NIDA Research Report on Methamphetamine by onm20503

VIEWS: 21 PAGES: 8

									                                              METHAMPHETAMINE
     The abuse of methamphet-
amine–a potent psychostimulant–
is an extremely serious and grow -
ing problem. Although use of

                                                                        Abuse and Addiction
methamphetamine initially was
limited to a few urban areas in
the Southwest, several major
Western cities and Hawaii have
seen dramatic increases in its                What is                                         system. The drug is made easily
use, and rural areas throughout
the country are becoming more                 methamphetamine?                                in clandestine laboratories with
affected by the drug. In addition,                                                            relatively inexpensive over-the-


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methamphetamine use among                              ethamphetamine is a                    counter ingredients. These
significantly diverse populations                      powerfully addictive                   factors combine to make meth-
has been documented.                                   stimulant that dramati-                amphetamine a drug with high
     As part of our Methamphet-
amine Research Initiative, the                cally affects the central nervous               potential for widespread abuse.
National Institute on Drug Abuse
(NIDA) has developed this publi-
cation to provide an overview of                             Trends in number of emergency department
the latest scientific findings on                            mentions of methamphetamine, 1997-2001
this drug. Methamphetamine is a
powerfully addictive stimulant
associated with serious health                                                          Methamphetamine
                                                    18
conditions, including memory
loss, aggression, psychotic                                                             Amphetamine
behavior, and potential heart and                   15
brain damage; it also contributes
to increased transmission of
hepatitis and HIV/AIDS.                             12
     One of NIDA’s most impor-
tant goals is to translate what
scientists learn from research to                    9
help the public better understand
drug abuse and addiction and                         6
to develop more effective strategies
for their prevention and treat-
ment. We hope this compilation                       3
of scientific information about
methamphetamine will help
inform readers about the harmful                     0
                                                                1997                1998                1999                2000
effects of methamphetamine abuse
and will assist in prevention and                 Source: Drug Abuse Warning Network, SAMHSA, 2000.
treatment efforts.
Glen R.Hanson, Ph.D., D.D.S.                  The Drug Abuse W arning N etwork tra cks the number of times a
Acting Director                               drug is mentioned in connection with emergency room visits in
National Institute on Drug Abuse              2 1 metropolitan are as.

U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s ● N a t i o n a l I n s t i t u t es o f H e a l t h
2   NIDA R E S EAR CH R EP O RT S E RIE S


     Methamphetamine is com-                      Methamphetamine is a                   become a substantial drug prob-
monly known as “speed,” “meth,”               Schedule II stimulant, which               lem in other sections of the West
and “chalk.” In its smoked form,              means it has a high potential              and Southwest, as well. There are
it is often referred to as “ice,”             for abuse and is available only            indications that it is spreading to
“crystal,” “crank,” and “glass.” It           through a prescription that can-           other areas of the country,
is a white, odorless, bitter-tasting          not be refilled. There are a few           including both rural and urban
crystalline powder that easily                accepted medical reasons for its           sections of the South and
dissolves in water or alcohol.                use, such as the treatment of              Midwest. Methamphetamine,
The drug was developed early                  narcolepsy, attention deficit              traditionally associated with
in this century from its parent               disorder, and––for short-term              white, male, blue-collar workers,
drug, amphetamine, and was used               use––obesity; but these medical            is being used by more diverse
originally in nasal decongestants             uses are limited.                          population groups that change
and bronchial inhalers.                                                                  over time and differ by geographic
Methamphetamine’s chemical
structure is similar to that of               What is                                    area.
                                                                                             According to the 2000
amphetamine, but it has more                  the scope of                               National Household Survey
pronounced effects on the central
nervous system. Like amphet-                  methamphetamine                            on Drug Abuse, an estimated
                                                                                         8.8 million people (4.0 percent
amine, it causes increased activity,
decreased appetite, and a general
                                              abuse in the                               of the population) have tried
                                                                                         methamphetamine at some time
sense of well-being. The effects              United States?                             in their lives.
of methamphetamine can last 6 to


                                              M
                                                                                             Data from the 2000 Drug
8 hours. After the initial “rush,”                    ethamphetamine abuse,              Abuse Warning Network
there is typically a state of high                    long reported as the               (DAWN), which collects infor-
agitation that in some individuals                    dominant drug problem              mation on drug-related episodes
can lead to violent behavior.                 in the San Diego, CA, area, has            from hospital emergency depart-
                                                                                         ments in 21 metropolitan areas,
        The preferred method of taking methamphetamine                                   reported that methamphetamine-
               varies among geographical regions.                                        related episodes increased from
                                                                                         approximately 10,400 in 1999
        60
                                 Smoking            Injecting                            to 13,500 in 2000, a 30 percent
                                                                                         increase. However, there was a
                                 Sniffing           Other
        50                                                                               significant decrease in metham-
                                                                                         phetamine-related episodes
        40                                                                               reported between 1997 (17,200)
                                                                                         and 1998 (11,500).
        30                                                                                   NIDA’s Community
                                                                                         Epidemiology Work Group
        20                                                                               (CEWG), an early warning net-
                                                                                         work of researchers that provides
        10                                                                               information about the nature and
                                                                                         patterns of drug use in major
         0                                                                               cities, reported in its June 2001
                  San Diego          Minneapolis-St. Paul            Texas               publication that methamphetamine
                                             Area                                        continues to be a problem in
  Note: C alendar year 2000 in Minneapolis/ St. Paul; July–December 2000 in San Diego,   Hawaii and in major Western
  and January–June 2001 in Texas.
  Source: C ommunity Epidemiology Work G roup.                                           cities, such as San Francisco,
                                                                           NIDA R E S EAR CH R EP O RT S E RIE S   3
Denver, and Los Angeles.             most Eastern and Midwestern           venously, the user experiences
Methamphetamine availability         metropolitan areas, such as           an intense rush or “flash” that
and production are being reported    Minneapolis-St. Paul and St.          lasts only a few minutes and is
in more diverse areas of the         Louis, where they accounted           described as extremely pleasur-
country, particularly rural areas,   for approximately 3 percent of        able. Snorting or oral ingestion
prompting concern about more         total admissions, or Baltimore,       produces euphoria––a high but
widespread use.                      where no stimulant-related            not an intense rush. Snorting
    Drug abuse treatment admis-      treatment admissions were             produces effects within 3 to 5
sions reported by the CEWG in        reported in the first half of 2000.   minutes, and oral ingestion
June 2001 showed that metham-                                              produces effects within 15 to
phetamine remained the leading
drug of abuse among treatment        How is                                20 minutes.
                                                                               As with similar stimulants,
clients in the San Diego area and
Hawaii. Stimulants, including
                                     methamphetamine                       methamphetamine most often
methamphetamine, accounted for       used?                                 is used in a “binge and crash”
                                                                           pattern. Because tolerance for


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smaller percentages of treatment
admissions in other states and               ethamphetamine comes          methamphetamine occurs within
metropolitan areas of the West               in many forms and can be      minutes––meaning that the plea-
(e.g., 9 percent in Los Angeles              smoked, snorted, orally       surable effects disappear even
and Seattle and 8 percent in         ingested, or injected. The drug       before the drug concentration in
Texas). By comparison, stimu-        alters moods in different ways,       the blood falls significantly––
lants were the primary drugs         depending on how it is taken.         users try to maintain the high by
of abuse in a smaller percent            Immediately after smoking         binging on the drug.
of treatment admissions in           the drug or injecting it intra-


   In the brain, dopamine plays an important role in the regulation of pleasure. In addition
   to other regions, dopamine is manufactured in nerve cells within the ventral tegmental
   area and is released in the nucleus accumbens and the frontal cortex.

                                                              Methamphetamine
                                                              Dopamine




                                                                    Methamphetamine stimulates the
                                                                    rele ase of excess dopamine.
4   NIDA R E S EAR CH R EP O RT S E RIE S


    In the 1980’s, “ice,” a smok-           on nerve terminals in the brain.      paranoia, auditory hallucinations,
able form of methamphetamine,               High doses can elevate body           mood disturbances, and delusions
came into use. Ice is a large,              temperature to dangerous,             (for example, the sensation of
usually clear crystal of high purity        sometimes lethal, levels, as well     insects creeping on the skin,
that is smoked in a glass pipe              as cause convulsions.                 which is called “formication”).
like crack cocaine. The smoke                                                     The paranoia can result in homi-
is odorless, leaves a residue that                                                cidal as well as suicidal thoughts.
can be resmoked, and produces                  Short - term effects                   With chronic use, tolerance
effects that may continue for                  may include:                       for methamphetamine can devel-
12 hours or more.                                                                 op. In an effort to intensify the
                                               Increased attention                desired effects, users may take
What are                                       and decreased fatigue              higher doses of the drug, take it
                                                                                  more frequently, or change their
the immediate                                  Increased activity
                                                                                  method of drug intake. In some
(short-term)                                   Decreased appetite

effects of                                     Euphoria and rush                     Long- term effects
methamphetamine                                Increased respiration                 may include:

abuse?                                         Hyperthermia                          Dependence and


A
       s a powerful stimulant,                                                       addiction psychosis
       methamphetamine, even in                                                         – paranoia
       small doses, can increase                                                        – hallucinations
wakefulness and physical activity           What are                                    – mood
                                                                                           disturbances
and decrease appetite. A brief,
intense sensation, or rush, is
                                            the long-term                               – repetitive motor
reported by those who smoke or              effects of                                     activity
inject methamphetamine. Oral
ingestion or snorting produces              methamphetamine                          Stroke

a long-lasting high instead of a            abuse?                                   Weight loss
rush, which reportedly can con-


                                            L
tinue for as long as half a day.                 ong-term methamphetamine
Both the rush and the high are                   abuse results in many damag-     cases, abusers forego food and
believed to result from the release              ing effects, including addic-    sleep while indulging in a form of
of very high levels of the neuro-           tion. Addiction is a chronic,
                                                                                  binging known as a “run,” inject-
transmitter dopamine into areas             relapsing disease, characterized by
                                                                                  ing as much as a gram of the drug
of the brain that regulate feelings         compulsive drug-seeking and drug
                                                                                  every 2 to 3 hours over several
of pleasure.                                use which is accompanied by
    Methamphetamine has toxic               functional and molecular changes      days until the user runs out of
effects. In animals, a single high          in the brain. In addition to being    the drug or is too disorganized to
dose of the drug has been shown             addicted to methamphetamine,          continue. Chronic abuse can lead
to damage nerve terminals in the            chronic methamphetamine               to psychotic behavior, character-
dopamine-containing regions of              abusers exhibit symptoms that         ized by intense paranoia, visual
the brain. The large release of             can include violent behavior,         and auditory hallucinations, and
dopamine produced by metham-                anxiety, confusion, and insomnia.     out-of-control rages that can be
phetamine is thought to con-                They also can display a number        coupled with extremely violent
tribute to the drug’s toxic effects         of psychotic features, including      behavior.
                                                                             NIDA R E S EAR CH R EP O RT S E RIE S   5
     Although there are no physical
manifestations of a withdrawal
                                       How is                                tion and feelings of euphoria
                                                                             experienced by the user. In con-
syndrome when methamphet-              methamphetamine                       trast to cocaine, which is quickly
amine use is stopped, there are
several symptoms that occur
                                       different from                        removed and almost completely
                                                                             metabolized in the body,
when a chronic user stops taking       other stimulants,                     methamphetamine has a much
the drug. These include depres-
sion, anxiety, fatigue, paranoia,      such as cocaine?                      longer duration of action and a
                                                                             larger percentage of the drug
aggression, and an intense craving                                           remains unchanged in the body.


                                       M
for the drug.                                   ethamphetamine is classi-    This results in methamphetamine
     In scientific studies examining            fied as a psychostimulant,   being present in the brain longer,
the consequences of long-term                   as are other drugs of        which ultimately leads to pro-
methamphetamine exposure in            abuse such as amphetamine and         longed stimulant effects.
animals, concern has arisen over       cocaine. We know that metham-
its toxic effects on the brain.
Researchers have reported that
                                       phetamine is structurally similar
                                       to amphetamine and the neuro-         What are
as much as 50 percent of the           transmitter dopamine, but it is       the medical
dopamine-producing cells in the        quite different from cocaine.
brain can be damaged after pro-        Although these stimulants have        complications of
longed exposure to relatively
low levels of methamphetamine.
                                       similar behavioral and physiologi-
                                       cal effects, there are some major
                                                                             methamphetamine
Researchers also have found that       differences in the basic mecha-       abuse?
serotonin-containing nerve cells       nisms of how they work at the


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may be damaged even more               level of the nerve cell. However,              ethamphetamine can
extensively. Whether this toxicity     the bottom line is that metham-                cause a variety of cardio-
is related to the psychosis seen       phetamine, like cocaine, results in            vascular problems.
in some long-term methamphet-          an accumulation of the neuro-         These include rapid heart rate,
amine abusers is still an open         transmitter dopamine, and this        irregular heartbeat, increased
question.                              excessive dopamine concentration      blood pressure, and irreversible,
                                       appears to produce the stimula-       stroke-producing damage to
                                                                             small blood vessels in the brain.
                                                                             Hyperthermia (elevated body
   Although both methamphetamine and cocaine are                             temperature) and convulsions
   psychostimulants, there are differences between them.                     occur with methamphetamine
                                                                             overdoses, and if not treated
   Methamphetamine              vs.    Cocaine                               immediately, can result in death.
                                                                                 Chronic methamphetamine
   Man-made                            Plant -derived                        abuse can result in inflammation
                                                                             of the heart lining, and among
   Smoking produces a high             Smoking produces a high               users who inject the drug,
   that lasts 8-24 hours               that lasts 20-30 minutes              damaged blood vessels and skin
                                                                             abscesses. Methamphetamine
                                                                             abusers also can have episodes
   50% of the drug is removed          50% of the drug is removed
                                                                             of violent behavior, paranoia,
   from the body in 12 hours           from the body in 1 hour
                                                                             anxiety, confusion, and insomnia.
                                                                             Heavy users also show progres-
   Limited medical use                 Used as a local anesthetic in
                                                                             sive social and occupational
                                       some surgical procedures
                                                                             deterioration. Psychotic symptoms
6   NIDA R E S EAR CH R EP O RT S E RIE S


can sometimes persist for months
or years after use has ceased.
                                            among injection drug users
                                            primarily through the re-use of
                                                                                 What treatments
     Acute lead poisoning is                contaminated syringes, needles,      are effective for
another potential risk for
methamphetamine abusers. A
                                            or other paraphernalia by more
                                            than one person. In nearly one-
                                                                                 methamphetamine
common method of illegal                    third of Americans infected with     abusers?

                                                                                 A
methamphetamine production                  HIV, injection drug use is a risk
uses lead acetate as a reagent.             factor, making drug abuse the                t this time the most
Production errors therefore may             fastest growing vector for the               effective treatments for
result in methamphetamine                   spread of HIV in the nation.                 methamphetamine addic-
contaminated with lead. There                   Research also indicates that     tion are cognitive behavioral
have been documented cases of               methamphetamine and related          interventions. These approaches
acute lead poisoning in intra-              psychomotor stimulants can           are designed to help modify the
venous methamphetamine                      increase the libido in users, in     patient’s thinking, expectancies,
abusers.                                    contrast to opiates which actually   and behaviors and to increase
     Fetal exposure to metham-              decrease the libido. However,        skills in coping with various life
phetamine also is a significant             long-term methamphetamine use        stressors. Methamphetamine
problem in the United States. At            may be associated with decreased     recovery support groups also
present, research indicates that            sexual functioning, at least in      appear to be effective adjuncts
methamphetamine abuse during                men. Additionally, methamphe-        to behavioral interventions that
pregnancy may result in prenatal            tamine seems to be associated        can lead to long-term drug-free
complications, increased rates of           with rougher sex, which may lead     recovery.
premature delivery, and altered             to bleeding and abrasions. The           There are currently no partic-
neonatal behavioral patterns, such          combination of injection and         ular pharmacological treatments
as abnormal reflexes and extreme            sexual risks may result in HIV       for dependence on amphetamine
irritability. Methamphetamine               becoming a greater problem           or amphetamine-like drugs
abuse during pregnancy may                  among methamphetamine abusers        such as methamphetamine. The
be linked also to congenital                than among opiate and other          current pharmacological approach
deformities.                                drug abusers, something that         is borrowed from experience with
                                            already seems to be occurring in     treatment of cocaine dependence.
Are methamphet-                             California.
                                                NIDA-funded research
                                                                                 Unfortunately, this approach
                                                                                 has not met with much success
amine abusers at                            has found that, through drug         since no single agent has proven
                                            abuse treatment, prevention,         efficacious in controlled clinical
risk for contracting                        and community-based outreach         studies. Antidepressant medica-
HIV/AIDS and                                programs, drug abusers can
                                            change their HIV risk behaviors.
                                                                                 tions are helpful in combating
                                                                                 the depressive symptoms fre-
hepatitis B and C?                          Drug use can be eliminated and       quently seen in methamphetamine
                                            drug-related risk behaviors, such    users who recently have become


I
    ncreased HIV and hepatitis B            as needle-sharing and unsafe         abstinent.
    and C transmission are likely           sexual practices, can be reduced         There are some established
    consequences of increased               significantly thus decreasing the    protocols that emergency room
methamphetamine abuse, particu-             risk of exposure. Therefore,         physicians use to treat individuals
larly in individuals who inject the         drug abuse treatment is also         who have had a methamphetamine
drug and share injection equip-             highly effective in preventing       overdose. Because hyperthermia
ment. Infection with HIV and                the spread of HIV, hepatitis B,      and convulsions are common and
other infectious diseases is spread         and hepatitis C.                     often fatal complications of such
                                                                             NIDA R E S EAR CH R EP O RT S E RIE S   7
overdoses, emergency room             A list of fact sheet topics follows:
treatment focuses on the immedi-
ate physical symptoms. Overdose
                                      Health Effects of Specific Drugs           Access information
                                        • Cigarettes and other
patients are cooled off in ice
                                           tobacco products                        on the Internet
baths, and anticonvulsant drugs
                                        • Crack and cocaine
may be administered also.                                                       • What’s new on the
                                        • Ecstasy
    Acute methamphetamine                                                         NIDA Web site
                                        • Heroin
intoxication can often be handled
                                        • Inhalants                             • Information on
by observation in a safe, quiet
                                        • LSD                                     drugs of abuse
environment. In cases of extreme
                                        • Marijuana
excitement or panic, treatment
                                        • Methamphetamine                       • Publications and
with antianxiety agents such as
                                        • Pain medications                        communications
benzodiazepines has been helpful,
                                        • PCP                                     (including NIDA N O TE S )
and in cases of methamphetamine-
                                        • Ritalin
induced psychoses, short-term                                                   • Calendar of events
                                        • Rohypnol and GHB
use of neuroleptics has proven
                                        • Steroids (anabolic)                   • Links to NIDA
successful.
                                      Drug Abuse and AIDS, Lessons                organizational units
Where can I get                       from Prevention Research, and
                                      Treatment Research
                                                                                • Funding information
further scientific                       • Treatment methods                      (including program
                                                                                  announcements and
                                         • Treatment medications
information about                        • Treatment methods for                  d ea d l i nes )
methamphetamine                            women
                                         • Behavior change through
                                                                                • International activities
abuse?                                     treatment                            • Links to related


T
      o learn more about metham-      Trends and Surveys                          Web sites (access to
      phetamine and other drugs          • Costs to society from                  Web sites of many
      of abuse, contact the                drug abuse                             other organizations
National Clearinghouse for               • High school and youth                  in the field)
Alcohol and Drug Information               trends
(NCADI) at 1-800-729-6686.               • Hospital visits and deaths
Information specialists are              • Nationwide trends
available to assist you in locating      • Pregnancy and drug abuse
                                                                                    NIDA Web Sites
needed information and resources.          trends                                   www.drugabuse.gov
Information can be accessed              • Treatment trends                        www.steroidabuse.org
through the NIDA Web                     • Workplace trends                         www.clubdrugs.org
site (www.drugabuse.gov) or
the NCADI Web site                    News Releases on Research
(www.health.org).                     Findings and Information                 National Clearinghouse
    Fact sheets on health effects     about NIDA                                for Alcohol and Drug
of drug abuse and other topics           • Web page                             Information (NCADI)
can be ordered free of charge, in        • Mission and structure                Web Site: www.health.org
English and Spanish, by calling          • Opportunities for special           Phone No.: 1-800-729-6686
NIDA INFOFAX at 1-800-                     populations
NIH-NIDA (1-800-644-6432)                • Funding opportunities
or 1-888-TTY-NIDA (1-888-889-            • Upcoming events and
6432)for the hearing impaired.             conferences
8   NIDA R E S EAR CH R EP O RT S E RIE S


Glossary
Addiction: a chronic, rela psing                       D et o xi f i c at i o n : a process of              Rush: a surge of euphoric ple a-
dise ase, chara cterized by compul-                    a llowing the body to rid itself of a                sure that ra pidly follows a dminis-
sive drug-seeking and drug use                         drug while mana ging the symp-                       tration of a drug.
and by neurochemic al and molec-                       toms of withdrawal; often the first
ul ar changes in the brain.                            step in a drug tre atment program.                   Serotonin: a neurotransmitter that
                                                                                                            has been implic ated in states of
Analog: a chemic al compound                           Dopamine: a neurotransmitter                         consciousness, mood, depression,
that is simil ar to another drug in                    present in regions of the bra in                     and anxiety.
its effects but differs slightly in its                that regul ate movement, emotion,
chemical structure.                                    motivation, and feelings of ple a-                   Tolerance: a condition in which
                                                       sur e .                                              higher doses of a drug are
B enz o di az epi nes : drugs that                                                                          required to produce the same
relieve anxiety or are prescribed                      Narcolepsy: a disorder chara cter-                   effect as experienced initially;
as sed atives; among the most                          ized by uncontroll a ble atta cks of                 often le a ds to physic al depen-
widely prescribed medic ations,                        deep sleep.                                          dence .
including valium and librium.
                                                       Physical dependence: an a d a p-                     Toxic: temporary or permanent
Central nervous system (CNS):                          tive physiologic al state that occurs                drug effects that are detrimental
the brain and spinal cord.                             with regul ar drug use and results                   to the functioning of an org an or
                                                       in a withdrawal syndrome when                        group of organs.
Craving: a powerful, often                             drug use stops.
uncontroll a ble desire for drugs.                                                                          Wi t hdrawal : a variety of symp-
                                                       Psychosis: a mental disorder                         toms that occur after use of an
Designer drug: an ana log of a                         chara cterized by symptoms such                      a ddictive drug is reduced or
restricted drug that has psycho a c-                   as delusions or hallucinations that                  st o p p e d .
tive properties.                                       indic ate an imp aired conception
                                                       of re ality.


Resources
“Blood Level of Intravenous Drug Users,” by R.L.       Methamphetamine Abuse (NIDA Capsules). National      Detailed Emergency Department Tables 2000, Drug
  Norton, B.T. Burton, and J. McGirr. Journal of        Institute on Drug Abuse, September 1997.              Abuse Warning Network. Substance Abuse and
  Clinical Toxicology 34(4):425-30, 1996.              National Methamphetamine Strategy. U.S.                Mental Health Services Administration, available
Epidemiologic Trends in Drug Abuse: Vol. I.              Department of Justice, 1996.                         online at www.samhsa.gov/oas/dawn.htm.
  Highlights and Executive Summary of the              National Survey Results on Drug Use From the
  Community Epidemiology Work Group , June 2001.         Monitoring the Future Study, 1975-1994, Vol. I:
  NIH Pub. No. 01-4916A. National Institute on           Secondary School Students . NIH Pub. No. 93-
  Drug Abuse, 2001.                                      3498. National Institute on Drug Abuse, 1995.
Epidemiologic Trends in Drug Abuse: Vol. II.           National Survey Results on Drug Use From the
  Proceedings of the Community Epidemiology Work         Monitoring the Future Study, 1975-1994, Vol. II:
  Group, June 2001. NIH Pub. No. 01-4917A.               College Students and Young Adults . NIH Pub. No.
  National Institute on Drug Abuse, 2001.                96-4027. National Institute on Drug Abuse, 1995.
“Integrating Treatments for Methamphetamine Abuse:     “NIDA Survey Provides First National Data on Drug
  A Psychosocial Perspective,” by A. Huber, W. Ling,     Abuse During Pregnancy,” by R. Mathias. NIDA
  S. Shoptaw, V. Gulati, P. Brethen, and R. Rawson.      Notes 10:6-7, 1995.
  Journal of Addictive Diseases, 16(4):41-50, 1997.                                                           NIH Publication Number 02-4210.
                                                       Summary of Findings from the 2000 National
“Like Methamphetamine, Ecstacy May Cause Long-                                                                  Printed April 1998, Reprinted
                                                         Household Survey on Drug Abuse. Substance
  Term Brain Damage,” by R. Mathias. NIDA Notes                                                                          January 2002.
                                                         Abuse and Mental Health Services Administration,
  11:7, 1996.                                                                                                 Feel free to reprint this publication.
                                                         2000.

								
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