National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
3.4 Negative physical health effects
ATS use in the short term can lead to increases in heart rate, hypertension, irregular body temperature and rates of breathing, constriction of blood vessels and cardiac arrhythmia (Lineberry & Bostwick, 2006; Maxwell, 2005). Short- and long-term ATS use can impact on the cardiovascular system (increasing heart rate, increasing blood pressure, cause arrhythmia and palpitations) sometimes resulting in cardio and/or cerebrovascular crises, such as myocardial infarction or stroke, aneurysm and hemorrhage (e.g., Buxton & McConachie 2000; Hung et al., 2003). Acute coronary syndrome is common in patients hospitalised for chest pain after methamphetamine use (Turnipseed et al., 2003).
ATS can impact on the ability to regulate body temperature in a changing environment, contributing to hyperthermia, and metabolic disturbances are not uncommon (see Gowing et al., 2002). Methamphetamine induces dose-dependent brain hyperthermia that precedes, and is greater than, overall body hyperthermia, suggesting methamphetamine-induced neuronal activation is a contributing source of that hyperthermia (Brown et al., 2003). ATS suppress the appetite, and can be associated with weight loss and general poor nutrition. Less common problems include renal and hepatic problems (see Allen & Tresidder, 2003; Gowing et al., 2002; Maxwell, 2005). Maxwell (2005) also reported that many longer–term ATS users experience a range of health problems that adversely affect their general well being. Such problems include: poor dental hygiene including damaged and discoloured teeth from dry mouth, heavy sugar intake and tooth grinding; appearing older than chronological age; and skin lesions – excoriations and ulcers from parasitosis.
As indicated earlier, evidence suggests that ATS impact on cognition and this may be associated with particular neurological consequences, which sometimes may endure even after abstinence (e.g., Davidson et al., 2001). It is postulated that long-term deficits could result from the capacity of MDMA and methamphetamine respectively to exhaust serotonergic and dopaminergic neurons (Clemens et al., 2007). These can include short and long-term consequences such as hyperactivity, confusion, agitation, low mood, lethargy, and anhedonia (see Baker, Lee & Jenner, 2004).
Toxicity and overdose
As reviewed in Dean (2004), toxic central effects of amphetamine use include psychosis, hyperthermia, seizures, and rhabdomyolysis (an acute, potentially fatal disease that destroys skeletal muscle), while cardiovascular toxicity includes ventricular arrhythmias, acute myocardial infarction and cardiomyopathis. Neurotoxicity refers to neurological changes that persist after cessation of use, and evidence suggests that chronic methamphetamine use leads to dopamine depletion and possibly also changes in serotonergic function (Davidson et al., 2001).There is also evidence that MDMA can produce neurotoxic effects in some users. From a review of the literature, Morgan (2000) found several cognitive and psychological effects from ecstasy use (outlined above) and suggested a likelihood that some of these problems are caused by ecstasy-induced neurotoxicity. Morgan (2000) found support for this from preclinical evidence of MDMA-induced neurotoxicity and behavioural deficits, evidence of depleted serotonin in heavy ecstasy users, and by dose-response relationships between the extent of exposure to ecstasy and the severity of impairments. Boot and colleagues (2000) suggested that those ecstasy users most at risk of neurotoxicity are those who consume two or more ecstasy tablets at a time, use the drug fortnightly or more, inject MDMA, and use for more than 24 hours.
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Severe MDMA overdoses are associated with intense sympathomimetic responses, active hallucinations, and thermoregulatory, neurologic, cardiovascular, hepatic and electrolyte disturbances (Gowing et al., 2002). Neurological symptoms include agitation, hallucinations, seizures, coma, and acute and chronic psychiatric symptoms (Kalant, 2001). To date, there are few studies that support the notion that MDMA causes neuronal cell death but rather, it appears to damage only the terminal regions of 5-HT neurons (Baumann et al., 2007). In general, there is considerably more evidence of long-term damage following chronic use of methamphetamine (Pubill et al., 2003).
ATS overdose can occur and is associated with circulatory collapse, cerebral hemorrhage and myocardial infarction (World Health Organisation, 1997). The most recent EDRS reported that 21% of the national sample had ever overdosed on ecstasy or related drugs (Dunn et al., 2007). Overdose was defined as ‘passed out or fallen into a coma’. The majority reported recently overdosing on ecstasy (36%), while 3% each reported overdosing on crystal methamphetamine and base. Data from the Australian Institute of Health and Welfare (AIHW) report the number of inpatient hospital admissions per million persons among persons aged 15 to 54 with a principal diagnosis relating to amphetamine. These figures have fluctuated during the six-year period from 1999/2000 to 2004/05. The latest figures show a decrease from 180 per million persons in 2003/04 to 156 per million persons in 2004/05 (Australian Institute of Health and Welfare, 2005b).
In 2005, there was a total of 68 drug induced deaths in which methamphetamine was mentioned among those aged 15 to 54 years, compared to 75 in 2004 (Degenhardt & Roxburgh, 2007). Of these deaths, methamphetamine was found to be the underlying cause in 26 cases in 2005 compared to 17 in 2004. Deaths from ecstasy consumption have variously involved persons with pre-existing cardiac conditions (World Health Organisation, 1997), hyperthermia, and ingestion of excessive amounts of water (Darke et al., 2000). Deaths following MDMA use are frequently the consequence of a serotonin syndrome and/or of sympathomimetic overstimulation, both of which are exacerbated by environmentally caused overheating (Schifano, 2003).
A study conducted by Schifano and colleagues (2003) investigated the number of ecstasyrelated deaths occurring in England and Wales between August 1996 and April 2002 recorded in the National Programme on Substance Abuse Deaths database. A total of 202 ecstasy-related deaths were recorded and showed a steady increase in the number of deaths each year. Of these, ecstasy was implicated as the sole drug causing death in only 17% of cases, with a variety of other drugs (mostly alcohol, cocaine, amphetamine and opiates) being identified. Toxicology results revealed MDMA accounted for 86% of cases, MDA for 13% of cases, and single deaths were associated with MDEA and PMA. An analysis of ecstasy-related deaths in Australia during 2000-2004 using data from the National Coronial Information System (NCIS) found 112 such deaths (Fowler et al., in press). Ecstasy was deemed to be the primary contributory factor in just under half of these cases, and the sole drug present in only six of these deaths (Fowler et al., in press).
Negative effects of specific routes of administration
Some effects are associated with specific routes of administration, as detailed at the National Leadership Forum on Ice (Ministerial Council of Drug Strategy Joint Communiqué, 2007). Nasal use by snorting has a delayed effect of approximately five minutes subsequent to dose. There is a potential risk for Hepatitis C to be passed on from tiny, often invisible amounts of blood on shared snorting equipment. Oral use of crystal methamphetamine by swallowing can cause irritation as crystal particles travel to the stomach. Anal and vaginal use, known as ‘shelving’ and ‘shafting’, can damage the lining of the anus or vagina and increase the chances of HIV and Hepatitis C transmission. In addition to the typical health and medical effects associated with smoking including addiction, smoking equipment can cause burns to mouth or gums, and Hepatitis C can be transmitted if equipment is shared. In addition to smoking, injecting is the route of administration most associated with dependence, and the latter mode of administration poses risks of contracting blood borne viruses, and repeated injection in the same spot can lead to vein inflammation, scarring, abscesses, blood clots and vein collapse.Top of Page
There is a paucity of research investigating transitions to injecting from other routes of administration. Those studies that have investigated this area have mostly recruited heroin users (e.g., Gossop et al., 1988; Neaigus et al., 2001; Parker et al., 1988). A paper by Strang and colleagues (1992) identified the pertinent issues, including variations of route of administration by time and place; influence of availability of drug paraphernalia; influence of context; and the association between changes in route of one drug and changes in route of other drugs.
One study that investigated transitions to injecting among amphetamine users was conducted by Darke and colleagues (1994). A sample of 301 regular amphetamine users was interviewed and two thirds reported injecting the drug in the previous six months. A transition to regular amphetamine injecting from other routes of administration was reported by 40% of participants, with males twice as likely to report such a transition. The main reasons provided were ‘liking the rush’ from injecting, and a perception that it was both more economical and a healthier way to use.
The 2006 EDRS reported that 20% of the national sample of regular ecstasy users (REU) had ever injected any drug and of these, 69% had injected in the previous six months (Dunn et al., 2007). Those who reported lifetime injecting first injected at a median age of 18 years and had been injecting for a median of eight years. Amphetamine (‘speed’) was the most common drug first injected (48%) and ever injected (84%). Crystal methamphetamine was reported as the most common drug injected in the previous six months (72%) and the most common drug last injected (35%).
Among the 2006 EDRS sample, lifetime injectors compared to non-injectors were significantly more likely to be older, male, have fewer years of education, have a prison history, be unemployed, be in drug treatment, and be less likely to identify as heterosexual. With regards to initiation into injecting, 43% of injectors reported doing so for the first time while under the influence of other drugs; most commonly alcohol and cannabis.
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