D. Cross System Collaboration

The majority of treatment programs in Washington State do not provide treatment services that specifically target Meth users either alone or in combination with other stimulant abusers. Where specialized treatment models for Meth addicts exist in Washington State, they vary considerably from provider to provider. However, most of the treatment models targeting Meth addicts combine elements from several treatment models including the traditional Minnesota Model and Reality Therapy to provide an intense and long-term treatment program. These approaches attempt to integrate elements such as family therapy, group therapy, and 12-step abstinence-based programs with reality therapy techniques. Reality therapy elements help the patient reconnect with other people and their living environment to meet the basic human needs for survival, love, belonging, power, freedom, and fun.

Research at the national level is attempting to identify the most effective methodologies for treating Meth addiction. The National Institute of Drug Abuse (NIDA) recommends cognitive behavioral interventions as the most effective treatment for Meth addiction. According to NIDA, these approaches help modify the patient’s thinking, expectancies, behaviors, and increase skills for coping with various life stresses. NIDA also recommends that patients participate in long-term Meth recovery support groups in conjunction with treatment.

The most recognized model for treating Meth addiction is the MATRIX Center model. This model incorporates elements of behavioral therapy, motivational interviewing, positive reinforcement, drug education, 12-Step relapse prevention, and family cooperation.

The experiences of some programs with the MATRIX model, such as the New Leaf program, report better outcomes with a longer course of treatment. Data collected from MATRIX model participants indicate statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission.

In an effort to close the gap between Meth research and treatment practices, the Center for Substance Abuse Treatment (CSAT) recently awarded grants to seven agencies on the West Coast to study the effectiveness of the MATRIX model. Five grants were awarded to California programs, along with one in Hawaii and one in Montana.

According to the Substance Abuse and Mental Health Services Administration and its CSAT, and the recently published Public Health Service Recommendations, psychosocial treatment approaches that incorporate well established psychological principles of learning are appropriate for and effective in treating Meth addiction. The Consensus Panel organized by CSAT recommends a contingency management approach for treating stimulant users. Among those modalities especially cited by the Consensus Panel as effective is relapse prevention first and foremost.

Relapse prevention teaches clients critical skills to prevent resumption of use and minimize impacts of reuse, how to cope with cravings, substance refusal assertiveness skills, general coping and problem solving skills, and how to apply strategies to prevent a full-blown relapse should an episode of substance use re-occur.

It is difficult to estimate the number of children in Washington State who are at risk from parents addicted to Meth. The Division of Children and Family Services (DCFS) does not report data on drug use by the type of drug involved. Residential Meth lab cleanup crews estimate they find evidence that children are or have been at the lab site in at least 35 percent of the drug labs they are called to investigate. It is routine now for law enforcement to call in Child Protective Services (CPS) to intervene on behalf of these children.

In response to the danger faced by children and CPS workers exposed to Meth in the course of an investigation, the Department of Social and Health Services is working with the WSP, the Department of Health, and the Washington State Community, Trade and Economic Development to develop a model response protocol. Additional training is planned to help CPS workers recognize Meth situations how to work with CPS clients involved with Meth.

It is not surprising that children are usually removed from the home until Meth-addicted parents have stabilized and are no longer using drugs.

Children found in the homes of Meth addicts may be neglected and are often found living in filthy, unsanitary conditions. Dr. Alex Stalcup recommends four steps for family re-entry:

One way to document the impact Meth abuse has on families is to look at the data for dependency filings. One example is dependency filings in Clallam County where in 1996, eighty-four percent of the children had parents who were personally impacted by substance abuse. That percentage rose to 91 percent of the dependency filings for 1997. Due in large part to a unique approach of working with substance abusing parents, 71 percent of the children who were the subjects of dependency filings in Clallam County in 1997 have been successfully reunited with a parent.

The DCFS social workers of Clallam County have developed a community-wide, multi-agency approach for working with substance abusing families. This approach involves the use of an outreach worker to engage the client in treatment. The outreach worker also works actively with inpatient and outpatient treatment providers to assist in follow-through for assessment, referral to inpatient treatment, and post-inpatient services.

Proactive discharge planning targets family reunification needs, including an assessment of housing needs, which takes place while the client is still in inpatient treatment. Serenity House Shelter and Evergreen Family Village in Port Angeles are used successfully to provide stable, drug-free transitional housing. Following this, clients are often assisted with finding housing through the Clallam County Housing Authority and Section 8 Housing. Throughout the process, joint staffings are held with the CPS worker, the treatment provider, and other agencies working with the family. Random UAs (urine analysis to determine drug use) are continued throughout this process to ensure that the client is remaining drug-free. Their experience in working with Meth addicts is that this process works best when inpatient services are provided for three to six months, and parents have demonstrated the ability to remain drug-free before family reunification takes place.

The NEON program in King County is a community-based program that combines prevention, education, and treatment models for a specific, high-risk population. NEON stands for Needle and sex Education Outreach Network. The program targets Meth use among gay and bisexual men. NEON is a collaboration between Public Health – Seattle and King County, and Stonewall Recovery Services.

The NEON program incorporates behavioral change theory, ethnographic research, and input from members of the Meth-using population in its project design. NEON’s continuum of mutually-supporting prevention, education, and treatment options encourages Meth users to reduce the harmful effects of their Meth use by/through:

NEON activities include peer-based outreach/education, abstinence groups, individual and group counseling, and the production and distribution of educational pamphlets, brochures, and needle exchange services.

The National Institute on Drug Abuse recommends several steps be followed in building an effective prevention approach:

The risk and protective factor-based model for prevention programs used in Washington State is consistent with the recommendations for prevention programs issued by the National Institute on Drug Abuse. Washington prevention programs begin with a community assessment of indicator data for the risk factors associated with increased drug abuse prevalence. Research-based prevention strategies targeting specific risk factors can then be implemented. These strategies work by either directly reducing the risk factor or by creating buffers (or protective factors) that help youth cope with the conditions in family, school, community, and peer domains that increase the risk youth will choose to use and abuse drugs. A topic for discussion among the Meth Workgroup members was whether this approach is adequate to deal with the growing Meth problem in our state.

Recipes for Meth are readily available on the Internet, and new recipes are continually being refined to adapt to the materials available.

Currently, there are at least three different processes used in the clandestine manufacture of Meth. In part, the current increase in the illegal manufacture of Meth is due to a newer method of cooking Meth that is easier and requires less equipment and set-up than the previously used methods. This method is similar to on used by Germany during WWII and is, therefore, known as the Nazi method.

There is a serious health threat to public employees such as law enforcement officers, child welfare, and even community members who may inadvertently come into contact with substances from illegal labs. Containers of chemicals, such as anhydrous ammonia, may explode when improperly stored. Physical contact or inhalation of certain precursor chemicals can cause lung or liver damage.

One approach to controlling the illegal manufacture of Meth is to control access to the precursor substances used for its manufacture. This can be difficult since most are common substances that are readily available from public retail outlets. Examples include pseudo-ephedrine commonly used in cold tablets, anhydrous ammonia used in fertilizers and refrigeration, lithium used in camera batteries, and red phosphorus used in road flares and match striker plates. Other precursors include ephedrine, ethyl ether, iodine, thionyl chloride, chloroform, palladium, perchloric acid, tetrahydrofuran, ammonium chloride, and magnesium sulfate.

There are ongoing efforts in Washington State to inform retailers who sell the precursors used for manufacturing Meth. Large retail store chains such as Wal-Mart and 7-Eleven have been particularly helpful in controlling and reporting the sale of large volumes of lithium batteries and cold tablets containing pseudo-ephedrine. Costco has also responded by limiting sales of products containing pseudo-ephedrine to no more than two grams.

In 1999 a group from the FarWest Fertilizer and Agrichemical Association met in Moses Lake to learn how to protect themselves from theft, and how to identify a potential sale of anhydrous ammonia for illegal use in the manufacture of Meth. Following this meeting, the group researched what legislative action could assist in controlling this problem. Their efforts were instrumental in developing legislation passed during the 2000 state legislative session.

Anhydrous ammonia, which is 82 percent nitrogen, is widely used by farmers as an inexpensive fertilizer. Mark-up on the black market for anhydrous ammonia can be as much as 100 percent, making the storage tanks of fertilizer distributors as well as individual farmers targets for theft. Distributors and farmers are concerned about the dangers of tampering with storage tanks and the potential liability should anyone be injured during the theft or use of stolen anhydrous ammonia.

In 1998 the Washington Legislature took action to double the sentence for manufacturing Meth. Legislation was passed during the 2000 Washington State legislative session making theft, or possession of anhydrous ammonia with the intent to manufacture Meth, a Class C Felony. Another bill, passed during the 2000 legislative session, added two years to the standard sentence for persons convicted of manufacturing Meth when children are present.

Several other states, including Arkansas, Illinois, Iowa, Kansas, Mississippi, Missouri, Nevada, Tennessee, and Texas, have taken specific legislative action to control the sale of some precursors for the manufacture of Meth. Some state laws are specific to anhydrous ammonia, making it a felony to purchase it for the intent of producing a controlled substance. Other states, like Iowa, have included purchase of any of the major precursors in their legislation. Proof of intent varies. Some states place the burden of proof that the precursor substance was purchased for agricultural use on the defendant. Other states place the responsibility on the prosecutor to disprove agricultural use or to specify intent to use the chemicals for Meth production.

In Washington State, law enforcement works closely with the Department of Ecology and local health departments on the investigation and cleanup of drug labs. Illegal labs are most often found in rented houses, apartments, and motel rooms. However, an increasing number of labs are also being discovered in motor vehicles, abandoned dumps, campgrounds, restrooms, and on open public lands.

Law enforcement agencies responding to these reports have a primary responsibility to obtain evidence of illegal activity for arrest and prosecution. The health departments and the Department of Ecology are responsible for public health and environmental concerns from contamination of the structure and surrounding land and water by the toxic chemicals used in the manufacture of Meth. All are currently struggling to meet a demand for service that far exceeds their budgeted resources.

Meth use and manufacturing have severely impacted law enforcement in Washington State since first appearing in the 1980s. Meth use has been linked to a wide variety of crimes ranging from mail theft to homicide. As an example, Thurston County experienced seven homicides in 1999, with five related to Meth.

Meth use often results in unpredictable paranoia, which heightens the threat/risk to citizens, including responding law enforcement officers. Numerous officers have received Meth awareness training, which includes specific tactics on how to handle "tweaked out" users; however, the use of deadly force has been necessary in some cases.

Meth manufacturing sites, often referred to as Meth labs, have dramatically increased since 1987 when the first response procedure was developed. Washington currently has five established Meth response teams:

The Drug Enforcement Agency (DEA) also has the ability to respond, but has focused most of their efforts on much needed lab response associated training.

Meth lab investigations in Washington, as reported to the Western States Information Network , have risen from 44 in 1994 to 567 in 1999. This dramatic increase has resulted in a severe impact to law enforcement response teams. The SIRT is the sole response team for 37 of the 39 counties. The SIRT’s responses escalated from 81 in 1995 to 262 in 1999. As a result, agencies requesting SIRT response must often wait for several days. This is costly for the requesting agency, and it results in dangerous delays in the removal of hazardous chemicals from community sites.

Many labs are discovered during the course of other criminal investigations. Pierce County Sheriff’s Office has discovered a direct correlation between the rising number of Meth labs and increased reports of domestic violence.

The detrimental effects of Meth production and use on children are seen first-hand by SIRT members. SIRT has found children, or evidence of their presence, at an average of 35 percent of Meth lab responses. Many children are found living in deplorable living conditions that include incredible filth, loaded weapons, accessible drugs, and dangerous contamination. A recent lab response in Pend Oreille County found an 11-year-old girl living alone in a mobile home with no running water, no bed, no furniture, and a broken door. The girl’s parents, Meth users and manufacturers, had placed her in the trailer because the main residence was being used as a Meth lab.

The volatile chemicals and poisonous gases resulting from Meth manufacturing occasionally result in fires and explosions. Several suspects have been critically injured and some have perished. In June 1999 a Thurston County husband and wife died from a Meth lab fire leaving two children who fortunately were not present at the time.

Additional resources are necessary to properly address the Meth lab response problem. Response teams are inundated with calls for service and operational costs continue to soar.

Law enforcement teams are experiencing difficulty in answering requests for processing Meth labs and are unable to provide adequate, proactive investigative ability in order to curb the Meth epidemic. Efforts are underway to form multi-agency regionalized response teams.

Since 1990 the Department of Ecology has been responsible for handling and disposing of hazardous substances found at illegal drug labs. Four regional response teams provide around the clock, on-site response, and disposal services. Ecology responders work closely with local and state law enforcement agencies, fire and emergency medical departments, and health authorities to respond to and clean up drug labs.

Substances found at drug labs can include various acids, sodium hydroxide, flammable solvents, anhydrous ammonia, lithium and sodium metals, red phosphorus, and pressurized cylinders and containers. Some substances can cause severe injury or death if inhaled or touched, while others can react violently if heated, mixed with water, or exposed to air. Illegal drug labs also commonly contain a wide assortment of contaminated glassware, hypodermic needles, and other debris. All these materials must be properly disposed of to protect public health and the environment.

Pressurized gas cylinders represent a particular problem for responders. Ecology has found fire extinguishers, scuba tanks, and soda dispensers used to generate hydrogen chloride gas. Anhydrous ammonia, a highly poisonous and corrosive material, is found in modified propane tanks and large pressurized cylinders. These tanks are extremely unstable and can be difficult to depressurize. Often, the homemade valves on these containers are so crudely crafted and corroded, the only safe way to ventilate the tanks is to have local law enforcement officials shoot them, under strictly controlled conditions, with a high-powered rifle. In January 2000, two 150-gallon commercial ammonia cylinders, eight 2½ to 5-gallon propane tanks with ammonia, and two pump sprayers containing hydrogen chloride (HCl) were found in one dumpsite in Oakville. During the first two months of 2000 alone law enforcement officers, working with Department of Ecology staff, shot 132 containers containing ammonia or hydrogen chloride acid gas.

Ecology staff pioneered many innovative and cost saving procedures as response expertise grew in proportion to the drug lab numbers. The 789 labs reported during 1999 have created a serious workload issue for Department of Ecology staff who are seriously overextended. This is particularly true for the southwestern region of Washington where about 60-70 percent of Washington’s drug lab responses occur. With no fiscal relief in sight for this current biennium (1999-2000), Ecology has begun to curtail drug lab services in order to stay within budget allocations.

The Washington State Department of Health (DOH) and local health jurisdictions work closely with law enforcement, the Department of Ecology, and other agencies to combat this serious drug problem.

Both the DOH and LHJs are concerned about the health risks associated with illegal Meth manufacturing labs (clandestine drug labs or clan labs) because innocent children and adults can be potentially affected by the residual chemicals left at these labs. Health hazards vary with the method of producing the drug and the drug produced. Generally, chemical residues left behind at these clan labs can cause chemical burns, upper respiratory distress (cold and flu-like symptoms), and in some instances, death. Young children, under the age of three years, are especially vulnerable and have become chronically ill.

The number of illegal, residential Meth lab sites in Washington increased from 18 in 1994 to 223 in 1999 (Figure 2). At all of those sites, Meth was produced using a combination of hazardous, toxic materials. The Meth production has also resulted in hazardous wastes (an estimated six pounds of waste is generated per pound of Meth produced). By law, the LHJ is responsible for assessing the health risks at a residential Meth lab site. When the site is found contaminated, the LHJ is responsible for ensuring the site is decontaminated. As the number of sites has increased, the LHJ resources to respond have been hard pressed to keep up with the demand for services.

The DOH and LHJs are concerned about the public health risks associated with illegal Meth manufacturing. The residual chemicals left at these lab sites potentially affect young children (under the age of three years). The health effects of chronic, low-level exposure to Meth on young children are largely unknown. Nothing is known about the health effects of the isomers produced at these labs. Health hazards and risks vary with the method of producing Meth. Also, there are many unknown health risks with these labs because the cooking normally overheats and/or under reacts the manufacturing process resulting in isomers.

Typically, residential lab sites have hypodermic needles and other drug injection equipment left in the wastes. These present biohazards associated with Hepatitis C, HIV, and AIDS. These wastes must be safely handled and properly disposed.

In urban areas hospital emergency rooms are prepared to deal with treating individuals who have been exposed to substances in Meth labs.

However, there is a need to provide more training and technical assistance to emergency room staff in smaller, more rural areas. There is also a need to provide more education and technical assistance to private medical providers who may come into contact with individuals who have been exposed to meth lab chemicals.

Also, DOH and LHJs are concerned about the cost to property owners associated with the decontamination of illegal Meth manufacturing sites. DOH is working with LHJs, contractors, real estate interests, property owners, and others to reduce decontamination costs. One strategy has been to allow the property owner to decontaminate the site without using the services of a certified contractor.

Past data indicates the number of drug lab sites will double each year. In the year 2000 it is estimated there will be more than 400 lab sites in Washington. This may very well overwhelm the resources of LHJs. More resources are needed to assess the risks, and cooperative effort by all parties is needed to reduce the number of labs.

The pervasiveness of Meth impacts in communities across Washington State has led to a number of efforts for cross-system coordination among agencies and programs that have rarely been partners in the past. Few agencies challenged by the Meth epidemic have failed to acknowledge the need to work collaboratively for solutions. The Meth Workgroup applauds the many efforts in communities and agencies across the state where people are coming together to attack this problem.

In many communities, Meth action teams are forming with representation that includes health departments, law enforcement, courts, child welfare, schools, businesses, local governments, substance abuse providers, and community crime and substance abuse prevention groups. At the state level, a coordinating committee of state agencies meets on a regular basis to share information and discuss strategies. Most of these agencies have participated in the preparation of this paper.

There was considerable discussion about how to build and sustain a proactive, collaborative strategy in the Meth Workgroup sessions to develop this paper. There was agreement that this is necessary in order to make the best use of the information, resources and skills of all agencies impacted by the Meth epidemic. This is a major focus for the Recommendations section that follows.

In communities where collaboration in already occurring, it is important to sustain and augment these efforts to a level that will maximize their effectiveness. This requires access to reliable, cross-system impact data, and training and technical assistance that includes all agencies and programs that come into contact with individuals, children, or families impacted by Meth. However, it is also essential that there be a clear commitment to develop and carryout joint responses to Meth incidents and services to individuals, children, and families impacted by Meth.

To sustain a collaborative Meth reduction strategy at state level agencies, it needs to be a written commitment to enable agency staff to participate effectively in an ongoing collaborative process. The Meth Workgroup believes, at a minimum, this requires a Memorandum of Understanding among members of the agency team that outlines individual agency responsibilities, joint procedures for responding to Meth impacts, and an agreement to share information and data.

Data was a frequent topic for the Meth Workgroup. Examples of the excellent data available are included in this paper. However, there is no system to routinely collect data across agencies for trend analysis and evaluation. Without this, it is difficult to accurately assess statewide impacts and plan effective reduction strategies.

One statewide analysis the Workgroup believes is necessary is one the Office of Financial Management can provide–a cost/benefit analysis of state agency programs currently impacted by the Meth epidemic. This could provide a useful tool for planning effective, proactive strategies and for establishing benchmark targets for Meth reduction.

The Meth Workgroup recommends a consortium of state agencies develop a written Memorandum of Understanding (MOU) among the member agencies to detail a strategic management approach to reduce Meth impacts in Washington State. The MOU should lay out a process for establishing and modifying cross-system solutions, specify the role of each consortium agency, and commit each agency to carry out specific responsibilities for dealing with Meth impacts. Other duties of the consortium should include the following:

The Meth Workgroup recommends Washington State Community, Trade and Economic Development, through its Community Mobilization Program and the Community Mobilization contractors in Washington’s 39 counties, form Action Teams in local communities heavily impacted by Meth. The purpose of these teams would be to respond to Meth impacts requiring an immediate community-level response. These teams would also act as community advisory groups to inform the consortium of state agencies of needed changes in policy and procedures to support community initiatives to reduce Meth impacts. Action Team membership should be determined by the needs in each community, but, at a minimum, should include law enforcement, justice, business, labor, education, public health, environmental health, child welfare, public housing, substance abuse treatment and prevention providers, local researchers, and representatives from community organizations.

The Meth Workgroup recognizes the Washington treatment system is so overextended that currently only one in five persons needing inpatient and/or outpatient substance abuse services have access to treatment. However, the Workgroup feels strongly that successful treatment of Meth addiction requires a concentrated, long-term approach currently not available in most communities. We believe that an adequate cost/benefit analysis, as proposed under the cross-system collaboration recommendations, will support the cost effectiveness of this treatment approach.

Treatment data from the TARGET system at the Division of Alcohol and Substance Abuse provides some of the best indicator data available for tracking drug abuse trends in Washington State. Unfortunately, this system does not break out Meth from other stimulant drugs in the collection and analysis of treatment data. The Workgroup recommends the following modifications to the collection and analysis of TARGET system data:

The generic Risk and Protective Factor model for prevention in Washington State provides an excellent basis for the development of Meth-specific, community-based prevention approaches. The Workgroup recommends Meth-specific prevention programs be piloted to assess whether these prevention efforts are more successful in reducing Meth use than generic drug abuse prevention programs.

The Meth Workgroup feels strongly that reducing the number of illegal Meth labs will require the participation of a well-informed public. Most labs are still discovered by accident in the course of other police business. A pro-active approach to discovery and investigation of suspected lab sites cannot occur without the involvement of informed citizens in neighborhoods across the state. We recommend state government take action to assure a strong Meth awareness and education program is provided statewide. The Meth Workgroup also cautions policymakers that the success of such a campaign will depend on having agency capacity in receiving reports to make a timely and adequate response.

Design and conduct a public information campaign to educate the general public about Meth impacts, when and how to report suspicious activity that may indicate the presence of an illegal Meth lab. These include unusual odors and the dangers for environmental contamination and personal exposure to toxic substances at Meth labs and dump sites. An important segment of this training should be targeted toward educating owners of rental properties about Meth lab contamination and the costs of cleanup that are currently borne by the property owners.

The major concern for law enforcement, environmental, and health professionals involved in the investigation and cleanup of Meth lab sites is the increasing number of reports of Meth labs have made it impossible to provide the level of response necessary to assure public health and safety. Even so, there are a number of system improvements the Meth Workgroup believes will enhance the success of efforts to reduce the number of Meth labs.