QJM Advance Access originally published online on January 25, 2008
QJM 2008 101(3):207-213; doi:10.1093/qjmed/hcm133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
What evidence is there that the UK should tackle the potential emerging threat of methamphetamine toxicity rather than established recreational drugs such as MDMA (‘ecstasy’)?
1From the Guy's and St. Thomas Poisons Unit, Guy's and St. Thomas’ NHS Foundation Trust, 2Analytical Unit, St. George's, University of London, 3Queen Mary's School of Medicine and Dentistry, 4Medscreen Ltd, 5Guy's and St. Thomas Poisons Unit, Guy's and St. Thomas’ NHS Foundation Trust, 6Guy's and St. Thomas’ NHS Foundation Trust, 7TICTAC Communications Ltd, St. George's, University of London, 8Analytical Unit, St. George's, University of London, and 9Guy's and St. Thomas Poisons Unit, Guy's and St. Thomas’ NHS Foundation Trust, London, UK
Address correspondence to Dr David Wood, Guy's and St. Thomas Poisons Unit, Avonley Road, London SE14 5ER, UK. email: David.Wood{at}gstt.nhs.uk
Received 22 August 2007 and in revised form 19 November 2007
 |
Summary |
|---|
 Top Summary IntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Background: There is increasing interest in whether methamphetamine is an emerging recreational drug in the UK.
Aim: To determine what evidence is there that methamphetamine use is an emerging drug in the UK compared to established recreational drugs such as MDMA.
Design and methods: We undertook a retrospective study collating data on the number of enquiries to both our poisons centre and the UK National Poisons Information Service (NPIS) relating to all recreational drugs, methamphetamine and MDMA; presentations to our Emergency Department (ED) with acute methamphetamine toxicity and the frequency of positive urine tests for methamphetamine and MDMA in workplace drug screening programmes.
Results: There was a small increase in the number of methamphetamine-related calls to our poisons centre, but it remained uncommon (0.1% of all recreational drugs cases in 2000 to 1.23% in 2006) compared to MDMA (17.3–42.7% of all recreational drugs cases). The number of 2005/6 enquiries to the UK NPIS for methamphetamine was 12, compared to 455 MDMA enquiries (0.014 and 0.52% of all enquiries, respectively). There were five presentations to our ED relating to methamphetamine over a 15-month period compared to 171 for MDMA. Of the 254 440 urine samples screened for the presence of drugs in the workplace (2000–06), three were positive for methamphetamine and 147 for MDMA.
Conclusion: There is no evidence of increasing use of methamphetamine or that acute methamphetamine poisoning is a significant clinical problem compared to established recreational drugs such as MDMA. In our opinion, healthcare, educational and law enforcement resources should be proportionally directed towards tackling drugs that pose an immediate and continuing healthcare risk to the population rather than emerging recreational drugs.
|
Introduction |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
There has been increasing attention in the UK media on the use and production of methamphetamine hydrochloride (‘crystal meth’) in the UK; with particular discussion about the reported changes in appearance, mood and psychological effects of users and potential associated increases in crime with its use.1,2 The focus of the recent medical literature on methamphetamine has been on the reported link between methamphetamine use, high-risk sexual behaviour and the risks of sexually transmitted infections (STI) such as HIV and Hepatitis C.3–8 There have been no published studies which have looked at whether acute toxicity related to methamphetamine use is a common issue, particularly in the UK.9
Methamphetamine hydrochloride, also known as ‘crystal meth’ and ‘Ice’, is a potent and addictive form of amphetamine.10 Smoking methamphetamine hydrochloride is associated with a rapid ‘high’, similar to other sympathomimetic stimulant drugs, with a half-life of 8–13 h.10 Methamphetamine use can cause a number of severe acute clinical features, including agitation and aggression, hyperpyrexia, tachycardia, arrhythmias, hypertension and seizures.11 In addition to its euphoric effects, use of methamphetamine has been reported to be associated with increased sexual drive and loss of sexual inhibition across all users, although this has been more widely reported amongst the men who have sex with men (MSM) community.6 These effects have been associated with increased high-risk sexual behaviour amongst methamphetamine users and a reported increased incidence of HIV seroconversion and other STIs, including Hepatitis C.3–5,12 Since a significant proportion of these studies are retrospective and based on recent/distant self-reported drug use and the degree of personal ‘sexual risk-taking’, the evidence for a causal relationship between methamphetamine use and these sexually transmitted diseases has not yet been established. However, despite the lack of a conclusive causal relationship, there have been numerous high-profile campaigns about the risks of methamphetamine, not only in the MSM community, but also aimed at the general population.1,2,13–15
In the recent Home Office consultation paper on ‘Drugs: Our Community, Your Say’, one of the issues raised was ‘To what extent and how should the UK tackle potential emerging threats (such as methamphetamine) as opposed to established drugs?’16 The aim of this study was to investigate, using a variety of data sources, whether acute methamphetamine toxicity is a significant problem in the UK, and whether methamphetamine use is associated with similar acute toxicological problems associated with established recreational drugs such as MDMA (‘ecstasy’).
|
Methods |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Frequency of presentations to the Emergency Department (ED) with acute methamphetamine toxicity
UK poisons information service enquiries
The Guy's and St. Thomas’ Poisons Unit (GTPU) poisons information service provides 24 h telephone advice for hospitals and doctors throughout the United Kingdom on the management of acutely poisoned patients. Data from all telephone calls are transcribed into a database, which allows trends and changes in drug poisoning to be analysed. Data on the total number of all calls received, calls relating to toxicity from recreational drugs and calls relating to either methamphetamine or MDMA toxicity from 1 January 2000 to 31 December 2006 were collected. Data on MDMA toxicity were collected as a comparator for all data sources.
The National Poisons Information Service (NPIS) also provides 24 h of poisons information services for UK hospitals, and data on methamphetamine related enquiries to the NPIS were obtained from the NPIS 2005/6 Annual Report.17
St.Thomas’ Hospital Clinical Toxicology Database
Data on all patients presenting to our large inner city ED with acute poisoning (recreational, deliberate or accidental) are collected on a dedicated clinical toxicology database. Within the catchment area of this ED there are several large club venues and late night establishments in which recreational drug use is common. The clinical toxicology database was interrogated to identify all presentations related to recreational drug ingestion and, in particular all cases of self-reported methamphetamine ingestion leading to acute toxicity and presentation to the ED for the period 1 October 2005 to 31 December 2006.
Frequency of methamphetamine in seized recreational drugs
All people attending MSM club venues in the Vauxhall area of South London are routinely searched by door staff prior to entry. Any suspected recreational drugs found on attendees are seized and placed into a secure ‘drug collection’ bin. The seized samples are then transported by the metropolitan police to the Home Office licensed recreational drugs storage and screening laboratory at St. George's, University of London. Samples were then analysed in batches to identify any illicit substances present, as previously described.18
Frequency of methamphetamine in occupational drug screening
Medscreen undertake occupational workplace drug testing for both UK and international centres across a wide range of transport, leisure, retail and professional sectors. For each workplace test, duplicate urine specimens are collected under a ‘chain of custody’ procedure and sent to the Medscreen central processing laboratory. One of the duplicate samples is screened using a primary automated immunoassay and, where there is a positive result, this is confirmed using gas chromatography with mass spectrometric detection (GC-MS). Under internationally accepted workplace drug testing guidelines,19 a positive result is only reported if the drug was present above a cut-off concentration of 500 ng/ml. In the case of methamphetamine, a positive result is only reported if amphetamine (a metabolite of methamphetamine) is also detected in excess of 200 ng/ml. Urine samples are also screened to look for the potential for adulterants or ‘substitute urine samples’.
|
Results |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Frequency of presentations to the ED with acute methamphetamine toxicity
UK poisons information service enquiries
The number of telephone enquiries about the management of acute methamphetamine toxicity to GTPU remained stable at between 5 and 8 enquiries per year between 2000 and 2005, but there was an increase in the number of calls (16) in 2006 (Figure 1). Expressed as a percentage of the total number of enquiries relating to recreational drugs, there was a small increase in the proportion of calls related to acute methamphetamine toxicity, 0.1% in 2000 to 1.23% in 2006 (Figure 2). There was no trend in the number of telephone enquiries relating to MDMA as a percentage of total number of enquiries relating to recreational drugs (17.3–42.7%) during this time period, and although the ratio of methamphetamine:MDMA enquiries remained extremely low it steadily increased from 0.004 in 2000 to 0.07 in 2006.
|
|
The NPIS reported 12 enquiries related to methamphetamine poisoning in 2005/6. This represented 0.014% of all enquiries, compared to 455 enquiries (0.52% of all enquiries) related to MDMA.
St. Thomas’ Hospital Clinical Toxicology Database
There were a total of 1077 recreational drug-related presentations to our inner city hospital ED between 1 October 2005 and 31 December 2006. During this time there were five (0.46%) presentations relating to self-reported methamphetamine use, compared to 171 (15.9%) relating to self-reported MDMA (‘ecstasy’) ingestion. Of the five presentations relating to methamphetamine, only one was an isolated ingestion of methamphetamine.
Frequency of methamphetamine in seized recreational drugs
Between 28 August 2006 and 14 January 2007 there were 418 samples seized from clubbers attending MSM club venues. Of these 12, 2.9% were crystalline in nature and one was found on analysis to contain methamphetamine (in combination with ketamine). MDMA alone was detected in six of these crystalline samples, benzocaine/cocaine mixture in three, ketamine alone in one and a mixture of benzocaine, ketamine and cocaine in the final sample.
Frequency of methamphetamine in occupational drug screening
From 2000–06 Medscreen undertook a total of 254 440 occupational drug screens on samples from people working in the UK (Table 1). Methamphetamine was detected in three samples (one sample in 2000 and two samples in 2001), but not in any samples between 2002 and 2006. MDMA was detected in samples from every year, at an annual frequency of 8–40 cases per year.
|
|
Discussion |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Use of methamphetamine has been reported to be increasing in South East Asia, Eastern Europe and North America, leading to significant acute and chronic problems related to its use.20 However, the focus of the literature to date has been the reported association between methamphetamine use and the risks of unsafe sexual intercourse, especially anal intercourse between MSM, and an associated increase in STI and HIV infection. There have been small published series from the USA and South East Asia describing severe acute toxicity and fatalities associated with methamphetamine use.21–24 However, there are no published data on the frequency of acute toxicity associated with methamphetamine use in the UK or on whether this is a significant issue. In this retrospective review we have shown that acute methamphetamine toxicity is not common in the UK as judged by enquiries to poisons information services, both GTPU and NPIS that cover the UK population. Whilst the data on presentation to our ED and analysis of drugs seized within local club venues are local data we feel that it has value as it represents an inner city population in a high recreational drug use area. The occupational drug screening information provides additional data that demonstrates that, overall, population-wide use of methamphetamine is likely to be low. However, the use of other recreational drugs, such as MDMA, appears to be more commonly associated with acute toxicological effects leading to presentation at hospital for treatment, and is more likely to be detected in the wider population/occupational drug screening dataset.
Methamphetamine may be synthesized illicitly from ephedrine or pseudoephedrine in a relatively simple chemical process that can, potentially, be undertaken by individuals or in small ‘production’ facilities.25 Initially, the process involves reducing either ephedrine or pseudoephedrine to methamphetamine using red phosphorus and hydriodic (or a similar acid). The compound is then converted to water soluble salt with hydrochloric acid, to form methamphetamine hydrochloride, which is then crystallized to form methamphetamine crystals. One major ‘advantage’ of methamphetamine hydrochloride is that it is heat stable. Therefore, it can be smoked, typically using a foil bowl or a specific heating apparatus, and then inhaled via a straw or glass tube. It can also be snorted or swallowed, and in rare instances can be inserted rectally, colloquially known as ‘booty bumping’. Since methamphetamine is very rapidly absorbed through the respiratory epithelium, leading to the rapid ‘high’ that users desire, smoking methamphetamine is usually the preferred route of use, without the need for intravenous use to achieve the same rapid ‘high’. Over the last decade there have been changes in the route by which methamphetamine is taken, with a change from the use of snorted powder to smoking as the preferred route.9
There are numerous reasons why the use of methamphetamine is thought to be common amongst the MSM community. Methamphetamine users often associate its use as ‘integral to sexual intercourse’, due to the fact that its use during sexual intercourse leads to sex that is ‘compulsive’ with loss of control over their sexual expression, allowing them to achieve the sexual experiences that they desire.6 However, in the ‘Boys Using Multiple Party Substances’ (BUMPS) Project in New York, individuals also used methamphetamine to ‘mask feelings of discomfort’,26 therefore its use is not solely related to the heightening of sexual desires.
The catchment area of our ED includes the largest MSM clubbing area in the UK and Europe and probably one of the largest in the world. However, over a 15-month period we had only five presentations with acute poisoning following self-reported methamphetamine use. The use of methamphetamine in the MSM community in London, UK has been described previously.27 A total of 1307 individuals with and without HIV were recruited from HIV treatment and screening clinics and gyms around London in a study to determine if methamphetamine use was associated with higher risk sexual activity. Overall the authors demonstrated that 
16% of the MSM community reported the use of methamphetamine, compared to 45% of the same population that had used MDMA (‘ecstasy’). There was greater use of methamphetamine in those recruited from gyms (20.7%) compared to those from HIV treatment and testing centres (9.2%), in comparison with the relatively similar use of MDMA (47.3 and 42.0%, respectively). However, the majority of those using methamphetamine used it only once or twice a year (70%), with significantly fewer using it once or twice a month (27%) or more than once a week (3%). In those with confirmed serological HIV status, use of methamphetamine in the last 12 months was greater (49/388, 12.6%), compared with HIV negative individuals (22/226, 8.3%). Interestingly there was no significant difference in the use of other recreational drugs (ketamine, amphetamine and cocaine) between HIV positive and negative people. Given the higher reported incidence of methamphetamine use amongst the MSM community in London, one may have expected a higher frequency of presentations with acute methamphetamine toxicity than we have seen.
Routine toxicological screening was not undertaken in either the patients presenting to our ED, or those patients for whom UK poisons information services (GTPU and NPIS) had been contacted for advice. It is possible that patients may not have been aware of exactly what they had purchased or ingested and, therefore, the true number of methamphetamine cases may have been under- or over-estimated; this would also apply to the MDMA cases that were used as a comparator in these parts of our study. However, routine toxicological screening is not a standard part of care for recreational drugs presentation in the majority of ED in the UK. Second, the drugs seized from people attending the club venues in the catchment area of the hospital, represent those drugs that were found by door staff during routine admission searches. It is possible that people may have already ingested drugs prior to admission to the clubs and, therefore, this will impact on the number of drugs that will be seized. Additionally, the number of seizures will relate to the thoroughness of the door search policy instigated, although door staffs are trained by the Metropolitan Police Service in terms of how to conduct a thorough search of an individual, increasing the proportion of concealed drugs that will be found on admission. It is not likely that this would change the relative proportion of one particular drug found during these door searches, so the impact on our study findings is likely to be small.
In our study of the analysis of seized substances in the MSM community, although there were few samples (12) seized that were crystal-like in nature, only one of these samples in fact contained methamphetamine (in combination with ketamine). Therefore, it is possible that people who report higher risk sexual activity whilst using methamphetamine are in fact not actually using methamphetamine. In addition most users of ‘crystalline’ methamphetamine hydrochloride will use either foil bowls or similar glass apparatus which is then heated with a cigarette lighter, or similar device, to allow the methamphetamine to be inhaled to achieve the desired ‘high’. People who attended MSM clubbing venues are unlikely to carry the necessary drug paraphernalia to use this form of methamphetamine with them.
There is evidence that, overall, recreational drug use in the MSM community is associated with ‘high-risk’ activity, rather than just methamphetamine as previously reported.28,29 Due to the unwanted effects of some recreational drugs on erectile function, use of sildenafil (Viagra®) is common and this has also been demonstrated to be associated with ‘high-risk’ sexual behaviour.30–32 Conversely, those individuals that would choose to have ‘high-risk’ sexual activity are more likely to use recreational drugs than those who do not.26
Although the long-term medical and psychological complications of intermittent and/or regular methamphetamine use are not clearly understood, recent studies have demonstrated the potential for long-term neurotoxicity.10,11 Neuroimaging in chronic methamphetamine users has shown significant neural damage in those patients with clinical evidence of cognitive impairment; whether this is an association or causally linked remains to be established.10,11
A UN report has demonstrated that methamphetamine use is increasing in the US and South East Asia.20 The 2005 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System has demonstrated that methamphetamine use and acute toxicity is a much more significant problem in the US than in the UK.33 There were a total of 3456 calls to US poisons centres relating to methamphetamine ingestion in 2005, compared with 10 921 for other amphetamines. Although the number of calls was lower for methamphetamine, there was a higher incidence of moderate/severe toxicity (36.7%) and mortality rate (1.1%) relating to calls concerning methamphetamine compared with other amphetamine like drugs (18.8 and 0.1%, respectively). Other similar studies in the US have demonstrated that regular users of methamphetamine have a high utilization of ED resources.21,34
There are also several case reports and small case series from the far East that support this geographical variation in the use and toxicity of methamphetamine in comparison to the UK.22–24,35–37 Autopsies of fatalities of 3958 Taiwanese prisoners and 646 members of the general population in Osaka, Japan, demonstrated rates of detection of methamphetamine of 3.4–12.1 and 2.3% per annum, respectively.24,36 Two autopsy-based studies have shown that post-mortem methamphetamine concentrations are similar in those cases in which it was directly related to death, those in which it may have been associated38 and those in which it was not associated at all.22 Therefore, the presence of methamphetamine in autopsy samples is useful for epidemiological data on frequency of use, but is difficult to interpret in terms of severity of methamphetamine toxicity. There are no published reports of fatalities in the UK related to acute methamphetamine toxicity.
Our study suggests that whilst there has been a small increase in the number of telephone calls to our poisons information service (GTPU) relating to methamphetamine toxicity, this still represents a very small proportion of calls relating to all acute recreational drugs poisoning from around the UK. Data from our ED, which serves a large number of MSM club demonstrates that acute methamphetamine toxicity is not common and other recreational drugs such as MDMA are much more commonly associated with acute toxicity requiring hospital assessment. The current educational campaigns, focusing predominately on the long-term risk of sexually transmitted diseases and HIV infection secondary to methamphetamine use, should be extended to include all recreational drugs used by the MSM community. In addition, more resources should be dedicated to increasing the awareness of the risk of acute toxicity from other recreational drugs that may be used either alone or in combination in the MSM community.
In this study we have tried to address the recent government consultation question on whether more resources should be directed to potential emerging threats such as methamphetamine.16 We have been unable to demonstrate that methamphetamine is a significant clinical problem compared to established recreational drugs, such as MDMA, and that there is no significant evidence of its increasing widespread use. Clearly there is still the potential for emerging use of methamphetamine and other agents in the future and it is important that there is continued surveillance, not only from clinicians dealing with recreational drugs users, but from other key agencies such as law enforcement agencies. In our opinion healthcare, educational and law enforcement resources should be proportionally directed at tackling drugs that pose an immediate and continuing healthcare risk to the population.
|
Acknowledgements |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
We acknowledge Mr Nick Edwards for assistance in providing the data on the number of telephone calls to our poisons information service.
Conflicts of interest: D.W. and P.D. have acted as scientific advisers to the UK Advisory Council on Misuse of Drugs (ACMD) and the European Monitoring Centre for Drugs and Drugs Abuse (EMCDDA). S.W. has provided information to the All Party Parliamentary Committee on Drugs in the Workplace.
|
References |
|---|
|
TopSummaryIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
1. Guardian unlimited. Police issue warning on spread of crystal meth. (2007) January 25. (last accessed 19 November 2007). http://www.guardian.co.uk/drugs/Story/0,1997972,00.html.
2. The times on line. Crystal meth: coming to a town near you. (2007) May 7. (last accessed 19 November 2007). http://www.timesonline.co.uk/tol/life_and_style/health/article1755178.ece.
3. Farabee D, Prendergast M, Cartier J. Methamphetamine use and HIV risk among substance-abusing offenders in California. J Psychoactive Drugs (2002) 34:295–300.[Web of Science][Medline]
4. Frosch D, Shoptaw S, Huber A, Rawson RA, Ling W. Sexual HIV risk among gay and bisexual male methamphetamine abusers. J Subst Abuse Treat (1996) 13:483–6.[CrossRef][Web of Science][Medline]
5. Gonzales R, Marinelli-Casey P, Shoptaw S, Ang A, Rawson RA. Hepatitis C virus infection among methamphetamine-dependent individuals in outpatient treatment. J Subst Abuse Treat (2006) 31:195–202.[CrossRef][Web of Science][Medline]
6. Reback CJ, Larkins S, Shoptaw S. Changes in the meaning of sexual risk behaviors among gay and bisexual male methamphetamine abusers before and after drug treatment. AIDS Behav (2004) 8:87–98.[CrossRef][Web of Science][Medline]
7. Molitor F, Truax SR, Ruiz JD, Sun RK. Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. West J Med (1998) 168:93–7.[Web of Science][Medline]
8. Buchacz K, McFarland W, Kellogg TA, Loeb L, Holmberg SD, Dilley J, et al. Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco. AIDS (2005) 19:1423–4.[Web of Science][Medline]
9. Rawson RA, Condon TP. Why do we need an addiction supplement focused on methamphetamine? Addiction (2007) 102(Suppl. 1):1–4.[Web of Science][Medline]
10. Barr AM, Panenka WJ, MacEwan GW, Thornton AE, Lang DJ, Honer WG, et al. The need for speed: an update on methamphetamine addiction. J Psychiatry Neurosci (2006) 31:301–13.[Web of Science][Medline]
11. Romanelli F, Smith KM. Clinical effects and management of methamphetamine abuse. Pharmacotherapy (2006) 26:1148–56.[CrossRef][Web of Science][Medline]
12. Danta M, Brown D, Bhagani S, Pybus OG, Sabin CA, Nelson M, et al. Recent epidemic of acute hepatitis C virus in HIV-positive men who have sex with men linked to high-risk sexual behaviours. AIDS (2007) 21:983–91.[Web of Science][Medline]
13. Be crystal clear – because everyone has the right to make informed choices. (last accessed 19 November 2007). http://www.lifeormeth.com/.
14. Doctors warn gays on crystal meth dangers. (2005) November 15. (last accessed 19 November 2007). http://www.pinknews.co.uk/news/articles/2005-188.html.
15. Gay men's 360° health. (last accessed 19 November 2007). http://www.posh-uk.org.uk/gmh/hiv.html.
16. HM Government. Drugs: Our Community, Your Say. Drug Consultation 2007. (2007) London, UK: Home Office. 1–57.
17. National Poisons Information Service Annual Report 2005/2006. (last accessed 19 November 2007). http://194.74.226.162/publications/2006/NPIS_annual_report/npis_ar_2006.pdf.
18. Kenyon SL, Ramsey JD, Lee T, Johnston A, Holt DW. Analysis for identification in amnesty bin samples from dance venues. Ther Drug Monit (2005) 27:793–8.[CrossRef][Web of Science][Medline]
19. Federal Drug-free Workplace Programmes. (last accessed 19 November 2007). http://www.workplace.samhsa.gov/FedPgms/Fed_DFWP.aspx.
20. United Nations office on drugs and crime. World Drug Report 2007. (last accessed 19 November 2007). http://www.unodc.org/pdf/research/wdr07/WDR_2007.pdf.
21. Richards JR, Bretz SW, Johnson EB, Turnipseed SD, Brofeldt BT, Derlet RW. Methamphetamine abuse and emergency department utilization. West J Med (1999) 170:198–202.[Web of Science][Medline]
22. Karch SB, Stephens BG, Ho CH. Methamphetamine-related deaths in San Francisco: demographic, pathologic, and toxicologic profiles. J Forensic Sci (1999) 44:359–68.[Web of Science][Medline]
23. Sribanditmongkol P, Chokjamsai M, Thampitak S. Methamphetamine overdose and fatality: 2 cases report. J Med Assoc Thai (2000) 83:1120–3.[Medline]
24. Shaw KP. Human methamphetamine-related fatalities in Taiwan during 1991–1996. J Forensic Sci (1999) 44:27–31.[Web of Science][Medline]
25. Meth labs on. (last accessed 19 November 2007). www.streetdrugs.org http://www.streetdrugs.org/methlabs.htm.
26. Halkitis PN, Mukherjee PP, Palamar JJ. Multi-level modeling to explain methamphetamine use among gay and bisexual men. Addiction (2007) 102(Suppl. 1):76–83.[CrossRef][Web of Science][Medline]
27. Bolding G, Hart G, Sherr L, Elford J. Use of crystal methamphetamine among gay men in London. Addiction (2006) 101:1622–30.[CrossRef][Web of Science][Medline]
28. Waldo CR, McFarland W, Katz MH, MacKellar D, Valleroy LA. Very young gay and bisexual men are at risk for HIV infection: the San Francisco Bay Area Young Men's Survey II. J Acquir Immune Defic Syndr (2000) 24:168–74.[Web of Science][Medline]
29. Woody GE, Donnell D, Seage GR, Metzger D, Marmor M, Koblin BA, et al. Non-injection substance use correlates with risky sex among men having sex with men: data from HIVNET. Drug Alcohol Depend (1999) 53:197–205.[CrossRef][Web of Science][Medline]
30. Colfax GN, Mansergh G, Guzman R, Vittinghoff E, Marks G, Rader M, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. J Acquir Immune Defic Syndr (2001) 28:373–9.[Web of Science][Medline]
31. Chu PL, McFarland W, Gibson S, Weide D, Henne J, Miller P, et al. Viagra use in a community-recruited sample of men who have sex with men, San Francisco. J Acquir Immune Defic Syndr (2003) 33:191–3.[CrossRef][Web of Science][Medline]
32. Kim AA, Kent CK, Klausner JD. Increased risk of HIV and sexually transmitted disease transmission among gay or bisexual men who use Viagra, San Francisco 2000–2001. AIDS (2002) 16:1425–8.[CrossRef][Web of Science][Medline]
33. Lai MW, Klein-Schwartz W, Rodgers GC, Abrams JY, Haber DA, Bronstein AC, et al. 2005 Annual report of the American Association of Poison Control Centers’ national poisoning and exposure database. Clin Toxicol (2006) 44:803–932.[CrossRef][Web of Science]
34. Richards JR, Johnson EB, Stark RW, Derlet RW. Methamphetamine abuse and rhabdomyolysis in the ED: a 5-year study. Am J Emerg Med (1999) 17:681–5.[CrossRef][Web of Science][Medline]
35. Chan P, Chen JH, Lee MH, Deng JF. Fatal and nonfatal methamphetamine intoxication in the intensive care unit. J Toxicol Clin Toxicol (1994) 32:147–55.[Web of Science][Medline]
36. Zhu BL, Oritani S, Shimotouge K, Ishida K, Quan L, Fujita MQ, et al. Methamphetamine-related fatalities in forensic autopsy during 5 years in the southern half of Osaka city and surrounding areas. Forensic Sci Int (2000) 113:443–7.[CrossRef][Web of Science][Medline]
37. Lan KC, Lin YF, Yu FC, Lin CS, Chu P. Clinical manifestations and prognostic features of acute methamphetamine intoxication. J Formos Med Assoc (1998) 97:528–33.[Web of Science][Medline]
38. Logan BK, Fligner CL, Haddix T. Cause and manner of death in fatalities involving methamphetamine. J Forensic Sci (1998) 43:28–34.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||