Amphetamine Type Stimulants and Harm Reduction Experiences from Myanmar, Thailand and Southern China

Drug Policy Briefing Nr. 37 October 2011

By Tom Blickman 1

Problematic use of amphetamine-type sti- KEY POINTS mulants (ATS)2 has become a significant  Problematic use ATS has become a signifi- health and social problem in East and cant health and social problem in East and Southeast Asia, in particular the use of Southeast Asia. ATS use is associated with methamphetamine, the most potent am- potentially life-threatening communicable phetamine derivative and most widely used diseases in particular among vulnerable substance in the region. According to the groups such as female sex workers, youth United Nations Office on Drugs and Crime and migrants. (UNODC), East and Southeast Asia have  Incarceration of ATS users in compulsory one of the most established methampheta- drug treatment/detention centres is ineffec- mine markets in the world displacing tradi- tive. There is evidence of serious human tionally plant-based drugs such as heroin, rights abuses and relapse rates are extremely opium and cannabis.3 high upon release. Community-based interventions based on prevention, early inter- ATS use is associated with a range of com- vention, harm reduction and treatment offer municable diseases such as HIV, hepatitis B a more effective and humane alternative. and C infections and other sexually trans-  Prevention, treatment and harm reduction mitted infections (STI), tuberculosis and strategies are in their initial phases. There is a mental health problems, in particular lack of professional expertise and counselling among vulnerable groups such as female training, and little experience in dealing with sex workers and other workers in the the psychosocial and mental health prob- entertainment/hospitality industry (clubs lems. There is a need to develop effective and casinos); youth (specifically among prevention, treatment and harm reduction homeless, unemployed and incarcerated measures that fit the cultural and socio- youth), and migrants. There is an urgent economic circumstances in the region. need to scale up prevention, treatment and  There is an urgent need for donors and harm reduction services in the region to governments to introduce harm reduction avoid the further spread of these potentially measures to counter the effects of rising life-threatening infections. methamphetamine use. Services are still focused on injecting heroin users as the main Little is known about the methamphetami- problem and have little to offer for ATS ne market in the region. Prevention, treat- users. The earlier a comprehensive package ment as well as harm reduction4 strategies of harm reduction measures for metham- are in their initial phases. There are strong phetamine is introduced the better. indications that the situation is deteriora-  More research is needed to understand ting: the substances are becoming stronger ATS market and user trends, the negative (from pills to crystal methamphetamine or impacts of law enforcement interventions on ‘ice’) and methods of use are becoming levels and patterns of use, as well as the more harmful (from swallowing pills to chemical composition of the substances.

Transnational Institute | 1 injecting), and the number of ATS users – been highly successful in preventing avoid- especially among youth – keeps increasing. able harms, in particular, averting HIV and In this briefing we will try to give an over- hepatitis B and C infections. Some of these view of the situation with a special focus on measures are useful for problematic meth- Burma/Myanmar,5 while taking into ac- amphetamine use (in particular in the case count the context in neighbouring coun- of injecting drug use), but do not cover the tries. whole range of specific problems associated with problematic methamphetamine use. Law enforcement and supply reduction approaches currently dominate the response ATS users rarely use harm reduction ser- to ATS use in the region. These approaches vices, largely because they do not identify frequently result in unintended negative with opioid users, who often belong to dif- consequences. One of these consequences ferent user networks. Most ATS users do has been a proliferation of trafficking not perceive harm reduction services as routes and expansion of the market, the so- relevant to them. The needs of ATS users called ‘balloon effect’ of interdiction. Evi- are usually neglected and few services are dence suggests that use increases along new geared to their special needs.7 The develop- trafficking routes. Thailand’s 2003 ‘war on ment, evaluation and expansion of harm drugs’ led to increased border surveillance reduction interventions specific to amphe- and a move of direct trafficking routes from tamines, should be the first priority for the Burma to Thailand to more indirect routes international harm reduction community, over the Mekong river via Laos and Cam- according to the Global State of Harm bodia, resulting in an increase of metham- Reduction report of 2010.8 phetamine use in those countries. ATS harm reduction programmes have Another negative consequence of the zero- shown positive results in some countries. tolerance law enforcement approach is the However, these programmes are limited to widespread incarceration of ATS users in Australia and North America. As the effec- compulsory drug treatment/detention cen- tiveness of pharmacological and psycho- tres (CDTDCs) whose treatment goal is social interventions for stimulant users is abstinence. Although it is the most promi- limited, interventions to stabilise and mini- nent intervention in the region there is no mise the negative consequences of ongoing evidence of effectiveness. All the evidence methamphetamine use are of paramount suggests that relapse rates are extremely importance. A wide range of health and high upon release from the CDTDCs. social problems associated with stimulant There is also mounting evidence of human use are largely unaddressed by current rights abuses in these facilities.6 The vast services.9 According to the World Health majority of users are, in fact, not proble- Organization Regional Office for the West- matic and compulsory treatment risks ern Pacific there is a lack of professional creating problems where there are none . expertise and counselling training in the region, and little experience in dealing with Treatment and harm reduction in South- the psychosocial and mental health prob- east and East Asia mainly focuses on her- lems of ATS users. Consequently, there is a oin, opium and cannabis users. Although need to develop harm reduction measures the majority of countries in the region have that fit the cultural and socio-economic embraced harm reduction as a legitimate circumstances in Southeast and East Asia. drug treatment, harm reduction services that target ATS users are inadequate. Most ATS IN SOUTH-EAST ASIA AND CHINA harm reduction services have been designed for opioid users, and generally focus In East and Southeast Asia the main type of on injecting drug users. These efforts have ATS is methamphetamine in the form of

2 | Transnational Institute tablets, popularly known as yaba (‘crazy- provinces of southern China, is seriously medicine’) or yama (‘horse-medicine’) pills affected by the production, trafficking and in Burma and Thailand; and as ma-huang- use of methamphetamine on a large scale. su in China. High purity crystal metham- Whereas previously Burma, the bordering phetamine or ‘ice’ (rock-like crystals resem- provinces of southern China and Thailand bling frozen water; ya ice in Thailand, or have been most impacted by ATS, the bingdu in China) is increasingly popular in problem has shifted over the past years to the region.10 Less common are ecstasy type Cambodia, the Lao People’s Democratic ATS or psychedelic amphetamines (ya-E in Republic and Vietnam, due to shifting Thailand; yao-tou-wan or ‘head-shaking patterns of trafficking routes throughout pills’ in China). the region.

Ecstasy type ATS in the region is most The ATS boom in the region is an example likely methamphetamine mixed with keta- of what can be described as ‘displacement’: mine with little if any MDMA (‘real ecstasy’ a campaign against one drug (opium and primarily produced in Europe), or else heroin) can lead to the rise of an equally or MDMA imported from Europe mixed with potentially even more harmful substitute caffeine, heroin or ketamine in labs in (methamphetamine). International pres- China. A third popular substance is keta- sure and national opium eradication cam- mine (ya-K in Myanmar and Thailand; k- paigns led to a decline in opium cultivation feng or ‘k-powder’ in China), which is an and heroin production in the Golden anaesthetic that has hallucinatory effects Triangle. At the same time, a methamphe- and is also used in pure form.11 tamine market in East and Southeast Asia developed, and resulted in the rise of According to the 2011 Global ATS Assess- manufacturing facilities in what was tradi- ment by the UNODC, the Greater Mekong tionally an opium and heroin area. Subregion, which includes Cambodia, the Lao People’s Democratic Republic, Myan- Adding to the displacement were rising mar, Thailand, Vietnam and bordering opiate prices. The surrender of Khun Sa

Transnational Institute | 3 and his Mong Tai Army (MTA) in 1996, The increase in the use of methamphetami- the largest player in the Burmese opium ne and other ATS has been driven by both market, disrupted the regional heroin trade demand and supply, as well as profound and caused price instability. The MTA had socio-economic changes in the countries begun production of and trade in ATS in affected, which have moved from rural the early 1990s. MTA breakaway groups agricultural based economies to urban, also became heavily involved in large-scale industrial and market based societies. ATS methamphetamine production, flooding appeal to what is perceived to be a modern the Thai market. lifestyle, both recreationally and occupa- tionally. Stimulants fit better in the new According to the UNODC, Burma “re- competitive and industrious cultures of mains the major source of methampheta- rising economies in Southeast and East mine pills in the Greater Mekong Sub- Asia (Japan in the 1950s, South Korea and region. Most illicit methamphetamine Taiwan in the 1970s and then Thailand and manufacture takes place in the eastern part China) and the changes in work habits and of Shan State. Forensic profiling of ATS in work pace. Thailand suggests there are at least 12 methamphetamine manufacturing sites in Methamphetamines give ambitious, up- Myanmar. In addition, there are indica- wardly mobile, urban people the energy to tions that at least 50 different organized succeed and the urban and rural labour criminal groups are involved in activities forces a necessary stimulant to work more related to the trafficking of drugs from and longer hours needed in competitive Myanmar.”12 economies with poor labour conditions. Methamphetamine helps labourers endure While the reduction in the availability of backbreaking work in the fields and allows opium and heroin during the mid- to late affluent urbanites to party till dawn. 1990s resulted in opiate users shifting to methamphetamine, this alone cannot The rise of ATS also reflects generational account for the significant increase of ATS. differences and fashions of drug use. Although there is some overlap and inter- Opium and heroin use are associated with action in opiate and methamphetamine older generations. Opium is perceived as a use, the methamphetamine market has its substance for ‘old people’ and ‘backward own distinct dynamics. hill tribes’, while heroin is perceived as a drug for losers. ATS on the other hand has By 2006, the trend of a declining opium a social acceptance, particularly among market and an increasing ATS market was young Asians. ATS are becoming popular apparent in all countries in Southeast Asia. among urban youth and are consumed in Although China, Burma and Vietnam still entertainment facilities, such as bars, kara- list opium and heroin as their main prob- oke clubs, and nightclubs. ATS are consid- lem, Cambodia, Laos, and ailand cited ered to be non-habit forming and more methamphetamine as the leading drug of ‘fun’ to use, while opium and heroin are concern. China, however, stated that considered a thing of the past, and seen as consumption in pill and crystal form was dangerous and addictive. still increasing. Thailand reported that use of crystal methamphetamine had increased, TRENDS IN USE IN THAILAND, BURMA but use of yaba was on the decline. Laos AND YUNNAN and Thailand ranked yaba as their primary drug of concern with only Laos reporting The main trends regarding use patterns are an increase in heroin too. Burma and a shift from opiates (opium/heroin) to ATS China still listed heroin first, both reporting and a shift from work-related use of meth- a decrease in its use.13 amphetamine to recreational use. Substan-

4 | Transnational Institute ces are getting stronger (from yaba pills to you use only two tablets “you don’t get high ‘ice’ or crystal methamphetamine) and you get lost”), mid-level usage is 10 per day, methods of use are getting more harmful: and high usage is more than 20-30 tablets from swallowing pills to smoking (‘chasing per day. Tablets are inhaled, smoked, injec- the dragon’) to injecting. ted and ingested. ATS is used in nightclubs and entertainment venues. Staff in these In 2003, Thailand’s Academic Substance venues also tends to use and often act as Abuse Network estimated that 3,500,000 middle men for dealers and receive com- citizens between the ages of 15 and 60 had mission. In night clubs and among com- ever used methamphetamine in tablet form. mercial sex workers ATS is used to get A second survey in 2003, suggested that stamina. There is also work-related use approximately 1 million people in Thailand among truck drivers and sailors etc., as well had used methamphetamine in the pre- as motorcycle traffickers at the borders. vious year. Of the 450,000 people who Mining areas also have high prevalence of reported using methamphetamine within drug use but not necessarily methampheta- the last 30 days, 73 percent were between mine. 12 and 24 years old.14 The use of methamphetamine among stu- In 2009, 82% of all drug users in Thailand, dents is alarming – especially at high school who received drug treatment, were treated age. ATS is seen as cool. Young people tend for methamphetamine pill use.15 ‘Ice’ was to use ATS in groups and at funerals and introduced to Thailand a few years ago and weddings when people often use to stay up is rapidly expanding to all of the country. all night during ceremonies. Yaba is at Recent research by the Thai Office of the times provided by the hosts at these gather- Narcotics Control Board (ONCB) indicates ings. Methamphetamine use is easier to that crystal methamphetamine is the most hide than other types of drug use, and par- popular drug among addicts, half of them ents are often unaware. Users mix metham- aged between 15 and 24 years old.16 phetamine with alcohol because this helps them to sleep. There is no preventive edu- In Burma very little research or surveys cation, and often young users do not know have been carried out, but anecdotal their limits. evidence suggests that methamphetamine use is on the rise. At an informal expert China is seeing an increase in the use of seminar on ATS and harm reduction in crystal methamphetamine, according to an Kunming (Yunnan, China), in November annual drug abuse monitoring report re- 2010, Burmese user groups and outreach leased by the country's State Food and workers said that the younger generation Drug Administration (SFDA) in April prefers ATS over heroin. ATS use has been 2011. The use of other drugs, such as her- recorded for more than ten years and the oin, has decreased over time. Heroin and generation which is now around 25 years crystal methamphetamine were still the two old is probably the last one that used most widely-used illegal drugs. heroin. They emphasised the urgent need for better surveys to improve the limited Illegal activity related to the use of crystal data available concerning ATS market methamphetamine and ketamine has trends, the number of users, and treatment increased in recent years. The report stated and relapse, as well as a scale up of aware- that police seized more crystal methamphe- ness raising programmes, and improved tamine than heroin in 16 of China's 31 pro- targeting of current users. vincial-level regions last year. Police re- cords showed that China had 432,000 ATS Average yaba use in Burma is around 3-4 users by the end of 2010, accounting for 28 tablets per day (drug users say that when percent of the country's registered 1.5 mil-

Transnational Institute | 5 lion drug users in 2010 (up from 560,000 legal sense, but users can be fined. Instead registered users in 1995).17 Last year saw of detoxification, ATS users pay the fine 118,000 more ATS users than 2009.18 and there is no other punishment. How- ever, emergency room doctors report major However, this figure only reflects the tip of issues with problematic ATS use by young the iceberg as most users are not registered, men, in particular high levels of aggression both because of stigmatisation and the pu- among ATS users. 21 nitive measures adopted by the Chinese authorities against drug users. Unofficially, The trend in Yunnan is that drug use is Chinese officials estimate the actual figure shifting from traditional opium to heroin to be higher than five million and in some and now ATS, mainly yaba. According to a more pessimistic assessments up to 15 mil- peer educator there are more ATS users lion. In 2006, Chinese official sources put than traditional opium and heroin users in 19 the figure at 4 million as a guesstimate. Yunnan nowadays. There are many nega- ATS are the preferred illegal substance of tive health effects, but there is hardly any choice for youngsters as part of the growing research on ATS and drug use trends. rave culture that has established itself in all major Chinese cities. The new population In Yunnan, methamphetamine pills are of ATS users does not appear on the Chi- mostly smoked, injection is rare. In villages nese radar-screen, as official Chinese statis- near the border with Myanmar there is a lot tics have focused on the heroin users.20 of methamphetamine use. At weddings and funerals young people come together and In Yunnan province in Southwest China use yaba, creating peer pressure to partici- bordering Burma, Laos, and Vietnam, the pate. Some users also use heroin to calm situation is different to the large cities in down after ATS use. They combine meth- the East of China, but closer to the situation amphetamine with heroin and this mixture in the neighbouring countries. Metham- is smoked. phetamine tablets are the ATS of choice in Yunnan, while in the northeast and south- There is limited research about polydrug east the crystal form is more popular. use among drug users in Yunnan. One Whether crystal methamphetamine from research project wanted to understand ATS labs in East China is entering Yunnan and use among methadone maintenance treat- onward to the Greater Mekong Subregion ment (MMT) clients and help to improve is unclear. However, crackdowns on the services in 68 MMT clinics in Yunnan. production of crystal methamphetamine in Research in 2008 among 1935 clients from East China might result in a displacement 12 counties in Yunnan Province showed of production to the Greater Mekong Sub- that 27.9% tested positive for heroin and region and Burma in particular, where 12.4% tested positive for methampheta- enforcement is difficult due to the compli- mine. During a three month period of cated situation with ethnic minority urine testing, 42% had used methamphe- groups. tamine more than three times.

Outreach workers in Kunming told TNI The younger generation is using ATS in researchers that the police generally do not different settings, and unlike heroin users arrest ATS users but only impose fines (300 they are not as marginalised in society and Yuan/45 USD). Police do not enter ATS are not seen as a nuisance. By and large, the offences into their surveillance databases. risks of ATS use are underestimated and Heroin users are much more stigmatised users feel that ATS is not addictive. Tablets and risk arrest and prison or compulsory are available in many colours and with detoxification for two years. With new different logos; prices vary a lot from 16 to drugs like ATS there is no addiction in the 40 Yuan per tablet (2.5- 6 USD).

6 | Transnational Institute PATTERNS OF USE lots of different people, using lots of different forms of methamphetamine, in lots of The growing use of ATS is associated with different ways, for many diverse reasons. the spread of HIV and hepatitis in diverse Without an understanding of how use fits segments of the population, largely due to into an individual’s life, of what function an increase in risk-taking behaviour and the substance serves, it is impossible to unsafe sex practices among users. There are offer credible or useful advice.24 also high rates of self-reported depression and alcohol consumption, and psychosis. People use methamphetamine for different According to the WHO, the public percep- reasons. The substance is attractive to users tions of the risks of ATS use are both under- because it is perceived as enhancing per- estimated and overestimated. Attempts to formance, including sexual performance, totally eliminate the problem by stringent and communication and, in some circles, law enforcement and compulsory treat- has come to embody a modern and fash- ment can be seen as an example of over- ionable lifestyle. Consumers usually start reaction – where even modest occasional off using because it makes them feel good. use is regarded as dangerous and criminal. Use is often initiated in ‘convenient’ and In contrast, others argue that recreational discrete pill form, avoiding the dangers and use is harmless, and that users will discon- social stigma of injection or smoking. They tinue themselves without needing outside are affordable, often sold in single tablet intervention. The truth, according to the units. WHO, lies somewhere in the middle. People say methamphetamine boosts their It is important to stress that not every user confidence, self-esteem, concentration, turns into a problematic user; the majority, energy and can help with work or study in fact, do not. 22 The vast majority of users and sexual pleasure. Despite these positive are either experimental or ‘recreational’ effects, regular users often begin to ex- users who use drugs occasionally on week- perience things like paranoia, aggression, ends or at parties, or irregular or ‘binge’ hallucinations, lack of sleep, loss of users who use a lot for a few days consecu- weight, dependence and a general de- tively but not regularly or consistently. crease in health and wellbeing. These may Research in Australia estimated that only a be understood as side effects of an over- minority, around 3% of methamphetamine stimulated or exhausted nervous system. users, can be characterized as regular users. The effects of methamphetamine on brain Other research indicates that the number of chemistry (especially on dopamine regula- dependent users that require specialist tion), combined with malnutrition, sleep interventions is larger and estimated at deprivation, and dehydration typically around 11%. 23 associated with regular stimulant use, can provoke these sorts of problems in other- However, even occasional nondependent wise healthy individuals. users may experience physical, social or psychological harm from their use, and Methamphetamine users range from occa- may progress to more harmful or intensive sional/recreational use to heavy, problem- drug use. They would benefit from harm atic injecting and polydrug use. It can be reduction interventions designed to moder- ingested (swallowed), snorted or smoked ate the potential harm from their ATS use and, less commonly, injected. In powder and associated lifestyle. Compulsory treat- form, methamphetamine is generally swal- ment of those kinds of users in closed cen- lowed or snorted. The crystalline form of tres is counterproductive and stigmatising, methamphetamine, ‘ice’, is typically and will only increase problems in the vast smoked. When smoked or injected, ‘ice’ majority of cases. Overall, the picture is of reaches the brain rapidly and is associated

Transnational Institute | 7 with a high risk of dependence. Growing There are some promising indications in evidence indicates that smoking crystal the region of a willingness to embark on methamphetamine has more harmful psy- new approaches, at least on paper. The chological effects and a higher addictive Sub-Regional Action Plan on Drug Control potential than other forms of methamphe- 2011-2013, agreed upon by the countries in tamine.25 Long-term use of ATS can result the Greater Mekong Subregion and the in dopamine26 reduction, which can cause UNODC, recognises that “while there are severe mood disorders as well as paranoia, internationally tested drug prevention violent behaviour, depression, psychosis, approaches and psychosocial interventions and cardiopulmonary damage. for ATS use and dependence, these have not yet been fully validated in Southeast Polydrug use is very common among meth- Asia, where ATS use is on an upward trend amphetamine users. Alcohol or cannabis and represents a majority of treatment are often used to reduce undesired over- demand in several countries in the region.” stimulation. The combination of alcohol The Action Plan recognises the need to and methamphetamine increases the risk of scale up public health oriented policies, as risky sexual behaviour and an increase of well as the need to develop alternatives to sexually transmitted infections (STI). Other CDTDCs and implementation of commu- harms among users include mental illnesses nity-based interventions based on preven- such as methamphetamine psychosis, tion, early intervention, treatment and care alcohol dependence and depression. programmes integrated in the health care system.27 RESPONSES The WHO Regional Office for the Western Despite the increase of ATS use and associ- Pacific recommends that “policy-makers ated problems, government responses in must aim to reduce the harms from ineffec- East and Southeast Asia have been ineffec- tive drug policies which allow for undiffer- tive. Traditional law enforcement and sup- entiated punishment and detention of all ply reduction approaches and zero toleran- drug users, and find common ground be- ce attitudes have not succeeded to reduce tween law enforcement and public health, the supply and the demand for ATS. One thus enabling appropriate interventions to might even argue that the unintended assist all ATS users.” 28 The office published negative consequences of ill-designed law a series of four technical briefings laying enforcement interventions and zero- out the latest available evidence on patterns tolerance policies have exacerbated the and consequences of ATS use; harm reduc- problems. tion and brief intervention; guiding principles of prevention and treatment; and the- Many factors contribute to ATS related rapeutic interventions.29 risks and harms. Not only the substance, but also the behaviour and choices of the Since the pattern of ATS use extends from individual user, the environment in which occasional and recreational use to heavy they use ATS, and the laws and policies and dependent use, and only a minority of designed to control drug use. Many policies ATS users fall into the problematic cate- and practices unintentionally create and gory, the response should vary in accor- exacerbate the risks and harms for users dance with the nature and severity of a including the criminalisation of use, dis- person’s involvement with ATS. Different crimination, abusive and corrupt policing interventions are required to address the practices, restrictive and punitive laws and complexity of ATS use. policies, denial of life-saving medical care and harm reduction services, and social According to the WHO, services should inequities. also provide help with social problems that

8 | Transnational Institute make lifestyle changes difficult (home- Burmese government, and this is a barrier lessness, unemployment, lack of marketable to getting the data needed. skills, etc.) as well as in dealing with legal problems such as arrests and involuntary  Best practice exchange and capacity incarceration in compulsory centres. Ser- building among self-help groups, outreach vice providers should arrange medically workers and health and harm reduction assisted detoxification and withdrawal sup- associations. Evidence based educational port, and refer clients to primary health or resources with experiences from other specialist medical or psychiatric services if countries need to be translated into local required, such as services for voluntary languages and adapted to the local and counselling and testing (VCT), and treat- cultural context to make them relevant and ment of sexually transmitted infections to support peer outreach. (STI), tuberculosis and mental health.30  The distinction between heroin and ATS users has become blurred in Australia as At the 2010 ATS and Harm Reduction well as other countries in the region and expert seminar, drug user groups and out- many injectors are polydrug users, using reach workers from Burma, Thailand and methamphetamines and heroin. In Burma, Yunnan formulated a series of possible there is also polydrug use of pharmaceuti- strategies to try to start tackling the situa- cals and raw opium mixed with cough tion: syrup, called ‘formular’. More research on Advocacy and awareness raising use patterns is necessary to detect new trends at an earlier stage in order improve  Governments, donors, and users still are proper responses. not fully aware of the problems associated with ATS use, and the rapid increase of  Awareness raising with drug users on ATS use among youth in particular. Aware- how to use more safely is necessary. In ness raising has to start at the ‘user level’. particular with vulnerable groups (youth, User organisations and NGOs need to raise migrants and sex workers) to educate them the issue with donors and multilateral of the risks and possible harms of ATS use. agencies. More advocacy is needed to edu- Awareness on sexual transmission of HIV cate policy makers, law enforcement, health and HCV in relation to ATS use needs to care providers, donor agencies, civil society be increased. In addition to unsafe injec- and community on ATS and effective and ting, risky sexual practices that often ac- humane responses. company ATS use can also lead to the spread of blood borne viruses and are pos-  The scale of ATS use is unknown. Cur- sibly even more unsafe. Commercial sex rently, all data is based on information in workers in particular urgently need self heroin injecting drug use but the picture help strategies and harm reduction infor- for ATS use could be quite different. More mation for ATS use. research and data are needed on ATS mar-  A major concern is not to criminalise ket trends, ATS use, patterns of use and ATS users in awareness raising campaigns harmful practices. A survey on use and pat- and advocacy towards donors and govern- terns of use is needed. Simple anonymous ment agencies. questionnaires to capture data on prices and availability, risky behaviours and meas-  Don’t get trapped in a ‘one size fits all ures to prevent them, as well as possible approach’. There is a need to differentiate self-help strategies, should be developed for between drug use patterns, per country drug user groups and outreach workers to epidemiology and cultural sensitive fill the information gap. However, research approaches to reach users. Targeted inter- permission has to be applied for from the ventions for specific groups of users are

Transnational Institute | 9 essential, such as injectors and non- materials for clients are needed, such as injectors, youth, women, minorities, sex short films. Ensuring community participa- workers, etc. tion in the planning stage of programmes is important. Programmes should include Treatment and harm reduction services harm reduction strategies and approaches and introduce these into the communities  Exchange of experiences in treatment where primary prevention programmes are and harm reduction measures were recom- being implemented. mended. There are some quite simple measures on personal hygiene and nutri-  Establishing links and a referral network tion that could be introduced easily at low to health and welfare facilities. Health care costs, such as making water and fruits measures should include primary health available at low threshold drop-in centres care, STI diagnosis and treatment, psycho- (DICs) as well as toothpaste and brushes. social support and personal hygiene. STI Information on how to improve diets, get clinics and condom distribution program- adequate rest, strategies to help control mes are good entry points for reaching drug intake and monitor behaviours should methamphetamine users. Drug education be available as well. Provide culturally should be integrated with condom distri- sensitive and clear messages. These should bution. be integrated and consistent, accurate and relevant to ATS users, highlighting the risks  Prescription of oral doses of sustained- of injecting and acquiring blood borne release dexamphetamine might help with diseases from shared contaminated equip- getting people off methamphetamine (just ment. These measures are inexpensive and like giving nicotine to people who are try- can make an enormous difference. ing to stop smoking). 31 Dexamphetamine substitute treatment for amphetamine  Preventive measures should be enacted dependence shows promising results and such as discouraging injection, distributing appears to be effective and safe in particular condoms and lubricants, needle and in preventing relapse. But research has syringe exchange programmes (NSEP), and been much more limited than for metha- providing of information, education and done treatment for heroin users.32 Possible communication (IEC) materials for drug use of mild plant-based stimulants as sub- users, their sexual partners and their fami- stitution treatment (kratom33 in Thailand lies. UNAIDS and WHO need to bring and Burma; ephedra in China) should be attention to this issue particularly looking evaluated as well. at the increased sexual risk through non- injected ATS use. NOTES  Psycho-social support needs to be 1. Tom Blickman is a senior researcher with the strengthened by expanding voluntary Transnational Institute (TNI). This briefing draws on counselling and testing (VCT), nutrition the outcomes of the Expert Seminar on ATS and support and ATS counselling. Experience Harm Reduction on November 26-27, 2010, in Kun- ming (Yunnan, China), organised by TNI with the in Thailand has shown that developing support of the Western Australian Substance Users psychosocial and peer-based intervention Association (WASUA). and peer driven activities, – as well as 2. The World Health Organisation (WHO) defines youth-centred and community-based harm amphetamine-type stimulants (ATS) as a group of reduction programmes – can be more sus- drugs whose principal members include ampheta- tainable and more effective than compul- mine and methamphetamine. However, a range of sory CDTDCs. Users of the same age need other substances also fall into this group, such as methcathinone, fenetylline, ephedrine, pseudoephe- to reach out to other users; this will have drine, methylphenidate and MDMA or ‘ecstasy’ – an greater impact. Engaging educational amphetamine-type derivative with hallucinogenic

10 | Transnational Institute properties. United Nations Office on Drugs and Crime, June http://www.who.int/substance_abuse/facts/ATS/en/i 2007. ndex.html 14. Detention of methamphetamine users in Cambo- 3. 2011 Global ATS Assessment, United Nations dia, Laos and Thailand, op. cit. Office on Drugs and Crime (UNODC), August 2011; http://www.unodc.org/documents/ATS/ATS_Global 15. Patterns and Trends of Amphetamine-Type Stimu- _Assessment_2011.pdf lants and Other Drugs: Asia and the Pacific 2010, Global SMART Programme, United Nations Office 4. Harm reduction refers to policies and practices on Drugs and Crime, November 2010; aimed to reduce adverse health and social conse- http://www.unodc.org/documents/eastasiaandpacific quences for drug users, their families and society as a //2010/11/ats-2010-report- whole, without necessarily ending drug consump- launch/ATS_Report_2010_web.pdf tion. 16. 'Ice' becomes drug of choice among young, The 5. In 1989 the military government changed the offi- Bangkok Post, September 9, 2011 cial name from Burma to Myanmar. They are alternative forms in the Burmese language, but their use has 17. China’s War on Narcotics: Two Perspectives, by become a politicised issue. Myanmar is not commonly Niklas Swanström & Yin He, Silk Road Paper - used in the English language. Burma is also used in this Central Asia-Caucasus Institute & Silk Road Studies report. This is not intended as a political statement. Program, December 2006 http://www.silkroadstudies.org/new/docs/Silkroadpa 6. The Nossal Institute for Public Health, Open Society Institute Public Health Program. Detention of meth- pers/2006/0612PRCNarcotics.pdf amphetamine users in Cambodia, Laos and Thailand. 18. China sees rising synthetic drug abuse: report, Open Society Institute, 2010. People's Daily, May 19, 2011 (http://www.soros.org/initiatives/health/focus/ihrd/artic les_publications/ 19. China’s War on Narcotics, op. cit. publications/detention-as-treatment- 20. China’s War on Narcotics, op. cit. 20100301/Detention-as-Treatment-20100301.pdf 21. ‘The ATS Boom in Southeast Asia’, op. cit.; per- 7.Technical Brief 2: Harm reduction and brief inter- sonal information at ‘ATS and Harm Reduction: vention for ATS users, Technical Briefs on ampheta- Experiences from China, Myanmar and Thailand’, mine-type stimulants (ATS), World Health Organi- TNI seminar in Kunming, November 26-27, 2010 zation, Regional Office for the Western Pacific; 22. Technical Brief 2: Harm reduction and brief inter- http://www.wpro.who.int/sites/hsi/documents/atstec vention for ATS users, op. cit. hnicalbriefs.htm 23. Technical Brief 2: Harm reduction and brief inter- 8. Speeding up the response: A global review of the vention for ATS users, op. cit. harm reduction response to amphetamines, by Sophie Pinkham, in the Global State of Harm Reduction 24. Everything You Ever Wanted To Know About 2010, International Harm Reduction Association, Methamphetamine, (but were too paranoid to ask), by 2010. Paul Dessauer, Outreach Coordinator of the Western 9. The fast and furious – cocaine, amphetamines and Australian Substance Users’ Association (WASUA); http://www.wasua.com.au/ harm reduction, in Harm reduction: evidence, impacts and challenges, EMCDDA, Lisbon, April 2010. 25. Technical Brief 1: Patterns and consequences of the 10. For more background, see the chapter ‘The ATS use of amphetamine-type stimulants, Technical Briefs Boom in Southeast Asia’ in Withdrawal Symptoms in on amphetamine-type stimulants (ATS), World the Golden Triangle: A Drugs Market in Disarray, Health Organization, Regional Office for the West- Tom Kramer, Martin Jelsma and Tom Blickman, ern Pacific; Transnational Institute, January 2009 at http://www.wpro.who.int/sites/hsi/documents/atstec http://www.tni.org/report/withdrawal-symptoms- hnicalbriefs.htm golden-triangle-4 (including Chinese and Burmese 26. Dopamine is the “reward neurotransmitter” that versions of the conclusions and recommendations). is highly active in numerous reward pathways of the 11. In fact ketamine does not really belong to ATS brain. Various studies have shown that in select group, but its hallucinatory effects, mixture with regions, amphetamine increases the concentrations methamphetamine, and use in the same set and set- of dopamine. This specific action hints at the hedonic ting makes it a related substance. response to the drug as well as to the drug’s addictive quality. 12. ‘ATS Situation in Thailand’, Thailand Office of the Narcotics Control Board, presented at the Global 27. Sub-Regional Action Plan On Drug Control 2011- SMART Programme Regional Workshop, Bangkok, 2013, United Nations Office on Drugs and Crime July 2009. (UNODC), May 2011. 13. Patterns and Trends of Amphetamine-Type Stimu- 28. Technical Brief 2: Harm reduction and brief inter- lants and Other Drugs: Asia and the Pacific 2006, vention for ATS users, op. cit.

Transnational Institute | 11 29. Technical Briefs on amphetamine-type stimulants tamine abusers on an ongoing basis to reduce crimi- (ATS), World Health Organization, Regional Office nality and legal problems, discourage injection drug for the Western Pacific; available at use and improve the health of their patients. See: http://www.wpro.who.int/sites/hsi/documents/atstechni Substitution therapy for amphetamine users, by James calbriefs.htm Shearer, John Sherman, Alex Wodak & Ingrid Van 30. Technical Brief 2: Harm reduction and brief interven- Beek, Drug and Alcohol Review (2002) 21, 179-185. tion for ATS users, op. cit. 32. Demand reduction and harm reduction, by Alex 31. Dexamphetamine and Ritalin are medications Wodak, Working Paper prepared for the First Meet- used to treat Attention Deficit Disorder (ADD). A ing of the Global Commission on Drugs Policy, legal form of methamphetamine (Adderrall) is pre- Geneva, 24-25 January 2011; scribed to treat ADD, narcolepsy, and obesity. Moda- http://www.globalcommissionondrugs.org/Arquivos/ finil (marketed under the name “Provigil”), a mild Global_Com_Alex_Wodak.pdf non-amphetamine stimulant originally approved as a 33. Kratom is attracting increasing attention as a medication for narcolepsy, is also being tested as a natural alternative to medically supervised opioid potential treatment in methamphetamine addiction. substitution therapy (OST) because of its capacity to In the United Kingdom dexamphetamine is used to attenuate potentially severe withdrawal symptoms. treat stimulant abuse. In a 2001 study, researchers See: Kratom in Thailand: Decriminalisation and found that prescribing dexamphetamine decreased Community Control? by Pascal Tanguay, Series on their clients’ consumption of street methampheta- Legislative Reform of Drug Policies Nr. 13, April mine and amphetamine and reduced the frequency 2011; of intravenous drug use. The UK’s Department of http://www.druglawreform.info/images/stories/docu Health recommends limited prescription of dex- ments/ dlr13.pdf amphetamine to patients who use street amphetamine in order to reduce craving, minimalize withdrawal, and stabilize them as part of drug treatment. British doctors prescribe dexamphetamine to amphe-

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