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 • 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 amphetamines 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 Methamphetamines 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, “meth mouth”) 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