especially in south-east asia€¦ · •global and asian trends •short and long-term effects...
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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