MULTIPLE DRUG USE NOW THE NORM, HEROIN SHUNNED BY YOUNG
Government drug policy is too centred on heroin abuse, fails to take account of the realities of current usage trends and needs to focus on individual user behaviour if it is to reflect the true picture and formulate meaningful responses, a leading academic at National University of Ireland Maynooth urged.
‘A Dizzying Array of Substances; An Ethnographic Study of Drug Use in the Canal Communities’ is the result of a long-term study which closely examined the realities of drug use in local life of Rialto, Bluebell and Inchicore, three communities served by the Canal Communities Local Drugs Task Force. It was led by principal investigator Dr A Jamie Saris and primary field researcher Fiona O’Reilly at the Department of Anthropology, NUI Maynooth.
The ethnographic research, carried out mostly in 2008 and early 2009, gives the most compelling evidence to date that multiple drug use is the norm amongst drug users in the Canal Communities and, the researchers concluded, most probably in other areas.
“The big problem is that as far as government is concerned, ‘drugs’, from a treatment perspective, has traditionally meant heroin. Thus, the apparent leveling off of the need for a very opiate-centric treatment service in the Canal Communities in recent years is deceptive” said Dr Saris.
Besides the ethnographic work, the study surveyed, on a long term basis, 92 people using either heroin or methadone in the study area. Unsurprisingly most of those surveyed were on methadone (98%). Of those surveyed:
•63% claimed to have used heroin in the previous three months
•30% had used crack cocaine
•22% had used powder cocaine
•46% had also taken street tranquilisers
•50% were on prescribed tranquillisers, and
•60% had also smoked cannabis within the past three months.
“The majority of those registered on the methadone treatment programme are also using a cocktail of other substances, very often including heroin. Multiple drug use is the reality for nearly all users, and official policy needs to have this understanding at its centre”, Saris said.
In the course of their study, the research team also noted a strong stigma against heroin use amongst the 16-25 age group who still regularly used a lot of other substances, including cocaine and off-label prescription medication. “The reality is that these people are difficult for a treatment infrastructure built around opiates to service. If they have issues, they are more difficult to address,” said Saris.
” The stress that policy-makers and community activists place on ‘crack’ or ‘heroin’ or any other single drug as clear and present social dangers obscures the ubiquity of polydrug use. It makes it appear that these users are very different from other drug-users in the rest of society including cannabis and recreational cocaine users, and it also obscures how commonly legal pharmaceuticals, such as benzodiazepines, even methadone itself, are regularly consumed ‘illegally’.”
He said that a focus on drug use alone is the mistake. “The lives we examined, however damaged by an attraction to certain pharmaceuticals, are rarely defined solely by such behaviour. These people are also sons and daughters, fathers and mothers, partners and lovers, as well as employees and community members. This sensibility does in fact inform a lot of local community activities aimed at assisting users, but such work is often difficult to justify to official funders under the rubric of ‘treatment’, as currently understood. Unless we can understand who users are, what they are taking and why, we will not be able to assign the appropriate resources, treatments or management systems.”
Tony MacCarthaigh, chairperson of the Canal Communities Local Drugs Task Force commented that “individuals and not chemicals need to become the focal point of treatment, and treatment needs to assist individuals in developing another orientation not just to drugs, but to life”.
Source: www.addictiontoday.org 9th July 2010

An 18-year-old male presents complaining of crampy abdominal pain, nausea, and intractable vomiting for the past year. The symptoms are episodic, lasting several weeks and remitting for weeks to months.

The patient states that his abdominal pain is 10 out of 10 in severity, and that he has been vomiting up to 20 times each day. He has been evaluated at multiple hospitals, and he has had numerous upper endoscopies, colonoscopies, swallowing studies, and CT and MRI imaging studies, all of which were unrevealing.

He underwent a cholecystectomy, but had no improvement in his symptoms after the surgery. His pain and nausea are unresponsive to antacids and antiemetics.

The patient’s only relief is with hot water bathing: he spends hours each day in the shower with the temperature set as hot as he can bear. The patient’s history is otherwise unremarkable, except that he admits to daily marijuana use beginning at the age of 14.

This patient’s story is typical of cannabinoid hyperemesis, a clinical syndrome characterized by intractable vomiting and abdominal pain associated with the unusual learned behavior of compulsive hot water bathing, occurring in the setting of long-term heavy marijuana use.
Treatment consists of medication for immediate symptomatic relief and marijuana cessation for long-term relief. Symptoms usually remit within weeks of becoming abstinent.

If this disorder is so easily diagnosed and treated, why were the patient’s past doctors confused to the point of performing what might have been an unnecessary surgery? Cannabinoid hyperemesis is a new diagnosis, first described in 2004, and currently sixteen papers on the subject have been published.

Therefore, it is likely that the patient’s prior doctors had never considered this disorder. Second, the pathogenesis of cannabinoid hyperemesis is poorly understood.
How can marijuana, which is used in cancer clinics as an anti-emetic, cause intractable vomiting? And why would symptoms abate in response to high temperature?

The connection between marijuana, vomiting, and heat is non-intuitive, and a medical team unfamiliar with this syndrome would be hard-pressed to reach the diagnosis.
The largest study of cannabinoid hyperemesis to date was the landmark report by Allen et al in 2004 in an area of Southern Australia where marijuana use is largely decriminalized.

The report tracked 10 patients who presented with cyclic vomiting after 3 to 27 years of cannabis abuse and no other history of drug abuse. All but one displayed compulsive hot water bathing; the remaining patient had only experienced his symptoms for 6 months, and the authors theorize that he had not yet learned to associate hot water with symptom palliation.

The 9 compulsive bathers reported that this bizarre behavior occupied hours of their days and said that their symptoms were ameliorated within minutes of bathing and returned when the water cooled. All 10 patients were counseled to cease cannabis use, and 7 did so. Within weeks of cessation, the symptoms resolved for these 7 patients; the remaining 3 patients did not cease cannabis use and continued to have cyclic vomiting and abdominal pain.

After several years of abstinence, 3 patients resumed cannabis use and were hospitalized again with cyclic vomiting and abdominal pain. Once again, 2 of these patients successfully stopped using cannabis, and their symptoms resolved. The remaining patient continued to use cannabis and continued to experience symptoms at the time of publication.
Following the first case report, further cases have been described on three continents.

All patients presented with the classic triad of symptoms described by Allen et al: cyclic vomiting and abdominal pain, an extensive history of cannabis abuse, and palliation with hot water bathing. The fact that this unique triad is preserved in diverse patient populations suggests that there is a pathogenic mechanism that underlies this syndrome.

Several authors have speculated about the pathophysiology of cannabinoid hyperemesis, and though the specifics remain unclear, there is consensus over some of the basic principals: It appears that the high lipophilicity of delta-9-tetrahydrocannabinol (Δ9-THC, the active compound in marijuana) causes cumulative increases in concentration with chronic use, which may lead to toxicity in susceptible patients.

The abdominal pain and vomiting are explained by the effect of cannabinoids on CB-1 receptors in the intestinal nerve plexus, causing relaxation of the lower esophageal sphincter and inhibition of gastrointestinal motility. This finding is supported by gastric emptying studies performed on one of the patients presented by Allen et al, which revealed severely delayed emptying. While cannabis appears to have anti-emetic effects that are centrally mediated, it is possible that these effects predominate at low doses whereas the gastrointestinal effects predominate at the high concentrations that occur with long-term use.

The proposed explanation for compulsive hot water bathing is based on the fact that cannabis disrupts autonomic and thermoregulatory functions of the hippocampal-hypothalamic-pituitary system. There is a high concentration of CB1 receptors within the limbic system, and the hypothalamus in particular is known to be responsible for integrating central and peripheral thermosensory input. Furthermore, Δ9-

THC induces hypothermia in mice in a dose-dependent manner. While this evidence links cannabis to the hypothalamus and to thermoregulation, it does not provide a causal relationship. Two mechanisms proposed by Chang et al are that (1) cannabinoid-induced hypothermia causes the desire for hot water bathing, or (2) hot water bathing is the direct result of CB1 activation in the hypothalamus.

The true mechanism underlying hot water bathing remains enigmatic, and further studies are needed to elucidate the relationship between this bizarre learned behavior and the other features of cannabinoid hyperemesis.

A timely diagnosis of cannabinoid hyperemesis is essential not only to effect proper treatment but also to prevent iatrogenic morbidity and mortality from unnecessary diagnostic procedures and surgical interventions. There are, however, several obstacles to effective diagnosis:

First, the legal status of marijuana makes eliciting an accurate drug history challenging. Second, the bizarre hot water bathing is likely often attributed to psychological conditions such as obsessive-compulsive behavior. Third, the knowledge of the anti-emetic effects of cannabis likely disguises cases of cannabinoid hyperemesis, leading to the erroneous belief that cannabis is treating cyclic vomiting rather than causing it.

Finally, the fact that this syndrome is so recently described and relatively unknown outside an esoteric subset of the GI literature means that most clinicians are unaware of its existence. The following diagnostic criteria adapted from Sontineni et al can be used to facilitate a diagnosis of cannabinoid hyperemesis syndrome:

ESSENTIAL FEATURES
History of chronic cannabis use
Nausea and cyclic vomiting over months
Relief with cessation of cannabis use
SUPPORTING FEATURES
Compulsive hot water bathing with transient relief of symptoms
Colicky abdominal pain
Exclusion of other etiologies (especially gall-bladder and pancreas)
In the case of the 18-year-old patient presented above, asking the open-ended question, “What makes you feel better?” followed by more focused questions regarding the temperature of the water and the history of marijuana use were sufficient to suggest the diagnosis of cannabinoid hyperemesis.
We propose that these questions be used as a screening tool for all patients presenting with cyclic vomiting. Based on our experience and a review of the literature, we believe that these questions may be both sensitive and specific for detecting this unusual syndrome.
The patient presented in this case was counseled on his likely diagnosis.

Though he was initially skeptical, giving him printouts of case reports on cannabinoid hyperemesis syndrome and discussing the etiology of the disease were sufficient to convince him of the diagnosis. He was treated symptomatically in the hospital. Two weeks after discharge, he remains abstinent from marijuana and reports that his symptoms are improving.
Sarah A. Buckley and Nicholas M. Mark both are 4th year medical students at NYU School of Medicine
Faculty reviewed by Robert Hoffman, MD, Director NYU Poison Control Center, Associate Professor Departments of Medicine and Emergency Medicine, NYU Langone Medical Center

Source http://www.clinicalcorrelations.org/?p=2877 July 15th 2010

 Around 44 0000 people have been recorded as entering specialised drug treatment centres in Europe in 2008 in 29 countries; data mainly cover outpatient and inpatient treatment centers
 Most clients enter treatment on their own initiative or under the pressure of family and friends (43 %); 27 % go to drug treatment through health or social services, including other drug treatment centres; around 20 % are referred to treatment by the criminal justice system, and the remaining through other referral sources
 The most frequent reason for entering treatment in 2008 (or most recent year available), is the use of heroin (48 % of all drug users and around 200 000 people), followed by cannabis (21 % and around 85 000 people) and cocaine use, (17 % and around 70 000 people), use of stimulants other than cocaine (5 % and around 22 000 clients) and other drugs use, which include hypnotics and sedatives, hallucinogens, volatile and other substances
 Among those who have entered treatment for the first time in their life the proportion of heroin users is lower and that of cocaine, cannabis users and clients consuming stimulants other than cocaine (mainly amphetamine and methamphetamine) is higher
 Differences between countries are relevant with 18 countries reporting more than 50 % of primary opioid users among drug clients, 8 countries with more than 20 % of primary cannabis clients and 3 countries with more than 20 % of cocaine clients.
 Stimulants other than cocaine, which will be the subject of one of 2010 selected issue are concentrated in some countries, namely the Scandinavian countries (amphetamine), Czech Republic and Slovakia (methamphetamine)
 Clients are mainly males (4 males for every female), with a mean age 31 years (those who have entered treatment for the first time are on average 1 year younger)
 Most clients start their drug use before the age of 20, around one third of the clients inject their primary drug, and the frequency of use varies by the main drug (the highest proportion of daily users is found among opioid clients and the lowest among users of stimulants other than cocaine)
 Social conditions of drug users entering treatment are generally poorer than in the general population (education, living and labour conditions)
 Differences are reported by primary drug and by country regarding gender, age distribution and patterns of drug use

 Recent comparable data on young people’s use of alcohol and drug come largely from surveys of 15- to 16-year-old school students. The European School Survey Project (ESPAD) conducted surveys in 1995, 1999, 2003 and more recently, 2007. The 2007 survey (Hibell et al., 2009) provides comparable data from 25 EU Member States as well as Norway and Croatia. Five countries conducted their own school surveys in 2008 (Belgium-Flemish Community, Spain, Italy, Sweden, United Kingdom-England)
 The latest ESPAD survey data from 2007 reveal that the highest lifetime prevalence of cannabis use among 15- and 16-year-old school students is in the Czech Republic (45 %) (Figure EYE-1 part (ii)). High lifetime prevalence estimates, ranging from 26 % to 32 %, are also reported in Estonia, France, the Netherlands, the Slovak Republic and the United Kingdom.
 Increases in cannabis use occurred in a number of European countries between 1995 and 2003 but have, in general, come to a halt or decreased more recently. Seven countries mainly located in Northern and Southern Europe (Greece, Cyprus, Malta, Romania, Finland, Sweden, Norway) reported overall stable and low lifetime prevalence of cannabis use during the whole period. Other western European countries, as well as Croatia and Slovenia, have shown a significant increase of lifetime cannabis use up to 2003 and since then nine of these reported a decrease of more than three percentage points, two were stable and none reported an increase. In most of central and eastern Europe the increasing trend observed between 1995 and 2003 seems not to have been reversed yet. In this region, two out of eight countries report increases of more than three percentage points since 2003, six or more a stable situation and none a significant decrease. In the five countries that conducted national school surveys in 2008, all reported stable or lower lifetime prevalence of cannabis use than reported in 2007 (Table EYE-11).
 Increases in lifetime cannabis use between 1995 and 2003 in Europe were in some countries accompanied by increases in the prevalence of cigarette smoking among school students. Since 2003, both trends have reversed, suggesting a possible link between tobacco and cannabis smoking.
 Estimates of the prevalence of other drug use among school students are much lower than those for cannabis use. For example, lifetime prevalence of cocaine use among 15- to 16-year-old school students is between 1 % and 2 % in half of the 28 reporting countries. Most of the remaining countries report prevalence levels of between 3 % and 4 %, while Spain, France, and the United Kingdom report 5 %. Among the five countries that conducted school surveys in 2008, two reported a decrease of 1%, one reported an increase of 1%, and two reported no change since the last survey (Table EYE-11). However, caution is required interpreting trends with such low prevalence.
 In the countries conducting their own national school surveys, drug prevalence questions may be considered comparable to the ESPAD questions but other aspects of the method mean the data are not strictly comparable.
Source: EMDDA July 10 2010

Q: How can I tell if my child has been using marijuana?
A: There are some signs you might be able to see. If someone is high on marijuana, he or she might:

• Seem dizzy and have trouble walking;
• Seem silly and giggly for no reason;
• Save very red, bloodshot eyes; and
• Have a hard time remembering things that just happened.

When the early effects fade, the user can become very sleepy.

Parents should be aware of changes in their child’s behavior, although this may be difficult with teens. Parents should look for withdrawal, depression, fatigue, carelessness with grooming, hostility and deteriorating relationships with family members and friends.

In addition, changes in academic performance, increased absenteeism or truancy, lost interest in sports or other favorite activities, and changes in eating or sleeping habits could be related to drug use. However, these signs may also indicate problems other than using drugs.

In addition, parents should be aware of:

• Signs of drugs and drug paraphernalia, including pipes and rolling papers;
• Odor on clothes and in the bedroom;
• Use of incense and other deodorizers;
• Use of eye drops; and
• Clothing, posters, jewelry, etc., promoting drug use.

Source: The National Institute on Drug Abuse 2010

Some people can drink a lot of alcohol without becoming addicted, and specific genes may help explain why, researchers say.
In a new study of Australian twins, scientists found that separate genes appear to be responsible, to some degree, for dependence on alcohol — addiction — and how much people drink. Understanding how these genetic factors work together should give researchers more insight into treatment of alcoholism in its various forms, said study co-author John B. Whitfield, a researcher at Royal Prince Alfred Hospital in Australia.
Alcoholism and alcohol consumption may appear to be similar, but researchers are increasingly studying them separately. Consumption refers to the amount of alcohol that someone drinks, while addiction refers to a person’s inability to go without a drink.
“The transition from social alcohol consumption to alcohol dependence is a gradual process, and it is often hard to notice it,” said Dr. Alexei B. Kampov-Polevoi, an assistant professor of psychiatry at Mount Sinai School of Medicine. “As a result, many alcoholics and their family members continue to think that a person ‘just drinks too much’ while this person already developed alcohol dependence and requires treatment.”
Whitfield and his colleagues examined statistics about alcohol use from three studies of Australian twins completed between 1980 and 1995. The number of twins in the studies declined from 8,184 in 1980 to 3,378 in 1995.
The findings appear in the August issue of Alcoholism: Clinical & Experimental Research.
The researchers found twins who were genetically similar were more likely to consume similar amounts of alcohol. According to the study, some genes affected both addiction and alcohol intake, while some just affected addiction.
“We found (as others have also found) that alcohol dependence is partly, but not entirely, due to genetic differences between people who are affected by it and those who are not,” Whitfield said. “We also found that variation in the amount of alcohol that people habitually drink is subject to genetic influence, and that there is some — but not complete — overlap between the genes affecting these two things.”
Howard J. Edenberg, professor of biochemistry and molecular biology at Indiana University, said the findings — that genes separately affect alcoholism and drinking — are “reasonable.” But “that is a long way from identifying individual genes that actually are involved,” said Edenberg, whose own research is looking into that area.
So what should ordinary folks take from this study? “There is no direct and new message for people with alcoholism in their families; they are at higher risk than average but this has been known for some time and there is only a statistical risk, not a certainty by any means,” Whitfield said. “The more positive message for such people, and the community at large, is that we are learning more about alcohol use and alcohol-related problems and their causes.”
Source : HealthDay News 18th August 2004

A Canadian-led international study finds that the causes of a heart attack are the same for people throughout the world, with cigarette smoking one of the main risk factors, the “There hasn’t been a study like this ever in the world,” said lead investigator Dr. Salim Yusuf, head of the Population Health Research Institute at McMaster University in Hamilton. “The risk factors that we’ve been able to measure account for 90 percent or more of heart disease. The impact of these risk factors in developing heart disease is global. It’s there in every ethnic group, in men, in women, in every region of the world, in young and old. It means we should be able to prevent the majority of premature heart attacks in the world.”

The research concluded that cigarette smoking and a poor ratio of bad to good cholesterol contribute to two-thirds of all heart attacks worldwide.

The five-year study involved 30,000 people in 52 countries. About half of the participants had suffered a heart attack. They were compared to an equal number of people with no heart disease, matched for age, sex, and city of residence.

“So now we’ll say: What causes the risk factor, not what causes the disease. And from a public-health point of view, there should be no more wallowing about that we need more information. We’ve got it,” said Dr. Sonia Anand, a specialist in vascular medicine and a member of the McMaster research team.

The latest figures show that 15 million people died from heart attacks worldwide in 1998. “The important issue is that the risk factors outlined in this study, the vast majority of them are modifiable,” said Toronto cardiologist Anthony Graham, a spokesman for the Heart and Stroke Foundation of Canada. “And what it suggests is that tobacco control is going to be as important in the developing world as it is in the western world.”

The study’s findings are published in issue of the British medical journal
Source: The Lancet. Sept. 11 2004

New research suggests that people who smoke and drink heavily are more at risk for oral cancer, the Researchers from King’s College in London, England, found an increase in oral cancer among men and women in their 20s and 30s who smoke and binge drink.

The researchers said that when tobacco smoke combines with alcohol, it produces dangerous levels of cancer-causing chemicals that attack the lining of the mouth.

“Our data show that smoking, drinking and poor diet are major risk factors, and that the younger people start smoking and drinking, the higher the risk,” said Newell Johnson, a professor of oral pathology at King’s College

Source: Daily Telegraph, London reported Nov. 9.2004

A DECISION by the Dutch government to decriminalise the smuggling of hard drugs could leave Britain vulnerable to a flood of cheap cocaine.
Customs officers are allowing traffickers caught at Schiphol airport, Amsterdam, with less than 3kg of cocaine to go free. The only penalty they face is the confiscation of their drugs.

In the first phase of a policy that could soon be extended to other hard drugs, the liberal measures are being applied to 35 so-called “cocaine flights” a week from the Caribbean.
Last year police caught 2,176 smugglers from the region and seized six tons of the drug. But from now on, traffickers no longer have to worry about hefty prison terms or even arrest.
The policy may prove even more controversial than Holland’s infamous “coffee shops”, where soft drugs such as cannabis have been sold openly for decades.
The Dutch authorities claim the measure will allow them to divert money spent prosecuting offenders into drug seizures. However, critics in neighbouring countries, including Britain, fear it will lead to a boom in the number of people ready to act as “mules” for drug cartels.
The National Drug Prevention Alliance in Britain has warned that the policy amounts to a capitulation by the police with consequences that could spin out of control.
“This won’t just hit the UK badly. It will affect the whole of Europe,” said David Raynes, a former chief narcotics investigator for Customs and Excise. “Holland is the drugs warehouse of Europe and by not controlling its problem it’s creating an infection that will spread to all the countries around.”
In Germany the street value of cocaine has already fallen from €150 (£102) a gram to just €50 (£34), raising the prospect of a sharp rise in the number of addicts. The Dutch government has ignored a plea from Otto Schily, the German interior minister, to toughen rather than weaken its deterrent.
However, Ivo Hommes, a spokesman for the Dutch justice ministry, said the initiative could save millions spent on prosecuting and jailing offenders, allowing more funds to go into the detection and confiscation of drugs. “Locking up thousands of smugglers doesn’t solve the problem. There will always be more of them,” he said. “We’ve been honest enough to admit that we only manage to stop 15% of the drugs coming in, so we are trying something new.”
A leaked ministry memorandum, however, has suggested that the policy was adopted because the prosecution service was overburdened. It emphasised that drug-related arrests should not be permitted to “block the justice system”. Britain’s National Criminal Intelligence Service is said to be eyeing the policy “warily”.
Source: February 01, 2004 The Sunday Times

Two Genes May Fuel Cocaine Addiction
Removing them caused withdrawal symptoms in mice
— Two related genes that help control signaling between brain cells may play an important role in cocaine addiction, says a study in the Aug. 5 issue of Neuron.
In research with mice, scientists found that deleting either of the two genes in the “Homer” family caused symptoms similar to those of cocaine withdrawal. The finding provides a new research target for trying to understand how both a genetic susceptibility to addiction and environmental factors cause addiction.
The study found the Homer1 and Homer2 genes appear to be specific for cocaine. When the researchers tested the effects of caffeine and heroin on mice that lacked the Homer genes, the rodents’ behavioral responses weren’t the same as they were with cocaine.
“While it can be anticipated that additional genetic models may be discovered that mimic or block behaviors associated with cocaine addiction, the striking concordant neurochemical phenotype between Homer2 deletion and withdrawal from chronic cocaine treatment indicates that Homer is a particularly good candidate to play a central role in cocaine addiction,” the study authors wrote.

Source WEDNESDAY, Aug. 4 (HealthDayNews) 2004