Amphetamine Type Stimulants problems Especially in South-East Asia

• Dr. Apinun Aramrattana• Southeast Asia HIV Addiction Technology Transfer Center

• Dept. of Family Medicine, Faculty of Medicine, Chiang Mai University, Thailand

• Global and Asian Trends

• Short and long-term effects

• Treatment of Stimulant Use disorder

• Methamphetamine treatment system in Thailand

Expanding market: Amphetamine-type stimulants (ATS)

• 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

ATS seized worldwide

NUMBER

Source: Dept. of Medical Services, MOPH and Institute of Health Research,C U., ONCB

DRUG TREATMENT STATISTICS

V.Poshyachinda

71.1 72.5 73.7 78.2 83.4 84.976

47.832.1 24.1 19.6

16.5 13.812.8

6

0.4 0.6 1.1 1

10.6

34.153.7 57.4 60.3

19.3

6.6

5.7

6.3

5.3

5.37.7

1.7 2.6

0%

20%

40%

60%

80%

100%

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000Heroin Opium Ganja Inhalant Alcohol ATS Others

Rapid methamphetamine pill epidemics in Thailand

- Methamphetamine 15-20 % + Caffeine 50-65%

Thai Act 1996: Amp./meth. moved to Sch.I

Methamphetamine tablets(Ya Ba), Marihuana,

and Kratom are the most common drugs used with Ice epidemics emerging.

Source: ACSAN,

ONCB, 2012

Household Survey Trends: Ever users: 2001-2016

Estimated Numbers ( x 1,000)

Source: The Office of Narcotic Control Board (ONCB)

War on Drugs since 2003

Level of risk by ASSIST scores

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.

Household Survey, Thailand, 2011

Estimated number of ATS users in Thailand, 2011: 910,361

WHO-ASSIST Score among ATS ever users, Household Survey, 2011.

Only about 12 % of MA ‘ever’-users would need treatment.

>26

4-26

0-3

High 1 %

Moderate 11 %

Low 88 %

ASSIST ScoresRisk levels

Source: The Office of Narcotic Control Board (ONCB)

Admission by major drug typeMethamphetamine, heroin and cannabis prevalence (/100,000 pop.)

Assoc.Prof. Manop Kanato @ASEAN NarcoKhon Kaen University, Thailand & ONCB, Thailand

Assoc.Prof. Manop Kanato @ASEAN NarcoKhon Kaen University, Thailand & ONCB, Thailand

Understand young ATS users:-

• Majority were

young males

• 99% Inhalation /

take orally

• Multiple sex

partners

• Age of first sex

around 13-14

years

Age at first use of methamphetamine

0

10

20

30

40

9 10 11 12 13 14 15 16 17 18 19 20 21

Age

Pe

rce

nt

91%

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

15

NIDA, 2006.

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 WithdrawalDysphoric 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

SensitizationSensitization (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

P < .0001

Celentano D D, Aramrattana A, Sutcliffe CG, et.al. (2008) Journal of Adolescent Medicine. 2(2):66-73.

High prevalence of depression

Male = 31%

Female = 45%

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

Harms: Prevalence rates Sexually Transmitted

Infections, methamphetamine users, 2005

18.5

29.4

5.57.7

0

10

20

30

40

50

Male Female Ref. Male Female Ref.

Pe

rce

nt p

osi

tive

Chlamydia trachomatis Neisseria gonorrhea

Celentano D, Sirirojn B, Sutcliffe C, et.al. (2008) Sexually Transmitted Diseases 35,400-5.

Less than 50% seek treatment from any health services.

High Sexually Transmitted Infection especially among female MA users.

Long-term study among MA Psychotic Patients at Suan Prung Psychiatric Hospital 2001-2007

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Number of Patients

Years

War on drugs Rehabilitation law

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

• Psychosis, including:

- Paranoia and delusions

- Hallucinations

- Repetitive motor activity

• Changes in brain structure and function

• Memory loss

• Aggressive or violent behavior

• Anxiety and mood disturbances

• Fatigue

• Severe dental problems

• High blood pressure

• Tachycardia

• Tachypnea

• Myocardial infarctions

• Skin lesions

• Stroke

• Dehydration

• Weight loss

• 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.

39

NIDA, Revised 2009.

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.

40

NIDA, Revised 2009.

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.

44Miller, n.d.

Negotiating Behavior Change

Based on an MET Approach

Establish Rapport

Set Agenda

Behavior

Assess Importance, Confidence, and Readiness

Explore Importance Build Confidence

45Rollnick, Mason, Butler, 1999.

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?”

46Rollnick, Mason, Butler, 1999.

Physician Tasks Based in

Patient Readiness to Change

CONTEMPLATION

PRECONTEMPLATION Raise doubt—increase the patient’s perception of

risks and problems with current behavior.

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

49

McLellan, et al., 2000.

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

Methamphetamine treatment system in ThailandRecommendations for

Health Care Providers

in the Treatment of

Methamphetamine Use

Disorders, 2015

• Evidence review on methamphetamine use disorders

• Effectiveness/efficacy of methamphetamine treatment

• 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 ThailandRecommendations for

Health Care Providers

in the Treatment of

Methamphetamine Use

Disorders, 2015

• Diagram 1 Treatment and referral system for people with methamphetamine use disorders in Thailand

• Diagram 2 Primary treatment recommendations for people with methamphetamine use disorders

• 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

52

The Optimal Mix for Services

Community-Based Drug Treatment & Care Approach

53

Coordination of Services

Community-Based Drug Treatment & Care Approach

BI+MI+CBT: @General Hospitals

BI + MI + Refer: @Drug Treatment Centers, Psychiatric Hospitals

Community-based Management:- In an initial stage- Relied on existing primary health care resources

- > 1 million village health volunteers nationwide- almost 10,000 health centers at sub-district level- almost 800 district hospitals

- Bridging with other local resources- leaders, justice volunteers, NGOs- polices, social workers, school teachers, monks, etc

Community-based services for drug users

SBIRT: Primary Health Care@Health Centers, District Hospitals

Community & Family care

District Health System (DHS)

Amphetamine Type Stimulants problems Especially in South-East Asia

Thank you very much

Q & A

• Global and Asian Trends

• Short and long-term effects

• Treatment of Stimulant Use disorder

• Methamphetamine treatment system in Thailand