Type Stimulants problems Especially in South-East Asia

• Global and Asian Trends • Short and long-term effects • Treatment of Stimulant Use disorder • treatment system in Thailand • Dr. Apinun Aramrattana • Southeast Asia HIV Addiction Technology Transfer Center • Dept. of Family Medicine, Faculty of Medicine, Chiang Mai University, Thailand Expanding market: Amphetamine-type stimulants (ATS)

ATS seized worldwide • Total ATS seizures: highest ever • Amphetamine and methamphetamine constitute considerable share of burden of disease, rank second only after opioids • Users of increased, reaching 37 million globally • Methamphetamine seizures up, East and South-East Asia overtaking North America • “Ecstasy” seizures stable but greater variety of products on the market Rapid methamphetamine pill epidemics in Thailand

DRUG TREATMENT STATISTICS

0.4 0.6 1.1 1 1.7 2.6 NUMBER 100% 10.6 12.8 7.7 5.3 19.3 16.5 13.8 34.1 80% 5.3 53.7 57.4 60% 60.3 6.3 Thai Act 1996:83.4 84.9 40% 73.7 78.2 76 71.1Amp./meth.72.5 moved to Sch.I 5.7 6.6 6 47.8 20% 32.1 24.1 19.6 0% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Heroin Opium Ganja Inhalant Alcohol ATS Others

Source: Dept. of Medical Services, MOPH and Institute of Health Research,C U., ONCB V.Poshyachinda - Methamphetamine 15-20 % + Caffeine 50-65% Household Survey Trends: Ever users: 2001-2016

War on Drugs since 2003 Estimated Numbers ( x 1,000)

Source: ACSAN, ONCB, 2012

Methamphetamine tablets(Ya Ba), Marihuana, and Kratom are the most common drugs used with Ice epidemics emerging.

Source: The Office of Narcotic Control Board (ONCB) Level of risk by ASSIST scores Household Survey, Thailand, 2011

Substance types Estimation %L %M %S Alcohol 27,907,999 76.8 20.3 2.9 Smoking 13,905,217 33.8 62.5 3.7 Marihuana 2,064,386 94.5 5.2 0.3 910,361 88.0 11.1 0.9 Benzodiazepine 885,559 84.5 14.1 1.4

Opiates 475,557 98.0 2.0 - Inhalants 200,407 92.9 7.1 -

Majority of substance users were in low risk except smoking. Estimated number of ATS users in Thailand, 2011: 910,361

Risk levels ASSIST Scores

High 1 % >26

Moderate 11 % 4-26

Low 88 % 0-3 WHO-ASSIST Score among ATS ever users, Household Survey, 2011. Only about 12 % of MA ‘ever’-users would need treatment. Source: The Office of Narcotic Control Board (ONCB) Admission by major drug type Methamphetamine, heroin and cannabis prevalence (/100,000 pop.)

Assoc.Prof. Manop Kanato @ASEAN Narco Khon Kaen University, Thailand & ONCB, Thailand Assoc.Prof. Manop Kanato @ASEAN Narco Khon Kaen University, Thailand & ONCB, Thailand Understand young ATS users:-

Age at first use of methamphetamine • Majority were

40 young males 91% • 99% Inhalation / 30 take orally 20 • Multiple sex

Percent partners 10 • Age of first sex

0 9 10 11 12 13 14 15 16 17 18 19 20 21 around 13-14 Age years Celentano D D, Aramrattana A, Sutcliffe CG, et.al. (2008) Journal of Adolescent Medicine. 2(2):66-73. Crystal Meth

Chemically similar to amphetamines White, odourless, bitter-tasting crystalline powder Route: oral, smoked, snorted, or injected Made in illegal labs by chemically altering OTC medicines (pseudoephedrine) Ecstasy

• Stimulant and hallucinogen properties • First synthesized by the German pharmaceutical company Merck in 1912. • Tested by the military in search for the “truth drugs” 1953 • Made in illicit labs and may contain other active such as amphetamine, mephedrone, methamphetamine, ephedrine, or caffeine • Some tablets sold as ecstasy do not even contain any MDMA • Street names include “E” , “X”, Molly, Skittles Prescription Stimulants

Methylphenidate (Ritalin, Concerta, Biphentin) Dextroamphetamine Sulphate (Dexedrine) Amphetamine and Dextroamphetamine (Adderall) Lisdexamfetamine (Vyvanse) The Brain in Stimulant Use Disorders

Methamphetamines Inhibit reuptake of synaptic dopamine AND promotes direct dopamine release Ecstasy: Acutely increases serotonin by blocking reuptake and directly releasing Chronically decreases serotonin levels by depleting serotonin stores and inhibiting the synthesis of new serotonin neurotoxicity Pharmacology of Stimulants

Water soluble Onset of action depends on route of administration: rapid onset of action with injection or smoking Duration of action dependent on route of administration: oral administration produces longer duration of action Short-term Effects

• Increased attention and decreased fatigue • Increased activity and wakefulness • Decreased appetite • Euphoria and rush • Increased respiration • Rapid/irregular heartbeat • Hyperthermia • A distorted sense of well-being • Effects that can last 8 to 24 hours

NIDA, 2006. 15 Stimulant Intoxication  Signs or Symptoms  1. Tachycardia or bradycardia  2. Pupillary dilation  3. Elevated or lowered blood pressure  4. Perspiration or chills  5. Nausea or vomiting  6. Evidence of weight loss  7. Psychomotor agitation or retardation  8. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias  9. Confusion, seizures, dyskinesias, dystonias, or coma Stimulant Intoxication

Clinically significant problematic behavioural or psychological changes such as: euphoria or affective blunting changes in sociability hypervigilance interpersonal sensitivity anxiety tension or anger stereotyped behaviours impaired judgement Stimulant Withdrawal Dysphoric mood and two (or more) of the following physiological changes, developing within hours to several days after cessation of prolonged amphetamine-type substance, cocaine or other stimulant use 1. Fatigue 2. Vivid, unpleasant dreams 3. Insomnia or hypersomnia 4. Increased appetite 5. Psychomotor retardation, or agitation

DSM 5 Acute Consequences of Stimulant Use

Neuro: seizures, strokes CVS: tachycardia, arrythmia, MI, HTN Kidneys: cocaine induced rhabdomyolysis Heme: Agranulocytosis (levamisole) Repro: placenta previa ENT: nosebleeds Infectious Disease: STI’s, cellulitis, bacterial endocarditis ECSTASY: Dehydration, Hyperthermia, Hyponatremia Stimulant Induced Mental Health Disorders

INTOXICATION WITHDRAWAL Psychotic Delusions Bipolar Bipolar Depression Depression Anxiety Anxiety OCD OCD Sleep Disorders Sleep Disorders Sexual Dysfunction Long Term Consequences of Stimulant Use

Tolerance and Withdrawal Sensitization Addiction (Stimulant Use Disorder) Restlessness, anxiety, irritability, paranoia, panic attacks, mood disturbances Insomnia Sensitization

Sensitization (opposite of tolerance) more you use the drugs more likely of symptoms happening such as: Seizure Psychosis (paranoia, visual, auditory, and tactile hallucinations) Stereotypical behaviors Long Term Consequences of Stimulant Use

Repro: irregular menses, prematurity ENT: nasal septum perforation, loss of sense of smell, chronically runny nose Infectious Disease: Hep C, HIV Weight loss Methamphetamines (neurocognitive impairment, “”) Psychosocial: homelessness, legal involvement, trauma Harms: Duration of amphetamine use (yrs) and frequency alcohol use in last 30 days) among MA users in Chiang Mai, Thailand, 2005 High prevalence of depression Male = 31% P < .0001 Female = 45%

Longer duration of MA use led to heavier drinking patterns and higher depression prevalence.

Celentano D D, Aramrattana A, Sutcliffe CG, et.al. (2008) Journal of Adolescent Medicine. 2(2):66-73. Harms: Prevalence rates Sexually Transmitted Infections, methamphetamine users, 2005

50 Less than 50% seek treatment 40 from any health services. 30 29.4

20 Percentpositive 18.5

10 7.7 5.5

0 Male Female Ref. Male Female Ref. Chlamydia trachomatis Neisseria gonorrhea High Sexually Transmitted Infection especially among female MA users.

Celentano D, Sirirojn B, Sutcliffe C, et.al. (2008) Sexually Transmitted Diseases 35,400-5. Long-term study among MA Psychotic Patients at Suan Prung Psychiatric Hospital 2001-2007 Number of Patients War on drugs Rehabilitation law 4500 4000 3500 3000 2500 2000 1500 1000 500 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Years

Long-term effects from MA psychosis. 8.2% mortality in 6 years among MA psychotic patients. Main causes were suicide, accidents & AIDS

Source: Kittiratanapaiboon, P. et.al., Drug Alcohol Rev. 2010 Jul;29(4):456-61 10-year trends of methamphetamine injection in Thailand, treatment statistics 2008-2017

• In general, methamphetamine injection of any forms were less than 1%. • Increasing trends of Ice injection (especially among MSM/TG)

Source: Thai Office of Narcotic Control Board, unpublished data, July 2018 TREATMENT OF STIMULANT INTOXICATION, STIMULANT WITHDRAWAL, AND STIMULANT USE DISORDER Treatment of Stimulant Intoxication

 Supportive  Phentolamine for hypertension (no beta blockers bc unopposed alpha-adrenergic stimulation can lead to coronary vasoconstriction and ischemia)  Chest pain: ECG, biomarkers, CXR, benzo and nitro  Treat stimulant induced psychosis if severe  Treat any infections: cellulitis, endocarditis, infectious diseases (HIV, Hep C, STI’s), abscesses, septic arthritis Treatment of Stimulant Withdrawal

Supportive Suicide prevention Treatment of Stimulant Use Disorders  SBIRT (Screening, Brief Intervention, Referral to Treatment)  Stages of Change  Harm Reduction (needle exchange/crack pipe programs)  Motivational Enhancement Therapy  Cognitive Behavioural Therapy  Contingency Management  Residential Treatment  Self Help Support  Matrix Model  Treatment of Underlying Mental Health Disorders  Treat any Medical Complications (HIV, HCV) Risk of Relapse

Re-exposure to the Drug Exposure to stress Exposure to environmental cues Conditioned response to drug-related stimuli (e.g. craving on seeing any white powderlike substance) Cognitive Behavioural Therapy for Stimulant Use Disorders

Identification of high risk situations Development of coping skills Development of new lifestyle behaviours Development of sense of self-efficacy References

 DSM 5 Diagnostic & Statistical Manual of Mental Disorders 5th Ed. Text Revision 2013  The ASAM Principles of Addiction Medicine Fifth Edition. Ries, Fiellin, Miller, Saitz. 2014  The Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2013  UNODC, World Drug Report 2016 (http://www.unodc.org/wdr2016/en/maps- and-graphs.html)  National Institute of Drug Abuse (NIDA) www.drugabuse.gov Short- and Long-term Effects of Use Long-term Effects

• Addiction • Fatigue • Psychosis, including: • Severe dental problems - Paranoia and • High blood pressure delusions • Tachycardia - Hallucinations - Repetitive motor • Tachypnea activity • Myocardial infarctions • Changes in brain • Skin lesions structure and function • Memory loss • Stroke • Aggressive or violent • Dehydration behavior • Weight loss • Anxiety and mood disturbances • Death

36 Drug Use Has Played a Prominent Role in the HIV/AIDS Epidemic in Several Ways

• Disease transmission - IV drug use - Drug user disinhibition leading to high-risk sexual behaviors • Progression of disease

37 Treatment Principles Basic Principles of Treatment

1. Addiction is a complex but treatable disease that affects brain function and behavior. 2. No single treatment is appropriate for all individuals. 3. Treatment needs to be readily available. 4. Effective treatment attends to the individual’s multiple needs, not just his or her drug use. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. 6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

NIDA, Revised 2009. 39 Basic Principles of Treatment (Cont.)

8. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets the person's changing needs. 9. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. 10. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. 11. Treatment does not need to be voluntary to be effective. 12. Possible drug use during treatment must be monitored continuously. 13. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.

NIDA, Revised 2009. 40 Treatments Types Pharmacological Treatments

• No approved medications • Off label use/treatment of co-morbid conditions - Antidepressants - Mood stabilizers - Antipsychotic medications • Symptomatic treatment

42 Non-pharmacological Treatments

• Motivation Enhancement Therapy (MET) • Cognitive behavioral therapy • Contingency management • Matrix Model • Family education • Group therapy • Self-help groups (12-step program)

43 Motivational Enhancement Therapy (MET)

• MET seeks to evoke from clients their own motivation for change and to consolidate a personal decision and plan for change. • MET is primarily client centered, although planned and directed. • The content of an MET session depends on the client's stage of motivation. Prochaska and colleagues (1992) have described five stages of readiness: - Precontemplation: the patient is not considering change. - Contemplation: patient is ambivalent, weighing the pros and cons of change. - Preparation: the balance tips in favor of change and the patient begins considering options. - Action: the patient taking specific steps to accomplish change. - Maintenance: the patient focuses on preventing relapse.

Miller, n.d. 44 Negotiating Behavior Change Based on an MET Approach

Establish Rapport

Set Agenda

Behavior

Assess Importance, Confidence, and Readiness

Explore Importance Build Confidence

Rollnick, Mason, Butler, 1999. 45 Assess Importance, Confidence, and Readiness

Examples: • “How important is it to you to stop smoking?” • “If you decided right now to change your smoking behavior, how confident do you feel about succeeding with this?” • “People differ quite a lot in how ready they are to change their smoking behavior. What about you?”

Rollnick, Mason, Butler, 1999. 46 Physician Tasks Based in Patient Readiness to Change

PRECONTEMPLATION Raise doubt—increase the patient’s perception of risks and problems with current behavior.

CONTEMPLATION Tip the decisional balance—evoke reasons for Change and risks of not changing; strengthen patient’s self-efficacy for change of current behavior.

PREPARATION Help the patient determine the best course of action to take in seeking change; develop a plan.

ACTION Help the patient implement the plan; use skills; problem solve; support self-efficacy.

MAINTENANCE Help the patient identify and use strategies to prevent relapse; resolve associated problems.

Prochaska, et al., 1992. 47 Outcomes Relapse Rates Are Similar for Drug Addiction and Other Chronic Illnesses

McLellan, et al., 2000. 49 Methamphetamine treatment system in Thailand

Recommendations for • Evidence review on methamphetamine use disorders Health Care Providers in the Treatment of • Effectiveness/efficacy of methamphetamine treatment Methamphetamine Use Disorders, 2015 • Principles for treatment of methamphetamine use disorders • Issues of concern in Thailand • Harm reduction approach • Considerations for specific groups of methamphetamine users • Implications for a Thai context

Source: Apisak Wittayanookulluk et al., Department of Medical Services, Ministry of Public Health, Thailand, 2015 Methamphetamine treatment system in Thailand

Recommendations for • Diagram 1 Treatment and referral system for people with Health Care Providers methamphetamine use disorders in Thailand in the Treatment of • Diagram 2 Primary treatment recommendations for people with Methamphetamine Use methamphetamine use disorders Disorders, 2015 • Diagram 3 Primary treatment recommendations for people with methamphetamine use disorders (high-risk users) • Diagram 4 Treatment recommendations for people with methamphetamine use disorders in emergency situations • Diagram 5 Assessment and management for methamphetamine overdose • Diagram 6 Assessment and management for methamphetamine use disorders with aggression and self-harm behaviour

Source: Apisak Wittayanookulluk et al., Department of Medical Services, Ministry of Public Health, Thailand, 2015 Community-Based Drug Treatment & Care TheApproach Optimal Mix for Services

52 Community-Based Drug Treatment & Care ApproachCoordination of Services

53 Community-based Management:- In an initial stage - Relied on existing primary health care resources - > 1 million village health volunteers nationwide - almost 10,000 healthBI + MI centers + Refer at: sub@Drug-district Treatment level - almost 800 districtCenters, hospitals Psychiatric Hospitals District Health - Bridging with other local resources System (DHS) - leaders, justice volunteers,BI+MI+CBT: NGOs @General Hospitals - polices, social workers, school teachers, monks, etc

SBIRT: Primary Health Care @Health Centers, District Hospitals Community & Family care Community-based services for drug users Amphetamine Type Stimulants problems Especially in South-East Asia

• Global and Asian Trends • Short and long-term effects • Treatment of Stimulant Use disorder • Methamphetamine treatment system in Thailand Thank you very much Q & A