PHARMACY 462

1. PHARMACY 462 Alcohol and Substance Use Disorders December 2/04

2. 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 non-users 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.

3. 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

4. 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.

5. Drug Use in the New Millennium

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Newborns • Suspected damage to fetus from drugs • Noxious influences transmitted via placenta or breast milk • Drug withdrawal syndrome in newborn of dependent mother

14. 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’.

15. 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 Direct Health Care Costs of Substance Abuse (1992)

16. Deaths – Legal vs. Illegal • There were 40,930 deaths attributable to substance abuse • 21% of total mortality for 1992 • Assume it has risen in 2004

17. MARIJUANA -Potency

18. Purity of Marijuana • Plant - Average 8.0%, slight decrease from 1999 (12%) (0.6 – 20.0%) • Hashish – 23.3% (0.04 – 50.0%)

19. 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

20. 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!

21. TOBACCO Why You Should 'Butt' Out

22. Ecstasy – Nothing to ‘Rave’ About • Street name for the chemical MDMA (3,4-methylenedioxymethamphetamine). • 1912 – synthesized as appetite suppressant but never commercially sold • 1950’s – psychotherapeutic agent for treatment of psychological problems • 1985 – restrictive drug because of toxicity

23. 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.

24. Party Drugs • Rohypnol- roofies, date-rape drug • GHB – (gamma-hydroxybutyrate) – liquid ecstasy, Georgia Home Boy, G, Goop, Grievous Bodily Harm • Ketamine – Special K • XTC, Meth, LSD

25. 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”.

26. 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?’

27. 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

28. 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.

29. 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!

30. Ketamine • Similar in action to PCP and LSD • ‘out of the body’ • Amnesia • Do not feel pain • Snort • Applied to ‘grass’ or tobacco

31. 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.

32. 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)

33. 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.

34. Alcohol • FAS –pre and post natal growth retardation • Facial dysmorphology • Congenital abnormalities • No known safe lower limit

35. Cocaine • Spontaneous abortions, prematurity, intrauterine growth retardation • Labor may be precipitated by bolus of cocaine • Cerebral infarction • CNS depression

36. Cannabis • Severe nausea on quitting • Decreased birth weight • 5X CHb levels • 3X tar • Preterm-premature

37. Heroin - Narcotics • Neonatal withdrawal • SIDS • Whole host of other complications since users usually do not look after themselves

38. Hallucinogens • Limb defects • CNS and occular abnormalities • Teratogenic effects

39. Solvents • Encephalopathy • Cortical and cerebellar dysfunction • Infants – facial dysmorphology, similar to alcohol • CNS dysfunction • Small heads

40. 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

41. 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

42. 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.

43. 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??

44. M &R Cont’d • Treatment and Prevention are the keys to reducing drug use. • Supply reduction is also part of the strategy- drug traffickers are the focus • In 1982 – 5.7 million casual users of cocaine in America • Today – 1.7 million (70% decrease)

45. 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’.

46. 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

47. 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

48. 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

49. Drugs and Crime • We have drugs to blame for crime • Need to break the cycle between addiction and crime- NOT pretend there is no linkage between one and the other!

50. 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