Transcript Of Panel Discussion Hosted by Attorney General Alberto R.

Gonzales for National Methamphetamine Awareness Day
Washington, D.C. November 30, 2006
10:30 A.M. EST MS. KATZ: Good morning, everyone. I am Ruth Katz, Dean of the School of Public Health and Health Services here at the George Washington University Medical Center, and I bring you a very, very warm welcome. We're delighted to have you here. Let me also extend a welcome on behalf of Dr. John F. Williams, the University's provost and Vice President for Health Affairs. Unfortunately, Dr. Williams is out of the country, and he obviously could not be with us this morning, but I know how terribly delighted he is that we are able to host this event here at GW. We have come together today to educate ourselves about the grave public health danger of methamphetamine. As many of you know, the Department of Justice has dedicated today as National Methamphetamine Awareness Day. Discussions similar to this one are taking place all across the country right now. But we are especially fortunate, because the Attorney General, Alberto Gonzales, is here to speak with us and guide our conversation this morning. It is fitting that GW has been chosen as the site for this exchange here in Washington, because our medical center trains both clinicians and public health professionals. As we consider how best to curb the widespread use of a terribly powerful addictive stimulant, it is obviously that the combined expertise of these disciplines must be brought to bear. All of that tells us that we must respond to the meth epidemic with a wise mix of policies. That includes, at least in part, identifying, prevention and risk reduction

interventions that work, and funding culturally sensitive community-based approaches with a demonstrated capacity to change norms. It is also vital, of course, to make treatment readily available to those who are prepared to fight back against addiction. Last year the CDC, the Centers for Disease Control and Prevention, hosted a national consultation of scientists, public health officials and community providers to talk about some of these issues and to identify needed research and programs. Putting their ideas and other good ones like those into action requires adequate resources and a strong national commitment. National Meth Awareness Day and meetings like this one here at GW are important steps for making that happen. As we will hear from our distinguished panel this morning, dealing with meth is a true inner disciplinary problem. To solve it, we must draw not only from public health and medicine, but also from law enforcement, environment science and other fields. Local, state and federal agencies all have essential roles to play as well. To present the panel and set the stage for today's discussion, it is now my great pleasure to introduce the Honorable Alberto R. Gonzales, Attorney General of the United States. Alberto Gonzales has served as the nation's top law enforcement officer since February 2005 when he was sworn in as our 80th Attorney General. Prior to his service at the Department of Justice, Attorney General Gonzales was counsel to President George W. Bush. He also served as a justice on the Texas Supreme Court, and as Texas Secretary of State, where he was a senior adviser during the younger George Bush's tenure as governor. Before entering public service, Attorney General Gonzales practiced law in Houston, Texas. An Air Force veteran who attended the Air Force Academy, he was born in San Antonio and raised in Houston. He is a graduate of Texas public schools, Rice University and Harvard Law School, for which we at GW will greatly forgive him. (Laughter.) MS. KATZ: We are honored, very honored to have him with us today. Ladies and gentleman, the Honorable Alberto Gonzales. ATTORNEY GENERAL ALBERTO R. GONZALES: Thank you. (Applause.) ATTORNEY GENERAL GONZALES: Thank you, Dean. I am reminded by her comments, by the dean's comments, that my first acceptance letter to a law school was George Washington, so, what might have been.

I am indeed pleased to be here to talk, to have a dialogue, a discussion with this audience, but also primarily with the American people, primarily with parents, about the dangers of meth. I've done town hall meetings around the country, talking about methamphetamine, and I've had a lot of parents come up to me afterwards and say, you know, we had no idea about the seriousness of this issue, and you really need to do more to educate the American public. And that's the reason why President Bush has declared this National Methamphetamine Awareness Day. It is a day where we're going to spend some time talking about the issues of meth. We have an outstanding panel today. These are the experts, and they will be doing most of the talking. I'll try to moderate the discussion by asking what I hope will be interesting questions. Some of these will be fairly basic questions. Many of you in the audience have a lot of experience, a lot of knowledge about this area, but we want to get it down to a fairly basic level, because there are many people in the American population, quite frankly, that don't know about meth and don't know about the effects of meth. So let me begin by introducing our panelists. We are joined by Dr. H. Westley Clark. He's the Director of the Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services. Also joined by Robert F. McDonnell, Attorney General of the Commonwealth of Virginia; Joseph T. Rannazzisi, Deputy Assistant Administrator for the Office of Diversion Control at the U.S. Drug Enforcement Administration; Vicki West Sickles, a research counselor with Iowa Health, Des Moines, and herself a former meth addict, and we obviously look forward to hearing her insights about that experience; and Dr. Nora D. Volkow, Director of the National Institute on Drug Abuse at the National Institutes of Health. I'm going to -- our discussion today will last for about an hour, and we're going to cover five main areas today, beginning with what is meth and the scope of the problem. Secondly, a discussion about the production process. Third, the effects meth has on the mind and body. Fourth, the impact on the community. And finally, effective prevention and treatment. So we'll go about an hour. I'll try to keep us on time. And then we'll have about twenty minutes or so that we'd like to entertain questions from the audience. So I'd like to begin by focusing on the scope and nature of the problem, and we'll begin with a question to Dr. Volkow. Now some people are confused about what kind of drug methamphetamine is. Let's have a general introduction to the American public about what is it. DR. VOLKOW: Good morning, everybody. It's a pleasure to be here, and I'm glad that there has been recognition of the importance of methamphetamine, among other things, by declaring it Methamphetamine Day.

Methamphetamine is a stimulant drug. And what do we mean by a stimulant? It's a drug that will activate you. Drugs of abuse, all of them, have a common characteristic, and that is they increase the concentration of a chemical called dopamine. And dopamine is a chemical that activates pleasure centers in your brain. Now the ability of increasing dopamine is different for different types of drugs of abuse. All of them do it, whether it's alcohol, heroin, marijuana, methamphetamine, but they do it in different ways. And of the drugs of abuse, methamphetamine is the one that leads to the highest concentrations of dopamine in the brain, and this is likely to account for the fact that probably methamphetamine is one of the most addictive of all of the drugs of abuse. What happens when you increase dopamine in your brain? Dopamine is there not for you to take drugs. Dopamine is there to activate the brain and say this is extraordinarily important. It's not only pleasurable, but pleasure in nature is linked with a behavior that will ensure survival. In this case, taking methamphetamine is not going to ensure survival. But your brain is reading it as this is a signal that says this is important for survival. So this is actually recorded in your memory very powerfully such that you will next time you get exposed to a place where you took the methamphetamine, generate the emotion that it felt having had the drug, and this will likely want you to take it again. And this is what initiates, is believed to be what initiates the drive and the interest in the drug that with repeated administration will result in those that are vulnerable in physical changes in their brain that will ultimately lead to what we call addiction, which basically the way that we define addiction is that compulsive use of a drug despite the fact that the person no longer wants to take and, and despite its catastrophic consequences. So, methamphetamine is a drug of abuse. It's a stimulant. It activates, and of the drugs of abuse, is the one that leads to the highest concentrations of dopamine in the brain. ATTORNEY GENERAL GONZALES: Well, we know it's a powerful, addictive stimulant. Are there legitimate uses for methamphetamine? Is it ever prescribed? DR. VOLKOW: Interestingly, yes, they were. Methamphetamine is an amphetamine, and we use amphetamines traditionally for the treatment of attention deficit disorder, and indeed at one point, methamphetamine was approved for the treatment of attention deficit disorder. What happens is that the effects of a drug are a function also not just of its chemical characteristics, but the way that you take it. So when you were using -- when we

were using methamphetamine for the treatment of attention deficit disorder, we would use it in a tablet in low concentrations, whereas when people have used methamphetamine, they take it in much higher doses, and very frequently by other routes of administration, such as injecting or smoking, which are much more dangerous both -- vis-a-vis its side effect, adverse consequences to the body, but also vis-a-vis the dangerousness of addiction. ATTORNEY GENERAL GONZALES: Mr. Rannazzisi, meth has become a national problem. It's not just a regional problem. Can you talk a little bit about what is the history of the use of meth in the United States? MR. RANNAZZISI: Oh, absolutely. Good morning. First of all, I'd like to build on what Dr. Volkow said. Methamphetamine is a synthetic substance. It's totally synthetic. It's man-made. We don't have to worry about somebody growing a plant somewhere in the world and then extract the product. It's man-made, relies on chemicals. So, obviously, without the chemicals, there is no drug, you can't make it. Now in the '70s and '80s, methamphetamine was pretty much concentrated in the West and Southwest. California, a large hotbed for methamphetamine manufacture. And what we had was biker groups or independents who were making small amounts, a pound, pound and a half, two pounds, sometimes ounces, in labs. And these labs were not crude labs. They definitely weren't labs you'd see at major drug companies, but they had reaction flasks and Reese flux condensers and they were making the product using a very, very difficult method that required industrial chemicals. And that went along from the '70s and '80s. As we approached the '90s, the methods changed. They refined the methods and actually the method became easier, and that method spread. Several methods using what they call the Burch reduction method or using iodine spread eastward. You didn't need glassware anymore. You didn't need chemicals. You could go out into the retail market and buy chemicals, buy pseudoephedrine, go to your local farm and obtain anhydrous ammonia or use an ammonia-based fertilizer to get the chemical you need. Go to the store and buy Duracell batteries and extract the lithium or remove the lithium strip from the Duracell battery. And that's basically all you needed to make meth. So as we saw it spread, we saw places that were traditionally not meth locations, like Missouri and Kansas, Iowa, explode with methamphetamine. Why? Because I know longer needed to go to the local dealer, the local biker to obtain my product. I could just make it myself. And that's exactly what happened. So that's why places like Missouri had over 2,000 lab incidents in 2003, 2004, 2005. Now, what happened? The states saw that there was an issue, and the states dealt with it. The states came out with restrictions, restricting the sale of pseudoephedrine products. And what we saw was a dramatic reduction. We peaked in 2004. We had about 17,700 lab incidents in the U.S. Seventeen thousand, seven hundred labs that

had to be -- incidents -- that had to be cleaned up by your local police departments and federal departments. Well, since the state restrictions and now with the Combat Meth Act, we went from 17,700 incidents to about 12,500 in 2005. And this year, we don't look to cross 9,000 lab incidents. So the legislation is working. ATTORNEY GENERAL GONZALES: We'll talk to General McDonnell about state regulations and whether or not they've been effective, how effective that they've been. And we know that meth is spreading across the United States. I want to ask Dr. Clark, who is using meth right now? What are the demographics here? DR. CLARK: We estimate that there are about 1.4 million people who have used methamphetamine in the past year. We know that the past month use of methamphetamine hovers around about 512,000 people. There is ethnic variations in the use of methamphetamine with Native Americans, Native Hawaiians, Pacific Islanders, American Indians, Alaska native and white Americans being the groups that are using methamphetamine the largest. We also know that there is a lot of use in rural states, states previously that did not have a problem with stimulant abuse, states like North Dakota and South Dakota, parts of Tennessee, western parts of Virginia. So, in short, methamphetamine affects a wide range of ethnic groups, a wide range of socioeconomic groups, and a wide range of geographic areas. ATTORNEY GENERAL GONZALES: Is the use and abuse of this drug different than what you see with other kinds of drugs? DR. CLARK: It's a stimulant, and those individuals who respond to stimulants are more inclined to use it. But many people use what we call poly substances. So they will add methamphetamine to alcohol or add methamphetamine to marijuana. So, in a sense, once you're in the illicit drug arena, once you know your favorite dealer if you're not making it yourself, the dealer also brings other drugs that can be used. But again, it does target specific areas, as Dr. Volkow pointed out. So those individuals who are looking for reinforcement in those areas would tend to prefer methamphetamine. ATTORNEY GENERAL GONZALES: Let's move on to the production process. Mr. Rannazzisi, as a DEA agent, you've had a lot of experience with illegal sale and production of meth. We know that meth can be produced in mom and pop labs in your neighborhoods. We also know it's being imported into the United States. I don't want to get into specific instructions for how to make meth, but what kind of ingredients are we talking about? MR. RANNAZZISI: Well, it depends on the type of lab. Again, as I've said before with the smaller labs, which is about 20 percent of the meth consumed in the United

States, these small toxic labs, everything is available in the retail sector. I mean, you could buy just about any chemical you need to manufacture meth or obtain it by stealing it off of farms or from farm bureau co-ops. But it's readily available. The larger labs, the larger labs that are run by organizations, produce about 80 percent of the meth consumed in the United States, roughly 80 percent. These large labs operating in the United States and in Mexico are controlled by large organizations, Mexican organizations. Those organizations use their trafficking routes to get the drug out into the market. They're using industrial chemicals. They're buying their chemicals in bulk. They're using ton quantities of ephedrine or pseudoephedrine that they obtain from foreign manufactures. They obtain large amounts of chemicals like iodine from foreign manufactures. So there's two components here. There's the small labs that rely on retail sale chemicals and products, and then those larger labs, what we call the super labs, that ones that produce ten pounds or more on a 24-hour production cycle, that rely on bulk chemicals, both tableted and bulk powder. ATTORNEY GENERAL GONZALES: If someone in the audience were walking around their neighborhood, what would be telltale signs that in fact there's meth production going on? MR. RANNAZZISI: That's a very interesting question. It used to be when there were actually these large labs, and we still have large labs, but there's things we always looked for. It's raining and the people in the house are outside smoking. Why? Because a lot of the chemicals they use are volatile and they could explode, like ether. We used to see a lot of people covering their windows with like black plastic or newspaper so you couldn't see in. Chemical odors, really pungent odors that you wouldn't forget once you smelled it. Things like people dumping or you see like land that's been colored by waste, red waste. That's basically what we were looking for. Traffic in and out of a location late at night or early in the morning, and not very long stays. Maybe they come in for, you know, a couple of minutes and then leave two, three, four o'clock in the morning. That's what we used to see, especially around hotel rooms, we saw a lot of labs operating in hotel rooms where, you know, you'd see this traffic. And it's a perfect place to cook because, you know, you cook and then you leave, and the waste is left behind. ATTORNEY GENERAL GONZALES: And so what should the American public do if you're walking around your neighborhood and you come upon a site where it smells kind of funny, chemical odor, there's some red waste. You notice some odd-

looking folks going in and out of the place. I mean, what should be people do when they suspect that there is meth production going on? MR. RANNAZZISI: Well, we always say call your local police department or DEA office immediately. You know, that's the first thing you should do. If you happen upon a lab or you happen upon a discarded lab, never touch anything. And you can tell if it's a discarded lab. You'll see like a propane cylinder that has a discolored valve that just isn't right with a bunch of big mason jars or dishes that have a cakey substance that is discolored. Don't touch anything. If you walk into a place that could potentially have a lab, don't touch anything. Don't turn off any electricity. Let it sit. Back yourself out, avoid as much exposure as possible, and call the local police department or the local DEA office. Now in the '70s or '80s, there was not very many lab teams. Today, every major police department, every county sheriff, drug task forces, they all have specially trained police officers, law enforcement officers, that go out and take care of these lab sites. That's available to everybody and they're all trained. ATTORNEY GENERAL GONZALES: Okay. Thank you. General McDonnell, we talked about what the states have done to combat meth, passage of laws restricting access to precursor chemicals. The President signed in March of this year the Combat Meth Act. Can you talk a little bit about whether or not -- how do you see these laws? Are they effective? Are they helping us in fighting the spread of meth? MR. McDONNELL: Well, I think they've been enormously effective in the last two years since these laws at the state and federal level were put into effect. A lot of it's awareness, and that's why I appreciate the Department of Justice and George Washington University doing what they're doing today to be able to talk about this. This is one of those law enforcement problems that kind of snuck up on the states. Nobody heard much about this back four or five years ago, but I know in Virginia, we went from one lab incident to 78 in a period of just a few short years. MR. McDONNELL: -- In Virginia, we passed a couple of important laws. One was a precursor law that created a new felony offense for the possession of the precursor elements, such as Sudafed and other things, with the intent to distribute. It gave law enforcement the ability to go in without actually having manufacture completed but with the core elements in place with the intent to manufacture. And then secondly, we passed a law as further implemented by a governor's executive order to require -- and this is what's been most effective, I think, General -- is to require that these precursor elements, pseudoephedrine containing elements, be put behind the counter.

Many stores, Wal-Mart and others, were doing it voluntarily before that, but this required the items that are not scheduled substances -- they're not controlled substances, but they still were subject to abuse, and so they were required to be put behind the counter and for those customers who purchased it to actually have to sign for it -- how many they bought, the date, their name, their address, and so forth -which puts a little more accountability on the part of the buyer if they were going to go in and buy certain amounts. The other thing that was done is a limit on the amount of the substance that could be purchased. In Virginia, we limited it to nine grams per day. Now the federal act -and I appreciate the General's leadership on that -- that passed in -- I think the President signed it in March of this year -- limited that to 3.6 grams per day and, I believe, 9 grams in a 30-day period and also required these additional registration requirements. That has had a huge effect, the combined state and federal action over the last year. In Virginia alone, from fiscal year 2004 to -- from 2005 to 2006, we've gone from 79 lab incidents down to 23, almost a 75 percent reduction in the number of labs that have been discovered in Virginia. And a lot of it is because they just can't get access to the high volume of Sudafed and/or ephedrine containing products. And so it is working. The combined state-federal approach is working. It's something that needs to continue because the nature of the addiction is so acute. It's cheap and easy to manufacture if you can get your hands on the precursor elements. You can get the recipes off the internet. Up until a couple years ago, you could get as much of the product that you wanted to make the methamphetamine inside any pharmacy or Wal-Mart, and it was highly profitable. But I think we're -- these laws now that were passed in the last couple of years, General, have been very successful. And Virginia is, I think, reflective of what's happening nationally. I was just at the National Association of Attorneys General meeting yesterday down in Florida, and this was a huge issue that we discussed. We see these programs being implemented at state to state level as well to tighten up their meth laws in every state. ATTORNEY GENERAL GONZALES: I couldn't agree more. I have to commend states for the leadership they've shown on this issue. They were out front and very early on identified the problem. And many of them passed laws dealing with limiting access to precursor chemicals. And obviously those of us at the federal level saw that it was working effectively, and that was the impetus for having some federal legislation. I want to move now to a discussion on the effects of meth on mind and body. Dr. Volkow, you spoke already about some of the effects on the brain. I don't know whether or not you want to elaborate on the short-term and long-term effects of that. But I'd also like you to talk a little bit about the toll on a person's body that

occurs when someone uses meth, both long term and short term. DR. VOLKOW: Yes. And indeed, again, I was commenting before that methamphetamine is considered to be one of the most addictive of the drugs -- of abuse. But it's also considered to be one of the most toxic, and I'll go into an explanation about why there is concerns in the scientific world about these. I was commenting about the fact that methamphetamine is a drug that induces the largest increases in dopamine. Now dopamine, being a chemical that's indispensable for your brain to learn that something is important for survival, triggers and facilitates learning. And it is believed that the physical changes that are linked with addiction actually relate to these physical changes akin to those that your learn when you memorize something. But it's a memory of an emotion; it's a memory of an experience. And when these become so ingrained in your brain, this can take over other motivations. Now what we've also come to recognize is that not all of the drugs are the same. And they are not the same in their ability to produce addiction. Cocaine has been recognized for many years to be very addictive, and yet when they look at the clinical data, for example, over all in average -- there is variation between one person and the other -- but in average, it may take a person two or three years to become addicted to cocaine. In the case of methamphetamine, the addiction can proceed within one year, and this highlights the importance and the seriousness of the effects of methamphetamine in the brain. The other thing about methamphetamine is that the increases in dopamine are so large that they actually damage the cells that are producing that dopamine itself, which does not happen with other drugs like cocaine, heroin, or marijuana. So at that level, methamphetamine is much more toxic to the brain than these other ones because ultimately it is disrupting, damaging the cells that allow us ultimately to feel pleasure. And indeed, one of the things that happens across all addictions but even more marked in the people that are addicted to methamphetamine is that though even when they get initially taking the drug they feel great, as they continue to take it, they take it no longer to feel great, but to feel normal because if they don't take it they feel horrible. The dopamine, which is what gives us our excitement, our motivation, our drive to do things, has been basically -- those cells have been damaged and so you normally no longer respond to everyday events, so that -- vis-a-vis the consequences in the brain. In the brain also, as in the rest of the body, methamphetamine, being a stimulant, has the characteristics of producing blood vessels to constrict. It's called vessel

constriction. Now there are certain organs that are very sensitive to the delivery of blood; if blood is not delivered properly, they suffer very rapidly damage. The number one organ for that is the brain. If blood is not properly delivered that can result in a stroke. What are the consequences? Well, it depends where the stroke happens. So if it happens in the back part of your brain, you may become blind from taking methamphetamine. If it happens in the areas of the brain that are involved with movement, you may become paralyzed from taking methamphetamine. So the consequences are pretty dire. If it happens in your heart, what can happen? You can develop a myocardial infarction. And indeed, what these communities where methamphetamine is very prevalent are observing is that the number one reason for admissions with cardiac problems in young people is because they are taking methamphetamine. There are many other body organs that suffer from it. We know that skin, for example, is very damaged. We all heard about the issue of the -- and the meth mouth. And that is, in part, a function not just of the adverse chemicals that are used in order to produce a methamphetamine, but also by vascular constriction. Your skin as well as your gums require proper delivery of blood to them, and if its not they start to damage themselves. So these can affect, as I say, organs that we see but also organs that we do not see. And finally, there is another aspect about methamphetamine that has been very problematic, and that is the notion that methamphetamine -- being a stimulant, one of the things that it does is it increases sexual arousal. Not only does it increase sexual arousal, but evidently it decreases inhibitory control, and as a result of that, people take this drug and engage in practices and behaviors that they would have not done otherwise. This puts them at very high risk of risky behaviors that can turn out to result in HIV/AIDS or Hepatitis C vaccine [sic]. And this property of methamphetamine of increased sexual arousal is utilized -- is used -- people use it for that specific purpose, and that has made methamphetamine play a very important role in terms of continuing in the dissemination of the HIV epidemic. Not, in this case, because people are injecting it -- if they are injecting contaminated materials, yes -- but because the drug itself is producing changes in their mental state that leads them to very risky behaviors. ATTORNEY GENERAL GONZALES: Thank you, Doctor. Blindness and possible heart problems, using your ability to appreciate pleasure -- you can really see how powerful a stimulant -- how powerfully addictive a drug this must be to have people risk all of that in order to enjoy meth. I want to introduce Miss Sickels, who is with us. We are fortunate to have a onetime meth user who managed to beat it, and even better, to dedicate herself to helping others beat it. So I would invited Miss Sickels to talk a little bit about her

own personal experience with meth. MS. SICKELS: Good morning. It's a privilege to be here this morning. When I first used methamphetamine in 1988, I'd never heard of it. I didn't know what it was. I had experimented with drugs in college and became addicted to cocaine for a time when I was in college, but I graduated from college in '86, and then was very careful to avoid hard drugs after that. But in 1988, I had just lost my father, and I was grieving, and I had -- I was sort of at loose ends, didn't quite know what to do with myself, didn't have any goals -- had some goals, but they didn't make any sense. And I met a man who asked me if I wanted to try some crank. And I asked him what it was, and he said, "Oh, it's like speed, sort of like coke. I'll chop it up. You can snort a line." And so I thought it's what you did when you couldn't find any cocaine. And the first time I did it -- it was October 19th, 1988 -- I was intoxicated. I would consider that alcohol was probably my gateway drug. I was intoxicated when I tried almost anything else that I did. But so I didn't feel it right away, but I woke up in the morning, sat straight up in bed at six o'clock in the morning and felt fantastic, and wanted to jump up and grab my journals and write poetry, and I felt so creative and energetic. And I loved it. Right from then, it was odd and fantastic and I loved it. But I didn't have to go out and do it again the next night, though I was really looking forward to seeing this guy again the next weekend -- and did it again. And did it weekends for about a couple of months, maybe a month, and then he and I started using together every day and injecting meth. And rapidly it became the only thing that I did. I quit working. I was just using meth, and it pretty much took over my being. At first, you know, it gave me energy. I had energy for my creative projects. I wasn't depressed about my father. I felt great. You know how you always wish -- there's not enough hours in the day to do what you think you need to get done? Well, this makes every one of the 24 hours of the day available to you, and that was attractive to me. I wanted all that time, and I wanted all that energy. But eventually I couldn't get anything done without it. I couldn't get off the couch unless I had some meth. And so it quickly became -- I needed it for energy, and I needed it for motivation, and it took me quite some time and quite a little effort to get off of it, more than one treatment, in fact. And mentally, you know, I was stimulated, I was confident, I felt great at the beginning. At the end mentally, I was obsessive, I was compulsive, I was looking

for bugs that weren't there. I was staring out the windows at things that weren't there. I mean it really kind of made me lose my mind, and my main focus was then using and getting more meth and dealing with the projects that I had in mind. And physically I would say -- physically I was fortunate. I lost a lot of weight. I had the bug thing going on, but I resisted the picking, so I didn't pick scars onto my face. I didn't see a dentist for the last five years I was using, so I had some periodontal stuff going on, but I didn't lose any teeth. I ended up with Hepatitis C though. I am -- I was an injecting drug user. And what they say about Hepatitis C is that if you inject for even one year, you have an 80 percent likelihood of ending up with Hepatitis C, so I came away with that. ATTORNEY GENERAL GONZALES: You mentioned some signs, and other panelists have mentioned it as well, but what would you look for in terms of identifying someone as a meth user? MS. SICKELS: I would say hyperactive kind of energy is the first giveaway, a noticeable increase in the level of energy. And a change in sleeping patterns, somebody who has pushed their bedtime way back into the middle of the night somewhere and then gets up at the crack of dawn, that's a pretty good sign. ATTORNEY GENERAL GONZALES: That's what I do every day. (Laughter.) MS. SICKELS: Is that with coffee? ATTORNEY GENERAL GONZALES: A lot of caffeine. MS. SICKELS: Well, it would be a change from what their usual behavior was -- is what you would look for. You would look for a change in their usual -- the company that they keep, if their friends -- a lot of times when someone starts using, they find friends who are doing the same thing that they are. Their old friends drop by the wayside. They stop calling mom; they stop showing up for holidays -- that would definitely be a giveaway. You know, a lot of people are -ATTORNEY GENERAL GONZALES: how many people -- you talked about -- is it called crank bugs? MS. SICKELS: Yes. ATTORNEY GENERAL GONZALES: -- where they imagine the sensation of bugs either on top of their skin or underneath their skin, they scratch and scratch, and they develop sores.

MS. SICKELS: Mm-hmm. ATTORNEY GENERAL GONZALES: Do you happen to know or any of the panelists happen to know what percentage of users develop this kind of symptom? MS. SICKELS: I don't have any numbers, but the -- what I see in the clinic where I work, about half of the people who come in have sores on their arms or on their face that they've scratched at. I actually -- we talked about medical profession as being a point of intervention. I once -- I thought that I had -- I had been digging in the carpet. I had to have marijuana to take the edge off of my high because I didn't like the anxious edge. So if I didn't have any marijuana, I would dig in the carpet or in the furniture looking for it obsessively. And I thought that I had parasites under my fingers. I was certain that I had just dug them in -- like dust mites. And I went to a doctor and said, "I'm certain that I have parasites in my skin." And he said -- he looked at me, he said, "Those are calluses." I said, "No, no. I'm certain they're parasites." So he took a razor -- he was a kindly older gentleman -- he cut a little bit of my skin off, what I thought was a parasite, put it under the microscope, said, "Look there, that's skin." So I looked in the microscope. I said, "No. I see a spine. That's a parasite." He said, "Parasites do not have spines. Go home and go to bed." ATTORNEY GENERAL GONZALES: Any other signs, panelists, we ought to be looking for? DR. VOLKOW: I think one that is pretty frequent is a loss of weight. One of the things that methamphetamine does -- all of the amphetamines remove your weight and your hunger. And indeed, that's important too, from another perspective, in that sometimes some girls will start using methamphetamine because they want to lose weight and not per se because they want to get high. And they get hooked, and indeed that may keep them taking the drug. So yes, methamphetamine makes you lose weight pretty rapidly. It also -- the more you take the more evident this becomes -- people become very suspicious and paranoid. And I agree with you. The main sign that you get when someone has shifted into a pattern of abuse, a change in their personality. So if you've always been very compulsive and wake up at five in the morning, I wouldn't worry. But if that is something that's all of a sudden different, then you want to understand what happened. DR. CLARK: Also, especially in the workforce, this issue of the paranoia can

become problematic. Individuals who are at work start to suspect other employees of threatening or plotting, and so the notion of workplace violence becomes an issue, and we need to be very careful about that. I think that's one of the reasons that we have workplace drug testing, because the person's judgment becomes impaired, particularly if they're operating heavy equipment, large motor vehicles. Their reaction time is altered and with the impaired judgment they're liable to increase their risk for accidents. ATTORNEY GENERAL GONZALES: Okay. MS. SICKELS: there's a physical thing that happens, too. There's a lot of kind of twitchy, fidgety thing that goes on, picking things up, putting them down, taking things apart, trying to put them back together. There's a thing that happens with the jaw where the jaw is working back and forth, and even a change in the posture because your muscles tense up, so there can be a change in the way somebody stands or walks or the way their face moves. So there's physical characteristics as well. ATTORNEY GENERAL GONZALES: Thank you. Let's have a brief discussion now on the impact on the community. I want to begin with Mr. Rannazzisi. We talked about the dangers of producing meth, and can you elaborate about the environmental problems caused by domestic meth production? MR. RANNAZZISI: Yes, sir. Well, they say that one pound -- the manufacture of one pound of meth produces between five and six pounds of hazardous waste. And the labs I've been -- the waste is -- there's a lot of waste in there. The fact is that they have to get rid of it somehow, so what they usually do is either they dump it in a rural area -- they dump it in a park or they'll pour the waste down the sewer system. Well, I don't know if it's -- if it's put in a park, the soil will be contaminated. If it goes into the sewer system, it could get into our water system, and obviously you have contaminated water. When we go in and clean up a lab, we don't do what's called a remediation. We do a gross contaminant removal. We remove all of the gross contaminant from the lab, but that does not mean there's no toxic substance left in the lab; there is residual toxicity in that lab. And to remove that residual toxicity, you'd have to pull down the walls and pull out the carpet or the floors, and that's a problem. We leave that to the landowner. The fact is that it's his property; he's got to remove that contaminant. So you could buy a place that -- buy property that had a lab on it and walk in there and not know that you're living in a place where there's residual contamination. We've had instances where residual contamination has caused respiratory problems for the new owners. They didn't know why, and later they

found that the residual contamination was the cause of their respiratory problems. So environmentally and also the health of the individuals in these labs or in these former labs -- it creates a major impact on the environment and on the citizens. ATTORNEY GENERAL GONZALES: Dr. Clark, as I've traveled around the country, I've heard some heartbreaking stories about the effect on children who are in these homes. How does meth use and production affect children? DR. CLARK: I'm glad you asked that. It's an important thing for us to keep in mind that many of these home labs -- parents are -- they have the kids in the next room or in the very room while they're producing methamphetamine. You've got a lot of toxic substances being produced, so the children are exposed to the noxious fumes. Some of these fumes not only can cause respiratory damage; they can also cause behavioral and neurologic damage in the children. Some of these labs explode. You've got kids in the labs who then are exposed to the risk of explosion and burns. You've got children whose parents are so preoccupied with the production and consumption of the methamphetamine that they really don't have much time left to nurture and protect their children. So you've got neglected children, physically or sexually abused because parents -- as Joseph pointed out, you've got a lot of traffic coming in and out, and while the parents may not be sexual predators, sexual predators avail themselves to the children because the parents are preoccupied with the manufacturing and the consumption of methamphetamine. So a lot of concern about children. Most jurisdictions -- actually all fifty jurisdictions now have drug-endangered children teams that are working with child welfare in order to protect kids. And they work with law enforcement when they go in -- drug-endangered children teams, and in order to mitigate the damage done. And then of course, you've got the issue of burdening the foster care system by increasing the demand with children who are in meth homes or have parents who are on methamphetamine and can't parent. MS. SICKELS: I would like to speak to that as well. I've seen, from my personal experience, and also in the clinic now where I work, that it's become a multigenerational problem where if the parent's addiction is allowed to continue unabated, eventually those children are pretty much destined to follow in their foot steps because it's a way of life in their household. I've had young people come to me who can't go home for support from their family because their parents and everyone in their household is using. And I've had people who have told me that they started using as young as nine years old with siblings or even step-parents that are there in the house. So it's become a multi-generational problem.

ATTORNEY GENERAL GONZALES: What about the effect of meth on crime, General? What kind of crimes -- people who engage in meth, how does that affect the crime in a local community? MR. McDONNELL: Because the epidemic proportions of the meth phenomenon are so new, we don't have great statistics at the state or the national level on it yet. There's been some surveys I know in Illinois, and Oregon and others that indicate that as much as 30 to 40 percent of the total jail population is in for meth-related crime. But most jurisdictions don't keep separate statistics about the link between meth and the criminal act. But based on what you've heard from both of the doctors about the nature of meth and how it affects the body, I think there's three categories anecdotally that we can say -- and we've seen it in Virginia -- that have increased. One is the garden variety property crimes: larceny, burglars, forgery and entering, bad checks, things like that -- people that just need money because of the nature of the addiction and the amount of money that it takes to support that addiction if they're not manufacturing themselves. If they've got to buy, they're engaged in a significant amount of property crime. The second would be domestic violence and child abuse. You heard Dr. Clark just speak about that. It goes into really two categories. One is having young children being around the manufacture of the product itself is a very abusive environment. And secondly, the compulsion of the user to do other things has them to neglect the child. And we've seen an increase in particularly the western part of Virginia of child neglect charges. And thirdly, and this is a new phenomenon. It's gotten some national articles written about it. And that is the rise in the link of internet-related crimes with methamphetamine use because you can stay up for extended periods of time, as you heard from everybody, and you have -- there's great energy and a compulsive nature of the addiction that we're seeing -- again, anecdotally, an increase in various types of internet crime like identify theft and fishing and farming and some of these new types of internet crimes that are going on because people can stay at that computer screen for 12, 15, 24 hours at a time if they're high on meth and looking for new and creative ways to try to scam somebody else out of their money, their identity, or their property via the internet. So even though it's anecdotal, I don't think we have any great national numbers. Those are the categories generally that we see in Virginia. ATTORNEY GENERAL GONZALES: Okay. Thank you. Now the final topic, which is prevention and treatment. Miss Sickels, I understand that meth addiction can be very, very difficult to treat, but it can be treated. Can you talk to us about your experience in treatment?

MS. SICKELS: Certainly. First of all, even though I became tired of doing it and what it was doing to my life, I could never make the decision that I'm sick of this and I want to quit and get myself to where I needed to be. That was never able to happen for me. What had to happen was somebody noticed that I wasn't -- the first time I went to treatment was in 1993, and it was my family who noticed I wasn't taking good care of my son, who was three years old at the time, and they told me that they were going to remove him from my care if I didn't get some help. So at that time, I checked myself into treatment. I was 28-day inpatient. They suggested a halfway house. I said, "No, I have a house. I'll just go home and go to 12 Step meetings and do what needs to be done." And I did that, and I stayed clean for six months. And at the end of that six months, I was as depressed as I'd ever been, and actually feeling like if this is all there is, I don't really care to go on. But I had a child, so I didn't actually become suicidal. What I did was relapse on sex is the way I tell the story because I was going to 12 Step meetings and I started to get involved with somebody who was there, and the sexual activity really stoked me in my brain again. Dr. Volkow has some great slides that show the regular dopamine in a person's brain as big red spots, and then at six months into recovery there are no red spots in the brain. The dopamine is not -- the brain hasn't started to produce it again on its own. So at six months into recovery, when I was thinking that things should be getting better, I still felt like hell, and so I looked for another way to feel better. And I started with sex, and within a couple of weeks I was using again, and injecting. And I knew I didn't want to live that way. And I would tell people -- I would go to the 12 Step meetings and say, "I've had a spiritual awakening now," as a result of my relapse, and I did feel better because I now had dopamine in my brain again. But I knew I didn't want to live that way, and I kept saying, "This is my relapse vacation. I'm going to get myself together and get off it again." Well, it took five years before I could get that done, and in that five years, I went places in my addiction that I never wanted to go -- homeless, and fired from jobs, and evicted, and jailed for hitting someone. It was then my addiction got really ugly. And at the end of that five years, when I could finally get into treatment again, it was legal intervention. Actually, it was in 1998 when the labs started exploding on the scene and we were hanging around with people who were cooking. So when the whole little village of us who were manufacturing meth were raided, I was able to get out of that situation and into treatment, and into treatment that lasted.

The last time I went to treatment in 1998, I said, "Put me on the list for a halfway house because if that's what it takes I never want to have to go on another relapse vacation." So that time, in 1998, I did the inpatient treatment. I did the 90 days at a halfway house. I'm fortunate to have a sister who is clean and productive, and she allowed me to live with her for a couple of years. And it took me that amount of time to really start feeling good about life and myself and be able to set goals and learn how to live again. It was that long-term, extended -- attending meetings and going to aftercare, and really getting the support that I needed for -- it was over a year; it was almost two years. ATTORNEY GENERAL GONZALES: What would you tell others to do to prevent their families and their friends from getting introduced to meth or getting addicted to meth? MS. SICKELS: I would tell them, for one thing, be aware. That's why I think that this day is so important. I was completely unaware of what meth was and what it did to people and how it impacted their lives. I had no idea about it when I started using it. And I like to think that if I'd been aware of what methamphetamine was and what it entailed, I would have avoided it. The other thing is, when I became vulnerable to it was a time when I was not coping with things that were going on in my life. And just in terms of prevention in general for all kinds of substance abuse, I think we need to do a better job of educating people about how to cope with the trials and tribulations that life throws at all of us. I got to college, and I hadn't experienced anything, and then when I was in college and things started occurring that were upsetting and caused me to be depressed, I didn't have any coping skills. So I think that we as a society need to do a better job of helping one another learn how to deal with things. ATTORNEY GENERAL GONZALES: Okay. Dr. Clark, in your experience, what types of treatment programs have proven to be most effective in dealing with meth? DR. CLARK: One of the things that I want to acknowledge, first off, is the importance that law enforcement has played in terms of treatment process, and that is drug courts. And law enforcement has actually been very useful in referring people to treatment. I think Vicki's point is well taken. It's treatment approaches then with drug court, with law enforcement referrals. We use various psychological, psycho-social treatments, nothing inherently unique to a methamphetamine. There is no targeted model, but different models like the matrix model -- it's a manualized treatment strategy originally developed to address cocaine. It's put together, is fostered by NIDA. SAMPS has also played a role in promoting the

matrix model. It's a combination of integrated strategies: individual counseling, cognitive behavioral treatment, motivational interviewing, family intervention, toxicology screen, urine testing, participation in 12 Step programs. The other treatment that we're using now is called recovery focus. That's getting community organizations, faith-based organizations involved in the recovery from the use of methamphetamine. I think Miss Sickels's point was well taken. After you've done the detox, after you've done the acute treatment, what do you do then? And by relying on entities like 12 Step programs, faith-, community-, and recovery-oriented strategy, we're able to normalize that person's existence and get beyond the acute effects -- and then dealing with some of the psychological walls that people run into down the road. So these are the things that we are involved in. There's no specific medication that you can give a person. People are using antidepressants for some effects and Dr. Volkow can comment about some of the medication development strategies that NIDA is promoting, but the key issue is we're working with our states. Our state governors' organizations are trying to include some of these developments like motivational incentives in the strategies. For instance, Christy Dye in Arizona has put together a nice little demonstration project where people are given incentives to stay in treatment, stay in the recovery process. ATTORNEY GENERAL GONZALES: Dr. Volkow? DR. VOLKOW: I will comment on that treatment -- but before I get into that, because I think that it's so extraordinarily important that it was mentioned is the notion of how important it is to do prevention because ultimately if you can prevent drug abuse, you then don't have to worry about all of the consequences, and the earlier you can do that, the more likely you are to succeed. Why? Because a lot of the drug experimentation, we know, happens during adolescence, and unfortunately, as it was commented, sometimes during childhood. Why do kids take drugs? They take drugs because they are curious. They take drugs because their friends are doing it, because they want to have a good time, without really a clear understanding of the consequences. And as a society, we need to know what works in prevention or not. And one of the things from research that has come across consistently is that one of the most important elements in that algorithm about what works is the family. And most of the prevention programs -- therefore emphasize the involvement of the parents and the family in the prevention process against the use of drugs. So that's -- I did want to highlight that because it can never, ever, ever be underestimated -- the importance of prevention.

In treatment, there are currently, as Dr. Clark was commenting -- we do not have currently any medications for the treatment of methamphetamine. However, we're working on different strategies that look very promising. One of them is the possibility of developing a vaccine against methamphetamine. This has been successful. We are actually at the stages of doing phase three clinical trials both for nicotine vaccine -- the pharmaceuticals involved with that -- and also for a cocaine vaccine. We're also working on a heroin vaccine. Methamphetamine has been harder to do. We have succeeded on developing the antibodies itself but not through a vaccine, and that's very useful when you get a patient that has intoxicated with serious arrhythmia on their heart or where you need to do an intervention right away. The antibodies will basically allow you to get rid of the methamphetamine. But we want to be able to do that for someone who, for example, goes to rehabilitation and then is out there -- you protect them by the vaccine so that, if they relapse because they have a stressor in their life, they'll have the vaccine; they will not feel the drug. That's one. Then we are working with a medication that has been shown to be quite effective in improving the ability of your brain to exert control of your emotions and your desires, which is one of the functions that is eroded, is damaged by the use of chronic drugs. So -- all of us are always in position maybe throughout the day, of "I want this," "I want the chocolate," but I catch myself saying it; I don't want to do it, and I exert cognitive control to say I shouldn't do it. Well, that is one of the areas that's damaged by drugs, very much damaged by methamphetamine, so we're developing medications there. Another type of medications that has shown already in clinical studies promise for methamphetamine -- most studies -- is anti-epileptics. Certain anti-epileptic medications evidently are able to decrease the craving and the desire for the drug that a person may feel when they get exposed to a place where they have taken the drug, or when they feel depressed, or when they feel stress. And finally, interestingly, this is data that has come from Europe where they show that methylphenidate, which is a medication that we use Ritalin for the treatment of attention deficit disorder, showed promising results in amphetamine injection drugusers. And there was a study in Amsterdam -- so these are different types of medications that we're working with. At the same time, we are optimizing and trying to take advantage of methodologies and technologies to be able to tailor behavioral interventions that can increase the likelihood that a person will stay clean of drugs. So we're working on both fronts. And the other big initiative that we have, because Dr. Clark mentioned it, but it is

incredibly important, is the opportunity that we have when an individual that has a problem with substance abuse ends up in the criminal justice system. That's an extraordinary opportunity to institute treatment. And it will, as has been heard -and I've heard it many, many times. It has made a difference in a person's life because it allowed them to have treatment that was of a sufficient long duration at an aftercare that made the difference between being able to stay drug free or fall out or going back. And the treatments in the criminal justice system have shown to be effective not just in what you said, on helping people stop taking the drugs, but in significantly decreasing the rate of incarceration, and that's why another aspect that is very, very important. DR. CLARK: One final thing on that is screening and brief intervention involving healthcare practitioners, making sure that we increase awareness among physicians, nurses, nurse practitioners, physician assistants, dentists, and anybody else in the primary care delivery system -- I think Vicki's point was well taken that she had problems with gingivitis -- and we need to make sure that dentists are aware about not only meth mouth but ask the question -- if people show up in the emergency room, asking the questions, people showing up in the healthcare centers, asking the questions. So part of what we're trying to do with the Office of National Drug Control Policy - is promoting is making sure healthcare providers are knowledgeable about addiction. Too often we find that they're not knowledgeable and there's a missed opportunity. And by the time its written on the wall, in the newspaper, and on TV, it's sort of after the fact. What we're trying to do is identify these issues early. ATTORNEY GENERAL GONZALES: General, I understand that you're engaged in an excellent cooperative effort with the U.S. Attorney's Office in the Western District. Can you talk a little bit about that? MR. McDONNELL: Sure. We've done some of the traditional law-enforcement cooperation, like looking at the penalty structures between state and federal law. And we realized we had some work to do at the state level, and we've bumped up the penalties to get it closer to what the federal law requires. We talk about cases where there's joint state police or federal authority investigations to see whether they ought to go to state or federal court, and so that's been helpful. But I think we realized also that we have a role to play in the prevention side. I think the panel has been very clear about getting a message, particularly to adolescents, young people, about not getting started. There's a lot of ways to do that. One I just discovered a couple days ago is this little bracelet to get to young kids, sort of like the Lance Armstrong approach. This says, "not even once." It's a black

arm band to kind of remind kids don't ever start. You heard Miss Sickels's example, just the first time was so good she kept coming back. Well, John Brownlee, who is the U.S. Attorney for the Western District of Virginia, do an outstanding job, but as part of your Project Safe Neighborhood program, General Gonzales -- decided he would created a video with a very clear message. It's called Meth Kills. And he invited me to be a part of that, and we really took an approach to try to get the message to young kids starting not in high school, but in the middle schools with a tough love message about the legal consequences, and what you heard today, the medical consequences of using meth, because kids care about their appearance and kids think their future is forever. But what they don't understand is what six months on meth will do to you. And so this video -- it's about 15 minutes long. It's actually a DVD that's been produced over the last couple months. We just stared distributing it to schools all over Virginia just about a month ago. But it's got some healthcare providers talking about what you heard today, about the physical impact on your body in a very short order of methamphetamine. It's got Mr. Brownlee and I and the state police superintendent talking about the legal consequences of using, manufacturing drugs, and what a felony will do to a young person for the rest of your life. And then, very powerfully is, we got folks like Miss Sickels, three folks who are recovering methamphetamine users telling their story about what methamphetamine has done to their life. So we think it is a very powerful, tough love message. He's raised some public and private money to get this all over the state. We think it's going to be very powerful. It's gone to all the schools, all the PTAs, to educate both parents and kids about this, and I think it's going to have an impact. We've also cooperated on something called Meth Watch. Many states have programs like this to be able to enlist the help of the private sector in discovering methamphetamine laboratories such as just training -- commonsense things like training cleaning personnel in hotels and motels around the state so they look for the evidence of -- the remnants of a meth lab, the folks that pick up the trash so that they know if they find things in the trash that look like they're a discarded methamphetamine cooking apparatus they can promptly notify law enforcement, and then the investigation can start. All that is very helpful from an investigative side, too. So he's done a great job with the Project Safe Neighborhood implementation in this area, General, and we think it's going to have an impact with kids in Virginia. ATTORNEY GENERAL GONZALES: Thank you. We have found meth labs in

homes and apartments, in penthouses, and vehicles, in parks -- they're all over the place. So that concludes the panel portion of this morning's program. I would now like to invite the audience to ask questions. I think we have mics available if you want to ask a question. Please give us your name, who you were with, and, if you can, specify which panel member you would like to answer your question. So why don't we begin? QUESTION: Hi. I'm Marcia Lee Taylor from the Partnership for a Drug Free America. I was interested to hear the panel talk today about the changing trends in meth use in the country from the production by the biker gangs to the mom-and-pop labs, and now, with the effectiveness of the federal and state laws, the decrease in the mom-and-pop labs. I'm wondering, as we're still seeing meth coming over the border now in more traditional distribution routes, if, Mr. Rannazzisi, you could talk a little bit about what you're seeing in the future. Do you think this is going to be more of an urban problem in the future than a rural one, it is now? MR. RANNAZZISI: I don't think we could characterize it as a rural problem anymore. We've seen labs in New York City. We've seen -- two or three years ago we had a lab in a vehicle right in D.C. It's not a rural -- it's not only a domestic problem; it's a global problem. Meth is everywhere. Now we are seeing a dramatic decrease in the small labs, which is great for us, but we are also seeing these large organizations taking up the slack and actually flooding the market in many areas, both rural and urban, with methamphetamine. So what are we doing? Well, we know the organizations, for the large part, are Mexican organizations. We're working very closely with the government of Mexico. We're training their officers to detect labs, to understand how to develop these investigations. We've trained Mexican law enforcement officers in all aspects of methamphetamine clandestine lab activity. We're putting clandestine lab trained Mexican officials in what we call the "lab hot spots" in Mexico, Sinaloa, Sonora, Baha Norte, Michocan, so we are training them. We are working closely with them. We have task forces on both sides of the border that are working together, trading information. Together we are going to address the problem. Meth is going to be on the street ‑‑ just because we see a downturn in the small labs ‑‑ meth is going to be there. We have to work with our counterparts in Mexico and Canada. But remember, it's a global problem ‑‑ Oceania, Europe, Southeast Asia, all have meth problems. Canada has got labs. Mexico has got labs. Labs are pretty much all over the place.

So I think that working with the Mexican government, we should be able to slow down the process of meth coming into the country, but we also have to look past Mexico. We have to look at Southeast Asia. It has become a major meth manufacturing area. ATTORNEY GENERAL GONZALES: Let me just say that on this particular issue, several months ago the Mexican Attorney General and I went to a conference in Texas that focused on dealing with this issue of meth, and there we announced a series of initiatives to try to address it, and I have had a number of conversations with the Mexican Attorney General about this issue. He is likewise very concerned about the issue. We have also had conversations in my travels, say, for example with China, discussions about limiting, trying to discourage or at least get some help from the Chinese government with respect to their exportation of precursor chemicals which finds its way into Mexico and creates a problem for the United States. So we realize we have a problem, an issue a challenge with respect to importation of meth through our southern border and we are working with our Mexican counterparts to try to deal with it. Other questions? We have got one back here. We have one over there. Also have got one back here. QUESTION: Thank you. It was a fascinating discussion this morning. My name is Leroy Charles. I am a vice president here at the George Washington University Medical Center, and the young lady sort stole over to my questioning, but I'll sort of ask in a different way. What is the, let's say, the pecking order for illicit drug use in the United States with meth? And the reason why I asked that question, if you go up 95 North, 45 minutes, we know that Baltimore has a serious heroin population. We know here in the District of Columbia back in the late '80s, early '90s, we had a crack cocaine problem. So where would you rant meth? Is it an epidemic in this country? Again, we have talked about demographics, but what is the geography of meth? Is it urban? Is it suburban? Is it rural? What is it exactly? DR. CLARK: Well, the answer to that is yes. (Laughter.) DR. CLARK: And I think it's an important thing to keep in mind, so what we are trying to do is promote through prevention and detection the individual experience in the specific jurisdiction, so whereas Baltimore may have more of an opioid, heroin problem, D.C. also has one, but D.C. has a subpopulation, gay-lesbian, of gay and bisexual men who use methamphetamine for sexual purposes, as Dr.

Volkow pointed out. We have got methamphetamine in western Virginia, but not necessarily in northeastern Virginia, so what we all have to do is work with the health authorities and the law enforcement to understand what is going on in the respective communities. We just funded a grant in Boston, Massachusetts has a low prevalence of methamphetamine problem but again in the gay community there is a higher prevalence. South Dakota has a high prevalence of methamphetamine use among adolescents relative to the rest of the country, so not only is it peculiar to particular geographic areas, but also certain age groups where the use is more prevalent, so we need to be working with state authorities, governors, law enforcement and public health people, rather than assuming it's not going to happen. It's low prevalence in the African American community, but it is not zero prevalence in the African American community ‑‑ something that people need to keep in mind, so with increasing sophistication you are able to address these issues. MR. McDONNELL: And I think the reason for that, if you look over the last couple of decades about drug use, and I think it's generally true across the country, is marijuana has generally been sort of, along with alcohol, been one of the gateway drugs to other types of drug use. Cocaine kind of burst on the scene a couple of decades ago, and was along with LSD became kind of the hard core drug of choice. Then crack became the poor man's cocaine, and now methamphetamine has become the poor man's crack, because of the price out there in the market, because up until these most recent laws to take the precursor elements off the shelf, it was so easy to make. The recipes are on the internet. You could cook it yourself. And so that's why I think it's become such an issue, as Dr. Clark pointed out, in northern Virginia ‑‑ it really does differ. In rural Virginia, the whole I-81 corridor is where we see most of the labs and most of the use of methamphetamines in Virginia. The inner cities is primarily still crack, so some of it is a cultural thing in terms of what the drug of choice is, but until we make the availability of the precursor elements extremely tight, it is still going to be a huge problem in virtually any community based on what their choice of the drug is. ATTORNEY GENERAL GONZALES: Yes? QUESTION: Ed Hutcheson of the National Sheriffs Association. My question is actually directed toward Mr. Rannazzisi, with the DEA. MR. RANNAZZISI: Yes, sir.

QUESTION: And we'd heard from Attorney General McDonnell in regards to how we are curbing access to the amphetamine portion of making methamphetamine. Could you go into some more detail about perhaps how other, the other elements, the precursor elements, are being curbed at the national level? MR. RANNAZZISI: Well, to start off, the government as a whole is working in the international community to stop large amounts of precursors from going into production countries like Mexico and the United States through the International Narcotics Control Board. We have held many meetings with the source countries, and we are trying to get a strong control over where precursor chemicals are transiting throughout the world. That is the key. If we can control those precursor chemicals, the ephedrines, pseudoephedrine, ephedra-alkaloids, those types of chemicals, we won't have a meth problem. Now locally iodine is a major problem, where we have steps in place to regulate iodine now, making it a List 1 chemical. We also have, we are looking at ‑‑ you know, the solvents are very difficult to control because solvents are widely used. Same thing with the acids and the drain cleaners and things like that. So our concentration is mostly with the precursors. Now there have been ‑‑ some of the states have worked with anhydrous ammonia, which is a major component to one of the manufacturing processes, using an additive in the anhydrous ammonia to try and limit the amount of methamphetamine that can be produced. I believe Iowa is working on that project, and I believe they are seeing successes with that. We are working internationally with the major precursor chemicals with the production countries and then locally ‑‑ the states, with the help of the federal government, are trying to control chemicals like anhydrous and iodine, things like that. ATTORNEY GENERAL GONZALES: Questions ‑‑ here, here, here. Back here as well. QUESTION: Good morning. My name is Dr. Christina Catlett, and I am an emergency physician here at GW. I trained actually at Hopkins in Baltimore, so I can spot heroin and crack a mile away, no problem. If you had asked me how many cases of methamphetamine abuse I have seen here at GW, I would have said probably three to five, and I thought that was because it wasn't a problem in this particular area of Washington, D.C. We have a fairly white collar crowd at GW. What I am realizing is that I think we are just not recognizing it, and I wanted to say thank you to Ms. Sickels for pointing out some of the psycho-motor clues that might help us detect somebody who is either intoxicated with methamphetamine or

a chronic methamphetamine abuser. I am wondering if there aren't some more physical clues that I need to be looking for. Pupillary either dilatation or constriction. Is there an acute withdrawal syndrome that I need to be recognizing? Changes in blood pressure or pulse? Anything that might be helpful to those of us that are clinicians that need to recognize this in the field. DR. VOLKOW: Yeah, well, what you will -- well, the are physical symptoms and signs that you will see in the patient will depend of course whether the patient is intoxicated or whether it's on withdrawal, and if it's intoxicated, it would be akin to what you see with other stimulant drugs at high doses. So you will see increases in blood pressure. Methamphetamine increases blood pressure, produces significant increases in heart rate, produces vasoconstriction, and that's what you will see. And the element of paranoia, suspiciousness, agitation, anxiety ‑‑ that restlessness is very, very typical in the intoxication state, and the person may be diaphoretic. In the withdrawal, on the other hand, you see a very different picture, and you see someone that is much more anergic. Sometimes it's actually even difficult to arouse them. They fall asleep and you cannot wake them up, so it is a completely almost opposite picture one and the other. At the end of the day, though, I mean, you are going to ask the question, but if you definitely have a suspicion, you do a drug toxicology test. You can screen. That's one of the advantages in terms of methamphetamine, that methamphetamine is a drug that we can screen, number one, and number two, because it takes a long time for your body to detoxify, you'll be able to pick it up. And I think that's one of the elements that we should be more proactive perhaps on starting to do -- testing for methamphetamine in those situations where you suspect that. Very important, for example, one of the things that to me has been very frustrating as the director of NIDA is to get a perspective about the impact of drugs in car accidents, because most emergency rooms are not testing for the drugs if you a person in an accident, since the insurance will not pay then for the treatment. Well, that's utterly wrong. We need to start to recognize that we need to treat the patient. That's our obligation as physicians, but at the same time, we need to understand the nature of what brought them there. So we cannot have both of them together. So I would encourage when you suspect based on the physical signs, that you screen for drugs, for the methamphetamine. DR. CLARK: You've got individuals who are presenting, as was previously

mentioned, with dermatologic lesions, individuals who are presenting, especially if they're relatively young, with renal functions or with coughs, with evidence of strokes, with paresthesias, you may want to ask about that, particularly between the ages of 18 and 45, where, as some of the emergency literature points out, anybody who comes in who's 30 years old with chest pain, you better rule out a stimulant, because unless that person has a family history of early cardiac dysfunction, disrhythmias, it's more likely some exogenous precipitant. So these are the kinds of things that you'll want to check out. Someone who's brought in, as Vicki pointed out, she goes to her doctor and says, look, you know, I've got these things under my hands. And you examine them and there's nothing there. You may want to -- you want to rule out substance use. And so we are promoting routine screening with the objective of helping that person deal with the problem. This whole notion of screening and brief intervention, early intervention, so that indeed we start communicating the message that it is not something that's purely organic. It's something associated with your substance use. ATTORNEY GENERAL GONZALES: Okay. There's a question back here. QUESTION: Thank you very much. My name is Dr. David Goldsmith. I'm on the faculty in the School of Public Health. One of the things that has arisen in some of our thinking about this was discussed very briefly, and I just would like to raise it again. We have heard about concerns about the -- and was mentioned, the solvents and the other chemicals that are used in the meth cooking process. And I am wondering if there are guidelines and suggestions for protecting the law enforcement personnel. In some cases, it's going to be first responders, in other cases, fire department personnel who may be the first people on the scene of finding a meth lab. And as an extension of that, a question about remediation of some of the cooked chemicals, the meth chemicals that are flushed down the toilet or disposed of in backyard waste areas and things like that. Is there more guidance with regards to how communities can do a better job of remediating some of these hazardous materials? MR. RANNAZZISI: Well, let's take the second question first. There is a book that was just published this year. It's an update called The Clandestine -- Guidelines for Clandestine Laboratory Clean-Ups. I believe it's on the DEA website. That basically sets out what the guidelines are for cleaning up a clandestine lab and how agencies should approach cleaning up a clandestine lab. As far as remediation, again, remediation is a very, very difficult task. A special company has to come in to do the remediation. There was a study done, was it National Jewish Hospital study? But there was a study done on lab toxicity. I can't remember the study. I believe it was National Jewish Hospital study, and it showed

residual contamination in labs at certain points in time. It's a study that you really should look at. Again, law enforcement goes in and we do gross contaminant removal. We take away all the immediate waste. We can't do a residual cleanup, we can't do a remediation, because we just don't have the resources nor -- it's just a very difficult process to do. And when you're dealing with 17,700 incidents, it becomes an impossible task. Health departments are notified when we go in and do a lab cleanup. Health departments, local county agencies, and we expect that with their notification, they'll take the proper steps with the home owner. Now as far as first responders, DEA trains many police officers throughout the year, clandestine lab response, first responder and train the trainer for first responder. We try and get local officers trained so then they can turn around and train their departments in what to look for. Now if you've gone through the clandestine lab training course, the lab safety and lab investigation course, you're perfectly trained to go out and dismantle one of these labs, to go in and operate safely and effectively. You should not have any issue -- you're issued all the equipment to safely go in and dismantle. Now, obviously, fire departments are usually, especially in a lab explosion, they'll be the first on the scene. We're hoping that those train the trainers, those trainers that we've trained, go out and not only do the police departments but do the fire departments as well. And our divisions have -- our division officers, our clandestine lab safety officers and our clandestine lab coordinators in our divisions throughout the United States have actually gone out and trained fire departments. So we're trying to get the word out. We're trying to get everybody to understand the dangerous nature of these labs and what to do when you get in there. It's just, you know, we need help. There's only 5,000 DEA agents, and there's a very small portion of them that are lab trained, so that's why we use the train the trainer program. DR. CLARK: We have been working with the DEA. SAMSA, ONDCP, with governor summits. And I think the DEA has been very assertive in not only the hands-on, but also getting the message out at the governors level where you've got prevention people, environmental health people, as well as law enforcement and first responders. So I think this ongoing dialogue heightens the awareness and provides access to information. It isn't just a one-shot we're going to train five people.

So I want to remind Joseph that the DEA has been active in the governors summit, and we've had these summits in multiple jurisdictions across the country, and it's an ongoing commitment, and we're working most recently with Scott Burns at ONDCP to continue to foster that. So that information is an ongoing thing, because we know people come and go in the workforce. But with the ongoing top-to-bottom kind of exposure of the information, that awareness persists. ATTORNEY GENERAL GONZALES: Well, we've come to the end of our time, and I apologize to those who have been unable to ask questions, but I want to be respectful of the panelists' time. I want to thank the panelists for participating in today's forum. I also of course want to thank George Washington for hosting today's forum. I also want to acknowledge our dedicated partners who are here today from the Partnership for a Drug Free America, the Community Anti-Drug Coalitions of America, the Fraternal Order of Police and the National District Attorneys Association. So, your participation, your involvement in this issue, being here today, sends a very strong signal. The information we gather here today, sharing it with people in the communities, is probably the best deterrent for meth use and meth addiction, and this is the beginning of the dialogue. It's certainly not the end of the dialogue. It's very, very important that we take the information that we've learned today and share it with the communities around the country. And that will be the most effective way in dealing with this problem. So, again, thank you for coming. ###