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Amphetamine Epidemics

AMPHETAMINE EPIDEMICS

Amphetamine, Methamphetamine, and related compounds have relatively brief abuse histories, dating from the 1930s and 1940s. Similar to the other major Psychomotor Stimulant of abuse, Co-Caine, the amphetamines are addictive, and a number of cycles of epidemic use have occurred in the United States and in other countries. Unlike cocaine, however, the amphetamines do not occur in nature and can only be synthesized in a laboratorya distinction that significantly influences the manufacture, distribution, and abuse patterns of the drugs.

EARLY USE IN THE UNITED STATES

Amphetamines were initially synthesized in 1887, with methamphetamine being developed approximately thirty years later. The rise in the popularity of the amphetamines parallels that experienced during the introduction of cocaine. Exaggerated publicity and fallacious claims about amphetamines, combined with medical optimism concerning potential uses and a lack of understanding of abuse, contributed to a dramatic increase in public interest in amphetamines. In 1933, Central Nervous System stimulant actions of amphetamines were reported, about the same time that reports of their effectiveness in treating narcolepsy and Parkinson's disease were released. When the American Medical Association (AMA) approved the use of amphetamines for these disorders, a mild warning was added that "continuous doses higher than recommended" might cause "restlessness and sleeplessness," but physicians were assured that "no serious reactions had been observed." Between 1932 and 1946 the pharmaceutical industry developed more than three dozen generally accepted clinical uses for amphetamines, among them the treatment of schizophrenia, morphine and codeine addiction, tobacco smoking, heart block, head injuries, infantile cerebral palsy, radiation sickness, low blood pressure, seasickness, and persistent hiccups. It was not until several decades later that the addictive properties and psychiatric complications of amphetamines were fully recognized by the medical community.

U.S. PATTERNS AND TRENDS

In the 1940s and 1950s amphetamines were prescribed liberally and soon surpassed cocaine as an illicit stimulant widely available on the street. The increase in the popularity of amphetamines was influenced by easy availability, low cost, and long duration of effect (eight to twelve hours). Between the 1930s and the 1970s the public could obtain amphetamines, such as Benzedrine, in a variety of over-the-counter (OTC) nasal inhaler preparations. Abuse involved breaking open the inhalers and ingesting directly or soaking the fillers in alcohol or coffee. Although inhaler use may have introduced hundreds of thousands of Americans to amphetamine abuse, this type of abuse was most prevalent in prison populations and among deviant groups. The ability to cause euphoria, dysphoria, and psychic stimulation resulted in removal of amphetamine-like drugs from OTC inhaler preparations in 1971. However, amphetamine products remained available in pill, capsule, or injectable form.

During World War II, methamphetamine and amphetamine were widely used by the American, British, German, and Japanese military as insomniacs and as stimulants to increase alertness during battle and night watches; they were used as well by war-related industries to enhance worker productivity. Perhaps as many as 200 million tablets and pills were supplied to American troops during the war. The U.S. armed services authorized the issue of amphetamines on a regular basis beginning with the Korean conflict, escalating to well over 225 million standard-dose tablets dispensed between 1966 and 1969.

R. R. Monroe and A. H. Drell (1947) reported that at the end of World War II, some soldiers who had used amphetamines returned home with drug habits. In addition, during the 1940s and 1950s enormous quantities of these drugs were prescribed in the civilian population without concern for any addictive effects, as the drugs continued to be marketed to treat obesity, narcolepsy, hyperkinesis, and depression. College students, athletes, truck drivers, and housewives began using amphetamines for nonmedical purposes, primarily to increase energy, decrease the need for sleep, lose weight, and elevate mood. Pharmaceutical production reached 3.5 billion tablets (about 20,000 standard dosage units per thousand U.S. residents) in 1958 and 10.0 billion tablets by 1970. In comparison, the medical use of amphetamines in 1996-98 averaged approximately 1.8 standard dosage units per thousand U.S. population.

One consequence of excessive production and widespread popularity of amphetamines was the diversion of pharmaceutical-grade drugs to illegal traffic and use. Drugs sold on the black market came from or would otherwise have gone to pharmaceutical companies, wholesalers, druggists, and physicians. Probably over half (and potentially 90 percent) of the total commercial product was diverted into the black market. In 1966, the Food and Drug Administration (FDA) estimated that more than 25 tons of amphetamine were illegally distributed (Fischman, 1990). One market for the product was composed of long-distance truck drivers who found that amphetamines allowed them to work for extended periods without resting. The all-night restaurants and truck stops served as a distribution network that spanned the entire country.

By the mid-1960s, the need for intervention and legislative controls over amphetamine production and distribution was clear. The Drug Abuse Control Amendments of 1965, passed by Congress, required increased record keeping throughout the system of manufacture, distribution, prescription, and sale. However, diversion of pharmaceutical amphetamine to illicit use continued. The Con-Trolled Substances Act (CSA) was passed in 1970. It further established the legal foundation of the government's fight against drug abuse, and placed amphetamine and some related stimulant drugs in Schedule IIacknowledging the drugs' high potential for abuse, development of psychological or physical dependency, and restricted medical use. In 1971 the Justice Department began imposing quotas on legal amphetamine production.

A significant shift from abuse of oral preparations to abuse of the intravenous form occurred during the 1960s. Intravenous methamphetamine abuse, described by S. M. Pittel and R. Hofer (1970), was particularly prevalent in the Haight-Ashbury district of San Francisco, where "speed," the street name for amphetamine and methamphetamine, began to replace hallucinogenic drugs, such as LSD, in popularity. Escalating doses of methamphetamine were taken, often as a series of injections over several days or weekswhat came to be known as a "speed run." Exhaustion, then depression, accompanied the end of a run, followed by readministration of the drug to mitigate the unpleasant side effects and regain the previous euphoria and highthus the cycle of high to low to high. Initially the drugs were diverted from pharmaceutical supplies. Later, some unscrupulous physicians who were already prescribing intravenous methamphetamine to treat heroin addiction became involved in illegal prescriptions. In 1963, injectable ampules of methamphetamine were voluntarily removed by manufacturers from sale to retail pharmacies in California.

Speed use escalated during the 1960s, with the Haight-Ashbury district serving as a focal point. With this escalation came an increase in violence and the diffusion of manufacturing and distribution of speed from Haight-Ashbury to other areas along the West Coast (Smith, 1970). Outlaw motorcycle gangs became heavily involved in methamphetamine manufacture and gained control of its clandestine production and distribution. Within the subculture, serial speed users became known as "speed freaks." A public campaign was initiated to inform users of the hazards associated with speed use. Partly as a result of the "speed kills" campaign, amphetamine and methamphetamine use dropped sharply after 1972. From 1972 through 1977, the characteristics of the drug-taking population changed from heavy users to predominantly light-to-moderate users, and a growing proportion were women.

Changes in Clandestine Manufacture.

Because of increasing controls on the prescribing and marketing of amphetamine, the clandestine manufacture of methamphetamine became more widespread. The availability of illicitly synthesized methamphetamine varied greatly during the 1970s and 1980s. Analyses of street samples of drugs purported to be methamphetamine revealed that until 1974, specimens were on average less than 30 percent methamphetamine. From 1975 through 1983 the composition of methamphetamine in samples increased from 60 to over 95 percent. For the street samples submitted as stimulants, including those submitted as amphetamine, methamphetamine, or speed, methamphetamine made up a relatively small percentage between 1972 and 1979, but increased to approximately 60 percent in 1983. These data demonstrate the increasing predominance of methamphetamine in the speed market during this time period. Prior to the increase in quality of street speed, the products sold as methamphetamine or speed were usually a combination of phenylpropanolamine hydrochloride, ephedrine, and caffeine and referred to as "look-alike" speed. The term referred to the similarity of appearance of these drugs and of central nervous system effects. Other constituents also found in products purported to be speed included pseudoephedrine and cocaine.

Since the mid-1980s, virtually all substances marketed illicitly as amphetamine or by street terms, such as "speed," "crystal," "crank," "go," "go-fast," "zip," or "cristy," contain methamphetamine. By analyzing contaminants found in street methamphetamine samples, researchers have determined that clandestine manufacture of methamphetamine, rather than diversion of pharmaceutical products, now supplies the illicit marketplace. According to the U.S. Drug Enforcement Administration (DEA), methamphetamine has been the most prevalent clandestinely manufactured controlled substance in the United States, and one of the only widely abused controlled substances that can be made in the home. Along with the increase in methamphetamine laboratory seizures was a localized resurgence of methamphetamine abusesince the clandestine manufacture of the methamphetamine in a community facilitates the development of a market for the drug. Clandestine labs also create other hazards for the community since the materials used (precursors, reagents, and solvents) are hazardous in the hands of inexperienced chemists, who may cause explosions and fires. Also, each pound of methamphetamine produced creates up to five pounds of hazardous wastes, and the operators (who rarely own the property) commonly discard the wastes on or near the site, creating long-lasting chemical contamination of the area. The number of laboratories seized declined in the early 1990s, largely because of the passage and enforcement of the Chemical Diversion and Trafficking Act of 1988, which placed under federal control the distribution of twelve precursor and eight essential chemicals used in the production of illicit drugs, including phenyl-2-propanone, the major methamphetamine precursor in use at the time.

In the late 1980s, however, the clandestine methamphetamine chemists brought into production a more efficient synthesis process utilizing ephedrine or pseudoephedrine as the precursor chemical. As knowledge of this process spread, in some cases not only by word of mouth, but also via the growing medium of the Internet, the number of clandestine labs began to increase again. In 1997, 98 percent of all clandestine laboratories seized by the Drug Enforcement Administration (DEA) were producing methamphetamine and, in 1999 more than 7,000 clandestine methamphetamine labs were seized, along with over 2,250 kg of methamphetamine. Figure 1 shows that the amount of methamphetamine seized domestically increased substantially from 1990 through 1999. While most of the labs seized early in the 1990s were in California, Texas, or Oregon, in 1998 the DEA seized labs in almost every state in the nation, with 371 labs seized in Missouri.

Another factor increasing the spread of methamphetamine was a change in control of the manufacturing and distribution process. Although motorcycle gangs continued to control a share of the market, in 1995 well-established Mexico-based polydrug trafficking organizations began manufacturing and distributing methamphetamine. Importing precursor chemicals and reagents into or through Mexico, these organizations established "superlabs" in Mexico and in southern California that were capable of producing ten pounds or more of high-purity methamphetamine in one to two days. These superlabs are in marked contrast to the more numerous and widely distributed "mom-and-pop" labs producing several ounces that may be set up in a motel room, a car trunk, or on a kitchen counter. By 1999, it was estimated that superlabs were producing approximately 85 percent of the methamphetamine in the U.S. mainland. Portions of the Crime Control Act of 1990 and the Chemical Diversion Control Act of 1993, as well as the Comprehensive Methamphetamine Control Act of 1996, were all enacted to counter the changes in the synthetic process, the changes in the trafficking patterns, the emergence of superlabs, and the proliferation of mom-and-pop labs for the clandestine manufacture of methamphetamine.

Changes in Indicators of Abuse.

The Drug Abuse Warning Network (DAWN), a nationally based surveillance system that monitors emergency medical consequences and deaths related to drug use, reflected a stable trend across the United States from the mid-1970s until the mid-1980s. Over seven hundred hospitals in twenty-one metropolitan areas and a panel of hospitals outside of these areas report to DAWN. During the mid-1980s sharp increases in nonfatal emergency-room episodes began to appear, largely in metropolitan areas on the West Coast. Increases in drug-use indicators were also reported for methamphetamine through the Community Epidemiology Work Group (CEWG), a network of state and local drug-abuse experts representing twenty cities and metropolitan areas across the United States.

Total methamphetamine and amphetamine mentions in DAWN rose from earlier levels during 1988 and 1989, decreased during 1990 and 1991, then rose sharply during the early 1990s to reach an erratic higher plateau for the rest of the decade (see figure 2). Among DAWN emergency-room cases, the most common route of administration of methamphetamine was intravenous. Methamphetamine accounted for approximately 3.0 percent of the total DAWN drug mentions in 1994 and just under 2.5 percent in 1998, compared with 16.0 percent and 17.5 percent for cocaine during 1984 and 1998, respectively.

The Treatment Episode Data Set (TEDS) collects information nationwide on admissions to drug and alcohol treatment facilities that report to state administrative data systems. Data on Primary, secondary, and tertiary substances of abuse, their route of administration, frequency of use, and age at first use are among the data collected. In 1997, TEDS captured data on an estimated 67 percent of all U.S. drug and alcohol treatment admissions. From 1992 to 1997, both the absolute number of admissions reporting methamphetamine or amphetamine as the primary drug of abuse and the percentage of such admissions, relative to treatment admissions for all substances, more than tripled. The most common route was inhalation, but almost 30 percent of admissions reported injecting the drug.

The demographic profile of methamphetamine abusers in several studies that looked at different populations in the late 1980s and through the 1990s showed the majority of abusers to be predominantly Caucasian, low to middle income, high-school educated young adults generally ranging in age from 20 to 35, with slightly more males than females. However, by the end of the 1990s, there were indications of growing numbers of women and Hispanic abusers. Routes of administration tend to vary from locale to locale and from subgroup to subgroup, and include injecting intravenously, smoking (inhaling vaporized drug), and snorting. Methamphetamine abusers carry an increased risk of both Hepatitis B and HIV infections, predominantly through sharing of needles and increased unsafe sex practices.

Other U.S. Trends.

At the same time that increases were being noted in methamphetamine use on the mainland of the United States, a new phenomenon was developing in Hawaii. Sharp rises in law-enforcement activity and in clients entering treatment because they smoked a new dosage form of methamphetamine were recorded between 1986 and 1989. The street names for this drug were ice, crystal, shabu (Japanese), and batu (Filipino for rock), and it looked like a large, usually clear crystal resembling broken fragments of glass or rock candy. Ice is of high purity (90 to 100 percent) and the d-isomer (the more psychoactive molecular form) of methamphetamine hydrochloride salt. In Hawaii it is almost always smoked in a glass pipe. The hydrochloride salt is sufficiently volatile to vaporize in a pipe so that it can be inhaled. This route of administration allows rapid absorption into the bloodstream, with onset of effects similar to those experienced with intravenous administration.

The use of ice was first detected by Hawaiian treatment programs during the summer of 1986, with more widespread use occurring into the 1990s. By 1997, The Treatment Episode Data Set reported that in Hawaiian drug and alcohol treatment admissions, methamphetamine/amphetamine was the most commonly reported single primary substance of abuse, accounting for almost one quarter of all admissions. This epidemic, which was described in an outbreak investigation and follow-up field study conducted by the National Institute on Drug Abuse, involved a population varying widely in age and ethnic background and included both sexes. The ice-using treatment population was studied and reflected a younger population, with a higher representation of women and a larger proportion of Hawaiian/part Hawaiian than other drug users in treatment in the state. Ice was typically smoked in runs, or periods of continuous use, averaging three to eight days, with one or two days between runs, during which the user would "crash" into deep, prolonged sleep. Users reporting this pattern became rapidly addicted and experienced numerous adverse medical, social, and physiologic consequences. Precipitants of the epidemic included both a law enforcement campaign that effectively eradicated large portions of the Hawaiian marijuana or pakalolo crop, and well-orchestrated marketing campaigns by Asian ice distributors holding out ice as a replacement drug.

Until the late 1980s, the ice form of methamphetamine came only from Asia, specifically Hong Kong, Korea, Japan, Taiwan, Thailand, and the Philippines. Attempts to smuggle ice from Taiwan and Korea into Hawaii can be documented back to the mid-1980s by the Drug Enforcement Administration (DEA). The importation and distribution of ice in Hawaii has been linked to Asian and Hawaiian criminal organizations and gangs. By 1989, limited distribution of ice had occurred on the West Coast of the United States. In the following year, increased amounts of ice were found in California and subsequently in other limited locations. The increase in availability of ice was believed to stem from clandestine laboratories operating in California. During 1990, domestically manufactured ice began to be supplied to distributors in Hawaii and seven clandestine ice laboratories were seized nationwide, six of them in California. This domestic production was compensating for a disruption of the major Asian trafficking organizations smuggling ice from South Korea.

INTERNATIONAL PATTERNS AND TRENDS

The use and abuse of amphetamines has also occurred in countries outside the United States, although the absence of significant epidemiologic information in many countries and the lack of standardization in data collection and analysis make multinational comparisons difficult. Based on available data, amphetamine use and abuse appear to be an endemic problem worldwide and, as in the United States, other countries reflect patterns that are episodic, localized, population-specific, and rooted in multiple etiologies. Senay (1991) cites a number of studies conducted principally in the 1970s and first half of the 1980s that document this phenomenon. Amphetamine epidemics have been evident in several countries during the past fifty years and continue to be the primary concern in some. The experience of three of these, Japan, Sweden, and Thailand, are described briefly, but are described at greater length elsewhere (Kalant 1973, Klee 1997, Chaiyawong, 1999).

Japan.

Methamphetamine has been the single most prevalent drug of abuse in Japan since the 1940s. Based on indicators from law-enforcement data, epidemic patterns appeared at several periods during that time.

The increase of methamphetamine abuse in Japan during the 1940s and early 1950s has been attributed to the wholesale appearance of the drug in the black market following World War II. Both amphetamine and methamphetamine were available to Japanese forces during the war and became widely used by the beleaguered civilian population following military defeat. In response to the escalation in abuse, Japan's Stimulants Drug Law of 1951 was enacted and the eventual decline in abuse was attributed to the effectiveness of the penal provisions of the law and subsequent control of the raw materials used to produce the drug. After a hiatus of fifteen years, Japan's methamphetamine abuse began to increase again and continued at relatively elevated levels through the mid-1980s. That epidemic was associated with illicit production of the drug and trafficking by criminal organizationsYakuza and Boryokudan. The downturn in recent years is being attributed to the implementation of a stimulant-abuse prevention campaign that was begun in 1979.

Sweden.

Amphetamines also have been at the forefront of the drug-abuse problem in Sweden since the 1930s. According to a 1988 report from the Swedish Council for Information on Alcohol and Other Drugs, abuse of amphetamines increased during the three decades following their introduction to the market as an over-the-counter (OTC) medication and their widespread promotion as a treatment for a variety of health conditions. While the prevalence of heavy, dysfunctional use during that era has been disputed, amphetamine abuse continues as a predominant problem in Sweden, especially among injection drug users.

Thailand.

Thailand had a 1998 population of just over 60 million, with low unemployment (3.5 percent) and high literacy (94 percent). A major transit route for heroin from Laos and Burma, the country began experiencing a large shift in drug use patterns during the 1990s. The drug began to be more widely used in the late 1980s, as the synthesis from ephedrine came into practice. In the late 1990s, production had changed from being centralized in the hands of large crime syndicates running superlabs, to being shared with a multitude of small mom-and-pop labsa pattern opposite that of the United States. Substantial increases have been seen in a number of use indicators. Figure 3 shows changes in the percentage of patients reporting drug use in the thirty days prior to admission for methamphetamine and heroin during the period 1993 to 1997.

CONCLUSION

In the United States, the overall magnitude of use and abuse of amphetamines, including methamphetamine, is relatively minor compared with the prevalence of other illicit drugs, such as marijuana and cocaine. The National Household Survey on Drug Abuse (NHSDA), a nationally representative survey of the household population age 12 and older, estimates that by 1998, 4.4 percent had ever used stimulantsincluding amphetamines, methamphetamine, and other prescription stimulants (U.S. Department of Health and Human Services, 1998). The NHSDA also estimated that 0.7 percent of the household population had used stimulants during 1998 and 0.3 percent had used them during the month prior to the interview. These numbers are in contrast to 35.8 percent estimated to have ever used any illicit drug, 33.0 percent who reported any use of marijuana, and 10.6 percent who had ever used cocaine. However, data from the national High school senior survey, Monitoring The Future, indicate that among twelfth graders surveyed each year since 1975, annual and past-30-day use of stimulants such as methamphetamines have always been substantially higher than use of cocaine. These differences in magnitude in no way diminish the impact of the health consequences and social problems, both at the individual and at the community level, resulting from amphetamine epidemics in the United States and in other countries.

In the United States, abuse of amphetamine and methamphetamine dates back to the early part of the twentieth century. During the ensuing years, abuse of amphetamine and methamphetamine has become endemic throughout this country, with focal problematic areas. Survey data and ethno-graphic information indicate a concentration of abuse in cities along the West Coast and in Hawaii that has been moving east and north across the United States. Historically, the typical composite methamphetamine user was white, male, young adult, and with a low to middle income, but this picture may be changing. As was experienced in the Hawaiian "ice" outbreak, and as seen recently in California, methamphetamine users can include diverse ethnic and socioeconomic groups. Methamphetamine is reported by the Drug Enforcement Administration (DEA) to be the most common product of illicit drug laboratories in the United States. With extensive production and distribution systems in placeand potentially serious medical, psychological, and social consequence to abusethese drugs continue to pose a significant public health threat.

The literature suggests that abuse of amphetamines has been and remains an endemic problem among diverse populations in countries throughout the world, at times reaching epidemic proportion. Measurement of the scope of drug abuse, trend analysis, and valid cross-cultural comparisons are fraught with difficulties. However, based on history, it is clear that the prevention of future epidemics requires the implementation of an effective program of international drug-abuse surveillance, communication, and early intervention.

(See also: Epidemics of Drug Abuse ; Ethnicity and Drugs )

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Marissa Miller

Nicholas Kozel

Revised by Martin H. Leamon

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