Letters to the Editor The journal publishes both invited and unsolicited letters.
SAMAN WARNAKULASURIYA1, PANKAJ CHATURVEDI2 & PRAKASH C. GUPTA3
ADDICTIVE BEHAVIOURS NEED TO INCLUDE ARECA NUT USE
We read the paper ‘Global statistics on addictive behaviours: 2014 status report’ in Addiction [1] with interest. Authors identified alcohol use, tobacco use, unsanctioned psychoactive drug use and gambling as addictive behaviours for the study. The first objective they listed was to identify major online, publicly accessible sources of data on addictive behaviours. Looking at this objective, we found it surprising that the authors made no mention of areca nut. Areca nut (also erroneously called betel nut in the literature) is a globally used addictive substance, and a huge amount of published literature is available concerning areca nut. For example, in 2002, an entire supplement of the journal Addiction Biology was devoted to areca nut. A PubMed search revealed 1745 citations on the subject. There are an estimated 600 million areca nut users in the world [2], and it is the fourth most widely used psychoactive substance (after caffeine, alcohol and nicotine). It is often used as an ingredient in betel quid and its use is widespread, from countries of South Asia to the Pacific Islands of Saipan and Guam. A spectrum of health problems has been identified linked to areca nut, and systemic adverse effects have been reviewed [3]. In particular, the evidence for carcinogenicity of areca nut among humans has been evaluated as ‘sufficient’ [4]. Although consumed predominantly in South Asia and in the Pacific basin, migrants from the subcontinent to the West have introduced this substance to where they live. Areca nut is readily available in Asian grocery stores in the United Kingdom. A strong dependency to areca nut was reported initially following the work of Winstock et al. [5], who described a dependency syndrome to areca nut among regular users. Although areca nut use is not common in every nook and corner of the world, that should not be a reason for excluding areca nut use as an important deleterious addictive behaviour. Declaration of interests
King’s College London, London, UK1 Tata Memorial Hospital, Mumbai, India2 and Healis–Sekhsaria Institute for Public Health, Navi Mumbai, India3 E-mail: [email protected]
References 1. Gowing L. R., Ali R. L., Allsop S., Marsden J., Turf E. E., West R. et al. Global statistics on addictive behaviours: 2014 status report. Addiction 2015; 110: 904–19. 2. Gupta P. C., Wanakulasuriya S. Global epidemiology of areca nut usage. Addict Biol 2002; 7: 77–84. 3. Garg A., Chaturvedi P., Gupta P. C. A review of the systemic adverse effects of areca nut or betel nut. Ind J Med Paediatr Oncol 2014; 35: 3–9. 4. International Agency for Research on Cancer (IARC). IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans Betel-quid and Areca-nut Chewing; and some Areca-Nut-Derived Nitrosamines, Vol. 85. Lyon: International Agency for Research on Cancer; 2004. 5. Winstock A. R., Trivedy C. R., Warnakulasuriya K. A., Peters T. J. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the Gujarat community in the UK. Addict Biol 2000; 5: 173–9.
REPLY TO WARNAKULASURIYA ET AL. Dear Sir, We are grateful to Warnakulasuriya et al. for their thoughtful comments on the global addiction statistics paper [1]. We can only but agree, and state in our defence that the task of finding, validating and synthesizing evidence on the addictive behaviours covered was a gigantic task. It was always our intention to expand the range of substances and behaviours in succeeding versions, and areca nut will be high on the priority list. We encourage others interested in the addictive behaviours globally to contact us through the pages of the journal and argue the case for other substances and behaviours to be included.
None.
Declaration of interests
Keywords Betel, cancer, dependency, India, migrants, pan, South Asia, South Pacific Islands.
R.W. undertakes research and consultancy for companies that develop and manufacture smoking cessation medicines.
© 2015 Society for the Study of Addiction
Addiction, 110, 1533–1535
1534
Letters to the Editor LINDA R. GOWING1 & ROBERT WEST2
Discipline of Pharmacology, University of Adelaide, Adelaide, SA, Australia1 and Department of Epidemiology and Public Health, University College London, London, UK2 E-mail: [email protected]
Reference 1. Gowing L. R., Ali R. L., Allsop S., Marsden J., Turf E. E., West R. et al. Global statistics on addictive behaviours: 2014 status report. Addiction 2015; 110: 904–19.
LITTLE FLY WING: A NEW DRUG OF CONCERN IN ARGENTINA
A form of crude cocaine base known as ‘paco’ has been the ‘drug of the poor’ in Argentina for more than a decade [1]. Paco typically contains adulterants such as inactive sugars, caffeine, local anesthetics (e.g. lidocaine) and stimulants (e.g. ephidrine), as well as production by-products (e.g. kerosene, soda ash). During the last few years, phenacetin has been detected as an adulterant to paco. Some of these adulterants pose the threat of serious short- and long-term health consequences independent of the negative health effects of cocaine, although there is insufficient research to quantify the nature and extent of such effects for most of these adulterants, phenacetin being an exception [2–6]. During the last year, a new version of cocaine—Little Fly Wing—has been identified, and is causing as much concern as paco. It is produced in crystalline form, and is sniffed or injected. In comparison to paco [typically sold at 10 pesos (~ US$ 1) per ‘hit’], Little Fly Wing sells for 300–500 Argentine pesos (~ US$ 30–50) per gram. Although assay data are unavailable, a newspaper article by the Chairman of the Anti-Drug Association of Argentina [7] and an interview with the head of the Chemical Laboratory, Chemical Precursors and the Technical Office of the former Dangerous Drugs of Santa Fe province, Argentina [8] indicate that it is composed of ±80% cocaine hydrochloride and ±20% phenacetin. While prevalence data are lacking, reports about consumption are occurring in the media and from patients entering treatment. Cocaine has both short- and long-term deleterious effects. It causes pulmonary (e.g. heart palpitations to heart failure) and neurological problems (e.g., seizures to strokes), with a heightened risk of various psychological problems, including addiction [9]. Due to the high amount of cocaine hydrochloride in Little Fly Wing (±80%), the nerve cells release abnormally large amounts of dopamine, more than are released by typical forms of freebase or crack cocaine, with significant deleterious effects on executive functioning, emotions and memory. © 2015 Society for the Study of Addiction
Phenacetin causes hemolysis: destruction of red blood cells. This is caused by an immunocomplex formation mechanism. Antibodies are formed against the drug, which leads to the formation of immune complexes that are absorbed over the red blood cells membrane, which then activates the complement triggering hemolysis. This cascade usually produces an acute intravascular hemolysis, often with renal failure and thrombocytopenia [10]. Phenacetin was once used in analgesic preparations, but has been found to be associated with an increased risk of carcinogenesis (e.g. urinary tract cancers), cardiovascular diseases, renal failure and certain blood disorders (e.g. methemoglobinemia), with its concomitant risk of shock, seizures and even death [11–13]. These issues led to its withdrawal from the market by the US Food and Drug Administration (FDA), the United Kingdom, Sweden and Japan. It is still available in Argentina [14]. Thus, this new preparation of a highly pure cocaine combined with phenacetin found in Little Fly Wing may pose a risk of morbidity and mortality equal to the risk posed by paco or crack cocaine for individuals who use it in Argentina or any other country where it may become popular. Public health surveillance systems should begin monitoring for the appearance of Little Fly Wing, and research on the nature and extent of its deleterious effects is needed urgently. Declarations of interest None. Keywords Adulterant, Argentina, cocaine, morbidity, mortality, paco, phenacetin.
1,2
3
HENDRÉE E. JONES , ROCIO SUAREZ ORDOÑEZ & 4
THOM BROWNE
UNC Horizons and Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 1
USA, Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, 2
Baltimore, MD, USA, Institute of Cognitive Neuroscience INECO 3
Oroño, Research Department, Rosario, Santa Fe, Argentina and US Department of State, Bureau of International Narcotics and Law Enforcement Affairs, Office of Anticrime Programs, Washington, DC, 4
USA
E-mail: [email protected]
References 1. Epele M. E. New toxics, new poverty: a social understanding of the freebase cocaine/paco in Buenos Aires, Argentina. Subst Use Misuse 2011; 46: 1468–76. Addiction, 110, 1533–1535
SAMAN WARNAKULASURIYA1, PANKAJ CHATURVEDI2 & PRAKASH C. GUPTA3
ADDICTIVE BEHAVIOURS NEED TO INCLUDE ARECA NUT USE
We read the paper ‘Global statistics on addictive behaviours: 2014 status report’ in Addiction [1] with interest. Authors identified alcohol use, tobacco use, unsanctioned psychoactive drug use and gambling as addictive behaviours for the study. The first objective they listed was to identify major online, publicly accessible sources of data on addictive behaviours. Looking at this objective, we found it surprising that the authors made no mention of areca nut. Areca nut (also erroneously called betel nut in the literature) is a globally used addictive substance, and a huge amount of published literature is available concerning areca nut. For example, in 2002, an entire supplement of the journal Addiction Biology was devoted to areca nut. A PubMed search revealed 1745 citations on the subject. There are an estimated 600 million areca nut users in the world [2], and it is the fourth most widely used psychoactive substance (after caffeine, alcohol and nicotine). It is often used as an ingredient in betel quid and its use is widespread, from countries of South Asia to the Pacific Islands of Saipan and Guam. A spectrum of health problems has been identified linked to areca nut, and systemic adverse effects have been reviewed [3]. In particular, the evidence for carcinogenicity of areca nut among humans has been evaluated as ‘sufficient’ [4]. Although consumed predominantly in South Asia and in the Pacific basin, migrants from the subcontinent to the West have introduced this substance to where they live. Areca nut is readily available in Asian grocery stores in the United Kingdom. A strong dependency to areca nut was reported initially following the work of Winstock et al. [5], who described a dependency syndrome to areca nut among regular users. Although areca nut use is not common in every nook and corner of the world, that should not be a reason for excluding areca nut use as an important deleterious addictive behaviour. Declaration of interests
King’s College London, London, UK1 Tata Memorial Hospital, Mumbai, India2 and Healis–Sekhsaria Institute for Public Health, Navi Mumbai, India3 E-mail: [email protected]
References 1. Gowing L. R., Ali R. L., Allsop S., Marsden J., Turf E. E., West R. et al. Global statistics on addictive behaviours: 2014 status report. Addiction 2015; 110: 904–19. 2. Gupta P. C., Wanakulasuriya S. Global epidemiology of areca nut usage. Addict Biol 2002; 7: 77–84. 3. Garg A., Chaturvedi P., Gupta P. C. A review of the systemic adverse effects of areca nut or betel nut. Ind J Med Paediatr Oncol 2014; 35: 3–9. 4. International Agency for Research on Cancer (IARC). IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans Betel-quid and Areca-nut Chewing; and some Areca-Nut-Derived Nitrosamines, Vol. 85. Lyon: International Agency for Research on Cancer; 2004. 5. Winstock A. R., Trivedy C. R., Warnakulasuriya K. A., Peters T. J. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the Gujarat community in the UK. Addict Biol 2000; 5: 173–9.
REPLY TO WARNAKULASURIYA ET AL. Dear Sir, We are grateful to Warnakulasuriya et al. for their thoughtful comments on the global addiction statistics paper [1]. We can only but agree, and state in our defence that the task of finding, validating and synthesizing evidence on the addictive behaviours covered was a gigantic task. It was always our intention to expand the range of substances and behaviours in succeeding versions, and areca nut will be high on the priority list. We encourage others interested in the addictive behaviours globally to contact us through the pages of the journal and argue the case for other substances and behaviours to be included.
None.
Declaration of interests
Keywords Betel, cancer, dependency, India, migrants, pan, South Asia, South Pacific Islands.
R.W. undertakes research and consultancy for companies that develop and manufacture smoking cessation medicines.
© 2015 Society for the Study of Addiction
Addiction, 110, 1533–1535
1534
Letters to the Editor LINDA R. GOWING1 & ROBERT WEST2
Discipline of Pharmacology, University of Adelaide, Adelaide, SA, Australia1 and Department of Epidemiology and Public Health, University College London, London, UK2 E-mail: [email protected]
Reference 1. Gowing L. R., Ali R. L., Allsop S., Marsden J., Turf E. E., West R. et al. Global statistics on addictive behaviours: 2014 status report. Addiction 2015; 110: 904–19.
LITTLE FLY WING: A NEW DRUG OF CONCERN IN ARGENTINA
A form of crude cocaine base known as ‘paco’ has been the ‘drug of the poor’ in Argentina for more than a decade [1]. Paco typically contains adulterants such as inactive sugars, caffeine, local anesthetics (e.g. lidocaine) and stimulants (e.g. ephidrine), as well as production by-products (e.g. kerosene, soda ash). During the last few years, phenacetin has been detected as an adulterant to paco. Some of these adulterants pose the threat of serious short- and long-term health consequences independent of the negative health effects of cocaine, although there is insufficient research to quantify the nature and extent of such effects for most of these adulterants, phenacetin being an exception [2–6]. During the last year, a new version of cocaine—Little Fly Wing—has been identified, and is causing as much concern as paco. It is produced in crystalline form, and is sniffed or injected. In comparison to paco [typically sold at 10 pesos (~ US$ 1) per ‘hit’], Little Fly Wing sells for 300–500 Argentine pesos (~ US$ 30–50) per gram. Although assay data are unavailable, a newspaper article by the Chairman of the Anti-Drug Association of Argentina [7] and an interview with the head of the Chemical Laboratory, Chemical Precursors and the Technical Office of the former Dangerous Drugs of Santa Fe province, Argentina [8] indicate that it is composed of ±80% cocaine hydrochloride and ±20% phenacetin. While prevalence data are lacking, reports about consumption are occurring in the media and from patients entering treatment. Cocaine has both short- and long-term deleterious effects. It causes pulmonary (e.g. heart palpitations to heart failure) and neurological problems (e.g., seizures to strokes), with a heightened risk of various psychological problems, including addiction [9]. Due to the high amount of cocaine hydrochloride in Little Fly Wing (±80%), the nerve cells release abnormally large amounts of dopamine, more than are released by typical forms of freebase or crack cocaine, with significant deleterious effects on executive functioning, emotions and memory. © 2015 Society for the Study of Addiction
Phenacetin causes hemolysis: destruction of red blood cells. This is caused by an immunocomplex formation mechanism. Antibodies are formed against the drug, which leads to the formation of immune complexes that are absorbed over the red blood cells membrane, which then activates the complement triggering hemolysis. This cascade usually produces an acute intravascular hemolysis, often with renal failure and thrombocytopenia [10]. Phenacetin was once used in analgesic preparations, but has been found to be associated with an increased risk of carcinogenesis (e.g. urinary tract cancers), cardiovascular diseases, renal failure and certain blood disorders (e.g. methemoglobinemia), with its concomitant risk of shock, seizures and even death [11–13]. These issues led to its withdrawal from the market by the US Food and Drug Administration (FDA), the United Kingdom, Sweden and Japan. It is still available in Argentina [14]. Thus, this new preparation of a highly pure cocaine combined with phenacetin found in Little Fly Wing may pose a risk of morbidity and mortality equal to the risk posed by paco or crack cocaine for individuals who use it in Argentina or any other country where it may become popular. Public health surveillance systems should begin monitoring for the appearance of Little Fly Wing, and research on the nature and extent of its deleterious effects is needed urgently. Declarations of interest None. Keywords Adulterant, Argentina, cocaine, morbidity, mortality, paco, phenacetin.
1,2
3
HENDRÉE E. JONES , ROCIO SUAREZ ORDOÑEZ & 4
THOM BROWNE
UNC Horizons and Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 1
USA, Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, 2
Baltimore, MD, USA, Institute of Cognitive Neuroscience INECO 3
Oroño, Research Department, Rosario, Santa Fe, Argentina and US Department of State, Bureau of International Narcotics and Law Enforcement Affairs, Office of Anticrime Programs, Washington, DC, 4
USA
E-mail: [email protected]
References 1. Epele M. E. New toxics, new poverty: a social understanding of the freebase cocaine/paco in Buenos Aires, Argentina. Subst Use Misuse 2011; 46: 1468–76. Addiction, 110, 1533–1535
