Discussion
This study explored the use of ATS among Palestinians in the north of the West Bank. The findings revealed that these drugs were widely used alone or in combination with other drugs. The results indicated that 8% of men in the north of the West Bank used ATS drugs, with the highest prevalence (14.8%) among young men (30–39 years). It was demonstrated that 28% of people in the middle of the West Bank who misuse drugs were found to have methamphetamines in their system17 compared with 6.2% in this study.
The production and distribution of illegal drugs were noticed remarkably in 2013 in the West Bank.9 Few studies suggested that the pattern of drug use in the north of the West Bank has changed since 2013.6 8–11 The results of this study indicated that a prominent feature has been a shift from THC use to amphetamines and related substances in the north of the West Bank. Several factors could contribute to the shift from THC use to ATS use. First, ATSs have been locally manufactured and seized in the West Bank in different forms, tablet form bearing the Captagon logo and ecstasy group substances.9 Second, liquid homemade methamphetamine (GG) was manufactured in rural areas and spread quickly to refugee camps.9 Due to the low cost and easy accessibility of the raw starting materials needed to manufacture meth-cooking and the ease of selling, the ATS has spread quickly among young adults in the West Bank.9 Thus, the suggested transformation to ATS use in the West Bank could be partially attributed to the increase in the local synthetic processes of methamphetamines.
The use of methamphetamines is a serious issue due to their highly addictive nature and the intense release of dopamine that they cause in the central nervous system.14 20 Unfortunately, these drugs are becoming more common worldwide, and individuals who use methamphetamines often also use other illicit substances.21 The study revealed that ATS was often combined with other drugs, particularly benzodiazepines, barbiturates and THC. These findings align with international studies, indicating consistent patterns of substance use behaviours. Benzodiazepines are a class of drugs primarily used for treating anxiety, but they are also effective in treating several other conditions. A benzodiazepine can be dangerous if used in excess, and it can be lethal if combined with alcohol or other drugs.22 23 Drug users rarely use benzodiazepines alone; instead, they frequently use them in conjunction with other substances to boost their effects.24 Therefore, benzodiazepine misuse is a cause for concern. Previous research has established a link between ATS and benzodiazepine use, as drug users tend to mix the two to achieve either stimulating or sedating effects.25–28 Combining amphetamines and benzodiazepines resulted in more significant driving impairment than either drug alone.29 People who combine benzodiazepines and amphetamines are at a higher risk of experiencing psychological issues such as depression, anxiety and social dysfunction.30 Studies have shown that those who use benzodiazepines are more likely to use amphetamines through injection and reuse needles, which increases their chances of contracting bloodborne viruses like hepatitis B and HIV.30 Additionally, combining benzodiazepines and amphetamines can result in higher levels of impairment while driving than using either substance alone.29 It is also believed that combining ATS and benzodiazepines can lead to more severe myocardial injury and an increased risk of cardiac mortality.23 These results suggest further investigation into these drugs’ usage patterns and adverse effects among Palestinians.
Barbiturates are also a significant concern, as they cause suicide.21 The United Nations Commission on Narcotic Drugs and the WHO Expert Committee recognise the health risks of these drugs and have called for stricter regulation of their manufacture, distribution and use.31 Withdrawal from barbiturates can even be more severe than withdrawal from opiates,32 underscoring the importance of addressing this issue as a public health concern. This study also found a correlation between ATS use and the use of barbiturates and THC. More recently, amphetamines have been used with one of the barbiturates, such as amobarbital or phenobarbital, to produce mood-elevating effects.25 26 In the early 1990s, methamphetamine availability at lower prices led to its growing popularity among local communities of cannabis users.33 The well-documented role of ATS and cannabis in the pathogenesis of psychiatric disorders, ranging from anxiety spectrum to psychotic and cognitive disorders, raises serious concerns about the sequelae of their combined use.34 35 It has been suggested that cannabis may prolong and intensify the sensation of euphoria associated with the consumption of ATS.36 37 However, it has been demonstrated to have various impacts on anxiety. It may worsen some of the harmful subjective effects of ATS, including panic and paranoia.38 This alarming scenario raises the urgency of a better understanding of the effect of combining THC with amphetamines on the Palestinian population. The implications of these findings warrant further exploration.
The risk associated with alcohol and amphetamine use increases when these addictive substances are used simultaneously. Unfortunately, when misused, amphetamines can reduce the tired and groggy feelings that come with alcohol intoxication. This extended time increases the risk of alcohol poisoning from overconsumption, leading to organ damage and death. On the other hand, alcohol can enhance the pleasurable effects of amphetamines.39 It is crucial to be mindful of these dangers and to practise safe and responsible substance use. In addition, experimental evidence suggests caffeine enhances the toxic effects of amphetamine-related drugs, increasing seizures, hyperthermia and tachycardia.40–42 The relevance of these interactions is uncertain, but caution is warranted given the popularity of these drug combinations and their potential for toxicity. According to the univariate analysis, ATS use was associated with alcohol and coffee intake. Studies have shown that individuals who have experienced traumatic events are more likely to develop substance use disorders.43 This is especially true for those with poor mental health who use stimulants to cope with their trauma.44 Unfortunately, those who experience trauma at a younger age are less likely to develop healthy coping mechanisms and are more likely to become socially isolated, leading to an increased risk of drug use.44–46 According to the univariate analysis results, ATS use was also more common among the young, the educated, the refugees and the workers. This could be attributed to their political situation, stress and financial constraints.6 13 16 Refugee camps were identified as one of the areas where novel psychostimulant products, including amphetamines, have appeared.9 11 In Palestine, there is a stigma around seeking help for mental health issues, which may contribute to the high prevalence of drug use among young people.16 Unfortunately, over half of Palestinian youth show signs of depression, and there are few accessible counselling services and a stigma around seeking therapy.47 Moreover, cultural stigma and high costs may prevent many individuals from taking prescribed antidepressants, and they may become more vulnerable to drug use. It is crucial to provide accessible counselling services and to promote a stigma-free environment to support those struggling with addiction, especially vulnerable groups like refugees. One of the most effective measures to curb the use of ATS in Palestine is to increase public awareness about the dangers of drug misuse and addiction. This can be achieved through public education campaigns, community outreach and media campaigns that emphasise the negative consequences of drug use and highlight the benefits of a healthy and drug-free lifestyle. In addition, law enforcement agencies can play a critical role in curbing ATS use by cracking down on illegal drug trafficking and distribution networks, and by imposing strict penalties on those caught manufacturing, selling or using drugs. This can serve as a deterrent to others and help reduce the overall demand for ATS in the community. Another approach is to increase access to drug treatment and rehabilitation services for those struggling with ATS addiction. This can include establishing community-based treatment centres, providing access to medications that can help manage withdrawal symptoms, and offering counselling and support services to help individuals overcome addiction and maintain long-term recovery. It is worth noting that Palestine lacked a fully integrated system of drug dependence treatment and care until 2014. However, the implementation of the project ‘Supporting the establishment-based drug dependence treatment and rehabilitation system’ marked a significant step towards addressing this issue. The project, which aimed to support the establishment-based drug dependence treatment and rehabilitation system for the Palestine National Rehabilitation Centre, resulted in the creation of the first science, gender and human rights-based drug treatment and rehabilitation centre in Palestine. Moreover, it is now fully integrated into the Palestinian health system, providing a solid foundation for the government to tackle the increasing drug use and related risks in the state.12 Finally, it is important to address the underlying social and economic factors that contribute to drug use, such as poverty, unemployment and lack of educational opportunities. By addressing these root causes, it is possible to create a more stable and prosperous society.
This study has several limitations. Drug use results could be underestimated in this study for several reasons. MDMA result is positive when MDMA concentration exceeds 500 ng/mL in the urine,48 and the half-life of MDMA is 7–8 hours.49 This relatively short half-life adds up to the underestimation of the prevalence of users of MDMA. The test does not detect some substances used in the West Bank, like tricyclic antidepressants, tramadol, ketamine, synthetic THC and other substances, which adds to underestimating the results.48 In addition, the test used to examine urine has a limited time frame to detect substances. The test we used has a variable ability to detect the presence of a drug in the urine depending on the specific drug itself. Some can be detected only within 1 or 2 days after drug use, like cocaine, while others can be detected up to several days later, like PCP.48 A negative result may not necessarily indicate drug-free urine. Negative test results can be obtained when the drug is present but below the cut-off level of the test. The test does not distinguish between drugs of misuse and certain medications.48 Unfortunately, there are no available confirmation tests for drugs in body fluids in Palestine. Moreover, the high rejection rate could add to the underestimated results. As our study only included men from the north of the West Bank, it is important to exercise caution when applying our findings to men from other governorates or to women. Therefore, generalising our results to other populations should be done with careful consideration. Despite these limitations, this study is the first to identify the associated risk factors with ATS use among Palestinians.
