infant is a dependent individual and needs to be tested be primarily for infant reasons. Maternal autonomy is discussed below. “
You may want to go to the following url because it contains the IHS policy on this topic, several national benchmarks, Instructions on how to receive a copy of a documentary about Methamphetamine use in Navajo Country, what types of consent are suggested, and many more resources on this topic http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc
My own personal experience with tribal councils has only been positive. Yes, it involves some time out of clinic, but many times if you have a question about expanding your drug testing beyond just clinically indicated testing, or whatever, the tribal councils are more often on your side than not. In many cases your wish for the improved health among your drug abusing patients is akin to returning to the natural harmony that many tribal boards are seeking, as well. It is worth the time is takes to talk it over with them. Neil
Murphy, Neil
Wed 4/20/2005 7:55 AM
Four possible resources on this topic
#1 Here is DRAFT Neonatal Drug Screening courtesy of Lori Byron (also attached as a Word document) DRAFT NURSING Guideline PURPOSE: To identify infants at risk for withdrawal and teratogenic effects of illicit drugs used by pregnant women. Since drug use during pregnancy places the infant at risk for abuse and neglect, intervention strategies in the home can be initiated early if the problem is identified.
PATIENT POPULATION:
Neonates with the following signs/symptoms may have been affected by maternal drug usage. If there is reason to suspect illicit drug usage and the patient is symptomatic, sampling should be done in order to optimize patient care.
The number one predictor of drug use during pregnancy is poor compliance with prenatal care (0-4 appointments kept).
SIGNS / SYMPTOMS OF POSSIBLE DRUG EFFECTS:
Hypoglycemia Jitteriness Lethargy SGA Microcephaly Height for weight disproportion Hypotonia Hypertonia Tremors Seizures Diarrhea Sweating
TREATMENT:
1. Withdrawal symptoms require close observation, hypoglycemia checks, and vital signs monitoring (as often as ordered by M.D.)
2. Swaddling, pacifiers, and increased comforting may be required. Minimal noxious stimulations – bright lights, unwrapping, bathing, may be indicated.
3. Sedatives or anti-convulsants may be required (per M.D. order)
MECONIUM TESTING:
Procedure: Meconium is collected and tested by gas chromatography/mass spectrometry and immunoassay screening methods in a testing lab. Testing can be done for amphetamines, cannabinoids (marijuana), benzoylecogonine (cocaine), opiates (morphine), and PCP, and reflects maternal usage for the 20 weeks preceding delivery. Stools must be meconium stools. Discard first meconium stool and collect second or third stool. To be accurate, stool should be collected within the first 24 hours after birth.
METHOD:
1. If ordered by physician, invert diaper or line diaper with plastic.
2. Transfer meconium (minimum 5 grams, or 5cc = 1 teaspoonful) with spatula into vial or cup.
3. Affix specimen label.
4. Place meconium vial in plastic bag.
5. Refrigerate in lab until shipped.
6. Enter “comprehensive meconium drug panel” on lab slip.
BLOOD TESTING:
Purpose: As meconium is much more accurate, blood or urine testing should not be done for the drugs testable in meconium. As alcohol usage cannot be detected in meconium, a STAT blood alcohol level on the newborn immediately after birth should be obtained if the mother is potentially intoxicated.
Procedure: 2cc whole blood via vein puncture is obtained immediately after birth.
ADD this paragraph to preprinted Infant orders LABS:
a. Meconium Drug Screen on all infants born to mother with 4 or fewer prenatal visits. b. Cord Blood: _______ABG Type and Coombs Type and Screen c. IF ABO INCOMPATABILITY Total and indirect Bili at 12 hours of age. IF ≥ 10, call MD and begin phototherapy.
Other resources #2 See this web based document for many other resources http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc
#3 DRAFT Obstetrics Dept Guideline for Drug Testing http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ScrOBdraft.doc
#4
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