• NCSACW
• Some Background and Data
• Treatment Issues and Effectiveness
• Issues for Children and Safety
• Implications for Child Welfare

NCSACW

A Program of the
Substance Abuse and Mental Health
Services Administration
Center for Substance Abuse Treatment
and the
Administration on Children, Youth and Families
Children’s Bureau
Office on Child Abuse and Neglect

• To improve outcomes for families by promoting effective practice, and organizational and system changes at the local, state, and national levels
  • Developing and implementing a comprehensive program of information gathering and dissemination
  • Providing technical assistance

NCSACW Consortium

• American Public Human Services Association (APHSA)
• Child Welfare League of America (CWLA)
• National Association of State Alcohol and Drug Abuse Directors (NASADAD)
• National Council of Juvenile and Family Court Judges (NCJFCJ)
• National Indian Child Welfare Association (NICWA)

Recent Products

• Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers – A short monograph for front-line workers
• On-Line Training
  • Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals
  • Understanding Addiction and Recovery: A Guide for Child Welfare Professionals

Some Background and Data

Methamphetamine

• Brief Description
  • An addictive stimulant that is closely related to amphetamine, but has longer lasting and more toxic effects on the central nervous system. It has a high potential for abuse and addiction.
• Street Names
  • Speed, meth, chalk, ice, crystal, glass.

Methamphetamine

• Effects
  • Increases wakefulness and physical activity and decreases appetite. Chronic, long-term use can lead to psychotic behavior, hallucinations, and stroke.
• Prevalence of Use
  • According to the 2002 National Survey on Drug Use and Health, about 12 million Americans (5.2% of population) have tried methamphetamine.

Issues Specific to Methamphetamine

• Meth users begin younger than other drugs
• Differ from other users in their drug use pattern—they use more days
• Differ in their cognition—particularly in early abstinence
  • Need alternative methods of imparting information

Effects of Methamphetamine

• Remains active for longer periods
• Half life – the length of time for half of the substance to be eliminated from the body
  • Cocaine half life is one hour
  • Methamphetamine half life is twelve hours
• Length of active effect may be related to long-term structural changes in the parts of the brain that control memory and motor coordination

Acute Effects of Methamphetamine (Graphic)

Foster Care Population (Graphic)

Foster Care Population and Persons Who First Used Crack or Meth in Past Year (Graphic)

Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older: Numbers in Thousands, 2003

 ¹ Any Illicit Drug includes marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any prescription-type psychotherapeutic used nonmedically. Any Illicit Drug Other Than Marijuana includes cocaine (including crack), heroin, hallucinogens, inhalants, or any prescription-type psychotherapeutic used nonmedically.
² Nonmedical use of any prescription-type pain reliever, tranquilizer, stimulant, or sedative; does not include over-the-counter drugs.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003.

Methamphetamine/Amphetamine Treatment Admission Rate
Per 100,000 Population Aged 12 or Older: 1992-2002

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

The Eastward Spread of Methamphetamine (Graphic)

Methamphetamine/Amphetamine Treatment Admissions, by Route of Administration: 1992-2002

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

Smoked Methamphetamine/Amphetamine Treatment Admissions, by Race/Ethnicity: 1992 and 2002 (Graphic)
Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).

Methamphetamine/Amphetamine Treatment Admissions, by Route of Administration: 1992-2002 (Graphic)
Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).

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), 2002

Female Treatment Admissions: States with Highest Percentages Meth/Amphetamine as Primary Substance (Graphic)

Treatment Admissions for Pregnant Females: by Primary Substance (Graphic)

Methamphetamine Lab Busts (Graphic)

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

Treatment Issues

Past Year Need for and Receipt of Specialty Treatment for Any Illicit Drug or Alcohol Use among Persons Aged 12 or Older: 2002 and 2003 (Graphic)

Past Year Perceived Need and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drugs or Alcohol: 2003

Did Not Feel They Needed Treatment: 94.9%
Felt They Needed Treatment and Did Not Make an Effort: 3.8%
Felt They Needed Treatment and Did Make an Effort: 1.3%

20.3 Million Needing But Not Receiving Treatment for Illicit Drugs or Alcohol

Treatment Issues

• Outcomes have not differed from other drugs of abuse treatment studies
• Positive treatment outcomes were achieved using:
  • Intensive outpatient setting
  • Three to five visits per week of comprehensive counseling for at least the first three months
  • Cognitive behavioral approach
  • Contingency management
  • Reducing consequences associated with drug use
  • Motivational interviewing & brief intervention models
  • Intervening earlier and reducing cumulative harm
  • Attending to co-occurring mental disorders

Women’s Issues

• Female methamphetamine (MA) users are more likely than male users to:
  • Be introduced to MA by partner
  • Initiate use to control weight and increase energy
  • Live alone with their children
  • Use MA more days
  • Smoke MA rather than snort or inject the drug
  • Progress to regular use more quickly
  • Have worse medical, employment and psychiatric consequences than male users

No Gender Differences:

• Number of years used meth
• Number of days of use in the last month
• Usual route of administration
• Number of prior treatment episodes
• Racial or ethnic background
• Level of education
• Number of chronic medical problems

Abuse During Lifetime

*** significant difference between women and men p < .001
Judith Cohen, Ph.D. Presentation to NASADAD June 2005

Age That Physical Violence Began

*** significant difference between women and men p < .001
Judith Cohen, Ph.D. Presentation to NASADAD June 2005

Abuse During Past 30 Days

Implications For Treatment

• Screen carefully for
  • Psychological problems
  • Abuse and violence
• Recognize pervasive gender differences
• Address substance abuse and psychological problems in an integrated treatment model

Long-Term Effects

• Recent studies have found no deficits in motor function, memory, learning, attention or executive function in meth users after four years of abstinence

Short-Term Implications

• Cognitive deficits
  • To manipulate information
  • To ignore irrelevant information
  • To recognize and recall words
  • To learn from experience
    • Picture recognition is less impaired and is a strategy to use in early abstinence

Short-Term Implications

• Health Effects
  • Cardiovascular risks
  • HIV risks
  • Weight loss and malnutrition
  • Dental problems
• Psychological Effects
  • Chronic use can lead to paranoia
  • Confusion
  • Auditory and visual hallucinations
  • Violent behavior
  • During abstinence – depression and anxiety

Treatment Outcomes:Good News? Bad News? (Graphic)

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)
• Drug Court involvement
• Family involvement

Risk of Relapse Higher:

• Prior dealing
• Partner not in treatment

Children’s Issues

Risks to All Children of Parents with Substance Use Disorders

• Two primary ways in which children are affected by parental substance use disorders
  • Prenatal exposure
  • Post-natal living environment

Children’s Issues

• Methamphetamine has effects on the developing fetus that continue into infancy and childhood, much like other drugs
• The environment where MA is used or manufactured is unsafe for children, posing some unique issues for child protection
  • DEA reports that children were present at more than 20% of seized MA labs

Substance Exposed Infants: How Many?

• Best estimates are that a total of 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs^1,2
  • That means about 400,000-480,000 substance-exposed births nationwide last year
  • An estimated 8 million of total of 77 million children 0-18

^1. Vega et al (1993). Profile of Alcohol and Drug Use During Pregnancy in California, 1992.
^2. SAMHSA, OAS. (2003). Results from the 2002 National Survey on Drug Use and Health: National findings.

Comparing Substance Exposed Infants and Child Welfare Cases

(From National 2001-2002 Data) Total 2002 births: 4,093,000 10% estimated to be SEI: 409,300 Total 2002 substantiated reports of abuse or neglect in children under age 1: 142,026 Children under age 1 in out-of-home care in 2001: 22,957 An estimated 5% of SEI are placed in OOHC.

Where do all the rest go?

Most go home...

80-95% are undetected and go home without assessment and needed services

Many doctors and hospitals do not test or may have inconsistent implementation of state policies Tests only detect very recent use Inconsistent follow-up for women identified as AOD using or at-risk, but with no positive test at birth CAPTA legislation raises issues of testing and reporting to CPS

Effects of Prenatal Substance Exposure

Research has shown that effects can manifest themselves in multiple developmental areas, including:

• Physical health consequences
• Lack of secure attachment
• Psychopathology
• Behavioral problems
• Poor social relations/skills
• Deficits in motor skills
• Cognition and learning disabilities

Pregnancy and Infant Outcome Study

• Population: Substance-exposed infants evaluated at Blank Children’s Hospital
• Population Characteristics:
  • Meth exposed: 61
  • Cocaine: 36
  • Meth/cocaine exposed: 12

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005

Maternal Data

Substance Abuse Pattern

• Women who use meth/cocaine in the first trimester are more likely to use during the third trimester
• Nicotine use is universal among drug-using pregnant women
• Marijuana and alcohol are secondary drugs, used in 60% of the group

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005

Pregnancy Outcome

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005

Infant Outcome

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005

Indicators of Child Well Being

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 2005

Developmental Outcome

From Dr. Rizwan Shah, presented at NASADAD Annual Meeting, June 200

Post-Natal Environment

Risks to All COSAs

• Chronic neglect
• Chaotic home life
• Violence associated with drug sales
• Inconsistent parenting
• Incarcerated parent(s)
• May be risk of HIV exposure if parent is a needle user

Know What Kind of ParentalMeth Exposure

• Super labs
  • Lower likelihood of children on site
• Traffickers
  • Risks of violence and guns
• Mom and Pop Cookers
  • Risks of chemical exposure
• Chemically Dependent
  • Risks of chronic neglect and poor family/social environment
• Drug Abuser/Users
  • Risks of episodic drug abuser and poor family/social environment

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

Medical Interventions for Children

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

http://www.colodec.org/decpapers/Documents/DEC%20Medical%20Protocol.pdf

Signs of Meth Use and Other Stimulants

• Euphoria
• Grinding of teeth
• Light sensitivity due to pupil dilation
• Dry mouth
• Rapid heartbeat and breathing
• Sweating and increased temperature
• Hyperactivity
• Tremor (shaking hands)
• Rapid/pressured speech
• Depression (when drug wears off)
• Irritability, paranoia, suspiciousness
• Hallucinations
• Presence of drug paraphernalia

Source: Mason, 2004; Crowell & Webber, 2001

Warning Signs for Workers

• Signs of methamphetamine use
• Client is extremely irritable 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
• Presence of knife, firearm, or other weapon in the immediate vicinity

http://www.drugfreeinfo.org/PDFs/strengthensupervision.pdf

Worker Safety – Components of a Safety Plan

• Inform supervisor/co-worker(s) that you will be visiting a client with a history of making/using methamphetamine
• Arrange for someone to check on you if you don’t call in by a pre-arranged time
• If you feel unsure of your safety, leave
• Do not let client get between you and an exit
• Park car so that you can not be boxed in
• Do not argue with or antagonize client
• Do not position yourself in the client’s peripheral vision area or where the client can not see you.
• Do not move suddenly
• Tell the client what you are doing and why
• Ask permission if you want to go to another area of the client’s dwelling or look in cabinets (e.g., to ensure food is in the house)

2001 Project Strengthen Supervision 5, Illinois State University/School of Social Work; Crowell and Weber
www.drugfreeinfo.org/PDFs/strengthensupervision.PDF

Signs to Watch for:

• Symptoms of stimulant use
• Methamphetamine paraphernalia
• Signs that client is becoming upset, angry or suspicious
• 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)
• Evidence of hallucinations
• Strong chemical odor (may indicate manufacturing of meth)

Summary

Summary

• Visit our website - ncsacw.samhsa.gov
• Meth specifics:
  • Remains in body for longer than other stimulants
  • Users tend to use for more days
  • Users have cognitive impairments in early abstinence
  • Users tend to smoke meth at higher rates
  • Population is majority Caucasian
• National survey data indicate meth use may be leveling
• Treatment admission data indicate continued increases through 2002
• Women are nearly half of meth admissions compared to one-third overall admissions
• Adolescent girls are 70% of admissions for methamphetamine
• About 2,800 children were removed from meth labs over 4 years – this compares to approximately 1,00,000 total children removed
• Women meth users in treatment have significant childhood physical and sexual abuse histories
• Treatment needs to also screen for past trauma and provide trauma services and mental health treatment
• Long-term effects tend to ameliorate with sustained abstinence
• Treatment, intervention and case planning need to account for short-term effects, especially cognitive deficits and verbal communication
• 30% of women in treatment remained continuously abstinent for four years
• Relapse risks include past drug sales and a partner who is not in treatment
• Most substance-exposed infants are not detected at birth although they are at high risk of poor developmental outcomes
• Methamphetamine prenatally-exposed children have high rates of feeding problems and in other aspects are similar to cocaine-exposed children
• It is important for child welfare workers to know which children of meth users they are working with
• There are established medical protocols for children in meth labs
• There are safety concerns for workers that must be attended to