Northern Cheyenne Service Unit Indian Health Service Lame

Northern Cheyenne Service Unit Indian Health Service Lame Deer, Montana Rosaline Begay, MD Internal Medicine Presented at “Healing our spirit with Traditions” Methamphetamine Solutions Symposium Billings, Montana August 3, 2017

NCSU IHS with Tribal Programs Ambulatory Clinic Emergency Department 5 adult provider teams 24 hour coverage 1 pediatric team Local EMS Dental Clinic 3 Dentists – 2 Dental Hygienists Behavioral Health 2 Counselors, monthly Psychiatrist for ½ day

NCSU STATS (OCT – SEPT) 2015 2016 2017 (ytd) A. Clinic visits per year - Adults Pediatric Walk-in 24, 834 17, 974 4, 892 22, 931 11, 013 17, 359 3, 842 9, 228 1, 968 B. Emergency Room visits Pediatric ER visits Medical clearances Social Service placements 8, 586 2, 984 (35%) 650 50 8, 521 2, 918 (34%) 586 5, 707 1, 986 (35%) 246 C. Urine Drug Screens Meth positive 795 108 (13. 6%) 1064 97 496 77 D. OB Deliveries – NCSU ER 4 14 19

Summary of deliveries at NCSU Babies Mothers Complications (baby) 1. No testing found (term) No testing found extra L 5 th digit 2. No testing found Meth+, THC+ Respiratory failure, L temporal and R occipital strokes, tracheal stenosis 3. No testing found (39 w) Meth+, THC+, Alcohol 4. No testing found Meth+ Developmental delay, required OT 5/6. Meth+ (38 w) Meth+ Clubfoot, delayed milestones 7/8. No testing found (35 w) Meth+, Benzo’s, THC+ Withdrawal after birth uncontrolled DM T 2 9. No info UDS - normal delivery 10/11. Meth+ no prenatal care, speech delay, cardiac murmur 12. No testing found THC+ 29 week preemie 13/14. no testing found (25 w) Meth+, THC+ Clift lip and palate, grade II IVH 15. No testing found UDS - no problems or risks 16. No info UDS- no issues 17/18. no testing found THC+, Meth + remote kept sober to keep baby and regain custody of previous 19. No testing found see #6 no follow up since birth 20. No testing found see #3 no follow up since birth 21/22. no testing found term baby, no risks 23. No info THC+x 5 38 wk birth 24. No info THC+x 2 miscarriage

Summary of deliveries at NCSU cont. Babies Mothers Complications (baby) 25. No testing found (term) No testing found late prenatal care 26. No testing found no testing found Bilateral pulmonary artery stenosis 27. No info Meth+ no prenatal care 28/29. No testing found Meth+ one prenatal visit 30. Meth+, THC+, Opiates+ mother Hep C baby with ASD vs PFO 31/32. No testing found (39 w) THC+, Opiates+ Necrotizing pneumonia, pyloric stenosis 33 -35. no testing found ETOH+ ASD, pulmonic vein stenosis, preemie 25 wks, pulmonary HTN 36. No info Meth+, THC+ Stillborn infant, postpartum hemorrhage Meth+

Methamphetamine History: • First discovered in 1887, in Germany during WWII. German, Japanese and American pilots used it in bombing raids to stay alert and decrease fatigue. • In 1893, a Japanese chemist found that Methamphetamine can also be made from ephedrine. • In 1950’s, it was used for weight loss but soon was realized that the side effects outweighed the benefits so it became a schedule II drug and it is strictly regulated. • Today, it comes in prescription forms used to treat ADHD, Narcolepsy and short-term treatment of weight loss. • It is a white bitter tasting powder or pill. It also can look like pieces of glass or shiny, bluish white rocks. • It can be smoked, swallowed, snorted, injected or inserted anally. • It is now made from legally obtained ingredients. It is readily absorbed into the blood stream and brain tissue, lasting from 4 to 30 hours.

Short term effects: • Increased attention • Decreased fatigue • Increased activity • Increased wakefulness • Decreased appetite • Euphoria and rush • Increased respiration • Hyperthermia • Rapid or irregular heart beat • Grinding teeth • Increased sexuality • Increased talking • Sweating • Itching Long term effects: • Addiction even after one use • Psychosis with paranoia, hallucinations, repetitive motor activity • Changes in brain structure and function • Deficits in thinking and motor skills • Increase distractibility • Memory loss • Aggressive or violent behavior • Mood disturbances • Severe dental problems • Weight loss • Infection with HIV or Hepatitis C • Increased risk of Parkinson’s Disease

Effects on pregnant women, infants and children: A. Pregnant Women: D. Other social consequences: premature delivery Gonorrhea placental abruption Chlamydia excreted into breast milk, mothers cannot breast feed Hepatitis C B. Infants: Syphilis Small size babies retinal deficits HIV lethargy malformation of ribs cleft palate delayed motor development decreased arousal slowed physical growth Increased stress Heart and brain abnormalities gastrochisis C. Children: significant attention impairments Anxiety Depressed moods ADHD Acting out Adderall Total doses: 2012 2013 2014 2015 2016 2017 (ytd) 10, 688 11, 718 17, 371 18, 845 15, 488 13, 808

Hepatitis C at NCSU: Total HCV Positive – 120 pts age range average Women childbearing age 12 -55 although ideal age is 20 – 35 years Females Males 72 (60%) 48 (40%) 17 – 66 23 – 67 39. 7 47. 4 43 (36% of total HCV patients and 60% of females with HCV)

Methamphetamine Overdoses: • • • Stroke Heart attack Organ failure Dose dependent change in heart rate, blood pressure Pulmonary edema Pulmonary hypertension Pneumothorax Pulmonary hemorrhage Hyperthermia Seizures

Methamphetamine Treatment: Most effective are behavioral therapies such as cognitive, behavioral and contingency management interventions. There is no FDA approved medical therapy for meth addictions. Two Clinical Trials in process: 1. AV 411 (ibudilast): targets activity of glial cells and suppress neuroinflammatory action of the glial cells 2. m. Ab 759: an anti-amphetamine antibody which neutralizes the drug in the blood stream before it reaches the brain For withdrawing in-utero babies and newborns: graded sedations frequent feeding constant attention for 1 – 10 weeks

Northern Cheyenne Tribal Code and Prosecution: A. Currently there is no specific code addressing methamphetamine use, distribution or production. B. As of 2015, methamphetamine related crimes were being charged under “Abuse of Solvents Code”, although methamphetamine ingredients are not listed and it is Class C offense, punishable by a maximum fine of $200. C. Basically a person has to be caught with the drugs on their person and the drug must be confirmed as methamphetamine. D. DWI is only written to address alcohol, not under the influence of any other drug or mind altering substances.

Code and Prosecution cont. : E. As of 2016, Title VII, Section 7. 9. 2 (A)(1) of the Northern Cheyenne Law and Order Code, was amended as follows: “Possesses, uses, sells, trades, transports, give away or manufactures an article or substance which contains any quantity of a substance classified as belonging to Schedule I, II, or III of the Federal Controlled Substances Act, unless such substance was obtained pursuant to a valid prescription or order from a licensed medical or health practitioner as defined by Title 21 United States Code § 802 (21) while acting in the course of his professional practice except Peyote in the Native American Church shall not be considered a controlled substance or drug under this section. ” This includes Methamphetamine which is a Schedule II drug.

Recommendations: 1. NCSU and the Northern Cheyenne Tribal Health Board should find ways to fast track medical clearances for detox centers or rehabilitation centers. This includes: • • Physical examinations Admittance to detox centers Admittance to treatment centers Transportation for patients 2. Concerted efforts to recruit more counselors, psychologists and psychiatrists for one-on-one therapy. 3. Contingency management interventions which provide tangible incentive in exchange for engaging in treatment and maintaining abstinence. 4. Specific changes in Tribal Codes and Prosecution for the use, distribution and manufacture of methamphetamine. 5. Focused attention on pregnant women and breast feeding mother who use or have used methamphetamines. .

For all your help and dedication, I wish to thank the following people: • • Cheyenne Tallbull, RN, QA Billie Jo Foote, RN Sable Kerzmann, RN Sara Strand, MT(ASCP), Lab Director Michelle Shot-Gunn, MSC William Ryman, Chief Pharm. D BIA Police Department Janet Wolfname, RN, PHN Director