The Methamphetamine Crisis

Methamphetamine is second only to marijuana as the most abused illicit drug in the world, and many law enforcement agencies view it as the No. 1 drug problem in the United States.1,2 This article explores the effects and use of methamphetamine and the unique scene safety hazards that clandestine drug labs pose to emergency responders.

According to the Centers for Disease Control and Prevention (CDC), 20%-30% of meth labs are discovered after a fire or explosion, where police officers, firefighters and EMTs are often the first on scene to secure the area and begin emergency care. A CDC review of injuries at 1,800 methamphetamine events in 16 states identified police officers as the leading group of patients. They and other emergency responders and bystanders suffered respiratory irritation, headaches, eye irritation and burns.3

Emergency responders may not have enough information to realize they are responding to a meth event and lack the appropriate personal protective equipment for such a response. To reduce risk for injury at methamphetamine events, the CDC recommends emergency responders do the following:

• Increase awareness of the risks associated with clandestine drug laboratories
• Train in situations involving hazardous materials
• Identify the nature of the event before entering the contaminated area
• Wear appropriate personal protective equipment
• Follow a proper decontamination process after exposure to hazardous substances.3

Methamphetamine
Methamphetamine is a highly addictive drug that has a severe impact on the central nervous system.3,4

It comes in a powder or a clear, chunky crystal and is known by users by many different slang names: meth, speed, chalk, ice, crystal, glass or Tina.

After entering the bloodstream, methamphetamine eventually travels to the brain, where it acts on nerve cells. It has historical and limited therapeutic uses to treat obesity, narcolepsy and attention deficit disorders.3

Illegal users choose methamphetamine for many reasons, including: fatigue reduction; to maintain productivity during tedious, repetitive or physically demanding tasks; to increase sexual desire and activity; and for rapid weight loss.

Routes of Administration
Meth is an odorless, bitter-tasting, crystalline powder that users ingest, snort, inject or inhale.1 The powder form is white, brown, yellow, gray, orange or pink and dissolves in water or alcohol.1,7 Methamphetamine crystals are inhaled by smoking.5 IV injection and inhalation cause an immediate and intense pleasurable rush that lasts a few minutes and is followed by a euphoric high that may last for 20 minutes to 8 or 12 hours.4,6 Oral and intranasal administration do not produce the immediate rush--just the long-lasting euphoric high.5

The method of taking methamphetamine varies among geographic regions. But evidence suggests that methamphetamine is increasingly being administered by IV injection, which puts the user at increased risk for contracting and transmitting infectious diseases, such as HIV/AIDS and hepatitis.4,8

Anatomy of the Brain
The brain is composed of billions of nerve cells called neurons, which have three components: a nucleus, dendrites and an axon.4 The nucleus coordinates the neuron's activities. Dendrites are short fibers that receive signals from other neurons and relay the signals to the nucleus. The axon transmits messages from the nucleus to the dendrites of adjacent neurons.

Axons and dendrites do not touch. Neurotransmitters, which are chemical messengers, carry the signal from the axon to the dendrite. After crossing the synapse (the space between neurons) to communicate the message, a neurotransmitter either is destroyed or returns to its original neuron.

Dopamine is the neurotransmitter most affected by methamphetamine. Dopamine is released by neurons to communicate a pleasure message. Methamphetamine fools neurons into releasing lots of dopamine, which causes the user to feel extra pleasure. Eventually, the euphoria or high dissipates and the methamphetamine user experiences a severe low and depression. Methamphetamine also impacts two other neurotransmitters, serotonin and norepinephrine, which negatively impact other body systems.10

Effects on CNS
The effects of methamphetamine on the central nervous system include:euphoria, alertness or wakefulness, feelings of increased strength and renewed energy, feelings of invulnerability, feelings of increased confidence and competence, and heightened sexual desire.5,8

Effects after the euphoric high can include: irritability, insomnia, confusion, drug cravings, anxiety, depression, extreme paranoia--including thoughts of homicide or suicide--memory loss, fatigue, violence, aggressiveness and hallucinations or delusions. One common hallucination reported by methamphetamine users is the sensation of insects crawling on or under the skin.

Methamphetamine also causes physiological changes of increased and irregular heart rate, increased blood pressure and breathing difficulty. Methamphetamine use can also cause dangerous hyperthermia, seizures and cardiac arrest.5

A methamphetamine high is followed by a "devastating low." The depression that accompanies the low is so uncomfortable that many users choose another dose of meth, other drugs or alcohol to combat the depression.8 Expect the user to be anxious, irritable and paranoid, and expect "unpredictable and dangerous behavior when the user is startled, confused or confronted."8

Extent of Meth Use
The 2003 National Survey on Drug Use and Health reported that 12.3 million, or 5.2%, of Americans age 12 and older had tried methamphetamine at least once; and 1.5 million Americans are regular meth users.2

Most methamphetamine users are between 18 and 34 years of age. A 2004 study reported that 6.2% of high school seniors had used methamphetamine.

It is suspected that methamphetamine use is growing because it is easily accessible, cheap and has a long-duration "high." It is also easy to make, can be made covertly in a day or less and is highly profitable.

Methamphetamine use is believed to be heaviest in Hawaii, parts of the West Coast and Southwest. In Honolulu, 40% of males arrested in 2003 tested positive for methamphetamine.5 Evidence suggests that methamphetamine use is spreading eastward. In 2004, more clandestine labs were raided in Illinois than California, and more labs were reported than ever before in Georgia, Minnesota and Texas.5

User Profile
Traditionally in the United States, methamphetamine use was associated with white, male blue-collar workers.4 Increased meth use is specifically being observed in:

• Men who have sex with other men and use drugs
• Young adults who attend "raves" and club parties
• Homeless and runaway youth
• Commercial sex workers
• Workers in occupations that "demand long hours, mental alertness and physical endurance."

Clandestine Drug Labs
The Drug Enforcement Agency defines a clandestine drug lab as an illicit operation that has the apparatus and chemicals needed to produce methamphetamine.12,13 In addition to the physical and mental consequences of meth use, people in and around clandestine drug labs are at significant risk for exposure to hazardous chemicals from volatile air emissions, spills, fires and explosions.

Most clandestine drug labs produce small quantities of methamphetamine--likely less than a pound---but just an eighth of an ounce is enough to get 15 people high.14 Any home, motel, trailer, cabin, office, warehouse, garage or vehicle can be used for meth production. Little equipment is required, which makes meth labs quick and easy to set up. A stove and a few pots are all that is needed to start cooking.12

Unsuspecting hikers, hunters and outdoor enthusiasts are discovering meth labs in national forests, wilderness areas, in or near caves, remote cabins and abandoned mines.6 At the same time, super labs that can produce 10 pounds or more of meth at a time are becoming more common.8,12

Methamphetamine Ingredients
Methamphetamine is a dangerous brew of common household chemicals, agriculture chemicals and medications that are obtainable from pharmacies and hardware stores. The active ingredient in methamphetamine is ephedrine or pseudoephedrine.8,15

There are two common processes for methamphetamine production, both of which reduce ephedrine or pseudoephedrine into methamphetamine in a six- to eight-hour process.13 One process uses red phosphorous and iodine, and the other uses lithium strips from batteries and anhydrous ammonia.

There is no single recipe for methamphetamine. In fact, users may receive a dangerous mix of altered chemicals that are not methamphetamine at all.4 Some users may obtain methamphetamine that is mixed with other drugs, such as cocaine.11

Clandestine Drug Lab Hazards
The volatile mix of chemicals used to produce methamphetamine is extremely dangerous and may result in an explosion and toxic fumes. Vapors released from the chemicals used to "cook" methamphetamine enter the body through mucous membranes, skin, eyes and respiratory tract. Manufacturing methamphetamine exposes people, animals and the environment to toxic and explosive chemicals. Every pound of methamphetamine produced results in five pounds of toxic waste.8

During production, toxins can be inhaled, ingested and absorbed through the skin, leading to respiratory and eye irritation, headache, dizziness, nausea and vomiting, and shortness of breath. The byproducts of methamphetamine production are hazardous to the cook, children, neighbors and others who enter the clandestine lab, including emergency responders. Toxic by-products of methamphetamine are often dumped in areas where children, pets and others live, eat, play or walk.13

Injuries
Methamphetamine may cause injuries to users, emergency responders and bystanders.

There is no typical presentation for a methamphetamine user or manufacturer, but potential injury patterns that may prompt a user or companions of the patient to call EMS include:

• Loss of consciousness or severely altered mental status from intentional or accidental inhalation of methamphetamine or the chemicals used in its production.
• Blunt or penetrating trauma that results from violent encounters with other users.
• Soft tissue wounds and infections from poorly performed injections and "picking." Many methamphetamine users report a sensation of bugs under their skin and pick at their skin until it bleeds.
• Possible burns from improper handling of chemicals and combustibles during the manufacture of methamphetamine. Over a period of three months, three patients were encountered at a Texas emergency department with burns to the eyes, face and chest from anhydrous ammonia.15

Inhalation is the most common route of injury for emergency responders.14 Respiratory irritation, such as a cough, difficulty breathing and throat irritation, is the most common complaint.

In most cases, emergency responders are not wearing appropriate personal protective equipment at the time of injury. Most EMTs' injuries are sustained through on-site inhalation exposure or direct contact with the skin or clothing of a contaminated individual.

As with any patient with altered mental status, rescuer safety is the primary concern. Methamphetamine users may experience episodes of sudden and violent behavior, intense paranoia, and visual and auditory hallucinations.4

Paranoid drug users are also known to booby-trap drug labs, and meth lab "cooks" may be armed.8 Call law enforcement and additional EMS units to assist with assessment and transport.

Initial Assessment
After ensuring a safe scene, identify and treat immediate life threats. Ensure an open airway, adequate ventilation and oxygenation, and begin circulatory system monitoring. Treat problems of hypertension, hypotension, hyperthermia, metabolic and electrolyte abnormalities, and severe agitation with the tools and training you have.11

During the initial assessment, obtain IV access to allow for treatment of agitation and seizures.11 Follow local protocols for appropriate medications, indications and dosages.

Initiate three-lead ECG monitoring for any patient suspected of methamphetamine use, as atrial and ventricular arrhythmias are possible.11 Consider a 12-lead ECG, if available, to assess myocardial ischemia.

If the suspected methamphetamine user is reporting chest pain and/or has symptoms of a myocardial infarction, treat as you would any other patient experiencing a heart attack.11

Seizures induced by methamphetamine should be treated like any other seizure of unknown cause.11 Protect the patient from additional injury, ensure an open airway and adequate ventilation, and administer benzodiazepines.

Patient History and Exam
Patients under the influence of drugs are notoriously poor personal historians. It is unlikely a meth patient will be able to clearly articulate events prior to injury and EMS arrival, or give a pertinent medical history. A user on a two-day to two-week "meth run" may inject the drug every two to three hours to maintain the high and avoid the devastating low. It is possible the patient has not eaten or slept for three to 14 days. Meth users frequently choose other drugs such as alcohol, heroin or marijuana to temper or control withdrawal from the drug.8

During the physical exam look for the following signs of meth use: dilated pupils, rapid eye movements, jerky motions, twitching, muscle spasms, tremors or convulsions, IV needle use or burns. Also look for signs of compulsive and repetitive behavior, such as cutting and picking of the skin.16

Vital sign trends for a patient high on methamphetamine include high blood pressure, increased and irregular heart rate and elevated body temperature.2

Withdrawal Signs and Symptoms
In the withdrawal state, the patient can be extremely depressed, irritable and paranoid, and the potential for violence is significant. Signs and symptoms of withdrawal include: eye movement 10 times faster than normal, jerky movements and quivering voice.2,18

When approaching and assessing these patients, follow these safety principles to avoid making the patient feel threatened or more paranoid:

• Keep your distance
• Don't use bright lights
• Slow your speech, lower your voice
• Slow your movements
• Keep your hands visible
• Keep the person talking.18

Children at Meth Labs
A growing concern for child protective agencies is children of methamphetamine users. It is estimated that children are present at 20% of clandestine drug laboratories and are sometimes forced to assist in meth production.13 In addition to exposure to toxic and explosive chemicals from home methamphetamine cooking, children may be neglected by their parents or guardians.8

Children living at home-based clandestine drug labs sustain enormous physical, developmental, emotional and psychological damage.13 In general, children living in meth lab homes face hazards from chemical contamination, fires and explosions, abuse and neglect, hazardous lifestyles and social problems.

Children, especially infants and toddlers, explore their environment on their hands and knees and put everything in their mouth. Children living, playing and eating in or near an area where methamphetamine is being cooked are likely to inhale toxic fumes and vapors; ingest drugs and chemicals that might be stored in soda cans, juice bottles or drinking glasses; receive accidental injections from discarded IV needles; or absorb drugs and chemicals from tables, floors and other surfaces.8,13 Unfortunately, regular dish and clothing cleaning techniques do not remove methamphetamine.13

Children living at meth labs are at greater risk for physical or sexual abuse and neglect from their parents and other adults.13 The effects of meth--irritability, depression, hallucinations--decrease an adult's capacity to parent effectively and to provide proper nutrition, personal hygiene, supervision, regular and appropriate medical care, and sleeping conditions.

Users in withdrawal can be abusive and violent to their own children.8 Children in a meth home are also likely to witness and participate in violence, care for an injured parent and watch a parent be arrested.13

A U.S. Department of Justice report on children living in meth labs described the living areas and physical condition of children living in a meth lab home as follows:

"The five children ranged in age from 1 to 7 years old. The one-bedroom home had no electricity or heat other than a gas stove with the oven door opened. Used hypodermic needles and dog feces littered areas of the residence where the children were found playing. Because there were no beds for the children, they slept with blankets underneath a small card table in the front room. The bathroom had sewage backed up in the tub, leaving no place for the children to bathe. A subsequent hospital exam revealed that all the children were infected with hepatitis C. The children had needle marks on their feet, legs, hands and arms from accidental contact with syringes."13

Children who live in a home where meth is being made and used may be exposed to the following hazards:

• Loaded guns and other weapons
• Explosives and booby traps
• Exposed wires
• Rodent and insect infestation
• Rotten food
• Used condoms
• Dirty dishes, clothing and garbage
• Inoperative heater, air conditioner, toilet, bathtub, refrigerator and running water
• Discarded used needles
• Drug paraphernalia
• Dangerous animals
• Animal feces
• Contaminated eating, play and sleep areas

It's easy to imagine that a child living in a meth lab home is likely to develop significant social problems from the stress, trauma, neglect and abuse they experience. This can lead to emotional and mental health problems, poor school attendance and performance, and poor peer relationships. Without intervention, as they age, children are likely to imitate their parents' behaviors.13

Indicators of a Clandestine Drug Lab
The following list of indicators of a clandestine methamphetamine lab comes from the DEA Clandestine Laboratory Team. If you observe any of these indicators at a scene, evacuate immediately and call local law enforcement:

• A large amount of cold tablet containers that list ephedrine or pseudoephedrine as ingredients.
• Jars containing a clear liquid with a white solid on the bottom.
• Jars labeled as containing iodine or dark, shiny, metallic purple crystals inside jars.
• Jars labeled as containing red phosphorus or a fine dark red or purple powder.
• Coffee filters containing a white pasty substance, a dark red sludge or small amounts of shiny white crystals.
• Bottles labeled as containing sulfuric acid or hydrochloric acid.
• Bottles or jars with rubber tubing attached.
• Glass cookware or frying pans containing a powdery residue.
• An unusually large number of cans of camping fuel, paint thinner, acetone or starting fluid. Lye and drain cleaners containing sulfuric acid or bottles containing muriatic acid.
• Large amounts of lithium batteries, especially ones that have been stripped.
• Soft silver or gray metallic ribbon (in chunk form) stored in oil or kerosene.
• Propane tanks with fittings that have turned blue.
• Strong smell of urine or unusual chemical smells like ether, ammonia or acetone.
  
  As you leave the scene:
• Avoid turning any switch on or off
• Do not eat or drink anything
• Watch for booby traps and hostile suspects

Exposure Signs and Symptoms
Children breathe faster, have a higher metabolic rate than adults, and their nervous system is still developing, which leaves them more susceptible to consequences of exposure to hazardous materials.13, 20 A child who is present at a methamphetamine lab should be assessed by EMS as soon as possible.21, 22 The child may not be toxic, but the environment and clothing are. Assess children outside of the toxic environment in the "cool zone" after removing their clothing and washing them with water.

Leave clothing on scene, as it is evidence. Provide clean and appropriate clothing after decontamination and assess as you would any child. Leave the children's belongings and clothing at the scene to avoid additional contamination and damaging evidence.

Every child removed from a meth lab needs emergency department evaluation; however, ambulance transport is only necessary if the child has a medical illness or traumatic injury. Healthy and uninjured children can be transported to the emergency department by social services or law enforcement.

Summary
Methamphetamine is a highly addictive drug that is an increasingly recognized problem for emergency responders in all areas of the country. Any clandestine drug lab is a hazardous materials incident and crime scene. Enter a clandestine drug lab only if you have proper training and equipment--do not become a victim.

Methamphetamine users are generally paranoid, agitated and anxious, and may become violent during assessment and treatment. Children living at a meth lab are at greater risk for physical and/or sexual abuse and neglect.

References

1. Meth: What's Cooking in Your Neighborhood? Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention. 11 Aug 2005. https://ncadi.samhsa.gov/multimedia/mediaDetails.aspx?ID=362.
2. Jefferson DJ. America's Most Dangerous Drug. MSNBC.com. 8 Aug 2005.
3. Acute Public Health Consequences of Methamphetamine Laboratories--16 States, Jan 2000-June. Centers for Disease Control and Prevention. 11 Aug 2005. www.cdc.gov/mmwr/pre view/mmwrhtml/mm5414a3.htm
4. NIDA Community Alert Bulletin on Methamphetamine. National Institute on Drug Abuse. 11 Aug 2005. www.drugabuse.gov/MethAlert/MethAlert.html.
5. NIDA InfoFacts: Methamphetamine. National Institute on Drug Abuse. 11 Aug 2005. www.nida.nih.gov/infofacts/methamphetamine.html.
6. Methamphetamine. Office of National Drug Control Policy. 11 Aug 2005. www.whitehousedrugpolicy.gov/drugfact/methamphetamine/index.html.
7. Methamphetamine Fast Facts: Questions and Answers. National Drug Intelligence Center. 11 Aug 2005. www.usdoj.gov/ndic/pubs3/3981/index.htm.
8. Myths, Facts & Illicit Drugs: What You Should Know. The Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Prevention. 11 Aug 2005. https://ncadi.samhsa.gov/govpubs/vhs143g/.
9. National Institute of Health. Methamphetamine Abuse and Addiction. NIH Publication Number 02-4210, April 1998.
10. National Institute of Health. Mind over Matter: The Brain's Response to Methamphetamine (BRAIN). NIH Publication No. 00-4394, 2000.
11. Derlet R, Albertson T. Toxicity, Methamphetamine. www.emedicine.com/emerg/topic859.htm.
12. Methamphetamine Laboratory Identification and Hazards Fast Facts. U.S. Department of Justice National Drug Intelligence Center. 11 Aug 2005. www.usdoj.gov/ndic/pubs7/7341/index.htm.
13. U.S. Department of Justice Office of Justice Programs Office for Victims of Crime. Children at Clandestine Methamphetamine Labs. NCJ 197590. June 2003.
14. Czarnecki F. Chemical hazards in law enforcement. Clinics in Occupational and Environmental Medicine 3(3): 443-456.
15. Lee JH, et al. Anhydrous ammonia eye injuries associated with illicit methamphetamine production. Ann Emerg Med 41:1, Jan 2003.
16. Kennamer M. Danger: Clandestine Drug Labs Making Crystal Methamphetamine. Thomson Delmar Learning. 11 Aug 2005. https://emarketing.delmar learning.com/ems/EMS_news_jun05_feature.asp.
17. Public Health Consequences Among First Responders to Emergency Events Associated with Illicit Methamphetamine Laboratories--Selected States, 1996-1999. Centers for Disease Control and Prevention. 11 Aug 2005. www.cdc.gov/mmwr/pre view/mmwrhtml/mm4945a1.htm#tab1.
18. Dealing with a Tweaker. METH Awareness and Prevention Project, Aug 2005. www.mappsd.org/tweakers.htm.
19. Methamphetamine Clandestine Laboratory Indicators. Drug Enforcement Administration (DEA) Clandestine Lab Enforcement Team, DEA Academy, Quantico, VA. 11 Aug 2005. https://ncadi.samhsa.gov/govpubs/clanlab/default.aspx.
20. Signs of Meth Exposure in Children. METH Awareness and Prevention Project. 11 Aug 2005. www.mappsd.org/DEC%20Exposure%20Signs.htm.
21. Provisional Guidelines for Methamphetamine Exposed Children: A Common Sense Approach. Kentucky Board of EMS/Kentucky EMS for Children Project. 11 Aug 2005. https://kbems.ky.gov/NR/rdonlyres/2FCC73E4-EE70-4272-B040-BA98197EB524/0/KYEMSCMethGuidelines.pdf.
22. Medical Protocols for Children Found at Methamphetamine Labs. Denver Family Crisis Center. 11 Aug 2005. www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf

Earn one hour of CECBEMS Advanced or Basic CE credit on the topic of methamphetamine use. Go to www.emsed.com to watch a multimedia lecture on methamphetamine use and complete the CE test for a low fee.

Greg Friese, MS, NREMT-P, WEMT, is president of Emergency Preparedness Systems LLC. EPS helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs for first responders, EMTs and paramedics. Friese is a paramedic, Wilderness Medical Associates lead instructor and EMS author. Contact him at gfriese@eps411.com.