Methamphetamine (MAP) abuse continues to increase worldwide, based on morbidity, mortality, drug treatment, and epidemiologic studies and surveys. MAP abuse has become a significant health care, environmental, and law enforcement problem. Acute intoxication often results in agitation, violence, and death. Chronic use may lead to infection, heart failure, malnutrition, and permanent psychiatric illness. MAP users frequently use the emergency department (ED) for their medical care. Over a 6-month period we studied the demographics, type, and frequency of medical and traumatic problems in 461 MAP patients presenting to our ED, which serves an area noted for high levels of MAP production and consumption. Comparison was made to the general ED population to assess use patterns. MAP patients were most commonly Caucasian males who lacked health insurance. Compared to other ED patients during this time, MAP patients used ambulance transport more and were more likely to be admitted to the hospital. There was a significant association between trauma and MAP use in this patient population. Our data suggest MAP users utilize prehospital and hospital resources at levels higher than the average ED population. Based on current trends, we can expect more ED visits by MAP users in the future.

Methamphetamine (MAP) is a central nervous system (CNS) stimulant that has an extensive history of abuse since its advent 80 years ago. Illicit MAP use has been increasing steadily in the United States and is rapidly spreading worldwide. MAP is now the most common drug of abuse presenting to emergency departments (ED) in the western United States. Intoxicated MAP patients often present with agitation, violence, and loss of self-control and represent a threat to themselves and caregivers. Chronic MAP users often develop paranoia and lasting psychosis as well as deterioration of judgment and fine motor skills, which may predispose them to injury from moving vehicle accidents. Chronic use also results in serious health problems including malnutrition, poor dentition, exhaustion, and systemic or soft-tissue infection from injecting MAP. Criminal and violent behavior associated with MAP may lead to blunt and penetrating traumatic injury. Patterns of use vary considerably and include occasional or sporadic use, to “bingeing” over a period of several days. Inevitably, increasing MAP abuse translates into more frequent ED visits by this population. To better appreciate the protean nature of MAP abuse, we reviewed ED visits by patients with positive toxicology screens for MAP to determine demographics, the relative frequency of associated medical and traumatic problems, and disposition. We also compared these variables with the remaining ED population to assess ED use patterns. generic actos

Materials and Methods
This study was done over a 6-month period from September 1996 through February 1997 at the University of California, Davis Medical Center, a large urban university hospital with an annual ED census of 70,000 visits. This hospital is a level I trauma center and represents the de facto public hospital for its urban geographic area, serving a population of 400,000 within the city limits and 1.5 million in the surrounding area. Our institution provides health care for a high proportion of uninsured patients and for those patients brought in by police from the street or from jail. Retrospective review of all patients presenting to the ED with a urine toxicology screen positive for MAP was performed. Charts were abstracted for patient demographics, insurance status, chief complaint, mode of arrival, vital signs, laboratory results, smoking habits, procedures, disposition, and outcome. The rapid urine toxicology screen for drugs of abuse, which detects cocaine, opiate derivatives, benzodiazepines, barbiturates, tetrahydrocannabinol, and phencyclidine, was processed on a CX-7 analyzer in the ED (Beckman Industries, Fullerton, California). Univariate statistical analysis was done using chi-square and unpaired Student t tests. Calculations were done with Stata 5.0. Data are reported as mean ± standard deviation (SD) unless otherwise stated. Statistical significance is assumed at a level P < 0.05. This study was approved by the human subjects review committee at our institution. cialis professional

Results
A total of 461 patients were identified as having MAP on their urine toxicology screens. During the study period there were 3,102 total urine toxicology screens performed on ED patients and 32,156 total ED visits. Comparison of demographics between patients with positive toxicology screens for MAP and all others are presented in Table 1. The range of age for MAP patients was 3 to 67 years.

TABLE 1. Demographic Differences Between MAP and Non-MAP Patients*

*AJI findings significant at P < 0.001.
SD = standard deviation, HMO/MCO = health maintenance organization/managed care organization

Concomitant drug use by MAP patients was also recorded. Tobacco use was documented in 413 MAP patients (90%). Ninety-two patients (20%) coingested ethanol, with an average blood level of 125 ± 32 mg/dl. Other drugs detected included opiates (n = 61, 13%), cocaine (n = 34, 7%), benzodiazepines (n = 21, 5%), tetrahydrocannabinol (n = 20, 4%), and phencyclidine (n = 2, 0.4%). With regard to mode of arrival, MAP patients were most likely to use ambulance transport (n = 319, 69%), followed by: brought in by self, family, or friend (n = 66, 14%); brought in by police (n = 56, 12%); and mental health facility transfer (n = 20, 4%). During this period there were 7,584 total ambulance transports to our institution. A significant difference in use of ambulance transport existed between MAP and non-MAP patients (69% versus 22%, P < 0.001). generic atomoxetine

Chief complaints and admissions are displayed in Table 2. A total of 268 MAP patients were admitted to the hospital from the ED (58%), followed by 89 who were discharged directly to home (19%). Sixty-three MAP patients were discharged to an inpatient psychiatric facility from the ED (14%), and 41 MAP patients went directly to jail (9%). During this period there were 7,074 admissions to the hospital from the ED. Difference in admission rates for MAP patients and non-MAP patients was significant (58% versus 22%, P < 0.001). Average stay for MAP patients was 2.8 ± 1.8 days, and 386 of the 461 MAP patients had two or more ED visits within the past 12 months.

TABLE 2 — Chief Complaints and Hospital Admissions of MAP Patients

LOC = level of consciousness

A total of 172 MAP patients (37%) had injuries from trauma (Table 2), of which blunt trauma was most common. Mechanism of injury is demonstrated in Table 3. For the study period there were 6,753 trauma-related ED visits. A significant difference was noted between MAP patients and non-MAP patients for trauma-related complaints (37% versus 21%, P < 0.001). Fifty-three of 172 MAP patients (31%) with trauma required sedation for acute agitation.  cheap viagra online

The next most common presenting complaint for MAP patients was altered level of consciousness (Table 2). In this subgroup, 83 patients were acutely agitated. Sixteen were noted on the ED record to have hallucinations, of which 10 were of the visual and tactile sensation of insects crawling on the patient’s body. None of these 10 patients were experiencing ethanol withdrawal at the time. Sixteen patients had tonic-clonic seizures, of which 12 were new-onset. The remaining 9 were evaluated for syncope.

Thirty-eight patients were suicidal. The most common attempted mode of suicide was overdose (n = 22), followed by slash wounds to extremities (n = 10), and jumps from heights (n = 5). One patient attempted suicide by striking a brick to his head several times after injecting MAP. A total of 52 patients were brought in or placed on a 72-hour psychiatric hold while in the ED. There were 8 cases of oral ingestion of MAP, 7 of which were for evading police detection of MAP possession. The remaining patient was a 3-year-old boy who ingested some of his parents’ MAP, which was lying on the floor. skelaxin muscle relaxer

Twenty-eight patients presented with skin infections from injecting MAP, including 21 with abscesses and 7 with cellulitis. All 21 abscesses required incision and drainage: 12 were performed in the ED under local anesthesia, and the remaining 9 were performed in the operating room. Of note, 18 of the 28 MAP patients with skin infections insisted that a “spider bit them.”