Methamphetamine Use
Indian and Rural Health
Special Interest Groups
Listserv Discussion,
February 2005
Date: 2/8/05
To: Rural Health and Indian SIG ListServ
From:
Steve Holve, MD, FAAP, Chairperson, Indian Health SIG Steering Committee
Location:
Tuba City, AZ
AAP
Affiliation: Indian Health SIG Steering
Committee
Attachments
were included from Dr Holve -6 pg Meth Summary document and 50 pg Powerpoint
slides.
The
2 presentations below can serve as a primer about meth and as a starting point
for discussion. Thomas Drouhard, MD, a longtime general surgeon, Tuba City,
wrote the meth “word” document. The
PowerPoint presentation was prepared by Drs. Harrison Alter, ER medicine and
Diana Hu working in Tuba City. Providers should feel free to use this
information in presentations. There is no copyright issue. The powerpoint may
be especially useful for those called upon to speak in communities or at
schools.
Methamphetamine (meth) has become an increasing drug of abuse in many rural areas, including Indian reservations, in past 2yrs. Primary care physicians see patients with meth issues in ER, clinics, delivery, 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
Legal
Status of substance:
While possession and use of meth is a federal crime it is currently not an illegal substance on many Indian reservations. The word document by Dr Drouhard was prepared as the educational tool for the Navajo Nation tribal council. In response the Navajo Nation just passed legislation in March that made manufacture, possession and use of meth a crime under the tribal code. We hope other tribal governments will follow suit in this matter.
Questions/Concerns:
How
common is meth use in your area?
In
your tribal area are there laws that make meth production and use a crime?
Are
there penalties for possession?
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?
Date: 2/9/05
To: Rural Health and Indian SIG ListServ
From:
Matthew Clark, MD, FAAP
Location:
Southern Ute Health Center, Durango, CO
AAP
Affiliation: Indian Health(IH) SIG
Meth
use is quite prevalent in the local community. County Social Services has noted
an increase in child neglect referrals due to Meth, apparently the flow of meth
from Mexico at low price has resulted in a low number of "meth
houses" for production locally.
One
matter that has arisen related to G13 disposition of infants born to mothers
with suspected meth use is the fact that testing of the mother must follow a
specific "chain of custody" which requires a special lab procedure if
the result is to be of benefit to Social Services related to the child. Our
hospital has devised a specific procedure for this
Date: 2/18/05
To: Rural Health and Indian SIG ListServ
From:
John Ratmeyer, MD, FAAP,
Location:
Gallup, NM
AAP
Affiliation: Indian Health(IH) SIG
Mother/Infant Issues
What
is fairly clear, 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
likelihood/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.
Questions/Concerns:
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?
Do
other people have written protocols/ guidelines for such testing of either
mothers or their newborns?
Date: 2/3/05
To: Rural Health and Indian SIG ListServ
From:
Judith Thierry, DO, FAAP on Behalf of Suzan Murphy, PIMC Lactation Consultant
Location:
Rockville, MD
AAP
Affiliation: IH SIG, IHS/USPHS
Mother/Infant Issues
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
Questions/Concerns:
Meth pops in many conversations. This from Suzan Murphy - - - We have a Pharm.D student addressing medications and drug exposure in breastfeeding moms. A format will be available at breastfeeding web site - user friendly info.
Need for Guidelines
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 preg 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.
Date: 2/3/05
To: Rural Health and Indian SIG ListServ
From:
Lori Bryon, MD, FAAP
Location:
Crow Res, Southern Montana, Hardin, MT
AAP
Affiliation:
Mother/Infant Issues
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.
Jan Bays of Portland's research showed that poor prenatal care(defined as 4 or
fewer prenatal visits) was the number one indicator of drug abuse in mothers.
Our
regional attorney approved our policy, ie, we do without parental consent,
meconium and urine screens on infant and urine on mother. Using that criteria
alone, about 50% of our screens are positive.
The Crow Agency Policy is shown below:
DRAFT NURSING POLICIES AND
PROCEDURES
NURSING SERVICES
ADMINISTRATION
SUBJECT: Neonatal Drug Screening
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.
Date: 4/27/05
To: Sunnah Kim, Division
Director, DOCHS, Native American Child Health
From: Steve Holve, MD, Chairperson, Committee on Indian SIG Steering
Committee
Location: Tuba City, AZ
Other Web site resources
about drug screening for pregnant women has come from Neil Murphy the IHS
OB/GYN Clinical Consultant:
·
See this web based
document for many other resources
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc
·
DRAFT Obstetrics Dept
Guideline for Drug Testing
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ScrOBdraft.doc
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/UNMScr.doc