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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 210-217

A retrospective chart review of trends and clinical characteristics of patients with amphetamine-type stimulant use disorder in a tertiary care center of Mumbai


1 Department of Psychiatry, CMC, Vellore, Tamil Nadu, India
2 Department of Psychiatry, Bombay Drug Deaddiction Center of Excellence, Seth G.S Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Amitkumar Ashok Chougule
Akshaysagar Bungalow, Shrikrishna Colony, Patolewadi, Kolhapur - 416 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_65_17

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  Abstract 

Introduction: This study aims to understand the sociodemographic and clinical profile of amphetamine-type stimulant (ATS) abusers seeking treatment from a tertiary care teaching hospital in Mumbai.
Materials and Methods: Retrospective chart review at deaddiction outpatient department of a tertiary care center in Mumbai using semi-structured printed proformas of the cases presenting with ATS use during the study period.
Results: The sample consisted predominantly of single males from lower socioeconomic strata of society, mainly comprising of students with a mean age of 21.66 (standard deviation [SD] = 4.699), with mean age of onset of ATS use being 17.35 (SD = 2.361). The mean duration of ATS consumption was 2.50 months (SD = 1.766) and the mean quantity of consumption in grams was 28.16 (SD = 20.599). Comorbid substance use was present in 80.9% of cases. A comparison was made between patients who presented with ATS use only (A) and ATS-dependent individuals who also used other psychoactive substances (AP). The mean age in years of (A) was lower 19.31 (SD = 4.47) as compared to AP Group 22.22 (SD = 4.61). The (A) Group had significantly longer mean duration of ATS use (3.15 vs. 2.35 months, t = 1.498, P = 0.006), higher number of students as compared to AP Group (69.2% vs. 41.8%, P = 0.07) and significantly more number of patients from ATS only (A) Group presenting with intoxication as compared to AP Group (38.5% vs. 12.7%, P = 0.044).
Conclusions: ATS which are recently introduced drugs in the market have serious health consequences, and its abuse is more common in young, single male students from lower socioeconomic status who have comorbid substance use leading to adverse life events.

Keywords: Amphetamine-type stimulants, chart review, mephedrone, methamphetamine, retrospective


How to cite this article:
Chougule AA, Adarkar S, Kadam K, Parkar S. A retrospective chart review of trends and clinical characteristics of patients with amphetamine-type stimulant use disorder in a tertiary care center of Mumbai. J Med Soc 2018;32:210-7

How to cite this URL:
Chougule AA, Adarkar S, Kadam K, Parkar S. A retrospective chart review of trends and clinical characteristics of patients with amphetamine-type stimulant use disorder in a tertiary care center of Mumbai. J Med Soc [serial online] 2018 [cited 2019 Aug 19];32:210-7. Available from: http://www.jmedsoc.org/text.asp?2018/32/3/210/251999


  Introduction Top


Amphetamine-type stimulants (ATS) are compounds that contain the basic substituted phenylethylamine structure of amphetamine as a skeletal component. Some members of this class include amphetamine, methamphetamine (METH), methcathinone (MD), phentermine, methylenedioxyamphetamine, and 3,4 methylenedioxymethamphetamine. Mephedrone also known as 4-methyl MD is a synthetic stimulant drug of amphetamine and cathinone classes. Recently, two types of ATS METH and mephedrone have become rampant in Mumbai and across India and have spread in the major cities of India at an epidemic proportion.[1],[2],[3],[4],[5]

ATS comes in powder, pills, or in the crystal form that can be crushed with cards and snorted. The drug can also be swallowed, injected, and smoked. Its forms are powder (usually white, but may be of other colors) or crystalline. Ice (glass or Tina) is a highly purified form of d-METH which is intended for smoking.[6],[7],[8]

ATS has multiple street names in Mumbai. METH is called as crystal, crystal meth, meth, and white, while mephedrone is called as MD, Drone, M-CAT, or Meow Meow.

A 2008 United Nations Office on Drugs and Crime Reports estimated 25 million abusers of amphetamines worldwide, exceeding the number of users for both cocaine (14 million) and heroin (11 million). In the last decade, Southeast Asia and East Asia have become global hubs for METH production and trafficking. Epidemic of psychostimulant abuse has been reported in these regions. It is estimated that over half of the world's METH consumers reside in Southeast Asia and East Asia. While meth has long been a problem across East and Southeast Asia, it has become a concern in India and Mumbai in the past 18–24 months.[9],[10],[11]

Along with China, India is the most commonly cited origin of illicit shipments of ATS precursor drugs destined for meth laboratories abroad particularly in neighboring Myanmar but as far afield as Central America and Africa.[12],[13],[14]

The acute effects of METH are those of the flight-or-fight response and central nervous system stimulation, which may result in euphoria, increased energy and alertness, intense curiosity and emotions, decreased anxiety, and enhanced self-esteem.[15],[16],[17],[18],[19]

It has been estimated that 40% of METH users have neuropsychiatric deficits. METH abusers suffer from mental illnesses, with anxiety, depression, and psychosis being the most common effects.[20],[21],[22]

METH use is high in men who have sex with men. Greater frequency of METH abuse is observed in homosexual and bisexual men in comparison to the general population.[15]

No medication is currently approved by the US Food and Drug Administration (FDA) for use in amphetamine-like stimulant abuse. Although considered preliminary, several therapeutic agents were identified that may prove beneficial in treating METH-dependent patients which include bupropion, mirtazapine, baclofen, topiramate, and risperidone. Psychosocial therapy remains the cornerstone of treatment, and drug therapy should be regarded as an adjunct, rather than a replacement for psychosocial approaches.[23],[24],[25],[26],[27],[28],[29]

ATS use is an emerging trend in India, with most users in their early twenties. This is a new-generation drug that has suddenly gained popularity in the market. The pushers are aiming at the young population including school and college students, aspiring actors, and advertising professionals. This is an area of extreme concern. Currently, no major Indian studies are available which are related to ATS abuse. ATS abuse has become a new challenge to addiction medicine specialist, and this prompted us to conduct this study.


  Materials and Methods Top


The study was conducted in the Drug Deaddiction Center under the Department of Psychiatry, at a tertiary care teaching hospital in Mumbai, Maharashtra, India. The Institutional Ethics Committee approval was taken before initiating the present study. Privacy and confidentiality of the cases were maintained by assuring that only the principal investigator and coinvestigator had access to patient proforma/file. All the patients presenting to the deaddiction Outpatient Department (OPD) from August 2014 to February 2015 were taken up for the present study.

The study was done by retrospective chart review method. Initially, all the proformas during the study period were screened. The proforma of the patients diagnosed with ATS use disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria by a professor or an associate/assistant professor was selected for the study. We found 68 proformas satisfying our inclusion criteria which formed our sample size. As our case record proforma has a printed and semi-structured format, complete and reliable information was available in all the records. Information was collected on sociodemographic and clinical variables. The data thus obtained were noted in a specially designed data sheet prepared for the present study. Our department also maintains a register where details of patients who followed up in deaddiction OPD are maintained.

Descriptive statistics regarding the percentage were used for categorical variables; mean and standard deviation (SD) were calculated for the continuous variables. The data obtained were analyzed using appropriate statistical software for Windows. The independent sample t-test and the Chi-square/Fisher's exact test were used for the comparison of continuous and categorical variables, respectively.


  Results Top


During the study period (August 2014–February 2015), total number of patients presenting to our deaddiction OPD was 815, out of which 68 cases were of ATS use disorder. Thus, 8.34% of the total sample had ATS use disorder.

The key sociodemographic findings of this study are as follows [Table 1] and [Table 2].
Table: 1 Sociodemographic variables (n=68)

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Table 2: Sociodemographic variables

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95.6% of the cases were male. The mean age of the presentation was 21.66 (SD = 4.699) years and mean age of the onset of ATS use was 17.35 (SD = 2.361) years with minimum age at presentation being 14 years and a minimum age of the onset of ATS use being 13 years. We found that 85.3% of the cases were single, 66.2% belonged to lower socioeconomic status. About 50% of the cases were undergoing secondary education, and 29.4% were in junior college. Nearly half 48.5% of the cases were students. Study of the current employment status revealed that 74.2% were unemployed. About 44.1% of cases belonged to central suburbs of Mumbai. In 42.6% of cases, mother accompanied the case to our OPD while in 33.8% of cases it was father who accompanied the cases.

The most common mode of consumption in 62 (91.2%) cases was by snorting, and 21 (30.9%) cases had binge pattern of intake of ATS. The total duration of ATS consumption was <1 month for 32.4% of cases and between 1 and 3 months for 35.3% of cases. The total quantity of drug consumption was up to 10 g for 32.4% of cases and up to 25 g for 38.2% of cases. About 35.3% of cases spent approximately Rs. 5000–7000 per month for procuring drugs. About 73.5% of cases were attracted toward ATS as it was introduced in the market as a new drug which gives the best possible high at a low price, and it is odorless, smokeless, and does not require any special equipment to consume.

Comorbid substance use was present in 80.9% of cases, and in 38.2% of these cases, it was tobacco + cannabis. In 27.2% of cases, it was polysubstance use where cases indulged in ATS, cannabis, tobacco, alcohol, and opioids. The comorbid substance in the form of opioid, alcohol, and tobacco was used by 5.9%, 5.5%, and 4.4% of the cases, respectively [Table 3].
Table 3: Type of comorbid substance use (n=55)

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About 67.64% of cases had a family history of psychiatric disorder or substance use disorder.

51 (75%) cases suffered multiple adverse life events or stressors secondary to ATS use such as academic failures/loss of job/interpersonal issues/family problems. Three (4.4%) male patients reported homosexual behavior under the influence of ATS.

Nearly 50% of cases had premorbid personality or temperament of Cluster B type. Caregivers of 67.7% of cases reported behavioral changes secondary to ATS use. These behaviors comprised new-onset aggression, irritability, lying, stealing, illegal activities, and defiance.

About 73.5% of cases presented to our OPD within 7 days of last consumption. Nearly 17.6% presented with intoxication, 4.41% of cases presented in delirium, and 23.5% of cases presented in withdrawal. 8.8% of cases presented with ATS-induced psychotic disorder while 5.8% of cases presented with ATS-induced mood disorder. Cases presenting with a psychotic disorder had symptoms comprising of severe aggression, hostility, extreme fearfulness secondary to visual hallucinations, increased psychomotor activity, and delusions of persecution, while those with mood disorder presented mainly with symptoms suggestive of a depressive disorder such as pervasive sad mood, anhedonia, loss of motivation, guilt, and loss of appetite. 45.6% of cases had Grade 2 insight, and motivation was poor in 73.5% of cases [Table 4].
Table 4: Clinical presentation secondary to amphetamine-type stimulant use (n=68)

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All the cases were diagnosed on the basis of DSM-5 criteria as stimulant use disorder, and all the comorbid substance use disorders and psychiatric disorders were also diagnosed on the basis of DSM-5 criteria. 29 (42.6%) of the cases had mild severity, 28 (41.2%) of the cases had moderate severity, and 11 (16.2%) of the cases were severe according to the DSM-5 criteria for ATS use disorder.

50% of cases were treated with adequate doses of risperidone while 20.6% of cases were treated with mood stabilizers. All the cases received psychoeducation, behavior therapy along with contingency management.

A comparison was made between patients who presented with ATS use only (A) and ATS-dependent individuals who also used other psychoactive substances (AP) [Table 5]. The mean age in years of the ATS only group (A) was lower 19.31 (SD = 4.47) as compared to AP group 22.22 (SD = 4.61). The ATS only group (A) had significantly longer mean duration of ATS consumption as compared to AP Group (3.15 vs. 2.35 months, t = 1.498, P = 0.006). ATS only (A) group had a higher number of students as compared to AP Group (69.2% vs. 41.8%), P = 0.07). ATS only group (A) had a higher number of patients with psychiatric comorbidity as compared to AP Group (27.3% vs. 14.5%). Significantly more number of patients from ATS only (A) group presented with intoxication as compared to AP Group (38.5% vs. 12.7%, P = 0.044). Family history of substance use disorder was present in less number of patients from ATS only group (A) as compared to AP Group (30.8% vs. 58.2%, P = 0.070).
Table 5: Comparison of pure amphetamine-type stimulant users (A) and amphetamine-type stimulant users with polysubstance abuse (AP)

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  Discussion Top


This study systematically evaluated the sociodemographic details, clinical profile, and current trends in cases with ATS use disorder presenting to a tertiary care center in Mumbai, India. We have not come across any previous study done in an Indian setting in this area.

Percentage of ATS users among the total number of patients visiting deaddiction OPD during the study period was 8.34. Data from a study conducted on the US population (2005, NSUDH) had a prevalence rate of 0.7% for METH use in the past year. The high rate of prevalence in our study can be attributed to selective sampling from a deaddiction OPD and recent introduction of ATS in the Mumbai market leading to the sudden rise of ATS use in this population.

Our study shows that young males with early age of the onset of substance use, from lower socioeconomic status who are single and school going have high prevalence of ATS use. These findings were similar to a prevalence study conducted in the United States[30] and in South Africa.[31]

The high prevalence of cases with lower socioeconomic status (66.2%) can be attributed to the high probability of these cases coming to our center. Our deaddiction center is run by Municipal Corporation providing low-cost care and is highly accessible, thus leading to greater treatment-seeking behavior in cases belonging to lower socioeconomic status. Hence, the findings show a prompt need to create awareness in this high-risk population through social media, awareness campaigns in schools and colleges, training of school teachers in assessing, and referral of cases in need of treatment.

The most common mode of consumption was by snorting. The reason for this can be a better and quicker high experienced by snorting as compared to other modes such as smoking, ingestion, etc., Thus, the nasal mucosa should be examined for any bleeding and ulcerations in all cases.

About 35.3% of the cases spent nearly Rs. 10,000–20,000 for procuring drugs. 23.5% of the cases consumed up to 50 g of the substance and 5.9% of cases consumed up to 75 g of the substance. As reported by parents, their children were involved in antisocial acts such as theft and robbery to get money for procuring drugs. They also engaged in activities such as selling their costly mobile phones, other household items, frequently lying to their parents, and become aggressive if they do not get money for substance use. As shown in our study, nearly 35.3% of cases developed antisocial personality changes, and 32.4% became irritable and aggressive secondary to ATS use.

We also came across the fact that nearly 25% of cases started using ATS due to false messages spread in the market by antisocial elements such as the substance was a cheap form of cocaine, it will help to give up opioid addiction, it will help in studying whole night by increasing concentration and decreasing sleep. Other 75% of cases started using this substance due to its beneficial properties such as being odorless, handy, smokeless, and no special equipment was needed to consume the drug. It was also considered glamorous as compared to other narcotics.

38.29% of the cases had comorbid substance use in the form of tobacco and cannabis smoking. Furthermore, a study conducted in USA[30] reports that early exposure to nicotine influences the development of stimulant addiction, and smokers with comorbid drug use have more severe stimulant use and may be more treatment resistant.

12 (17.6%) cases presented to OPD or casualty with ATS intoxication. The main symptoms of ATS intoxication were aggression and agitation. This finding was similar to previous study.[32] Other features seen were impaired social and personal judgment, insomnia, and anorexia. 16 (23.5%) cases reported withdrawal symptoms after discontinuing ATS use. The main symptoms reported by cases in withdrawal were dysphoria, severe craving, hypersomnia, hyperphagia, apathy, and anhedonia. The withdrawal symptoms peaked in 2–3 days of last consumption and generally lasted for 7 days.

6 (8.8%) cases presented with ATS-induced psychotic disorder. The presentation was similar to that of schizophrenia spectrum disorders. Hence, it is very important to rule out ATS use before the diagnosis of schizophrenia is made. ATS-induced psychotic disorders have symptoms such as visual hallucinations, hyperactivity, hypersexuality, confusion, and incoherence while the effect is appropriate unlike schizophrenia spectrum disorders. According to Bramness et al., amphetamines may induce symptoms of psychosis very similar to those of schizophrenia spectrum disorders. This has been an argument for using amphetamine-induced psychosis as a model for primary psychotic disorders.[33]

4 (5.88%) cases presented with ATS-induced mood disorder which was depression in all cases. Zweben et al. in 2004[34] also reported that depression was the most common ATS-induced mood disorder. The prevalence of ATS-induced intoxication, psychotic, and mood disorder was very less in our study as compared to the previous study conducted by Vos et al.[32] in South Africa in 2010 which reported the prevalence of these disorders in the range of 70%–80%. This difference can be attributed to the recent introduction of ATS in Mumbai with duration of <1 year. Furthermore, nearly 60% of our cases used ATS for a duration of <3 months, and quantity was <25 g.

Nearly one-third of the cases had a binge pattern of use. The binge pattern consists of continuous, rapid, and compulsive use of ATS for a period ranging from 4 to 7 days without sleep or food. This part is called a “RUN” which is followed by loss of consciousness or dizziness with hypersomnia, dysphoria, apathy, and sad mood for a few days which is called a “CRASH.” This history is very important as the majority of severe medical complications such as hyperthermia, electrolyte disturbances, renal failure, acute cardiac and cerebrovascular events, seizures, and coma which can lead to death have occurred during the “RUN” phase of consumption while during “CRASH” phase, which is characterized by extreme fatigue, loss of motivation, and pervasive sad mood, there are high chances of users committing suicide. Detailed psychoeducation regarding severe medical complications, the risk of death is crucial in this population.

51 (75%) cases suffered multiple negative life events secondary to ATS use such as academic failures/loss of job/interpersonal issues/family problems but still continued the substance taking behavior. Gilbert and Burgess[35] have reported damage to executive function secondary to ATS use. According to this study, with impaired executive function, METH abusers are likely to be distractible, impulsive, act inappropriately despite social cues to the contrary, and lack goals. Another consequence of impaired executive function is perseveration: the inability to change behavior even when the current behavior becomes destructive. Thus, ATS-induced damage to executive function might result in continued METH abuse despite facing multiple negative consequences.[35]

About 4.4% of our cases (all males) had homosexual contact under the influence of ATS. This figure is very less as compared to previous studies done by Reback et al.[15] The history of homosexual contact is very important as the practice of putting meth powder or crystal in the anus and having anal coitus is quite common in ATS users. This can lead to the spread of HIV and other sexually transmitted diseases. The low figure in our study can be secondary to stigma and discomfort related to discussing sexual details prevalent in Indian patients.

The pharmacotherapy was tailored for each case, as no treatment guidelines exist for ATS use disorder. The patients presenting with psychotics symptoms or severe aggression were given adequate doses of risperidone. The patients having impulsivity or secondary antisocial traits and mood swings were given mood stabilizers. Patients having comorbid tobacco smoking were started on bupropion which helps in smoking cessation and helps in decreasing craving for ATS due to its activating effects. All the patients received psychoeducation and behavioral therapy. Behavioral therapy and contingency management are the only approved therapies in these cases. Currently, no pharmacological treatment is approved by US FDA. Our pharmacotherapy given was based on multiple review articles published in the past.[36],[37],[38]

Comparison of pure ATS abusers with ATS abusers along with polysubstance abusers:

We compared participants with pure ATS use and participants who used ATS along with other psychoactive polysubstances [Table 5]. Younger participants, predominantly students with longer duration of ATS use with high rate of intoxication and presence of psychiatric comorbidity distinguishes participants with pure ATS use from the other group who abuse polysubstances along with ATS. Thus youngsters, mainly students, who do not indulge in other psychoactive substances, are attracted toward ATS. The possible reasons for this behavior can be hypothesized as, they are unaware of the consequences of the drug as the drug is new in the market, and the drug is easily accessible. Furthermore, other unique characteristics of the drug such as being cheap, giving quick high, being odorless, smokeless, and introduction in the market as a drug which helps to study whole night might have attracted these groups of youngsters toward ATS. Moreover, the high rate of intoxication of pure ATS users points toward the high addictive potential of ATS resulting in severe craving, leading to continuous use for 4–6 days (RUN Phase) which leads to intoxication in inexperienced hands.

Our study is limited by its retrospective design and lack of comparison group. Hence, the finding should be interpreted in that background. This study was on treatment-seeking population, and hence, may not truly reflect the clinical profile of patients with ATS use disorder in the community.


  Conclusions Top


Young school-going children belonging to lower socioeconomic strata of society are most vulnerable to ATS use disorder. The amount of money spent by this group on procuring substance is high, and the severe craving compels these cases to commit crime and antisocial acts for want of money. The adolescents, especially students, are experiencing multiple adverse life events such as academic failure, family discord, and criminal records due to ATS use.

This study helps to give an idea about trends in ATS use among the population, and this can be used to design the public health strategy to prevent and to control the spread of these substances. This study creates more awareness among clinicians with respect to different clinical presentations and peculiarities of the patients with ATS abuse. This will help them to develop a better management strategy to treat the patients with ATS abuse. More community studies are needed in this area. Strict laws and punishments of drug dealers, prompt referrals and treatment of the cases, and awareness through media for the masses are the need of the hour.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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