INTRODUCTION:
In
Malaysia, the drug addiction has huge consequences to the individuals involved
and their family. It has a devastating impact on the individuals’ physical and
mental health, as well as their psychosocial well-being. Drug addiction is also
a heavy burden for the government because it needs a lot of enforcement from
the authorities and drains available health care resources. The history of
Malaysia’s battle with its drugs problems is long. Various measures were
introduced and this included the legislation of the Dangerous Act 1952 [1].
Drug
trafficking and abuse are serious issues confronting Malaysia. The illicit drug
use has been well thought-out as major social intimidation in Malaysia[1].Up
until the 1960s drug abuse in Malaysia mostly involved opium, and it was
restricted to the Chinese immigrant population. By the 1980s the Malays had become the ethnic group in Malaysia that is most likely to
abuse illegal drugs. Concerns for the rapid increase in
heroin used were so high that the government passed a decree that it was a
national threat. This led to the creation of a national anti drug task force
team along with a mandatory death sentence for anyone caught smuggling more
than 15 grams of heroin[2]. The government also decided that anyone caught using
heroin would be forced to undergo compulsory de addiction treatment. Of
particular concern is the growing popularity of methamphetamine – seizures of
this substance in 2013 were the highest on record [3].
While
the local drug situation remains serious and
challenging, recent trends and developments are a cause for concern.
Malaysia is facing a changing of drug landscape from traditional drugs such as
opium, heroin and cannabis to newer psychoactive substances particularly of
Amphetamine-type Stimulant (ATS) methamphetamine, ecstasy and eramin 5 etc [4].
The demand for ATS, and the lucrative profits generated from the trade,
continues to provide ample incentive for drug traffickers to expand their
illicit activities [5]. At the same time, improved infrastructure and increased
vehicle traffic which facilitate the smooth flow of licit goods, services, etc
simultaneously provide opportunities for an expansion of international drug
trafficking syndicates in Malaysia[6].
Reports
reveal that there is a changing landscape of Methamphetamine trafficking. Previously,
the West African region is not known to produce ATS but has prominently become
a point of origin of Methamphetamine trafficked to South East Asia including
Malaysia [1, 2]. The Nigerian syndicates in Malaysia which used to traffic
primarily cocaine and heroin, are trafficking increasing amount of
methamphetamine in Malaysia by air couriers and parcel services. Intelligence
also revealed the emergence of Afghan opiates in Malaysian shore. It’s been
trafficked from Afghanistan to Malaysia via Islamic Republic of Iran and
Pakistan by the Iranian syndicates and the Pakistani syndicates which
collaborate with the Nigerians and local syndicates [2, 5, 6]. In their bid to
avoid detection by the authorities, they diversify their mode of transportation
from using air couriers to maritime trafficking (sea cargo). Even though
maritime trafficking is the least common among cases involving other modes of
transportation i.e. via air and land route, by weight of seizure reveals that
maritime seizure is consistently the most likely to be a large seizure (more
than 6 kg) [4-6].
The
ambition of the Malaysian government has been to completely eradicate drug
problems by 2015, but the problem is in some ways getting worse [3-6].
Origin and History of amphetamines
Amphetamine was first synthesized by a Romanian
chemist named Lazar Edeleanu (A.K.A. Edeleano) at the University of Berlin in
1887, but was not used clinically until Gordon A. Alles re-synthesized the drug
in the 1920s for use in medical settings to treat asthma, hayfever, and colds. In 1932, Smith, Kline, and
French Laboratories marketed the first amphetamine product, an
amphetamine-based inhaler (trade name, Benzedrine) to treat nasal congestion.
During the remaining 1930s, amphetamines were promoted by U.S. pharmaceutical
companies as treatments for ailments such as rhinitis and asthma[7].
Methamphetamine (MA), a variant of amphetamine, was
first synthesized in Japan in 1893 by Nagayoshi Nagai from the precursor
chemical ephedrine. MA was not widely used until World War II (1940s), at which
time German, English, American, and Japanese governments began giving their
military personnel the drug to enhance endurance and alertness and ward off
fatigue [8].
Chemistryof amphetamines
Structure of Structure of
amphetamine
methamphetamine
Amphetamines are man-made chemicals that bear a close
resemblance to several naturally occurring substances―phenylethylamine,
for example, which is found in various food stuffs, including chocolate,
cheeses, and some wines. When consumed, phenylethylamine has little or no
effect because it is rapidly degraded by the enzyme monoamine oxidase[7,8].
Amphetamine is a simple synthetic derivative of
phenylethylamine, which differs only in possessing a methyl group (-CH3)
attached to the side chain (see chemical structures of phenylethylamine and
amphetamine presented on the right). This is a significant alteration,
however, as the methyl group protects amphetamine from degradation by monoamine
oxidase. As a result, amphetamine can enter and persist in the bloodstream,
positioning it to exert a variety of biological effects[9].
Because the methyl group of amphetamine can be
attached to the side chain in a left- or right-handed manner, amphetamine
exists in two different mirror-image forms, or stereoisomers. One of
these, the right-handed or dextro-isomer, is far more biologically active than
the left-handed or levo-isomer. It is referred to as ‘D-amphetamine’
(also S(+)amphetamine, dexamphetamine, dexedrine) [10].
Metabolism
The liver is primarily responsible for the breakdown
of MA. The drug undergoes oxidation and glucuronidation in the liver creating
amphetamine, norephedrine, and p-hydroxynorephedrine. The oxidation
of MA to amphetamine is partly done by cytochrome P-450 (CYP) isoenzyme
2D6. The elimination half-life (t-1/2) of MA is dependent on the urine
pH. When urine pH is six to eight, the half-life is about 12 hours,
staying constant and unaffected by the route of administration [9, 10].
Pharmacology of amphetamines
MA affects the central nervous system (CNS) by
releasing monoamine neurotransmitters such as dopamine, norepinephrine, and
serotonin[11]. Administration of MA leads to many pharmacological effects
due to its ability to use various molecular processes. MA increases
levels of monoamines by forcing the monoamines out of their storage vesicles
and expelling them into the synaptic gap by making the dopamine transporters
work in reverse. Other mechanisms by which methamphetamine are known to
increase monoamine levels are by [11-13]:
·
Blocking the reuptake of monoamines by
inhibiting the activity of monoamine transporters
·
Decreasing the expression of dopamine
transporters at the cell surface
·
Increasing cytosolic levels of monoamines
by inhibiting the activity of monoamine oxidase (MAO)
·
Increasing the activity and expression of
the dopamine-synthesizing enzyme tyrosine hydroxylase (TH)
In addition to releasing potent amounts of monoamines,
MA has a high lipid solubility that leads to a relatively fast transfer of the
drug across the blood brain barrier [12,13].
Timing of Effects
Injecting or smoking MA results in an almost
instantaneous euphoric sensation that lasts several minutes and is described by
users as a “rush;” this is then followed by a “high” (a less intense euphoric
effect) that can last for hours. When users smoke methamphetamine, it is
taken directly to the pulmonary vascular bed which has a large surface area and
can absorb the drug quickly. Smoking, consequently, approximates
injecting in terms of delivering the drug to the brain [14,15].
Unlike injecting and smoking, snorting or oral
consumption do not produce a rush. They do, however, produce a high that
lasts longer than the high associated with smoking and injecting, possibly
because snorting and oral administration result in slower and thus lengthier,
absorption [16].
Stastical analysis of amphetamine abuse in malaysia
The
drug problem in Malaysia continues to expand. Seizures of illicit drugs
increased substantially in 2011 [2-6]. During the year, record amounts of
methamphetamine, heroin and other psychotropic substances were seized, and a
large number of facilities used for the manufacture of methamphetamine, ecstasy
and ketamine were dismantled. In addition, the illicit manufacture of
nimetazepam [1-3] and illicit cultivation of the local plant kratom[2]takes
place in Malaysia (NADA and RMP 2011). Amphetamine-type stimulants continue to
pose a serious public health and law enforcement threat in Malaysia. At the
same time, the trafficking and use of heroin and cannabis are also getting
worse [1,2,5,6].
Half of
all illegal drug use in Malaysia involves heroin. It is believed that at least
1.1% of the Malaysian population is involved in illegal drug use. The number of registered drug
users is about 250,000 in a 2008 report, and is expected to reach half a
million by 2015[4].
The UNODC observed that
although heroin remains the primary drug used in Malaysia, amphetamine-type
stimulants (ATS) are the drug of choice for new drug users and those arrested
for the first time [2]. The top three drugs favoured by Malaysians last year
were heroin, crystal meth and cannabis. Transnational drug trafficking
organisations also seem to be increasingly favouring Malaysia as both a
destination and transit country for meth, according to the UNODC[2-5].
US
newspaper the Wall Street Journal (WSJ) reported drug experts as attributing
the comeback of ecstasy — which is generally more expensive than
methamphetamine, another stimulant drug — to economic expansion in countries
like Malaysia and Indonesia[6].
Seizures
of ecstasy in Malaysia multiplied more than 10 times from 60,713 pills in 2010
to 772,421 pills in 2012, according to UNODC. Seizures of meth pills in the
country also increased by 43 per cent from 364,909 in 2011 to 521,384 in 2012,
while arrests related to meth pills almost tripled from 5,863 in 2011 to 16,818
last year. Seizures of crystal meth, however, dropped 31 per cent from 1.2 tons
in 2011 to 852 kg in 2012. Crystalline methamphetamine manufacture, trafficking
and use remains the most significant drug threat in Malaysia [7].A large share
of the crystalline methamphetamine trafficked to Malaysia originates from the
Islamic Republic of Iran. Significant quantities of crystalline methamphetamine
and ‘ecstasy’ are also manufactured domestically in clandestine laboratories
using precursors and essential chemicals smuggled into the country or diverted
from licit trade.
The
UNODC noted that a whopping 227 million meth pills were seized in East and
Southeast Asia in 2012, surging 59 per cent from 2011 and increasing more than
seven times since 2008. The number of ecstasy pills seized in the region also
more than tripled to over 5.4 million pills last year from 2011. ATS have
ranked among the top three drugs of use in all countries in the region since
2009 [1-7].
Forensic data
The
average purities of methamphetamine samples analysed in 2011 – 94,000 samples
of less than 50grams and 6,300 samples of more than 50 grams – was 70%
methamphetamine. A large portion of the pills sold as ‘methamphetamine pills’
showed an average weight of 80 mg and contained unspecified quantities of methamphetamine
as well as MDMA. Heroin samples analysed in 2011 showed average purities of 10%
heroin[2].
Problems Related to Drug Addiction in Malaysia[1-6, 16 -18]
Drug addiction in Malaysia causes huge difficulties for the individual and
their family. The main problems associated with such behavior include:
·
An individual does not have to be using
these substances for very long before they become addicted to them. Once the
individual has developed a physical and psychological dependence these drugs
take over and destroy their life.
·
Most drug users do not have the financial
resources to cover their drug habit. This means that they will often turn to
crime in order to be able to afford these substances.
·
Drug abuse has a devastating impact on the
individual’s mental and physical health. Unless these people are able to stop
the substance abuse it will kill them.
·
Some individuals will become violent when
they are intoxicated from these substances. They may also engage in other
inappropriate ways
·
The drug user will be unable to live up to
their potential while they are addicted to these substances. It can mean that
their life is wasted.
·
It
is common for drug users to overdose on these substances. The fact that these
substances are provided illegally means that their strength cannot be
controlled – the individual ends up playing a dangerous game of Russian
roulette.
·
A
significant number of drug users will end up in prison. They may develop a
revolving door pattern where they are in and out of prison on a regular basis.
·
Young people who become addicted to these substances
will be limiting their future possibilities in life. It is not possible to
perform well in school or college while abusing drugs.
·
Drug users will find it hard to maintain
steady employment and most become unemployable.
Treatment of Drug Addiction in Malaysia
Up until the late 1990s the main means for tackling drug addiction was
enforced rehabilitation in detention centers. This approach has not been
successful and now other means of dealing with the problem are being
considered. Some of the options open to those who wish to escape addiction
include:
The
only illicit substance with established pharmacological treatment is opioid.
The main approach of treatment for other substances such as amphetamine and
marijuana inhalants are mainly psychosocial using matrix module, motivational
interviewing technique, 12 steps approach, etc. Ahmad H et al studied
the efficacy and safety of aripiprazole for treatment of psychosis, retention
and abstinence in patients with methamphetamine dependence. The study showed
that aripiprazole was no more effective than placebo inmaintaining abstinence
from methamphetamine use. However, it facilitated treatment retention and
reduced the severity of psychotic symptoms. Aripiprazole was found to be generally
safe and well tolerated [17,18].Studies on the pharmacological treatment of
opiods involved methadone and acupunture [19, 20].
Lua et
al studied the clinicaloutcomes of methadone maintenance treatment (MMT)
aloneand MMT plus AA (MMT+AA) in terms of the daily methadonedose, number of
cigarettes smoked/week, relapse rates, and withdrawal symptoms. The findings
implied that AA could be beneficial as an adjunct to MMT in managing addiction,
but the effectiveness of AA still requires further extensive investigation
[20]. In another study, Lua et al looked into patient satisfaction level and
preferred coping strategies among MMT patients in addition to AA intervention;
and found that addition of of AA did not influence patient satisfaction and
their coping ways [21]. Mahmood Nazar M et al studied drug substitution
therapy; the success and limitations of the methadone and buphrenorphine
maintenance programmes. The study looked at GPs’ adherence to the Ministry of
Health-prescribed maintenance protocols, the number of clients/patients under
the Drug Substitution Therapy (DST), psychosocial intervention given and record
keeping. They found more than 50% of the respondents reported benefits of the
therapy; however incidences of nonadherence among the GPs were also identified.
More importantly, almost half of the respondents reported abusing the
substitute therapy by injecting and mixing with other substances [22, 23].
RECOMMENDATIONS:
There
have been many claims made about the ability to cure addiction, but in reality
evidence show even the most elaborate forms of treatment produce minimal
success (less than 10%effectiveness) [24]. This is because addiction is a
chronic relapsing disorder and requires multiple treatment programmes and long-
term treatment modalities [25]. Most often, treatment approach require
psychological and social intervention with additional pharmacological
treatment. It has been reported that treatment programmes which concentrate
only to rehabilitation programmes like those in Serenticentres, produce poor
results and inefficient use of public funding [26]. As mentioned above,
in Malaysia, after many years of experimenting with social treatment and
ignoring medical input, the drug addiction problem has not only escalated but
has exposed our society to the danger of the HIV and AIDS epidemic [27].
Therefore, it is timely for us to rethink of new
approaches forward by combining the medical and psychosocial approach in
managing the addiction problem in Malaysia[28]. It is the hope for present and
future generations to continue enjoying an independent Malaysia without
succumbing to drug addiction [29]. Otherwise, a situation may arise in which
the next generation will die prematurely or lose their potential to maintain
what we currently enjoy. This is because addiction to drugs is like a silent
virus that, once established, can make our whole generation be enslaved by
their addicted brain [30].
CONCLUSION:
The
changing trend of drug problems from traditional drugs of abuse such as
cannabis and opioids towards synthetic drugs such as methamphetamine and Amphetamine-type
Stimulants (ATS) reveals the need to move in that direction. Future studies
should focus on these changes from opioid-based substances to recreational
drugs such as MDMA (3,4 methylenedioxy-N-methylamphetamine) that is widely used
socially, thus suggesting future epidemiological and clinical research studies
addressing the prevalence of synthetic drugs.
There
should be more collaboration with law enforcement agencies such as the police
and Agensi Anti DadahKebangsaan to establish data on prevalence of ATS, and
other drugs abused in Malaysia [31, 32].
More
attention should be given to studying special populations who abused drugs such
as prison inmates, female drug abusers and homosexual/bisexual drug abusers, as
well as the scope of issue covering drug abuse, HIV/AIDS and mental health
problems. Outcomes of substance abuse treatment should be studied in detail to
evaluate and ensure the effectiveness of current approaches. New treatment modalities
are another aspect to be explored as drug problems become more complicated and
are interwined with more biological and psychosocial factors. However, we
should expand our knowledge on substance abused such as kratom and betel quid
which are specific to our region. The possibility of using kratom as a drug
replacement therapy for opioids dependency should be properly and extensively
studied. Effortsto determine the co-morbid mental illness among drug abusers seeking
treatment must be intensified.
CONFLICT
OF INTEREST:
None
REFERENCES:
1. Abdul
Rani K. The misuse of drugs in Malaysia: past and present. Malaysian Anti-Drugs
Journal 2007; (1): 1-24.
2. Patterns
and Trends of Amphetamine-Type Stimulants (ATS) and Other Drugs - Challenges
for Asia and the Pacific 2013.www.unodc.org/southeastasia and pacific/en/ats-2013.html.
[assessed on 05-02-2015].
3. Kamarudin
H, Abd Majid MI, Abdull Halim A, et al. A study of drug abuse among new
students of institutions of higher learning. [Kajian pengaruh dadah dalam
kalangan pelajar baru institusi pengajian tinggi.]. Malaysian Anti-Drugs
Journal 2007; (2): 1-12.
4. Kamarudin
H, Abd Majid MI, Abdul Halim A, et al. A study of drug abuse among
students in the public institutions of higher learnng.[Kajian penyalahgunaan
dadah bagi pelajar lama institusi pengajian tinggi awam.]. Malaysian Anti-Drugs
Journal 2008; (3): 153-73.
5. Mahmood
Nazar M, Sabitha M, Nadiyah E, et al. Pattern of substance and drug
misuse among youth in Malaysia. Malaysian Anti-Drugs Journal 2008; (3): 1-56.
6. Sabitha
M, Mahmood Nazar M, Rosnah I. Trend dan punca penggunaan dadah di kalangan
penagih dadah wanita di negeri Sabah: implikasi kepada rawatan dan pemulihan
dadah. Malaysian Anti-Drugs Journal 2007; (2): 111-36.
7. Wolkoff
DA. Methamphetamine abuse: an overview for health care professionals. Hawaii
Medical Journal 1997 Feb;56(2):34-6.
8. MacKenzie
RG, Heischober B. Methamphetamine. Pediatrics in Review 1997 Sep 1;18(9):305-9.
9. Sulzer
D, Mark SS, Poulsen NW, Galli A. Mechanisms of neurotransmitter release by
amphetamines: A review. Progress in Neurobiology 2005; 75:403-33.
10. Nagai T,
Kamiyama S. Forensic toxicologic analysis of methamphetamine and amphetamine
optical isomers by high performance liquid chromatography. International
Journal of Legal Medicine 1988 Sep; 101(3):151-9.
11. Alles
GA. The comparative physiological actions of the DL-B-phenylisopropylamines. I.
Pressor effect and toxicity. The Journal of Pharmacology And Experimental
Therapeutics 1993; 47:339-54.
12. Edeleano
L. Über einige derivative der Phenylmethacrylsaure und der
Phenylisobuttersaure. Berl Dtsch Chem Ges 1887;20:616-22.
13. McGuinness
T. Methamphetamine abuse. American Journal of Nursing 2006 Dec; 106(12):54-9.
14. Derlet
RW, Heischober B. Methamphetamine. Stimulant of the 1990s? Western Journal of
Medicine 1990 Dec; 153(6):625-8.
15. Lineberry
TW. Methamphetamine Abuse: A Perfect Storm of Complications. Mayo Clinic
Proceedings 2006 Jan 1;81(1):77-84.
16. Meredith
CW, Jaffe C, Ang-Lee K, Saxon AJ. Implications of Chronic Methamphetamine Use:
A Literature Review. Harvard Review of Psychiatry 2005 May; 13(3):141-54.
17. Ahmad Hatim
S, Gill JS, Mas Ayu S, et al. A randomized, placebocontrolled trial of
aripiprazole for the treatment of methamphetamine dependence and associated
psychosis.Int J Psychiatry ClinPract 2013; 17(2): 131-8.
18. Ahmad
Hatim S, Mas Ayu S, Mohd Hussain H, et al. The risk andassociated
factors of methamphetamine psychosis inmethamphetamine-dependent patients in
Malaysia. Compr Psychiatry 2013
19. Ahmad
Hatim S, Mas Ayu S, Gill JS, et al. Non-psychotic psychiatric
comorbiditiesin patients with methamphetamine dependence inMalaysia.
International Medical Journal (Tokyo) 2013; 20(4).
20. Lua PL,
Talib NS. Auricular acupuncture for drug dependence: an openlabel randomized
investigation on clinical outcomes, health-related quality of life, and patient
acceptability. AlternTher Health Med 2013; 19(4):28-42.
21. Lua PL,
Talib NS, Ismail Z. Methadone Maintenance Treatment Versus Methadone
Maintenance Treatment Plus Auricular Acupuncture: Impacts on Patient
Satisfaction and Coping Mechanism. J Pharm Pract 2013.
22. MahmoodNazar
M, Muhamad Dzahir K. Drug substitution therapy: success and limitations of the
methadone and bephrenorphine maintenance programmes. Malaysian Anti-Drugs
Journal 2007; (1): 25-72.
23. Zulkhairi
A, Mahmood Nazar M. Effectiveness of counselling and drug rehabilitation programme:
perspective of the inmates of PusatSerenti. Malaysian Anti-Drugs Journal 2007;
(2): 13-28.
24. National
Anti-Drug Agency. Ministry of Home Affairs, Malaysia. Available from:
www.adk.gov.my. 13 January 2008.
25. Chawarski,
MCM, Schottenfeld, RSM. Behavioural drug and HIV risk reduction counselling
(BDRC) with abstinent-contigent take-home buprenorphine: A pilot randomised
clinical trial. Drug Alcohol Depend 2007.vol: pp?
26. Rusli N,
Abdul Rahman I, Mohamed Rusli A. Prevalence of sexually transmitted diseases
among new female drug abusers in a rehabilitation centre. Malays J Med Sci
2001; 8(2): 9-13.
27. Vicknasingam
B, Narayanan S, Navaratnam V. Prevalence rates and risk factors for hepatitis C
among drug users not in treatment in Malaysia. Drug Alcohol Rev 2009; 28(4):
447-454.
28. Mazlan,
MS., RS. Chawarski, MC, New challenges and opportunities in managing substance
abuse in Malaysia. Drug Alcohol Depend 2006; 25(473-78).
29. Prison Statistics Report. Prison Department of Malaysia; 1996.
30. Habil,
H. Managing heroin addicts through medical therapy. Kuala Lumpur: University
Malaya Press, 2001.
31. Nasir M,
Nurfadhlina M, Nazila T, et al. High frequency of CYP3A4* 1B among
opiate dependent patients in Malaysia. Journal of Addiction Research and
Therapy 2012; 3(3): 1000130.
32. Sim MS,
Hatim A, Reynolds GP, et al. Association of a functional FAAH
polymorphism with methamphetamine-induced symptoms and dependence in a
Malaysian population. Pharmacogenomics 2013; 14(5): 505-514.
