Temas de actualidad / Current topics In recent years the United States of America Use and abuse of has experienced economic growth, low unemploy- ment, low inflation, and technological advances. amphetamine-type However, coexisting with these favorable condi- stimulants in the United tions are underlying and underaddressed social in- equalities that may have an impact on patterns of States of America use and abuse of substances, including ampheta- mine-type stimulants (ATSs). For example, since 1975 most of the increase in national income has benefited people who are at the top 20% of the in- G. Cajetan Luna1 come range. There are disparities between those who do have and those who do not have the skills needed to thrive in a technologically dependent so- ciety, and the gap may be widening. New patterns of substance abuse being seen in the United States may in part be explained by the increasing compe- tition to survive financially and interpersonally, the need that those failing to adapt to rapid technolog- ical change have to escape psychologically and ex- istentially, and the desire of the socially alienated and disenfranchised to self-medicate with ATSs and at least temporarily avoid social and economical inequities. According to the 1998 National Household Survey on Drug Abuse, an estimated 13.6 million Americans were users of illicit drugs (1). This num- ber is less than the 13.9 million estimated for 1997, and by comparison less than the highest level, in 1979, when the estimate was 25 million. With re- spect to stimulants in particular, the overall level of usage has remained constant, but increases have been observed in specific high-risk populations, who need focused outreach and intervention ef- forts. This article will focus on ATSs in the United States, including relevant demographic and cul- tural dimensions of their use and abuse, and sug- gested directions for future ATS research and pro- gram development. ATS USE AND ABUSE IN THE UNITED STATES Key words: Drug abuse, amphetamines, United The history of ATS use and control States of America. For many decades in the United States pu- nitive actions have been taken against persons 1 AIDS Resources, Information, and Services of Santa Clara County, seeking substance-induced altered states of con- 380 N. First Street, Suite 200, San Jose, California 95112-4050, United States of America. Telephone: (408) 293-2747; fax: 408-293-0341; sciousness. These have ranged from the alcohol e-mail: [email protected] “prohibition” in the 1920s to the “drug bust” arrests 114 Temas de actualidad • Current topics of users in the psychedelic 1960s to the “war on States during the 1950s, large drug companies sold drugs” campaign of the 1980s. There are now more quantities of the drugs to bogus companies in care persons incarcerated in the United States for drug- of post office boxes. Known as “pep pills,” the related “crimes” than in any other country in the drugs were used for nonmedical purposes by many world. In 1997, 19% of prisoners in state facilities World War II veterans. In the 1960s, some doctors and 16% of those in Federal penitentiaries reported in San Francisco began prescribing amphetamine they had committed their current offense in order injections for treatment of heroin addiction. Other to obtain money for drugs (2). physicians, known as “script writers,” would, for The desire to expand reality, to lower inhi- the cost of an office visit, write prescriptions for bitions, or to soften the consequences of unpleas- amphetamines. ant life circumstances has remained consistent, but ATSs came under new, stricter controls with the popular or preferred substances employed for the passage of the Federal Drug Abuse Control Sub- those effects have varied with succeeding genera- stances Act of 1965. Subsequently, that legislation tions. Tobacco, alcohol, and marijuana are still the was consolidated with other laws into the Con- substances most widely abused by American chil- trolled Substances Act of 1970. That 1970 legislation dren and adolescents (3). regulates the manufacture and distribution of ATSs Various amphetamine compounds have been and other stimulants, as well as of narcotics, hallu- abused in the United States for over 90 years (4). cinogens, steroids, and chemicals used in the illicit Amphetamines comprise a large class of stimulants production of controlled substances. and include ones produced and used both legally Further limitations on ATSs came with the and illegally. When used appropriately, ampheta- Federal Domestic Chemical Diversion Act of 1993, mines can help reduce attention deficit hyperac- which controls the diversion of ephedrine and other tivity disorder, the most common psychiatric prob- legally obtainable chemicals for use in the illicit lem reported among children in the United States. production of controlled substances, including While widely prescribed for this disorder, amphet- methamphetamine and methcathinone. Ephedrine amines are also frequently diverted from prescrip- is present in many easily obtainable, legal products, tion to recreational use. Amphetamines can elevate including ones used to control coughs, asthma, and mood, promote feelings of euphoria, decrease inhi- allergies. Ephedrine occurs naturally in ma huang bitions, increase energy and alertness, reduce the (Ephedra equisetina), and it is a bronchodilator and a need for sleep, and suppress appetite (5). Users common ingredient in products for weight loss. have reported enhanced cognitive and physical abil- Ephedrine is structurally related to methampheta- it i es, as well as increased libido (6). mine, but ephedrine’s central nervous system ac- Among the legally produced pharmaceuticals tions are less potent. In 1995 the United States Food that are sometimes diverted to recreational use are and Drug Administration (FDA) mandated that methylphenidate (Ritalin) and phenmetrazine (Pre- producers of bronchodilator drugs remove from ludin). Illegally produced “street” ATS drugs in- them ephedrine and related ingredients, including clude amphetamine (in slang called “black beau- ephedrine hydrochloride, ephedrine sulfate, and ties,” “white bennies,” “speed”) and such related racephedrine hydrochloride. The FDA acted in re- compounds as dextroamphetamine (“dexies,” sponse to a request from United States Justice De- “beans”), methamphetamine (“crank,” “crystal,” partment’s Drug Enforcement Agency (DEA) to re- “meth”; also “speed”), methylenedioxymetham- strict over-the-counter (OTC) use of bronchodilator phetamine (MDMA, known as “ecstasy,” “XTC,” drugs because of their use as the primary precur- and “E”), and methcathinone (“cat,” “bathtub sor in the illicit synthesis of methamphetamine and speed,” “goob”). These illicit drugs can be con- methcathinone. sumed in different modes, including being taken A number of states in the United States have orally, injected, smoked, or snorted (inhaled into taken actions of their own to control products con- the nose). Injecting or smoking facilitates an imme- taining ephedrine. Of the 50 states in the country, diate, intense sensation, called a “rush.” at least 14 of them have switched products contain- Since the early 1900s, amphetamine users and ing ephedrine to prescription-only status. Several abusers have tended to be white males, persons liv- states have introduced legislation that would ing in the western United States, and individuals tighten controls on ephedrine, phenylpropanol- working in blue-collar, transportation, or service- amine, and other precursor chemicals used to il- related occupations. Other regular users and abusers legally produce ATSs. The attorney general of of amphetamine-type stimulants have included the state of Arizona plans legislation specifically athletes, college students, and those desiring quick limiting individual purchases of most ephedrine- weight loss. Although a prescription was required containing OTC cold and allergy medications (7). for the medical use of amphetamines in the United That legislation would limit purchases to 20 pack- Rev Panam Salud Publica/Pan Am J Public Health 9(2), 2001 115 ages in a 24-hour period. A major national chain of dioxymethamphetamine (MDMA), which is com- retail stores already restricts the number of pack- monly known as “ecstasy.” Ecstasy causes mesca- ages of these products that their customers can buy. line-like psychedelic effects. First used in the 1980s, If a customer exceeds the limit, the cash register au- ecstasy is found in many major cities and suburban tomatically shuts down. areas of the United States. Relatively inexpensive, the drug is popular among the young. Continuous “techno” music, rampant ecstasy use, and a “uto- ATS usage patterns and populations at risk pian” togetherness fuel urban dance scenes, includ- ing energetic all-night “raves” that feature euphoric ATS abuse occurs among a wide variety of marathon dancing and chemically induced “soul populations in the United States. Such users are expansion.” Clandestine by nature, raves are opti- predominately white middle-class teenagers and mally held in vast open-air environments, with the young adults. Amphetamines are also frequently location announced by promoters through flyers, used, in various forms, by male and female com- secret phone numbers, and Internet mailing lists. mercial sex workers (both street-based and through And while raves have declined more recently in organized call services), transgendered people, ha- some urban areas, they have grown in popularity in bitués of gay and