Mapping the spread of methamphetamine abuse in California from 1995 to 2008

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

Development and evaluation of a social marketing campaign to address methamphetamine use in Los Angeles County

Background

This study describes the development and impact of a social marketing campaign in early 2020 intended to prevent and reduce methamphetamine use in Los Angeles County (LAC). We used social marketing principles and the transtheoretical model to design the campaign, which was intended to avoid stigmatization of methamphetamine users and communicate compassion, empathy, and support.

Methods

To evaluate its impact, we collected cross-sectional online survey data post-campaign (n = 1,873) from LAC residents in population segments considered higher risk for methamphetamine use. We examine associations between campaign exposure and outcomes using bivariate analyses and binary logistic regression models, which control for the impact of the COVID-19 pandemic on methamphetamine use or likelihood of use.

Results

The analyses revealed that campaign exposure was associated with having more negative attitudes toward methamphetamine, calling LAC’s substance abuse service helpline, using methamphetamine fewer days, and considering abstaining. Frequency of exposure to campaign advertisements was positively associated with calling the helpline, suggesting a campaign dose effect. COVID-19-related factors were associated with using methamphetamine in the past 30 days.

Conclusions

Social marketing campaigns hold promise for impacting methamphetamine prevention and cessation behaviors. This study adds to the limited literature on mass marketing interventions to address this major health issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14180-y.

Socioeconomic Burden of Rising Methamphetamine-Associated Heart Failure Hospitalizations in California From 2008 to 2018

BACKGROUND

Methamphetamine-associated cardiomyopathy/heart failure (MethHF) is an increasingly recognized disease entity in the context of a rising methamphetamine (meth) epidemic that most severely impacts the western United States. Using heart failure (HF) hospitalization data from the Office of Statewide Health Planning and Development, this study aimed to assess trend and disease burden of MethHF in California.

METHODS

Adult patients (≥18 years old) with HF as primary hospitalization diagnosis between 2008 and 2018 were included in this study. The association with Meth (MethHF) and those without (non-MethHF) were determined by meth-related International Classification of Diseases-based secondary diagnoses. Statistical significance of trends in age-adjusted rates of hospitalization per 100 000 adults were evaluated using nonparametric analysis.

RESULTS

Between 2008 and 2018, 1 033 076 HF hospitalizations were identified: 42 565 were MethHF (4.12%) and 990 511 (95.88%) were non-MethHF. Age-adjusted MethHF hospitalizations per 100 000 increased by 585% from 4.1 in 2008 to 28.1 in 2018, while non-MethHF hospitalizations decreased by 6.0% from 342.3 in 2008 to 321.6 in 2018. The rate of MethHF hospitalization increase more than doubled that of a negative control group with urinary tract infection and meth-related secondary diagnoses (7.82-fold versus 3.48-fold, P<0.001). Annual inflation-adjusted hospitalization charges because of MethHF increased by 840% from $41.5 million in 2008 to $390.2 million in 2018, as compared with an 82% increase for all HF hospitalization from $3.503 billion to $6.376 billion. Patients with MethHF were significantly younger (49.64±10.06 versus 72.20±14.97 years old, P<0.001), predominantly male (79.1% versus 52.4%, P<0.001), with lower Charlson Comorbidity Index, yet they had longer length of stay, more hospitalizations per patient, and more procedures performed during their stays.

CONCLUSIONS

MethHF hospitalizations increased sharply during the study period and contributed significantly to the HF hospitalization burden in California. This emerging HF phenotype, which engenders considerable financial and societal costs, calls for an urgent and concerted public health response to contain its spread.

Factors associated with methamphetamine withdrawal symptoms among people who inject drugs

BACKGROUND

Regular methamphetamine (MA) use can result in withdrawal syndrome characterized by fatigue, agitation, depression, and anxiety. No studies that we are aware of have examined the prevalence and predictors of MA withdrawal symptoms among people who inject drugs (PWID).

METHODS

PWID were recruited using targeted sampling methods in Los Angeles and San Francisco, California from 2016 to 2017. Survey questions included demographics, drug use, and MA withdrawal symptoms, frequency, and symptom severity. Participants who reported regular MA use (> 12 times in the last 30 days) were included in this analysis (N = 595). Multivariable regression models were developed to examine factors associated with any MA withdrawal, withdrawal frequency, symptom severity, and receptive syringe sharing.

RESULTS

MA withdrawal symptoms in the past 6 months were reported by 53 % of PWID, with 25 % reporting weekly withdrawal symptoms, and 20 % reporting very or extremely painful symptoms. In multivariable logistic regression, presence of any MA withdrawal symptoms was positively associated with more frequent MA use and non-injection tranquilizer use and inversely associated with crack cocaine use. Among those reporting any withdrawal, female sex was associated with more frequent withdrawal symptoms. Very or extremely painful withdrawal symptoms were associated with being in residential treatment. Receptive syringe sharing was associated with any MA withdrawal symptoms and weekly frequency of symptoms.

CONCLUSION

MA withdrawal symptoms are common among PWID and are associated with receptive syringe sharing. Strategies for implementing MA use treatment, safe supply programs, and syringe services programs targeting people who inject MA are indicated.

Opioid epidemics

In this paper, I propose an economic theory that addresses the epidemic character of opioid epidemics. I consider a community in which individuals are heterogenous with respect to the experience of chronic pain and susceptibility to addiction and live through two periods. In the first period they consider whether to treat pain with opioid pain relievers (OPRs). In the second period they consider whether to continue non-medical opioid use to mitigate cravings from addiction. Non-medical opioid use is subject to social disapproval, which depends negatively on the share of opioid addicts in the community. An opioid epidemic is conceptualized as the transition from an equilibrium at which opioid use is low and addiction is highly stigmatized to an equilibrium at which opioid use is prevalent and social disapproval is low. I show how such a transition is initiated by the wrong belief that OPRs are not very addictive. Under certain conditions there exists an opioid trap such that the community persists at the equilibrium of high opioid use after the wrong belief is corrected. Refinements of the basic model consider the recreational use of prescription OPRs and an interaction between income, pain, and addiction.

A longitudinal analysis of the spatial spread of police-investigated physical child abuse

BACKGROUND

Research has shown that problematic behaviors, such as violence and drug use, may spread through shared physical space and social norms, lending rise to the notion of contagion theories of human behavior.

OBJECTIVE

This study examines whether physical child abuse spreads across time and space in a pattern reflective of a contagion model.

PARTICIPANTS AND SETTING

This study uses 15 years of data from a large U.S. city police department. Data points are geo-located police-investigated physical child abuse incidents that occurred from 2001 to 2015.

METHODS

Police department data are combined with U.S. Census estimates of the number of child residents in each of the Census Tract comprising the study site to derive annual rates of police-investigated physical child abuse cases per 1000 children residing in each Census tract. A panel data spatial regression model is used to analyze the association between this dependent variable, the rate of police-investigated physical child abuse cases in surrounding Census tracts, and time. The analysis statistically controls for multiple covariates commonly associated with Census tract-level estimates of child maltreatment, specifically household median income, residential instability, racial composition, population density, and the concentration of child residents.

RESULTS

The rate of physical child abuse in a Census tract is positively associated with the rate of physical child abuse in the surrounding Census tracts, net of the covariates and the effect of time (β = 0.461, p <  .001).

CONCLUSION

This finding provides preliminary evidence that physical child abuse, like some other problematic human behaviors, may spread spatially.

Investigating the Social Ecological Contexts of Opioid Use Disorder and Poisoning Hospitalizations in Pennsylvania

OBJECTIVE

Opioid use disorder (OUD) and overdose rates have been sharply on the rise in the United States. Although systematic patterns of geographic variation in OUD and opioid overdose have been identified, the factors that explain why opioid-related hospitalizations increase in certain areas are not well understood.

METHOD

We examined Pennsylvania Health Care Cost Containment Council (PHC4) hospital inpatient discharge data at the ZIP code level to measure the geographic growth and spread of OUD as measured by 44 quarters of inpatient hospitalization data (from 2004 through 2014) for the entire state of Pennsylvania (n = 16,275 ZIP codes). We assessed the relative contribution of specific attributes of areas (e.g., population density) to patterns of OUD, heroin poisonings, and non-heroin opioid poisonings. Unit misalignment and spatial autocorrelation were corrected for using Bayesian space-time conditional autoregressive models.

RESULTS

The associations between a greater density of manual labor establishments and all opioid-related hospitalizations were well supported and positive. A dose-response relationship between population density and opioid-related hospitalizations existed, with a stronger association for heroin poisonings (relative rate, densest quintile vs. least dense: 3.40 [95% credible interval 2.68, 4.39]).

CONCLUSIONS

Posterior distributions from these models enabled the identification of locations most vulnerable to problems related to the opioid epidemic in Pennsylvania. Understanding spatial patterns of OUD and poisonings can enhance the development and implementation of effective prevention programs.

Opioid-related diagnoses and HIV, HCV and mental disorders: using Pennsylvania hospitalisation data to assess community-level relationships over space and time

BACKGROUND

We assessed the community-level spatiotemporal connexions between hospitalisations for common opioid comorbidities (HIV, hepatitis C (HCV) and mental disorders) and opioid-related hospitalisations in the current and previous year.

METHODS

We used Bayesian hierarchical spatiotemporal Poisson regression with conditionally autoregressive spatial effects to assess counts of HCV-related, HIV-related and mental disorder-related hospitalisations at the ZIP code level from 2004 to 2014 in Pennsylvania. Models included rates of current-year and previous-year opioid-related hospitalisations as well as covariates measuring demographic and environmental characteristics.

RESULTS

After adjusting for measures of demographic and environmental characteristics, current-year and previous-year opioid-related hospitalisations were associated with higher risk of HCV, HIV and mental disorders. The relative risks and 95% credible intervals for previous-year opioid-related hospitalisations were 1.092 (1.078 to 1.106) for HCV, 1.098 (1.068 to 1.126) for HIV and 1.020 (1.013 to 1.027) for mental disorders.

CONCLUSION

Previous-year opioid-related hospitalisations are connected to common comorbid conditions such as HCV, HIV and mental disorders, illustrating some of the broader health-related impacts of the opioid epidemic. Public health interventions focused on the opioid epidemic must consider individual community needs and comorbid diagnoses.

Methamphetamine use association with pulmonary diseases: a retrospective investigation of hospital discharges in California from 2005 to 2011

BACKGROUND

Methamphetamine can have acute and long-term adverse health consequences. Our objective was to determine whether methamphetamine use is associated with more hospitalisation codes for asthma exacerbation, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia and acute respiratory failure (ARF).

METHODS

The Health Care Utilization Project (HCUP) database includes retrospective inpatient discharge abstracts from 2005 through 2011 from the California state inpatient databases (SIDs). ICD-9 codes were used to identify hospitalisations for asthma exacerbation, COPD exacerbation, acute pneumonia, ARF and methamphetamine use from discharges with complete demographic data and ages 18 to 75 years. Adjusted rate ratios comparing methamphetamine users with nonusers were estimated separately for each pulmonary disease diagnosis by sex using negative binomial regression models.

RESULTS

We included 21 125 249 inpatient discharges from 2005 through 2011 in California in our analysis; 182 766 (0.87%) had methamphetamine use. The rate ratio comparing pneumonia in discharges with methamphetamine use versus those without were 1.40 (95% CI 1.18, 1.67) for women and 1.18 (95% CI 1.04, 1.35) for men; comparing ARF 1.77 (95% CI 1.59, 1.98) for women and 1.24 (95% CI 1.12, 1.37) for men; and comparing COPD exacerbation 1.40 (95% CI 1.18, 1.67) for women and 0.90 (95% CI 0.79, 1.02) for men.

CONCLUSIONS

A positive association was found when comparing inpatient hospital discharge diagnoses for methamphetamine use and those for pneumonia and ARF in both sexes. This association was not seen when comparing discharge diagnoses for methamphetamine and those for asthma exacerbation in both sexes or COPD exacerbation in men. While future investigation for is warranted, this finding may help to further characterise the pulmonary toxicity of methamphetamine.

Social and structural factors associated with substance use within the support network of adults living in precarious housing in a socially marginalized neighborhood of Vancouver, Canada

BACKGROUND

The structure of a social network as well as peer behaviours are thought to affect personal substance use. Where substance use may create health risks, understanding the contribution of social networks to substance use may be valuable for the design and implementation of harm reduction or other interventions. We examined the social support network of people living in precarious housing in a socially marginalized neighborhood of Vancouver, and analysed associations between social network structure, personal substance use, and supporters' substance use.

METHODS

An ongoing, longitudinal study recruited 246 participants from four single room occupancy hotels, with 201 providing social network information aligned with a 6-month observation period. Use of tobacco, alcohol, cannabis, cocaine (crack and powder), methamphetamine, and heroin was recorded at monthly visits. Ego- and graph-level measures were calculated; the dispersion and prevalence of substances in the network was described. Logistic mixed effects models were used to estimate the association between ego substance use and peer substance use. Permutation analysis was done to test for randomness of substance use dispersion on the social network.

RESULTS

The network topology corresponded to residence (Hotel) with two clusters differing in demographic characteristics (Cluster 1 -Hotel A: 94% of members, Cluster 2 -Hotel B: 95% of members). Dispersion of substance use across the network demonstrated differences according to network topology and specific substance. Methamphetamine use (overall 12%) was almost entirely limited to Cluster 1, and absent from Cluster 2. Different patterns were observed for other substances. Overall, ego substance use did not differ over the six-month period of observation. Ego heroin, cannabis, or crack cocaine use was associated with alter use of the same substances. Ego methamphetamine, powder cocaine, or alcohol use was not associated with alter use, with the exception for methamphetamine in a densely using part of the network. For alters using multiple substances, cannabis use was associated with lower ego heroin use, and lower ego crack cocaine use. Permutation analysis also provided evidence that dispersion of substance use, and the association between ego and alter use was not random for all substances.

CONCLUSIONS

In a socially marginalized neighborhood, social network topology was strongly influenced by residence, and in turn was associated with type(s) of substance use. Associations between personal use and supporter's use of a substance differed across substances. These complex associations may merit consideration in the design of interventions to reduce risk and harms associated with substance use in people living in precarious housing.

Features and Outcomes of Methamphetamine-associated Pulmonary Arterial Hypertension

RATIONALE

Although amphetamines are recognized as "likely" agents to cause drug- and toxin-associated pulmonary arterial hypertension (PAH), (meth)amphetamine-associated PAH (Meth-APAH) has not been well described.

OBJECTIVES

To prospectively characterize the clinical presentation, histopathology, and outcomes of Meth-APAH compared with those of idiopathic PAH (iPAH).

METHODS

We performed a prospective cohort study of patients with Meth-APAH and iPAH presenting to the Stanford University Pulmonary Hypertension Program between 2003 and 2015. Clinical, pulmonary angiography, histopathology, and outcomes data were compared. We used data from the Healthcare Cost and Utilization Project to estimate the epidemiology of PAH in (meth)amphetamine users hospitalized in California.

MEASUREMENTS AND MAIN RESULTS

The study sample included 90 patients with Meth-APAH and 97 patients with iPAH. Patients with Meth-APAH were less likely to be female, but similar in age, body mass index, and 6-minute-walk distance to patients with iPAH. Patients with Meth-APAH reported more advanced heart failure symptoms, had significantly higher right atrial pressure (12.7 ± 6.8 vs. 9.8 ± 5.1 mm Hg; P = 0.001), and had lower stroke volume index (22.2 ± 7.1 vs. 25.5 ± 8.7 ml/m²; P = 0.01). Event-free survival in Meth-APAH was 64.2%, 47.2%, and 25% at 2.5, 5, and 10 years, respectively, representing more than double the risk of clinical worsening or death compared with iPAH (hazard ratio, 2.04; 95% confidence interval, 1.28-3.25; P = 0.003) independent of confounders. California data demonstrated a 2.6-fold increase in risk of PAH diagnosis in hospitalized (meth)amphetamine users.

CONCLUSIONS

Meth-APAH is a severe and progressive form of PAH with poor outcomes. Future studies should focus on mechanisms of disease and potential therapeutic considerations.

Oxytocin-enhanced motivational interviewing group therapy for methamphetamine use disorder in men who have sex with men: study protocol for a randomized controlled trial

Background

The prevalence of methamphetamine use disorder (MUD) in the United States has risen dramatically in the past four decades and is concentrated in populations such as men who have sex with men (MSM). Despite the public health consequences of MUD, there are no FDA-approved psychopharmacological treatments. Psychosocial treatment alone has been shown to reduce methamphetamine use, but high attrition rates limit treatment efficacy. Promising findings from animal models of MUD using exogenous oxytocin, a social neuropeptide, have set the stage for translational work. Along with unique anti-addiction effects, oxytocin holds a primary role in enhancing social salience and modulating stress. In humans, oxytocin administration, combined with evidence-based psychosocial interventions, may act synergistically to improve addiction treatment outcomes and improve retention rates in current MUD treatment.

Methods/design

We are conducting a randomized, double-blind, placebo-controlled trial of oxytocin-enhanced motivational interviewing group therapy (MIGT). Oxytocin or placebo 40 IU is administered intranasally in conjunction with six, weekly MIGT sessions. We will recruit 50 MSM, initiating treatment for MUD from specialized community health programs in San Francisco, CA, USA. Individuals will be randomized (1:1) to receive six, weekly sessions of MIGT with or without oxytocin. Our primary outcome is session attendance. Other outcomes of interest include: measures of group cohesion, anxiety, psychophysiology, and stimulant craving and use.

Discussion

This will be the first study of oxytocin’s effects in humans with MUD. Findings from this novel protocol will attempt to bridge existing animal data with the need for innovative clinical treatments for MUD, inform the growing field of pharmacologically-enhanced psychotherapy, and help to elucidate mechanisms behind oxytocin’s potential anti-addiction effects.

Trial registration

ClinicalTrials.gov, ID: NCT02881177. Registered on 26 August 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3225-7) contains supplementary material, which is available to authorized users.

Methamphetamine and the risk of pulmonary arterial hypertension

PURPOSE OF REVIEW

Methamphetamine is a highly addictive drug originally developed for the treatment of neuropsychiatric disorders. At present, the epidemic rise of illicit methamphetamine use has increased the number of patients living with medical complications. Our group has recently identified a definite association between methamphetamine use and pulmonary arterial hypertension (PAH), a life-threatening disease characterized by occlusive vasculopathy and progressive right heart failure. This review will discuss the evidence that links methamphetamine with PAH and how to approach the diagnosis and management of methamphetamine-associated pulmonary arterial hypertension (Meth-APAH) patients in clinic.

RECENT FINDINGS

Compared with idiopathic (I) PAH, Meth-APAH patients present with worse functional status, right ventricular dysfunction, and exercise tolerance. Despite therapy, the 5-year survival of Meth-APAH patients is significantly lower compared with IPAH. Genetic studies suggest that loss of function variants in genes involved in drug detoxification can increase susceptibility for methamphetamine-related vascular injury and trigger occlusive vasculopathy.

SUMMARY

PAH patients undergoing diagnostic evaluation should be screened for a history of current or past methamphetamine use. Pharmacovigilance should be implemented to monitor patients being treated with methamphetamine for neuropsychiatric disorders (e.g., attention-deficit hyperactivity disorder). More studies will be needed to identify which susceptibility factors increase risk of PAH in methamphetamine users.

Injection drug use, HIV/HCV, and related services in nonurban areas of the United States: A systematic review

BACKGROUND

Injection drug use (IDU) in nonurban areas of the United States is a growing public health concern, but there has been no comprehensive assessment of existing research on injection-related HIV and hepatitis C (HCV) in nonurban communities. We conducted a systematic review to assess the current literature and identify knowledge gaps.

METHODS

We systematically searched six databases for relevant articles published between January 1990 and June 2016 and screened, extracted, and analyzed the resulting data. Studies were included if they reported original findings from the nonurban U.S. related to 1) IDU and its role in HIV/HCV transmission, and/or 2) HIV/HCV services for people who inject drugs (PWID).

RESULTS

Of 2330 studies, 34 from 24 unique research projects in 17 states met inclusion criteria. Despite increasing HCV and high vulnerability to injection-related HIV outbreaks in nonurban areas, only three studies since 2010 recruited and tested PWID for HIV/HCV. Twelve reported on sharing injection equipment but used varying definitions of sharing, and only eight examined correlates of injection risk. Nine studies on syringe access suggest limited access through syringe exchange programs and pharmacies. Only two studies addressed HCV testing, none addressed HIV testing, and three examined behavioral or other interventions.

CONCLUSIONS

Despite growing concern regarding nonurban IDU there are few studies of HIV/HCV and related services for PWID, and the existing literature covers a very limited geographical area. Current research provides minimal insights into any unique factors that influence injection risk and HIV/HCV service provision and utilization among nonurban PWID.

Nonocclusive mesenteric ischemia in patients with methamphetamine use

BACKGROUND

Data suggest that methamphetamine may increase the risk of nonocclusive mesenteric ischemia (NOMI). We describe patterns of presentation and outcomes of patients with methamphetamine use who present with NOMI to a single institution.

METHODS

This is an observational study of patients from January 2015 to September 2017 with methamphetamine use who presented with NOMI at an academic medical center in Northern California. We summarize patient comorbidities, clinical presentation, operative findings, pathologic findings, hospital course, and survival.

RESULTS

Ten patients with methamphetamine use and severe NOMI were identified. One patient was readmitted with a perforated duodenal ulcer, for a total of 11 encounters. Most presented with acute (n = 3) or acute-on-chronic (n = 4) abdominal pain. Distribution of ischemia ranged from perforated duodenal ulcer (n = 3), ischemia of the distal ileum (n = 1), ischemia of entire small bowel (n = 2), and patchy necrosis of entire small bowel and colon (n = 5). Six patients died, three within 1 week of admission and three between 3 months and 8 months.

CONCLUSION

Methamphetamine use may be associated with significant microvascular compromise, increasing the risk of mesenteric ischemia. Providers in areas with high prevalence of methamphetamine use should have a high index of suspicion for intestinal ischemia in this patient population. Patients with methamphetamine use admitted for trauma or other pathology may be at particular risk of ischemia and septic shock, especially in the setting of dehydration. Use of vasoconstrictors in this patient population may also exacerbate intestinal ischemia.

LEVEL OF EVIDENCE

Therapeutic Case series study, level V.

Evaluation of the effect of methamphetamine on traumatic injury complications and outcomes

Background

This study investigates the impact of methamphetamine use on trauma patient outcomes.

Methods

This retrospective study analyzed patients between 18 and 55 years old presenting to a single trauma center in San Bernardino County, CA who sustained traumatic injury during the 10-year study period (January 1st, 2005 to December 31st, 2015). Routine serum ethanol levels and urine drug screens (UDS) were completed on all trauma patients. Exclusion criteria included patients with an elevated serum ethanol level (> 0 mg/dL). Those who screened positive on UDS for only methamphetamine and negative for cocaine and cannabis (MA(+)) were compared to those with a triple negative UDS for methamphetamine, cocaine, and cannabis (MA(−)). The primary outcome studied was the impact of a methamphetamine positive drug screen on hospital mortality. Secondary outcomes included length of stay (LOS), heart rate, systolic and diastolic blood pressure (SBP and DBP, respectively), and total amount of blood products utilized during hospitalization. To analyze the effect of methamphetamine, age, gender, injury severity score, and mechanism of injury (blunt vs. penetrating) were matched between MA(−) and MA(+) through a propensity matching algorithm.

Results

After exclusion, 2538 patients were included in the final analysis; 449 were patients in the MA(+) group and 2089 patients in the MA(−) group. A selection of 449 MA(−) patients were matched with the MA(+) group based on age, gender, injury severity score, and mechanism of injury. This led to a final sample size of 898 patients with 449 patients in each group. No statistically significant change was observed in hospital mortality. Notably, a methamphetamine positive drug screen was associated with a longer LOS (median of 4 vs. 3 days in MA(+) and MA(−), respectively, p < 0.0001), an increased heart rate at the scene (103 vs. 94 bpm for MA(+) and MA(−), respectively, p = 0.0016), and an increased heart rate upon arrival to the trauma center (100 vs. 94 bpm for MA(+) and MA(−), respectively, p < 0.0001). Moreover, the MA(+) group had decreased SBP at the scene compared to the MA(−) group (127 vs. 132 bpm for MA(+) and MA(−), respectively, p = 0.0149), but SBP was no longer statistically different when patients arrived at the trauma center (p = 0.3823). There was no significant difference in DBP or in blood products used.

Conclusion

Methamphetamine positive drug screens in trauma patients were not associated with an increase in hospital mortality; however, a methamphetamine positive drug screen was associated with a longer LOS and an increased heart rate.

Drug-induced pulmonary arterial hypertension: a primer for clinicians and scientists

Drug-induced pulmonary arterial hypertension (D-PAH) is a form of World Health Organization Group 1 pulmonary hypertension (PH) defined by severe small vessel loss and obstructive vasculopathy, which leads to progressive right heart failure and death. To date, 16 different compounds have been associated with D-PAH, including anorexigens, recreational stimulants, and more recently, several Food and Drug Administration-approved medications. Although the clinical manifestation, pathology, and hemodynamic profile of D-PAH are indistinguishable from other forms of pulmonary arterial hypertension, its clinical course can be unpredictable and to some degree dependent on removal of the offending agent. Because only a subset of individuals develop D-PAH, it is probable that genetic susceptibilities play a role in the pathogenesis, but the characterization of the genetic factors responsible for these susceptibilities remains rudimentary. Besides aggressive treatment with PH-specific therapies, the major challenge in the management of D-PAH remains the early identification of compounds capable of injuring the pulmonary circulation in susceptible individuals. The implementation of pharmacovigilance, precision medicine strategies, and global warning systems will help facilitate the identification of high-risk drugs and incentivize regulatory strategies to prevent further outbreaks of D-PAH. The goal for this review is to inform clinicians and scientists of the prevalence of D-PAH and to highlight the growing number of common drugs that have been associated with the disease.

Effects of social and spatial contexts on young latinas' methamphetamine use initiation

In this article, we examine methamphetamine (meth) use initiation as influenced by Latinas' social positions within institutions (e.g., family and economy). We conducted ethnographic fieldwork in five women's residential substance use treatment facilities in Los Angeles County with women who considered meth to be their primary drug of choice. Using an urban ethnographic framing, we demonstrate the effects of low-income young Latinas' spatial- and social-context rendered vulnerability to abuse and neglect, and the resulting emotional distress, on meth use initiation. When considering pathways to substance use intervention for vulnerable Latina girls and women, clinicians, researchers, and policy makers need to understand substance use pathways as dynamic processes to cope with psychosocial stress while living in communities with easy access to illicit substances such as methamphetamine.

Modeling spatio-temporal variations of substance abuse mortality in Iran using a log-Gaussian Cox point process

Substance use disorder is one of the main mental health problems in Iran. In this paper, the six-monthly counts of deaths due to substance abuse in Iran at provincial level between March 21, 2005, and March 20, 2014, were modeled using a log-Gaussian Cox point process model. By assuming population density as the exposure variable, the considered model incorporated known and unknown influential factors in order to describe spatio-temporal variations in the relative risk of substance abuse mortality. We found evidence of spatial heterogeneity and inequality by gender in deaths related to substance abuse across Iran. This study provides the first evidence in Iran on the spatio-temporal heterogeneity in mortality caused by substance use disorders.

Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California

OBJECTIVES

A robust literature documents generational trends in drug use. We examined the implications of changing national drug use patterns on drug injection histories of diverse people who inject drugs (PWID).

METHODS

Drug use histories were collected from 776 active PWID in 2011-13. Using descriptive statistics, we examine drug use initiation by year and birth cohort (BC) differences in drug first injected. A multivariate linear regression model of time to injection initiation ([TTII] (year of first injection minus year of first illicit drug use) was developed to explore BC differences.

RESULTS

The first drug injected by BC changed in tandem with national drug use trends with heroin declining from 77% for the pre-1960's BC to 58% for the 1960's BC before increasing to 71% for the 1990's BC. Multivariate linear regression modeling found that shorter TTII was associated with the 1980's/1990's BC (-3.50 years; 95% Confidence Interval [CI]=-0.79, -6.21) as compared to the 1970's BC. Longer TTII was associated with being female (1.65 years; 95% CI=0.40, 2.90), African American (1.69 years; 95% CI=0.43, 2.95), any substance use treatment prior to injection (4.22 years; 95% CI=2.65, 5.79), and prior non-injection use of drug that was first injected (3.29 years; 95% CI=2.19, 4.40).

CONCLUSION

National drug trends appear to influence injection drug use patterns. The prescription opiate drug era is associated with shorter TTII. Culturally competent, demographically and generationally-targeted prevention strategies to combat transitions to drug injection are needed to prevent or shorten upstream increases in risky drug use practices on a national level.

Reduced carboxylesterase 1 is associated with endothelial injury in methamphetamine-induced pulmonary arterial hypertension

Pulmonary arterial hypertension is a complication of methamphetamine use (METH-PAH), but the pathogenic mechanisms are unknown. Given that cytochrome P450 2D6 (CYP2D6) and carboxylesterase 1 (CES1) are involved in metabolism of METH and other amphetamine-like compounds, we postulated that loss of function variants could contribute to METH-PAH. Although no difference in CYP2D6 expression was seen by lung immunofluorescence, CES1 expression was significantly reduced in endothelium of METH-PAH microvessels. Mass spectrometry analysis showed that healthy pulmonary microvascular endothelial cells (PMVECs) have the capacity to both internalize and metabolize METH. Furthermore, whole exome sequencing data from 18 METH-PAH patients revealed that 94.4% of METH-PAH patients were heterozygous carriers of a single nucleotide variant (SNV; rs115629050) predicted to reduce CES1 activity. PMVECs transfected with this CES1 variant demonstrated significantly higher rates of METH-induced apoptosis. METH exposure results in increased formation of reactive oxygen species (ROS) and a compensatory autophagy response. Compared with healthy cells, CES1-deficient PMVECs lack a robust autophagy response despite higher ROS, which correlates with increased apoptosis. We propose that reduced CES1 expression/activity could promote development of METH-PAH by increasing PMVEC apoptosis and small vessel loss.

Down in the valley: Trajectories of injection initiation among young injectors in California's Central Valley

BACKGROUND

Injection drug use initiation represents a critical point of public health intervention, as injection increases risk for blood borne infections including Hepatitis C and HIV. In this paper, we explore pathways to injection initiation among youth (≤30) in the rural context of California's Central Valley, where rates of injection drug use are among the highest in the nation.

METHODS

We draw on semi-structured qualitative interviews with 20 young injectors to examine drug use histories, including the factors that participants associated with their transition to injection drug use.

RESULTS

The average age was 24.7 years (range: 20-30), 45% were female (n=9), and 30% were Latino (n=6). Participants described a variety of pathways to injection, culminating in a first injection that involved either opioids (n=12) or methamphetamine (n=8). Among the opioid group, the majority used prescription opioids before transitioning to injection, while a smaller number transitioned to opioid injection from non-opioid recreational drug use. Injectors who first used prescription opioids often described growing up in affluent suburban areas and transitioned to injection with peers, owing to a combination of factors related to individual tolerance, cost, and shifting drug markets. In contrast, methamphetamine initiates grew up in less affluent families with histories of substance use that exposed them to drugs at an early age. Methamphetamine users transitioned from smoking and snorting to injection, often with family members or intimate partners, within broader contexts of social disadvantage and stress.

CONCLUSION

While much of the focus on young injectors has centred on the current opioid epidemic, our data suggest a need to consider multiple pathways towards injection initiation of different drugs. Targeted interventions addressing the unique injection transition contexts of both opioids and methamphetamine are urgently needed in the Central Valley of California.

Heterogeneous Costs of Alcohol and Drug Problems Across Cities and Counties in California

BACKGROUND

Estimates of economic and social costs related to alcohol and other drug (AOD) use and abuse are usually made at state and national levels. Ecological analyses demonstrate, however, that substantial variations exist in the incidence and prevalence of AOD use and problems including impaired driving, violence, and chronic disease between smaller geopolitical units like counties and cities. This study examines the ranges of these costs across counties and cities in California.

METHODS

We used estimates of the incidence and prevalence of AOD use, abuse, and related problems to calculate costs in 2010 dollars for all 58 counties and an ecological sample of 50 cities with populations between 50,000 and 500,000 persons in California. The estimates were built from archival and public-use survey data collected at state, county, and city levels over the years from 2009 to 2010.

RESULTS

Costs related to alcohol use and related problems exceeded those related to illegal drugs across all counties and most cities in the study. Substantial heterogeneities in costs were observed between cities within counties.

CONCLUSIONS

AOD costs are heterogeneously distributed across counties and cities, reflecting the degree to which different populations are engaged in use and abuse across the state. These findings provide a strong argument for the distribution of treatment and prevention resources proportional to need.

Barriers to accessing methamphetamine treatment: A systematic review and meta-analysis

BACKGROUND

Methamphetamine use is associated with a range of poor health, social and justice outcomes. In many parts of the world increased methamphetamine use has been identified as a major public health concern. Methamphetamine treatment programmes have been effective in reducing and ceasing use, however a range of barriers have prevented these programmes being widely adopted by methamphetamine users. This review examines the barriers to accessing meth/amphetamine treatment identified in the literature.

METHODS

Databases were systematically searched using relevant terms for peer-reviewed articles describing original research exploring the barriers to accessing treatment for meth/amphetamine use. Reviews and grey literature were excluded. Eleven studies conducted in 5 countries were included in data synthesis; this involved a systematic review of all 11 studies, and meta-analysis of the prevalence of barriers reported in 6 studies that published sufficient quantitative data.

RESULTS

Psychosocial/internal barriers to accessing methamphetamine treatment were most prevalent across studies (10/11 studies). Meta-analysis confirmed the four most commonly endorsed barriers to treatment access across studies all psychosocial barriers were embarrassment or stigma (60%, 95% CI: 54-67%); belief that treatment was unnecessary (59%, 95% CI:54-65%); preferring to withdraw alone without assistance (55%, 95% CI:45-65); and privacy concerns (51%, 95% CI:44-59%).

CONCLUSIONS

The primary barriers to accessing methamphetamine treatment are psychosocial/internal. Services and treatment models that address these barriers are urgently required. There is a growing need for methamphetamine-appropriate treatment services. Further research evaluating treatment engagement and effectiveness for methamphetamine and polysubstance use, including the development of effective pharmacotherapies is warranted.

Risk Behaviors Among Suburban Women who Use Methamphetamine: Social Harms and Social Solutions

We propose that female methamphetamine users who live in suburbia experience risks for disease transmission stemming from their social environment that remain under the radar of public health surveillance networks. The data analyzed in this paper were collected from 2007 to 2011 and were drawn from two sequential studies on methamphetamine use. The studies were conducted in the suburbs of a southeastern United States metropolis. We analyzed a total of 65 qualitative interviews with former and active methamphetamine-using women. Data from focus groups also were included in the analysis. The participants' ages ranged from 18 to 51 years. We identified three major themes with regards to risk behaviors and transmission of infectious diseases: (1) setting risk behaviors, such as sharing syringes and homelessness, lack of transportation and unemployment; (2) sexual risk behaviors such as condom use and having multiple partners; and (3) service- related risks, such as risk awareness and prevention behaviors as well as utilization of social services and healthcare. Our findings point to the pervasive nature of social influences on the risk for infectious disease transmission. We suggest that harm reduction programs be implemented in suburban communities to increase access to these services. Secondly, our data support the concept of social recovery for drug users to better their health and social lives holistically.

Global patterns of methamphetamine use

PURPOSE OF REVIEW

As the most popular psychostimulant in the world, methamphetamine use has reached epidemic proportions. Its enormous popularity has created subcultures of methamphetamine users all over the globe. The purpose of this review is to describe the geographic availability of different types of methamphetamine, the characteristics of each user population, and the psychosocial impact the two have on society.

RECENT FINDINGS

Methamphetamine has diversified immensely from the early days of its use. Different forms of methamphetamine - ICE, powder, and pills - have different pharmacokinetic characteristics that make them popular among certain types of users. New studies have shown that addiction to methamphetamine results in a very characteristic loss of inhibition that augments various risk-taking behaviors in its users. Also, recent seizure data suggest that its production and trafficking is spreading into new areas of the globe.

SUMMARY

From recreational use to addiction, methamphetamine use represents a serious risk to health and wellbeing of the community. Recognizing the pattern of abuse in specific populations is the key to assessing the risk, implementing prevention, and harm reduction measures, as well as making public policies.

Stimulants and the lung : review of literature

Illicit stimulants, such as cocaine, amphetamine, and their derivatives (e.g., "ecstasy"), continue to exact heavy toll on health care in both developed and developing countries. The US Department of Health and Human Service reported over one million illicit drug-related emergency department visits in 2010, which was higher than any of the six previous years. Both inhaled and intravenous forms of these substances of abuse can result in a variety of acute and chronic injuries to practically every part of the respiratory tract, leading potentially to permanent morbidities as well as fatal consequences--including but not limited to nasal septum perforation, pulmonary hypertension, pneumothorax, pneumomediastinum, interstitial lung disease, alveolar hemorrhage, reactive airway disease, pulmonary edema, pulmonary granulomatosis, infections, foreign body aspiration, infections, bronchoconstriction, and thermal injuries. Stimulants are all rapidly absorbed substances that can also significantly alter the patient's systemic acid-base balance and central nervous system, thereby leading to further respiratory compromise. Mounting evidence in the past decade has demonstrated that adulterants coinhaled with these substances (e.g., levamisole) and the metabolites of these substances (e.g., cocaethylene) are associated with specific forms of systemic and respiratory complications as well. Recent studies have also demonstrated the effects of stimulants on autoimmune-mediated injuries of the respiratory tract, such as cocaine-induced midline destructive lesions. A persistent challenge to studies involving stimulant-associated respiratory toxidromes is the high prevalence of concomitant usage of various substances by drug abusers, including tobacco smoking. Now more than ever, health care providers must be familiar with the multitude of respiratory toxidromes as well as the diverse pathophysiology related to commonly abused stimulants to provide timely diagnosis and effective treatment.

Pregnancy and fetal loss reported by methamphetamine-using women

To better understand substance use disorder treatment needs of pregnant and parenting women who use methamphetamine (MA), this paper describes pregnancy histories and fetal losses for women who were treated for MA use (N = 153) with reference to a national sample, and describes their drug use, sexual risk behaviors, and mental health status. MA users reported an average of 4.6 total pregnancies and 2.1 fetal losses, whereas women in a general population survey reported 3.2 and 1.2, respectively. Higher numbers of pregnancies and fetal losses were correlated with specific substance abuse and mental health problems including early sexual abuse and cognitive problems. The combination of MA users' especially high numbers of pregnancies, fetal losses, and rates of risk behaviors suggest high social and health care costs for this population. Prenatal care may provide a vector through which women can be connected to risk reduction interventions and gender-responsive treatment services addressing substance use and mental health needs.