Solving the ecstasy puzzle case study in the Netherlands

Transcription

1 Solving the ecstasy puzzle case study in the Netherlands Margriet van Laar Head of Drug Monitoring department & Netherlands Focal Point Meeting on 20 years EMCDDA Key Indicators

2 Ecstasy Many studies show Limited long term (clinically relevant) (neurocognitive) effects Low dependence potential Ecstasy no more dangerous than horse riding Drug risk ranking: 2

3 However Several fatal emergencies in 2013 and 2014 What s going on? 3

4 Trends in ecstasy use (according to the Key Indicators) 1. Use (pupils and general population)? 2. Problematic use? 3. Treatment demand 4.(infectious) diseases? 5. Deaths? 4

5 Trends in ecstasy use (KI 1) General population survey (2009) N= xxxxx: Not enough to get insight into use patterns or characteristics of current users GPS are mainly surveys on Non-drug users 5

6 Stabilisation ecstasy use among pupils years (KI 1) % Lifetime 3,4 5,8 3,8 2,9 2,4 2,6 Current 1,0 2,3 1,4 1,2 0,8 0,9 6

7 Number of problematic ecstasy users (KI 2)? Ecstasy dependence? Long term-users Acute health-related problems? 7

8 Number of primary ecstasy clients in addiction care (KI 3) 8

9 Decreasing number of ecstasy clients in addiction care Number Primary Secundary

10 Number of hospital admissions related to psychostimulants 10

11 Ecstasy-related deaths (KI 5) General Mortality Register Specific ICD-10 codes: (other) psychostimulants, e.g. T53.6 may contain amphetamine, MDMA, caffeine, methylphenidate etc. (Many?) MDMA deaths may go unnoticed: no routine toxicological analyses; Indirect deaths (accident after behavioral change) Combined pathology and toxicology (e.g. heart failure and MDMA) Delay in reporting.. Yet: increase from 2-5 cases per year up to 2013 to 14 (mostly accidental poisonings) in

12 Letter of a parent.my son died, indirectly after using an ecstasy pill (which was probably mixed with another substance) on the day after visiting a party in Amsterdam. In the morning after, he was exhausted and overheated. He jumped over a wall, ended up five metres lower and died instantly. He was not a stupid boy, he was in training to become a medical specialist. There are occasional reports of people dying from ecstasy after visiting a dance party, but I am sure that our son does not turn up in these statistics, because the death occurred elsewhere and with a delay. This may happen in other cases as well. I would like people to realise that the dangers of using ecstasy are bigger than usually assumed. It is still being trivialized, even by my surviving son who is also a well educated boy... Best regards, a broken father.. 12

13 Forensic data Netherlands Forensic institute Post mortem investigations only for judicial cases Relatively low number of cases with toxicological analyses. Number of cases per million inhabitants: Finland (2013): 1203 England/Wales (2013): 239 Netherlands (2014): 13 13

14 Some missing pieces of information (apart from the Key Indicators) Market data Acute emergencies Data on high risk populations 14

15 Drugs Information and Monitoring System (DIMS) Chemical/toxicological monitor of recreational drug samples from drug users delivered to test services of addiction care centres throughout the country Continuous data collection and feedback About 10,000 samples annually, increasing due to market situation

16 Signal verification Sources of information The Drugs Information and Monitoring Forensic Psychotropic System (DIMS) Drugs-related Institute substance from drug user incident Police Addiction care centres Hazard identification Chemical analysis User information Risk characterization Literature search Expert consultation Risk management Informing user(s) about effects and risks Specific warning General warning Red Alert 16

17 MDMA concentration in tablets bought as ecstasy <100 mg mg >150 mg increased risk of toxic effects 17

18 Increase in average concentration of MDMA in ecstasy tablets 18

19 Other substances (e.g. NPS) Examples other substances 4-fluoramphetamine 6APB (benzo fury) Methoxetamine Additional information collected from fora on drug users and online markets Ad-hoc web surveys targeting users (e.g. 4-FA) 19

20 Participants of Monitor Drug-related emergencies Participating health care agencies in sentinel regions: Hospitals first aid Ambulance services Police doctors Groningen Purmerend Enschede Amsterda Ede/Arnhem m Rotterdam Nijmegen Nationwide: Eindhoven first aid posts at large scale events 20

21 Continuous data collection Anonymous data on drug-related emergencies (excluding cases involving only alcohol) Year of birth, gender, date emergency Consumed substances (not routinely verified by toxicology) Severity of the intoxication (mild, moderate, severe) Nature (intoxication, trauma) Setting Tourist (yes/no) Follow-up (home, hospital admission death) Information fed back to participants in case of red alerts or dangerous substances on the market (DIMS) Between 2009 and 2013: 12,156 drug emergencies, about onethird ecstasy related First aid post at events: 39% ecstasy-related emergencies in 2009 upt to 62% in 2013 Increase in severity 21

22 Increase in ecstasy potency co-incides with increase in (sever) health-related emergencies Bron: DIMS en Monitor Drugs Incidenten 22

23 Warnings high doses [Useof ecstasy is never safe ] 23

24 [ Deadly ecstasy on the market] 24

25 Surveys among high risk populations The Big Club and Party Survey Web survey in 2013 among 3,335 (frequent) club/party visitors between 15 and 35 years Self selected (convenience) sample Recruited through online community (Partyflock), other websites for nightlifers, student unions and other social media Questions on substance use, risk behaviour (sexual, driving under the influence, aggression/violence), personal characteristics (impulsivity, sensation seeking) and health-related consequences (emergencies etc.). 25

26 Drug use among frequent visitors of dance parties (15-35 years) Lifetime (%) Last year (%) Last month (%) Cannabis 76,7 52,0 32,8 Ecstasy 69,6 60,6 34,8 Amphetamine 45,2 33,4 19,0 Cocaine 40,5 27,1 12,7 Nitrous oxide 39,9 25,5 7,2 2C-B 15,8 9,4 2,4 4-9,9 8,5 3,8 Fluoramphetamine Mephedron 5,2 2,5 0,7 Methylone 4,2 2,2 0,5 Methoxetamine 3,0 2,3 0,3 6-APB 2,9 2,1 0,6 Spice 2,3 1,3 0,6 26

27 Other (local) surveys among visiters of parties and clubs Antenna Monitor Amsterdam Current (last month) use: increase from 22% in 2008 to 55% in 2013 Survey among clubbers in the Hague (Van Dijk et al, 2014) Ecstasy is a drug that belongs to entertainment for many young people (normalisation) "Ecstasy (XTC) seems by clubbers accepted as the party drug, but knowledge about the composition of the pills is low " 84 % believe 130 mg of MDMA in an ecstasy tablet is not too much or do not know if it's too much 27

28 General population survey 2014 (published in July 2015) Recent use: 1.4% (15-64 years in 2009) 2.5% (15-64 years in 2014) Increase?...Methodological changes High compared to other countries Recent ecstasy use (%) in EU 28 and EU countries 28

29 Ecstasy use by age group (2014) 29

30 Ecstasy use highest among high educated (2014) 30

31 Putting all pieces together Yes, something is going on High and increasing concentration of MDMA in ecstasy tablets Associated health risks (increase emergencies) Increased number and scale of (dance-) festivals and parties Apparent normalization of the use of recreational drugs under (outgoing) youth Secretary of State of Public health announced a new (innovative) prevention approach to counter normalisation Challenge: how? 31

32 Missing pieces No complete picture of DRD (direct and indirect) No conclusive evidence of role of high dose and other risk factors Limited knowledge on emergency users : (e.g. experienced or incident users, education level, use of HR measures)? Verification by toxicological analyses 32

33 Conclusions Population survey data: useful for nuancing and making international comparisons But they may miss relevant trends (and are generally slow data) Monitoring in high risk populations needed Problematic use of ecstasy? Need for indicator on acute emergencies Continuous user level market and emergencies data are useful, both for surveillance and monitoring Many pieces needed to complete the puzzle 33

34 Thank you for our attention! For questions 34