Discussion
The demographics of MAP patients in this study correlate well with previous studies describing defined populations of MAP users. Baberg and colleagues screened inpatient psychiatric consultations at a university medical center and found that MAP use doubled over 6 years in a population with demographics similar to ours. Bailey studied toxicology screens in university hospital patients and reported demographics similar to our data. The typical user in our study was a Caucasian male in his early thirties with no health insurance. Thirty-six percent of MAP patients were female, however, and the use of MAP by females in general has been increasing. Proposed reasons for this trend include the following short-term benefits of MAP use: increased wakefulness allowing for multiple jobs and overtime, weight loss, and enhanced sexual drive. Anderson and Flynn reported an estimated 7,000 MAP injectors in Sacramento County, of whom most are male, Caucasian, young, and employed. A survey of adolescents by this same team found that MAP was the most commonly used drug after alcohol and marijuana, and 54% admitted using MAP at least once. A 10-year-old study by Derlet et al examined 127 cases of amphetamine toxicity in the ED, and this group found these patients presented with a wide range of complaints, of which altered mental status was foremost. They found less associated trauma compared to our results.

A remarkable association between MAP use and injury from trauma existed in this study. Interpersonal trauma, including gunshot wounds, stabbings, and assaults, was responsible for a large number (n = 67) of ED visits (Table 3). The predisposition for violence and suicide from MAP abuse may account for the large proportion of these cases. This association has been investigated in previous studies. Kratofil and colleagues described self-injury and mutilation by MAP users. Logan reported a correlation between MAP and violent behavior in drivers arrested for driving under the influence of alcohol. In another series by the same author, 146 deaths involving MAP were reviewed on autopsy, and 27% resulted from homicidal and 15% from suicidal violence. A similar study from Spain also found a high percentage of violent deaths in MAP-positive autopsies. Bailey and coworkers reported MAP presence in almost one-third of homicides and accidental overdoses in San Diego County. In the subculture of MAP users, in which paranoia, poor judgment, predisposition for violence, and access to weapons coexist, any potential misunderstanding or disagreement, however insignificant, may lead to interpersonal violence. buy imitrex

The deleterious effect of MAP on psychomotor and cognitive skills has been well documented. The most notable consequence of this effect is an increased incidence of moving vehicle accidents and falls. In a series of moving vehicle accidents described by Logan et al, poor coordination and judgment was responsible for the majority of crashes, and typical driving behaviors included drifting out of the lane of travel, erratic driving, weaving, speeding, drifting off the road, and high speed collisions. The majority of MAP patients with blunt trauma in our study were involved in car crashes and other moving vehicles, including 2 MAP users who were riding bicycles and crashed into each other (Table 3). Crouch and coworkers investigated fatal track crashes over a one-year period and found that an alarmingly high percentage tested positive for MAP postmortem. Although MAP does significantly extend periods of wakefulness, this benefit is quickly negated by poor task functioning. Wiegmann and colleagues studied the effect of MAP on cognitive processing, which deteriorated considerably with extended periods of wakefulness induced by MAP. omnicef 300mg

TABLE 3 —Mechanism of Trauma for Injured MAP Patients

Chronic MAP use also has been associated with the development of schizophreniform mental illness, which
may be permanent. The paranoia accompanying MAP use is well documented. In one study only 32% of patients admitted to using MAP when confronted with their positive toxicology results. A large number of MAP injectors in our study (n = 18) claimed that their soft-tissue infections were the result of a “spider bite.” For 10 patients in this study, note was made in each patient’s record that the patient stated someone may have “slipped something in my drink” or “spiked my drink.”

The association of MAP use and smoking was profound in our study. This association has been previously described.10 The combination of nicotine and MAP results in a byproduct, cyanomethylmethamphetamine. In one study by Sekine et al, this compound was demonstrated to have even greater psychostimulant effects than MAP alone. canadian pharmacy levitra

Our study population also demonstrated a strong propensity for ethanol use. Slawecki and colleagues studied the effect of MAP on ethanol use and found MAP to increase the craving for ethanol and the volume consumed. Concomitant ethanol ingestion further compromises the already impaired coordination and judgment of MAP users who operate moving vehicles.

Users who inject MAP intravenously expose themselves to a large number of serious health problems. Human immunodeficiency virus (HIV), viral hepatitis, endocarditis, and pulmonary abscess may result from MAP injectors using poor needle hygiene. Molitor and colleagues reported that MAP users, especially those who administer MAP by injection, indulge in higher-risk sexual behavior when compared to other users of illicit drugs and are more likely to have a sexually transmitted disease.

The byproducts of clandestine MAP synthesis are extremely hazardous, and there is litde or no quality control for the finished product. In Oregon, many injectors developed lead poisoning from a contaminated batch of MAP.

This study had several limitations. The study is a retrospective review. No protocol existed for selection of patients for urine toxicology screening, which may have biased our results. Our institution is located in an area noted for high levels of MAP production and consumption and provides health care to a large number of uninsured patients. Studies drawn from toxicology results also may underestimate the frequency of drug abuse, because patients who admit to using illicit drugs often are not tested. The urine toxicology test was not followed by more specific gas chromatography confirmation. Although it is possible that some of the toxicology results in this study may have been from false positives or iatrogenic medication, we believe this number to be small and did not measurably affect our results. There were no indications in reviewing patient records that positive toxicology screens resulted from legitimate intake of over-the-counter medications or from prescribed amphetamine derivatives. Definitively linking MAP with the patient’s chief complaint was not possible because the amount of time elapsed between last MAP dose and presentation to the ED could not be established. Viagra Professional 100 mg

Conclusion
Methamphetamine abuse patients presenting to the ED tend to be young Caucasian males, tobacco smokers, and have no health insurance. Compared to the average ED patient, MAP patients use ambulance transport at a much higher rate and are more likely to be admitted to the hospital. A significant association between MAP patients and trauma also existed. Methamphetamine abuse will continue to worsen if current trends prevail. Clinicians must be aware of the variable nature of MAP abuse and its deleterious effect on patients’ mental and physical health.