Prevalence of use in New Zealand

Although most damage from drug use comes from the legal drugs alcohol and tobacco, it is often illegal drugs that capture the concern and fear of communities. Illegal drugs include methamphetamine in its pure form (“P” if NZ made; ‘ice’ or ‘crystal meth’ if imported), heroin and ‘homebake’ (NZ made opiate), GHB (“Fantasy”; induces memory loss), cocaine, and lesser strength amphetamine-like drugs such as MDMA (“Ecstasy”, which also is a hallucinogen), non-prescribed Ritalin and some party drugs (BZP) which were made illegal in April, 2008. The prevalence of illegal drug use is estimated use from confidential interviews of drug users, public surveys which tend to under-estimate usage, and the rate of drugs recovered from Police or Custom actions. Concerning figures are:

• Currently more than half of the High Court trials awaiting hearing are methamphetamine trials, and these have increased by 73% in the last 5 years since methamphetamine manufacture/supply became a Class A drug (possible life imprisonment)
• Many are large prosecutions e.g. 150 kg methamphetamine and precursor worth $50M in late 2007
• In a 2007 survey by Police of arrestees found 77% had used cannabis and 52% had used methamphetamine in the previous year (but excluded those under 17)
• It is estimated that the brain reward circuit chemical dopamine is enhanced 400% by cocaine and 1500% by methamphetamine
• Substance Use Disorders were most common amongst younger people, males, and Maori

What makes some addictive?

Addiction
Addiction is a somewhat imprecise term but essentially includes the development of a physical and/or psychological need to consume substances (or participate in a behaviour). It can become chronic, result in cravings, neuro-chemical brain changes, and withdrawal effects when the person tries to stop or cut down. Most importantly, a tolerance often develops whereby increased consumption is necessary to get a desired effect, and despite negative costs of the behaviour, the person perseveres, with cost to themselves and others. An example may be the initial use of P methamphetamine at $100 per ‘point’ (0.1 grams) that can increase to 1 gm or more per day ($1,000) that can only ultimately be maintained through crimes against others, becoming a manufacturer or dealer in the drug, or prostitution. It is generally agreed nowadays that the majority of addictions are developed and maintained through a mix of biological changes in the brain, psychological learning or ‘conditioning’, and social relationships and environments.

Biological-psychological-social addiction process
The brain comprises many billions of nerve cells with linked areas that can be associated with addictive behaviours. A particular pathway that is focussed upon is the mesolimbic reward pathway that connects the nucleur accumbens and ventral tegmentum and the prefrontal cortex, hippocampus and amygdala. This pathway involves a number of addictive influences, such as motivation for a behaviour, memory of past ‘highs’, levels of the reward neurotransmitter dopamine (high=reward, low=cravings), tolerance and sensitisation. As higher levels or longer periods of dopamine availability (or dopamine plus serotonin) can result in tolerance, the brain adapts by reducing its supply of the neurotransmitter, or its specific receptors. By contrast, it can also be sensitised by reacting more quickly to the drug/behaviour as the process reoccurs, and this promptness of the effect can accelerate the addictive process. The actual addictive process in the brain is only now starting to be understood and it appears a range of brain chemicals that connect its nerve cells may be involved in addiction (e.g. dopamine, serotonin, glutamate, norepinephrine, GABA, NMDA). To further complicate things, high levels of dopamine damage the nerve endings (partly reversible), reducing the ability of the nerves to fire, as well as rapidly altering the brain’s future production of its own dopamine, receptor activation levels and, indeed, their numbers overall. After a time, the only dopamine that can lift a person’s mood must be stimulated by the addictive drug. The level of the ‘high’ can be associated with the intensity and length of time dopamine remains in the neural synapses, and it has been estimated (Lee – Prof Psychiatry Columbia U) that cocaine increases the effectiveness of dopamine processes by 400%, and methamphetamine by a huge 1500 percent. Cocaine partly bridges the gap through ‘learning’ resulting from the shorter high it produces. The brain retains a memory of the ‘high’ from the drug, however that is often less able to be re-achieved as the biological adaptations described above develop. Motivation to seek out previously enjoyable activities reduces, and the reward-seeking behaviour reduces largely to the drug. Sensitisation, that increases the promptness of the rewarding reaction to the drug, ensures that the behaviour is well learned, as promptness of reward (in addition to the size of the reward) is a well-recognised element to repetition of behaviour. Accessibility of drugs, or the belief that they can be accessed, can stimulate the drug-seeking drive over more considered thoughts about negative consequences of continued use. Some drugs such as cocaine have an entirely psychological effect, without biological withdrawal due to brain adaptation that can occur with methamphetamine or heroin, and yet cocaine addiction can be harder to address than heroin addiction. This perhaps shows how complex addictions to drugs can be, as well as the necessity to approach addictions from a holistic perspective, rather than either a biological, psychological or social perspective alone.

Gateway drugs
Research with marijuana appears not to support that those who start using this drug are likely to progress on to harder drugs. Research by SHORE when party pills were legal, identified only 10% who stated they started out using party pills and now mostly use illegal drugs. A confusing factor is that most tend to use both party pills and illegal drugs. Although there appears not to be a link between use of less potent illegal drugs and progression to more potent drugs, it is the case that sellers of illegal drugs are often gangs who obtain greater returns from potent drugs and often sell both. Therefore opportunity arises to progress either through social opportunity or marketing.

Impact and costs

Costs arising from illegal drugs can be substantial for the individual, their family, and society as a whole. The 2005/6 Drug Harm Index estimated drugs cause over one billion dollars in costs to NZ. For society, the costs are crime with violence to obtain drug money, fear and concern for safety, high costs for both prison (50%-60% offenders affected by a drug (including alcohol) at the time of offending) and Courts (over 50% of High Court trials currently involve P).

For family members, illegal drugs can appear to be an unsolvable problem, with the drug user seeming to become an amoral, self-interested stranger who destroys family relationships and assets, and has little insight into the costs of their behaviour. Family members often become depressed, indebted, and become confused and guilty, wondering about their role in the development of the addiction.

For the addicted drug user, lives can become entirely focused upon accessing money for drugs, and for some, uncomfortable withdrawal effects when they cannot access them. Goals in life can become very short-term, with negative effects on their work, relationships, future and finances. A dependence on drugs can develop at varying rates, with drugs that have a prompt and powerful effect more likely to develop dependence over a much briefer period. In most cases, dependence will develop without the user realising, as compromises, skewed thinking and excuses mask progression. Mixing with other users can normalise the drug use and reduce criticism. For many drugs, health risks combine with depression, suicidal ideation and adverse reactions to ingesting drugs that have an unknown chemical composition and strength. The need for often substantial amounts of money to meet a consumption rate that has increased with tolerance often requires the user to participate in illegal activities or behave in ways they would have rejected in the past.

Health problems expand with methamphetamine
Although addiction of any kind cause financial, psychological and relationship problems to name just a few, methamphetamine and other powerful drug addictions come with additional health issues. Unfortunately, the over-stimulation of the dopamine system in the brain causes release of free radicals that damage important connection to the prefrontal cortex, that can amongst other things cause cell damage and even cancer. The prefrontal cortex is important in restraining impulsive decisions, and its damage can reduce ability to deal with the addiction, and increase relapses. In addition, weight loss caused by the drug, with the more concentrated crystal form particularly causing dry mouth and osteoporosis caused by the malnutrition, which along with grinding of the teeth causes tooth destruction, commonly called ‘meth mouth’. Psychosis like effects are common (insects crawling on or under the skin – ‘formication’), scratching the skin resulting in sores, and compulsive sexual behaviour are all additional costs methamphetamine addiction can impose.

What can we do?

Continuum
Illegal drug use occurs on a continuum of behaviour, with controlled use, risky use, moderate problem then serious addiction, with many more people in the risky use/moderate problem categories than serious addition. Resources required can be much lower for these earlier stages, as ability to recognise changes, higher motivation to try to change, and willingness to take on board advice provided in an appropriate way is much higher than in later stage addiction. Later stage addiction may require more resources as coexisting addictions and mental health issues develop, Reduced positive moods develop from neurobiological changes, reduced motivation, unwillingness to forgo the only source of enjoyment, and isolation from non-users result in maintenance of the drug use. Life becomes lived over the short term and focused upon the drug availability, with little insight or motivation to refocus upon the medium or long term. Increased stress can heighten thoughts of self harm as a solution.

Aims
Effective solutions to address illegal drug use involves strategies that address prevention or later starting of drug use (risk of addiction correlates with early age use), harm reduction through stopping the progression of, or controlled use, and the often the best harm reduction option for those severely affected, abstinence from the drug.

Individual help
In most cases illegal drug users will have to reach their own decision to limit or stop their use. More recently, with the Effective Interventions Strategy in NZ, those who have been sentenced for offences can be mandated to attend therapy. Views are often polarised as to whether users forced into therapy will successfully address their drug use. However, when motivation is generally low to change, even those volunteering to attend therapy are often under some element of compulsion, such as family threats of last chance, work pressures/threats, and debt bailout requirements, to attend therapy. The more explicit compulsion arising from a Court sentence can still be addressed in therapy and be reduced as a barrier to change.

Options can be day treatment (e.g. CADS), residential programmes that can be free to the user (e.g. Odyssey Trust, Higher Ground) or commercially priced. Programmes are also available in prisons (e.g. CADS) and for youth (e.g. Altered High). There are a range of Maori and Pacific based programmes, free to the user and their family.

Self help programmes such as twelve-step (e.g. Narcotics Anonymous) are available in most centres.

There are a wide range of therapies available for drug addiction, often alongside appropriate medicine that either reduces the urge through substitution or detoxification (e.g. methadone or buprenorphine for opiate addiction), prevention of the ‘high’ (e.g. naltrexone with opiates), although medication of the effects for methamphetamines is still in the experimental and research phase. Antidepressants with or without anxiolytics have also been used for addictions, as well as milder dopamine enhancers and GABA based drugs to reduce the urge for the user to ‘self medicate’ their dysphoria when reducing their drug use. These medical or pharmacological approaches are best provided alongside counselling, or alternatively addressing the drug use through counselling alone where the dependence is not advanced (or medical approaches unavailable or refused). These approaches are effective, especially when support and motivation is developed to sustain the effects of the therapy, post-treatment. Although there is good evidence for the effectiveness of many psychotherapy interventions (types of counselling and help), there is no one ‘gold standard’ that should be used.

Reminder 1:
A reminder here is appropriate, that those either seeking help or being required to attend treatment comprise only a small proportion of those affected by addictive drugs. They are usually in the more advanced stage of the addiction where a crisis may have raised their awareness of the need for help (in older terms, have reached their ‘rock bottom’), or have been compelled to receive help through offending and sentencing direction. It should be recalled that motivation often reduces as addictions advance, with many coexisting disorders developing alongside the drug use, and therefore concentrating resources at this stage is expensive and often ongoing. Helping those with moderate drug abuse, or at risk for this, can both prevent the abuse advancing (together with the costs to others and the community) with much lower resources. The Counties Manukau District Health Board’s (‘CMDHB’) project described below is a community approach that resources the community to identify individuals and help them access further specialist support, if necessary.

Reminder 2:
A further reminder: motivation is not a fixed asset of an individual. It can be increased by others providing an appropriate word or encouraging environment for those with addictions, and is a far better approach than waiting until those with addictions are sufficiently self-motivated to seek help themselves, often following a crisis that has high costs for the individual, their family, and the community.

Help for family
Family members are often affected by a member’s use of illegal drugs and may require information about help for the user. In addition, they may often need their own counselling to reduce stress from the often long term association with the roller coaster experience of living with addiction. Free help is available from a range of drug treatment services, such as CADS, or from counsellors in private practice, for a fee.

Community help
Knowledge is often an effective element for reducing illegal drug use. Awareness of the effects of illegal drugs, symptoms of their use, messages from influential community leaders, school programmes and feedback from past users (consumers) can all influence prevention of use, reduced demand for illegal drugs, and reduced cultural acceptance for them. It is likely that less than 10% of those who use illegal drugs seek help to stop or reduce their use. For the 90% who don’t, opportunities can exist in the community whereby non-specialists can supply help, advice and motivation to those using illegal drugs, especially in a crisis. These brief interventions can be highly effective because they strike a note with the drug user and raise their insight as to the costs of their use. Non-judgemental, empathetic listening and unforced advice/support can often be the only help ever accessed by the majority of illegal drug users.

An example of a community programme is the CMDHB project to develop the local workforce to reduce hazardous, harmful and dependent alcohol and other drug use. This project is delivered by Abacus over the past year and continues until June 2009. It is likely that over 1,000 community members will be trained to provide brief interventions for risky and problematic drug use, with consumers providing an insight at training of the user’s, and recovering user’s perspective. Community leaders are mentored in their addressing off these issues, as a process that mobilises the community to actively address the growing use of illegal drugs.

Raising awareness of the costs and influence of parents’ use of illegal drugs upon their children’s use can address the cultural acceptance of illegal drugs.

Conclusion

Police and Customs’ actions can reduce supply of illegal drugs while knowledge of costs to the community, and awareness of risk can reduce harm. Specialist help from drug treatment counsellors can provide help for those with an established drug problem or those affected by another’s use. Illegal drugs appear to be an established problem in modern communities, with high profits coexisting with highly addictive drugs. Many urban myths exist about either the safety or risk of drug use, with many younger people accepting the use of drugs such as Ecstasy and BZP Party Pills as part of their culture. Threats and misinformation have been shown to be either ineffective or counter-productive while valid information, opportunities to receive uncritical support and motivation are effective strategies.

Reference sources

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NZ Drug Foundation (2007) Reducing alcohol and other drug problems in NZ’s criminal justice system: review of the evidence Aug 2007. Well: NZ Drug Foundation.

Childress A (2006) What can human brain imaging tell us about vulnerability to addiction and to relapse? In Miller W & Carroll K (eds) Rethinking Substance Abuse. NY: Guilford Press.

Hasin D, Hatzenbuehler M & Waxman R (2006) Genetics of substance use disorders. In Miller W & Carroll K (eds) Rethinking Substance Abuse. NY: Guilford Press.

Crumpler A (2006) Understanding addictions. Paradigm. Summer 2006: Illinois Institute for Addiction Recovery.

Wilkins C, Girling M & Sweetsur P (2008) Recent trends in illegal drug use in NZ 2005-2007. Auckland: SHORE, Massey University