metamphetamine / meth / ice

see also:

• the meth epidemic video
• amphetamines and related psychostimulant substances
• Mx of psychostimulant toxicity from amphetamines and related substances
• addiction medicine (alcohol and other substance use)
• managing violence or the aggressive patient in the ED
• NDARC - Ice Fact Sheet (pdf) or low res. version (pdf)
• https://www.abc.net.au/news/science/2019-04-20/chemsex-crystal-meth-ice-sex-risks/10993800

• releases large amounts of serotonin and dopamine, and prevents reuptake of these neurotransmitters, and thus has mainly sympathomimetic actions
• it has the most potent cardiovascular effects of all amphetamines, greater CNS effects than amphetamine
• results in a far higher brain dopamine level than other commonly abused substances
• inhaling or injecting ice is the most addictive methods of metamphetamine use
• 10 points = 1g
• most users use 1 point at a time but 5-10 points is regarded as high use and 30 points a day is generally the maximum tolerated
• it is sometimes mixed and injected with heroin
• users often take metamphetamine to deal with depression but it's use invariably results in depression creating a viscious cycle further perpetuated by the usual financial requirement to become involved in the criminal culture of dealing
• using ice was quite uncommon in Australia in the 1990's with only a few percent of regular drug users using ice, this rapidly has increased to over a third by 2004

• Meth, Speed, Whiz, Fast, Rabbit, Tail
• powder can be injected as a 'dry shot', or snorted, ingested or inserted rectally or dissolved in water to become the liquid form
• usual dose is 0.5g once or twice in a day or evening session

• often mixed with other drugs such as ketamine to given an ecstasy-like experience
• usually only contain a small dose of methamphetamine

• metamphetamine base is the oil form but cannot be easily injected or snorted
• a sticky, gluggy, waxy, damp or oily powder form
• often yellow or brownish hue
• usually converted to salt form or crystal form but may be sold as base and measured in points (0.1g)

• Red Speed, Liquid red, Leopard's blood, Ox blood
• can be injected or ingested

• Ice, d-meth, Glass, Crystal, Batu, Shabu, Point
• translucent colorless to white HCl salt of metamphetamine which easily dissolves in water
• is the purest form
• usually sold as points supposed containing 0.1g and generally costs ~$100 per point or $500-700/g which is approx. double the street price of cocaine
• meth labs produce crystal meth from pseudoephedrine or ephedrine mixed with sodium hydroxide, acid and a organic solvent such as ether with a very high risk of serious explosions, hence most is imported into Australia rather than manufactured here
• can be heated in a glass pipe and fumes inhaled or on aluminium foil (chase) - “chasing the white dragon” giving the most rapid method of obtaining a 'high'
• can be mixed with cannabis and smoked through a bong (snow cones)
• can be injected
• users can stay high for most of the day then they have a comedown phase of prolonged sleep
• in the withdrawal phase, anhedonia, anorexia, depression, cravings, mood swings and agitation dominate, leading to malnutrition and further use, with risk of having to become a dealer to pay for usage, and hence becoming embedded in a criminal culture
• during a high, there is increased risk of unprotected sex
• it is extremely addictive and users who use it more frequently than once weekly will soon develop:
  • personality change and behavioural change which are likely to lead to domestic violence and abuse and eventually government bodies are likely to be forced to take custody of children, while partners will be forced to issue intervention orders for their own and their children's safety.
  • and over years of use causes marked rapidly aged “ice-users” facies which are 20 years older than actual often with multiple skin lesions, poor dentition from jaw clenching, teeth grinding, dry mouth, poor hygiene and immunity systems
• variations in purity markedly affect the rates of criminal and medical presentations of meth users

• usually taken with friends before they go out to parties once or more each week as it heightens their sexual experience but also their risk taking behaviours
• euphoria
• energy
• confidence, but may give the user the delusion of super-human strength
• alertness
• excessive dose may cause:
  • dysphoria
  • agitation
  • aggression
  • sweaty, clammy skin
  • dilated pupils
  • tachycardia
  • hypertension
  • cardiac toxicity
  • uncommonly stroke (CVA)
    • 20% of fatal strokes in Australia 2009-2016 in those aged 15-44yrs are due to psycho-stimulant use, in particular, metamphetamine which has a 10 fold risk of stroke which is mainly haemorrhagic with a third being fatal ¹⁾
  • metamphetamine psychosis usually lasting 2-3hrs but may last days
    • often found walking the streets naked in a psychotic state
    • pressure of speech
    • flight of ideas
    • irrational, unpredictable behaviour which makes them dangerous as they are usually also hyper-alert and hostile
      • to avoid injury, others should keep their distance, avoid physical contact, minimise direct eye contact, avoid arguments or trying to negotiate with them, thus speak quietly and reassuringly
    • confused thought processes
    • paranoid delusions
    • ideas of reference
    • auditory and tactile hallucinations
    • ~25% of regular users will have an episode each year
    • psychotic symptoms are frequently experienced among patients using methamphetamines with some studies reporting almost half of those using the substance will be affected
• may mimic features of a noradrenaline secreting phaeochromocytoma and also increase urinary catecholamine assays

• ensure staff and other patient safety as these patients have a tendency to suddenly become aggressive and physically violent
• manage in a safe place with as low a stimulus as possible
• de-escalate with calm voices if possible
• avoid any known triggers for escalation of aggression
• consider early pharmacotherapy +/- mechanical restraint if there is no less restrictive manner to keep them and others safe
• most can be safely discharged from ED within 12-14 hours - refer to addiction medicine for harm reduction strategies

• exhaustion
• increased sleep
• depression
• anorexia
• restlessness and irritability

• strong but generally brief severe episodes of cravings to use ice
• marked mood swings, agitation, stress, anxiety, lacking energy
• very disturbed sleep
• poor concentration
• headaches, aches and pains
• paranoia
• symptoms tend to improve but may recur over the 1st month or so until return in normal in 1-3 months

• 5-10mg oral diazepam prn to max dose 30mg/24hrs
• allow uninterrupted rest
• encourage fluid intake