Chemical Dependency vs. Behavioral Addictions
June 6th, 2008A discussion of the difference in treating chemical dependency vs. behavioral addiction (e.g., gambling, eating, etc.) and how the brain is affected.
Patterns in Drugs Use Across Decades
May 27th, 2008Dr. Darryl Inaba comments on the patterns and cyclical use of different drugs of use, abuse and addiction.
Current Status of Prevention Efforts
May 9th, 2008New Connections - 3rd Annual Southern Oregon Educational Conference on Advances in Chemical Dependency and Mental Health Treatment, April 17-18, 2008, Medford, Oregon
This consistently brilliant symposium is hosted by the Genesis Recovery Center of Asante Health System, Central Point, Oregon. It was my third consecutive year of participation and I was again inspired by the content as well as the style of each presentation.
Dr. Cardwell (“CC”) Nuckols from Orlando, Florida presented on Neuroscience, Spirituality and 12 Step Facilitated Recovery. Dr. Chuck Jackson from Tulsa, Oklahoma gave a heartfelt address on compassion fatigue and the need for all recovery professionals to continuously self-monitor their healing energy. Dr. Andrea Barthwell, former Deputy Director for Demand Reduction in the Office of National Drug Control Policy traveled from Chicago to bring us up to date on Pharmacotherapy of Substance Dependence Disorders in Psychosocial Settings. I closed the conference with a presentation addressing the growing abuse of prescription and Over the Counter (OTC) medications. I can only hope that my presentation was at least half as well received by the audience as those of Drs. Barthwell, Jackson and Nuckols who gave some of the best talks I’ve ever heard and I attend several conferences each year.
The presenters shared so many “pearls” of knowledge and fascinating clinical experiences that I could write a number of blogs on what I learned. Dr. Barthwell’s discussion on current substance abuse prevention strategies struck me as the most interesting of the conference. She wove this topic into her talk on the science of addiction and treatment and it captivated my interest. Perhaps this is because I am continuously disappointed with what empirical longitudinal research reveals about prevention strategies or maybe it was because Dr. Barthwell described these activities from a new and challenging perspective.
In our book, Uppers, Downers, All Arounders, Bill Cohen and I explore three levels of substance abuse prevention, each with unique strategies and tools that focus on eliminating or minimizing the abuse of drugs in three target populations. Beginning with the first edition the three levels of prevention are described as Primary, Secondary and Tertiary - preventing first abuse of drugs or alcohol, preventing experimentation, social or recreational alcohol/drug abuse from progressing on to more serious problems, and providing intervention and/or treatment to those with problematic use or chemical dependency to get them into abstinence or “Recovery” lifestyles. In the most recent edition (the 6th), we recognize that some educators now use the terms: Universal, Selective and Indicated to describe the three levels of prevention strategies. This classification scheme recognizes the need to develop more intense strategies for those who have not used drugs (traditionally the target population of Primary Prevention) but who are at greater risk to develop problems because of parental drugs use, genetics, or environmental stressors. These and other risk factors, subject individuals who have never used drugs to Selective Prevention interventions that were previously employed in Secondary Prevention. Universal Prevention strategies are targeted at those with no or little risk factors who have never experimented with drugs. Indicated Preventions looks for early signs of abuse or behaviors and intervenes much earlier with traditional Tertiary Prevention techniques than previous models implemented those techniques. (Inaba, DS & Cohen, WE (2007), Uppers, Downers, All Arounders, 6th ED,CNS Pub, Inc., Medford Oregon, p. 375; Eggert, L. L. (1996). Reconnecting Youth: An Indicated Prevention Program. National Conference on Drug Abuse Prevention Research http://www.drugabuse.gov/MeetSum/CODA/Youth.html (accessed May 18, 2007).
As part of her presentation, Dr. Andrea Barthwell outlined a prevention classification scheme that she developed through research in her role as our nation’s Deputy Director of Demand Reduction. Dr. Barthwell looks at the three main targets for prevention strategies as:
“Non-Users consisting of Never Used, Not Using, and Never to Use Again”
“Non-Dependent Users”and
“Dependent Users”.
Research findings demonstrate ways certain risk factor variables can help sustain abstinence in Non-Use populations. These consist of decreasing drug/alcohol availability, reducing opportunities to use, limiting popularization of prior drug experiences, and diminished drug using behavior of peers. These variables also include increasing the perceived risk of use and bolstering respect for social norms. It is Dr. Barthwell’s belief that effective promotion of these variables will result in better prevention outcomes for Non-Users of drugs or alcohol.
Dr. Barthwell describes Non-Dependent Users (often referred to as “social” or “recreational drug users,” terms she strongly dismisses) as the population that fuels and promotes every drug epidemic experienced in our nation. This is the result of the false expectations this group projects about alcohol/drug use to other, more vulnerable populations. It is for this reason that Dr. Barthwell considers Non-Dependent Users the most important target group for intense prevention efforts. Drug prohibition, responsibility, and illegality are the elements of a strategy focused on Non-Dependent Drug Users. These individuals are more likely to respond to zero tolerance policies, detection and exposure activities. Stemming the flow or access of drugs to this population is also found to be effective. Unfortunately, the perception that Non-Dependent Drug Users are the force behind every drug epidemic is used to justify the government’s promotion of random drug testing of middle and high school students. Fortunately, most Americans still regard this strategy as too invasive of our civil liberties to seriously consider, though Drug Czar, John Walters estimates more than 1,000 U.S. high schools and middle schools conduct random drug testing. Mr. Walters also emphasizes that the U.S. Supreme Court has twice carved out exceptions to students’ privacy rights enabling schools to conduct random urine drug test within strict limits - either students for whom there is “reasonable suspicion” of drug use, or randomly testing athletes and students who participate in other extracurricular activities (USA Today Editorial Debate, http://blogs.usatoday.com/oped/2007/05/lede_ed.html, accessed 4/25/08).
Dr. Barthwell also outlined prevention strategies targeted at Dependent Users. Research shows an “Awareness Gap” (also called “Denial”) in this population, 76% of those who met DSM-IV-TR criteria for alcohol or drug problems, say they don’t have a problem. Of those who recognize that they have a problem with drugs or alcohol, only 5% will try to find treatment, a “Motivation Gap”. Two percent of those who desired and sought treatment could not access it, the “Treatment Gap” and 17% of those who met criteria for drug or alcohol problems had at least one admission to treatment in the preceding 12 month, a “Success Gap”. (SAMHSA, (2001), NHSDUH) Dr. Barthwell quoted another set of data that she used to develop her demand reduction strategies. Of those who do access treatment, only 25% to 31% will complete treatment with a positive discharge, another type of a “Motivation Gap” and only 50% of those who complete treatment will stay clean and sober for at least a year after being discharged, an “Outcome Gap” (SAMHSA, (2001), TEDS; SAMHSA, (2001), UFDS). Effective strategies targeted to address these gaps were identified as: increased Screening and Brief Interventions by health professionals that are buttressed by Case Management and a Continuum of Chemical Dependency Treatment Services that is actively supported by communities, labor, and faith-based resources.
Despite the meticulous research and careful development of the current spectrum of prevention strategies in America, Dr. Andrea Barthwell confessed that like me, she too is concerned that rigorous empirical research fails to document significant positive long-term outcomes from U.S. drug and alcohol prevention programs. She is especially disappointed by those activities targeted for Non-Users and Non-Dependent Users. I call this an “Efficacy Gap”. Dr. Barthwell described current drug and alcohol prevention efforts as a “blunt instrument”. She stated that we need to discover better tools to prevent drug and alcohol abuse in our communities but quickly added that at the moment we are using the best tools that our science can provide and that using these flawed tools is a lot better than not using any at all. Perhaps there is truth in Dr. Barthwell’s statement since the current prevention efforts were really developed to prevent alcohol and illicit drug abuse and every survey indicates a dramatic decline of these substances since 2001. The recent edition of NIDA Notes states that teen substance abuse continues to decline with current use (any use during the past month) declining by at least 24% for marijuana and any other illicit drug in 2007 as compared to 2001. Use of methamphetamine and ecstasy declined by 64% and 54% respectively and alcohol use had declined by 15% and cigarettes by 33% during that period of time. (NIDA Notes (2008), Teen substance abuse continues to decline. 21(5):15, March) This dramatic decline in teen abuse of alcohol and illicit drugs seems to indicate that prevention strategies are having a much greater impact than either of us had believed. Unfortunately, this illusion is quickly shattered when current data on teen or adult abuse of prescription and OTC drugs are examined.
The number of U.S. adults abusing prescription drugs (approximately 15-17 million) has doubled over the last decade. Abuse of these medications has risen even more rapidly among teens, tripling during the same period of time. By 2006, 9.2% of the U.S. population over the age of 12 (22.6 million people) were dependent on or abused alcohol and/or illicit drugs (Prescription drug misuse grows, but illicit drugs are less popular. Pharmacy Today, 13(10):2, 2007). Teen abuse of prescription opioid pain medications increased over 540% in the last few years alone (CASA, 2005). Non-medical use of all prescription drugs in young adults grew from 5.4% in 2002 to 6.4% in 2006 (Prescription drug misuse grows, but illicit drugs are less popular. Pharmacy Today, 13(10):2, 2007). Abuse of prescription and OTC medications by teens now exceed abuse levels for many of the media hyped street drugs like ecstasy and methamphetamine. By 2006, prescription drugs became the drugs of choice for abuse by 12- and 13-year olds in the U.S. (SAMHSA 2007, National Survey on Drug Use and Health, 2006; ONDCP 2007, Teens and Prescription Drugs: An Analysis of Recent Trends on the Emerging Drug Threat). Regrettable, prescription drugs are now involved in 30% of all hospital emergency room deaths and 80% of drug mentions during an emergency room visit (CASA, 2005).
This was a perfect segue for my conference presentation on the misuse and abuse of prescription and OTC drugs. Hopefully, Dr. Barthwell will now work on prevention strategies that target the abuse of prescription and OTC drugs as well as alcohol and illicit drug. If the current trend continues, these medications will clearly become the major drug problem of this decade. I am very grateful to Dr. Andrea Barthwell for participating in the New Connections - 3 Conference and especially for her continued contributions to our nation’s demand reduction strategies.
Darryl S. Inaba, PharmD., CADC III
Bromo-Dragonfly & the DEA Microgram Bulletin
April 10th, 2008Since moving to southern Oregon about 18 months ago, I have become aware of a psychedelic drug I had never heard of called “Bromo-DragonFLY”, “DragonFLY”, “B-Fly” or just “FLY”. It is also referred to by the letters: BrDF, 2C-TFM and ABDF. The young people who made me aware of the drug range in age from 18 to 24 and most describe their experience with this substance as mildly or sometimes ambivalently negative: “too intense”, “LSD for robots”, “rat poison”, “lasts too long and leaves you drained”, “definitely not for everyone, just too powerful”.
“B-FLY”, bromo-benzodifuranyl-isopropylamine was synthesized in the 1990s and was first used in rat brain research at Purdue in 1998. Though some have told me that it was developed as a rat poison, I could find no references to verify this claim. Dr. Alexander “Sasha” Shulgin describes FLY as a phenethylamine psychedelic but the phenyl ring of this molecule is bound between two dihydrofuran rings giving it more potency and longer lasting effects than most other phenethylamines (A Shulgin & A Shulgin, 1998, PIHKAL: a Chemical Love Story. Transform Press: Berkeley, CA 4th printing). The molecular representation of this chemical resembles a dragonfly and hence its street name. By 2005, FLY began to appear as a street drug notably in Ashland, Oregon, Queensland, Australia, Germany, Sweden and Denmark.
As with all illicit street drugs, there are reports of discrepancies in the liquid, blotter paper and other dosage forms of Bromo-DragonFLY. What one gets from street purchases of the drugs is further complicated by the fact that the molecule can form two distinct chiral or optical isomers and especially by the fact that originally 5 other related synthetic molecules are also called FLY. At least 2 of these have already been misrepresented as Bromo-DragonFLY in street sales. In addition to Bromo-DragonFLY; 2C-Fly, 2C-B-Fly, 3C-Fly, Fly, and DOM-Fly were also synthesized by 1996 (AP Monte, et al, 1996. Dihydrobenzofuran analogues of hallucinogens. J of Medicinal Chem, 39:2953-2961; EC Reed & GS Kiddon, 2007. The characterization of three FLY compounds (2C-B-Fly, 3C-B-Fly, and Bromo-DragonFLY, DEA Microgram Journal, 5[14]:4-12). This may explain reports of a stronger “European or German Batch” of the drug that was on the streets in 2005 replaced by a less potent “American Batch” in 2006.
I found very few scientific papers on FLY but discovered three recent postings about B-Fly on the Drug Enforcement Administration (DEA) Microgram Bulletin site, and its Microgram Journal site.
An August 2007 Bulletin posted a brief entry about the seizure of a dropper bottle from an Ashland, Oregon resident that contained a clear, colorless, aqueous liquid. The individual was suspected of selling drugs and the liquid was analyzed to be 1-(8-bromobenzo[1,2-b:4,5-b']difuran-4-yl)-2-aminopropane which is the more precise chemical/technical name for Bromo-DragonFLY (DEA August 2007, “Bromo Dragonfly” [bromo-benzodifuranyl-isopropylamine] in Ashland, Oregon, DEA Microgram accessed 4/3/08). Both the DEA Microgram Bulletin and Journal have excellent information on street drug trafficking accompanied by photos. (DEA Microgram Bulletin February 2008. “Bromo-dragonfly” in Queensland, Australia, 41[2]:16-17;EC Reed & GS Kiddon, Jan-Dec 2007. The characterization of three FLY Compounds [2C-B-FLY, 3C-B-FLY, and Bromo-DragonFly] DEA Microgram Journal, 5[14]:4-12 both accessed on 4/3/08). I don’t recommend these web sites for anyone in recovery because the photos could evoke strong cravings.
Less scientifically reliable web sites like Vaults of Erowid, Drug Forum, Wikipedia and Cannabis Culture Forums have interesting postings on B-FLY along with practical advice. Although these sites can be easily corrupted by people adding or changing information, I found the content to be consistent with what is known about the dosage and effects of this drug. These sites indicate B-FLY is sold in liquid, powder, blotter paper and tablet forms on the street. Inconsistencies regarding which “fly” chemical are sold or what chiral form of the drug is used produces conflicting reports of threshold doses and effects. The “European Batch” is said to be active at 200 to 500 ug doses while the “American Batch” requires 800 to 1800 ug. These variances between threshold and common dose ranges of B-FLY products create a potential for drug overdose problems. Additionally, many users state that the onset of its effects, though usually 30 to 90 minutes after oral ingestion, can be delayed for up to 6 hours which can lead to “double dosing” (the ingestion of another dose of B-FLY thinking that the first dose was inadequate to cause any effects) and/or the use of additional drugs while waiting for the effects to kick in. A couple of deaths from abuse of this drug have been noted in Norway and Sweden. The R-(-) chiral form of the drug is thought to be the more active stereoisomer.
B-FLY is usually described as a powerful hallucinogen though some have said that it is milder with significant entactogenic and empathogenic activity. Like phenethylamine psychedelics, it causes: anorexia, mood elevation, physical and emotional stimulation, and increased associative thinking. Strong effects associated with its use include hallucinations, visual distortions, muscle tension, memory loss, confusion and even acute anxiety reactions with depersonification, derealization, and panic. One southern Oregon youth described watching thick smoke billow from his feet (visual hallucination), and multicolor blood gurgling (auditory hallucination) from his TV onto the floor during the “roller coaster” phase of a DragonFLY trip. The “roller coaster” phase is described as mentally oscillating between peaks of psychedelic drug effects and feelings of complete normalcy with no hallucinogenic effects. This oscillation begins after the plateau effects of psychedelics are over; the peak effects then become less intense as the drug experience is on the wane. The total duration of a B-FLY can vary from 6 hours to 4 days due to the variations in the molecules sold as the drug. Almost every reference strongly recommends against use citing the potential dangers of its effects, the lack of research, and the unreliability of products sold as Bromo-DragonFLY.
Early research on dihydrobenzofuran indicates that its psychedelic effects are due to its agonistic action on serotonin receptors. B-FLY has strong binding and activation of 5-HT2A, 5-HT2B and 5HT2C serotonin receptors (AP Monte, et al, 1997. Mescaline derivatives. J of Medicinal Chem, 40(19):2997-3008).
Bromo-DragonFLY is not scheduled as a controlled substance in the U.S. but it could be considered a chemical analog of other Schedule I drugs like DOB or 2C-B. If the DEA declares it as such, consumption or possession would be prosecuted under the 1986 Federal Analogue Act.
When a new synthetic psychedelic drug like B-FLY, Tripstasy (2-CB), Blue Mistic (2C-T-7), and Foxy Methoxy (5-methoxy-N,N-diisopropyl-tryptamine) makes its debut on the street it generates my sense of amazement at the complexity of the brain’s chemical processes. It also reminds me of the lifelong work of Drs. Alexander and Anna Shulgin who have created hundreds of these substances in their quest to better understand those processes.
Darryl S. Inaba, PharmD., CADC III