• Meth use has increased
• Use has spread from the West
• Accounts for a small percentage of the total number of people affected by drug and alcohol problems
• The impact of meth use on child welfare varies widely among States and among Counties

Meth/Amphetamine Treatment Admission Rate (Graphic)
Per 100,000 Population Aged 12 or Older - 1993-2003

Eastward Spread of Methamphetamine (Graphic)

Treatment Admissions by Primary Substance - 2003

Impact of Increasing Methamphetamine Use

• Methamphetamine is affecting communities that have not experienced prior stimulant drug problems
• Child welfare agencies are dealing with more cases involving methamphetamine

Smoked Methamphetamine/Amphetamine (Graphic)
Treatment Admissions, by Race/Ethnicity: 1992 and 2002

Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).

Meth/Amphetamine & Cocaine Treatment Admissions
According to Census Division 2003
RATE per 100,000

Source: Treatment Episode Data Set (TEDS)

Gender Differences

• 47% of admissions are women
• Since women are often caretakers of children, more children are likely affected.

Treatment Admissions: Percent Methamphetamine/Amphetamine as Primary Substance, By Gender

Source: Treatment Episode Data Set (TEDS)

Methamphetamine/Amphetamine Admissions: Gender Breakdown, 2002

Source: Treatment Episode Data Set (TEDS).

Female Treatment Admissions (Graphic)
States with Highest % of Meth/Amphetamine as Primary Substance

Trends in Primary Substance Use (Graphic)
Treatment Admissions for Pregnant Females by Primary Substance 1995-2003

Foster Care Population and Persons Who First Used Crack or Methamphetamine in Prior Year (Graphic)

Effects of Methamphetamine Addiction

Short-Term Effects of Methamphetamine (Graphic)

Methamphetamine Chronic Physical Effects

• Tremors
• Weakness
• Headaches
• Sweating
• Coughing
• Dry Mouth
• Oily skin/complextion
• Burned lips/sore nose
• Dental
• Weight Loss/Anorexia

MethamphetamineChronic Psychological Effects

• Confusion
• Irritability
• Concentration
• Paranoia
• Hallucinations
• Panic reactions
• Fatigue
• Depression
• Memory loss
• Anger
• Insomnia
• Psychosis

Cognitive Effects

• Decreased ability to:
  • Recognize and recall words and pictures
  • Make inferences
  • Manipulate information
  • Ignore irrelevant information
  • Learn from experience
• Users and people in early recovery may find it difficult to:
  • Pay attention
  • Comprehend spoken and written information
  • Remember information
• Abilities that improve after 12 weeks abstinence:
  • Manipulate information
  • Ignore irrelevant information
• Abilities that do note improve after 12 weeks abstinence:
  • Recognize and recall words
  • Recognize and recall pictures (declines less than word recognition and recall)
• Rate of recovery is associated with severity of abuse and days of abstinence.
• Study documented significant recovery with Meth abusers who were able to stay drug free for at least 9 months.
• After 4 years of abstinence, no deficits in:
  • Memory
  • Learning
  • Attention
  • Executive function
  • Motor function

Risks to Children When Parents Use Meth

Six Different Situations for Children

• Parent uses or abuses methamphetamine
• Parent is dependent on methamphetamine
• Mother uses meth while pregnant
• Parent “cooks” small quantities of meth
• Parent involved in trafficking
• Parent involved in super lab

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Six Different Situations for Children

• Each situation poses different risks and requires different responses
• Child welfare workers need to know the different responses required
• The greatest number of children are exposed through a parent who uses or is dependent on the drug
• Relatively few parents “cook” the drug

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Parent Uses or Abuses Meth

Risks to safety and well-being of children:

• Parental behavior under the influence: poor judgment, confusion, irritability, paranoia, violence
• Inadequate supervision
• Inconsistent parenting
• Chaotic home life
• Exposure to second-hand smoke
• Accidental ingestion of drug
• Possibility of abuse
• HIV exposure from needle use by parent

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Parent Is Dependent on Meth

Risks to safety and well-being of children:

• All the risks of parents who use or abuse, but the child may be exposed more often and for longer periods
• Chronic neglect is more likely
• Household may lack food, water, utilities
• Chaotic home life
• Children may lack medical care, dental care, immunizations
• Greater risk of abuse
• Greater risk of sexual abuse if parent has multiple partners

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Mother Uses Meth While Pregnant

• Risk to child depends on frequency and intensity of use, and the stage of pregnancy
• \isks include birth defects, growth retardation, premature birth, low birth weight, brain lesions
• Problems at birth may include difficulty sucking and swallowing, hypersensitivity to touch, excessive muscle tension hypertonia)
• Long term risks may include developmental disorders, cognitive deficits, learning disabilities, poor social adjustment, language deficits

Sources: Anglin et al. (2000); Oro & Dixon, (1987); Rawson & Anglin (1999); Dixon & Bejar (1989); Smith et al. (2003); Shah (2002)

Mother Uses Meth While Pregnant

• Observed effects may be due to other substances, or combination of substances, used by the mother
  • For example, if the mother also smokes, growth retardation may be significant
• Observed effects may be complicated by other conditions, such as the health, environmental, or nutritional status of the mother

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Mother Uses While Pregnant

• Scope of the problem:
  • An estimated 10% to 11% of all newborns are prenatally exposed to drugs or alcohol; this amounts to 400,000 to 480,000 newborns per year
  • Only about 5% of prenatally exposed newborns are placed in out-of-home care; the rest go home without assessment and services

Sources: Vega; SAMHSA, OAS, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003

Mother Uses While Pregnant

Home environment is the critical factor in the child’s outcome

Consequences can be mediated

Shah, R. (2005, June). From NASADAD presentation

Parent “Cooks” Small Quantities of Meth

• All the risks of parents who use or are dependent on meth, with added risks of manufacturing the drug:
  
  • Chemical exposure
  • Toxic fumes
  • Risk of fire and explosion

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Environmental Methamphetamine Exposure and Risks

• Toxic effects of manufacturing
• Children more at risk:
  • Higher metabolic rates
  • Developing bone and nervous systems
  • Thinner skin than adults which absorbs chemicals faster
  • Children tend to put things in their mouth and use touch to explore

Source: Mason (2004)

Parent Involved in Trafficking

• Presence of weapons
• Possibility of violence
• Possibility of physical or sexual abuse by persons visiting the household

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Parent Involved in Super Lab

• Lower likelihood of children on the site

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005

Number of Children in Meth Labs

*The 2003 figure for the number of incidents is calendar year, while the remaining data in the column are for fiscal year
**Data for 2000 and 2001 may not show all children affected

4 years = 2,881; all children ~1,000,000

Medical Interventions for Children

• Field medical assessment
• Immediate care protocol
• Baseline assessment protocol
• Initial follow-up care protocol
• Long-term follow-up care protocol

Source: Colorado DEC

Treatment for Methamphetamine

CSAT’s Methamphetamine Treatment Project

• Largest randomized clinical trial of treatment for meth dependence
• Compared the MATRIX manualized treatment model developed at UCLA to treatment as usual
• 8 study sites; site in HI was all women

Matrix Model

• Intensive outpatient setting
• Three to five visits per week of comprehensive counseling for at least the first three months
• Cognitive behavioral approach
• Contingency management

Urinalysis Results

Results of UA tests at discharge, 6 months and 12 months post admission *

*Over 80% follow-up rate in both groups at all points

Similar Outcomes

• Treatment outcomes do not differ from other drugs of abuse
• Treatment outcomes have more to do with the quantity and quality of treatment than type of drug abused

Treatment Outcomes for Women (Graphic)

Gender Differences and Implications for Treatment

• Co-occurring mental health problems
• Trauma
• Body image

Behavior Symptom Inventory (BSI) (Graphic)
Scores at Baseline

Beck Depression Inventory (BDI) (Graphic)
Scores at Baseline

Self-Reported Reasons for Starting Methamphetamine Use (Graphic)

Gender Differences and Implications for Treatment

• Co-occurring mental health issues complicate treatment and require longer duration for treatment
• Violence linked to meth use is related to trauma and safety needs which must be addressed in treatment
• Body image and nutrition need to be addressed
• Threats of violence and reduced cognitive capacity to manage activities of daily living suggest that a period of residential treatment will most often be indicated for women with serious addiction to methamphetamine
• When residential care is not available, IOT may be indicated, with additional supports such as transportation, meals, child care, referral to safe houses or supervised housing

What Predicts Longer Abstinence?

Longer abstinence following treatment for women with:

• Longer time in treatment (e.g. those with 4 or more mo. of treatment have more than double the rate of 24-48 mo. abstinence)
• More sessions per month of individual counseling (or sexual recovery groups)
• Treatment, intervention and case planning need to account for short-term effects, especially cognitive deficits and verbal communication
• Drug Court involvement
• Family involvement

M.L. Brecht, Ph.D., et al. (2005)

Sacramento, California Model of Effective Child Welfare and Substance Abuse Services

• Comprehensive training—to understand substance abuse and dependence and acquire skills to intervene with parents
• Early Intervention Specialists—Social workers trained in motivational enhancement therapy are stationed at the family court to intervene and conduct preliminary assessments with ALL parents with substance abuse allegations at the first court hearing
• Improvements in Cross-System Information Systems—to ensure that communication across systems and methods to monitor outcomes are in place as well as management of the county’s treatment capacity
• Prioritization of Families in Child Protective Services—County-wide policy to ensure priority access to substance abuse treatment services
• Specialized Treatment and Recovery Services (STARS)—provides immediate access to substance abuse assessment and engagement strategies conducted by staff trained in motivational enhancement therapy. STARS provides intensive management of the recovery aspect of the child welfare case plan and routine monitoring and feedback to CPS and the court
• Dependency Drug Court—provides more frequent court appearances for ALL parents with allegations of substance use.

Treatment Discharge Status by Primary Drug Problem

18-Month Child Placement Outcomesby Parent Primary Drug Problem (Graphic)

Methamphetamine: Implications for Workers

Methamphetamine: Implications for Workers

1. Signs of Use and Warning Signs for Workers
2. Oregon’s Response

Signs of Use and Warning Signs for Workers

Signs of Methamphetamine Use and Use of Other Stimulants

• Euphoria
• Grinding of teeth
• Rapid breathing
• Sweating
• Hyperactivity
• Tremor - shaking hands
• Rapid or pressured speech
• Depression - when drug wears off
• Irritability, paranoia, suspiciousness
• Hallucinations
• Presence of drug paraphernalia

Source: Crowell & Webber (2001)

Warning Signs for Workers

• Client is extremely irritable, suspicious, or argumentative, or there is an escalation of irritability
• Regular client does not appear to know who worker is
• Evidence of paranoid thinking, delusions
• Client verbalizes implicit or explicit threat against worker

Source: Crowell & Webber (2001)

Other Severe Signs of Meth Use

• Scratch marks or scabs, particularly on client’s hands and arms - may be evidence of tactile hallucinations and indicate a prior episode of stimulant psychosis
• Severe damage to teeth and gums
• Drawn face and underweight
• Strong chemical odor - may indicate manufacturing of meth

Source: Crowell & Webber (2001)

Natural Rewards Elevate Dopamine Levels (Graphic)

Effects of Drugs on Dopamine Levels (Graphic)

Denial = Super-memory Imprinting

• Memory imprinting increases in power as dopamine activity increases.
• Addicts remember the “good-times” and fail to remember the “bad-times”.

Research on Cognitive Impairments of MA addicts

• Ability to manipulate information (multi-relational or “synthesis”).
• Ability to make inferences.
• Ability to ignore irrelevant information.
• Ability to learn new or recall information.

“Methamphetamine: Snapshot Phenomenon” Wurscher & Martin (Graphic)

Oregon’s Response

Oregon 2004

• 9,500 CW cases (kids)
• 50% connected to Meth
• Up to 75% in some counties
• Usually exaggerated because they are the most Chaotic Cases
• Major Media coverage
• Major Crime issue – Labs & ID theft

Oregon CW Success

• CW - FIT – Family Involvement Team
• CADC's
• CW - ART – Addiction Recovery Teams
• Ourreach Workers
• DHS Staff
• ASFA Video

Oregon Response

• Governor’s Meth Task Force
• Legislative Response – Labs Crushed & Drug Court TX increased
• Pseudo – RX Drug as of July-2006
• DHS Meth Response Team

Summary

Summary

• Methamphetamine is a dangerous drug with serious physical, cognitive, and health consequences
• The effects of long-term use are reversible with prolonged abstinence
• Treatment for methamphetamine is as effective as treatment for other drugs
• A high percentage of methamphetamine users are women of child-bearing age
• Meth accounts for 7% of treatment admissions nationally, but in some States 30- 44% of women admitted were admitted for methamphetamine
• Scope of the problem:
  • The number of meth users is small compared to other drugs and alcohol
• Admissions increased through 2003
• Communities that have not experienced prior drug problems may lack the resources to handle a meth problem
• Meth use may be leveling off
• Parents’ use of methamphetamine puts their children at risk
• The best outcome for both child and parent is achieved when:
  • The parent receives immediate, effective treatment and comprehensive services
  • The child receives immediate assessment and services, as well as follow-up services
• Child welfare workers must distinguish between
  • Children whose parents use meth, and
    Children whose parents manufacture meth
• They must learn the established medical protocols for children present in meth labs
• We need early diagnosis and intervention for children affected by meth before and after birth
• We need comprehensive, timely, and state-of-the-art treatment for parents referred to treatment as a condition of keeping or reunifying with their children
• We need information systems that capture the necessary data to support effective approaches

For Further Information

SAMHSA Resources

• Treatment Improvement Protocols (TIP 33)
  • Best Practice Guidelines for Treatment of Substance Abuse
  • Researched, Drafted, and Reviewed by Substance Use Disorder Professionals
• KAP Keys & Quick Guide
  • Developed to accompany the TIP Series
  • Based entirely on TIP #33
  • Designed to meet the needs of busy clinicians for concise, easily accessed “how-to” information
  • http://www.samhsa.gov
• SAMHSA’s Addiction Technology Transfer Centers (ATTC)
  • Pacific Southwest ATTC
    http://www.psattc.org/events/cates/I/presentations/index.html
  • Methamphetamine 101: Etiology and Physiology of an Epidemic

ATTC’s Introduction to Evidence-Based Treatments for Methamphetamine

• CD-ROM Learning Tools
• DVD Training Module
• Produced by: Applied Behavioral Health Policy at the University of Arizona for the Pacific Southwest ATTC
• web www.psattc.org

Contact NCSACW

• www.ncsacw.samhsa.gov
  Project Director:
  Nancy Young, Ph.D.
  714-505-3525
• Government Project Officer:
  Sharon Amatetti, SAMHSA/CSAT
  240-276-1694
  sharon.amatetti@samhsa.hhs.gov

References

Anglin, M., Burke, C., Perrochet, B., Stamper, E. & Dawud-Noursi, S. (2000). History of the methamphetamine problem. Journal of Psychoactive Drugs, 32(2), 137-141.

Brecht, M.-L., M. D. Anglin, et al. (2005). "Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes." The American Journal of Drug and Alcohol Abuse 31(2): 337.

Brecht, M.L.(2004) Women and Methamphetamine: Characteristics, Treatment Outcomes. Presentation to the Center
For Substance Abuse Treatment, State Systems Development Conference. August 13.

Cohen, Judith, Ph.D. Presentation to NASADAD, June 2005.

Colorado DEC. Retrieved from www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf

Crowell and Webber, 2004. Retrieved from www.drugfreeinfo.org/PDFs/strengthensupervision.pdf.

Dixon, S.D., & Bejar, R. (1989). Echoencephalographic findings in neonates associated with maternal cocaine and methamphetamine use: Incidence and clinical correlates. Journal of Pediatrics, 115(5 Pt 1), 770-778.

Ferguson, T. (2001). Overview of medical toxicology and potential exposures to clandestine drug laboratories in California. Paper presented to the Minnesota Department of Health.

Lundahl, L.H., Keenan, P., Schuster, C.R., & Johanson, C.E. (2004, June). Neurocognitive function in chronic high dose methamphetamine abusers following long term abstinence. Poster session presented at the 66th Annual Scientific Meeting of the College on Problems of Drug Dependence, San Juan, Puerto Rico.

Mason, A. P. 2004. Methamphetamine labs. Presented at the annual conference of the North Carolina Family-Based, Services Association.

Obert, J.L., London, E.D., & Rawson, R.A. (2002). Incorporating brain research findings into standard treatment: An example using the Matrix Model. Journal of Substance Abuse Treatment, 23(2), 107-113.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS).
Office of Applied Studies, Substance Abuse and Mental Health Services Administration, National Survey of Alcohol and Drug Use During Pregnancy, 2002 and 2003.

Oro, A.S., & Dixon, S.D. (1987). Perinatal cocaine and methamphetamine exposure: Maternal and neonatal correlates. Journal of Pediatrics, 571-578.

Rawson, Richard, Ph.D., Presentation to SAMHSA, August 2005.

Rawson, R., & Anglin, M.D. (1999, June). Methamphetamine: New knowledge, new treatments. Retrieved April 2004, from the UCLA Integrated Substance Abuse Programs Web site: http://www.uclaisap.org/slides/Index46/index.htm

Simon, S. (1999). Cognitive impairment in individuals currently using methamphetamine. Retrieved April 2004, from the UCLA Integrated Substance Abuse Programs Web site: http://www.uclaisap.org/slides/Index46/sld034.htm

Smith, L., Yonekura, M.L., Wallace, T., Berman, N., Kuo, J., & Berkowitz, C. (2003). Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. Journal of Developmental and Behavioral Pediatrics, 24(1):17-23.

Shah, R. (2005, June). From NASADAD presentation

Thompson, P.M., Hayashi, K.M., Simon, S.L., Geaga, J.A., Hong, M.S., Sui, Y., et al. (2004). Structural abnormalities in the brains of human subjects who use methamphetamine. Journal of Neuroscience, 24(26), 6028-6036.

Vaughn, C. (2003). Get up to speed on methamphetamine use. NCADI Reporter. Retrieved from http://www.health.org/newsroom/rep/215.aspx

Vega et al (1993), Profile of Alcohol and Drug Use During Pregnancy in California, 1992.

Volkow, N.D., Chang, L, Wang, G.J., Fowler, J.S., Leonido-Yee, M., Franceschi, D., et al. (2001b). Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. American Journal of Psychiatry, 158, 377-382.

Young, Nancy K., Ph.D. Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005.

Zickler, P. (2000). Brain imaging studies show long-term damage from methamphetamine abuse. NIDA Notes, 15(3).