Workshop on Problems Relating to the Use of Amphetamine-type Stimulants (ATS) in the Western Pacific Region, Manila, Philippines, 16-20 February 1998 : report

(WP)HPRlMNHlICPIADT1001-E Report Series Number: RS/98/GE/01(PHL) English only

REPORT WORKSHOP ON PROBLEMS RELATING TO THE USE OF AMPHET AMINE-TYPE STIMULANTS (ATS) IN THE WESTERN PACIFIC REGION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 16-20 February 1998

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines October 1998

NOTE The views expressed in this report are those of the participants in the Workshop on Problems Relating to the Use of Amphetamine-Type Stimulants (ATS) in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Problems Relating to the Use of Arnphetamine-Type Stimulants (ATS) in the Western Pacific Region, Manila, Philippines, from 16 to 20 February 1998.

CONTENTS

I. INTRODUCTION ................................................................................................................... I 1.1 Objectives ....................................................................................................................... I 1.2 Participants ...................................................................................................................... I 1.3 Organization .................................................................................................................... I 1.4 Opening remarks ............................................................................................................. 2 2. PROCEEDINGS ...................................................................................................................... 2 2.1 Country reports ............................................................................................................... 2 2.2 Summary of papers and discussion ................................................................................. 3 2.3 Evaluation ..................................................................................................................... 12 3. CONCLUSIONS .................................................................................................................... 12 ANNEXES: ANNEX I LIST OF PARTICIPANTS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT .............................................................................. 15 WORKSHOP PROGRAMME .................................................................. 21 LIST OF DOCUMENTS .......................................................................... 25 GLOBAL SITUATION AND TRENDS IN RELATION TO AMPHETAMINE-TYPE STIMULANTS ................................................ 27 AMPHETAMINE-TYPE STIMULANTS AND DRUG CONTROL IN EAST ASIA ..................................................................... 39 REGIONAL SITUATION IN RELATION TO AMPHETAMINE-TYPE STIMULANTS ................................................ 65 PROCEEDINGS OF THE NATIONAL CONSENSUS MEETING ON THE USE, ABUSE AND SEQUELAE OF ABUSE OF METHAMPHETAMINE WITH IMPLICATIONS FOR PREVENTION, TREATMENT AND RESEARCH (SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION) ............................................................................... 91 REVIEW OF THE BIOLOGICAL, TOXICOLOGICAL, PSYCHOLOGICAL AND PHARMACOLOGICAL ASPECTS OF ATS (DR ROBERT ALI) ................................................................. 133 EVALUATION QUESTIONNAIRE ...................................................... 163

ANNEX 2 ANNEX 3 ANNEX 4

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ANNEX 5 ANNEX 6 ANNEX 7

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ANNEX 8

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ANNEX 9

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Keywords Substance abuse / Psychotropic drugs / Amphetamines / Philippines

I. INTRODUCTION

1.1

Objectives (I) To review epidemiological and demographic patterns and trends of amphetamine-type stimulants (ATS) use and identified the range of health, social and other problems relating to ATS use within each of the participating countries; (2) to review current methods and techniques of prevention, treatment, harm reduction and rehabilitation programmes related to ATS use, with a focus on improvements in accordance with contemporary best practice models, adapted within the context ofthe social norms, customs and culture of each participating country; and (3) to discuss future collaboration among countries for the development of prevention, integrated treatment, and rehabilitation programmes in the Region.

1.2

Participants

The workshop was attended by 20 participants who are senior officials responsible for drug prevention and control programmes and treatment and rehabilitation programmes in Australia, the People's Republic of China, Japan, the Lao People's Democratic Republic, Malaysia, the Northern Mariana Islands, the Federated States of Micronesia, Palau, the Philippines, the Republic of Korea, Singapore and Viet Nam. In addition there were representatives/observers from Johns Hopkins University, United Nations International Drug Control Programme, U.S. Substance Abuse and Mental Health Services Administration and two WHO staff members who acted as the secretariat. A list of workshop participants, representatives/observers and the secretariat is listed in Annex I. 1.3 Organization

The workshop programme is described in Annex 2 and a list of documents distributed during the workshop in Annex 3. The documents included Amphetamine-type stimulants (ATS): (A report from the WHO meeting on Amphetamines, MDMA and other Psychostimulants, Geneva, 12-15 November 1996), working papers and handouts. Ms Rossida Dolah, Central Narcotics Bureau, Ministry of Home Affairs, Singapore, chaired the overall workshop. The participants presented their country reports and papers on the health and social consequences of ATS use, prevention and treatment options. Three group discussions were organized on: • • • identifying the consistencies and emphasis of the WHO and UNDCP recommendations on ATS that are contained in their expert reports; identifying appropriate approaches to the development of an ATS strategic plans; and examining ATS-related harms and potential responses from a historical perspective.

Before undertaking the group activities the chair introduced the topics and ways to carry out the discussion. Following each group session, the groups reported their discussion to all participants. This was followed by a general discussion. At the completion of all the group discussions, overall participants drew workshop conclusions.

- 21.4 Opening remarks

Dr Adrian Reynolds, Regional Adviser in Health Promotion and Mental Health, welcomed all participants to the Philippines and to the Workshop on Problems Relating to the Use of Amphetamine-Type Stimulants (ATS) in the Western Pacific Region. Dr B.P. Kean, Director, Programme Management, WHO Regional Office for the Western Pacific, presented the opening remarks on behalf of Dr S.T. Han, Regional Director, WHO Regional Office for the Western Pacific. He stated that at present, people who use A TS and who develop health and other problems as a consequence are known to be less likely than those with an opioid drug problem to seek help. Importantly, there is a lack of scientific evidence to guide the provision of effective prevention and treatment responses and no consensus internationally regarding effective treatment for A TS-related problems. He drew attention to the need to focus on the prevention or containment of HIV, as it relates to the use of stimulant drugs and the difficulties of treating drug dependence among regular ATS users. Dr Kean added that preparation for life and protection of life are particularly relevant to improving the health of young people and are major objectives of the WHO policy framework document, New horizons in health. The document emphasizes the importance of promoting and supporting lifestyles and living conditions conducive to health, through health promotion and health protection. These policies, adapted within the context of the social norms, customs, values and aspirations of particular countries, have particular relevance to substance use.

2. PROCEEDINGS

2.1

Country reports

Participants from 12 countries presented their country reports. The participants detailed the patterns, trends and health problems related to ATS use. The country reports were supplemented by a global and regional overview by a representative of WHO and a global and Southeast Asian report on drug control measures by a representative ofUNDCP. The reports identified that use of ATS appears to be widespread and increasing in the Western Pacific Region. Countries where this is particularly so include Australia, Japan, the Republic of Korea, Malaysia, the Northern Mariana Islands, the Federated States of Micronesia, Palau, and the Philippines. The use of ATS, particularly methylamphetamine, is on the rise in the Region. This presents reason for serious concern in some countries while use is only beginning to emerge in others. In some countries in the Region ATS use and related problems substantially outnumber those related to the use of all other illicit drugs. There has been a shift to younger ages of initiation in the use of ATS in a number of countries. In four of the countries represented at the meeting, injection of ATS represents reason for particular concern, as it is the main route of administration of the drug and poses particular risk for transmission of blood-borne diseases. In a further three of the countries present, injection of A TS is emerging. However in many countries, administration by smoking, swallowing and sniffing are still reported as methods of drug administration. Only a few countries are, at present, identifying injection of ATS and associated sexual behaviour as important risk modes for the transmission of HIV / AIDS within their community.

-3The appearance of crystal methamphetamine or "ice" has seen a shift from injection to non-injection routes of administration in a number of countries. Polydrug use appears to be almost universal among ATS users and this may present substantial added biological, psychological and social risks, raising attention to the need for public health workers and other human service providers to educate people who use these substances. There appear to be no common themes across the Region with respect to perceptions about the forms of harm that are most frequent and most weighty. In some countries, the social harms associated with the use of ATS are. reported as being of most significance. In others, the legal, acute and chronic health or economic harms are seen as most problematic. These responses appear to be based on anecdotal and personal impressions rather than on the basis of any systematic measurement reflecting specific quantitative and qualitative indicators. 2.2 Summary of papers and discussion

Dr Adrian Reynolds, Regional Adviser in Health Promotion and Mental Health, presented a paper entitled "Global situation and trends in relation to amphetamine-type stimulants, from the public health perspective". A copy of the paper is attached in Annex 4. Although levels of illicit drug use in many developed countries have remained stable or have even declined for a number of years, this situation appears to be changing. In many parts of the world it appears there is an increase in the use of psychoactive substances, accompanied by a 10wtIing of the age at which use begins. This trend of increased use of psychoactive substances among young people in many developed countries is nevertheless now overshadowed by evidence of increasing and changing patterns of drug use in developing countries. It is estimated that 15 million people worldwide are exposed to significant health risks arising from their use of psychoactive substances, other than alcohol and tobacco. It is in addition estimated that one-third of people who use drugs (5 million people) do so by injection. The number of drug injectors appears to be rising worldwide, and dramatically so in some developing countries. Recent estimates suggest that worldwide, between 100 000 to 200 000 deaths per year are related to the injection of drugs. The World Drug Report (1997) of the United Nations Drug Control Programme identified that global production of cocaine increased by more than 200% during the last decade (to 1995) and heroin production increased by more than 300%. It is difficult to derive such estimates for ATS production for a number of reasons, including the variety of covert ways these substances can be produced from a range of precursor chemicals and in locations close to end-point markets. Since the mid-1980's the world has seen an increase in synthetic stimulant use. In the course of the 1990' s, the growth rates of illicit ATS production and trafficking are reported to have surpassed those of cocaine and of heroin. In parallel, consumption of ATS has begun to outstrip that of the traditional drugs in an increasing number of countries. A TS are now consumed in every region of the world and, if present trends continue, the problem of generalized unsanctioned synthetic stimulant drug use may become a truly global one, with rapid expansion in both the industrialized and developing worlds. A paper was presented by Mr Wayne Bazant, Demand Reduction Adviser, UNDCP Regional Centre For East Asia, entitled "Amphetamine-type stimulants and drug control in East Asia". A copy of the paper is attached in Annex 5. Mr Bazant identified the concern over the use of A TS had become generalized. From an historical perspective, people have used stimulants for a long time in medicine, especially

-4ephedrine in China. The use of ATS in the developed world is a relatively more recent event. For instance, in the USA ephedrine was used and marketed in the early 1920's. UNDCP has also identified rises in the production of amphetamine analogues such as MDMA. This is reflected in increases in arrests for possession and trafficking. Thailand remains a main transiting country for illicit drugs from the Golden Triangle, but its relative importance in heroin trafficking has decreased as other routes have more recently developed through Southern China, the Lao People's Democratic Republic and northern Viet Nam. At the same time, the importance of Thailand has increased with regard to A TS production and transiting. For example, during the first six months of 1996, more than 5 million methamphetamine tablets were seized. In some countries of the subregion, precursor chemicals essential for the production of heroin and ATS are not sufficiently controlled because of inadequate legislation, organizational infrastructure and resources. The trafficking situation is further complicated by the absence of common legislation and regulations that would allow countries in the subregion to pursue extradition or charges of money laundering. Modalities for sharing information and organizing joint operations between countries are still in the early stages of development. Dr Adrian Reynolds, Regional Adviser in Health Promotion and Mental Health, presented a paper entitled "Regional situation in relation to amphetamine-type stimulants". A copy of the paper is attached in Annex 6. Cocaine use is not common in the Western Pacific Region while Methamphetamine use is particularly common in countries experiencing rapid economic growth. Smoking and sn iffing are the main methods of adm inistration in some countries. Oral and injecting drug use are common in others. The prevalence of A TS use among females is increasing, however males continue to be the main consumers. Initiation of ATS use is shifting to progressively younger groups in some countries and polydrug use is common. Acute health and social problems, including psychotic and violent behaviour, are being reported more in some countries than others, sometimes with dramatic and tragic outcomes. The contribution of confounders to this psychotic and violent behaviour, such as individual predisposition, past history, alcohol use, polydrug use and sociocultural expectations are uncertain. In general, countries of the Region are more inclined to place greater emphasis on supply reduction rather than public health policies and strategies. In some countries where the latter approach predominates, the problem is viewed as either lying within the province of mental health or the broader bio-psycho-social/public health model. In some countries communication and integration of approaches between the Ministries of Health and law enforcement agencies appears less than adequate. Drug intervention budgetary allocations are frequently heavily weighted towards the law enforcement sector, without apparent attention to evaluation of the efficacy of this approach or its impact on social well being, cohesion and conviviality of communities. In this regard, such strategies may have either a positive or negative effect. However, the assumption that they will always be helpful invariably goes unchallenged and untested. The possibility that they may sometimes be associated with substantial, albeit unintended, harm, is invariably excluded from analysis. The same shortcoming can also often be observed in relation to evaluation of prevention, harm reduction, treatment and rehabilitation approaches. Dr Robert Ali presented a paper on the findings, conclusions and major recommendations of the two international workshops on ATS hosted by WHOIPSA in Geneva on November 1996 and UNDCP in Shanghai on November 1996. The workshop proceedings were included in the background information for this meeting.

- 5The WHOIPSA meeting prepared a "state of the art" review of the nature, extent, context and consequences of ATS with particular reference to public health, prevention, treatment and policy responses. The scope of the paper was on both licit and illicit ATS but not cocaine, nicotine, caffeine or herbal stimulants. The review covers the epidemiology, social context, pharmacology, toxicology, health effects, social consequences, treatment approaches, prevention approaches, and policy responses to ATS. The major emphasis of the reports recommendations, which have important implications for the Region, were identified as; (1) WHO can be of substantial support to member countries through the adoption of a long-term commitment to the establishment and maintenance of a strategic response to ATS use. This could include a WHO commitment to the following: • • • • developing population-based and targeted needs assessments in relation to ATS use; applying, supporting and evaluating rapid assessment methods and innovative rapid reporting systems; taking a lead role in developing reliable, valid and comparable epidemiological and trend data on the extent and patterns of ATS use; and encouraging the development of national plans of action to address ATS which provide a framework for government and nongovernmental sectors, service providers and communities, enabling the development of appropriate and supported activities at the national or local level.

To assist governments in the planning, implementation and assessment of the (2) effectiveness of their strategic response WHO should: • • improve the monitoring and assessment of rapidly changing patterns of ATS use, related problems and the impact of such changes; explore avenues to promote responsible media coverage (including dissemination of information by Internet) in relation to the health and social consequences of ATS.

(3) The meeting identified the limitations of current treatment approaches to ATS use and the primacy given to the treatment of opiate-related health problems. Most ATS users do not seek treatment because their pattern of use does not cause chronic health or lifestyle problems. However, the meeting identified groups of severely dependent ATS users whose overall treatment needs appeared to be similar to other severely dependent drug users. WHO has an important role in this respect and should: • • • • identify the treatment and other service needs of ATS users; take a lead role in developing and evaluating screening and diagnostic instruments for identifying disorders related to ATS use; assess the efficacy and effectiveness of treatment approaches for ATS-related problems including pharmaceutical and non-pharmaceutical approaches; develop clinical guidelines for managing acute and chronic problems related to amphetamine type stimulant use;

-6• support countries in developing explicit policies and guidelines to provide treatment for amphetamine type stimulants users, where necessary; support the furthering of understanding of the natural history of A TS use, including the process of natural recovery; support the furthering of understanding of the barriers to access to treatment and care to stimulant users; train health professionals in management of ATS use; and involve the community in treatment and rehabilitation of ATS users.

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(4) The meeting identified current limitations to the prevention of ATS use and ATS-related health problems. WHO has an important role in the identification and testing of evidence-based practice for prevention. In this respect WHO should: • promote the development and testing of prevention approaches to A TS which are effective in different cultures and settings, and which recognize the different needs of the target groups; support the role of schools in providing an important setting for promoting primary prevention and for early identification of problem use of A TS; and promote effective school drug education, implemented using a social competency approach which promotes knowledge base and development of skills by young people to assist in development of healthy behaviour.

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The Economic and Social Council requested UNDCP to arrange a meeting of experts to examine counter measures against illicit manufacture, trafficking and use of ATS and their precursors. The report was forwarded to CND for consideration last year. The report covers four main areas, namely: • • • Reversing the trend of amphetamine-type stimulant abuse becoming a part of mainstream consumer culture The dilemma of drug-related information: freedom versus restraint; irresponsible versus responsible information Reducing economic incentives and limiting the availability of precursors for clandestine manufacture Closing the legislative and regulatory gaps

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Dr Bruce Grant and Dr Amelia Arria provided a review of epidemiological and demographic patterns and trends in A TS use in American Samoa, Guam, and the Northern Mariana Islands. A copy of their paper is attached in Annex 7. Dr Grant also tabled a copy of the SAMHSA Proceedings of the National Consensus Meeting on the Use, Abuse and Sequelae of Methamphetamine with Implications for Prevention, Treatment and Research. Dr Agueda Sunga reviewed the epidemiological and demographic patterns and trends in ATS use and related health problems with an emphasis on the Philippines. Seventy percent of the 1.7 million Filipino drug users are in the Metro Manila area. Ninety five percent are methamphetamine users. In the Philippines Drug Summit held in August 1997 five components for a unified drug policy were identified as being: • information dissemination;

- 7• • • • prevention and education campaigns; law enforcement; legislation; and treatment and rehabilitation.

Dr Robert Ali presented a review of the biological, toxicological, psychological and pharmacological aspects of ATS. The paper also examined the context and patterns, current methods of prevention and treatment, implications for public policy and decision-making. A copy of the presentation outline can be found in Annex 8. The amphetamine class of drugs is comprised of a large number of psychoactive agents with a wide range of pharmacological properties. Depending on the exact location and composition of substituents on the basic amphetamine structure (i.e., phenylisopropanolamine), drugs in this class include those which produce predominantly stimulant (e.g., methamphetamine, MA,), hallucinogenic (e.g. paramethoxymethamphetamine, PMA) or appetite suppressant (e.g., phenethylamine, fenfluramine) effects. Other amphetamine derivatives produce a mixture of stimulant and psychedelic effects (e.g., 3,4- methylenedioxymethamphetamine, MDMA). The compounds stimulate central and peripheral monoamine neurotransmission. This is done variously by enhancing release, blocking re-uptake and inhibiting the monoamine oxidase (MAO). It was confirmed that only a small percentage of ATS users seek treatment. They are much less likely to seek treatment than heroin users. The patterns of use have been categorized into experimental, occasional, instrumental, chronic and compulsive. The latter groups are more likely to have ATS-related problems and seek assistance. Patterns of use will vary across settings and within cultures. Typically, ATS use commences in the late teens and lasts for between six and eleven years. Metabolism of ATS occurs in the liver while excretion of metabolized and unmetabolized forms occurs through the kidneys. The liver metabolism is inducible and subject to the effects of drug interaction Medical prescribing of ATS is I imlted to Attention Deficit Hyperactivity Disorder (ADHD) and as an anorexic agent. Some countries in the Region are experiencing an increase in the level of prescribing ATS for ADHD. HIV risk taking is common among ATS users. Several studies have reported 30%60% of ATS users sharing their injecting equipment. Comparable estimates were found for unsafe sexual practices. Engaging in these practices is the context that ATS users believe they are at low risk of contracting HIV and other blood-borne viruses. The acute toxicological effects of ATS are exaggerations of the expected central and peripheral effects. Behavioural and psychological effects include aggression, violence, paranoid thinking, depression and psychosis. While death is rare from acute toxic effects, deaths from accidents, cerebrovascular haemorrhage, myocardial infarction, hyperpyrexia and suicide have been reported. The effects of exposure during pregnancy are unclear at this time. The obstetric complications appear to parallel cocaine. Common adverse effects associated with chronic use include weight loss, insomnia, dependence and psychosis. There are preliminary animal studies that indicate the potential for neurotoxicity. This area requires further investigation. The psychosis induced by ATS use is similar to schizophrenia and can be difficult to differentiate. The general treatment of acute toxicity is consistent with the principals of the management of other drug toxicities. Long-acting benzodiazepines can be used for a limited

- 8duration to reduce the discomfort of withdrawal. Dopamine agonists, antidepressants and anticonvulsants have not generally been found to be helpful in this context. Pharmacological interventions for ATS dependence have been categorized into blocking, adversive and replacement drugs. At this time there is no consensus on the most appropriate pharmacological options. Most of the research to date has been undertaken among cocaine-using popUlations. Nonpharmacological interventions for ATS-related problems include inpatient programmes, therapeutic communities, self help, behavioural strategies, cognitive therapies, nontraditional options, group therapy and psychodynamic therapy. On the current evidence, especially for heavy users, cue exposure and multifaceted interventions appear to be superior to the other nonpharmacological interventions in reducing cravings and relapse. Mr Steve Tamplin and Dr Ogawa, Regional Advisers in Environmental Health, conducted a plenary session on the development of primordial and primary prevention strategies related to drug use and problems within the context of health promotion. Reference to the Healthy Cities - Healthy Islands project within the context of New horizons in health brought out examples of health promotion and health protection activities and the framework of strategic planning. They identified environmental problems such as the forces that initiate and maintain drug use not being solved by only the health sector and the need to collaborate with different sectors. The policies and programmes for an adequate and appropriate response need to be agreed upon and supported at the highest level to ensure success. Dr Caleb Otto gave a presentation on the balance between public health policies and interventions aimed at preventing or reducing the health problems associated with ATS. Group work I: The participants were divided into three groups and asked to consider the following Issues: (1) Examining the recommendations and emphases of the ESCAP/ UNDCP and WHO/ PSA reports, do you think that these are likely to: • • • reduce use; reduce health harm; and reduce social harm.

(2) Which of the major findings, conclusions and recommendations that emanated out of the two major meetings held by WHO/ PSA/ HQ and UNDCP respectively, on ATS do you think were of most importance and relevance to your country? (3) Does your country have a documented strategic approach to problems relating to the use of ATS? If so, what is the emphasis of this approach? (4) What approach are countries in the Region adopting for the dissemination of responsible and accurate information on ATS? (5) Do you think that attention should be paid to population-based and targeted needs assessment for ATS related problems? (6) Are current models of school drug education programmes in your country consistent with the recommendations of the WHO report?

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(7) The ATS meeting held in Shanghai covered a range of strategies in relation to the availability of precursors and economic incentives for illicit ATS manufacture. What emphasis do countries in the Region place on precursor control as a means of reducing supply of amphetamine-type stimulants? Participants agreed that there was compelling evidence of an emerging ATS problem within the Region, evidenced by the increasing availability and harms associated with the use of ATS. Concern was expressed that this probl<:m was increasing in magnitUde and there is need for urgent action. Concern was also expressed that some countries had not recognized the existence of an A TS problem within their country. Accordingly, participants felt there was a need for a coordinated regional response. Further, participants felt that all countries within the Region should be urged to develop, implement, monitor and evaluate a national strategic approach aimed at reducing the use and harms associated with the use of ATS. This approach should be consistent with, and form a part of, a broader comprehensive national commitment which responds to the harms associated with alcohol, tobacco and other drug use. Participants confirmed the need for a national commitment to a balanced approach that reflected supply reduction, demand reduction and harm reduction initiatives. Emphasis was placed on the need for prevention, health promotion, health protection and health maintenance strategies. Group work 2: The participants were divided into three groups and asked to consider the following Issues: (1) What new information have you acquired during this workshop that may provide reasons for change to the current approach towards ATS in your own country and what might those changes be? (2) (3) What barriers to your intended efforts in seeking change do you anticipate? How might this workshop help you overcome, remove or reduce these barriers?

(4) What factors in relation to substance use problems influence our ability to follow normal models of health planning? Participants identified the need for the development of a register of the technical expertise available within the Region that could support countries in responding to their identified priorities. The development and testing of a screening instrument would enhance the capacity of countries to respond to ATS-related harms as would the development of best practice treatment methodologies for people with ATS-related problems. These should be culturally sensitive and appropriate for the primary health care setting. Several countries identified a need for training in the use of screening instruments and treatment methodologies for people with A TS-related problems that are appropriate for primary health care and specialists drug and alcohol clinicians within the Region. Participants felt there was a need to develop, through collaborating centres, rapid assessment techniques, survey tools, monitoring instruments and training in these methodologies along with resources and training in data collection, analysis, monitoring and evaluation. Participants identified the need for the development of guidelines for the medical prescribing of ATS in the treatment of ADHD and obesity. A participant from Australia tabled their National Health and Medical Research Councils draft guidelines for the management of ADHD. Group work 3:

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The participants were divided into three groups and asked to consider the following issues: (I) What new information have you acquired during this session that may provide reasons for changing the environmental influences on the nature, patterns, extent and consequences of ATS use in your country? (2) (3) (4) What might those changes be? What barriers to your intended efforts in seeking change do you anticipate? How might this workshop help you overcome, remove or reduce these?

(5) Did the strategies outlined in the Healthy City projects presentation have any relevance in achieving a reduction in ATS use? Participants determined they would forward the summary report of this meeting to the key decision-makers within the key decision-makers within their governments for consideration. The participants intend that their report should include an assessment ofthe priorities for their country and suggested mechanisms for action. Those countries that have ATS and other drug strategic plans determined that they would provide WHO with copies of all current and future plans. It was felt that countries would benefit if WHO were to receive and disseminate to countries within the Region all current and future ATS and other drug strategic plans from those countries within the Region that have developed such plans. Discussion of the country questionnaires that were sent out and completed prior to the meeting was also proposed and supported for distribution.

UNDCP could support those countries that have no existing legal sanctions against manufacture, supply or trading in ATS to develop a consistent legal approach. In developing an ATS strategy, participants felt the ideal model would be for a country to develop it within a philosophical context that included: (I) a critical analysis of determinants of their drug policy, including an emphasis on supply reduction, demand reduction, hazard identification and risk reduction initiatives; (2) an ecological and environmentally balanced strategy, incorporating the role of cultural and social values in the initiation and prevention of ATS-related problems; (3) community development strategies that decrease the incidence and prevalence of drug-related problems; (4) community input into ATS policy development and consideration of the inclusion of people who currently or formerly have experiential knowledge of ATS use; (5) emphasis on the detection and care of people who have ATS-related problems in the primary health care (PHC) setting (PHC should be encouraged to see the identification and management of alcohol and other drug problems, including ATS related problems, as an integral component of their work practice); (6) development of a formal relationship between PHC and specialist alcohol and other drug services to facilitate shared care; (7) the use of self-help resources as a way of making contact with people who have problematic ATS use but who are not seeking direct care;

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(8) encouragement to continue reflecting on the appropriateness of existing drug control policy; (9) opportunities for collaboration with other countries within the Region in reducing the level of ATS-related problems; (10) a social competency-based approach in drug education within the school health education curriculum; and (11) ethical standards within the mass media in their reporting of ATS related issues.

In undertaking a needs-based planning approach to ATS strategic plan development, participants identified an ideal process should: (1) facilitate dialogue between community-based and all government-based organizations and sectors; (2) identify specific needs of urban and rural communities, and ethnic minorities within countries; (3) identify barriers to treatment for those ATS users who are in need of treatment and care; (4) identify potential opportunities for entry into the primary health care and specialist drug treatment process for those who have ATS-related problems; (5) encourage community groups such as religious organizations to act as agents to intervene and provide support to people who have ATS-related problems; (6) bring ATS issues to the attention of the Healthy Cities/Healthy Island projects in the respective countries and determine the emphasis and priority of ATS-related problems within that context; Participants felt it would be beneficial if WHO in collaboration with UNDCP could: (1) act as clearinghouse for resources, research findings and training opportunities that exist within the region (2) use their Internet capability for information and resources dissemination. This could include source documents that identify: • • • • • • • epidemiological trends; individual country drug policies; treatment options and related evidence of their effectiveness; existing legislation; a categorized register of expertise available within the Region; examples of social competency based approaches to school drug education programmes; and opportunities and mechanisms for greater sharing of information within the Region

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2.3

Evaluation

All participants completed and returned an evaluation questionnaire. Analysis of the responses indicated a high approval rating in achieving the objectives of the workshop. A copy of the responses can be found in Annex 9. Participants also generally agreed that they had learnt new skills that had relevance in their country. There was acceptance of the workshop process, with adequate time spent on the topics. Just under half of the participants raised concerns about having an inadequate time to consider the background papers that were circulated prior to the meeting. Some participants identified that Thailand's involvement in the workshop would have made a positive contribution. Many participants suggested the need to repeat the workshop biannually.

3. CONCLUSIONS

This workshop reviewed epidemiological and demographic patterns and trends, identified problems and assessed current methods and techniques of prevention, harm reduction, treatment and rehabilitation related to ATS use in the Western Pacific Region. It focussed on developing broad-based strategic options in accordance with contemporary best practice models and empirical evidence, with acknowledgment of the need to adapt these within the context of available resources and the social norms, customs, culture and national aspirations of each participating country. The workshop contributed to future collaboration among participating countries and WHO in the development of prevention, integrated treatment and rehabilitation programmes, and a reduction in the hazardous use of ATS and related problems in the Region. It was found that while there are substantial adverse consequences associated with AST use, the harms are not adequately documented and the health protection, treatment and care needs of an increasingly large group of A TS users are not being adequately met.

Participants agreed that there is a need for attention to needs assessment, strategic planning, information transfer, capacity development, training and clarification of terminology. Workshop participants also emphasized the need for training in all areas related to the health, social and other harms associated with the use of ATS. This will facilitate capacity building among member states to deal more effectively with these problems. Workshop participants learned that drug policy is often based on considerations other than empirical evidence and the practical experience and collective wisdom of those working in the field. It was agreed that a better understanding ofthe factors that influence public policy and decision-making might support and give direction to the development of healthy public policy. Workshop participants heard that the majority of resources invested in policies, strategies and activities aimed at reducing the use and harms related to ATS go to the supply reduction area. Workshop participants also heard that most countries in the Region have not as yet undertaken rigorous studies to evaluate the effectiveness of the components of their drug strategies.

- \3-

Participants felt the area of prevention in its various forms is most important and should be accorded due priority in policy and planning. The success of prevention projects may hinge in part on the involvement of users themselves who are often interested in becoming involved in peer education, peer support and other outreach activities within their own subculture and who are often very willing to participate in the planning and implementation of such preventive and harm-reduction activities. Conventional educational materials, which tend to use fear-related and/or medically orientated drug prevention messages, may be seen by A TS users as irrelevant to the needs of the group. The workshop participants learned that there is no consensus regarding effective treatment for ATS users and A TS dependence, pointing to the need for continued research effort in this important area. With regards to pharmacological interventions, there are no pharmacotherapies that have been demonstrated to be highly effective or reliable in reducing the symptoms of withdrawal or in eliminating craving for the drug following withdrawal. This is an important area for continued research. During the workshop differing opinion was expressed as to the manifestations of an ATS withdrawal syndrome. Workshop participants heard that certain nonpharmacological interventions have proved more efficacious than others in the treatment of A TS dependence, cravings and relapse and other A TS related problems. These need to be applied more widely in order to confirm their clinical usefulness. It was agreed that more attention needs to be paid to developing improved models of treatment, rehabilitation and care that are more acceptable and attractive to those in need of care, and that can help a higher proportion of people with problems related to the use of A TS. Workshop participants placed great emphasis on the need for more up-to-date information as well as mechanisms that can facilitate rapid, inexpensive and easy transfer of new knowledge, as it becomes available. Information dissemination through various means such as the Internet, email, WHO Collaborating Centre activity, workshops and technical support could all playa role in this regard. The importance of broad-based strategic planning and the role that WHO might play in coordinating and facilitating such activity was noted. This would be based on a comprehensive assessment of the nature, extent and severity of the problems at country level, the needs of those using ATS and the barriers to prevention, treatment, harm reduction and care services which they may face. It is anticipated that new screening, assessment and clinical management tools that are being developed by WHO will be important in supporting such activity.

ANNEX I

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFACE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP ON PROBLEMS RELATING TO THE USE OF AMPHETAMINE-TYPE STIMULANTS (ATS) IN THE WESTERN PACIFIC REGION Manila, Philippines 16-20 February 1998 INFORM....\.TION BULLETIN NO.2

WPRJADTfHPRIl\fNH(1 )/98/IB/2 23 February 1998

ENGLISH ONLY

LIST OF PARTICIPANTS, REPRESENTA TIVES/OBSERVERS AND SECRETARIA T

1.

PARTICIPANTS

AUSTRALLA..

Dr Robert Ali Director Clinical Policy and Research, Drug and Alcohol Senices Council 161 Greenhill Road, Parkside, SA 5063 Adelaide South Australia Fax no. 61-88373-0749: Telephone no.: 61-88274-3349 E-mail: rali@medicine.adelaide.edu.au Mrs Laurayne Bowler Acting Director Chemicals and Non-Prescription Drug Branch Therapeutic Goods Administration Department of Health and Family Senices Woden, AC.T. Fax no.: (02) 6232-8659; Telephone no.: (02) 6232-8660 E-mail: laurayne.bowler@health.goy.au

CHINA

Dr Liu Zhirnin Associate Professor National Institute on Drug Dependence Beijing Medical University 38 Xue Yuan Road, Haidian District Beijing 100083 Fax no.: (86-10) 6203 2624; Telephone no.: (86-10) 6209-2460(office); 6257-0005 (horne)

- 16 -

Annex 1 Dr Zhao ChengziIeng Associate Professor Chief, Department of Drug Information National Institute on Drug Dependence Beijing Medical University 38 Xue Yuan Road, Haidian District Beijing 100083 Fax no.: (86-10) 6203-2624; 6611-0901 Telephone no.: (86-10) 6203-2625 (office); 6611-0901 (home) E-mail: NIDDBMU@PUBLlC3.BTA.NET.CN JAPA.N Dr Shinji Hirai Psychiatrist, National Psychiatric Institute of Sbimofusa 578, Heta-machi, Midori-ku Chiba-shi. Chiba-ken, 266 Fax no.: +8143291 2602; Telephone no.: +8141291-221 E-mail: shinjih@msn.com Mr Yujiro Oki Narcotics Control Officer Kyushu Regional Narcotics Control Office Ministry of Health and Welfare No.2, 2-10-7 Hakataeki Higashi, Hakata-ku Fukuoka Fax no.: +81924514539; Telephone no.: +81 92 472 2331 E-mail: okiy@mtd.higlobe.ne.jp LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Vilayvang Phimmasone Director, Food and Drug Department MInistry of Health Vientiane Fa, no.: (856-21) 214015; Telephone no.: 214013-14 E-mail: Cabinet@'.moh.godao Dr Ang Kim Teng Deputy Director, Medical Development Division Ministry of Health Jalan Cenderasari 50590 Kuala Lumpur Fax no.: (603)2942251; Telephone no.: (603) 293 4267 1\11' Loo Chiang Jiu Deputy Director (Licensing and Enforcement) Pharmaceutical Services Division, Ministry of Health 11th Floor, PERKlM Building, Ipoh Road 51200 Kuala Lumpur Fax no.: (603) 441-1623; Telephone no.: (603) 4412892; (603) 4421211 E-mail: loocjiu@tm.net.my

M.ALAYSIA

- 17 -

Annex 1

MARIANA ISLANDS, COMMONWEALTII OF THE NORTHERN

Mr Joseph Kevin Villagomez Director, Division of Mental Health and Social Service Department of Public Health P.O Box 409 CK, Saipan, MP 96950 Fax no.: (670) 323-6580; 234-8930 or 234-8931; Telephone no.: (670) 323-6560; 234-8950 E-mail: JKVSAIPAN@aol.com;healthl@gtepacifica.net Dr Rilunen Lanzo Clinician and Primary Health Care Physician STDINCD/CD and Surveillance Coordinator Pohnpei State Hospital Nett, Pohnpei, FM 96941 Fax no.: (691) 320-5394/5253; Telephone no.: (691) 320-6257 Mr Rhine William Substance AbuselMental Health Coordinator P.O. Box 127, Tofol, Kosrae, FSM 96944 Fax no.: (691) 320-5263; Telephone no.: (691) 370-3006/3199

MICRONESIA, FEDERATED STATES OF

PALAU, REPUBLIC OF

Dr Caleb Otto Chief of Public Health, Bureau of Public Health P.O. Box 6027 Koror 96940 Fax no.: (680) 488-3115; Telephone no.: (680) 488-1757/2450 E-mail: phpal@palaunet.com Mr Patrick Aribuk Professional Nurse II Ministry of Health P.O. Box 6027 KoroT 96940 Fax no.: (680) 488-1211; Telephone no.: (680) 488-1907 E-mail: bhd@palaunet.com

PHILIPPINES

Dr Agueda Sunga Medical Specialist III; Program Manager National Substance Abuse Prevention Treatment and Rehabilitation Program Office of the Secretary, Department of Health San Lazaro Compound, Rizal Avenue, Sta. Cruz Manila Fax no.: (643) 743-1829 Telephone no.: (643) 743-8301, e>.."t. 1129; (643) 711-9503 (direct no.) E-mail: creodica@planet.net.ph

- 18 Annex 1 Dr Edgardo Juan Tolentino, Jr. Executive Assistant, National Program for Mental Health Department of Health, Administration Building National Center for Mental Health Compound Nueve de Febrero Street, Mandaluvong City, Metro Manila Fax no.: (643) 531-8739; Telephone no.: (643) 724-5894 REPUBLIC OF KOREA DrYoung-ki Jeong Assistant Director of Narcotic Control Narcotic Control Division, Ministry of Health and Welfare 2nd Government, 1 Jungang-dong Kwachon-shi, Kyonggi-do Fax no.: (82-2) 504-6418; Telephone no.: (82-2) 503-7561 Ms Rossida Bte Dolah Head, Preventive Education Unit Central Narcotics Bureau Ministry of Home Affairs No.2, Outram Road Sinl!apore 169036 Fax no.: 65-222-1774; Telephone no.: 65 329-2949 Professor Nguven Dang Dung Director of Central Psychiatric Hospital and Vice Director of National Institute of Mental Health Ministry of Health and Welfare Thuong tin Hatav Fax no.: (84-34) 853 190; Telephone no.: (84-3) 485-3210; 4853227 Mr Bui Duc Phong Deputy Director, Department of Health Inspection Ministry of Health 51 Pham Ngoc Thach, District 3 Ho Chi Minh City Telephone no.: (848) 824-1596

SINGAPORE

VIETNAM

2. REPRESENT A TIVES/OBSERVERS

Johns Hopkins University

Dr Amelia Arria Johns Hopkins University School of Public Health 624 North Broadway, Baltimore, MD 21205 United States of America Fax no.: (410) 955-9088 Telephone no.: (410) 955-0415 E-mail: aarria@jhsph.edu

- 19 -

Annex 1

United Nations International Drug Control Progranune (UNDCP)

Mr Wayne Bazant Demand Reduction Adviser U1\'DCP Regional Centre for East Asia United Nations Building, 14th Floor Rajdarnnern Avenue, GPO Box 618 Bangkok 10501 Thailand Fax: no.: +66 2 281 2129; Telephone no.: +6622882091 Internet: rcdcp@kscl5.th.com Dr Bruce Grant SAMHSA Pacific Health Coordinator PPG Program Branch Rocl..-wall II, Suite 880 5515 Security Lane Roch~lIe, Maryland 20852 United States of America Fax no. (301) 443 8345 Telephone no.: (301) 443-3820 E-mail: BGRANT@S.>\l\fl-ISAGOV

U.S. Substance Abuse and Mental Health Services Administration (S .>\1\fl-I SA)

3. SECRETARlA T

Dr Adrian D.B. Remolds Acting Regional Adviser in Health Promotion and Mental Health 'Vorld Health Organization Regional Office for the Western Pacific Manila, Philippines Fa...: no.: (632) 521-1036; 526-0362; 526-0279; Telephone no.: (632) 528-8001; 528-9982 (direct) E-mail: postmaster@who.org.ph;reynoldsa@who.org.ph

Mr Masanobu Tanimoto Technical Officer, Prevention of Substance Abuse World Health Organization Regional Office for the Western Pacific Manila, Philippines Fax no.: (632) 521-1036; 526-0362; 526-0279; Telephone no.: (632) 528-8001 E-mail: postmaster@who.org.ph;tanimotom@who.org.ph

- 21 -

ANNEX 2

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAl DU PACIFIQUE OCCIDENTAL

WORKSHo.P o.N PRo.BLEMS RELATING TO. THE USEOF AMPHETAMINE-TYPE STIMULANTS (ATS) IN THE "'ESTERN PACIFIC REGION Manila, Philippines 16-20 February 1998

\VPRlADTfHPRlMNH(I)/98.1 05 February 1998

ENGLISH o.NLY

PROVISIONAL PRo.GRAMME

Mondav. 16 Februarv 1998 0830-0900 hours 0900-0940 Registration Opening ceremony Introductory remarks by the \\'HO Operational Officer (Dr Adrian Reynolds, Acting Regional Adviser in Health Promotion and Mental Health, \\1iOfWPRO) Opening remarks by the Regional Director (Dr S.T. Han. Regional Director, \\1iO/WPRO) - Announcement of Chairman, Vice·Chairman and Rapporteur Self introduction of participants Adm inistrative announcements 0940-1000 1000-1030 1030-1040 1040·1055 Group photograph Coffee break Adoption of the agenda Global situation and trends in relation to ATS, from the drug control and public health perspectives - (Mr Wayne Bazant, UNDCPfBangkok, and Dr Adrian Reynolds, WHOfWPRO) Regional situation in relation to ATS, from the public health perspectives; framework for policy, planning and action - Dr Adrian Reynolds (WHOfWPRO) Country reports: (in alphabetical order, 10 minutes each): Australia, China, Japan, Lao People's Democratic Republic, Malaysia, Commonwealth of the Northern Mariana Islands and the Republic of Korea

1055-1110

1110-1230

- 22 -

Annex 2 WPRI ADT/HPRlMNH( 1)/98.1

1230-1330 1330-1430

Lunch CountrY reports: Micronesia (F;!derated States of), Palau (Republic of), Philippines, Singapore and Viet Nam Coffee break Plenary discussion: summary of regional situation in relation to identified ATSrelated problems, trends, major challenges and matters of particular importance that this workshop should seek to address Informal get-togeLljer

1430-1450 1450-1530

1600-1700

Tuesdav. 17 February 1998 0800-0845 hours Plenarv DaDer: presentation of the findings, conclusions and major recommendations of the two international workshops on A TS hosted by WHOIPSA in Geneva on 12-15 November 1996 and by UNDCP in Shanghai on 25-29 November 1996 -Dr Robert Ali, Australia; Comments by Mr Wayne Bazant, UNDCP Plenarv paper: global and Southeast Asia situation regarding A TS drug control measures, coordination and integration among UN agencies and countries (referring to Global Plan of Action and regional applications) Mr Wayne Bazant, UNDCPlBangkok Group session: to examine the major findings, conclusions and recommendations of the Geneva and Shanghai workshops and the strategies of UNDCP Coffee break Group session: continued discussion in relation to findings and recommendations of the Geneva and Shanghai meetings and strategies of UNDCP Plenarv discussion: each group to present their findings. Progress towards regional strategic planning in relation to A TS problems Lunch Plenary paper: Review of the epidemiological and demographic patterns and trends in ATS use in American Samoa, Guam and tbe Commonwealth of the Northern Mariana Islands; resources, mechanisms and opportunities for collaboration and networking in the Pacific region - Dr Bruce Grant and Dr Amelia Arria, Substance Abuse and Mental Health Services Plenary paper: Review of the epidemiological and demographic patterns and trends in ATS use and ATS-related health problems in Asia; current responses in Asia - Dr Agueda Sunga, Philippines

0845-0920

0920-1000

1000-1020 1020-1120

1120-1230

1230-1330 1330-1410

1410-1450

- 23 -

Annex 2 WPRIADTIHPRlMNH( 1)/98.1

1450-1530

Plenary session: discussion of plenary papers focl1<;inl1 on conclusions to be drawn, particularly in terms of strategic and operational planning at national, regional and global levels

Wednesdav, 18 February 1998 0800-0840 hours Plenary paper: Review of the biOlogical, (acute and chronic) toxicological, psychological and pharmacological aspects of ATS and their use in various contexts and patterns; current methods of prevention and treatment; the implications for public policy and public health decision-making D{ Robert Ali, Australia Group session: discussion of country experiences with ATS in relation to the health, social, economic, legal and other harms being experienced and responses to date Coffee break Group session: groups to re-convene to continue above discussion Plenary session: groups to report back on findings, followed by plenary discussion of ways forward at country, regional and global levels Lunch Plenaf'.' paper: on the development of primordial and primary pre\'ention strategies related to drug use and drug problems, within the context of the settings approach for health promotion - Mr Steve Tamplin and Dr H. Ogawa, Regional Advisers in Environmental Health, WHOfWPRO Group session: further discussion on the morning's theme focusing on experiences at country level Coffee break (while in group session) Plenary session: groups to report back followed by plenary discussion. Conclusions to be drawn

0840-1000

1000-1030 1030-1130 1130-1230

1230-1330 1330- I 400

1400- I 450

1430-1450 1450-1530

Thursdav, 19 February 1998 0800-0830 hours Plenary paper: achieving the balance between public health policies and interventions aimed at preventing or reducing health problems associated with the use of ATS and other responses aimed at achieving more ideal outcomes (non drug use) - Dr Caleb Otto, Palau Group session: to review current and possible future methods and techniques for the prevention, reduction in harm and treatment of persons with problems relating to the use of ATS Coffee break

0830-1030

1000-1030

-

24 -

Annex 2 WPRlADTfHPRlMNH(I)/98.1

1030-1130 1130-1230

Group session: discussion

';0

continue on above theme

Plenary session: groups to report back and workshop findings and conclusions on this topic to be drafted Lunch break Plenary session: the opportunities and strategies for promoting future collaboration and networking among organizations and countries for the development of public policy principles and frameworks. prevention. integrated treatment/rehabilitation programmes. the linkage with supply reduction strategies and research in the Region aimed at preventing or reducing problems related to ATS - Dr Reynolds. Mr Bazant, Dr Ali. two Pacific island representatives and two Asian representatives Coffee break (while in plenary session) Plenary session: drafting of workshop findings alld conclusions to be presented to plenary by chairman. for penultimate comments and preliminary approval by the group

1230-1330 1330-1500

1430-1450 1500-1530

Frida\'. 20 February 1998 0800-1000 hours Plenary session: rapporteur to present summary of findings and conclusions in each identified priority area (public and instItutional policy. prevention. treatment/rehabilitation, hann reduction, research, supply reduction as it links with other strategies), followed by plenary discussion to clarify, amend, and formulate definitive commentary, findings and conclusions for the report Coffee break Evaluation to be completed by all participants Plenary session: final conclusions to be ratified Closing ceremony

1000-1030 1015-1030 ) 030-1130 1130-1145

- 25 -

AHHEX 3

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR TH: WESTERN PACIFIC BUREAU R~GIONAl DU PACIFIQUE OCCIDENTAL

WORKSHOP ON PROBLEMS RELATING TO THE USE OF A!\1PHETAl\1Th""E-TYFE STIMULANTS (ATS) IN THE \\'ESTERN PACIFIC REGION Manila, Phili ppines 16-20 February 1998

09 February 1998

ENGLISH Ofl.'L Y

LIST OF DOCUMENTS

WPRJA DT/HPR/l'v11\1-I( 1)/98.1 WPRJADTiHPR/M~H( 1)'98.1 a WPRJADT/HJ'RfJ\11\l-J( 1)198, I b IXFOR.c'\1ATIO~ BLLLET~S

Provisional agenda Pro\'isional programme Tentative timetable

WPR! ADT'HPR'M~1-I( 1)l98 '18/1 WPR/ADTiHPRfJ\1NH( I )l98/IB::Z

Information Bulletin no, I Infonnation Bulletin no, 2

3,

WORK.P.\G PAPERS WPR/ ADT/HPRfJ\1NH( I )l98.2 Amphetamine-type stimulants (ATS) (A report from the WHO Meeting on Amphetamines, MDMA and other Psychostimulants, Geneva. 12-15 November 1996) Abuse of and illicit trafficking in stimulants (Report of the Expert Meeting on Amphetamine-type Stimulants held at Shanghai, China, 25-29 November 1996)

\\'PR/ADTlHPR/MNH(1 )198.3

WPR/ADT/HPR/MNH( I )9 8fI}..'F .II WPR/ADT/HPRfJ\1NH(I)98/Th'F.!2

Country reports Creating Healthy cities in the 21st century (Background paper, United Nations Conference on Human Settlements, Habitat II, Istanbul, Turkey, 3-14 June 1996)

-

26 -

Annex 3

WPRJADTfHPRlMNH(1)98IINF.l3

Conferen~e

report - Healthy Cities and Healthy Islands in the W ~stern Pacific Region, 1991-1996 (International Conference on Healthy Cities, 14-16 October 1996, Beijing, China; Regional Consultation on Healthy Cities, 16-18 October 1996, Beijing, China) Discussion paper on healthy islands (Meeting of Directors of Health and Ministers of Health for Pacific Island Countries, 4- 7 August 1997, Rarotonga, Cook Islands) Building a healthy city: A practitioners guide WHO Healthy Cities: A programme framework The Rarotonga Agreement - Towards healthy islands The Jakarta Declaration on Leading Health Promotion into the 21st Century Yanllca Island Declaration

WPRJADTfHPRlMNH(1)98IINF.l4

\VPRJADTfHPRJM}"'H( I )98/Th'F.l5 WPRJADTfHPRJMNH(1)98IINF.l6 WPRJADTfHPR/M}..'H(1)98/Th'F.17 WPRJADTfHPRlM}..'H(1 )98/Th'F.l8

WPRJADTfHPR/MNH(I)98/Th'F.l9

- 27 ANNEX 4

WORLD

HEALTH

. ORGANIS~TIONMO~DIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RkOGIONAL DU PACIFIQUE OCCIDENTAL

\VORKSHOP ON PROBLEMS RELATING TO THE USE OF A.l\1PHETA...lVIINE-TYPE STIMULANTS (ATS) IN THE WESTERN PACIFIC REGION Manila, Philippines 16-20 February 1998

WPRI ADT fHPRlMNH(1 )/98.5 13 February 1998

ENGLISH ONLY

GLOBAL SITUATION A.1\'"O TREl\'"OS IN RELATION TO A_l\1PHETA.c\1I!\""E-TYPE STIMULA1\'TS, FROM THE PUBLIC HEALTH PERSPECTIVE

by Dr Adrian Reynolds Acting Regional Adyiser in Health Promotion and Mental Health

The issue of this document does not constitute formal publication. It should not be revieWed, abstracted or quoted without the agreement of the World Health Organization. Authors alone are responsible for views expressed in signed articles.

Ce document ne constitue pas une publication. II ne doit faire I'objet d'aucun compte rendu ou resume ni d'aucune citation sans I'autorisation de ('Organisation mondiale de la Sante. Les opinions exprimees dans les articles signes n'engagent que leurs auteurs.

- 29 -

Annex 4

WORKSHOP ON PROBLEMS RELATING TO THE USE OF AMPHETAMINE-TYPE STIMULANTS (ATS) IN THE WESTERN PACIFIC REGION (16-20 FEBRUARY 1998) Dr Adrian Reynolds Acting Regional Adviser in Health Promotion and Mental Health WHO Regional Office/or the Western Pacific 16 February 1998

Opening Remarks On behalf of the Regional Director, Dr S.T. Han, Dr B.P. Kean, Director, Programme Management, commented this morning that problems related to amphetamine-type stimulants are increasing in many countries in the Western Pacific Region. He added that there are very substantial gaps in our knowledge regarding effective methods for preventing or addressing these problems. It is my hope that during the next five days we will as a group develop a better understanding of the situation at country, regional and global levels, a better understanding of current strategies and the outcomes associated with these and some level of consensus on priorities for future action in the Region.

Global Trends in Drug Use Including ATS Although levels of illicit drug use in many developed countries have remained stable or have even declined for a number of years, this situation appears to be changing. In many parts of the world it appears there is an increase in the use of psychoactive substances, accompanied by a lowering of the age at which use begins. This worrisome trend of increased use of psychoactive substances among young people in many developed countries is nevertheless now overshadowed by evidence of increasing and changing panems of drug use in developing countries.' It is estimated that some 15 million people worldwide are exposed to significant health risk

arising out of their use of psychoactive substances, other than alcohol and tobacco. It is further estimated that one-third of people who use drugs (5 million people) do so by injection. The number of drug injectors appears to be rising world wide, and dramatically so in some developing countries. Recent estimates suggest that world wide, between] 00,000 to 200,000 deaths per year are related to the . injection of drugs. 2 The World Drug Report (1997) of the United Nations Drug Control Programme states that global production of cocaine increased by more than 200 % during the last decade (to 1995) and heroin production increased by more than 300 %. It is difficult to derive such estimates for ATS for a number of reasons including the variety of covert ways these substances can be produced from a range of precursor chemicals and in locations close to end-point markets. ;.4 Since the mid-1980s the world has seen an increase in synthetic stimulant use. In the course of the 1990s, the growth rates of illicit ATS production and trafficking are reported to have surpassed those of cocaine and ofheroin. 2•3 In parallel, consumption of ATS has begun to outstrip that of the traditional drugs in an increasing number of countries.; ATS are now consumed in practically every region of the world and if present trends continue, the problem of unsanctioned synthetic stimulant drug use may become a truly global one, with rapid expansion in both the industrialized and developing worlds. I.;

- 30 -

Annex 4 WPRlADTIHPRIMNH(1)98.5 page 2

United States of America

Some evidence suggests that methylamphetamine use is increasing in some parts of the United States of America, however, other evidence suggests that since 1994, overall levels of use may have fallen. There is substantial and possibly increasing use of amphetamine-type stimulants in the treatment of attention deficit disorder and for instrumental purposes such as attempted weight loss in those who are obese. 1.5

Countries of Latin America

There is some evidence of chronic or recreational use of illicit amphetamine-type stimulants in the countries of Latin America. The local production of cocaine and basoko in some parts of Latin America may partly explain the absence of chronic or recreational use of amphetamines. However, A TS ar~ used extensively in Latin America for instrumental purposes, for example, in the treatment of obesity. 1

Central and Eastern European Countries

In some countries of central and Eastern Europe, methylamphetarnine has long been used in an unsanctioned manner. In other countries, the use of ATS is newly emerging, particularly among young people and in association with music and the dance sub-culture. Ecstasy (1v1DM/I.) is becoming more popular. 1

Western European Countries

The use of ecstasy has been reported in all European Union countries. There is great variation ber,\,een countries. Use is particularly common in the United Kingdom and in the Netherlands. In general, across the European Union, amphetamines appear to be the second most commonly used illicit drugs. They are often used in combination with other drugs. !

African and Middle Eastern Countries

There is little use of amphetamine-type stimulants in most countries in Africa and the Middle East. It is unclear whether this reflects a true low prevalence of use or poor data. Most use is instrumental in nature and supplies are diverted from licit sources. Another stimulant drug, Khat (qat) is used in some parts of Eastern Africa. ATS-related problems are reported in Nigeria, Egypt and Yemen.!

Setting the Scene • A TS prob lerns increasing in Western Pacific Region • Substantial gaps in knowledge regarding effective prevention/intervention

Workshop Goals • Better understanding of: - situation - current strategies and outcomes - consensus on priorities for future action in Region

.... .....

> (1)

x

=' ='

""

,. ::s ::s (1) )C ~

~----

Global Trends in Drug Use Including ATS

Global Trends in Drug Use & Drug Injection

• Illicit drug use in many developed countries reportedly remained stable or declined (80's) - situation changing during last decade or more - increased use of psyehoaeti ve substances -lowering of the age at initiation

• 15 million people worldwide incur significant risk to health from use of psychoactive substances other than alcohol & tobacco

'" N

• Overshadowed by evidence of increasing & changing patterns of drug use in developing countries

Global Trends in Drug Use & Drug Injection • One-third of these users (5 million people) inject • Injector numbers rising worldwide, especially in developing countries • Between 100 000 to 200 000 persons die each year from injecting drug use

Global Trends in Drug Use Including ATS • Global production of cocaine increased> 200% during last decade (to 1995) • Heroin production increased by morc than 300% (World Drug Report, UNDep, 1997 • Increase global synthetic stimulant usc since mid-l980s.

'" ""

> ::s ::s ~

>< ~

::I ::I

:>

'>< " ~

Global Trends in Drug Use Including A TS • Illicit ATS production/trafficking growth rates surpassed cocaine & heroin (1990s) • ATS consumption outstripping traditional drugs in many cowltrics • ATS now consumed - every region or world

Global Trends in Drug Use Including A TS • Unsanctioned synthetic stimulant drug use may become truly generalized, globally • Rapid increases in both industrialized & developing worlds

'" ~

United States • Some evidence: since 1994, overall ATS use fallen • Other evidence: methylamphetamine use increasing substantially • Substantial & increasing use for instrumental and mcdical purposes: ADD & obesity

Countries of Latin America • Somc chronic & recreational illicit use • Local cocaine production may partly explain absence of chronic or recreational use • Used extensively for instrumental purposes (e.g. obesity treatment)

..... uo

» ;:! ;:!

II>

)( .Do

:> <l>

::s ::s ><

~

Central and Eastern Europe • In some countries methy lamph etamin c long used • In others, use newly emerg ing • Youn g people • Music and dance sub-cu lture • Ecstas y (MDM A) becom ing more popul ar

Western European Countries • Ecstasy reported in all E. U. countr ies • Great variation betwe en countries • Use comm on in U.K. & Nethe rlands • ATS secon d comm onest illicit drugs in EU • Often used in combi nation with other drugs

""' 0-

African & Middle Eastern Countries • Little ATS use • True low prevalence of use or poor data - uncertain • Most use instrumental • Supplies diverted frol11 licit sources ..... '"

,. :::l :::l

>: J>-

~

- 39 -

ANNEX 5

li~lTED NATIONS INTERNATIONAL DRUG CONTROL PROGRAMME

AMPHETAMINE TYPE STIl\1ULANTS (ATS) AND DRUG CONTROL IN EAST ASIA

A review of ATS issues in relation to UNDCP regional drug control plans with suggestions for the further deyelopment of A TS demand reduction initiatives,

prepared by \Vayne Bazant, Demand Reduction Adviser, UNDCP Regional Centre For East Asia, Banakok. b '

[pr the Workshop On Problems Relating To The Use Of Amphetamine Type Stimulants In The Western Pacific Region, Manila, 16-20 February 1998.

The views expressed in this paper are those of the author and may not necessarily represent the policies and positions of UNDCP or its affiliated national drug control agencies,

- 41 -

Annex 5

A.

INTRODUCTION

The global issues of substance abuse have been increasingly centred on synthetic drugs over the past two decades and it is often asserted in the context of iJlicit drug use that they may be associated with the most significant of all future substance abuse problems. This concern is reflected in a 1995 resolution of the Economic and Social Council in which many member states of the United Nations called for a thorough study of psychotropic substances, particularly stimulants and their precursor chemicals. The resolution provided the impetus for a comprehensive review of amphetamine type stimulants (ATS) by the United Nations International Drug Control Programme (UNDCP), subsequently presented to a global forum at Shanghai in 1996, and later published as part of the expanding UNDCP Technical Series. The results of the Shanghai meeting have established a framework for future action in the area of ATS by United Nations agencies, other international bodies, governments and non-government organizations. This paper is intended to provide a review of the current issues surrounding drug control in the region and specifically in Southeast Asia, to report on the progress of a drug control action plan and other developments related to A TS, and to suggest some immediate strategic possibilities for the development of a further regional response.

B.

GLOBAL TRENDS

In historical context, stimulant drugs have been compelling to human beings for centuries. Long before amphetamines were introduced to Western medicine. Indians of the Andes region were che\\"ing leaves of the coca shrub, and Ma-huang, the natural occurring form of ephedrine was being used in China for at least 5000 years. The Western experience with stimulants began over the past century, more or less beginning with Sigmund Freud who in the 1880s obtained cocaine to study its effects, including experimental use for morphine withdrawal. The experiments were eventually stopped because of concerns about the development of toxic psychosis. Amphetamine and methamphetamine were first synthesized during the late 1920s in the United States as a substitute for ephedrine which was difficult to obtain. The result of this work was introduced to the marketplace around 1935. Early reports during the same period warned about the addictive properties of these new drugs. These substances have been associated with cyclical epidemics beginn.ing in the 1890's in the United States and Europe with the surging use of cocaine, initially thought to be safe, then later reduced when the problems of abuse became more obvious. The pattern was repe~ted in the 1920s, and again in the United States during the 1950s and 1960s when the emerging abuse of amphetamine and methamphetamine in both injectable and oral forms became more apparent. Increased control over the use of amphetamines and reduced licit production were initiated during the same time in North America, resulting in a significant but temporary drop in the illicit diversions. However, in the 1970s, clandestine manufacturing of methamphetamine increased and by the 1980s, a dramatic rise in methamphetamine abuse was seen in urban areas of both the East and West coast of the United States.

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Annex 5

Since the 1980s, the world has faced a rapid rise in synthetic stimulant abuse, primarily relating to amphetamine and methamphetamine, as well as the recently popularized methylene-dioxymethamphetamine (MDMA) known as ecstasy, and methcathinone. This trend is reflected in various health indicators such as hospital admissions, drug treatment services, number of AIDS related cases, frequency of daily and lifetime use, substance abuse related mortality cases, and the number of countries reporting rising consumption levels. Related indicators from law enforcement include the number of drug seizures, possession arrests and convictions, and trafficking arrests and convictions. Within East and especially Southeast Asia, the health indicators are not sufficiently developed to establish quantitative measures, nor are there significant scientific studies worthy of international comparison to facilitate an understanding of the regional trends in stimulant abuse from the health perspective. However some inferences can be drawn from the law enforcement indicators. A TS abuse is regarded as a serious problem in some parts of the region, although the level of severity is not currently considered to be equivalent to that of opiate abuse. Among the ATS substances, the region is most seriously effected by methamphetamine. Within the past two years, there have been increasing reports from countries such as Laos, Myanmar, Thailand and Vietnam about heroin laboratories which have additionally or alternately begun to produce methamphetamine. In 1995, 24 methamphetamine smuggling groups were dismantled in the Republic of Korea. In 1996, a large illicit methamphetamine laboratory was detected in the Philippines, leading to the seizure of more than 600 kilograms of the end product and 1.6 tons of ephedrine, a precursor chemical used in the production process. The Philippines case reflects other observations that methamphetamine has been a dominant feature of drug problems in that country during recent years. Similar observations have been made of Taiwan. In Thailand over the past two years, national concern has emerged about the spread of methamphetamine use among adolescents. This is additional to the continuing problems of methamphetamine abuse among special groups such as transport drivers, construction workers, and those employed in the Thai fishing fleet. The concern is also supported by the Drug Abuse Trend Index for Thailand, compiled in the UNDCP World Drug Report, showing ATS abuse trends with a rate of increase higher than heroin abuse. While not conclusive, the available body of information from the region suggests that ATS manufacturing, trafficking and use have significantly increased in the 1990s. In some Within the A TS group, countries, the growth rate has surpassed that of heroin. methamphetamine appears to be the most often produced and used in the region. There is also some evidence about increasing trends in the trafficking and use of ecstasy in Southeast Asian. However, its origin is usually associated with European countries, as apparent for eXlUlOlple in two recent cases where 1,000 litres of ecstasy precursor manufactured in China was confiscated in the Netherlands and a further 3,000 litres of the same shipment, destined for the production of amphetamine, was stopped in Hong Kong.

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Annex 5

c.

REGIONAL ISSUES

In relation to the overall capacity for effective drug control, including both supply and demand aspects, the East Asia region in general and countries in Southeast Asia in particular are faced with many challenges. Opportunistic use of legitimate trade liberalization

Changing economic, technological, social and cultural conditions, trade liberalization, the opening of border areas, as well as large investments in communications infrastructure not only foster economic progress in the subregion, but also establish the infrastructural, monetary and social platform for illicit drug production and trafficking, markets for drugs among new and vulnerable populations, and skills and facilities for money laundering, thereby leading to further escalation and regionalisation of drug problems. Not withstanding some recent temporary economic setbacks, these developments continue in most parts of the subregion. Opium Production

The illicit production of opium poppy in the "Golden Triangle" area, intersecting, Laos, Myanmar and Thailand, continues to present the need for national, regional, and international drug control responses. While eradication of opium poppy crops and substitution measures have been successful in some areas such as Thailand, there have been corresponding increases in opium cultivation and heroin production in other areas, most notably Northeastern parts of Myanmar and to a lesser extent in other countries such as Laos. Drug Trafficking

Drug trafficking within and through the subregion continues on a large scale and the area still ranks as one of the top two suppliers of opium and heroin for the world market. Many major opium poppy growing and heroin producing areas are under the control of trafficking insurgent groups with extensive military and financial resources, as well as links to syndicates often located outside the subregion. Traffickers in many parts of the region have the resources to conunand favours from corrupt officials, and intimidate those who are locally opposed to the trafficking business. Thailand remains a main transiting country for illicit drugs from the Golden Triangle, but its relative importance in heroin trafficking has decreased as other routes have more recently developed through Southern China, Laos and Northern Vietnam. At the same time, the importance of Thailand has increased with regard to ATS production and transiting as numerous publicized drug seizures over the past two year5 would indicate. For example, during the first six months of 1996, more than 5 million methamphetamine tablets were seized in the country. In some countries of the subregion, precursor chemicals essential for the production of heroin and ATS are not sufficiently controlled because of inadequate legislation and limits to their organizational infrastructure and resources.

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Annex 5

The trafficking situation is further complicated by the absence of common legislation and regulations which would allow countries in the subregion to pursue extradition or charges of money laundering. Modalities for sharing information and organizing joint operations between countries are still in the early stages of development for most nations in Southeast Asia. Heroin Abuse and Injecting

Taken as a whole, the drug abuse situation in the subregion is worsening. It continues to be prevalent among disadvantaged groups such as ethnic minorities, unemployed youth, street children, prisoners, migrant and itinerant workers and commercial sex workers. In some countries such as Laos, traditional opium smoking continues, but generally there is a subregional decline in this form of drug use. However there is a widespread increase in the use of heroin, especially by injection, leading to both chronic dependence and the high risk of HIV infection. Myanmar has one of the most serious problems with injection drug use, estimated to be the preferred form of drug administration in more than 70% of all registered drug users. Within the group treated for drug dependence, approximately 50% are HIV infected. Institutional Limitations

Lack of skill and experience with demand reduction strategies is a further issue which confounds more effective responses to drug abuse in the subregion. Only since the international community began to place greater emphasis upon demand reduction during the late 1980s have Southeast Asian countries begun to consider the possible benefits of combining new demand reduction and existing supply reduction strategies. But to date the national responses have been largely ad hoc and mostly based on national experience. Scientific study on the aetiology and epidemiology of drug use in Southeast Asia is rare. Where regularized prevention and treatment programmes operate, the results are often not professionally evaluated and accumulated knowledge has not been shared to any significant degree. These limitations hinder demand reduction programme development. The Additional A TS Burden

With the emerging ATS issues, many countries in the region are confronted with the need to adapt existing supply reduction measures and develop new demand reduction initiatives while continuing to address the ongoing burden of opiate production, trafficking, and abuse. Countries in the region are committed and responsive to their international obligations through the international conventions and other agreements as related to opiates. However the available resources are not geared to encompass a response to the new ATS issues. There are also some special issues surrounding ATS in both the supply and demand sectors which are particularly challenging to governments and the international community. The supply issues largely appear to be driven by economic advantage in which there are incentives for high profits, even more than from heroin sales. The incentives are influenced by numerous favourable conditions from the perspective of illicit producers and distributors.

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Annex 5

Many simple chemicals can serve the process of ATS synthesis and are cheap and widely available in most countries. This condition particularly applies to the East Asia region where China represents the second largest manufacturer and exporter of ephedrine and pseudo ephedrine in the world after Germany. There are more than 20 factories in China producing about 300 to 400 tons of ephedrine and ISO tons of pseudo ephedrine annually. These legitimately produced chemicals are sometimes diverted for the illicit production of methamphetamine and other ATS. A TS have simple chemical structures, making them ideal for clandestine experimentation and conversion, requiring only amateur skills for synthesis. Numerous simple methods of synthesis have been patented, published and made widely known through Internet communications. The methods offer comparatively fewer steps in synthesis than those required for plant based drugs, including heroin and cocaine. ATS are ideal for minor modifications to obtain a different end-product, which by intention may fall outside the existing provisions of national legislation and regulation. There are also a number of special concerns within the domain of demand for ATS. While there are individual differences from one product to another, the entire group of ATS have similar effects. Therefore the potential for use of substitutc products within the group is high. Compared to the traditional stimulants such as betel nut which continue to be used in Asia, ATS use carries a "modem" or "fashionable" image which is particularly attractive to young adults. In the recreational use of ATS such as ecstasy, there are risks that patterns of dependence may develop which are largely unnoticed by the consumer, leading to subsequent involvement in other high risk behaviours and eventually the development of a more enduring dependence. The Western experience with the emergence of cocaine addiction in the 1970s is one example of this pattern. In the region, ATS has a relatively benign image and in some work environments such as the construction and fishing industry , its use is more or less socially acceptable. Within these drug taking situations, those who find themselves having to manage the • consequences of dependence are less likely to seek assistance.

D.

UNDCP RESPONSE

As an international body responsible for drug control, UNDCP with its capacities for programme operations and support to international bodies such as the International Narcotics Control Board (INCB) and the Commission on Narcotic Drugs (CND), is providing responses to the emerging issues of ATS production, trafficking and abuse within the

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Annex 5

framework of complimentary global and regional activities. The driving forces for global action are embodied in the policies of CND, the international drug control conventions and the regulatory provisions of the INCB, and by the development of regional agreements, programmes and projects which have particular relevance to local conditions. The global initiatives are also influenced by collaborative arrangements among UN agencies in the development of a System Wide Action Plan which outlines 10 thematic areas of drug control, including 8 related to demand reduction. Some of these themes are also supported by global projects. UNDCP works directly with governments and also collaborates with international, region and national non-government organizations that are concerned with issues of drug control. E. SUBREGIONAL COOPERATION In East Asia, the efforts of UNDCP are largely centred upon countries which have been historically involved in the production or trafficking of plant based drugs and which do not have sufficient technical and financial resources to provide the necessary interventions for supply and demand reduction. The Governments of Cambodia, China, Laos, Myanmar, Thailand and Vietnam generally fall into this category, although the particular capacities and resource limitations vary from one country to the next. The working arrangement for subregional cooperation among these countries and UNDCP is covered by a Memorandum of Understanding (MOU) developed through a series of meetings including the signing of two joint agreements in 1992, the holding of two Ministerial Conferences in 1992 and 1994, and a Senior Officials Meeting in 1994. These initiatives resulted in a Subregional Action Plan which currently guides the efforts of the UNDCP Regional Centre For East Asia, Bangkok. UNDCP also provides separate services to Laos, Myanmar, and Vietnam through its country offices which advocate and support national drug control plans. The action plan is based on broad principles toward which participating governments: affirm support for a comprehensive, balanced and integrated approach to drug control problems designed to meet various manifestations of the problem in the subregion with due respect to national and local differences; agree that development of national strategies on drug control is essential for the establishment of effective subregional drug control objectives and priorities and for the mobilization of resources; affirm their readiness to support activities aimed at the establishment of national drug control legislation in line with international conventions and at becoming parties to the 1961, 1971, and 1988 drug control conventions; affirm their readiness to support subregional and cross border cooperation for the purpose of preventing the production, trafficking and consumption of illicit drugs.

,

- 47 -

Annex 5

Based upon situational reviews leading up to the MOU, with additional inputs provided through ongoing meetings among the participating countries, the governments have established priority activities in the areas of demand reduction, alternative development and law enforcement. In most cases, the planned ectivities are linked to projects which are either in the final stages of preparation or are currently being delivered.

Subregional Demand Reduction Priorities In the area of demand reduction, there is an acknowledged need to improve the quality and availability of data on drug abuse on a national and subregional basis. Within this objective, designated institutions and organizations will serve as collection and dissemination focal points in each of the countries covered by the plan. Provision, where necessary, will be made to provide technical assistance to support institutional capacity in the development of data collection and reporting procedures, methodologies, and coordinating mechanisms, while also supplying data collection system hardware and software as required. These interests have been organized within a subregional project nearing the final stages of approval. In relation to ATS, it is expected the stimulant group will form one part of the overall data collection and analysis process in each country. Another subregional demand reduction initiative which may have direct implications for ATS interventions is the enhancement of knowledge and skills of relevant government agencies as well as NGOs for demand reduction approaches and methodologies targeting high risk groups. The aim is to improve the capacities to assess emerging drug issues such as ATS and inhalants, while also providing the opportunity to examine and test new models of intervention v.ith vulnerable groups. This will be accomplished by mounting subregional exchanges of information about high risk groups, providing access to international experts who are familiar with the assessment and intervention models, devising appropriate models and delivering them along with an evaluation design over a period of approximately three years. Like the data collection initiative, these interests have also be organized into a subregional project which is close to finalization. Project commencement is anticipated by mid year, 1998. The third direction in drug demand reduction acknowledges the continuing need to reduce illicit drug use and related social problems in selected highland communities of East Asia. Special emphasis is placed on the selection of communities which are vulnerable to drug use. Community based approaches are used to identify drug and other related socioeconomic issues, prioritize the issues, then organize and deliver suitable interventions. The project is in the second year of implementation with different levels of progress among the participating countries. Base line data and existing prioritizations of drug issues have not shown ATS use to be a prime concern at the highland project sites which are more closely involved with problems of opiate use.

HN vulnerability through injecting drug use (IDU) is a further issue of importance in the action plan. The specific interests are strengthening the knowledge base on the drug use

- 48 -

Annex 5

situation in the subregion, building capacity for strategic planning, programming and evaluation on drug use and HIV, and advocating best practice and policy formulation on drug use and HIV in the context of preventing and reducing the public health consequences of injecting illicit drugs. No specific subregional project has been planned with these interests in mind. However the UNDCP Regional Centre, Bangkok, is working with the Asia Pacific Intercountry Team of UNA IDS on a special task force directly related to the identified issues. The task force has been in operation for approximately one year and through a contracting arrangement with the Asian Harm Reduction Network will soon distribute the results of an intercountry situation assessment that was undertaken in 1997. A preliminary analysis of the results suggests injecting practices in the region are for the most part related to opiates and sometimes in combination with other substances such as sedativelhypnotics. Subregional Alternative DevelopmenUSupply Reduction Subregional priorities in the area of supply reduction through alternative development are mainly concerned with the improvement of national and subregional capacity to identify and measure opium poppy cultivation, and to improve cooperation among the concerned institutions involved in the reduction of opium poppy through alternative development. Neither of these interests directly relate to the emerging issues of ATS since the target activities mostly deal with opiate producing communities. However within the framework of new alternative development plans, the addition of demand reduction components for the improvement of health and education can also make allowances for the prevention or treatment of A TS abuse.

Subregional Law Enforcement Subregional initiatives with law enforcement to some extent reflect the specific issues arising from the Shanghai meeting on A TS, while also addressing the outstanding fundamental issues of limited institutional capacity in drug control agencies of the participating countries. Six law enforcement initiatives are either planned or under way through the Subregional Action Plan. Within this group, five are related to the development of generic law enforcement practices in drug control, with subregional cooperation forming an additional element. One project is specifically concerned with the issues of precursor control. Improving the capacity of judges and prosecutors in the application of drug control legislation is one objective to be initiated as a subregional project. The strategy involves training at the national and subregional levels to provide immediate understanding of existing legislation while also providing a focus on the conditions which would facilitate cooperation and mutual legal assistance in both the regional and international arenas. If countries have provision for legislation surrounding ATS, it will be addressed in the project. The project is currently in the planning stage.

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Annex 5

An interactive computer trammg strategy will be the feature of a second law enforcement project intended to address the basic information needs of larger numbers of personnel in the MOU countries who have drug control within their area of responsibility. Police, customs officials and other enforcelrent personnel will participate in the project scheduled to begin in 1998. Identification, investigation, and application of the laws and regulations pertaining to A TS will be covered in the training package. Another project is planned to improve the capability of law enforcement agencies to rapidly communicate with each other in the subregion on drug control matter. Communications equipment will be the focus of this project which has yet to be finalized. Closely related to this development ",,>ill be another project conunencing in 1998 to enhance the capacity of law enforcement agencies in Southeast Asia to gather and exchange information regarding drug trafficking. It is envisioned that small national control units will be trained to gather and analyse information and provide linkages to one another. Both of these projects Mil have a bearing upon the reduction of illicit production and movement of ATS in the subregion. Application of the special provisions for investigation in the 1988 Convention will be the main focus in the fifth law enforcement project which will seek to establish agreements and procedures within and between subregional countries that will facilitate international cooperation in drug investigations or inquiries. International trafficking of ATS and their precursors Vvill form a part of this project. The sixth initiative concerns the development of better national capabilities to implement adequate national and subregional measure for regulating precursors, in particular those used in heroin and methamphetamine production, and to suppress their diversion. The project recognizes that precursors are used for both legal and illegal purposes and that a combination of law enforcement and regulatory measures are called for as well as coordination of all involved agencies. The project builds upon earlier activities of a similar nature which were initiated in Thailand to prevent, detect, and coordinate investigations in the diversion of precursors. Training is a large component of the project with staff targeted from regulatory, law enforcement, other concerned control agencies and the chemical industry. Initial training has been completed at the national level in Cambodia, China, Laos, Myanmar, and Vietnam during 1997 and further in-house training is now anticipated in each of the countries. As well, a somewhat unique workshop on the prevention of diversion of precursors from legitimate trade was held in 1997 in Bangkok with representation of fortytwo chemical companies, together with seven regulatory and law enforcement agencies. The workshop concluded with a commitment by the chemical industry in Thailand to develop a code of conduct to prevent diversion.

,

The same project also conducted missions to five of the six MOU countries in order to assess the local situation concerning the production and use of ATS. The investigations concluded:

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Annex 5

Myarunar has very little trade in precursor chemicals because of the lacking industry. However smuggling precursors across the Myarunar/China border and production are main concerns which will require law enforcement interventions. In China, a huge chemical industry flourishes while the control of domestic trade in most precursors is generally limited, primarily due to a lack of regulations to support the national drug laws. Regulatory control and voluntary compliance by the chemical industry are the existing priorities to prevent diversion. Vietnam generally does not have a significant concern over the need to control precursors, mainly because of the absence of drug production. However there is an issue of transhipment of precursors from the China border which may be deVeloping. Vietnam became a party to the 1988 Convention in February, 1998. Laos has a relatively low level of drug abuse and few known problems of ATS production. However some cases of transhipment have been identified. Many of the precursors and substances named in the 1988 Convention are under the control of the Ministry of Health. The need for law enforcement to prevent the cross border flow of precursors has been indicated as a priority under the precursor project. Cambodia has very little capacity for precursor control in both its administrative and legislative provisions. It is not a party to the 1988 Convention and the level of knowledge in the field of precursor control is somewhat challenged. Cambodia has been identified as a transhipment country. F. THAILAND AND ATS

The relatively low level of ATS use reported in five of the six MOU countries is in sharp contrast to the Thailand experience. ATS use has been kno'wn in Thailand since the early 1960s, but emerged as a major problem in the 1990s. The high level of concern is demonstrated by recent decisions to tighten control over the licit trade in ephedrine by withdraviing the ephedrine import licences of all private companies. As a result the Food and Drug Administration of Thailand has become the only legal importer and distributor of ephedrine. Other provisions have also been made to increase the levels of punishment for possession and trafficking of ATS. The concern is also reflected in a 1995 survey showing ATS use in approximately 6 % ofa sampled student popUlation. Because Thailand is at the forefront of ATS use for Southeast Asian countries, it also has the most experience with demand reduction interventions. Recently, the Ministry of Interior, in conjunction with the Office of the Narcotics Control Board, launched a major antiATS campaign as a preventive strategy attempting to change the fashionable image of stimulant drug use. The messages focused on the difference between the perceived benefits of A TS use and the sociallhealth consequences, with particular emphasis upon the shock value of real cases involving violent behaviour. Billboards, television, and the print media were extensively used during 1997. Within the education system, information about the risks

- 51 A.nnex 5

of ATS use has been introduced and routinely provided. With a focus on local comnllmities, during the same period, a national programme to develop sportsgrounds for youth was started as a means of encouraging healthy behaviour and discouraging drug use. Among these programmes, some evaluation has been conducted in the area of preventive education. However the results have not been widely circulated. During 1997, one of the regulatory agencies attempted to introduce drug testing among students in the secondary school system. However the methodology was not supported by the Ministry of Education because of concerns about the possible infringement upon individual rights and negative influences upon the education environment. Other options such as selective voluntary testing are currently under review. Treatment has also been provided to ATS abusers and the rising trend in admissions is a further indicator of emerging problems. However the actual number of presenting cases is small. Data from 1992 showed approximately 0.2% of all admissions related to ATS as compared to approximately 83% presenting with opiates as the drug of first choice. Undoubtable, the numbe:r of ATS admissions have increased, but overall the rate continues to be low. This may reflect limitations in the reporting system, as well as fewer problems with initial withdrawal symptoms compared to cases of opiate addiction. In the existing data, one important feature is the relatively large proportion of cases concerning students and unemployed youth in the 15 - 19 age range. This has direct implications for treatment and rehabilitation programme planning, which may need to consider the more fundamental issues of education, social competency and family support normally associated with adolescent development, as well as the specific problems arising from A TS use. To consider new linkages between residentially based treatment and aftercare services, the UNDCP Regional Centre, Bangkok, is partly supporting an initiative of ONCB to selectively train teachers from 9 institutes in Singburi Province for the introduction of post treatment peer support activities with recovering students. To date there are no kno ....'11 rehabilitation facilities which are directly related to ATS abuse in Thailand, and given the relatively low rates of admission, significant developments in this area are not soon anticipated. However there are some examples of more generic services which encompass the ATS cases. One is a juvenile detention centre in Bangkok, which over the past three years has given more emphasis to a therapeutic community (TC) model. In-house activities have placed increasing responsibility upon adolescents to participate in the programme despite its involuntary nature, and the results have been promising in terms of developing better personal capacities. However like many other TC programmes, it is challenged to facilitate the transition of residents back into their conununities. This difficulty is also complicated by the initial family and community circumstances from which the juvenile cases arise. In many instances, the home situation is dysfunctional, while basic conditions of poverty and the risks of slum dwelling are also significant impediments to the recovery and personal development process.

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Annex 5

Community based approaches to drug abuse have also been used with some measure of success in rural areas of Northern Thailand and elsewhere. The approach involves selection of target villages based upon gross law enforcement and drug dependence indicators, the deVelopment of community '5tructures to assess drug abuse conditions and organize demand reduction activities with external assistance, and to provide ongoing supervision and support until the dependent persons are again fully functioning. The evaluation of two projects in Thailand and one elsewhere in the region have shown that community based approaches are effective in reducing the prevalence of drug dependence over a relatively short period of two years, and are amenable to replication not withstanding social, cultural, economic and political differences. The evaluations also pointed to the importance of community leadership in the approach and the concurrent need to ensure the availability of external law enforcement services when social controls established by community leaders are thwarted by the intimidation of local drug traffickers. Valuable lessons have also been provided to support the use of integrated education, personal skill development, and social control strategies, together with parallel efforts to develop the organizational capacities of communities. The lessons have further reinforced the conventional wisdom about the need for a balanced approach to drug control. With respect to the particular issues of ATS abuse and the typical environment in which it occurs, the community based approach has certain limitations. The approach has been largely used with distinct ethnic groups in fairly well defined geographic communities. Also the target group of drug dependent persons are often in the age range of 25 years or more and usually present opiate problems. This is in contrast to the current know patterns and characteristics of ATS abuse, which has been increasingly associated with the adolescents in urban environments where the geographic boundaries and social influences of communities are less clearly defined. G. FUTURE STRATEGIES

In relation to the global trends in ATS abuse and the cyclical patterns which have emerged over the past twenty years, there are nun1erous models which may have application to some extent in the development of appropriate programmes for East Asia. However, programme experience has also shown that simply replications which do not take the local drug use situation into account are most certainly bound to fail, even in circumstances where the cultural dimension is more or less the same. The nature of the substance used, the characteristics of the user, and the context in which drug use occurs must each be considered as part of the programme planning process. This imperative suggests the need for preliminary investigations and assessment of the situation when either individual or programme development is being considered across the range of treatment and prevention options. In prac~ce, assessment and treatment planning should form part of the intervention process for ATS abusers, and rapid assessment techniques, among others, should be employed as an initial step in preventive programme development Participation and involvement of the target groups are two important factors which, depending upon the level of emphasis, tend to facilitate or reduce the impact of

- 53 -

Annex 5

programmes. Within education settings, peer education and support have shown promise in both the Asian and Western experiences. Similarly, the approach has been successfu;ly used for the reduction of risk to special groups who are engaged in commercial sex work and/or injection drug use. Applications of the approach are already under way in Thailand and elsewhere. and the shared reports of these experiences may provide some insight toward the preferred approaches to the prevention and reduction of ATS use. In the treatment domain specifically relating to the process of detoxification, much can be learned from the Western experience with stimulants, especially protocols used for cocaine and methamphetamine dependence. The United States and other developed countries have a body of research on pharmacotherapeutic approaches to the treatment of stimulant abuse, including applications for the temporary reduction of craving, which in many instances is seen to be an important determinant for relapse. Health officials in the region should have the benefit of current information about these applications in order to determine the best forms of intervention. Sharing information through clearly established focal points is a strategy within the regional approach to law enforcement which may also have particular relevance to those who are concerned with the demand issues of ATS. Within East Asia, there are some countries with a relatively long history of ATS abuse that may be in a position to facilitate the exchange of programme experience, including best practices. Such a network may also have considerable value in more generally identifying, connecting and effectively using the available regional expertise on demand reduction matters. Within the existing framework for demand reduction in the subregion, and strategies suggested for future consideration, the UNDCP Regional Centre looks forward to contributing toward the development of capacities for policies and programmes in the prevention, treatment and control of illicit ATS use in the region. It appreciates the opportunity to collaborate with the WHO Western Pacific Regional Office on this important matter and anticipates further combined efforts to assist countries in the region.

REFERENCES Centre For Drug Research, Asia Multi-city Project Summary Report of the Asian Multi-city Epidemiology Work Group, University Sains Malaysia, 1997. Commission on Narcotic Drugs, Abuse Of And Illicit Trafficking In Stimulants, Report of the ~xpert Meeting on Amphetamine-type Stimulants held at Shanghai, China, from 25 to 29 November 1996, Vienna, 1997. International Narcotics Control Board, Precursors And Chemicals Frequently Used In The Illicit Manufacture Of Narcotic Drugs And Psychotropic Substances, Report of the International Narcotics Control Board for 1997 on the Implementation of Article 12 of the

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Annex 5

United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988, New York, 1998. Office of the Narcotics Control Board, Progress report on a project for the development of a school-based treatment and rehabilitation programme in Thailand, Bangkok, 1998. Shick, 1. Fred E., Stimulant Abuse And Dependence, Review Papers Series No.1, Centre For Drug Research, University Sains Malaysia, Penang, 1997. Subregional Action Plan on Drug Control, prepared and revised by the UNDCP Regional Centre For East Asia for the Governments of The Kingdom of Cambodia, The People's Republic of China, The Lao People's Democratic Republic, The Union of Myanmar, The Kingdom of Thailand, and The Socialist Republic of Vietnam, Bangkok, 1997. UNAIDS Task Force on Drug Use and HIV Vulnerability, The Hidden Epidemic - A (draft) situation assessment of drug use in South East and East Asia in the context of illV vulnerability (Brunei Darussalan1, Cambodia, China, Indonesia, Japan, Lao PDR, Macau, Malaysia, Mongolia, Myanmar, Philippines, Republic of Korea, Singapore, Taiwan (Province of China), Thailand, Vietnam), Bangkok, 1997. UNDCP Regional Centre for East Asia, Community Based Approaches To Drug Demand Reduction, a selective review of project results among the MOU countries prepared for the Meeting of MOU Countries on Drug Control, Bangkok, 1997. United Nations International Drug Control Programme, Amphetamine-type Stimulants: A Global Reyiew, prepared by UNDep at the request of the Commission on Narcotic Drugs, Vienna, 1996. United Nations International Drug Control Programme, Semi-annual Project Progress Report on Precursor Control in East Asia, Bangkok, 1997. United Nations International Drug Control Programme, World Drug Report, Oxford University Press, Oxford, 1997. G:\SWlWBIATSIATSPP.WPD Rev. 26 Feb 98

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. '''II!

Suurce:

UNOCI' ARQ Oata.

tlNDel.'

UNDCI' negionnl Cenlre for Ensl Asia, Februnry 1998

x

vo

» ;::l ;::l (1)

><

CHINA KUlIlIling • GuiYllng

U1

•

a

llnikou

a-

U1

MAIN OPIU.M PRODUCTJON AREAS IN SOUTH EAST ASJA ~I . . ~ %~-'dl '""7",""" UNUC!' UNDO' Hcgiollil Crnll't for lUI AJla, OctoUeI' 1997

~.;-:-:.-,~

57

Annex 5

AMPHETAMINE ~ TYI'E STIlVIULANTS : TH.E MAIN FUTURE DRUG THREAT'!

• • •

COlVIPARATIVELY LOW PlUCKS LOW PRODIJCTION COSTS HIGHER PROFIT MARGINS uo ': ..

•

ALLOWS I'HODlJCTlON CLOSE TO MARKET

'"

• •

PENIGTRATES NEW TAnGln' GROUI)S COUNTERMEASUHES DlFFICULT

ffr~~~ ~f~ "'"7~

> ;:l ;:l (1)

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UNDO'

UNDCI' 1l"lIlonRI Centre fur En,t AsiA, Oct .. ber 1997

> ::s to

::s ><

VI

UNDCP'S STRATEGY

•

PROMOTION OF SUllREGIONAL COOPERATION

•

DEVELOPMENT OF NATIONAL LEVEL CAPACITY

a-

o

•

BALANCED APPROACll INCORPORATING DEMAND REDUCTION,

ALTERNATIVE DEVELOPMENT AND LAW ENFORCEMENT

!rfJ.si' ~)~ ~~. ~"l? ~'-

.••.I.J( "'"7<;-

UNI)CI'

UNUCI' noglonll C.nlro for Eul Asia, Mud. 1997

.... :.' ,. :':.'.::;i.::.i':{)::·\:. :::,·

.,.,<.':......-::.;._------------------------------------....;,. SUBREGIONAL COOI>ERATION ON DRUG CONTROL

• FIRST SIX-COUNTRY l\'lEETING AT MINISTERIAL LEVEL IN BEIJING, MAY 1995 ~

ACTION PLAN API'IWVED

• TWELVE SUlH{I~GJONALI'nOJICCTS ~

STRONG EMI'HASIS ON INSTITUTIONAL DEVELOPMENT a. ,...

• UEVELOI'l\1EN'I' Olr NEW l'IWJECTS ENVISAGED

• SECOND MINISTERIAL MEETING IN BANGKOK,

,JULY 1997 • nEVISED ACTION PLAN API'IWVED

~"a:'=<· . ~ -;>'~

~ ~:::,-,iI UNDO' UNJ)C1' H.gIII .. al Cell!rc Ii,t EM! AsiA, Oct" .... t 1997

> ::I ::I (I)

X UI

> ::s ::s ~ "

SUBREGIONAL ACTION PLAN PRO.JECTS Dcmand Reduction

><

'"

Alternative DcYelopment N

a-

Law Enforcement

I~.;-.'l'~ UNI)CI'

8 ~~'~ ~;.::.c

T'hailand and ATS Number of Addicts by Type of Narcotic (TORI,. 1993) Heroin Opium 5% Amphetamines 20% 17% Glue and Thinner

IJ)},,'If\SA 32% Marijuana 26% .. Heroin a....,

illJ Glue and Thinner Im Marijuana Ll Amphetamines ED Opium l'rulJlc/ll Scvcrity Ist Heroin 2nd ATS

Incrcasing Trcnds 1st ATS 2nd Hcroin (mcasurcd by change in Iltrcatcd, number of seizurcs) UNDO' n'glonnl C,ntro ror E.. t AII_, AlllilI997

(~,~~ ~J!i! ....-,-;--. '

(1l1casurcd by monthly prcvalencc, injccting II trcatcd, Drug rcl ated dcaths)

I!

;2 ;2

:>

'X" VI

TI-IAILANI) DEMAND REDUCTION

PROGRAMMES

• • • • • •

Public Campaign School-based education Community-based "Spo rts Against Drugs" Prog ram me Institutional Trea tmen t Community based services School based rehabilitation 0\

....

~ ~t~ ~f:p ~

UNDCl' nrKlonal Ce"t", Cor EMt Asia, April 1997

- 65 ANNEX 6

WORKSHOP ON PROBLEMS RELATING TO THE USE OF AMPHET AMINE-TYPE STIMULANTS (ATS) IN THE WESTERN PACIFIC REGION (16-20 FEBRUARY 1998) Dr Adrian Reynolds Acting Regional Adviser in Health Promotion and Mental Health WHO Regional Office/or the Western Pacific

Levels, Patterns & Problems relating to the Use of Amphetamine-type Stimulants in the Western Pacific Region of WHO

- A Policy and Research framework for moving forward? • The Western Pacific Region, with one-third of the world's population, is characterised by more rapid social and economic change than any other region. It is now being targeted with aggressive marketing of both licit (alcohol and tobacco) and illicit psychoactive substances. 2 I will not elaborate on individual country situations here, as I do not wish to pre-empt the country reports that are to follow. However, it is possible to make some general observations. The use of amphetamine-type stimulants (ATS) appears to be widespread. significant and in some cases increasing in the Western Pacific Region. Countries where the prevalence of use is high include Australia. Japan. the Republic of Korea. Northern Mariana Islands (Commonwealth of the), Palau. and the Philippines. :; In some countries in the Region, it is reported that amphetamine-type stimulant drug use and related problems substantially outweighs the use of all other illicit drugs combined (Japan, Korea and Philippines).) Injection of ATS represents greater reason for concern about possible transmission of blood-borne diseases in some countries (Australia, Japan and Korea) however in most, administration by smoking, sniffing and fume inhaling are reported as the main methods of drug administration. Among four countries represented at the workshop (China, CNMI, Philippines and Viet Nam), there is early evidence of injection of ATS. Few countries are at present identifying injection of amphetamine-type stimulants and associated sexual behaviour as important at-risk modes for the transmission of HIV/ AIDS.' The appearance of crystal methamphetamine or "ice" has seen a shift from injection to noninjection routes of administration in several countries. '2.7 Notwithstanding, drug injection of ATS remains an identifiable problem in certain parts of the Region (e.g. in Australia) '. The prevalence of use of amphetamine-type stimulants among females may in some countries in the Region be catching up with rates seen among males, however in most countries, use among males remains substantially higher than in females. The use of ATS is shifting to progressively younger groups in some but not all countries.' Polydrug use among those using amphetamine-type stimulants is common.' There appear to be no common themes across the Region with respect to perceptions about the forms of harm that are most frequent and most weighty. In some countries, the social harms associated with the use of A TS are reported as being of most significance, whereas in others, the legal, acute and chronic health or economic harms are seen as most problematic. These responses appear to be based in large part on anecdote and personal impression rather than on the basis of any systematic measurement reflecting specific quantitative and qualitative indicators. At present, no country in the Region has a comprehensive data collection mechanism or database on licit and illicit use of amphetamine-type stimulants. 7

- 66 Annex 6 WPRlADT/HPRlMNH(I)/98/4

Acute health problems including psychotic and newly emerging patterns of violent and criminal behaviour are reported in association with the use of amphetamine-type stimulants, sometimes leading to dramatic and tragic outcomes. 1.1 It is not clear whether or to what degree such violent or acute psychotic reactions are more likely to occur in those persons with a predisposition for such behaviour, a history of alcohol or polydrug use or other characteristics. Stated in another way, the nature and level of health risk associated with the use of specific types of ATS in varying doses and contexts remains to be more clearly understood. There is however a body of evidence demonstrating that that the use of A TS may be associated with an acute psychosis. Regardless of the reasons, the violent behaviour that is sometimes associated with amphetamine-type stimulants has in some countries led to a hardening of popular opinion towards amphetamine-type stimulants and subsequent adoption of increasingly harsh and punitive public policies and legislation. 1.1

Responses to Drug Problems in the Western Pacific Region In general, countries of the Region are substantially more inclined towards placing emphasis on supply reduction rather than public health policies and strategies. In some countries, use of amphetamine-type stimulallts is viewed principally as a social and! or public health problem while in others, emphasis is placed on the legal dimensions. In some countries where the former approach predominates, the problem is viewed as lying within the province of mental health whereas in others, a broader bio-psycho-social! public health model is adopted. In the context of this broader model, those manifesting symptoms and signs of severe dependence and abnormal cognition, affect and behaviour (e.g. psychosis) might be understood to lie in an area of overlap between public health and mental and behavioural disorders related to the use of substances. 1 In many countries, communication. integration and co-ordination of approaches between the Ministries of Health, Education, Internal Affairs, Police and other relevant sectors appears less than adequate. Drug intervention budgetary allocations are frequently heavily weighted towards the law enforcement and interdiction sectors without apparent useful attention to rigorous evaluation of the effectiveness of this approach nor to its potential positive and negative social and health impacts. ' Such strategies may be productive or counter-productive in this regard, however, the assumption that they will always be helpful invariably goes unchallenged and untested. The possibility that they may sometimes be associated with substantial albeit unintended (extrinsic or man-made) harm is also invariably excluded from analysis of the likely effectiveness and cost-benefits of such approaches. The same methodological shortcomings can also often be observed in relation to prevention, harm reduction, treatment and rehabilitation approaches. Public health and in particular, harm minimization strategies have been actively adopted by only a handful of governments in the Region. 1.2.1.' Some countries appear to be adopting a perspective that there is no value in or need to evaluate supply reduction, demand reduction or treatment strategies and activities. Some countries do not appear to view health protection strategies as they relate to drug use as relevant, necessary, potentially helpful or acceptable. 1 Many countries have poorly developed treatment responses in place. ' ·1 Some appear to offer no form of treatment or other forms of positive support at all. 1.1 Traditional medicines and approaches do not appear to have featured prominently in the Region as a means of assisting managed A TS withdrawal or aftercare, although there are some examples of their use. 1 Major and minor tranquillisers may be used for this purpose. While these particular medications may be of some short-term benefit in reducing the severity and dysfunction associated with acute intoxication (e.g. anxiety, agitation or psychosis) and in increasing the tolerability of psychological symptoms associated with abrupt cessation of use, available empirical evidence suggests that these are by themselves often of limited effectiveness. _.Il This finding reflects the dearth of alternative well-tested and proven pharmacological and non-pharmacological intervention options that are available to clinicians.

- 67 -

Annex 6

WPRI ADT/HPRlMNH{ I )/98/4

It should be noted that the proportion of amphetamine-type stimulants users who use on a moderate to heavy and daily or most daily basis and who are neuro-adapted, will most likely vary a great deal between countries, cultures, subcultures or groups. Many people who present for help with problems related to their use of amphetamine-type stimulants are likely to need or benefit from some forms of non-pharmacological psycho-social intervention. An uncertain proportion of ATS users would likely benefit from additional pharmacological interventions aimed at preventing or reducing the severity of symptoms and potential complications of withdrawal. That is, if effective forms of intervention of this nature could be developed and made available. _,12 The development of interventions to reduce or eliminate craving presents a further important research challenge for the future. However, it appears that these propositions are by no means universally accepted. 7

The absence of dramatic visible physical signs of withdrawal from amphetam ine-type stimulants is sometimes taken to mean that there is no neuro-adaptation and no withdrawal syndrome. This opinion may be accompanied by an added belief that no specific clinical intervention or assistance, pharmacological or non-pharmacological, is required or indeed appropriate in such circumstances. While the physical signs of amphetamine-type stimulant withdrawal are poorly defined, there is evidence of neuro-adaptation and a neuro-adaptation reversal syndrome (withdrawal) in association with the use and abrupt cessation of use of amphetamine-type stimulants, Internationally, many clinicians and researchers would hold a view that the withdrawal syndrome, where manifest, does merit active supportive intervention. _,12 There is also substantial support for the view that the "psycho-social symptoms" are just as worthy of active clinical intervention if not more important than the observable physical manifestations of withdrawal, if an increase in the rates of successful completion of voluntary withdrawal is to be achieved, 1314,1'1.,17,18 It is therefore suggested here that the absence of visible or expressed physical symptoms associated with abrupt cessation of dependent amphetamine-type stimulants use does not negate the potential need for and potential benefits of both pharmacological and non-pharmacological interventions. Reducing distress, discomfort, drug craving and urges to relapse following cessation of use may be very important if treatment compliance, retention and completion rates are to be maximised. _,12,\l,14 Notwithstanding, it should be added that the proportion of amphetamine-type stimulant users who do use on a daily or most daily basis and who could be said to be neuro-adapted might in many sociocultural contexts be relatively modest in comparison to the proportion who use on an episodic, nondependent basis. The treatment and health protection needs of all groups of users who seek formal assistance should be met in the best way possible so as to ma.ximise their treatment seeking and health outcomes.

It is significant to note that in this regard that in almost all countries in the Region, few people who use amphetamine-type stimulants are corning forward for treatment or other help, in any of its various possible forms. This may reflect a perception that treatment services are not designed for this purpose and have little or nothing of value to offer. Alternatively, it may mean that few amphetaminetype stimulant users feel they have a problem that requires clinical intervention, or that a combination of factors is operating. It would also seem true that many people who use A TS suffer no serious or enduring health harm and that many of these people will mature out of such hazardous, harmful or unsanctioned drug use by natural processes, over time. _,12 Some clinicians take the view that any clinically supported drug withdrawal should be an unpleasant experience, based on an hypothesis that an aversive drug withdrawal experience can serve to motivate an individual more strongly to cease and maintain abstinence from drug use. That is, based on a belief that such persons would not wish to repeat this bad experience. An alternative hypothesis that finds some support in the literature is that aversive drug withdrawal experiences are likely to reduce the individual's confidence (or "self-efficacy") that they are able to see the withdrawal period through to completion on this and any future occasions, to make it less likely that they will remain in treatment on this occasion and to reduce their confidence and trust in the clinician's interest and ability to help them.

- 68 Annex 6 WPRIADT/HPRlMNH( I )/98/4

High treatment relapse and drop-out rates may in turn reduce the confidence, trust and commitment of clinicians towards those with drug problems, making for a counter-productive set of health and social outcomes all round. '.Il

It should be remembered that almost all people who come to voluntary drug treatment would on many occasions have previously attempted unsuccessfully by themselves to cut down or cease their drug use. These attempts may often be associated with substantial negative physical, psychological and social impacts and it is the accumulation of these unhappy experiences that may ultimately motivate the individual to seek help from the formal health system. These repeated aversive experiences associated with attempted self-withdrawal are likely to reduce the drug using individual's personal confidence in their ability to stop and stay stopped or alternatively, to modify their drug use so that it is less hazardous - rather than enhance their confidence. What people invariably hope to find when coming to voluntary treatment is positive support from health providers who are are technically competent, confidence inspiring, non-judgmental, empathic and caring. )fthese expectations are not met, people inevitably drop out of (voluntary) treatment prematurely and do not readily return, if at all. They also make their aversive experiences known to their peers and word rapidly spreads that drug treatment services are neither user friendly, caring or helpful. There is a body of research evidence that is consistent with the concept that the adoption of a kind, caring, empathic, non-judgmental and supportive approach to people with drug problems in the context of a low stimulus, calming environment and good explanation of what to expect is more likely to attract people to preventive, health protection and treatment services, retain them and to lead to better outcomes than an approach that one that pays little or no attention to these principles. ""."".""'.20 These principles apply equally to the clinical management of ATS withdrawal as they do to alcohol and other drug withdrawal syndromes. Arguably, there is a need for the deyelopment of better methods for reducing the severity of discomfort or distress that may often accompany cessation of use of amphetamine-type stimulants in the managed care situation, as well as reducing the risk of complications. It should be noted that such complications are more likely when amphetamine-type stimulants use is combined with alcohol and other drugs, on a regular basis. '." Such multiple drug use has become commonplace in many countries. 1.:!.3,4.~

Notwithstanding these general observations, it is to be acknowledged that the relationships between treatment seeking, the nature of the treatment experience and clinical responses may in some respects be socio-culturally influenced. This raises certain questions. In what ways might this be so? What empirical evidence is available in support this notion? Are the differences immutable or alternatively, might the above-mentioned principles have broader application than is currently accepted? Or might the principles and the empirical evidence in support of these principles be flawed? These are important questions for future scientific investigation in the context of international and cross-cultural research.

Evaluation of Drug Policies and Interventions Few countries in the Region report actively evaluating the impacts and outcomes (causally) associated with their drug policies, legislation and related interventions and none appear to do so in a scientifically rigorous manner.'·1 There is repeated mention of this need in the Report to the Economic and Social Council, Commission on Narcotics.' Any evaluation of law enforcement activity that is undertaken appears to be heavily weighted towards process (e.g. how many arrests or how many kilograms of drug were intercepted, during the year). As noted above, some countries appear to take the view that such rigorous evaluation is neither useful nor necessary. Few countries are currently undertaking research with a goal of developing more effective ATS-related prevention and treatment

- 69 Annex 6

WPRJADTIHPRlMNH( I )/98/4

methodologies. I.., Few countries report attempting any systematic evaluation of the relative and absolute burdens of health and other harm associated with the use of ATS and other drugs including tobacco and alcohol nor of the relative and populatbn attributable risks. '.21 Some countries have made a conscious and seemingly reasonable decision to focus on tobacco and alcohol, given the greater burdens of health and other harm occasioned in relation to these licit drugs.' In many countries, prevention activity appears to be based principally on rather simplistic and questionable models of health information and education that for example often ignore the constructs of individual motivation, self-efficacy and readiness for change and that undervalue or even ignore individuals as a social beings who interact with family, friends, sub-cultures and the broader community and who may have widely varying beliefs, values and different ideas as to what is normal, what is good, what is desirable and what is morally or socially right. 2l These behaviour change strategies also often ignore the potential countermanding effects of the socio-cultural, family, economic, commercial, political, religious, spiritual, policy and other environments, that may often serve to enable and promote hazardous, unsanctioned and harmful alcohol and other drug use. ' Some countries h~ve moved towards other models and methods of education and communication including social competency-based health education delivered in schools and through outreach and peer-led activities.""" Notwithstanding, little if any attention appears to be paid to the theoretical bases underpinning assumptions about intervention-response relationships and their validity (e.g. knowledge! attitudes! behaviour (KAB), health belief and rational decision-making models) nor to the need to undertake research or draw upon existing empirical evidence on the efficacy and practical effectiveness of current information strategies aimed at modifying popUlation behaviours. Equally important, little if any attention is being paid to primordial factors as modifiable determinants of population risk and health harm. While a number of countries in the Region report an intention to proceed with research on ATS in the near future, many do not appear to have the institutional and resources capacity that might enable or justify such activity, given the multitude of other health and social problems and challenges which they currently face. ' There is an urgent need for the development of more proactive and effective prevention, treatment and rehabilitation policies and programmes, based on existing empirical evidence, practical experience, collective expert opinion and new thinking, as well as policy reforms and programmes that might better protect and promote public health and social well-being. As a generic observation, there is also an urgent need for more rigorous and strategic thinking and accountability in relation to the manner in which resources are allocated to all sectors including the health, law enforcement and education sectors and to all approaches. This is easier stated than implemented. Many countries are yet to establish drug policies, strategic plans and programmes that can best address their drug-related problems and needs. For the developing nations, this may in part be due to inadequately developed infrastructure, insufficient availability of human service providers who have had opportunity to develop substantial skills in this area and severe budget constraints. In some countries, it would seem that government policy and stated cultural values are incongruent with or do not allow the adoption of certain health protection policies, strategies and activities even if world experience and empirical evidence might strongly suggest their greater potential effectiveness in comparison to those polley choices, strategies and activities that are most commonly adopted at present. It is of great concern that current models of intervention are often adopted without scientific question or exploration and the assumptions and hypotheses that underpin their design are often very tenuous in nature and unsupported by available empirical evidence or practical experience.

- 70 -

Annex 6

WPRJADT/HPRlMNH(I)/98/4

Use of Amphetamine-Type Stimulants for Medical Purposes There has been a worldwide increase in the use of amphetamine-type stimulants for medical purposes during the past several decades. There were reports a decade ago that some 3% to 6% of school-age children in the United States were receiving amphetamine-type stimulants for the treatment of Attention Deficit Hyperkinetic Disorder (ADHD). • It was further estimated at that time that about 3% of children suffer from this condition worldwide. 10 Notwithstanding the controversy surrounding the aetiology, diagnosis and treatment of ADHD, high rates of prescribing amphetamine-type stimulants for ADHD continue in a number of countries in the Region and globally. There is considerable divergence in prescribing practices in different countries as well as among individual physicians in relation to the use of ATS in treating ADHD. There is similar controversy in relation to their use in the treatment of obesity.' There is a need for prescribing guidelines and standards for such purposes, based on a meta-analysis of best available international research combined with "expert opinion" and other methods of analysis and decision-making.

Framework for the Workshop - Best Practice Interventions Increasingly, people in many nations of the world refer to the concept of "best practice", as it refers to a range of human endeavours including health care delivery. In truth, we possess only relatively primitive knowledge and understanding of \\ hat best practice might consist of when we refer to prevention and treatment of problems related to amphetamine-type stimulants. During this workshop you wi II hear about the range of prevention and treatment approaches that have been trialed and documented. particularly in industrialized Western countries of the world. You will hear about an approach to prevention that might usefully be accorded more attention in the future "primordial prevention". Primordial prevention refers to strategies that seek to alter or eliminate the conditions in society that lead to causation of risk or harm. Primordial prevention lies further upstream to primary prevention in its targets for policy and socio-cultural reform. The reduction in smoking that is being experienced in many industrialized countries of the world at present might reasonably be attributed, at least in part, to changes in certain primordial factors. These include increasing attention to the policy levers related to access, pricing, taxation and commercial promotion and to evolving societal attitudes, norms and aspirations. You wi 11 hear that there have been no well designed placebo-controlled trials of sufficient sample size demonstrating consistent positive outcomes in various identified prevention and treatment goal areas. You will also hear that, by and large, few of these prevention, health protection and treatment methods and programmes could be said to be effective in terms of reaching more than a small proportion of those at risk, engaging them in a sustained manner and producing enduring beneficial outcomes. If the country situation questionnaires and country reports that participants of this workshop have completed are any indication, it would seem that similar difficulties and uncertainties are being experienced in this region as a whole. You will hear about the importance of ensuring good knowledge, skills and core competencies among all human service providers, be they professional or non-professional workers, who in the context of their work endeavour to help persons at risk or experiencing problems in relation to the use of amphetamine-type stimulants. You will also hear about the importance of values clarification training for human service providers, as this set of principles relates to always maintaining a empathic, caring, non judgmental and supportive approach to those seeking treatment or other help for amphetamine-type

- 71 -

Annex 6

WPR/ADT/HPRlMNH( 1)/98/4

stimulant-related problems. You will hear that this approach is far more likely to attract people at risk into contact with prevention, health protection and treatment services and more likely to yield positive public health outcomes. During this workshop it will be important that we share our respective experiences and knowledge about such matters. Most importantly, it will be important that we use this forum to pose serious questions about what has gone before us and why, and explore what might be required at local, national, regional and global levels in order to keep moving forward in developing our knowledge, understanding and capacity to adopt good if not best practices. During this workshop we want to encourage active communication, lateral thinking and openness to new ideas. Furthermore, we wish to encourage all of you to repeatedly ask the "why" and "how do we really know this is true?" questions of yourself and of each other, so that no assumption or belief necessarily goes unexplored or unchallenged. We would like you to consider the hypothesis that a reluctance or even unwillingness among many decision-makers to consider all possible policy and strategic options is retarding progress in the drug and alcohol area. This might sometimes be based simply on inadequate knowledge, understanding and first hand experience in the area. It might relate to interceding personal moral values, beliefs and conviction that pay no attention to scientific evidence or best available expert consensus and wisdom. In other cases, it may stand as a simple reflection of political process. And sometimes, those of us who work in the field may not pay sufficient attention to scientific rigour when evaluating the impacts and outcomes of our endeavours. In addition, decisionmakers and the public alike may fail to adequately consider the unintended and unforeseen harms that some policies, strategies and actions may bring about.

Public Policy and Decision-making on Drugs During the meeting, you will hear an overview of the major findings, conclusions and recommendations that emanated out of two major meetings held by WHOI PSAI HQ and UNDep respectively, on amphetamine-type stimulants. The reading materials that we sent you were of course the reports of these meetings. The purpose of this presentation will be to ensure that this workshop proceeds without ignoring or duplicating the outcomes of these two meetings, since this would seem unwise. However, during our discussions this week you might decide that you do not agree with some or many of those conclusions and recommendations, or with their emphasis. Whether you do or do not, it will be in part our challenge to discuss what has gone before, what questions or new ideas now deserve careful exploration and how might these ideas be best pursued? We would like this workshop to consider what might be accepted as reasonable short and longterm goals of treatment for Amphetamine-type stimulant problems and what is required at local, national, regional and global levels to facilitate progress in this direction. Should societies demand and pursue total and sustained abstinence from drug use as their goal or might other more modest intermediate goals be considered as acceptable, feasible and worthwhile? The goals that are set can be expected to have a fundamental influence on implementation and outcomes. Might it sometimes prove counterproductive to aim towards various definitions of Utopia or perfection, with no allowance for our imperfection and humanity? These are things that we would like you to consider during this workshop, in discussing options and priorities for future action. We would offer a drug policy, planning and activity decisional framework as a guide to better decision-making in all relevant sectors (health, law enforcement, social affairs, education and other departments of government, the non government and private sectors, the international organizational

- 72 -

Annex 6 WPRIADT/HPRlMNH( I )/98/4

sector and so on). During this workshop we will ask you to consider the utility of the following set of questions for those planning and implementing drug intervention strategies.

.

,',

Drug Policy, Planning and Activity :Decisional Framework , , . , ' '

~

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Identify:",-" .-1,

L .!ni speciffc goals and objectives, .. '". " ",," .;',". ' , ' ':

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<

'. 't.!J~ sp.~~ific;harms tosod~lJI.,lIIhich ~ progra~,!,e/!t polj9:.it:~..:£.p~~i:ting or re~~~,!B;,

J: .

.;~.:; til: l!?~~~ies•. 1t:.'i(~~~!5·,cu:clf!cP'!,it~e.f pl~ne~'r.~~fif,:;~'1<"; ..'-', j!~<~'~I,~~, ""';' ", ,:' ", ·'.,\l ,_ ,5.. ho.w it is hypothesi~edthep'olides.strategies and activities. will achie.ve,the,desired outcomes; ': 6: the costsan4, 0fPor~~ity cbsts assoda/ed wi/~"t~;pro1ij~d policie~:': ~!tpt,;iies and qcth,ities. 7. the marginalc,osMenejitsofadditional investments in sp.~cific polici~s.sl1:'aiegies and activities, . _ -. -, , , . ' . . ,',_ -! ': ',' . , :: -. _ .' _'''1'' . , . 8. the existing enipirii:qlevi"~l!fe in support oft~es~ poljc!e.r. str!'tegi.e~':"!f!.Acfivities, .' .,' . 9. the. manner in whicht~e degree of achieve"'.e~t,iJf the goals Oiu! obJ,e~tive~ wU/ be measured, . 10. a prediction of any poten/iaV unintended! wiavoidableside effects or harms which might arise in adopting these policies. strategies and activities and inclusion of these unintended! unavoidable harms in any future evaluation. ":'!_ , .. .. _.'. ','-; _', '. '. " .' . -

" 3.,; '~the J71agnitude ofproblem prevention, treatment response or reductio.n In harm which is sought. ~'-~.' .~~ ~ -,~, -"1 .'

•

•

All hypothesis and assumptions ought be identified as such and ought be subjected 10 due scientific appraisal, rather than implemented uncritically on the basis of unsubstantiated theory, intuition or popular belief Indicators of the implementation fidelity. impact and outcomes of all strategies should be accordingly developed alld utilized to evaluate all drug-related policies, programmes and activities. Modified afier G. Wardlaw, J986

A final but vitally important issue that we would like you to explore in this workshop is that of the special attention that must be paid to the cultural norms, customs and values of a particular country or society, in seeking to develop acceptable, feasible and effective drug policies, strategic approaches and activities that can in turn lead to a reduction in ATS-related harm. In doing so, careful consideration will need to be given to how this information and understanding might be used to appropriately modify strategies, whilst preserving effectiveness.

• This document has been amended following the workshop to correct errors contained in the original versIon, that were identified during the meeting. A number of paragraphs have also been added to provide clarification on certain matters raised during the meeting.

- 73 Annex 6

References I. Amphetamine-Type Stimulants-A Report on Amphetamines. MDMA and other Psychostimulants. Geneva. 12-15 November 1996 (Pre-publication Issue), Programme on Substance Abuse, Division of Mental Health & Prevention of Substance Abuse, World Health Organization, Geneva, 1997. 2. Global and Regional Dimensions of Substance Abuse. Programme on Substance Abuse, Division of Mental Health & Prevention of Substance Abuse, World Health Organization, Geneva, 1996. 3. World Drug Report, United Nations International Drug Programme, Oxford University Press, 1997.

4. Abuse of and Illicit Trafficking in Stimulants: Report of the Expert Meeting on Amphetamine-type Stimulants held on Shanghai. China. from 25-29 November 1996, Economic and Social Council, Commission on Narcotics, fortieth Session. Vienna, 18-27 March 1997.

5. Amphetamine-Types Stimulants: A Global Review, United Nations International Drug Programme, 6. Vienna, 1996. Kamieniecki, G., Vincent, N., Allsop, Sand Lintzeris, N. Models of Intervention and Care for Psychostimulant Users. Final Report, March, 1997. National Centre for Education and Training on Addiction, South Australia (1997).

7. Country reports to workshop on problems relating to the use of amphetamine-type stimulants (ATS) in the Western Pacific Region (16-20 February 1998). 8. Internal communications with WHO/ WPRO 9. 10. II. 12. \3. 14. 15. 16. 17. 18. Safer. DJ. and Krager, J.M. (1988), A Survey of Medication Treatment for Hyperactive/ Inattentive Students. Journal of the American Medical Association (JAMA). 260 (15). pp. 2256-2258. Cowart, V.S.(l988), Attention Deficit Hyperactivity Disorder: Physicians Helping Parents Pay More Heed, Journal of the American Medical Association (JAMA). 259 (18). pp. 2647-2652. Wardlaw, G. "The Realities of Drug Enforcement", The Journal of Drug Issues, 16(2), 171-182. 1986 Wickes. W. (1992) Amphetamines and other psychostimulants. A guide to the management of users. Australian Government Publishing Service, Canberra. Bandura. A. (1977). Self-efficacy: Toward a Unifying Theory of Behavior Change. Psychological Review, (May) pp. 191-215. Phillips, G.T., Gossop, M., & Bradley, B. The influence of psychological factors on the opiate withdrawal syndrome. British Journal of Psychiatry, 149, (1986) 235-238. Green, L., & Gossop, M.( 1988). Effects of information on the opiate withdrawal syndrome. British Journal of Addiction, 83, 305-309. Gossop, M., Johns, A., & Green, L. (1986) Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignments to treatment. British Journal of Psychiatry, 293, p.p. 103-104. Lipton, D.S., and Miranda. M.1. (1983). Detoxification from heroin dependency: An overview of method and effectiveness. Advances in Alcohol and Substance Abuse, 2, 31-55. A Treatment outline for approaches to opioid dependence: quality assurance project (1993). Australian National Drug Strategy Monograph Series, No 21, Australian Government Publishing Service, Canberra ACT Miller, W.R. "Emergent Treatment Concepts and Techniques". Annual Review of Addictions Research and Treatment. Vol. I, 1-14, 1991. Egan, G.(1986). The skilled helper: A systematic approach to effective helping. California: Brooks / Cole. Murray, I.L. and Lopez, A.D. (1996). The Global Burden of Disease, Harvard University Press. Selander. S., Troein, M., Finnegan, I. and Rastam, L. (1996). The discursive information of health. A study of printed health education material used in primary care. Patient Education and Counseling. 31,181-189.

19. 20.

21. 22. 23. 24.

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Trends in Drug Use in Western Pacific Region • Western Pacific Region population =

General Observations Regarding ATS in WPR • ATS widespread &! or increasing • ATS use! problems> all other illicit drugs - in some countries • Injection of ATS: risk for B.B. disease transmission in some! (7) many countries ..... ~

one-third world's

• More rapid social and economic change than in any other region • Targeted with aggressive marketing by licit (alcohol, tobacco, pharmaceutical industries) & illicit markets

Trends in Drug Use in Western Pacific Region • Cocaine use is not common in Western Pacific Region • Methamphetamine use: particularly common in countries experiencing rapid economic growth

General Observations Regarding ATS in WPR • Smoking & sniffing main methods of administration in some countries • Oral & injecting use common in others • Few countries identify injection as an important at-risk mode • Little attention paid to possibility

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General Observations Regarding ATS in WPR • Prevalence of use among females . . Increasmg • ATS use shifting to progressively younger groups in some countries • Polydrug use common

General Observations Regarding ATS in WPR • Acute health! social problems including psychotic & violent behaviour reported more in some countries than others - dramatic & tragic outcomes • Contribution of confounders uncertain - predisposition! past history - alcohol & polydrug use - socio-cultural expectancy

'"

....

General Observations Regarding ATS in WPR • Hardening of popular opinion towards ATS - some countries • Increasingly harsh & punitive public policies & legislation

Responses to Drug Problems in the Western Pacific Region • More are inclined towards undue emphasis on supply reduction instead of a balanced approach to public health policies & strategies • Public health I harm reduction policies & strategies actively pursued by only handful of countries

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Responses to Drug Problenls in the Western Pacific Region • Many countries - poorly developed treatment responses • Some offer no treatment at all

Responses to Drug Problems in the Western Pacific Region

• Inadequate treatment & public health oriented drug policies & programmes in many developing countries • poor infrastructure • limited skilled human resources • budget constraints

.... 00

Responses to Drug Problems in the Western Pacific Region • Government policy & cultural values may often preclude certain health protection policies! actions - even if world experience & empirical evidence suggests greater effectiveness c.f. current policy choices

Best Practice Interventions • Concept of "best practice" - range of human endeavours including health care delivery • Embryonic knowledge & understanding of best practice (prevention! treatment) for ATS

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Best Practice Interventions • Workshop - range of prevention & treatment approaches trialed in world - no well designed & replicated ReT's of sufficient sample size demonstrating a consistent positive effect (pharmacological & psycho-social)

Best Practice Interventions • None are effective in: .. reaching more than small proportion of at-risk persons .. engaging treatment seekers in sustained & "compliant" manner .. producing enduring beneficial outcomes • Questionnaire suggests similar difficulties & uncertainties in WPR o 0>

0 I

INTRINSIC Harm attributable to the Drug INDIRECT INTRINSICDIRECT INTRINSIC HARM HARM • Cirrhosis of the liver • Neurotoxidty • Drug overdose DIRECT EXTRINSIC HARM

I N

Responses to Drug Problems in the Western Pacific Region • None appear to evaluate drug control policies & activities in a scientifically rigorous manner (e.g. precursor legislation) • Few undertaking research to develop more effective prevention & treatment services & strategies

0 I

R E C Hann T to tf1e UHr

• Lung cancer from passive smoking

R E

Hann C INDIRECT EXTRINSIC to T HARM others

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II • Sligmatization of the • HIV Infection spread by unsafe Injecting technique family of drug users • Criminalisation of users EXTRINSIC Hann attributable to the use of the drug but not Inherent In the drug Itself

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Responses to Drug Problems in the Western Pacific Region • None appear to evaluate drug control policies & activities in a scientifically rigorous manner (e.g. precursor legislation) • Few undertaking research to develop more effective prevention & treatment services & strategies

Responses to Drug Problems in the Western Pacific Region

• Few possess institutional & resource capacity to enable or justify such activity - multitude other health & social problems & challenges

'"

CD

Responses to Drug Problems in the Western Pacific Region • Current models intervention often adopted without scientific question • Assumptions & hypotheses are often tenuous • Unsupported by available empirical evidence & practical expenence

Responses to Drug Problems in the Western Pacific Region • Urgent need for: - empirically supported approaches to prevention & treatment - policies & programmes that protect & promote public health - more rigorous strategic thinking & accountability processes regarding resource allocation in all sectors

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Adaptation to Cultural Nonlls, Customs & Values • Special attention to cultural norms, customs & values .. acceptable, feasible & potcntially effective drug policies & strategic approaches .. that can in turn lead to a reduction in A IS-related harm. .. While preserving effectiveness

A Complemenlary and interactIVe Model 01 Harm MmUnizatKln - A. Reynolds 1997 (Adapted from A BUIOhc. Queensland Health, 1994)

HEALTH MAXIMIZATION DRUG RELATED ':'fRM MINIMIZATION

.u, .. Consumption Safer Drug Reduction Safety Consumption I I Oe1mand Supply Hann Administration Drug Hoalthy Reduction Reduction Remedlatlon Saloty Modification Public Polley ~_., ~"u"

,

,

,

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• Sociacuhural normallve

change • Sirudural change

• Legal status of drugs • Policing policy • Interdict·

• AccldeOiresponse

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• Safer route of

• lower

I

admlnlsttaUon • Hygienic

• MedIcal

trealment

eclmlnlstrallon techniques • Sterile

• Drug

Ion

substitution • Penalties ror supply • Treatment dependence offences • Rlskcomm· unication • Education

equipment MonItoring/ • Risk recludion

Evaluatlonl

educahon

Relearch

• Possession toxicity 0( of needles side effect and Iyringe. profile drugs madeleval • User friendly • Self·admlnpharmocoIstraUon not logbl profile Iilepal (2nd day dollO; • Police policy With king hall' support of lif.lt.b.tltuOon NSEP

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availability opUDnJ

Levels of Prevention Lenl of rreventioR PhB5c of Diseasel Social Problem

Target

Framework for the Workshop • Consider hypothesis: progress in D & A retarded by reluctance/ unwillingness among decisionmakers to consider all possible policy & strategic options. - Inadequate knowledge, understanding & first hand experience in the area - Personal moral values, beliefs & convictions - no attention to scientific evidence or best available expert consensus & wisdom. co VI

Primordial

Aimed at altering or eliminating conditions leading to causation of risk/health harm Altering responses to speci fic causal [acton c1(posing individual! community to risk Intervening at early stage of disease (scrcening &. early intervention) Intervening at lale stage of disease (treatment. rehabilitation)

Total population ami selected grour~

Primary

Total population, ~clcctcd groups and hc:ahhy individuals

Secondary

Patients

Tertiary

Patients

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Framework for the Worl{shop • Simple reflection of political process • Insufficient attention to scientific rigour when evaluating impacts/ outcomes • Decision-makers & public inadequately consider unintended/ unforeseen harms of policies, strategies & actions

Framework for Better Decision-Making • Framework for better decisionmaking (all relevant sectors) • Consider utility of following questions in planning! implementing strategies c:c a-

Framework for Better Decision-Maldng elll; 'Y I Hr .fp,el Ie Koo.r tlllt (I .ItCIIl'e.t. Ihe .tPt!CijIC harm., 10 ,\I"'-Ci.i-;--wJ,'Ch-(; program or policy ;s aimed til p~,'e"';"K (,r "ti"cillK. 'he mtl1:IIIlmlt of prob/,·", prr:,ornl;oll, Ina/me'" n:rpon.fe or reduclio" ill Ira'''' w1.ic/, i.r .UIIIX"'. lIlt pII/icie,f. .ftrvlegiu m,d «IiI'Wes pJo""ed, /rOlf! ;1 ;.r hYPolhe.fl,ted ,Ire policiC'.f, .l/rCliI'Kif'.'i (IIU/ act;v;lies will odJie'~ Ihe dt!s;rtd Ollicomn, ,I't! co.tls mid apportu,,;,y C.Uf.' (I,UOci(I,C'd M-;,I! 1M proposed policies, ,f'f'CII~eS am/ ac,;,·jties, the morgilllil co.'iI.hl'"ejiH 0/ (It/tlilimUlI ilf"t!,ftmelllS ;11 .t~cljic policies. sIraleg;e.t am' aclil'i/ie.t. flte ui.rli"J! empirical tI'llJCIICt! i" .tupport of Ihe.';e policlu, Slmug;l'.t {lrkJ (1CIil'ilic.t. ,Ire mumlu ill which 'he dt1l."'" of "dliel't"'t!II' of ,,,, goal.f a"cI ohjectil'(!.' will be mea.mred, " pN!diclillll oj 1111.1' 1'0ll''''I,,11 ,,,,illfellded' Imol'oidohle side efftct., or Illmtu II·/tid, mi"/" uri.'(! i" lItlOPlillg ,/t".ft! fJ(Jlicje.f,

Public Policy & Decisionmaking on Drugs • Major findings, conclusions & recommendations of WHO/ PSAI HQ & UNDep meetings • Ensure don't ignore or duplicate - unwise • May reach different conclusions & recommendations • Differing views on relative emphasis CD

.....

.flralegies ami actil'i/ies eRld ;"c/luirm (if t/rest lII,illle"deeV wICI1'oidah(c h(lnll.' ill fltl)' Jlllllrf' (,1'O/UOIion. All hypoIJ~si.f and dUlln/pliollS IJIIg'" ht idm'~fit!d (H .me" all" IIIIXhl hf' subjecttd 10 dllt SCitlllijic approi,m/, roil,er Ihall impltmellftr/ulluil;mlly /Jr' lire hd.ti.f 01 ,lnsllbstm./ia/td Illtory, i,,(IIi1ioll or popllllIr helief ,"dicalnrs II/ ,lit' ''''pit'lIIel/lmio" jith/ily. imp«1 and oulcOIIK$ of all,flroltgies .tl,ould be uccoNi"RI.v tle,'e/f)fW" tnul IIlili.fed 10 el'(l/ualt all dnlg relaled policie,f, proxrtlmmt.f and aelirilie.f, I~""<l .....- , -

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Public Policy & Decisiollmaking on Drugs

Public Policy & Decisionmaking on Drugs • Short, intermediate & long term goals of treatment for ATS problems? • What is required at local, national, regional & global levels to facilitate progress? CD CD

• Encourage new ideas that deserve careful exploration • How best pursued strategically & tactically?

Framework for the Workshop

Framework for the Workshop • Encourage active communication, lateral thinking & openness to new ideas • Encourage to repeatedly ask "why" & "how do we really know this is true" .. of yourself and of each other .. no assumption or belief unexplored/unchallenged ex> -D

• Share respective experiences & knowledge • Pose serious questions about past approaches & rationale • Requirements at local, national, regional & global levels to move forward .. knowledge, understanding & capacity to adopt good/ best practices

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- 91 -

ANNEX 7

PROCEEDINGS OF TIlE

NATIONAL CONSENSUS MEETING

ON THE USE, ABUSE

AND SEQUELAE OF ABUSE OF

METHAMPHETAMINE WITH

IMPLICATIONS FOR PREVENTION,

TREATMENT AND RESEARCH

u.s. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

Rockwall II, 5600 Fishers Lane Rockville, Maryland 20857

- 92 -

Annex 7

ACKNO~DGEMENTS

This activity was sponsored by a SAMHSAlCSAT contract with the College on Problems of Drug Dependence.. The meeting was held at the Caribe Hilton Hotel, San Juan, Puerto Rico on June 27 and 28, 1996. Martin Adler, Ph.D., Executive Officer with the College on Problems of Drug Dependence, Temple University served as the Project Director and Scott E. Lukas, Ph.D., Associate Professor of Psychiatry, Harvard Medical School, wrote the report. Charlene Lewis, Ph.D., CSAT, served as the Government Project Officer.

Public Domain Notice All material appearing in this publication, except where cited, is in the public domain and may be reproduced or copied without pennission from SAMHSAlCSAT. Citation of the source is appreciated. The opinions expressed herein are the views of the author and participants and do not necessarily reflect the official position of SAMHSAlCSAT or any other part of the U.S. Department of Health Human Services (DHHS).

DHHS Publication No. (SMA 96-8013) Printed 1997

- 93 -

Annex 7

TABLE OF CONTENTS

BACKGROUND

1

METHAMPHETAMINE-THE DRUG AND ITS USE THE NATIONAL DRUG ABUSE STRATEGY EPIDEMIOLOGY AND PAlTERNS OF USE PREVENTION STRATEGIES METHAMPHETAMINE EFFECTS ON BEHAVIOR MECHANISMS OF ACTIONIREINFORCING EFFECTS NERVOUS SYSTEM TOXICITY OTHER ORGAN TOXICITY TOXIC PSYCHOSIS

2 3 4

12 14 16

18 20 22

DEVELOPMENTAL TOXICITY TREATMENT OUTCOME IN COMMUNITY PROGRAMS MEDICATION DEVELOPMENT EFFORTS AT NIDA GAPS IN OUR KNOWLEDGE ABOUT METHAMPHETAMINE RECOMMENDATIONS LIST OF PARTICIPANTS

24 27 32 34 3S 37

- 94 -

Annex 7

BACKGROUND

In 1990, the American Society for Pharmacology and Experimental Therapeutics and the Committee on Problems of Drug Dependence (now the College on Problems of Drug Dependence) held a joint meeting under the aegis of the National Institute on Drug Abuse to review the problem of methamphetamine abuse. Although the focus at that time was on a smoked form (so-called ICE), the symposium., Anticipating a new ICE Age: The Pharmacology and Abuse Implications of Methamphetamine, resulted in a consensus paper summarizing what was then known about the epidemiology, patterns of use, subjective effects, and toxicity associated with methamphetamine abuse. However, the anticipated and feared epidemic never materialized and cocaine and crack cocaine abuse continued to be the predominant stimulant of abuse. Renewed interest in methamphetamine abuse is now warranted because of recent reports of increased use. These include: mentions in the Drug Abuse Warning Network and Household Survey reports, identification of regional "pockets" of use in the west, Pacific northwest, Hawaii, U.S.-affiliated territories along the Pacific rim (e.g., Guam and the Northern Marianas) and the emergence of significant methamphetamine abuse in midwestern and southern states. Clandestine laboratory seizures have also increased and changes in illicit methods of making methamphet.am.ine now produce more active drug per batch. Although significant increases in methamphetamine use seem to be limited to a few areas on the west coast, the proliferation of illegal laboratories, especially in the rural midwest, has raised concern that use may also be spreading eastward. Methamphetamine's popularity among gay men who inject it intravenously has also raised concern that such use may accelerate the spread of the AIDS virus. In the spring of 1996, Dr. Nelba Chavez., Administrator of SAMHSA, asked the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention (CSAT and CSAP) to organize a scientific symposium to again review methamphetamine abuse. Because of its earlier role, the College on Problems of Drug Dependence (CPDD) was selected to run this meeting. It was then scheduled as a satellite symposium of CPDD's annual meeting. The symposium was held on June 27-28, 1996 in San Juan, Puerto Rico and included 18 scientific presentations on epidemiology, mechanisms of action, toxicity, prevention and treatment strategies. Issues concerning illicit trafficking and drug policy were also discussed by government representatives in those areas. Both government and nongovernment scientists contributed to the sessions. After the fonnal presentations, three work groups of the participants developed a consensus on present gaps and what is needed to better address the methamphetamine problem from basic

- 95 -

Annex 7

pharmacological, toxic, treatment and prevention perspectives. The three work groups also discussed methods for more rapidly disseminating new and important infoqnation to treatment staffs to improve their prevention and treatment methods. This report represents a summary of the presentations and discussion by the participants in the San Juan symposium and provides a bird's eye view of the knowledge and opinions of infonned professionals whose interests include: developing a national drug policy, drug use epidemiology. problems of law enforcement, scientific issues relevant to methamphetamine abuse, .the drug's behavioral. developmental and physical toxicity, and the prevention and treatment of its abuse. In addition to briefly summarizing our present knOWledge. these proceedings also underscore the multiple areas in which knowledge is lacking. METHAMPHETAMINE-THE DRUG AND ITS USE

D-methamphetamine hydrochloride is known by many street names such as speed, crank,. go, crystal, crystal meth and the "poor man's cocaine." It can be used by all of the common routes of illicit drug administration (inhalation, intranasal "snorting", intravenous injection or orally), but it must be purified before it can be smoked. ICE is one purified fonn of the d- isomer that is frequently sold as large crystals which are smoked. Pharmacologically. methamphetamine is a potent central nex;vous system (CNS) stimulant that produces many effects indistinguishable from those of cocaine although they typically last for hours instead of minutes. Methamphetamine hydrochloride (hereafter referred to as methamphetamine) is sold on the street in either the crystal fonn or as rocks. Contrary to popular belief, these rocks are not freebase methamphetamine. Instead, the freebase form of ·methamphetamine is a liquid at room temperature and so its abuse is very limited. Rocks are made by melting crystals using a variety of techniques, but "the turkey bag method" appears to be the most popular. Dry methamphetamine crystals are placed in an aluminum turkey roasting bag which is then closed and dipped into boiling water until the methamphetamine melts. The melted material is then placed in cool water or in the refrigerator until it solidifies as a large crystal. The crystal is then cut into rocks that fit the various glass pipes that are used for smoking methamphetamine. Methampbetamine is usually smoked by inhaling it from a sheet of aluminum foil

Or through a glass pipe. When foil is used, the drug is heated in a crease of the foil until it vaporizes and is then inhaled via a straw. Pipes for smoking methamphetamine differ from those used for smoking crack cocaine. Because methamphetamine vaporizes at a mueh lower temperature than crack, smoking it in a crack pipe at high heat would destroy it. Methamphetamine pipes have a large

- 96 -

Annex 7

glass ball at the end for holding the methamphetamine and a lighter is held under the ball to vaporize the drug. Air flow is regulated by a finger placed over a hole on the top of the pipe. Some users reportedly prefer glass pipes for smoking methamphetamine because they fear developing Alzheimer's disease from using aluminum foil. There are anecdotal reports of individuals making a developmental progression from ice smoking to injection ofmetharnphetamine. This has serious implications, not only for increased toxicity associated with methamphetamine per se (e.g., toxic psychoses described later in this report), but also in relation to HIV and other infections secondary to injection practices, with resulting serious medical complications such as AIDS. THE NATIONAL DRUG CONTROL STRATEGY

With the appointment of a new "drug czar", General Barry McCaffrey, in the spring of 1996, the Office of National Drug Control Policy (ONDCP) became involved in Anorney General Janet Reno's effort to develop a new national methamphetamine strategy, thus incorporating the Department of Justice's methamphetamine initiative into the national drug control strategy. The Deparunent of Justice published a document outlining this strategy in April 1996. The biggest challenge will be to integrate the specific programs so that focusing on a single emerging drug problem does not overshadow the need to attend to the others. Because the White House does not usually concentrate efforts on a single drug, doing so within the context of a larger drug control plan will be a difficult task. For example, heroin abuse has been waning for some time, but there now seems to be a slight return to higher use panerns and it remains a primary drug abuse problem in many eastern States where methamphetamine abuse is rare. Thus, the recent increase in methamphetamine abuse must be placed in context with the general drug abuse problem. A major change in the methamphetamine policy is a shift in the focus of concern from hard-core users alone to American youth more generally. nus was prompted by the changing trends in the geographical "pockets" of methamphetamine abuse from the west coast to a nwnber of locations in the midwest, south and southwest. While current law requires developing a drug strategy on an annual basis, General McCaffrey supports a longer tenn strategy based on planning in 5- and 10-year increments. By adopting this approach. time spent in preparing an annual request for Congressional approval would be bener spent implementing the long range plan. The General plans to debate this year's strategy during the coming months and then adopt a final plan that Congress can approve. Subsequent years will no

- 97 -

Annex 7

longer be wasted in debates over developing new strategies, but instead will involve reporting on progress made on the long term drug strategy. If accepted, this approach will be very different from prior years. Two aspects of methamphetamine abuse that have received little scientific attention are: the long tenn potential psychotic effects of methamphetamine use, and its impact on infants and children. This meeting was regarded as an opportunity to demonstrate how science can respond to health crises. While a national methamphetamine strategy is now in place, it will continue to evolve as new infonnation, including that presented at this meeting, is incorporated into the national drug control strategy. EPIDEMIOLOGY AND PATTERNS OF USE

Narional Scale Surveys The National Household Study on Drug Abuse (NHSDA), Monitoring the Future (MrF), (also called the National High School Survey), Treatment Episodes Data Set (TEDS), Drug Abuse Warning Network (DAWN), and Drug Use Forecasting System (DUF) are the most important instruments available for gauging trends in drug use across the United States. While each of these has its advantages and disadvantages, used collectively, they provide a reasonably accurate "snapshot" of drug abuse trends.

The NHSDA samples the civilian, non institutionalized population of the United States age 12 and older and is primarily used to monitor drug abuse trends in the general population. The survey excludes some populations such as the homeless outside of shelters, prisoners, institutionalized populations, military personnel living on bases, and those who are CWTently in residential treatment progr.uns. It can not provide accurate estimates for drug use that is rare in the general populations (e.g., heroin abuse). The surveys are conducted in the home by trained interviewers using confidential answer sheets to ensure that the respondents cannot be later identified. Names are never associated with these answer sheets; the results are credible general population estimates of drug use. In 1994, the NHSDA found there were about 4 million people who reported ever having used methamphetamine with the highest rate of use by 26 -34 year old males living in the western United States.. For the nation as a whole, lifetime rates rose slowly between 1994 and 1995--from 1.8 percent in 1994 to 2.2 percent in 1995-not a statistically significant increase. The rate for the 26-34 year old age group was about double that of younger. 18-25 and older, 35+ age groups (3.8%, 1.9% and 2.1 %, respectively). Three percent of the lifetime users were male compared to 2 percent female. Finally, use in 1995 in the Northeast region

- 98 -

Annex 7

continued to be the lowest at 1 percent with higher rates in the South (2%), North Central (2%) and the West (4%). The Monitoring the Future program is supported by NIDA and conducted by the University of Michigan on an annual basis. These surveys are conducted in the classroom and are aimed at 8th, 10th and 12th graders. Because the questioning occurs outside the bome, use reports are generally slightly higber than the NHSDA survey data. Questions about crystal methamphetamine were added in 1990; prior to that time, methamphetamine was included with other stimulant An estimated four percent of students surveyed for the MTF study now report having smoked "ice" and there is a general trend toward increasing prevalence since 1992, except among graduating seniors who show a fluctuating trend- The number of participants in the survey allows for regional analyses (east, west, north and south), but does not pennit fmer geographic analysis.

use.

The Treatment Episode Data Set (TEDS) bas been collected by SAMHSA' s Office of Applied Studies for the past three years and includes drug use profiles from clients who enter a treatment facility that receives public funding. Thus, about 63 percent of all treatment facilities are included in the survey and represent between half and two-thirds of the nation's treattnent admissions to publicly funded programs. Infonnation is gathered from 45 states, the District of Colwnbia and Puerto Rico. Each state sends its data to SAMHSA where it is compiled into a single data set Arkansas, Connecticut, Oregon and Texas do not report amphetamine and methamphetamine use separately and five states do not participate at all (Arizona, Kansas, Kentucky, Mississippi and Nebraska). Other indicators show that methamphetamine use has been rising rapidly in Arizona, but the lack of TEDS data in this and other non participating states limits tracking of treatment admissions in those states. As in the other surveys, the nwnber of methamphetamine treatment facility admissions is highest in the western states. In the far west the rate per 100,000

persons admitted for primary methamphetamine abuse in 1994 is now double that reported in 1992. In California, primary methamphetamine admissions to treatment rates rose from 36/100,000 in 1992 to 7311 00,000 in 1994. By contrast the admission rates in all the northeastern states are less than 21100,000. Primary methamphetamine admission rates are, however, beginning to rise in some southern and midwestern states such as Iowa (341100,000) and Oklahoma (101100,000). Among major cities, San Diego has the highest rate of methamphetamine admissions at 143/100,000. San Francisco is second at 53/100,000; other high rate cities in decreasing order include: Los Angeles (241100,000), Denver (221100,000), Seattle (17/100,000), Minneapolis (131100,000) and Dallas (10/100,000).

- 99 -

Annex 7

In 1994. admissions for cocaine abuse/dependence exceeded admissions for methamphetamine use in Denver, Los Angeles, Minneapolis, San Francisco and Seattle. However, methamphetamine treatment admissions now surpass cocaine admissions in San Diego; cocaine remains second to heroin in Los Angeles, San Francisco and Seattle. However, to keep these data in perspective, methamphetamine users aCCO\Ult for only 1 percent of the treatment population in the nation as a whole. The largest reported reason for seelcing treatment is still alcohol abuse, accounting for 58 percent of all admissions. The Drug Abuse Warning Network (DAWN) provides information from a different perspective, with a focus on individuals who are treated in hospital emergency departments (ED) or who die from a drug-related cause. ED data are collected in a random sample of Ens natioDwide in 21 mid-to-large size cities. The information from emergency departments is obtained from abstracts of medical records by trained per5OMel. The data reflect the contribution that the non-medical use of a drug (either legal or illegal) had on the patient's presenting problem. Compared to cocaine and heroin, methamphetamine accounts for a very small, but growing, percentage of the nation's drug-related ED visits. However, between 1991 and 1994, there was a dramatic increase in methamphetamine-related ED episodes-from about 5,000 to nearly 18,000-a profile similar to that charted for cocaine in the early 1980's. Again, the highest rates ofDA WN episodes are on the west coast, with San Francisco reporting 7511 00,000 population; San Diego and Phoenix each reported 40/100,000. The rates of these episodes have been increasing steadily since 1992. However, except for San Diego, the rates for cocaine- and heroin-related ED episodes still exceed those of methamphetamine. Caucasian patients account for the majority of the episodes, but the rate for Hispanic patients is increasing and may be related to the increased production of illicit methamphetamine in Mexico and to increased marketing of the drug to the Hispanic conununity. DAWN medical examiner data are reported by 138 medical examiners in 42 metropolitan areas. Although the absolute numbers of methamphetamine-related deaths are small compared to heroin- and cocaine-related deaths, there has been a 200 percent increase in the number associated with methamphetamine (from 155 in 1991 to 433 in 1994). Data from 1995 are not yet available. In 1994. 80 percent of deaths were among whites and 5 percent among blacks, 12 percent among Hispanics.. The cities with the highest number of deaths parallel the DAWN ED data and include Los Angeles. San Diego. Phoenix and San Francisco. Rates are highest in San Diego followed by San Francisco, Phoenix and Los Angeles. Phoenix has witnessed a six fold increase in methamphetamine-related deaths from 20 in 1992 to 122 in 1994.

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Drug Use Forecasting (DUF) is a 24-site program in the U.S. that involves giving those who are arrested the opportunity to report their recent drug use and then to provide a urine specimen to verify their actual use. About 90 percent of arrestees agree to participate and about 80 percent of their urinalysis results match their self-reports. These data provide some indication of drug use patterns of individuals who are involved in criminal behavior and for whom drug use may play some role in that behavior. The rate of arrestees admitting to methamphetamine abuse (and confirmed by urinalysis) was highest in the west with San Diego, Phoenix, San Jose, Portland and Los Angeles comprising the top five cities Surprisingly, a number of sites in the midwest showed up (Omaha, Dallas and Denver) with rates in the 2.6 to 6.1 percent range. Notable mentions in a number of other cities further east such as Binningham., Houston, S1. Louis, Atlanta. Philadelphia and San Antonio indicate that use is spreading eastward.

Supply Side - Abuse and Trafficking Fatterns and Indicators of Use Strict regulatory controls on lawfully manufactured methamphetamine limit its diversion from licit to illicit channels. Therefore, the vast bulk of methamphetamine currently on the streets has been illegally manufactured. Recipes for manufacturing methamphetamine are widely available through pamphlets and the Internet The clandestine manufacturing process has undergone substantial changes over the years. Phenyl-2-propanone (P2P) which was originally used in illegal manufacturing, is now seldom used since becoming controlled by the Drug Enforcement Administration as a bulk "immediate precursor" of methamphetamine. Lab operators then shifted first to ephedrine and after that was regulated, to ephedrine in single-ingredient tablets. Subsequent regulatory efforts have led manufacturers to switch to the use of pseudoephedrine tablets, and most recently even to phenylpropanolamine. The ephedrine! pseudoephedrine reduction method yields a higher percentage of the more active d-isomer while the P2P method results in equal amounts of the d- and 1- isomers. The yield from both methods is typically 70 percent of the precursor. Thus one kilogram of ephedrine yields 700 grams of methamphetamine. The higher purity of present street methamphetamine may have offset the reduced availability of the precursors. Nevertheless, the purity of purchases seized by the DEA remains in the 50-70 percent range with only occasional batches exceeding 87 percent purity. Methamphetamine trafficking was once dominated by outlaw motorcycle gangs, but in the last three years criminal drug trafficking organizations comprised of Mexican nationals, with ties to criminal organizations in both Mexico and the United States, have usurped their position. With assistance from organization members who specialize in obtaining chemical precursors, the Mexican

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organizations have been able to set up very large laboratories and to make primarily d-methamphetamine. Involvement of Mexicans also has been reported in th~ Pacific region (e.g., in Guam), where supply lines previously conveyed the drug product from the Philippines, Japan, or the Asian mainland. The Mexican involvement may also have contributed to the rapid spread of the drug because the distribution networks originally developed for transporting cocaine, heroin and marihuana from Mexico have been in place for years and are now being used for methamph~e.

Methamphetamine seizures are one measure of the increased size of the problem. In 1995, both the number and weight of methamphetamine seizures were the highest in over a decade. The numbers rose most substantially along the southwest border-from 6.S kg in 1992 to 616 kg in the fust nine months of 1995. (n California alone, the California Bureau of Narcotics Enforcement (BNE) reported an increase in seizures from 1,400 Ibs (636 kg) in 1991 to over 18,000 Ibs (8,182 kg) in 1995. Although there bas been an increase in the number ofvery large, "superlabs," they are not the only source of the problem. There is also an increasing number of small scale labs being set up in rural areas of midwestern states such as Missouri, Kansas and Iowa. As the report A.mphetamine Trafficking Situations in the emphasizes, methamphetamine trafficking patterns were very different before 1991. These differences are highlighted in Table I (page 9). .

u.s.

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Table I. Methamphetamine trafficking patterns and clandestine laboratory factors prior to 1991 and in 1995. Category Prior to 1991

Geographic location: Midwest/Southeast US

Western States Mexico

Lab organization: smuggling

Independents

Large scale from Mexico

and smaller shops in the midwest Lab size: Production quota: lbslmonth Precursor chemicals: pseudoephedrine phenylpropanolamine Access to chemicals: China & Local Small & crude Large

40lbslmonth

1000

P2P

Ephedrine,

International, Europe

Trafficker Characteristics only

Users first, then traffickers

Traffickers

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Chemists can detennine the chemical process used to make the methamphetamine by examining the by-products and chemicals discarded at the lab site. Since 1992. pseudoephedrine has increasingly been used. The ephedrine/pseudoephedrine reduction method is preferred for three reasons: it is similar to thePlP method. the chemicals are less strictly controlled than P2P and it produces a higher proportion of the active d·isomer per unit of weight. However, for every pound of finished product, 5 or 6 poWlds of chemical waste is left at the illicit lab site. In contrast. the result of using phenylpropanolamine (ppa) as a precursor is amphetamine, which is often sold as methamphetamine. The clandestine methamphetamine laboratory presents a chemical hazard both to law enforcement personnel and to the environment. Some precursors are toxic, caustic and highly flammable. and the useless by-products (which are also toxic) are discarded. The special problem these materials pose to the officers who raid these labs have required they have special hazardous materials (HAZMAT) handling trnining. Special HAZMAT removal companies are also needed to remove these toxic chemicals at a cost often exceeding S5,000 per laboratory. In 1988, the BNE spent $147,000 in cleanup costs; that figure rose to $2.4 million in 1995. Strategies, Legisla/ion. Penalties and Regulation

In February 1996, in cooperation with the California Bureau of Narcotic Enforcement, the DEA conducted a national conference on Federal, State and local law enforcement issues surrounding the methamphetamine problem. The proceedings and recommendations of that conference are published in the docwnent Methamphetamine: National Conference of Federal, State and Local Law Enforcement, by the U.S. Department of Justice, February 1996. Subsequently, the Department of Justice spearheaded an inter-agency process, in which ONDCP played a coordinating role, which resulted in the April 1996 release of the National Methamphetamine Strategy. That strategy includes a threat assessment and action-<>riented plan that incorporates many of the law enforcement recommendations from the DEA conference, but also includes broader initiatives in other disciplines, such as education, prevention, treatment and research. The key features of this action-oriented strategy include: tighter regulation of precursor chemicals; increased international cooperation, with a special emphasis on Mexico; increased criminal penalties for trafficking in methamphetamine and its precursors; new civil money penalties, injWlction authority and administrative powers to stop suspect chemical transactions; improved use of technology to track illegal operations; identifying envirorunental risks associated with labs; safety and health training for officers; training officers to deal with methamphetamine users during an arrest; training prosecutors; and a range of other education, prevention, treatment and research initiatives.

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Federal drug penalties are based primarily on the type and quantity of drugs involved, although other factors. such as the use of farearms, violence.. or a person's role in the offense are also considered. In order to set fair and appropriate sentencing levels, the legal/law enforcement community seeks input from the scientific community on the quantity of methamphetamine that is "equivalent" to other illicit drugs, such as crack or powder cocaine. (Note that for most drug sentences, methamphetamine, is an exception to this rule). The consensus was that fairness in sentencing for drug offenses should be based as much as possible on scientific information. Information on abuse patterns and the quantities typi~y consumed by users would better enable policy makers and legislators to decide what drug quantities are likely to be associated with drug trafficking versus personal use. Participants agreed that additional scientific information is needed by the legalllaw enforcement community. Details of effective prevention and treatment programs are needed in order to make intelligent decisions regarding the disposition of cases. Law enforcement officers have noted that abusers of methamphetamine arc a particularly violent population. They need information and advice on how to protect themselves from arrestees, as well as how best to ensure the safety of arrestees. For example, it is not clear whether these individuals should be restrained using different techniques from other arrestees, taken immediately to a hospital, or locked in a holding cell. Regulatory measures have had some success; the eost of ephedrine on the black market has risen to S55,000 or more for a 25 kg container. Although declared imports of ephedrine (even from legitimate sources) have increased dramatically over the past few years, strict U.S. controls on ephedrine have driven clandestine lab operators to alternative sources for this precursor and to seek substitutes such as pseudoephedrine and, most recently, phenylpropanolamine (which results in amphetamine) or to synthesize their own ephedrine. A proactive approach is highly desirable as the best drug "seized" is the one that is never made in the first place. It was reported that a methamphetamine bill would probably emerge from Congress (starting in the Senate Judiciary Committee) that would include civil, criminal and administrative features. Under the then-current, preliminary draft, penalties for trafficking in methamphetamine and its precursor chemicals would increase and "long ann" jurisdiction would be created to reach those persons who manufacture and distribute these chemicals from abroad with the intention of illegally importing them into the United States. The bill also proposed that envirorunental damage caused by clandestine methamphetamine laboratories result in separate and additional penalties. On the regulatory side, Drug Enforcement

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Administration would be granted the power to suspend suspicious domestic precursor chemical shipments. Postscript: On October 3. 1996, President Clinton signed into law "The Comprehensive Methamphetamine Control Act of 1996," most of which became effective immediately. This law: increases penalties for specified crimes, such as knowingly supplying precursor (list I) chemicals and other equipment to methampbetamine

manufacturers; without explicitly raising penalties, it directs the Sentencing Commission to increase penalties for unlawful trafficking in methamphetamine; extends Federal "long arm" jurisdiction to the manufacture and distribution of listed chemicals abroad with intent to import them into the United States; authorizes civil penalties of up to S250,000 for finns that recklessly sell a "laboratory supply" to an operator of or procurer for a clandestine drug laboratory; grants the Attorney General authority to commence civil actions, including injunctive proceedings, to stop the suspect activities of "rogue chemical firms" and others who supply materials to clandestine lab operators; imposes regulatory requirements (effective in one year) that will induce firms to sell certain FDA-approved over-the-counter drug products containing ephedrine, pseudoephedrine or pbenylpropanolamine at retail in "blister packs" or in relatively small transactions (under 24 grams of base cbemical); requires that mail order firms engaging in retail sales of key methamphetamine precursors submit monthly transaction reports to DEA; and establishes several other programs and task. forces, including a "Methamphetamine Interagency Task Force" under the Attorney General. PREVENTION STRATEGIES

Given the speed and localized nature of methamphetamine outbreaks in the United States, no comprehensive or national prevention programs have been developed.,

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although some local health departments have created brochures and video and videotapes for use in efforts to curtail these outbreaks. Whereas there is evidence that methamphetamine use is spreading to new areas of the country, there are still many areas of the country where methamphetamine use has not been observed. For this reason. the question of mounting a national prevention campaign faces a challenge. Namely, a national program to warn our population about the dangers of methamphetamine use actually might draw attention to the allure of this drug, introducing a large segment of the population to methamphetamine for the first time. Such adverse consequences must be avoided by ensuring that any national prevention strategy is extremely well-conceived and evaluated. One of the major weaknesses of current prevention strategies is that they focus on one main approach with the hope that it is going to be the "magic buIIel" Unfortunately, a single strategy for preventing drug abuse does not exist and it is now recognized that it may be bener to combine methods that can reinforce and support each other. It is also important to recognize that drug abuse does not oceur in a vacuum., but typically occurs with other social and or behavioral problems. Current conventional wisdom holds that drug abuse prevention programs work best when it is possible to coordinate community and media campaigns with school and family-oriented efforts, and new evidence to support this position has been accumulating over the past decade of prevention research funded by NIDA and private foundations. Knowledge about the specific form of classroom programs that can help prevent tobacco smoking, drinking, and illicit drug use has advanced faster than knowledge about the effects of specific community and media campaigns. There was also a tendency for informational skills to be provided within a didactic framework although they are better learned through a dialectical or a Socratic approach- For example, there now is good evidence that peer leaders (e.g., students) trained to lead group exercises in social skills, decision-making, and peer resistance can have a greater beneficial impact than either outside experts (e.g., police volunteers) or teachers who use standard classroom lecture approaches to deliver prevention messages. Nonetheless, the evidence on prevention programming too often has come from evaluation research designs with inadequate experimental control. This has been especially true in the evaluation of specific community and media campaigns. The result has been major gaps in the knowledge needed to guide prevention programming, and these gaps ultimately can be filled only by taking advantage of the most powerful research designs at our disposal, namely, randomized controlled trials.

It also is important to pay attention to the experience of Japan and Sweden., where amphetamine epidemics were faced after World War II. In addition, the highly localized character of recent methamphetamine outbreaks in the U.S. and its

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Annex 7 territories, indicate it might be valuable to study the experience of relatively isolated communities (Le., isolated by ocean or land mass from other communities). As has been true in epidemiological research .on communicable diseases such as measles, experiences of this type might provide key insights into the nature and dynamics of the spread of methamphetamine use throughout the population, -indicating not only how ice smoking can spread rapidly but also the boundaries of vulnerability across which it does not spread. Experiences in the Pacific region and in the Hispanic communities of the United States and Mexico might be especially informative, given the relatively greater family cohesion in these populations, which creates special opportunities for the study of familial aggregation and spread within extended families (e.g., via estimation of secondary attack rates after a family has experienced its first index case) With a better understanding of the nature and diffusion of methamphetamine use through special populations or population sub-groups. it may be most useful to craft specific prevention strategies for these groups, focusing precisely upon methamphetamine. For example, there are some local areas where the methamphetamine problem already has been publicized widely. and young people already seem very knowledgeable (e.g_, Hawaii, Guam). In these areas, this familiarity reduces the potential for adverse consequences otherwise associated with methamphetamine-specific programming. In other parts of the U.S., available evidence suggests that young adult gay men and lesbians are disproportionately affected by methamphetamine problems_ Here, the experience with prevention of HIV infection and AIDS in this population can help guide methamphetaminespecific progranuning for these groups. In this manner, effective prevention campaigns can be directed at those who need them, and introducing information about the drug to vulnerable population groups or in areas where methamphetamine still remains essentially unknown can be avoided. METHAMI'HETAMINE EFFECTS ON BEHAVIOR

There is limited data on the effects of methamphetamine on human behavior. Much of the available information has been surmised from the cocaine literature. In addition to the physiological effects (e.g., rapid heart rate, elevated blood pressure, increased body temperature and respiratory rate, pupillary dilation) there is a heightened sense of well-being or euphoria, increased alertness and increased vigor, reduced food intake and decreased sleep time. Higher doses result in stereotypic behavior (repetitive and automatic acts in both animals and humans). Acute administration of amphetamines has been shown to increase socialization among humans. Thus, it is valuable to quantify the effects of acute doses of methamphetamine in volunteers who do not use drugs to provide a framework with which the effects in dependent individuals can be compared. These data also

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provide insights into how experimental use of a drug may lead to more frequent use and ultimately dependence. Tolerance develops to many of the behavioral effects of amphetamines, so that increasing doses are required to achieve the same effect. The reverse of tolerance is sensitization, which appears to be unique to the psychomotor stimulants. Sensitization is a reaction to multiple exposures of a drug that lead to the development of new effects. For example. in animals, seizure activity or convulsions do not typically occur after the first series of exposures to low-tomoderate doses of methamphetamine. However, with repeated exposures the animal can become sensitized to methamphetamine and have a seizure after receiving a single dose that previously did no harm. Like other abused drugs., methamphetamine may have a malleable effect on subjective responses. Recent studies suggest that the setting in which it is used affects the nature and degree of subjective effects of methamphetamine. This has implications for the treatment community because clients who seek treatment may describe their methamphetamine experiences differently under different environmental conditions. Ethanol is often consumed along with methamphetamine because the stimulant can reverse the effects of ethanol-induced drowsiness. This process of attempting to "fme tune" or titrate a particular mood state may be one of the contributing factors to polydrug abuse. Research has shown that most psychomotor stimulants are very similar in their effects on the brain and, by analogy, in their subjective effects. It is the profile of these SUbjective effects that allows an individual to identify a drug as "stimulant-like" and to discriminate it from another drug that may be "opiate-nor "depressant-like." Thus, this feature may be exploited in medication development programs because not all of the psychomotor stimulants are equally reinforcing and therefore have different potentials for abuse. An optimal medication might be one that is "perceived" as being methamphetamine-like, but is not likely to be selfadministered. This characteristic may also increase treatment compliance. Individuals who need treatment frequently avoid medications devoid of any desired pharmacologic activity; thus a small amount of phannacologic stimulation may be necessary to treat the individual. Stimulants enhance perfonnance of certain types of psychomotor tasks and also contribute to continued use. For example, cocaine enhances and ethanol detracts from many types of performance, but perfonnance may be restored to normal when the two are oombined. A similar effect occurs for sleepiness which may contribute to the development of abuse in certain populations. Finally. psychomotor stimulants., like other abused drugs, can augment the conditioned reinforcing effects of other associated stimuli. Because of the stimulant's

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reinforcing effects, other stimuli (inanimate objects and people) also acquire reinforcing effects thus promoting a cycle of conditioned reinforcers which contributes to relapse when clients are returned too quicldy to their old drug-using envirorunent after being detoxified. Such information may be integrated into treatment programs and desensitization techniques used to break the associations between methamphetamine use and other cues.

Animal models of psychostimulant self-administration are very predictive of human behavior. Under conditions of unlimited access (Le., continuous 24-hour availability of methamphetamine), animals will self-administer in cyclic patterns, just like humans. In addition, given an unlimited supply of drug, the animals will self-administer methamphetamine until its toxic effects cause death. Use of progressive ratios in animal studies is analogous to increasing the cost of a drug for human abusers and provides information on the drug's reinforcing efficacy. Using this procedure, the number of responses required to obtain an injection (i.e., drug reinforcement) is progressively increased following each injection. The «breakpoint" is the ratio at which the animal will no longer respond to obtain the drug. Drugs that maintain very high breakpoints are considered to have higher reinforcing efficacy than those with lower breakpoints. Using this paradigm. cocaine maintained higher breakpoints than methamphetamine, but because methamphetamine has a longer duration of action. the animals may not need to take as many injections over the same time period. Genetic factors may also affect an individual's predisposition to abuse methamphetamine. The speed of acquiring self administration behavior and the magnitude of the response is higher in rats that, by nature, are more sensitive to methamphetamine's acute effects than in other groups of less reactive rats. These same animals were very responsive and reactive to a novel envirorunent The level of reactivity to the novel situation is predictive of whether or these animals will self-administer amphetamine. MECHANISM OF ACTIONIREINFORCING EFFECTS

Methamphetamine is structurally similar to amphetamine but quite different from cocaine and although these psycho stimulants have similar behavioral and physiological effects. there are differences in the ways in which they affect nerve terminals. Methamphetamine enhances monoaminergic neurotransmission by causing a release of monoamines from storage sites within the axon terminal. While cocaine is rapidly metabolized by plasma and tissue esterases, methamphetamine is much more slowly metabolized, resulting in a longer duration of action and a half life of about 10-11 hours compared to about 50 minutes for cocaine.

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The neurotransmitter transporters (which have been recently discovered and characterized for dopamine tenninals) are the sites where neurotransmitters are taken back up into the nerve terminal following their release by a nerve signal or a drug. The transporter is made up of 12 protein chains that can bundle together to fonn a channel through which neurotransmitters can pass. There are also storage sites for neurotransmitters (vesicles) in the neuron and there are different transporter proteins present in these synaptic vesicles. These are the transporters that concentrate neurotransmitters from cytoplasm of the neuron into the storage vesicles. The interior of the vesicle is acidic and reducing; in this environment monoamines are. "chemically comforiable~ and remam stable. The cytoplasm, in contrast. is not as acidic as inside the vesicles, and is more oxidizing and thus less hospitable for monoamines such as dopamine, norepinephrine, and serotonin..

..

Although the precise mechanisms of action are not fully understood, recent information indicates that methamphetamine-induced toxicity may occur as follows. Amphetamines block the exchange through both the nerve membrane (synaptic membrane) and the storage vesicle. Thus, methamphetamine actually enters into the nerve terminal cytoplasm and then into the storage vesicles. Cocaine does not cross these membranes; it only blocks the synaptic transporters so that dopamine once released into the synapse cannot pass back into the axon terminal. When methamphetamine enters the nerve terminal via the synaptic or membrane transporter, it then enters the storage vesicles inside the neuron through the vesicle transporters and forces neurotransmitters such as dopamine and norepinephrine to leak out of the terminal and into the synaptic cleft. It is this action that increases neurotransmission resulting in an over stimulation of the postsynaptic membrane. The mechanism of methamphetamine's toxic effects on nerve terminals also focuses on these transporters, especially the transporters on the storage vesicles. The mechanism by which dopamine gets inside a vesicle is actually protondependent This means that for dopamine to move inside the vesicle two hydrogen atoms have to move outside the vesicle. This difference in proton concentration ensures that the inside of the vesicles is acidic. If protons are unavailable, dopamine cannot enter the vesicle and it remains in the cytoplasm. Because methamphetamine is a basic compound, it will disrupt the acidic interior of synaptic vesicles by a process called alkalization. The protein pump is inactivated, and the dopamine that remains in the cytoplasm undergoes a process of autooxidation that results in the production of a number of highly toxic and reactive chemicals called oxygen radicals, peroxides and bydroxylquinones. Thus, it appears that methamphetamine itself is not toxic, but rather it is the accumulated dopamine that is toxic to the nerve terminal. The uptake of methamphetamine and the oxidative stress it produces occurs primarily in the ventral tegmental area of the brain where there are many dopamine cells. Using special techniques, this

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Annex 7 process can be directly observed and the toxicity is evidenced by the swelling and bleb bing of neurons. Radiotracer techniques reveal that hydrogen peroxide and free radicals are present in these areas of swelling. Finally, methamphetamine can cause neurotoxicity indirectly by mobilizing the dopamine out of the safe storage vesicles within neurons and into the cytoplasm of the neuron where it is converted to toxic and reactive chemicals. Thus, the neurotransminer dopamine itself is the neurotoxin. In summary, there is a paucity of information on methamphetamine with respect to the conditions under which it acts as a reinforcer. Many facets of chronic use ineluding tolerance, dependence and sensitization are not well understood and so it is difficult to detennine if strategies for developing treatments for methamphetamine abuse will be the same as those developed for cocaine. NERVOUS SYSTEM TOXICITY

To date, most of our infonnation on methamphetamine neurotoxicity has been obtained from animal studies. Methamphetamine CNS toxicity is produced by one of two mechanisms: stress on the vasculature and a direct toxic effect on neurons. Long term toxicity to the central nervous system may occur via hemorrhagic or ischemic strokes. Such lesions can be seen USing high technology neuroimaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRJ). The direct toxic effects on neurons must meet two criteria: chemical (alterations in the transmitter function of a neuron) and anatomical. Thus, if methamphetamine damages a serotonin or a dopamine neuron then the typical intracellular contents of that particular neuron might be expected to be reduced on a long-term basis; this reaction should also be visible as structural damage. Methamphetamine produces a dose-related depletion of dopamine and serotonin levels that is evident as long as 2 weeks after the drug is discontinued nus profile suggests that this is long term toxicity and not due to the acute pharmacologic effects of dopamine release that are caused by the drug, as has been ·previously discussed. In addition, methamphetamine not only depletes dopamine and serotonin, but also their unique biosynthetic enzymes, tyrosine hydroxylase and tryptophan hydroxylase. It follows that the major metabolites of these transmitters may also be depleted. In addition, the density or the number of transporters (uptake sites) located on the nerve endings of dopamine and serotonin neurons may also be reduced.

- 1I2 A.nnex 7

•

These biochemicaVneurochemical deficits within the dopamine and serotonin systems have been verified via anatomic or structural measures. The substantia nigra, located in the brainstem just above where the spinal cord attaches to the brain, contains cell bodies that project through the base of the brain via a group of nerve fibers called the medial forebrain bundle. They tenninate in the center of the brain in an area called the striatwn which serves as a command center for incoming and outgoing information. In rats, two weeks after dosing with methamphetamine the once profuse innervation from the substantia nigra to the striatum is reduced to a smattering of fibers. Similar fiber loss is evident in serotonin innervated brain regions. Thus, methamphetamine can damage both axons and axon terminals. This effect is not limited to rodents; it occurs in primates as welL. The available data in animals suggests that the cell bodies are actually spared, and it is not known if this damage to the fibers is a long tenn or pennanenteffecL . To swnmariz.e the animal studies, both biochemical and anatomical data demonstrate that methamphetamine damages dopamine and serotonin systems. Methamphetamine toxicity occurs after repeated high dose administration and it is selective for certain neuronal systems. Swprisingly, it spares the noradrenergic system. The damaging effects of methamphetamine are not restricted to rats; they occur in mice, guinea pigs, cats, rhesus monkeys and baboons. However, one interesting difference is that methamphetamine toxicity in mice affects dopaminergic systems, but leaves the serotonergic system intact. Finally, methamphetamine toxicity is highly dependent on: dose, route of administration, frequency with which the drug is given, the ambient temperature, and species. As there is a paucity of human data, Positron Emission Tomography (PET) imaging studies in baboons are being conducted in an effort to develop and validate a method for evaluating human methamphetamine users. Using specially labeled cocaine analogues, the dopamine terminals in the striatum of a baboon can be easily visualized. A profound reduction in the density of dopamine terminals (transporters) in the striatum occurs after a one day treatment with 8 mgllcgfday of methamphetamine. This reduced number of dopamine transporters corresponds well with the reduction in dopamine measured directly in the striatum of the same animal. Loss of serotonin, particularly in the cerebral cortex, is quite severe and could be better visualized with more specific CQmpounds (ligands) that attach to serotonin transporter sites. Such compounds are currently being developed and are in the early stages of testing. Future studies will involve imaging both dopamine and serotonin transporters in individuals previously exposed to high doses of methamphetamine, as well as studying individuals in the drug-free condition. Because these chemical probes image the transporter, inferences about whether or not there are long-tenn changes following methamphetamine exposure can be made.

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While the demonstration of neurooal toxicity in specific brain regions is of great academic importance, the functional consequences of such damage need to be kept in ~rspective. Examples of extreme depletion of dopamine (on the order of 9095 percent) .include Parkinson's Disease. The clinical consequences of this disease are welllcnown, but it is clear that greater than 80 percent depletion of dopamine levels is needed to result in such a severe clinical condition. It is currently not known if dopamine neurons are damaged in chronic methamphetamine users. If the mechanisms of neurotoxicity from methamphetamine and Parkinson's Disease prove to be the same, our understanding of disorders such as Parkinso!\'s Disease and the basic neurobiology of many systems in brain may improve. It is also possible thai methamphetamine-induced deficits in dopamine and serotonin may not result in any obvious changes in the individual's brain function or behavior. In fact. the animals that receive high doses of methamphetamine do not exhibit any obvious functional consequences after detoxification is complete. However, such neurotoxicity at a relatively early age may not be reversible and thus may predispose to development of movement disorders and other problemS in later life. In summary, although there is good evidence in the animal literature demonstrating neuronal toxicity, the issue of whether methamphetamine damages dopamine or serotonin neurons in humans remains very much an unanswered question. Because of the inherent dangers associated with this type of research, the information will have to come from postmortem studies, advanced neuroimaging studies, and the development of new strategies for detecting toxicity-possibly tluough the use of operant behavioral pharmacology. Finally, the degree of neurotoxicity must be placed in perspective and the functional consequences require further scrutiny to determine the impact of chronic methamphetamine abuse on brain function. OTHER ORGAN TOXICITY

Apart from the nervous system, methamphetamine affects mUltiple other organ systems including the heart, lungs, kidneys and liver. Methamphetamine-induced cardiotoxicity is sometimes manifested as arrhythmic sudden death. In such cases, subendocardial hemorrhages arc often present. Considering the large number of individuals who use and abuse methamphetamine, the rate of methamphetamineinduced sudden death is remarkably low, Possibly this is due to the rapid development of tolerance. which offers some protection against cardiotoxicity, or to the predominantly oral route of administration. which results in a more gradual rise and lower peak blood levels. Recent increases in the number of reported methamphetamine-related sudden deaths with the shift to smoking and intravenous abuse suggest that rapid delivery of a bolus drug dose is more likely to precipitate a severe reaction that can lead to death.

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A less conunon consequence of methamphetamine cardiotoxicity is myocardial infarction, which has been reported primarily after "snorting" or intravenous injection of methamphetamine, or after oral use of amphetamine analogues, such as fenfluramine and pseudoephedrine. Although the underlying mechanism for methamphetamine-related myocardial infarction is not yet know, coronary spasm appears to be a significant contributing factor. Cardiomyopathy, characterized by acute onset of heart failure, can also result from methamphetamine-related cardiotoxicity. Because most of these patients recover with treatment, the underlying morphologic changes have not been well described. The cardiotoxicity of methamphetamine, like that of cocaine, is related to catechol excess. However, the cardiotoxic effects of methamphetamine are more profound because, unlike cocaine which remains extracellular, methamphetamine is transported into the presynaptic terminal where it inteIferes with further storage of catecholamines and inhibits monoamine oxidase, resulting, in tum, in further elevation of catecholarnines, which are cardiotoxic. Pulmonary edema can accompany cases of acute fatality from methamphetamine abuse. This finding is not unique to methamphetamine abuse and is probably a reaction to adulterants present in illicit drugs. The more serious pulmonary complications of methamphetamine abuse arise insidiously from thrombosis of the small pulmonary vessels with a gradual reduction of the pulmonary vascular bed and increase in vascular resistance, leading in time to chronic obstructive lung disease from pulmonary fibrosis and granuloma formation. Rhabdomyolysis which can also cause a reversible form of renal failure among cocaine abusers, has also been attributed to methamphetamine abuse. Renal toxicity can occur directly from release of myoglobin and degradation products, producing tubular obstruction, or indirectly from hypotension and ischemia. While the exact mechanism by which methamphetamine causes this syndrome is not known, hyperthennia and free radical formation are believed to be significant contributors. Hepatic damage, while rare, has been reported in association with two amphetamine analogues, pemoline and methylphenidate (RitalinTM) used therapeutically and illicitly. The condition liJcely occW'S as a result of idiosyncratic reactions leading to liver cell necrosis. Methamphetamine-induced hepatotoxicity has also been attributed to lead poisoning from the by products of poorly controlled drug manufacturing. In summary, methamphetamine affects a number of organ systems, however, organ toxicity, with its inherent potential for medical complications, is apparently not

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conunon enough to deter users. The recent increase in methamphetamine-related deaths may be related to changes in routes of administration. to the increased potency of the drug, or to the increased number of methamphetamine abusers. As with many other drugs of abuse, some of the medical complications associated with methamphetamine appear to develop over time and may not be readily apparent to the user. ToXIC PSYCHOSIS

The incidence apd severity of methamphetamine-induced side effects and toxic reactions is dose-related. As the dose is increased the profile of side effects progresses from mild excitement to nervousness, irritability, anxiety, tremors, aggressiveness, paranoia and, often. auditory hallucinations. The resultant psychotic reaction is indistinguishable from scbiZDphrcnia except on some subtle dimensions. There is a paucity. of information on drug-induced psychosis. in part because it can no longer ethically be induced in the laboratory setting. Thus. amphetamine psychosis can be studied only on an opportunistic basis when affected individuals seek treatment At such times, treatment concerns must prevail and there is little time to devote to exploring the underlying progression of the disorder. In addition, little is known about the withdrawal syndrome after chronic, high dose methamphetamine use under conditions permitting careful observation. Older studies report that major depression frequently appears after multiple doses of methamphetamine. Animal models have been used to explore the behavioral effects of chronic high dose methamphetamine exposure, and there is also an abundance of clinical information derived from case reports. Such case reports have obvious weaknesses, the most obvious are the premorbid psychiatric status is generally not known nor is the actual content of the drug consumed and its percentage of adulterants. Doses and time course of use are also not usually known with precision. The few exPerimentally-induced cases, from studies conducted in the 1970s, also have their strengths and weaknesses. Thdr major strength is that the premorbid psychiatric status of subjects participating in the experiments was known. Their main weakness is that., for ethical reasons, these studies were only done with drug abusers. Thus, issues of tolerance and sensitization were not studied empirically although the subjects had probably developed some degree of both. Results from these limited experimental studies have led to some understanding of the dose/time function. The administration of very low oral doses over time failed to precipitate any reaction until a cumulative dose of 50 mg bad been attained at which time the .subjects became depressed., withdrawn and developed a negative anitude. Accumulation after intravenous dosing resulted in a somewhat different pattern in that there was no change in affect, only a rapid progression to

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Annex 7 psychotic reactioDS. The administration of an intermediate dose results in both patterns. Thus, the way in which the drug is administered can determine its effects onaffed CoMell's now classic 1958 description of amphetamine psychosis symptomatology observed in users who self-administered amphetamines is still apl A paranoid psychosis ensues characterized by ideas of reference, delusions of persecution, or auditory or visual hallucinations in a setting of clear consciousness. The intensity of high is usually severe and is typically seen only in chronic abusers after a dose administration. The incidence of thought disorder is controversial in amphetamine psychosis. but if thought disorder is present, it is usually very mild. The symptoms usually abate within a week, although there are exceptions.

r:un

The results of the two largest case report studies (42 and 94 cases, respectively) indicate a remarkable degree of agreement Paranoid delusions occur in well over 80 percent of the cases, hallucinations appeared in 60 - 70 percent .of the cases and disorientation was an uncommon feature in each independent study. Thus, the profile of amphetamine psychosis (in late stages) is well delineated and usually results in a fairly distinct syndrome, although there is still considerable individual variability with respect to the specific manifestations of the disorder. This may have to do with the. potent lability of affect that occurs and because the amphetamine user actively interacts with hislher environment Differences in that environment may precipitate these modified reactive states and behaviors. There is considerable animal evidence suggesting a connection between sensitization and psychosis, and sensitization has been observed in every marrunalian species that has been studied. The clinical data on the role of sensitization is much weaker for amphetamine, but the evidence for cocaine is strong. Sensitization manifests itself with the appearance of psychotic reactions after a shorter "run" of drug use. Frequently, paranoia does not begin during the flISt few months of high dose i.v. use, but as the individual continues to use, paranoid symptoms may begin sooner after the re-initiation of use. Once paranoia has occwred, it will readily return even after a long period of absence often at reportedly low doses. This profile is very consistent with the animal descriptions of sensitization. The weakness of these c~inica1 data is that it is not easy to detennine if the individual took higher doses over time. Although the development of psychosis may occur at some "threshold" dose, it is nearly impossible to verify this in the clinical case reports. The best clinical example of sensitization is an older "induced" study in which chronic users were given intravenous doses of methamphetamine. Nearly half of these subjects became psychotic at less than their usual dose, but more than half took more than their usual dose. Another study of abstinent methamphetamine addicts who relapsed and imrnediatdy became psychotic is often cited as an example of sensitization. Ten of the 16

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subjects had taken their usual dose (no sensitization) but 4 of the subjects became psychotic after taking only 20-50 percent of their usual dose (sensitization). Such clinical case reports cannot provide definitive proof that toxic psychosis is related to sensitization because the dose and content of the illicit material is generally unknown, and the rate of prior episodes of psychosis is extremely difficult to document The fact that the incidence of psychosis among psychostimulant users is much higher than in the general population is circumstantial evidence that sensitization does occur in spite of the weaknesses in these studies. The percent of subjects who become psychotic after methamphetamine is quite consistent across studies as is the percentage experiencing either more paranoia over time or developing paranoia earlier in the drug use run. The issue of whether methamphetamine psychosis persists when the drug is no longer present in the body has been debated as well. Many studies are flawed because urine drug screens were not obtained and so the possibility that the patient was still taking the drug or it was still in the body can not be ruled out One well controlled hospital study found that out of 104 cases of psychosis, 27 remained psychotic for over a month. All the patients had negative urine screens suggesting that persistent psychosis may be a complication in some individuals after methamphetamine abuse. In summary, there is no doubt that a psychotic reaction can develop in individuals who use methamphetamine. There remain some unanswered questions about whether drug-induced psychosis is a psychotic reaction or "releases" a latent psychosis. However, prospective studies done in the 1970s found that after exposure to the drug more than 80 percent of subjects without pre-existing psychosis developed psychotic symptoms. It appears, therefore, that having a latent psychosis is not necessary in order to develop these symptoms. Other remaining questions are whether some minimum dose and some minimum duration of use are required to precipitate a psychosis. The 50 mg dose appears to be around the threshold required to precipitate psychotic reactions in sensitive individuals. The evidence is overwhelming that toxic psychosis develops over time and that the rare cases of psychotic reactions after a single dose may have occurred in individuals already predisposed to such a reaction. However, the development of sensitization predicts that psychotic reactions would occur very soon after drug use begins, but in general, this does not occur with the very first exposure to a psychostimulant. Finally, there is still no good model to predict who will develop toxic psychosis. DEVELOPMENTAL TOXICITY

NIDA recently published a pregnancy and health survey that evaluated the incidence of illicit drug use during pregnancy and found that about 5.5 percent of pregnant women across the country were using an illicit drug. Unfortunately, the

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report was not divided by drug class and there was no indication of the prevalence of methamphetamine abuse during pregnancy. A series of studies that evaluated the effects of amphetamine use during pregnancy (particularly using prevalence . strategies) found that amphetamine use was most common on the west coast. particularly in California and Oregon. However, in 1990, the prevalence of methamphetamine use among pregnant women studied was zero. A 1995 study included a stratified sample of pregnant Iowa women studied in 7 substance abuse health planning regions. These women who were receiving prenatal care from both private and public centers received urine screens at various times during their pregnancy. The rate of positive urine fmdings for amphetamines in these women was 0.27 percent compared to 0.28 percent for cocaine and 3.0 percent for marihuana. These figures are consistent with the cocaine and marihuana national data reported in the NIDA study cited above. Analysis of urban and rural samples revealed that the urban areas had higher rates of cocaine use while rural areas had higher rates of amphetamine use. Also, every woman who had a positive urine test for amphetamine also had a positive urine for either marihuana or cocaine; there were no women who used only amphetamines. The literarure on amphetamine use in pregnancy comes primarily from three different research groups in San Diego, Dallas, and Sweden. The frequency of placental abruptions, premature birth., low birth weight, smaU head circumference, cerebral infarctions, and congenital anomalies after maternal amphetamine use was similar among the populations studied. They were virtually identical to those that have been reported to occur after cocaine use. There are two possible mechanisms by which cocaine or amphetamine may affect pregnancy outcome. The first is vascular, which leads to reduced blood flow to the fetus. The second is a direct toxic effect on the developing fetal brain. The impact of reduced blood flow in a developing fetus can be manifested by significant limb reduction deformities. Cocaine and methamphetamine rapidly cross the placenta where they can induce vasoconstriction in the fetus. Because of the great difference in weight between the mother and child, the dose that the fetus receives is significantly greater. Thus, limb reductions and myelomeningoceles can occur secondary to pronounced and prolonged ischemia. Reduced blood flow may also be implicated in the observed incidence of low birth weight among cocaine and methamphetamin~xposed fetuses. The average birth weight for the amphetamine-exposed children is about 300 gm lower than controls. However, just as has been observed in cocaine-exposed children, the single most common drug leading to low birth weight is not cocaine or amphetamine, but tobacco. The direct effects of psychostimulants on the developing brain have been studied most extensively during long term outcome studies. The Swedish group is now in

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its 16th year of prospective follow ups of a group of children whose mothers used amphetamines during pregnancy. Although lacking a control group, children exposed prenatally to amphetamines scored in the normal range on standardized IQ tests, but by age 7 or 8 they began to have higher levels of aggressive behavior, more problems with adjusting to environments and higher rates of school failure. Unfortunately, fetal alcohol exposed children were not separated from the group, nor were there any controls for the frequencies of the observed behaviors in the parents of these children, again emphasizing the difficulties of conducting this type of research. Becallse of the lack of data with methamphetamine, some of the potential consequences of its use during pregnancy must be surmised from the cocaine literature. Even this is flawed because there are no "pure" cocaine users-virtually all are polydrug abusers, a factor that complicates the interpretation of the developmental data. When measuring long-term growth, IQ (cognitive development), home environment and behavior, a number of different instnunents must be used. The Home Screening Questionnaire provides a measure of developmental support within the home and correlates with whether the mother is continuing to use drugs after pregnancy. Other indices of drug effects include biological measurements such as birth weight and head growth after birth and child behavior such as externalization (hyperactivity and aggressiveness) and internalization (distractibility and thought disorders). For comparison purposes, it is very important to obtain and follow an appropriate control group that is selected from a similar social, economic and geographic area.. In studies conducted in Chicago, the typical pattern of drug use among the study populations was the combined use of cocaine, alcohol, marihuana and tobacco. There is a significant impact of prenatal drug exposure on IQ at 3 years of age. However, this impact is ameliorated by a favorable home environment which also affects IQ. Because of the nature of the polydrug abusing population, the impact of cocaine, amphetamine or alcohol use cannot be separated. The worse combination is alcohol and cocaine. Prenatal exposure and a small head size coupled. with a poor home environment, especially if the mother continues to use drugs, together with high levels of distractibility are most predictive of a low lQ a( 3 years of age. This same model has been applied to the same children who are now six years old. Anempts to attribute variations in IQ to prenatal drug exposure alone fail because home environment is the single most important factor predicting IQ. This is indicated by studies in which prenatally exposed infants were adopted at 2 to 3 days of age and tested at ages three and six. A recent cohort of such children at 6 years of age had a mean lQ of 115 as compared to an IQ of 89 in the prenatally exposed group who were not adopted but raised by their birth mothers.

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In order to fully evaluate the multiple factors that can affect long term outcome of prenatally exposed children, a broad range of measures is necessary. Using the Achenbach Child Behavior Checklist and teacher report fonn and a continuous perfonnance task collectively, the srudy in Chicago demonstrated that, regardless of environment, children prenatally exposed to cocaine (data on amphetamines are Wlavailable) have increased rates of impulsive and aggressive behavior, thought disorders (the mind wandering) and difficulty in maintaining attention at age six. The children's behavior can be divided it into two categories: 1) internalizing and 2) externalizing behaviors. ContraIy to popular belief, the prenatally exposed children have higher rates of internalizing behaviors manifested by difficulty in concentrating, thought disorders and higher levels of frustration which then spill over and are often manifested as externalizing behaviors. Exposure to methamphetamine via side stream smoke inhalation can result in detectable levels in the child's urine. Also, as a result of the emergence of small rural labs malcing illegal methamphetamine, the incidence of children appearing in emergency rooms with seizures, tachycardia, cardiac arrhythmias, and other medical complications resulting from drug exposure may increase, especially in areas that may not be adequately equipped to handle such emergencies. In summary, to evaluate possible effects of maternal drug abuse on human development, a more global view of drug abuse is needed. Factors which are sometimes viewed as confounding by the researcher, such as the mother's use of other drugs, her nutritional status, socioeconomic level and other environmental variables, must all be considered relevant in dealing with the realities of drug abuse. Because of these complexities, it is unlikely that any adverse effect can be attributed to a single drug. Moreover, it may not be cost effective or realistic to try to identify the effects of methamphetamine abuse alone since it is so rarely the only factor adversely affecting the infant or child's development. Fortunately, children have remarkable resiliency and capabilities for recovery. If a behavioral or developmental problem is detected early and efforts are made to provide maternal treatment and to foster parenting skills, or the child is removed from the environment, the prospects for a more Dormal devciopmental pathway are often good. TREATMENT OUTCOME IN COMMUNITY PROGRAMS

The concept of interlocking ecologie! or networks helps put treatment outcome data in perspective. Treatment does not occur in a vacuum, but in dynamic interaction with other relevant factors. These include: user characteristics, support networks, the role of law enforcement agencies, consequences of use, other social services available, as well as the treatment system itself. All of these have

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different boundaries, levels of penneation, and interaction with the other networks. There is also a link between epidemiology and treatment that results in three categories for classifying drug ~: 1. Casual users (usually identified in the National Household Survey and other broad population studies) do not, as a rule, need treatment 2. Currently, high severity users such as the convicted criminals. homeless and mentally ill generally do not get treatment either because they are either in prison, unable to negotiate access to the resources or they are prematurely released because the treatment seivice cannot meet their complex needs. 3. Moderately severe cases constitute the majority oftbose who currently receive treatment However, not all of those assigned to treatment programs may actually need treatment (some casual users, as well as persons more seriously involved with drugs, are directed to such programs simply because of having been arrested for drug possession). Because California is one of the few states in which there is a widespread regional epidemic of methamphetamine use, the California Alcohol and Drug (CAD) Data System provides one of the most comprehensive sources of information on methamphetamine treatment outcome. Among arrestees identified in the California DUF project, most users, regardless of their primary drug of choice, have had no prior treatment Of the treatments available, the most commonly received was pharmacotherapy which was most common for heroin and speedball abuse (simultaneous use of heroin and a stimulant drug). In general, it is not easy to get into treatment. One must have a need for treatment, and frequently the individual does not recognize herlhis own need. More commonly, the courts or the individual's family wil.1 recognize the need and strongly urge or judicially coerce the individual into treatment. Acknowledging a need for treatment, gaining access to a program and getting into it are all major obstacles that drug users have to overcome. A biased and selective sample of users needing treatment eventually gets into treatment and treatment attrition is common. As a general rule for all substance abuse treatment, if short-term treatment is delivered, the individual experiences good short-term and long-term outcomes, but improved functioning is most likely when the client remains in treatment for longer periods. Excluding clients who are in methadone programs or who are primarily alcohol abusers (because they skew the data), the number of drug treatment admissions for methamphetamine abuse in California from July 1, 1994 to June 30, 1995 was 22,644, accounting for a third of admissions and the most common reason for

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seeking treatment. Use of heroin/opiates and of cocaine/crack., at 18,101 and 15,981 admissions, respectively. were the next most common reasons for seeking treatment. If all secondary drug use is considered, the percentage of methamphetamine-related drug treatment admissions jumps to nearly 40 percent. Demographically, those seeking treatment for methamphetamine abuse are predominantly white (76.5%), eqUally male or female, and between 25 and 35 years old (51.5%). The distribution of admissions to treatment in California parallels trends in national epidemiology 'data in that the prevalence of methamphetamine abuse as a reason for seeking treatment in urban areas is less than that in rural counties. In large cities such as Los Angeles, methamphetamine abuse accounts for about 13 percent of admissions, but many rural counties have admission rates in the 50-80 percent range. The rates of admission with amphetamine as the major problem in these rural areas even exceed the 4S percent rates for methamphetamine treatment admissions in San Diego. An interesting pattern is that while the DUF data identified Sacramento as having a very large nwnber of methamphetamine users, the treatment system was not treating them. This degree of variation in California is important becaU!;e it is unclear what accounts for the large disparities within this single state. Of the available treatment programs, the outpatient drug-free type is currently the most popular, followed by residential non-detoxification, residential detoxification, and day care treatment. In California, hospital inpatient treatment is virtually nonexistent The mean length of stay in each of the above programs differed somewhat by the substance used, but in general, methamphetamine users were similar to other primary drug users. Compared to those who abuse only opiates, they stayed a little longer in outpatient programs. The higher incidence of day treatment is likely due to the high proportion of women because California has a system of day care treatment programs for women. The CALDAT A study was commissioned by the State Department of Alcohol and Drug Programs and collected field data during 1991-1992. The intake characteristics of this sample do not show the same proportion of women as the CAD data. The percentage of whites is a little lower and the percentage of Hispanics higher than in other databases. The 25-35 year age group still predominates and they are a relatively well educated group. Other characteristics of methamphetamine abusers who received treatment in this study include a high frequency of having been arrested (83 percent), incarcerated (38 percent) and having shared needles (57 percent). Methamphetamine users did not differ from other drug users with respect to their reasons for entering treatment. Among methamphetamine users, personal motivation was highest at 69 percent, followed by pressure from the criminal justice system and from a relationship at 31 and 22

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percent., respectively. Reasons for leaving treatment were not significantly different from other drug abusers; having "completed treatment" was the most frequent reason at 41 percent, followed by unsuccessful treatment at 20 percent. Many different treatment services were actually received, including education classes, residential detoxification, ambulatory detoxification, activity groups, 12 step activities, day treatment, case management and sober living. The highest completion rate was observed in the 12 step program in which 53 percent were classified as completers. The services received by methamphetamine users are characteristic of the treatment modalities they are able to access. Reported reductions in drug consumption after treatment across all drug classes was about the same for all treatment groups. Thus, based on the self-reports used by CALDAT A, methamphetamine users are neither more nor less successful than heroin, crack/cocaine, speedball or marihuana users in quitting drug use. There continues to be slightly higher rates of polydrug abuse among the In general, the data on methamphetamine group even after treatment methamphetamine abusers from Los Angeles County reflect statewide data with respect to ethnic profile, age range, sex distribution, education level, program type, completion rates. arrest rates. As the types of treatment available in the state are delivered at many different

sites, direct comparisons to determine the relative success of methamphetamine abusers compared to other types of drug abusers is not possible using the CALDA T A data set For such comparisons to be meaningful, a controlled study performed at the same site is needed to directly compare the outcomes of groups of cocaine and methamphetamine dependent patients. The Matrix program treatment protocol was developed with NIDA funding and uses a combination of group and individual methods that draw from the eognitive-behavioralliterature. Relapse prevention and psychoeducation are presented via a manualized method and the treatment is delivered in a highly sttuctured manner. Three different populations of methamphetamine and cocaine abusers were studied: those entering an outpatient treatment program, those entering an outpatient demonstration program, and non treatment· and treatment·seeking gaylbisexual men. The demographi~ of the outpatient treatment population mirror the state popuhtions and except for ethnic distribution there were no large differences between the cocaine- and methamphetamine-abusing groups. The routes of administration did differ in that methamphetamine users preferred the intranasal route while cocaine abusers preferred smoking, However, methamphetamine users tended to use multiple routes of administration because the drug causes significant irritation to the nasal mucosa or lungs. Methamphetamine is typically used on a ~egular daily basis while crack smokers tend to ''binge" on large amounts, mterspersed with periods of non·use. Methamphetamine users integrate their drug

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use into many of their daily activities. In contrast. cocaine use tends to be limited to binges or specific situations. Compared to the crack users, there appears to be less alcohol use among methamphetamine users although there is still a significant amount of alcohol use. However, there is a high rate of marihuana use among methamphetamine users. Methamphetarr.ine users spend much less on drugs than cocaine users primarily because methamphetamine is much less expensive. The incidence of side effects such as chest pain., seizures, loss of consciousness, and suicidal thoughts are approximately equal in the two groups. Some notable differences include a higher incidence of headaches, severe depression and hallucinations among methamphetamine users. The incidence of paranoia was similar for both groups. The conditions of treatment delivery and patient compliance were exactly the same for both groups, including treatment dmation. number of sessions attended, treatment hours, urinalyses collected and the percentage of clean urine samples. The discharge status was also very similar for methamphetamine and cocainCi users. The treatment responses between methamphetamine and cocaine users did not differ and in the placebo controlled desipramine trial there were no statistically significantly differences for any variable. The responses on all eight Addiction Severity Index domains (medical, employment, alcohol, drug, family, social, legal and psychiatric) were similar for cocaine and methamphetamine users. A non-treatment-seeking sample was described that included 1,400 individuals randomly interviewed on the street by a Street Outreach Worker in Hollywood. Of the gay and bisexual male injection drug users, 87 percent reported using methamphetamine in the last 30 days. TIlls frequency is higher than any other drug reported. Of the gay and bisexual male injection methamphetamine users, 54 percent reported sharing needles in the last 30 days, 74 percent reported. providing sex for money or drugs. Of the gay and bisexual male non-IOU methamphetamine users, 58 percent reported providing sex for money or drugs. In this sample of 1,400 subjects, the methamphetamine users were less educated, more likely to be unemployed, bad begun drug use at an earlier age, bad more daily use patterns, spent less time abstinent, spent less money on drugs, had more . drug using friends, more depression, headaches and hallucinations and needed more medical treatment than cocaine abusers. In spite of these numerous minor differences in demographics, the participation in treatment was similar among a group of methamphetamine and cocaine abusers and the outcome was the same. Nevertheless, this data from a controlled treatment study might be interpreted to mean that methamphetamine abusers are a sicker group but have an equally good response to treatment as their cocaine-dependent counterparts.

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Annex 7 Washington State has witnessed a six-fold increase in methamphetamine admissions to treatment programs since 1992. Of these, 38 percent inject methamphetamine; other characteristics such as being primarily Caucasian and under the age of 25 parallel those of other regions in the United States. In this State, there is a large gaylbisexual population with a high prevalence of HIV infection. Perhaps as a result, the flI"St needle exchange program. targeted towards methamphetamine users was established in King County, Seattle. The results of treatment studies in such well circumscribed populations are needed to understand the unique dynamics of methamphetamine abuse and how it spreads throughout a community. In summary, a comprehensive evaluation of the statewide treatment services provided by California revealed that methamphetamine users do not differ from other drug abusing populations with respect to treatment types and outcome. Some differences in ethnic distribution. age and male/female ratios were evident, primarily between opiate and crack/cocaine users. Statewide, the 12 step program had the greatest success among methamphetamine users, but activity groups were a close second. Ambulatory detoxification was least effective. In a NIDAsupported program (Matrix) that used a manualized treatment protocol, methamphetamine users did as well as cocaine users with respect to treatment outcome. Thus the symposium presenters concluded that there is no reason to believe that special programs need to be developed to treat methamphetamine abusers. MEDICATION DEVELOPMENT EFFORTS AT NIDA

It is well accepted that no single program is effective for treating all drug abusers. The current strategy is to have a variety of tools at one's disposal to offer to a particular patient in order to optimize treatment to meet his or her particular needs. Phannacotherapy represents a major effort in this area. CUITently, there are no programs developing medications to treat methamphetamine abusers per SI! although NIDA currently funds individual grants for this pwpose. However, it remains to be seen whether a special program is needed or, alternatively, whether the existing cocaine medication program at NIDA can meet the needs of methamphetamine abusers in treatment. The budget for the NIDA Medications Development Program is currently S58 million a year. The division dispenses $20 million dollars of that to clinical studies and $20 million to preclinical (animal) studies; the money is split about evenly between grants and contracts. In addition to fonnal drug testing, NIDA supports chemists who are engaged in structureactivity studies and synthesizing compounds for subsequent testing. The scope of the medication development program ranges from in vitro assays of promising compounds to multicentered clinical trials. The screening program for

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cocaine medications begins with very basic phannacologica1 testing and progresses to behavioral tests, motor activity. drug discrimination and then self-administration studies. The strategy is currently aimed at identifying two types of medications: cocaine-like agents and cocaine antagonists. As there are two main families of dopamine receptors (D, and 0/0/0.), an important aspect of this program is that the antagonists are not limited to receptor antagonists, but include any compound that can reverse the physiological andlor behavioral effects of cocaine. In addition, the rationale for studying a particular compound can be receptor-based or what is tenned "rationale of CNS activity" based. The latter refers to pursuits based on knowledge of a drug's effects on a particular area of the brain known to be affected by cocaine. The next step in the screening process is to test whether the new drug increases locomotor activity and whether the magnitude of effect is greater or less than that of cocaine. If s drug does not have locomotor stimulating activity, then it is tested for its ability to block cocaine's locomotor stimulating activity. Behavioral testing follows using a drug discrimination procedure. The drug is tested to determine if it blocks cocaine discrimination. Finally, the drug is tested to see if it is selfadministered or if it blocks cocaine self-administration in rats. This strategy of evaluating antagonism and substitution serves as the basis for exploring new medications to treat cocaine dependence. The second major principle that is followed relates to detecting specificity of effect. Ideally, a drug that reduces cocaine self-administration should not also reduce all other behaviors. Conversely. a medication that reduces self-administration of a nwnber of different drugs belonging to different pharmacologic classes (i.e., lacks specificity) would be of tremendous value in treating polydrug abuse. Other strategies currently being pursued include evaluating compounds that bind to the dopamine transporter and detennining whether this results in an increase in dopamine transmission. Immunologic approaches are also a high priority with an emphasis on developing antibodies to cocaine in order to inactivate it soon after administration. Other approaches might be to increase the amount of catabolic enzymes responsible for metabolizing cocaine. Because of the many similarities between cocaine's and methamphetamine's effects, many of the above strategies could be easily applied to develop medications for methamphetamine abuse. However, some of the techniques, especially those that depend on structure-activity relationships and immunology, will Dot work directly as the physical properties of the two drugs are too different.

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Annex 7 GArs JN OUR KNOWLEDGE ABOUT METHAMPHETAMINE

The consensus of the three work groups identified the following key gaps in our knowledge about the basic pbannacology, toxicity and treatment of methamphetamine abuse: Basic Phannacology: 1. What n~obiologica1 and' behavioral mechanisms of action of methamphetamine can be exploited to develop a more effective treatment program? To what extent can cocaine-related basic research programs be used to study methampbetamine-related treatments? . Using laboratory models, to what degree does acute and chronic methamphetamine increase aggressive, impulsive, risk-taking, hyperactivity, hyper-reactive and hypersexual behaviors? How does sensitization affect the development of dependence on methamphetamine? Do sensitization and dependence develop at the same rate? What are the biological and behavioral mechanisms of methamphetamine that determine an individual's vulnerability to toxicity and dependence?

'.

2.

3.

4.

5. 6.

Toxic Complications:

1. .

What pharmacological and environmental conditions predict the onset and the severity of toxic psychosis? What role does sensitization play in the development of toxic psychosis?

2. 3.

Does CNS toxicity occur in humans? The use of post-mortem studies and PET scans may be useful to more fully understand the real clinical consequences of CNS toxicity. In addition to methamphetamine use, what is the role of environment and other drug use on the developing fetus?

4.

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5.

To what extent does vasculitis and pulmonary and hypertension contribute to methamphetamine's toxic profile? What is the natural history of withdrawal from chronic methamphetamine use?

6.

T reatmentlPrevention: 1. What are the specific psychosocial and pharmacotherapy treatment strategies that are effective in addressing the outreach, treatment engagement, and treatment retention and relapse prevention issues of methamphetamine users? Can standard chemical dependency treatment programs (and phannacotherapies) be used to treat methamphetamine abusers. or do the programs need to be modified to address special needs/conditions? What is the impact of alternative media and community level interventions and what are the mechanisms by which they act (using randomized field trials)? Which foons of personal and social harm are associated with methamphetamine abuse and how can Strategies to eliminate them be identified (i.e., to reduce their social cost)? To what extent can the study of island community outbreaks of methamphetamine abuse be applied to study the spread of the problem through larger populations? To what extent do the outbreaks of methamphetamine abuse in Japan and Sweden resemble those here in the U.S. and can we apply the knowledge gained from their experience to help prevent/treat the problem here? What role does methamphetamine play in the transmission of HlV?

2.

3.

4.

5.

6.

7.

RECOMMENDATIONS

1.

Evaluate current research/contract programs at NIDA and detennine how the above gaps can be filled by supplementing existing research endeavors rather than relying on new initiatives because the research grant avenue is too slow to respond to rapid developments of this nature.

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2.

Encourage comparative studies between cocaine and methamphetamine with the aim of detennining if there are enough similarities to warrant using treatment strategies that have been developed for cocaine to combat methamphetamine. Place an emphasis on studying the methods and rate at which methamphetamine abuse spreads through a micropopulation. 1b.is information could very well hold the key for curtailing the spread through larger populations. Develop a method of communicating new information from the researchers to the clinicians who are treating the methamphetamine abusers. Standard methods of communication via scientific publications are too slow to keep up with rapidly emerging trends. Possible vehicles include teleconferences, cable TV stations, videotapes and technical reports.

3.

4.

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LIST OF PARTICIPANTS

Bert Angrist, M.D. New York V A Medical Center New York, NY 10010 James Anthony, Ph.D. John Hopkins University Baltimore, MD 21218

lerry Frankenheim, Ph.D. NIDA Rockville, MD 20856 Gantt Galloway. Phann. D. Summitt Medical Center Oakland, CA 94609 Janet C. Greenblatt, MP.H. SAMHSA Rockville, MD 20857 Jerome H. Jaffe, M.D. Center for Substance Abuse Treatment

Douglas Anglin. Ph.D. Director, UCLA Drug Abuse Research Center Los Angeles, CA 90024

John T.Camevale, Ph.D. Office of National Drug Control Policy Washington, D.C. 20503

Rockville, MD 20857 Mary A. Jansen, Ph.D.

Ira J. Chasnoff, M.D. NAFARE Chicago, IL 60601 Dorynne Czechowicz, M.D. NIDA Rockville, MD 20857

Center for Substance Abuse Prevention

Rockville, MD 20847 Chris-Ellyn Johanson, Ph.D. Wayne State University Detroit, MI 48207 Barbara Kittay, J.D. Department of Justice Washington, D.C.20038

Robert Denniston Center for Substance Abuse Prevention Rockville, MD 20857 Brian R. Flay, D.Phil. University of Illinois

Mark. Kleiman, MD. University of Califamia

Chicago, IL 60607

at Los Angeles Los Angeles, CA 90095

'"

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Michael Kuhar. Ph.D. Emory University Atlanta, GA 30322 Charlene Lewis, Ph.D. Center for Substance Abuse Treatment

Sally L. Satel, M.D.' 801 Pennsylvania Ave. Washington. D.C. 20004 C. Robert Schuster, Ph.D. Wayne State University Detroit, M1 43207 Lewis S. Seiden. Ph.D.

Rockville, MD 20857 Walter Ling. M.D. The Matrix Center, Inc. Los Angeles. CA 90025

University of Cbicago Chicago. IL 60637-1431 Scott Springer DBA

Scott E. Lukas. Ph.D. ADARClMcLean Hospital Belmont. MA 02178 Harry J. Matt, 1.0. Dep~entoflustice

Washington. D.C.20S37 Frank SuUivan, Ph.D.

SAMHSA Rockville, MD 20851

Washington, D.C. 20038 Richard Rawson. Ph.D. The Matrix Center, Inc. Los Angeles. CA 90025

Frank J. Vocci, Ph.D. NIDA Rockville, MD 20857 Donald Wesson. MD. Summitt Medical Center Oakland, CA 94609

Peter H. Reuter, Ph.D. University of Maryland College Park, MD 20142 George A. Ricaurte. M.D .• Ph.D. Iohn Hopkins Bayview Medical Center

Baltimore. MD 21224

ATS PHARMACOLOGY, TOXICOLOGY, PATTERNS I(DF USE, CONSEQUENCES AND RESPONSES DR ROBERT ALI DRUG & ALCOHOL SERVICES COUNCIL 161 Greenhill Road Parksidc , South Austral ia 5063 rali@medicinc.adclaidc.cdll.all

.... ....

.....

~ >< 00 ~

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ATS PHARMACOLOGY, TOXICOLOGY, PATTERNS F USE, CONSEQUENCES AND RESPONSES DR ROBERT ALI DRUG & ALCOHOL SERVICES COUNCIL 161 Greenhill Road Parkside. South Australia 5063 rali@medicine.adelaide.edu.au

AMPHETAA11NES ~ Phenylisopropanolamine • large number of psychoactive agents • effect depends on • location and composition of substituents

• effects • stimulant (e.g. MA, methylphenidate) • hallucinogen (e.g. DOM) • appetite suppressant (e.g. fenfluramine) • euphorics (mixed e.g. MDMA)

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AMPHETAMINE USE PATTERNS OF USE • • • • • Experimental Occasional (Recreational) Situational (Instrumental) Intensive (Chronic) Compulsive

-EXPERIMENTAL ADOLESCENTS, LOW DOSE, INTERMITTENT -OCCASIONAL MAJORITY, USED FOR SOCIAL INTERACTION, -SITUATIONIINSTRUMENTAL PERFORMANCE ENHANCEMENT, OR ANOREXIC PROPERTIES -INTENSIVE MAJOR PART OF THEIR LIFE OFTEN ASSOCIATED WITH INJECTING/SMOKING -COMPULSIVE RUNS AND CRASHES OFTEN ASSOCIATED WITH INJECTING/SMOKING

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AMPHETAMINE USE FREQUENCY .30% .13% .28% .29% 2 times per week or greater once per week once per month

less than once per month • mean 2-4 times per month

AMPHETAMINE USE DURA TION OF USE • Commence use in late teens • Mean duration typically 6-11 years INITIAL USE • Snort 67% • Swallow 16% • Most common initially injected drug (45%)

- 137 Annex 8

AlvfPHETAMINE USE WHO USES 1995 NDS survey Australia • Males» Females • 4th ranked ever used for non-medical purposes • 6% surveyed ever used • 19% 20-24 year old used (25% male 12%female)

.75% recreational drug users ever used • most common drug after cannabis

TYPOLOGY OF USERS EXPERIMENTERS AND RECREATIONAL • Experimenters • Ravers • Speeding drinkers • Young mothers

-

138 -

Annex 8

OLOGY OF USERS(cont) CONTROLLED AND UNCONTROLLED • careful user • modified user • poly-drug user • isolate user • criminal user • gangs • self medicators • performance enhancer

AMPHETAMINE PHARMACOLOGY

• Stimulate central and peripheral monoamine neurotransmission pleasure • Central appetite alertness sympathetic nervous system • Peripheral (fight/flight/fright) cardiovascular respiratory gastrointestinal skin

-enhance release monoamines (dopamine, serotonin, norepinephrine) -block reuptake -inhibit MAO -hallucinogens (DOM, DOB) and? fenfluramine act directly on serotonin receptor

- 139 -

Annex 8

HETAJvfINE PHARMACOLOGY (cant) • dose-response depends on • formulation, route, prior pattern of use

• typical doses • amphetamine 5-20 mg • hallucinogenic 15-25 mg • fenfluramine 60-120 mg • IvIDMA 75-175 mg

• tolerant user higher doses

·tolerant user MA 300-800 mg, MDMA 300-500mg

'HETAJvfINE PHARMACOLOGY (cant) • basic compound with high lipid solubility • easy absorption orally • first passed metabolism

• salt absorbed through nasal mucosa • easily crosses the BBB

• free base methamphetamine can be smoked

- 140 Annex 8

HETAMINE PHARMACOLOGY (cont) • metabolised in the liver • mediated by cytochrome P450 enzyme • tolerance • drug interaction effect on enzyme

• renal excretion • both unchanged substance and metabolites • excretion rate pH dependent

·N-dealkylation deamination para hydroxylation

'P450 induced by alcohol etc 'P450 inhibited by fluoxetine 'genetic variability in activity 'acidic urine increases clearance

MEDICALLY PRESCRIBED ATS ADD • methylphenidate and dexamphetamine • USA 90% world consumption • 3-5% of all children • substantial global increase in the 1990' s + 3 tonnes in 1990 to 10 tonnes in 1995 • increasing rates of diagnosis in adults

'methylphenidate minimum 10mg/day, usual20-30mg/day 'amphetamine 5-40mg/day 'second opinion to confirm diagnosis to cap use 'diversion to black and grey markets

- 141 -

Annex 8

MEDICALLY PRESCRIBED ATS ANORECTICS • phentermine and fenfluramine • no evidence of long term effectiveness • problems • over the counter sale (inspite of prescription requirement) • media publicity of efficacy • diversion • risk of primary pulmonary hypertension • linked with anabolic steroid abuse in Netherlands

AMPHETAA1INE EFFECTS PSYCHOLOGICAL LOW DOSE • Increased alertness and energy • Postpone fatigue • Euphoria

- 142 -

Annex 8

AMPHETAMINE EFFECTS PHYSIOLOGICAL LOW DOSE • Increased heart rate • Constrict blood vessels • Raise blood pressure • • • • • Dilate bronchi Increase respiration Increase muscle tension Mydriasis (pupil dilation) Raise blood sugar

AMPHETAMINE EFFECTS PHYSIOLOGICAL (cont'd) LOW DOSE • • • • • Reduce appetite Reduce blood coagulation time Lessen peristalsis of intestinal muscles Increase availability of free fatty acids Stimulate adrenal glands

- 143 -

Annex 8

ACUTE TOXICiTY • Exaggeration of pharmacological action • behavioural • Talkative and restlessness • Sense of power and superiority • Aggressiveness or hostility • • • • Confusion Paranoid Depression Hallucinations

-death rare

ACUTE TOXICITY • hypertension with possible cerebral haemorrhage • tachyarrhythmias with possible heart failure • fever, sweating with possible hyperthermia • convulsions • Accidental- 47% amphet deaths (USA) • Suicide - 13% of amphet deaths (USA) • 90% amphet deaths poly drug involved

-death rare -death has also occurred when mixed with MAOI's

- 144 -

Annex 8

CHRONIC USE • insomnia • anxiety • weight loss with poor nutrition • psychosis • dependence • animal model for neurotoxicity

-taken up into neurone and cause release of dopamine or serotonin into the cytosole

GENERAL CONSEQUENCES • route of administration • injecting .HIV • hepatitis • bacterial endocarditis

• intranasal • inhalation

.STD • social consequences

- 145 Annex 8

AMPHETAMINE USE INJECTORS (Australia) .mV<3%IDU • Hep C 90% injectors after 8 years .40-60% of amphetamine users inject .30-60% share injecting equipment • High co-existent use of alcohol

DIAGNOSIS OF INTOXICATION • Full drug history • friends/relatives often useful

• Medical history • Examination • Excited and irritable • Need to speak • ± Suspicion, aggression or psychosis • Enlarged pupils • Repetitive movements (grind teeth, choreic)

- 146 Annex 8

DIAGNOSIS OF INTOXICATION (Cont'd) • Examination (cont' d) • Pale • Sweaty • Tremor, twitching of voluntary muscles • Raised BP • Raised Heart Rate • Increased Deep Tendon Reflexes • Dry mouth • ?Track marks • ? Nasal septum damage

GENERAL MANAGEMENT OF INTOXICATION • accepting • • • • • • open non-critical allow their need to talk to be satisfied create a sense of security, confidence, support reduce environmental stimulation supportive friends/relatives may be useful helpers

- 147 -

Annex 8

GENERAL MANAGEMENT OF INTOXICATION (Cont'd) • vital signs • urinary drug screen • encourage fluids • acidification of urine not recommended • benzodiazepines • ?cooling measures

INTOXICATION complications • benzodiazepines for agitation • sodium nitroprusside or phentolamine for blood pressure • tachyarrhythmias • propranolol or verapamil supraventricular • lignocaine or bretilium ventricular + diazepam or chlorrnethiazole infusion for seizures • rapid cooling if temp > 39°C ± dantroline • haloperidol for toxic if diazepam doesn't settle psychosis • thiamine and glucose and naloxone if confused and or unconscious

- 148 Annex 8

PSYCHOSIS • Similar to paranoid schizophrenia • difficult to differentiate

• May occur after single dose • Typically-high dose, long term intravenous use • Info from friends/relatives often useful • Disturbance • thinking • mood • behaviour

- 149 -

Annex 8

PSYCHOSIS (Cont'd) • Differential Diagnosis • paranoid schizophrenia • MDP in manic phase • anxiety neurosis/phobia - with panic • other drugs • hyperthyroid crisis • phaeochromocytoma

TREATMENT APPROACHES OBJECTIVES OF TREATMENT

• • • • •

reduce dependence reduce morbidity and mortality maximise physical, mental and social abilities full social integration hazard identification and risk reduction

- 150 -

Annex 8

TREATMENT APPROACHES VENTI ON STRATEGIES • WITIIDRAWAL • • • • setting monitoring relapse prevention pharmacotherapies (REDUCE DISCOW'ORT) • benzodiazepines • dopamine agonists • antidepressants • anticonvulsants

-BENZO risk of benzodiazepine dependency. max of 2/52. no studies of efficacy. Use long acting (diazepam) for agitation, anxiety -DOPAMINE AGONISTS dopamine agonists (bromocriptine amantadine) only examined in cocaine. Mixed results on withdrawal and cravings. Dopamine precursors (tryptophan) not effective also on withdrawal and cravings. -ANTI DEPRESSANTS tricyclics not helpful in withdrawal. 8 RTC's for cocaine relapse (4 +ve 4-ve) Desipramine if any to be used. Use for agitation and sleep problems. 3-6/12 treatment if works after 4-6/52. Taper off over 2/12. SSRI's Fluoxetine the only one investigated. No benefit demonstrated. SSRI's can increase agitation. heterocyclics: Trazodone for cravings was a cocaine study. MAOI's Theoretical basis. Cocaine withdrawal study confounded by coexistent Axis1 or 2 diagnosis. -ANTICONVULSANTS Only cocaine studies on withdrawal and craving. NOTE: dopamine antagonists (haloperidol) can treat toxic psychosis BUT due to short duration better to use benzodiazepines. cease after further 2/52 beyond symptom resolution.

- 151 Annex 8

TREATMENT APPROACHES INTERVENTION STRATEGIES • BLOCKING DRUGS • lithium • dopamine antagonists • serotonin antagonists

-rationale: block euphoric effect -lithium not effective -dopamine antagonists not effective on blocking euphoria, do assist with paranoia.

? Flupentixol shows some promise. No ReT's to date -serotonin antagonists Ondansetron pretreatment didn't attenuate symptoms of use

- 152 -

Annex 8

TREATMENT APPROACHES INTERVENTION STRATEGIES • ADVERSIVE DRUGS • no clear antabuse analogue • MAOI's nearest • risk of hypertensive crisis • ? Moclobemide • more reversible and selective

TREATMENT APPROACHES INTERVENTION STRATEGIES • REPLACEMENT (principles) • cross tolerance and cross dependence with psychoactive substance causing dependence • reduces craving and suppresses withdrawal • clients can be stabilised on the substitute substance • facilitates psychosocial functioning and improves health • acceptable to clients • no long-term toxic effects • affordable and available

- 153 -

Annex 8

TREATMENT APPROACHES INTERVENTION STRATEGIES • REPLACEMENT (principles can't) It is also desirable that the substances chosen for substitute prescribing:

• doesn't grossly impair psychomotor functioning • less attractive for diversion than the psychoactive substance causing dependence • doesn't have gross short-term toxic effects.

TREATMENT APPROACHES INTERVENTION STRATEGIES • REPLACEMENT • existing treatment aimed at sedative drugs • major deterrent to seeking treatment • poor KA&S of staff about A TS • needs of clients not met

• research literature on substitution small and poor design • area of further work

-monitoring extraneous use dll isomers in urine -neurotoxicity of some ATS prevent their therapeutic use -duration of treatment not certain ?upto 14/12 -only for severe dysfunctional dependent use -?ATS psychosis an exclusion criteria -small dose oral preparation -frequency of dose administration not clear

- 154 Annex 8

TREATMENT APPROACHES INTERVENTION STRATEGIES • pharmacotherapies • ATS users with an underlying psychiatric condition • antidepressants • lithium • dysthymic or bipolar disorder • dopamine antagonists • antipsychotic effect takes weeks • flupentixol depot formulation may be useful

-self medicate affective, anxiety or personality disorder or underlying psychosis

TREATMENT APPROACHES VENTI ON STRATEGIES • NON PHARMACOLOGICAL • • • • • 28 day inpatient program therapeutic communities 12 step program peer interventions behavioural • contingency management • cue exposure • image exposure • multifaceted behavioural

-28 day not formally evaluated

-TC evaluation inadequate -12 step one study that showed equal efficacy to relapse prevention -peer intervention no formal evaluation. -behavioural interventions small studies that show promise for contingency management image exposure. Cue exposure effective for cocaine. Multifaceted superior to standard out patient

- ISS -

Annex 8

TREATMENT APPROACHES VENTI ON STRATEGIES • NON PHARMACOLOGICAL • eBl • relapse prevention • brief interventions • self help manuals

• multimodal • nontraditional • family approaches • group therapy

oRelapse prevention cocaine studies show promise for heavy users. oSelf help no studies oMultimodal noncontrolled studies have demonstrated efficacy. °Acupuncture not effective. but limited studies oON CURRENT EVIDENCE(esp HEAVY USERS) CUE EXPOSURE AND MULTIFACETED THE BEST OPTIONS. sUPERIOR TO OTHER NON PHARMACOLOGICAL OPTIONS °family approaches may show promise in the developing world. Problematic parental drug use needs to be watched. ogroup best if among peers. limited evidence of efficacy opsychodynamic controversial.

. WHO ATS MEETING Geneva, November 1996 • Prepared a "state of the art" review of nature, extent, context and consequences ofATS • Particular reference to public health, prevention, treatment and policy responses • Scope licit and illicit but not cocaine, nicotine, caffeine or herbal

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- WHO ATS MEETING Geneva, November 1996 • Topics: Epidelniology, social context, pharmacology, toxicology, health effect, social consequences , treatment approaches, prevention approaches, policy responses > ::s ~

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. WHO ATS -MEETING Geneva, November 1996 • Identify • Key issues • Gaps in Imowledge • Recommend

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• Future direction • Priority

Recommendations • • • • • Strategic respOllse Prevention responses Treatment responses Epidelniology Pharmacology & Toxicology » ;:3 ;:3 ~

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UNDCP 2nd EXPERT MEETING ATS, NOVEMBER 1996 • Economic and Social Council requested meeting to examine counter measures against illicit manufacture, trafficl(ingand use of A TS and their precursors • Report to CND (1997)

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Recommendations • Reversing the trend of amphetaminetype stilTIulant abuse becoming a part of mainstream consumer culture • The dilemma of drug-related information: freedom versus restraint; irresponsible versus responsible information

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Recommendations • Reducing economic incentives and limiting the availability of precursors for clandestine manufacture • Closing the legislative and regulatory gaps

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- 163 -

Al\!\EX

9

WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R£GIONAL DU PACIFIQUE OCCIDENTAL

WORKSHOP ON PROBLEMS RELATED TO THE USE OF AMPHETAMINE-TYPE STIMULANTS (A TS) IN THE WESTERN PACIFIC REGION (16-20 FEBRUARY 1998)

EV ALVATION QUESTIONNAIRE COMMENTS 1. 1.1 (I)

Educational gains Were the following objectives met? Reviewed epidemiological and demographic patterns and trends of A TS use and identified the range of health, social and other problems arising from ATS use in each of the participating countries. Reviewed current methods and techniques of ATS-related prevention, treatment. harm reduction and rehabilitation, with a goal of developing broad-based strategies options in accordance with contemporary best practice models, adapted within the context of the social norms, customs and culture of each participating country. Discussed and planned future collaboration among countries for the development of prevention, integrated treatment, and rehabilitation programmes in the Region. If no, please describe: • • More details and accurate programmes are needed and considered. We believe harm reduction approach is not suit for ATS. Because of serious not only individual but social problem. We believe no compromised way in ATS . 17

(2)

16

(3)

17

• 1.2 Have useful new skills or concepts been learnt at the meeting? 16

1.3 ,Can many of these skills and concepts be applied in your country?

16 N/A - 1

2. 2.1

Process and outcome Did you have acceptable opportunity to express your ideas, concerns or problems at the meeting? 16 Blank

- 164 -

Annex 9

Yes 2.2 Was there sufficient opportunity to exchange knowledge and experiences with other participants? If response to any of the above is no, give comments as appropriate:

No-

16 Blank - I

•

Although I often emphasize on social problem, or to identify the problem, not enough time allocation was made on the matter.

2.3

Were you satisfied with all working papers provided? Ifno, please explain for specific paper(s):

15 Both -

• • •

I feel more emphasis should involved in the area of "psychosis" cased by ATS a.nd social problem. I recommend if the working papers be sent out to participants much sooner so that they could be thoroughly reviewed before the workshop I think it would han been more helpful to have had draft proposals and a draft strategy plan to focus discussion. I think this would have been particularly helpful for those with limited English

2.4

Specify which of the working papers distributed for the meeting are suitable for wider distribution:

• All • Questionnaire from each country • Report of Meeting on ATS in Geneva, 12-15 November 1996 • A report on meeting on ATS in China, 25-29 Nonmber 1996 • WPRlADTIHPRlMNH(I)/98.2 to 6 • Major findings • . Final pro posals • Country reports • Amphetamine-type stimulants • Creating Healthy Cities in 21 st century • Healthy Cityllsland - too much materials given (50% of the workshop materials) 2.5 Did you have enough time to study the working papers?

9 7 Blank 1

If no, did you receive the working papers sufficiently in advance? • I did not receive all the working papers prior to departure

1

6

Blank - 10

- 165 -

Annex 9 Yes 2.6 Were methods of introduction and presentation of different topics satisfactory?

No

15 Blank 1

If no. explain your response:

• •

As mentioned, time allocation should be made to identify or analyse harm or dangerousness of ATS use rather than philosophy of drug policy The papers and presentation were most helpful and useful but in the context of a workshop to identify the regional situation, they presented conclusions rather than drawing them out from participants. As part of a training course, awareness-raising exercise they would have been ideal 17 16

2.7

Were the workshop instructors/ presenters well informed on their subjects? Was everyone made to feel comfortable and included in the workshop? Were you fully satisfied with discussions (a) at the plenary sessions?

2.8

2.9

16

(b)

at the group sessions?

15

2

Ifno. please explain:

• •

Some of the members did not have proficiency in English to really participate/share. Perhaps the requirement for English understanding should really be emphasized unless interpretation/translation is available. Given the short time and lack of clear focus as well as the limited English of some participants, these would have been improved with more time or by having more detailed/draft papers for discussion

2.10 Was there sufficient time for questions and discussion?

15 17

2

2.11 Did the presentations and discussions improve your knowledge and understanding of the topic sufficiently for you to feel that your attendance at the workshop was worthwhile from this perspective?

2.12 Are you confident that there will be worthwhile outcomes including. where relevant. benefits to your country and the Region as a whole. arising out of the discussions and conclusions of the workshop?

17

- 166 -

Annex 8 3. 3.1 Organization of the meeting Were the duration and scheduling of different activities - presentations, group and plenary discussions - satisfactory? If llQ, please describe:

Yes

No

IS

2

• • • • 3.2

The group discussions were limited time. Should extend time and discuss in more details on specific subjects and should be limited on specific topic for exchanging experiences Lack practical time Group time were generally rushed and there was not always adequate time for participants to make their \'iews Management of facilities for presentation could be improved

Do you think that all of the most appropriate peoplel professional disciplinesl representatives from the community were invited to the workshop? If not, who else or what groups of people do you think could have contributed very usefully?

7

10

• • • • • • • • • • •

Thailand representatil'es should have been invited. Drug policy makers from countries Perhaps law enforcement agencies should have been included. Also lawmakers? Representatives from law enforcement and politics should have been present One representati\le from each country should be from the law enforcement Uustice) and the other from health Somebody from the law enforcement group of Philippines could ha\le been present Key government officials (other than Ministry of health) who are involved with drug issues Representative from the National Narcotic Agency, Malaysia I would say we should invite some people from congress (lawmakers), private and NGO Some people had limited knowledge of their countries' policies and approaches - were more focused on their own arcna. The number of countries represented was also limiting factor It all depends on country structure in management and control of ATS in terms of practice and management of treatment. These involved in regulatory and enforcement, and practices (in Health Ministry - in licit control) could be included

-

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Annex 8

Yes 3.3 What additional topics or issues do you believe could very usefully have been discussed, discussed in more detail or discussed in a different manner at this workshop so as to add to its beneficial 9utcomes? • • •

No

• • •

• • • • • • • • • •

Nil To identify harm or hazardous use of ATS Perhaps just a simple focus on small steps/activities that could be taken in the area of prevention/promotion of health in city/island settings Strengthen the methodology of drug epidemiology and academic exchange The concrete methodology of survey on ATS use Although I agree that we need to focus on primary health care and thus, school and community-based strategies for intervention are important, we would have profited from hearing and sharing experiences in hospital-based treatment options as most countries remain tied to hospital-based treatment. Information dissemination and networking with other countries. The role of UNDCP The methodology of survey on ATS use The control system (organization) The legislation (law enforcement) Methodology of prevention and treatment. Review of the epidemiological and demographic patterns and tends in ATS use in American Samoa, Guam Healthy Cities - Healthy Islands Drugs hat are used as substitution for ATS treatment There was limited focus on supply control, prevention control - but this not WHO's primary role. However, it may have been worth exploring the potential harms which could result from these measures e.g. greater use of other possibly more dangerous substances Malpractice(?) by medical professionals in the use of ATS

4.

Administrative aspect Were organizational and administrative arrangements for travel, accommodation, payment of per diem, meeting room, secretarial support & interpretation satisfactory? If no, please describe: 16

• • • 5.

Announcement was not sufficient from secretariat and caused confusion at accommodation, in particular transportation Very pleasant staff and very good arrangement on travel plans Excellent! Thanks to WHO

Your overall conclusions Do you feel that (a) The findings, conclusions and forward planning reflected the meeting consensus? Ifno, please explain: 16

(b)

Such meetings should be held regularly?

17

•

2 yearly

-

168 -

Annex 8

Yes (c) Your attendance was worthwhile to you personally?

No

17 17

(d)

Your participation was worthwhile to your c·.)untry? Comments (if any): I hope Highly dependent on what we do upon return. Sometimes we get too busy to share. It is good to meet on regular basis with all countries keeping up-to-date with progress on ATS issues Will be able to initiate changes within the Ministry of Health and provide a more effective support to the National Narcotic Agency in addressing problems related to ATS.

• •

• •

6.

Is there any better way to achieve the meeting objectives? If yes, please describe briefly: • • • • • • • •

4 8 Blank - 5

Send background materials ahead of time Detailed information related to tbe meeting should be distributed before the meeting The topic of the meeting is wide. So you need to itemize the subject WHO follow-up tbe implementation of proposals Current approacb works well If any, for more effective meeting, if possible - should organize tbe groups to visit tbe centre oftreatment or rehabilitation on ATS use (tbeory and practice) See comments above re more focussed approaches and need to involve more countries Detailed information of tbe objectives of the meeting should be distributed to tbe participants before the meeting

7.

What follow-up activities, if any, would you recommend? (a) by national government• • • • • • • • • • • • Meetings to discuss conclusions and proposals of tbis meeting Nil, already incorporated in tbe proposal segment of tbe report Comprehensive survey on ATS use Summary report to agencies concerned Echo seminar on relevant issues Progress report Organize forum involving health and law enforcement agency on ATS issues Information dissemination of what was done at this workshop Create awareness among the Ministry of Health's policymaker and clinician on the emerging problem of ATS and its future impact Dissemination oftbis workshop's findings and recommendations t the relevant agencies Convene a meeting involving the National Narcotic Agency, the Police and MOB personnel to discuss tbe ATS issue As no data oof ouse on ATS, Lao government agency should have a survey programme in ATS use, to identify the problem related to ATS use, for planning strategy and Plan of Action in prevention and treatment. To manage strictly the import and export of amphetamine To manage and control strictly the production, distribution and use of amphetamine

• •

- 169 -

Annex 8

Yes • •

No

Improve liaison with regional countries Stimulate awareness among practitioners, enforcement and regulatory personnel. Improvement of detection of illicit use and cases of abuse in licit use

(b) • • • • • • • • • • • • (c)

by WHOSend an enquiry (questionnaire) 3 months from now about follow-up activities All the plans should be put into action by WHO Training in experts, development of survey tools. Facilitate sharing of data and information Follow up with participants in about 2-3 months to look at progress or problems encountered. Provide materials for education (Dr Robert Ali's slides) Provide screening touls, rapid assessment technical tools Provide updates from time-to-time and relevant information on ATS to Member Countries Should organize a regular meeting and given support. Set up a global strategy and guidelines in prevention and treatment on ATS Provide new information of ATS Support methods and techniques for the prevention of ATS use, treatment, harm reduction and rehabilitation To facilitate exchange of information and approaches training More awareness campaign and workshops within specific regions by other agencies (specify type)ASEAN. To identify A TS problem among ASEAN countries L"ICB and related agency (such as UNDCP) should join this plan of A TS control Education on treatment of ATS users by any rehabilitation centres Publishing the results of this seminar/workshop and distribution Support regional forum that can meet annually or twice a year Provide countries with current and future directional trends and strategies for ATS control Another regional meeting and written report from each country representative. Networking so that we all are aware with the extent of ATS issues Should be involved in funding the training course on prevention and treatment, participation in dissemination and education the community Collaboration among countries for the development of prevention Ul'\'DCP should liaise closely with \\'HO and facilitate evaluation of prevention, implementation and outcomes

• • • • • • • • • • •

8.

How many meetings - WHO and others - have you attended in your professional capacity outside your country over the last twelve months?

D

Meetings

• • • • •

0 1 2 meetings 3 6(?) meetings

• •

8

Evaluation of dependent potential of tamadol (Beijing, Nov. 1997)

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