R report
// drugs in the middle east
Amphetamine Abuse a Growing Reality in Saudi Emergency Departments Saudi Arabia accounts for upwards of a third of all global amphetamine seizures. Government officials have long been in denial about the growing problem, but emergency physicians are bringing the issue to light.
by eyad khattab, md
N
ot long ago I had a night shift in the emergency department. While I was writing patient notes for a previous case a nurse asked me to look at a patient who was acting strangely: He was lying on the floor gasping for air. He could not talk and I still remember how he tried to show me the location of the pain by pounding his chest continuously. Before walking into the room I’d been ready to send the patient to the triage area, but then I saw the scene in front of me and quickly proceeded with checking vital signs, including EKG. Just then I was thinking an ischemic heart attack was occurring. The Acute Coronary Syndrome (ACS) Protocol was started immediately. At that time, his wife and son were waiting outside and I was able to talk to him alone. After asking me to close the curtain, he confessed in a low voice that he used stimulant tablets, also known as sympathomimetic drugs, and followed it by saying “don’t tell my family.” Fortunately, he survived that experience and hopefully learned from it. He was lucky to be alive. Because of religious and cultural norms, there has been insufficient research and lack of data collection on drug abuse in KSA, making it hard to identify the actual volume of the problem. In fact, some decisionmakers in the Middle East have been in denial for years that drug abuse occurs at all. However, that is slowly changing, in no small part thanks to the medical establishment. At medical conferences, suddenly the usage of stimulant drugs is becoming a big topic. I, for one, have witnessed too much drug abuse as a Saudi emergency physician to keep silent. I’ve compared notes with my brothers, both toxicologists, and the evidence is clear. One of the most common sympathomimetic tablets used in K.S.A is “Captagon”. However, Captagon was banned in 1986, so virtually all versions available today are Captagon mimics. According to a 2012 article in the Anatolian Journal of Cardiology, “Today,
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most of the Captagon mimic and counterfeit tablets contain amphetamine, caffeine, ephedrine, quinine, theophylline acetaminophen, diphenhydramine and lactose or a combination of these substances.2” Captagon mimics are currently a popular stimulant drug among the young population in the Middle East3. The Captagon trade journey usually starts from Eastern European countries then passes by into Turkey, then finally is shipped to the Middle East. Interestingly, Captagon is not widely used in Turkey2. Saudi Arabia has been reporting large amphetamine seizures since 2004. According to Council of The European Union, Saudi Arabia accounted for nearly 30% of all global amphetamine seizures in 20085. This represented a dramatic rise in amphetamine seizures in Saudi Arabia, which could signal the development of new routes and target populations for the drug. Another popular stimulant substance in the Middle East is Khat (Catha edulis). What complicates the situation and makes Khat hard to control is that it is legal and a common social habit in Yemen. Khat is packaged in Yemen and transported to Saudi Arabia. According to an overview of Middle East drug trends published in Life Science Journal, “Many Saudis also visit Yemen with the purpose of consuming Khat. Yet, Khat is cultivated as well in the Saudi Arabian part of the Yemeni border ( Jazan), where locals consider it as a part of their daily lives and culture.6” In Saudi Arabia, most of drug-related emergency room visits are due to drug abuse. The most frequently reported drugs are sympathomimetic followed by opiates, and psychotherapeutic drugs like Benzodiazepines. However, we do see a few cases of cocaine and heroin abuse from time to time. Cannabis is widely used in Saudi Arabia but does not usually cause acute medical emergencies. Psychosis and hallucination are the only cannabisrelated emergencies I have seen, and that was one
Spring 2013 // Emergency Physicians International
case. Club drugs like Lysergic Acid Diethylamide (LSD), Ketamine, and Gamma-Hydroxy Butyrate (GHB) are rarely reported. Car accidents secondary to drug intoxication are not uncommon. Euphoria, hypertension emergency, myocardial infarction, hyperthermia, rhabdomyolysis, and acute renal failure have been reported after the use of stimulant drugs like amphetamine. Opioid toxicity can lead to loss of consciousness, respiratory depression, pulmonary edema and coma. Convulsions and agitations are common with Benzodiazepine withdrawal. Many drug-induced emergencies are discharged with an out-patient follow-up appointment, though some needing admission. We need more research in order to understand the reasons behind this rapid increase in the number of cases of recreational drugs used in Saudi Arabia and the Middle East. We must understand the actual size and the amount of this problem, improve law enforcement efforts, and raise public awareness. We also need to develop plans to control this threat by using direct and indirect measures. Health education and information campaigns are a crucial part of any program, especially when we deal with behavioral issue like drug addiction and abuse. Finally, continuous evaluation of the outcomes is another valuable thing to do to determine program sustainability, design statistical measures, and know more about the community status before and after the application of programs. REFERENCES 1. Anglin, D.M., Burke, C., Perrochet, B., Stamper, E., Dawud-Noursi, S. (2000). History of the methamphetamine problem. Journal of Psychoactive Drugs. 32(2), 137-141. 2. Uluçay, A., Arpacık, K. C., & Aksoy, M. F. (2012). Acute myocardial infarction associated with Captagon use. Anadolu kardiyoloji dergisi: AKD= the Anatolian journal of cardiology, 12(2), 182. 3. Mahmoud A Alabdalla. Chemical characterization of counterfeit captagon tablets seized in Jordan. Forensic Sci Int. 2005; 152(2-3): 185-8. doi:10.1016/j. forsciint.2004.08.004. 4. UNODC (United Nations Office on Drugs and Crime). World Drugs Report. UN, New York. 2008. 5. Council of The European Union. Regional Report on the Near East. No. 5020/11 CORDROGUE 1. Brussels, Belgium. 2011. 6. Rahim, B. E. E., Yagoub, U., Mahfouz, M. S., Solan, Y. M., & Alsanosi, R. (2012). Abuse of Selected Psychoactive Stimulants: Overview and Future Research Trends. Life Science Journal, 9(4). 7. Ayalu A. Reda, Asmamaw Moges, Sibhatu Biadgilign, and Berhanu Y. Wondmagegn. (2012). Prevalence and Determinants of Khat (Catha edulis) Chewing among High School Students in Eastern Ethiopia: A