Is Captagon (fenethylline) helping to fuel the Syrian conflict?

At the time of writing, the Syrian conflict has led to the death of more than 200 000 people since the onset of violence 5 years ago, with 440 000 besieged and 12 million people currently displaced 1. It has arisen from a number of political, religious and economic pressures. However, given the complex network of factors involved, it is worth considering the role possibly played by psychoactive drugs. We want to bring to the attention of Addiction readers the possible role of the manufacture, use and exportation of clandestine forms of the pharmaceutical drug called Captagon®. We believe it is traded to fund the war, and according to a number of reports it is used as a stimulant by fighters to induce greater fighting aggression, detachment and for cognitive enhancement and alertness on long missions. Captagon® is the trademark name for the synthetic stimulant 'fenethylline hydrochloride', which is a central nervous system stimulant with euphoric and analgesic properties. Captagon® was first synthesized in 1961 for the treatment of hyperactivity, depression and narcolepsy 2. It metabolizes to form two active stimulant drugs—amphetamine and theophylline 3, 4. Fenethylline was controlled in 1981 as a Schedule 1 substance and currently does not have an accepted medical use in the United States. It was made illegal in most countries after 1986 by inclusion in the international scheduling under the Convention on Psychotropic Substances 1971, despite low reported incidences of abuse and a lower abuse potential compared with amphetamine 2. Adverse health consequences include psychosis, acute heart failure and myocardial infarction 5-7. In the early 2000s, a shift toward clandestine manufacture of Captagon® was observed in southeastern Europe and Anatolia (Slovenia, Serbia-Montenegro, Bulgaria and Turkey) by the International Narcotics Control Board (INCB) and Interpol, with stockpiling and trafficking of this new synthetic amphetamine-type stimulant (ATS) through Turkey, Syria and Jordan into the Arabian Peninsula 8. Counterfeit versions marked with the Captagon® logo are widely available across the Arabian peninsula (and also in Turkey and Europe), and do not contain fenethylline hydrochloride itself due to low stocks of diverted fenethylline and the sporadic availability of precursor chemicals for clandestine synthesis. However, these pills contain other easily produced amphetamines and amphetamine derivatives capable of inducing similar effects 9-11. Content commonly includes amphetamine, methamphetamine, procaine, caffeine, quinine, ephedrine, metronidazole, theophylline, chlorphenamine, trimethoprim and chloroquine 10. Syria is now the premier producer and exporter of counterfeit forms of Captagon, taking over from Lebanon in 2013. Pills branded as Captagon® are reportedly selling for between $5 and $20 within the country. The use of this pharmaceutical drug is not new in the Middle East 8, 9. It has been and is one of the most widely used substances within the region 12-14. Google Trends data also reveal strong trends in online searches for Captagon originating in Saudi Arabia. Investigations by the American magazine Time and the Reuters News Agency have revealed that sales of Captagon® have become a major source of revenue in Syria, as economic activity has slowed considerably within the country because of the civil war 15. In 2013, 12.3 million Captagon® pills were seized near the border between Lebanon and Syria. In 2014, 29.09 million Captagon®-branded pills were seized in Dubai, with Turkish law enforcement seizing 7 million pills en route from Syria to Saudi Arabia. Seizures recorded in 2015 are speculated to be due to the migrant flow and establishment of drug-smuggling routes through Turkey from Syria 16. The increasing impact of the Syrian conflict on Europe is not only confined to migration and the recent outrages perpetrated in Paris on 13 November 2015, but is also initiating changes in new routes for human and drug trafficking which, as a result, are increasing the availability of a range of drugs 17. Seizures in Syria in 2015 also increasingly suggest the use of Captagon® by militant groups (with the exception of al-Qaeda-linked groups who adhere to a more puritanical interpretation of Islamic law in the area of substance use). When Captagon® is used in military combat soldiers feel euphoric, fearless and powerful, can remain awake for days and kill in a numb and reckless manner 18. Its stimulant properties offer military advantages during protracted fighting enabling those using it to operate for significantly longer periods of time 15, 18. In that regard, it is similar to amphetamine and methamphetamines that have a long history of military use for their stimulant and performance-enhancing effects 19, 20. None.