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PHARMACY 462
Alcohol and Substance Use
Disorders
December 2/04
Substance Use
• Use of illicit drugs is one of the most difficult
problems facing communities
• Situation in which drug use occurs, types of drugs
and modes of use are as diverse as users
themselves
• Consequences are wide reaching: from physical
harm to users, to violence affecting user and nonusers alike
• Controversy regarding methods of dealing with
these issues ranging from harsher penalties for
use, to harm reduction strategies, to proposals for
legalization of selected substances.
General Information
• Use of certain drugs, such as cannabis, MDMA,
and hallucinogens have increased over the past
decade and currently remain at an elevated level
• Increase in seizures of marijuana and MDMA over
the past decade; decline in seizures of heroin and
cocaine
• Marijuana seized substantial – 1,274 kg
• Crack Cocaine most popular drug on the street
General Information Cont’d
• Crack – smoking but also injecting. Raises
concerns regarding spread of Hepatitis C
• Crack injection – short duration of action which
may lead to as many as 20 or more injections per
day
• Poly-drug use is widespread. Health effects?
Interactions?
• Toronto Drug Treatment Court – first of its kind in
Canada.
Fall 2003
• Ecstasy is finally seeing its first decline
since 1991
• Use of Cigarettes and LSD is declining
since 1999
• With all the talk of student drug use, more
than two-thirds of the students surveyed
indicated they have not used and illicit drug,
including cannabis, this past year.
Fall 2003
• Heavy or Binge Drinking rates have not declined
and remain at an elevated level
• 66.2% tried alcohol at least once
• 29.6% have tried cannabis at least once
• Cannabis is the most widely used illicit drug with
the onset of use getting younger
• 6% of Grade 7 students and nearly 28% of Grade
9 tried cannabis at least once compared to 4% and
26% in 1999
Fall 2003
• Cocaine use has increased in the short term
– 3.4% in 1999 to 4.8% in 2003
• Average age for smoking the first cigarette
is 13. In early 80’s it was age 11
• Alcohol – 13 years – fairly consistent
• Cannabis – 14 years – went up in the ’80s
and decreased in the 90’s
Fall 2003
• Except for ecstasy, student perceive less risk
surrounding most substance use.
• 1.4% report they have received alcohol and
drug treatment in the past year which could
be problematic since nearly 1 in 5, or 18%
report they use drugs to feel better about
themselves or use drugs alone – indicators
of drug use problem
New Trends in Toronto
• Powder cocaine gaining popularity among youth
in the ‘rave’ or party scene – snorting
• Use of tryptamines is increasing – from plants and
animals or synthesized in the laboratory
• FOXY (5-methoxy-di-isopropyl-tryptame and
AMT (alpha-methyl tryptamine). Both taken
orally, snorted or smoked. Concern as to the
effects that can be triggered by minute variation in
dosage
New Trends in Toronto
• Ketamine appears to be growing in
popularity. K or Special K – anaesthetic,
similar in chemical nature to PCP
• Smoke it, inject it or snorting.
• A number of serious urinary tract infections
linked to sythetic drug made from
veterinary de-wormer.
New Trends in Toronto
• Methamphetamine gaining popularity. The
smoked form, know as crystal or ice, is used on
the street as well as raves
• Other lesser know substances – Thalium which is
found in cocaine keeps high from disappearing
and can cause heart attacks
• Cocoa puffs, a mixture of marijuana and crack
• Salvia divinorum – a type of sage – powerful
psycho-active – frightening, hallucinogenic exp
Newborns
• Suspected damage to fetus from drugs
• Noxious influences transmitted via placenta
or breast milk
• Drug withdrawal syndrome in newborn of
dependent mother
Costs of Substance Use $
• $400 billion in the
U.S.
• $110 billion excluding
alcohol and tobacco
• $18.45 billion in
Canada (2.7% GDP)
• ‘probably higher and
could be significantly
higher’.
Direct Health Care Costs of
Substance Abuse (1992)
• Ontario - $1.5 billion
• Quebec - $1.0 billion
• British Columbia $487 million
• Alberta - $350 million
• Manitoba - $ 161
million
• Nova Scotia - $146
million
• Saskatchewan - $ 119
million
• New Brunswick $100 million
• Newfoundland - $71
million
• Prince Edward Island $17 million
Deaths – Legal vs. Illegal
35,000
30,000
25,000
1992
20,000
15,000
10,000
5,000
0
A
T
IL
• There were 40,930
deaths attributable to
substance abuse
• 21% of total mortality
for 1992
• Assume it has risen in
2004
Purity of Marijuana
• Plant Average 8.0%, slight
decrease from 1999
(12%)
(0.6 – 20.0%)
• Hashish – 23.3%
(0.04 – 50.0%)
Cannabis
• Marijuana accounted for 52% of all drug
seizures in 2000
• Cannabis is the second most frequently
cited illicit drug to be identified as
problematic by new treatment clients –
exceeded by cocaine.
• 60 unique chemicals- cannabinoids and 400
active compounds in cannabis sativa
Cannabis
• Evidence of psychological addiction
• Cannabis use impairs driving. This effect can last
well beyond the period of perceived intoxication.
• Devastating consequences of driving under the
influence of marijuana and alcohol.
• Driving under the influence of marijuana is
generally seen as the most significant, urgent
health concern. Designated drivers!
Ecstasy – Nothing to ‘Rave’
About
• Street name for the chemical MDMA (3,4methylenedioxymethamphetamine).
• 1912 – synthesized as appetite suppressant
but never commercially sold
• 1950’s – psychotherapeutic agent for
treatment of psychological problems
• 1985 – restrictive drug because of toxicity
MDMA
• Psychological – anxiety, paranoia, delusions
• Physical – involuntary teeth clenching,
increased body temperature, tooth grinding
(wear through the enamel), increased heart
rate and blood pressure.
• Long-term damage to brain – neurotoxic –
decreases in serotonin levels which effects
memory.
Party Drugs
• Rohypnol- roofies,
date-rape drug
• GHB – (gammahydroxybutyrate) –
liquid ecstasy, Georgia
Home Boy, G, Goop,
Grievous Bodily Harm
• Ketamine – Special K
• XTC, Meth, LSD
Rohypnol
• “Tom stopped for a drink at a bar one
evening. About 20 minutes later he felt so
sleepy he had trouble staying awake and
sitting upright. Hours later, he woke up in
an alley. He was bruised, bleeding and his
clothes were torn. Tom’s wallet was also
gone. It appeared that when he fell asleep
he was taken outside, beaten and robbed”.
Rohypnol
• Trade name for flunitrazepam. 10 x
stronger than Valium. It was initially
developed for the treatment of severe
insomnia. Today is imported from Mexico
and Columbia since it is illegal in the
U.S.A. A $1-$5 pill is popular with
teenagers as a ‘quick punch-drunk hit’.
• Blackout – I did ‘Wha-a-a-a-t?’
GHB
• Synthesized in the
’60’s as a sedative and
as an IV anesthetic for
use in children – side
effects
• ’90’s used for
euphoric, sedative and
anabolic effects
• Banned in ‘92
GHB
• White male presented as being dependent
on ‘Speed’ and abusing benzodiazepines.
He also admitted daily use of GHB for the
past 2 years. He took the drug for its
euphoric effects and to handle the
withdrawal from ‘Speed’. Ingestion of 15
grams of GHB – vomited and could not be
aroused for three hours. Lost control of his
bladder and bowel – discontinued use.
GHB
• GHB is produced in clandestine lab
operations and requires no scientific
expertise or laboratory skills. Produced by
addition of NaOH to gamma-butyrolacetone
(GBL). GBL is an industrial solvent quite
often used as a floor cleaner and is readily
available. Mixed in any glass container
without heat or additional chemicals.
“Cooks” can set up shop anywhere!
Ketamine
• Similar in action to
PCP and LSD
• ‘out of the body’
• Amnesia
• Do not feel pain
• Snort
• Applied to ‘grass’ or
tobacco
PMA (paramethoxyamphetamine
• a.k.a. Death, Mitsubishi Double Stack, Chicken
Yellow, Chicken Powder
• Largest single PMA seizure to date was in the Peel
Region in January, 2001 with a pill count
estimated to be over 4000
• Doses of PMA of more than 50 mg are considered
potentially lethal; risk intensified when combined
with alcohol or other drugs.
PMA (paramethoxyamphetamine)
• Has both stimulant and hallucinogenic
properties. Easier and cheaper to produce.
• More potent and more toxic
• 3x hallucinogenic potency of MDMA
• Associated with serious side effects
including delirium, rigidity, rapid heart rate,
sweating, high fevers, increased b.p.,
seizures, coma, death. (2 deaths in 2000)
Effect on Newborns
• Prenatal drug exposure
remains high in
Toronto.
• In 1999, 3rd highest
total recorded in 13
years they have been
keeping statistics.
• Between 1990-2000:
upswing in use by
adolescents.
Alcohol
• FAS –pre and post
natal growth
retardation
• Facial dysmorphology
• Congenital
abnormalities
• No known safe lower
limit
Cocaine
• Spontaneous abortions, prematurity,
intrauterine growth retardation
• Labor may be precipitated by bolus of
cocaine
• Cerebral infarction
• CNS depression
Cannabis
•
•
•
•
•
Severe nausea on quitting
Decreased birth weight
5X CHb levels
3X tar
Preterm-premature
Heroin - Narcotics
• Neonatal withdrawal
• SIDS
• Whole host of other
complications since
users usually do not
look after themselves
Hallucinogens
• Limb defects
• CNS and occular
abnormalities
• Teratogenic effects
Solvents
• Encephalopathy
• Cortical and cerebellar
dysfunction
• Infants – facial
dysmorphology,
similar to alcohol
• CNS dysfunction
• Small heads
Admitting Defeat – CPJ, 10/00
• Global war on drugs is now causing more harm
than drug abuse itself?
• U.S. has led a global battle – results have been
catastrophic
• Montreal motorcycle gangs escalating wars to
control drugs – 15 murders –1st six mo/00
• 100,000 more people imprisoned in US than there
are prisoners for all offences in European Union
Admitting Defeat, Cont’d
• In many parts of the world, drug war
politics impede public health efforts to stem
the spread of HIV, hepatitis, and other
infectious diseases – signed by Joycelyn
Elders, the former American Surgeon
General – as well as Federal NDP Leader
Alexa McDonough, Liberal Senator Sharon
Carstairs
Pharmacists
• We trust that CPJ readers – some 20,000 of
the country’s leading drug experts – will
want to take part in the discussion.
• Suggest we acknowledge our mistakes and
explore alternatives to prohibition,
platitudes, and reckless, iron-fisted
enforcement for our drug policy.
Myth and Reality
• “Drug War” is a term used to conjure
visions of street-scene battlefields depicting
weapons as the major tool in the anti-drug
arsenal.
• Drug Wars have failed, other than to
imprison multitudes for the essentially
victimless crime of enjoying an illicit
substance??
M &R Cont’d
• Treatment and Prevention are the keys to
reducing drug use.
• Supply reduction is also part of the strategydrug traffickers are the focus
• In 1982 – 5.7 million casual users of
cocaine in America
• Today – 1.7 million (70% decrease)
M & R Cont/d 2
• To characterize such results as failure is akin to
walking away from the fight against illiteracy
because some people remain illiterate.
• What about peaceable citizens being put behind
bars for smoking a toke?
• 2000 Justice Dep’t report – increase in prisoners
(lowest since 1979) – over half resulted from
convictions for violent crimes. Another third –
property crimes and ‘other crimes’.
M & R Cont’d 3
• Less than one in five incarcerated as a result
of drug arrests:
• Most were repeat offenders with other
serious crimes
• 1998 out of 100,000 prisoners – 33 for
marijuana (less than 5,000 g) and 1,299 for
marijuana offenses involving between
100,000 and 3,000,000 grams
M & R Cont’d 4
• Florida: only 40 out of 68,000 – marijuana
possession. All of them had previous criminal
history – many for cocaine and other drug offenses
such as violent offenses (homicide, aggravated
battery and armed robbery). Of the 40, over 60%
had been in prison before. All of the others had
prior probation sentences and over 80% had
violated their probation for offenses including
weapons, resisting arrest, burglary, grand theft
Should we legalize?
• Fewer crimes?
• Can Users hold steady jobs?
• 60-80% of all crime in America is related to
substance abuse, virtually none of which is
“victimless”
• Drug addiction is seldom voluntarily
admitted –coerced to treatment
Drugs and Crime
• We have drugs to
blame for crime
• Need to break the
cycle between
addiction and crimeNOT pretend there is
no linkage between
one and the other!
You can be part of the solution
• Understand the effects of abused substances
• Education should be clear and discussed at
the level of audience comprehension
• Don’t forget about tobacco and alcohol