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Kansas and Australia Team Up To Fight Methamphetamine (Meth) Abuse

Methamphetamine (also known as “speed” or “meth”) is a fairly common drug of abuse in this country. The National Institute on Drug Abuse estimates that as many as 3% of 12th graders have tried the drug, and about 0.3% of the population actively abuses it. Meth stimulates the release of dopamine in the brain, which produces a feeling of intense well being, as well as increases in wakefulness, respiration, heart rate, blood pressure, and hyperthermia. It is very addictive, and its tragic, long-term effects include permanent brain damage, personality changes, psychosis, hallucinations, and impaired learning and memory.

While most meth is produced by “superlabs” in foreign countries, there are a substantial number of small, illegal labs in the US that produce it. Meth can be created by extracting pseudoephedrine (found in many cold and allergy medicines like Sudafed) and transforming it into meth via a chemical process that creates toxic environmental waste.

In order to clamp down on local production of meth, it is critical to control the diversion of pseudoephedrine from local pharmacies into illegal labs. The US government introduced a “Combat Meth Act” to improve the tracking of pseudoephedrine purchases, but some believe that this approach doesn’t go far enough. One successful anti-meth program in Australia (called the MethShield) is now being piloted in Kansas. I spoke with Shaun Singleton, the creator of MethShield, to learn more about how we can reduce meth production and sales in the US.

Dr. Val: Tell me about the Combat Meth Act and why it dovetails nicely with MethShield.

Singleton: The Combat Meth Act was introduced in 2005 and it has substantially reduced the number of meth labs in the US. The Act limits consumer purchase of pseudoephedrine to 3600mg of active ingredient per day (or 9000mg in a 30 day period). In order to purchase pseudoephedrine, you have to present a form of government-issued I.D. (like a driver’s license) and the pharmacist records that information and keeps it in a log book. However, since this information is not electronic, pharmacies don’t share information with other pharmacies, and so meth producers are able to present fake I.D.s and travel from one pharmacy to the next without anyone realizing that they’re over their legal limit. So unfortunately, people found a way to circumvent the Combat Meth Act and local production of meth continues to be a problem.

The MethShield is a real-time tracking program for pseudoephedrine sales. Instead of keeping paper records, it allows pharmacists to enter information into a secure online database. This makes it much more difficult for people to travel from pharmacy to pharmacy, purchasing their maximum allowed dose at each one. With MethShield the pharmacist knows exactly how much product the client has purchased in the past (from any participating pharmacy), and whether they’re eligible to purchase more or not. The information in the database is aggregated and made available for law enforcement to review.

Dr. Val: How do you protect patient privacy?

Singleton: First of all, you have to realize that we’re not interested in people who have a sinus infection, or use 50 Sudafed tablets per year. We’re talking about the 1% of people who are purchasing 20 packs of Sudafed in a day. Those people are the ones who are flagged by the MethShield system and are investigated by law enforcement.

The MethShield database offers superior privacy to current methods – which basically involve hand-writing peoples’ names in a binder and keeping it open on the counter top at the pharmacy (not very secure at all). MethShield was originally conceived and developed by the Pharmacy Guild of Australia and took great care to engineer the database in the most secure way possible. We ask for informed consent from clients and train pharmacy staff in how to maintain the database. In Australia we processed several million transactions during our pilot and did not receive a single privacy complaint. Most people are quite willing to give their driver’s license number to their pharmacist, understanding that the process might help to catch meth lab criminals.

Dr. Val: Can’t people just use fake I.D.s?

Singleton: We can’t stop people from using fake I.D.s, but the system renders them useless very quickly. Once you’ve entered one I.D. in the system to purchase 9000mg of pseudoephedrine, you generally can’t use it to buy more for another 60 days.

Dr. Val: Couldn’t the MethShield check the I.D.s against the DMV records to identify fake I.D.s more rapidly?

Singleton: Law enforcement officers can do this manually, but for privacy reasons the MethShield database does not connect to any other databases. Also, MethShield was designed to support pharmacists – so they can sell pseudoephedrine products safely – and it’s not really their role to be checking peoples’ I.D.s against a DMV database.

Dr. Val: What inspired you to create the MethShield?

Singleton: I’m married to a pharmacist and we live in Queensland, the once meth capital of Australia. I head a team that has devoted itself to creating IT solutions that make life easier for pharmacists, since they spend a lot of their time filling out forms to comply with government and insurance regulations instead of dispensing drugs and counseling people. We wanted to try to automate some of those processes to help pharmacists like my wife do what they’re really skilled at. We applied innovative thinking to kill two birds with one stone – to address the meth problem and free up pharmacists from some of their overly burdensome administrative tasks.

MethShield launched in November, 2005 and within the first 6 months of the program we were able to reduce the number of illegal meth labs detected by law enforcement by 23%. After 18 months we reduced the number of meth lab detections by 37%, and also had an increase in arrests and a number of charges raised. It’s really exciting to see such a visible impact.

Dr. Val: How are you planning to quantify the success of the program in Kansas?

Singleton: There will be 128 pharmacies in the pilot (as opposed to the 950 that we had in our Australian pilot program) and the success of the program really depends on the participation rate of the pharmacies. If they are careful to process all their transactions through the database we’ll get some meaningful data. Ideally we’d like to establish clear patterns of use and help the law enforcement agents to discern where the products are being abused. Law enforcement detected 97 illegal meth labs last year in Kansas, and we hope that the MethShield will further assist in the crackdown. If we can demonstrate the cost effectiveness of the program, we hope that Kansas will implement it state-wide.

*More about the MethShield*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

When Physicians Are Attacked By Patients

This alarming story (h/t KevinMD) of a physician attacked by a drug-seeker reminded me of my intern year.  I worked in an inner city hospital in New York, and was scheduled to work in the “detox unit” for a full month. We interns had mixed feelings about our “detox month” – on the one hand, the patients were generally healthy and were unlikely to need blood draws, procedures, spinal taps, intubations, and such. This meant less work to do during our shifts. On the other hand, the patients were hardened drug users, often with a history of violence — and let’s just say that depleting the system of all the heroin, crack, alcohol, and various other substances didn’t tend to put them in the best mood.

I personally did not enjoy my detox month. I’d prefer a “crashing” ICU patient any day over a beligerant, hep C positive man trying to threaten me into giving him an additional dose of colace. And frankly, as a woman it was kind of scary to be around these guys. I never knew if they were going to snap, and no matter how many security guards are around, a lot of damage can happen in the 60 seconds or so it takes them to get to you.

One night the “detox resident” appeared for duty. His shift started at 11pm and the day shift nurses were eager to get home. The security guards were changing shift as well, and had not entered the lock-down area inside the unit. The resident went in alone. Suddenly, one of the patients snapped, and grabbed the unsuspecting doctor by the throat. The patient threw him up against the wall and punched him in the face, breaking his nose and fracturing his eye socket. Blood flew everywhere and the resident tried to fight back to defend himself. Unfortunately he was no match for the 250 pound patient, and sustained a few kicks to the ribs before the security guards were able to subdue the man. The resident was transferred off the detox unit rotation and given an extra week of vacation. I was the intern who was asked to fill in for him.

I felt somewhat paranoid that month, and refused to be inside the lock down area without a security guard within 15 feet of me. Fortunately, I was not physically attacked – I only experienced verbal abuse and the occasional very awkward conversation about genital deformities.

But it was a real wake up call for me – medicine can be a risky business, and white coats do not protect against psychotic aggression. I guess it’s just one of the risks we take in caring for all-comers.

***

Addendum: here’s another example of doctors being abused by narcotic-seekers.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Email-Free Fridays: Do You Have An Internet Addiction?

Have you ever been singled out in a lecture and picked on? Or maybe at a comedy club? It’s somehow awkward when everyone is looking at you, and you can’t really defend yourself. That happened to me yesterday in a lecture about how email can transform medical practices. My friend Joe Scherger was talking about the beauty of asynchronous communication, and how much time it saves – when out of the blue, he said that Blackberries defeated the whole purpose of emailing, and that people who used them lead unbalanced lives. He then pointed at me and said, “See my friend Val Jones, there? She uses a Blackberry all the time!”

All eyes fixed on me with a sort of half pity, half “tisk, tisk” expression.

“She answers all her emails within minutes… She never unplugs.”

I shrugged and smiled sheepishly. Soon the conversation turned to other subjects, and I resisted the urge to pull my Blackberry out of my bag to check my emails.

Today I heard that Intel instituted email-free Fridays as a means to force their engineers to talk to others face-to-face. Apparently, the company was worried that interpersonal skills were being lost, and that people were not developing normal working relationships because of the artificial distance created by email-only communication.

“Well, at least I’m not alone,” I thought as I read the news story. “This is a serious problem across the country.”

There has been recent debate in the psychiatric community about whether or not video games could be considered an addiction (just as drugs and alcohol can be). Some have proposed that it be added to the DSM-V due out in 2012, others have said that compulsive video game playing is a sign of other underlying pathology (such as depression or social anxiety) but not a true addiction.

But the bottom line is that overuse of the Internet can disrupt a person’s time available for meaningful interpersonal relationships, be they with a spouse, a parent, a relative, or a friend. When your husband is sitting in the same room with you and has to get your attention by IM-ing or emailing you, you know there’s a problem.

And there doesn’t seem to be much of a break in sight – with Facebook, MySpace, Linked-In, YouTube, Pownce, Twitter, GTalk, blogs, podcasts, discussion boards, chat rooms, forums, etc. available as 24-7 forms of entertainment and communication, and companies like Intel trying to forbid this kind of stuff at least 1 day per week, Blackberries are the least of our worries. I wonder if these programs are like junk food for the brain? Will we soon suffer from cerebral obesity?

I’m afraid that I recognize that there is a problem, but I’m not sure what the solution is. “Just say no” to email doesn’t work for me… I like the fast-paced interactivity and connection I get from these activities. Maybe there’s a positive feedback loop at work, though – we spend a lot of time involved in online activities and become more isolated and lonely in our personal lives. In the end we become more and more engaged with the Internet to fill the emotional gap that we’re actually creating by overusing it.

I’ll ask my husband what he thinks… perhaps I’ll send him an email about it tonight.

What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The High Tech Approach To College Camaraderie

The Washington Post featured an article about how social networking tools like Facebook are influencing student socialization at college.  Some say that the frenetic texting, online communications, and iPhone chatter are causing students to lose the ability to socialize normally in-person.  Others say that technology levels the social “playing field” for introverts.  I interviewed Revolution Health’s psychologist, Dr. Mark Smaller, to get his thoughts on the matter.  Feel free to add your perspective in the comments section of this blog.

Dr. Val: The article
suggests that technology can become a social crutch, keeping people from making
new friends.  Do you think that the
Internet can isolate students from one another?

Dr. Smaller: I think the long term impact of the Internet in
social interactions is unclear.  For now
such technology does allow students to remain in touch with one another
instantly, but that’s not too different from what the telephone did for
previous generations.  If anything, I’d
say that technology can interfere with isolation, especially for the new
college student away from home for the first time.  If there is a propensity for isolation, any
activity in excess – reading, school work, drinking, etc. will become the means
to continue that isolation.

Dr. Val: Do you think
that social networking and Internet based methods of communication are
particularly healthy for introverts?

Dr. Smaller: Being able to communicate sincerely or
genuinely but indirectly and not in person may help the otherwise shy person.  Some of our most brilliant artists and
writers have used their craft as a means to communicate to others in ways they
could not in social situations.

Dr. Val: Overall do
you think that socializing via the Internet is a good thing or a bad thing for
college students?

Dr. Smaller: One things is certain on and off the Internet:
relationships for children, adolescents, and adults can become quite intense
with this way of communicating because of fantasy and anonymity.  Previous generations used the art of letter
writing to express intense feelings, followed by the telephone, and now online
communication.  What they all have in
common is the essential human need to connect – including the satisfaction of
doing so and the frustration when it chronically does not occur.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

This Is Your Brain On Drugs

This story is from my intern year diary.  It’s a quick snapshot of a patient who had overdosed on heroine, coded, and was resuscitated.  I think about him sometimes… especially when I read about the rampant drug abuse problem in the US.

—————

I poked my head into the 4-bed communal room on the sixth
floor.  The nurse had called to say that
one of the patients was agitated and required restraints.  I was asked to assess the situation.

It was immediately clear to me which of the four patients required
my attention.  In the far, right corner
was a pale young man, stark naked and thrashing about in his bed.  He was babbling something about Ireland and how
he needed to get home.  I had gathered
from a quick review of his chart that he had overdosed on heroine, was
resuscitated after coding in the E.R. and transferred to the floor for
observation as he detoxed from the overdose.

I approached the flailing body tentatively.  “Hello.
I’m Dr. Jones.  You appear to
be quite distressed.  What seems to be
the matter?” I said as I pulled a sheet up from the bottom of his bed and
placed it over his genitals.

The young man, barely in his twenties, lay very still as I
spoke to him.  He stared at my face with
bulging eyes, speechless for a full 10 seconds.

“Are you alright?” I asked.

“Where am I?” asked the man in a quiet voice.

“Where do you think you are?” I asked, using the opportunity
to assess his mental status.

“I’m somewhere in Ireland,” he said, head turned
towards the window with a view of the Chrysler building.

Seeing that his reasoning was not intact, I replied kindly,
“Well, actually you’re in a hospital in New
York City.  You
took an overdose of heroine and your heart stopped…”

“Wow, that sucks,” said the man, sincerely surprised by the
news.

“We were able to resuscitate you in the emergency room,” I
added.

“Cool,” he said, as if the event had transpired in another
person’s life.

“So right now you still have a lot of drugs in your system
which is why you feel confused,” I said, “I think it will take several days
until you return to your normal state of health.”

“Sounds good,” nodded the man.

“Do you know where you are right now?” I asked, suspecting
that his short-term memory had been completely lost.

“I’m in Amsterdam,”
he said, undisturbed by his delirium.

I sighed as I realized that nothing I said to him would
register for longer than a second or two.
“Such a young person, what a waste,” I thought.

The man started to thrash about in his bed again.

“What are you doing?” I asked.

“The back stroke,” he said, surprised that I didn’t know.

I glanced at the man in the bed nearby.  He was watching our interaction with some
amusement.  He had been reading the New
York Times with a book light.  He was a
private patient on a heparin drip for a deep venous thrombosis behind his right
knee.   I nodded at him and shook my
head.

Weeks later I heard that the young man’s thoughts were no clearer than they were that night, and that he was transferred to a nursing home for long term care.  The brain damage that he suffered from his drug use (and lack of oxygen during his cardiac arrest) had caused permanent, irreparable damage.  Another tragic victim of a brain on drugs.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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