The Cut of Your JIB Costs us All

The Cut of Your JIB Costs us All

No.  In this case the cut of your Jib is not a reference to nautical slang but rather to a recent public health emergency in Eastern Canada that costs us all.  Imagine, the arrival of a 36-year-old female to the local Emergency Department (ED) accompanied by the Royal Canadian Mounted Police (RCMP) after having been picked up outside a local convenience store. The patient had been acting erratically and speaking to herself.  RCMP stated that the patient admitted to using street drugs prior to the incident, including smoking crystal methamphetamine, otherwise known on the street as “Jib.” She was brought into custody and detained.

While in custody, she developed extreme agitation and paranoia. She stated repeatedly to RCMP that she had “charges” (bombs) under the skin of her right arm and hand. She argued with police that these charges needed to be removed from her body and that if they weren’t removed, they would explode and kill her. Despite best efforts by RCMP to reassure the patient, she proceeded to bite the skin overlying her right 2nd metacarpophalangeal (MCP) joint and right forearm in an attempt to remove the charges. She entered into the subcutaneous fat and came close to disrupting the joint capsule before she stopped. She allegedly tried to use her fingernails to dig into her right forearm after biting into it. Thankfully, she stopped before any significant damage had occurred. She was then brought to the ED for assessment.

On arrival the patient’s vital signs were as follows: heart rate 130 bpm, blood pressure 170/100 mmHg, respiratory rate 30 bpm, oxygen saturation 98% on room air, temperature 37.6 degrees Celsius. Her GCS was 15. She was in a state of excited delirium and was having auditory and visual hallucinations. She felt unsafe and was extremely paranoid. Cardiovascular and respiratory examinations were unremarkable aside from the obvious sympathomimetic response. Abdominal examination was non-contributory. She had an obvious bite injury over her right 2nd MCP with an intact extensor tendon.  Her forearm demonstrated an open wound that was not actively bleeding, and she had scratches and abrasions over her right patella with no significant skin disruption.

With helpful counseling, intravenous access was established and the patient was given parenteral midazolam (Versed), a benzodiazepine. She required, in total, 15 mg of parenteral Midazolam to attain reasonable control of her symptoms for further assessment. She subsequently received 5 mg of parenteral haloperidol (Haldol), a first-generation antipsychotic, with marked improvement in her symptoms. Furthermore, her heart rate, blood pressure, and respiratory rate all returned to normal. Her laboratory analyses were all within normal limits, aside from a slightly elevated creatine kinase (CK), likely from a combination of extreme muscle use and dehydration.

Her hand and forearm wounds were irrigated copiously and loosely closed with non-absorbable sutures. She was given tetanus and antibiotic prophylaxis and follow up was arranged with Plastic Surgery. She remained sedated overnight and was discharged from the ED the next day, completely unaware of her psychotic presentation.

Methamphetamine is a powerful central nervous system (CNS) stimulant that produces alertness, increased energy, and wakefulness.1 It inhibits dopamine re-uptake at the synapse, thereby increasing dopamine concentration at the synaptic cleft.2 There is also some increase in norepinephrine levels. The powerful addictive properties of methamphetamines are mediated through the dopaminergic mesolimbic pathway3. This pathway produces the euphoric response that is demonstrated when methamphetamines are used.

Crystal methamphetamine (Jib) is a highly stable crystalline form of methamphetamine with unique properties. The psychoactive ingredient, S-methamphetamine hydrochloride, vaporizes without pyrolysis. This allows near-complete delivery of the psychoactive substance to the user creating an immediate effect of euphoria.  This is thought to be one of the factors driving its powerful addictive properties.4

Jib use in Canada is not as high as other illicit drugs, but its use is on the rise.5 Several jurisdictions report a three-fold increase in Jib use in vulnerable populations, including those accessing harm reduction programs. Furthermore, a reported 590% increase was reported in methamphetamine-use related drug offences from 2010-2017 (Canadian Centre).  Anecdotally, a discussion with a recent patient revealed that Jib is financially much more accessible than other illicit drugs, with reports of intoxication being attainable for upwards of 48 hours for as little as $5CDN.

The clinical effects of Jib use are widespread. Direct effects include euphoria, sexual arousal, psychosis, paranoia and agitation. Indirect effects include tachycardia, hypertension, and tachypnea. Often patients have formication (a sensation of foreign body or moving object on or underneath the skin) which has been shown to increase the risk of Staphylococcus aureus skin infections.6

The mainstay of treatment of Jib-induced delirium and psychosis are sedative medications. Benzodiazepines are first-line medications and generally inhibit the neurological excitatory pathways responsible in Jib toxicity. Lorazepam (either oral/sublingual or parenteral) and midazolam (parenteral) are often required at high doses to suppress clinical toxidromes.7 First-generation (typical) antipsychotics, such as haloperidol, are effective longer-term sedatives.  Second-generation (atypical) antipsychotics, such as olanzapine, are effective sedatives as well. There is a theoretical risk with concomitant administration of benzodiazepines and second-generation antipsychotics, but this has largely been debunked.8 Of note, ketamine should likely be avoided in these patients. Its properties as an effective dissociative medication would be complicated by its potential for ketamine-induced hypertension, tachycardia and excited delirium.9 This can be particularly concerning with the increased use of pre-hospital ketamine for analgesia and sedation.

Crystal methamphetamine-related ED visits present a unique set of challenges to all health care professionals.  From the prehospital setting, to the ED and potentially beyond to inpatient care, patients are often highly volatile and require intensive nursing care. Moreover, they routinely require law enforcement personnel accompaniment in the ED. They often have a prolonged ED stay as a result of their need for sedation and monitoring. Given that these patients require a relatively larger proportion of ED resources, an argument could be made that any further diversion of ED resources to this patient population could alter the ability of the ED to care for the rest of its patient population.

It is well known amongst health-care providers in the ED that acute care bed access is becoming increasingly challenging. Data collected from an Emergency Department in Eastern Canada shows that the ED is routinely above 100% capacity. Furthermore, nursing resources are at a critical shortage as reported by the Canadian Institute for Health Information (CIHI).  An estimated 41% of current nursing staff employed in the province of New Brunswick, Canada, will be eligible to retire in the next five years.10 Given these facts, a short- and long-term strategy to manage methamphetamine use and misuse in our region is required imminently.

The clinical case outlined above is a snapshot of the extreme dangers of Jib use. This is one of many cases seen in the ED and anecdotally these cases are becoming much more commonplace. This case report and clinical review was conducted to highlight the urgency for support and leadership in dealing with the effects of Jib use in our community and our region.

In summary, the cut of your JIB costs us all! Jib use and abuse is increasing within the region and emergency department visits secondary to Jib use are on the rise. Patients presenting with a Jib-induced toxidrome are challenging and require careful management and many resources. Coupled with increasing ED wait times and a paucity of ED resources, Jib use should be considered a public health emergency. Further strategies to prevent Jib use and Jib-related health effects are required.

References

1. Bramness, J. G., Gunderson, O. H., Guterstam, J., et al. Amphetamine-induced psychosis – a separate diagnostic entity or primary psychosis triggered in the vulnerable. BMC Psychiatry 2012, 12:221-228.

2. Seiden, L. S., Sabol, K. E. Amphetamine: Effects on catecholamine systems and behavior. Annual Reviews in Pharmacology and Toxicology 1993, 32: 639-677.

3. Robinson, T. E., Berridge, K. C. The neural basis of drug craving: An incentive-sensitization theory of addiction. Brain Research Reviews 1993, 18(3): 247-291.

4. Cruickshank, C. C., Dyer, K. R. A review of the clinical pharmacology of methamphetamine. Addiction 2009, 104: 1085-1099.

5. Canadian Centre on Substance Use and Addiction November 2018. Methamphetamine. Retrieved from https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Canadian-Drug-Summary-Methamphetamine-2018-en.pdf

6. Cohen, A. L., Shuler, C., McAllister, S., et al. Methamphetamine use and methicillin-resistant Staphylococcus aureus skin infections. Emerging Infectious Diseases 2007, 13(11): 1707-1713.

7. Wilson, M.P., Pepper, D., Currier, G. W., et al. The Psychopharmacology of Agitation: Consensus Statement of The American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine 2011, 13(1): 26-34.

8. Williams, A. M. Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness. Mental Health Clinician 2018, 8(5): 208-213.

9. Hopper, A. B., Vilke, G. M., Castillo, E. M., et al. Ketamine use for acute agitation in the emergency department. Journal of Emergency Medicine 2015, 48(6): 712-719.

10. New Brunswick Nurses Union 2019. New Brunswick’s nursing shortage. Retrieved from https://nbnu.ca/advocacy/social-justice/new-brunswicks-nursing-shortage/

Cite this article as: Michael Matchett, “The Cut of Your JIB Costs us All”, EMcenterED Blog. December 16, 2019. Available at https://emcentered.com/the-cut-of-your-jib-costs-us-all/

Please check out some of our other posts such as The Death of CAC.

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