a practical guide for frontline workers
TREATMENT APPROACHES FOR
USERS OF METHAMPHETAMINEa practical guide for frontline workers
TREATMENT APPROACHES FOR
USERS OF METHAMPHETAMINE© Commonwealth of Australia 2008
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Project team
Turning Point Alcohol and Drug Centre Biotext
Nicole Lee Janet Salisbury
Linda Jenner Eve Merton
Kieran Connelly Ruth Pitt
Jacqui Cameron
Anthony Denham
ISBN: 1-74186-632-4
Online ISBN: 1-74186-633-2
Publications Approval Number: P3-3917
Suggested citation:
Jenner L and Lee N (2008). Treatment Approaches for Users of Methamphetamine:
A Practical Guide for Frontline Workers. Australian Government Department of Health
and Ageing, Canberra.iii
Acknowledgments
This publication was made possible by the input of many people who willingly gave of their
valuable time, expertise, and experience to offer suggestions and critical commentary. The
project team would especially like to thank the members of the Steering Committee:
Steve Allsop Linda Gowing Annie Madden
Amanda Baker Rebecca McKetin Katherine-Walsh Southwell
Adrian Dunlop
We would also like to thank the workers from the following organisations for their
valuable participation in focus groups that were undertaken in various locations throughout
Australia:
ACT Health, Drug and Alcohol Services
Addiction Medicine Clinic, Southern
Health Service, Victoria
Byron Place Community Centre, Adelaide
Canberra Alliance for Harm Minimisation
and Advocacy (CAHMA)
Cyrenian House, Perth
Drug and Alcohol Services South Australia
(DASSA)
Drug and Alcohol Withdrawal Network
(DAWN), Perth
Directions ACT
Galambila Aboriginal Health Service Inc,
Coffs Harbour
Gold Coast Alcohol Tobacco and Other
Drug Services (ATODS)
Gold Coast Drugs Council, Mirikai
Goldbridge Rehabilitation Services, Gold
Coast
Next Step Drug and Alcohol Services,
Perth
Palmerston Assoc Inc, Perth
Peninsula Drug and Alcohol Program
(PenDAP)
Pilbara Aboriginal Alcohol and Drug Project
Queensland Injectors Health Network
(QuIHN), Brisbane
QuIHN, Gold Coast
SHARPS Needle Syringe Program,
Melbourne
Streetlink Youth Health Service, Adelaide
Tedd Noffs Foundation, ACT
The Link Youth Health Service, Hobart
Vietnamese Community in Australia,
South Australia Chapter
Western Australia Substance Users
Association (WASUA)
Wirraka Maya Aboriginal Health Service,
South Hedland
Yirra Program, Mission Australia, Perth
Youth Substance Abuse Services (YSAS),
Victoria
We also wish to thank the user representatives from CAHMA for their generosity in sharing
personal stories, which contributed to the development of the content of this guide; and
the Western Australian Network of Alcohol and Other Drug Agencies (WANADA), and Drug
and Alcohol Office Western Australia (DAO), for assisting with the organisation of focus
groups in WA.
Finally, we wish to thank Jeremy Williams and Linda Rigby from the Australian Government
Department of Health and Ageing for their assistance with the project.iv Treatment Approaches for Users of Methamphetamine
iv
Contents
Acknowledgments...iii
Introduction... 1
Summary of important points from each chapter..................................................................... 3
Chapter 1: About methamphetamine (p.13).........................................................................................3
Chapter 2: Effects, risks and harms, and how these can be reduced (p.19).......................................3
Chapter 3: Recognising and managing intoxication (p.25)..................................................................4
Chapter 4: Recognising and managing overdose (p.27) ......................................................................4
Chapter 5: Recognising and responding to a person with mental health problems (p.29) ................5
Chapter 6: Helping a person get through withdrawal (p.43)...............................................................7
Chapter 7: Use of other drugs and possible effects of mixing drugs (p.47) .......................................7
Chapter 8: Overview of the range of treatment options (p.53) ...........................................................8
Chapter 9: Assisting families, carers and significant others (p.71) ....................................................9
Chapter 10: Legal issues (p.79)...10
Chapter 11: Making links and creating partnerships (p.83) ..............................................................10
1 About methamphetamine... 13
What is methamphetamine?...13
How many people use methamphetamine?......................................................................................13
How and why people use methamphetamine...................................................................................14
How does methamphetamine work?.................................................................................................15
Information for workers...15
Information for clients...17
References Chapter 1: About methamphetamine .............................................................................18
2 Effects, risks and harms, and how these can be reduced............................................. 19
What are the short-term effects?...19
During intoxication...19
At higher doses...19
In overdose...19
What are the long-term effects?...20
What are the other risks and harms?................................................................................................20
How can the risks and harms be reduced?........................................................................................21
Eat and drink enough...21
Rest sufficiently...21
Understand the actions and effects of methamphetamine .......................................................21
Attend to other health and lifestyle issues................................................................................22What about pregnancy?...22
Concerns about foetal development in babies of methamphetamine users.............................23
Concerns for breastfed babies of users.....................................................................................23
Advice for pregnant women ...24
References Chapter 2: Effects, risks and harms and how these can be reduced ............................24
3 Recognising and managing intoxication........................................................................... 25
Intoxication: what to look for...25
Responding to an intoxicated person ................................................................................................25
What you should do...25
What you should not do ...26
References Chapter 3: Identifying and managing intoxication .........................................................26
4 Recognising and managing overdose................................................................................ 27
Methamphetamine overdose: what to look for.................................................................................27
First aid for methamphetamine overdose..........................................................................................27
What not to do...28
Recommended service response...28
References Chapter 4: Recognising and managing overdose...........................................................28
5 Recognising and responding to a person with mental health problems.................... 29
Background...29
What is psychosis?...29
About methamphetamine psychosis..................................................................................................30
What is schizophrenia?...31
Methamphetamine psychosis or schizophrenia?...............................................................................31
Impending or ‘subacute’ psychosis: what to look for........................................................................32
Acute psychosis: what to look for...32
First steps in response ...32
Communicating with a person who is experiencing psychotic symptoms.......................................33
What the communicator should do ............................................................................................33
What the communicator should not do......................................................................................34
Longer-term management...35
Depression...36
Anxiety...37
Referring to emergency mental health services........................................................................38
Referring for nonemergency mental health assessment...........................................................39
Recommended service response...40
References Chapter 5: Identifying and responding to a person with mental health problems........40
6 Helping a person get through withdrawal........................................................................ 43
About methamphetamine withdrawal...............................................................................................43
Assisting a person who is withdrawing ............................................................................................44
References Chapter 6: Helping a person get through withdrawal....................................................45
7 Use of other drugs and possible effects of mixing drugs.............................................. 47
Risks associated with prescribed medications..................................................................................47
Risks associated with other drugs...48
Possible interactions with methamphetamine: quick reference list ................................................50
Advice for methamphetamine users..................................................................................................51
References Chapter 7: Use of other drugs and possible effects of mixing drugs............................52vi Treatment Approaches for Users of Methamphetamine
vi
8 Overview of the range of treatment options..................................................................... 53
About treatment seeking...53
Brief interventions...54
Assessment ...54
Current and past methamphetamine use...................................................................................55
Other drugs use...55
Dependence on each drug...5
Physical health and psychological health ..................................................................................56
Previous methamphetamine withdrawal or treatment..............................................................57
Social factors and history of gambling ......................................................................................57
Trauma history ...57
Readiness to change...58
Counselling...58
Cognitive behavioural approaches.............................................................................................58
Other counselling approaches...59
Cost of counselling ...59
Behavioural approaches...59
Contingency management...60
Residential rehabilitation...60
Self-help or mutual support groups...................................................................................................61
Medications (pharmacotherapies) ...62
Stimulant treatment programs...62
Other supports...62
Special considerations for young methamphetamine users.............................................................63
Guidance for working with young stimulant users....................................................................63
Special considerations for Indigenous methamphetamine users.....................................................64
Special considerations for methamphetamine users from culturally and linguistically diverse
backgrounds (CALD) ...66
General tips for agency responses to methamphetamine users.......................................................67
Respond promptly and acknowledge the client’s effort.............................................................67
Be open and nonjudgmental...67
Provide written resources and advise of the availability of treatment options........................67
Appoint a case manager and follow up on missed appointments............................................68
Refer when needed...68
Provide adequate staff training and supervision .......................................................................68
References Chapter 8: Overview of the range of treatment options................................................69
9 Assisting families, carers and significant others............................................................ 71
Tips for helping families, carers and significant others....................................................................71
Dependent children of adult methamphetamine users .............................................................73
Young carers...74
Supports for families...74
Resources...74
Contact numbers and websites..................................................................................................75
References Chapter 9: Assisting families, carers and significant others.........................................77vii
10 Legal issues... 79
Clients who are forced into treatment (coerced clients)...................................................................79
Mandatory reporting ...80
Crime...81
References Chapter 10: Legal issues.................................................................................................81
11 Making links and creating partnerships........................................................................... 83
Why create partnerships?...83
Barriers to effective partnerships...83
Tips for developing partnerships...84
Local agencies...84
Mental health services...85
General practitioners...86
Police and ambulance...86
Antenatal teams...87
Maintaining and improving established links....................................................................................87
Types of referral ...88
Strategies for effective referral ...89
References Chapter 11: Making links and creating partnerships.....................................................89
Glossary... 91
Resources... 97
For workers...97
Written materials...97
Websites and useful contacts...98
For users...99
Written materials...99
Websites and telephone contacts............................................................................................100
Appendix 1 Severity of dependence scale ........................................................................... 101
Appendix 2 Example family emergency plan........................................................................ 102
Appendix 3 Example young carer’s emergency plan........................................................... 103
Appendix 4 Example Memorandum of Understanding........................................................ 104viii Treatment Approaches for Users of Methamphetamine
viii
Introduction
Stimulants such as amphetamine have been used by some people in Australia
for many years. However, a more potent form, methamphetamine, has come
to dominate the illicit stimulant market over the past decade. Because of its
potency, many users have experienced a range of significant physical and
psychological health problems.
Alcohol and other drug (AOD) workers from a variety of service settings are now
frequently required to respond to methamphetamine users who are experiencing
the harmful effects of methamphetamine, going through withdrawal or seeking
methamphetamine-specific treatment.
Clinical treatment guidelines that provide a step-by-step guide to structured
counselling are available for trained AOD workers such as A Brief Cognitive
Behavioural Intervention for Regular Amphetamine Users (Baker et al 2003)
and Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14:
Methamphetamine Dependence and Treatment (Lee et al, 2007). However, the
Australian Government Department of Health and Ageing recognises that clear
and up-to-date information is required by all AOD workers, not just those with a
clinical or professional background; hence, this publication has been developed
to bridge an identified gap in available resources.
The guide is based on recent research, national and international guidelines,
and expert opinion. Because a comprehensive review of the research literature
was undertaken for the Commonwealth Monograph Models of Intervention
and Care for Psychostimulant Users (Baker et al 2004) and published in 2004,
the literature from 2003 to the present was reviewed for this guide. Databases
including PubMed and PsychInfo were used to find studies on relevant topics.
Guidelines from Australia and overseas were also consulted and form the basis
for a range of topics. Treatment Approaches for Users of Methamphetamine
The signs of methamphetamine overdose are now well recognised and frontline
workers are advised to familiarise themselves with the emergency management
techniques detailed in Chapter 4 Recognising and managing overdose.
Best practice in methamphetamine treatment involves a clear, mutually
acceptable treatment plan that is designed to meet the needs of the individual.
Early engagement, good communication and the development of a strong
helping relationship between the worker and service user or client are important
to attract methamphetamine users into treatment and to keep them engaged.
Numerous high-quality studies have suggested that psychosocial treatments,
especially cognitive behaviour therapy (CBT), should be a standard intervention
in methamphetamine treatment. CBT also assists with mental health problems,
such as depression and anxiety, which are common among methamphetamine
users.
Dependent psychostimulant users experience withdrawal symptoms when
they stop using the drug. Although we do not know a lot specifically about
methamphetamine withdrawal yet, evidence suggests that, for mild cases of
withdrawal, medication is not usually required and most symptoms resolve
within two weeks. In contrast, users with more severe dependence might
go on to have a longer and more intense withdrawal, and need targeted
ongoing support.
In circumstances where a methamphetamine user does not wish to stop
using the drug, harm reduction interventions are recommended and a range of
suggestions are offered in the guide.
Finally, where research evidence is lacking regarding issues such as
methamphetamine use among young people and those from culturally and
linguistically diverse backgrounds, the Indigenous community and pregnant
women, advice based on good practice and expert opinion is included to provide
a starting point to guide workers’ responses.
Summary of important points
from each chapter
Chapter 1: About methamphetamine (p.13)
• Methamphetamine is a strong stimulant that comes in various forms such
as ‘ice’ (a potent, crystal form that can be smoked or injected), base (an oily
powder or paste that can be injected), powder (‘speed’ or ‘louie’ that can
be injected or ‘snorted’ into the nasal passage) and tablets that are usually
swallowed.
• All methamphetamine forms quickly raise and sustain levels of the brain’s
chemical messengers (neurotransmitters), particularly dopamine, which
is responsible for memory, attention, purposeful behaviour and pleasurable
feelings.
• Over time, neurotransmitters become depleted, leading to poor concentration,
low mood, lethargy and fatigue, sleep disturbances and lack of motivation.
Chapter 2: Effects, risks and harms, and how these can
be reduced (p.19)
• Although there is variation between individuals, short-term effects include
euphoria, alertness, increased confidence and wakefulness. Higher doses can
cause agitation, sweating, tremors, irritability, teeth grinding, anxiety or panic,
paranoia and hallucinations (seeing or hearing things that others cannot).
• Longer-term effects of regular use can include weight loss; dehydration; poor
appetite or malnutrition; kidney problems; mood swings including depression;
anxiety; paranoia; chronic sleep disturbance; changes in brain structure and
function leading to memory, thinking, and emotional disturbances; disrupted
decision making ability; grossly impaired contact with reality (psychosis); and
dependence on methamphetamine.
• Due to the high potency of crystal methamphetamine, smoking and injecting
ice can rapidly lead to dependence in some users. Treatment Approaches for Users of Methamphetamine
• Risks of use include vein infections from injecting; blood-borne virus (BBV)
transmission; heart infection (endocarditis); heart attack; brain haemorrhage;
lung and skin infections; poor oral health including tooth decay and gum
disease; poor nutrition; psychosis and other mental health problems; and
social, occupational and legal problems.
• Harm reduction approaches include good diet; regular fluids; adequate
rest; regular breaks from using; good oral hygiene (brush and floss regularly);
contact with supportive and stable friends and family; education about
effects, signs of overdose and psychosis; and advice to seek professional
help if psychotic symptoms emerge.
• Pregnant methamphetamine users should receive regular antenatal care
to reduce risks and to improve outcomes for both mother and baby. Even if
psychostimulants have been used in the earlier stages of pregnancy, there
are possible benefits of reducing or ceasing use in the later stages. Pregnant
users should avoid use of other drugs, such as alcohol and tobacco.
Chapter 3: Recognising and managing intoxication (p.25)
• Signs of methamphetamine intoxication can include rapid or difficult-tointerrupt
speech; restlessness or agitation; jaw clenching and teeth grinding;
sweatiness; large pupils; irritability.
• An appropriate response involves sound communication skills; prompt
response to a service user’s needs; avoidance of lengthy questioning; provision
of written materials for later reference; opportunistic brief interventions
if possible; and the maintenance of a calm, safe, supportive and helpful
environment.
• Do not attempt to interview or counsel an intoxicated client, offer another
appointment if required.
Chapter 4: Recognising and managing overdose (p.27)
• Methamphetamine overdose (toxicity) is a medical emergency.
• Signs of toxicity include hot, flushed or very sweaty skin, which may
indicate high fever or overheating; severe headache; chest pain; changes in
consciousness; muscle tremor, spasm or fierce jerky movements; severe
agitation or panic; difficulty breathing; changes in mental state (eg confusion,
disorientation); seizures (fits); and symptoms of psychosis can also occur.
• First aid includes calling an ambulance immediately even if unsure of
cause; providing a non-stimulating and safe environment; making sure the
person can breathe; cooling the body (loosen restrictive clothing, use ice SUMMARY OF IMPORTANT POINTS FROM EACH CHAPTER
packs); removal of dangerous objects if the person has a seizure; continual
reassurance and waiting with the person until the ambulance arrives.
Chapter 5: Recognising and responding to a person with
mental health problems (p.29)
• Methamphetamine users can experience mental health problems such
as depression, anxiety or psychosis. Symptoms often resolve when the
user cuts down or stops using, but some people experience longer-lasting
symptoms.
• Symptoms of psychosis may be low-grade or ‘subacute’ and can include:
deterioration in general functioning in day-to-day life; expression of unusual
thoughts or ideas, strange, inappropriate or out-of-character conversational
style; fear or paranoia; a sense of self, others or the world being different
or changed in some way; suspiciousness or constant checking for threats
in an exaggerated way; over-valued ideas (ordinary events have special
significance or are more meaningful than usual); illusions (misinterpretation
of surroundings); and erratic behaviour.
• Psychosis in its acute form describes a disorder in which a person’s contact
with reality is grossly impaired. Symptoms include hallucinations (hearing,
seeing or feeling things that other people cannot); delusions (fixed, false
beliefs); disordered thought processes; disturbance in mood; and strange,
disorganised or bizarre behaviour.
• Methamphetamine can cause a psychotic episode in healthy people with
no previous history of mental health problems. It can also trigger a mental
health problem such as schizophrenia in vulnerable people, which will endure
even after they stop using the drug (for a diagnosis of schizophrenia at least
one obvious psychotic symptom must persist for longer than a month in the
absence of drug use or withdrawal).
• Psychosis is more likely among dependent methamphetamine users,
injectors, and those with other health problems.
• Many people will spontaneously recover from psychosis within hours, as the
effects of the drug wear off, while some will go on to experience symptoms
for some time.
• Immediate management of psychosis includes reducing risk to the
person, other workers and bystanders; a calming environment; effective
communication (eg never argue, calm voice, repetition of key messages);
calling an ambulance to facilitate an emergency assessment if the person
remains acutely disturbed; or calling police if risk of harm to self or others
is high. Treatment Approaches for Users of Methamphetamine
• Longer-term management of psychosis includes interventions aimed at
discontinued use; education regarding sensitivity to future psychotic episodes;
lifestyle management; and harm reduction strategies for those who do not
want to stop using (eg regular breaks from using; advice not to use more than
small amounts; avoidance of use of multiple drugs; and early intervention
should symptoms recur).
• Depression commonly occurs among methamphetamine users. Symptoms
of depression (eg withdrawal from social contact; negative thoughts; feelings
of sadness, guilt, pessimism; changes in appetite, libido and energy) may
persist for weeks, months or in some cases even several years after stopping
methamphetamine use.
• Workers and clients should regularly review symptoms of depression and seek
specialist help if symptoms worsen, especially if suicidal thoughts occur.
• A depressed person might be at high risk for suicide if he or she has tried
before; has a clear and lethal plan with the means to carry it out; has a lot of
stressors; feels hopeless; has psychotic symptoms; continues to use alcohol
and other drugs; or has few or no social supports.
• Clients considered to be at high risk should have an urgent and thorough
specialist assessment by mental health services. Workers should keep
the contact number for emergency mental health services on hand and
refer appropriately.
• Anxiety can occur in many forms and usually involves excessive worry. Other
features of anxiety can include agitation; racing heart; sweatiness; difficulty
breathing; tightness in the chest or chest pain; fear or panic; and sleep
disturbance.
• Anxiety symptoms often subside when the drug is no longer used, but if
symptoms persist after stopping, a mental health specialist should assess
the client. Cognitive behaviour therapy is an effective intervention for
anxiety disorders.
• Anxious clients should be provided with a low-stimulus environment and
encouraged to take slow, deep, calming breaths. Other relaxation strategies
include tensing and relaxing all the large muscle groups in the body; and
actively imagining a peaceful, safe place of the client’s own choosing.
• Workers should keep the contact numbers for both emergency and nonemergency
mental health services on hand at all times and familiarise
themselves with procedures for appropriate referral or consultation.SUMMARY OF IMPORTANT POINTS FROM EACH CHAPTER
Chapter 6: Helping a person get through withdrawal
(p.43)
• Many recreational users will experience a ‘crash’ period after they stop
using, which lasts a few days. During this time, they often sleep and eat a lot,
can become irritable, and might feel ‘flat’, tired and lethargic or generally out
of sorts. They usually do not require specialist assistance during this ‘coming
down’ period.
• Some dependent users, however, will experience full-scale methamphetamine
withdrawal, which often lasts for about a week or two. For some people,
certain symptoms, such as depression, can linger for several weeks, months
or even longer.
• During withdrawal, a person can feel depressed; irritable or anxious; be
agitated; have difficulty sleeping; be unable to experience pleasure; have poor
concentration and memory; have aches and pains; and strong cravings to
use methamphetamine.
• Support includes written materials and education about typical length of
withdrawal and common symptoms; the need for self-monitoring symptoms
of depression and intervention if severe; management of cravings; relapse
prevention; and relevant referral to a general practitioner for medical support if
insomnia, symptoms of anxiety or depression linger or place the client at risk
of relapse.
Chapter 7: Use of other drugs and possible effects of
mixing drugs (p.47)
• Use of multiple drugs with methamphetamine, particularly alcohol, nicotine,
cannabis, heroin and benzodiazepines, is common.
• Dangerous effects can result when medications for depression (antidepressants)
are taken within two weeks of using methamphetamine and can include
overheating, high blood pressure, and seizures (serotonin toxicity).
• Heroin used in conjunction with methamphetamine increases risk of
heroin overdose.
• Methamphetamine can stop people from feeling drunk after drinking alcohol,
even when blood alcohol levels are high. Therefore, the risk of accident and
injury is increased, as is the potential for driving while intoxicated. Clients with
problems related to the use of alcohol need targeted interventions. Treatment Approaches for Users of Methamphetamine
• Methamphetamine can also stop people from feeling the full effects of
benzodiazepines, leading to increased risk of accident and injury. There is
also the potential to take large quantities of benzodiazepine, which increases
risk of dependence and subsequent withdrawal. Some people can experience
withdrawal symptoms if benzodiazepines are stopped abruptly after just
one month. Signs of benzodiazepine withdrawal include sensitivity to loud
noises/light/touch; feelings of unreality; numbness; anxiety, fear of open
spaces (agoraphobia) and panic states; metallic taste in the mouth; pain,
stiffness and muscular spasms resulting in headaches and muscle twitching;
and seizures.
• Methamphetamine reduces the effectiveness of antipsychotic medication
and increases risk of seizures.
• Users should be informed of the potential for harmful effects of mixing
methamphetamine and medications and advised to seek advice from the
prescribing doctor.
Chapter 8: Overview of the range of treatment options
(p.53)
• Approaches to methamphetamine users should be individually tailored and
match each client’s goals for treatment.
• Cognitive behaviour therapy has been evaluated most extensively and is
effective for a range of problems related to methamphetamine use, including
mental health problems such as depression and anxiety. Medicare pays for
up to 12 sessions of counselling by a registered psychologist if a general
practitioner refers clients.
• Other approaches include brief interventions; counselling (eg narrative
therapy, solution-focused therapy); residential rehabilitation; self-help groups;
and behavioural therapy.
• Assessments should be offered in the context of a safe, reassuring,
supportive, nonjudgemental environment to enhance a client’s engagement
with the service. In the early stages, this may be more important than the
specific drug treatment.
• No medications have yet proven to be more effective than others in treatment
(eg for withdrawal or to prevent relapse). However, research is continuing
into several medications including dexamphetamine and modafinil. Following
a specialist assessment, the appropriate prescription of medications to treat
mental health and medical problems is strongly recommended.SUMMARY OF IMPORTANT POINTS FROM EACH CHAPTER
• Young people can benefit from a thorough assessment of factors such
as leisure and social functioning; family relationships; peer interactions;
hobbies; and educational history. Intensity of treatment should be matched
to the severity of problematic methamphetamine use. Treatment approaches
should be youth friendly and include easy access, drop-in capability, follow-up,
collaboration between service providers and family therapy.
• Workers should be sensitive to the cultural and social needs of Indigenous
clients and those from culturally and linguistically diverse (CALD)
backgrounds. Considerations include the provision of culturally appropriate
information including media other than print (eg art or video); role of family
in the client’s life; need for translation services; outreach service and case
management; and culturally appropriate harm reduction messages.
• Services should respond promptly to all clients’ requests for help; provide
support and assistance with immediate concerns before offering targeted
interventions for methamphetamine use; have information readily available;
attempt to address a range of user’s needs; and actively assist clients to
access other services as required.
Chapter 9: Assisting families, carers and significant
others (p.71)
• Disruption to family and other relationships is common in the context of
methamphetamine use.
• Families should be encouraged to access support for their own needs (eg
mutual support groups; telephone support and advice; educational materials)
and ensure that they continue to live their own lives while they continue to
care for their family member.
• Families should be provided with information on how methamphetamine works
including the range of possible effects. This should include information about
the ‘crash’ period and withdrawal symptoms, how regular methamphetamine
use can adversely affect a person’s mood, concentration, and decision-making
abilities, and the risks of dependence and psychosis.
• Families require assistance with developing an emergency plan should serious
consequences such as hostility or violence, or psychosis arise (see Appendix
2, Example family emergency plan).
• Methamphetamine use can sometimes affect the ability to parent, so others
might take on the role of caring for a client’s children until he or she is better
equipped to do so. In this case carers should be encouraged to access
ongoing support and practical assistance (eg financial support).10 Treatment Approaches for Users of Methamphetamine
• Young carers should also be encouraged to pay attention to their own lives
and pursue interests appropriate to their age. They should be encouraged
to seek support from appropriate sources (eg school counsellor, teacher,
trusted relative, kids help line, or dedicated websites such as
http://www.
youngcarers.net.au), and to develop an emergency plan (see Appendix 3,
Example young carer’s emergency plan).
Chapter 10: Legal issues (p.79)
• Interventions tend to be as effective for people who are pressured to enter
treatment (coerced clients) as for those who seek help voluntarily.
• Coercion can be formal (eg court ordered) or informal (pressure from
a spouse or family).
• Clients who have been formally coerced into treatment should be informed
of which agencies and under what circumstances workers are legally
obliged to disclose information regarding the client’s progress without his or
her consent.
• Informally coerced clients should give consent before any information
about their progress can be shared with their spouse, family member or
significant other.
• Mandatory reporting describes legislation that requires some workers
to report all cases of suspected or confirmed child abuse and neglect.
As legislation varies across each state and territory, workers have a duty
to be familiar with mandatory reporting requirements in their own state
or territory.
• Although there is a perception that all methamphetamine users are violent,
this is not the case. Rates of violent crime, although higher than the general
population, tend to be restricted to methamphetamine-dependent, multipledrugs
users with a history of violence. Violence, when it does occur, usually
happens when people are paranoid or psychotic. Therefore, hostility and
violence is often time-limited, and tends to occur only when symptoms
are acute. SUMMARY OF IMPORTANT POINTS FROM EACH CHAPTER 11
Chapter 11: Making links and creating partnerships (p.83)
• Service partnerships can help facilitate timely, appropriate and targeted
responses to a client’s needs, minimise access barriers for clients, and
ultimately improve client outcomes.
• Services should identify appropriate or helpful agencies for potential
partnerships; decide on the level of cooperation or collaboration that would be
useful; initiate contact; agree on a desired outcome for cooperation; ensure
regular liaison, prompt responses, support, and ongoing education for partner
agencies; and evaluate the effectiveness of partnerships.
• Staff members should learn and use appropriate terminology when
referring a client to other agencies, particularly mental health services and
general practitioners.
• Referral can be improved by ensuring that workers address the client’s
pressing needs first, before suggesting referral to another agency for
assistance with less important matters; enhancing awareness of other useful
agencies or services including location, hours of opening, cost, who is eligible
for assistance, and waiting times for service; understanding the needs of the
client (eg financial resources; access to transport; requirement for child care;
cultural and social issues; level of ability to advocate for self; literacy level;
mental health concerns) prior to making a referral; and matching referral to a
client’s need.12 Treatment Approaches for Users of Methamphetamine13
1
About methamphetamine
What is methamphetamine?
Methamphetamine is a synthetic substance that can come in various forms:
• crystalline (‘ice’, ‘crystal’, ‘crystal meth’, ‘shabu’, ‘glass’)
• oily powder or paste (‘base’)
• coarse or fine powder (‘speed’, ‘louie’)
• tablet (‘pills’)
• oil (base) is the least commonly available form, but it is the purest form
that is converted by manufacturers into the other forms; base is stronger
than powder forms and nonadulterated crystal is estimated to be about
80% pure.
The chemical structure is similar to amphetamine, but methamphetamine tends
to be more potent than amphetamine sulphate and amphetamine hydrochloride
(also called ‘speed’), which were typically used before the mid-1990s. The
stimulant effects of methamphetamine can last from 7 to 24 hours or even
longer, depending on the form used (for photographs of methamphetamine
forms see the fact sheets at
http://ndarc.med.unsw.edu.au).
Methamphetamine can also be mixed with a range of other substances or
drugs. For example, methamphetamine is sometimes mixed with ketamine, a
powerful anaesthetic, to form a tablet that is then commonly sold to users as
ecstasy (for information on ecstasy, see
http://www.druginfo.adf.org.au/article.
asp?ContentID = ecstasy).
How many people use methamphetamine?
Every three years, the Australian Government undertakes a study in which a
representative sample of Australians, aged 14 years and over, is asked about 14 Treatment Approaches for Users of Methamphetamine
their use of drugs. This survey is known as the National Drug Strategy Household
Survey. In 2007:
• meth/amphetamine had been used at some time in the life of 6.3% of
those surveyed
• the highest proportion of recent meth/amphetamine users were those in the
20–29-year age group (9% males and 4.8% females)
• two-thirds of injecting drug users identified meth/amphetamine as the drug
injected most recently, compared with heroin at 39.7%.
How and why people use methamphetamine
People use methamphetamine for different reasons and in a variety of
patterns:
• Experimental — many people, often adolescents and young people, try a
range of drugs once or twice out of curiosity.
• Instrumental — some people use methamphetamine for specific purposes,
for example, to stay awake (eg long-distance truck drivers), improve
concentration (eg students), reduce weight and enhance endurance (eg for
sporting events), or boost energy for a range of other activities.
• Recreational — some people use occasionally, for enjoyment or socialising, at
private parties, clubs or dance parties.
• Binge — others use moderate to high doses in an on–off pattern.
• Regular — some people use weekly, several times weekly or daily. Regular
users are more likely to be dependent on methamphetamine and have
problems with their mental health.
The way that people take methamphetamine generally depends on the
form used:
• Powder is often ‘snorted’ into the nasal passage.
• Ice is often smoked by heating the crystal in a pipe until it is vaporised or by
mixing it with cannabis and smoking it (‘snow cone’).
• Ice and base can also be injected or swallowed (known as ‘bombing’).
• Smoking methamphetamine, although considered less harmful than injecting
by some users, has high potential to lead to dependence due to the rapid
onset of euphoria (a strong feeling of wellbeing or elation) and subsequent
intense cravings for more of the drug. It is also difficult for smokers to know
how much they have used, which can lead to toxic (poisonous) effects.
• Bombing and snorting are common among experimental and recreational
users; injecting is typically associated with regular users, and both recreational
and regular users smoke methamphetamine.About methamphetamine 15
• Methamphetamine powder is typically purchased by gram or half-gram
weights, whereas ice and base are usually bought in a much smaller amount,
known as a ‘point’ or one-tenth of a gram, because of their high potency.
People rarely use methamphetamine exclusively, and the use of multiple drugs,
known as polydrug use, is common (see Chapter 7, Use of other drugs and
possible effects of mixing drugs).
How does methamphetamine work?
The way methamphetamine works is complex, but it is extremely important for
workers to understand how this drug works in the body so they can help inform
their clients. Understanding the mechanism of methamphetamine’s actions,
the short- and long-term effects of methamphetamine use, and the impact on
a person’s mental health helps the worker understand the user’s behaviour and
treatment options. The end of this section contains a suggested plain language
explanation that can be used by workers to help clients better understand the
effects of methamphetamine.
Information for workers
Methamphetamine disrupts the brain’s chemical messengers known as
‘neurotransmitters’. The main neurotransmitters involved are dopamine,
noradrenaline and serotonin, which have a broad range of important functions.
Dopamine controls movement, attention and memory, and purposeful behaviour.
It is the main neurotransmitter involved in feelings of pleasure and euphoria
when a person engages in activities that are essential for human survival, such
as eating, drinking, and sexual activity. Dopamine encourages these behaviours
by making people feel good so they are motivated to repeat them. This system
is referred to as the ‘reward pathway’ and, because dopamine is also linked to
cravings to use all drugs, it is thought to be involved in the development and
maintenance of drug dependence in general.
Noradrenaline is involved primarily in preparing individuals to either run away
from, or stand and fight against, perceived threats (‘fight or flight’ response): it
stimulates the central nervous system, and is involved in heart function and blood
circulation, concentration, attention, learning and memory.
Serotonin is involved in a variety of important activities including control of
mood; appetite; sleep; thinking and perception; physical movement; regulation
of temperature, blood pressure and pain; and sexual behaviour.16 Treatment Approaches for Users of Methamphetamine
Short-term use
Methamphetamine quickly and substantially raises the levels of these
neurotransmitters and stops them from being cleared (known as ‘re-uptake’),
so their levels remain high for a much longer time than usual. (Selective
serotonin reuptake inhibitor [SSRI] antidepressants also work in this way, but
this is beneficial in depressed people who have low levels of these transmitters
without treatment.) Methamphetamine causes the brain cells to be awash with
dopamine, which markedly accelerates the normal bodily processes. A person
will be alert and energetic, and have an intense feeling of wellbeing (euphoria).
The euphoria is usually much more intense and lasts longer than that felt from
natural survival behaviours. For example, in animal studies, dopamine level
increases by around 50% after eating, but increases tenfold after administration
of methamphetamine (see Chapter 2, Effects, risks and harms, and how these
can be reduced).
After a while, stores of these neurotransmitters peter out, and the levels drop
from too high to too low, like overdrawing a savings account. When the level is
low, a person can experience a range of symptoms of varying intensity that are
mostly the opposite to those of intoxication: low mood, lethargy and fatigue,
poor concentration, disturbed sleep, increased appetite, and lack of motivation
for daily tasks. It takes some time for the neurotransmitters to be replenished
(adequate diet, rest and avoidance of methamphetamine are critical for this),
during which time the person might continue to feel out of sorts and have
difficulty taking pleasure in normal activities. Recovery or ‘coming down’ from
short-term or binge exposure might take the person a couple of days to a week
(see Chapter 6, Helping a person get through withdrawal).
Long-term use
Both animal and human studies have shown that long-term exposure to heavy
methamphetamine use leads to both short-term neurotransmitter depletion
and changes in brain structure and function. To reduce overexposure to
neurotransmitters, particularly dopamine, the body responds by reducing
both the number of receptors (receivers) and transporters (carriers) of these
neurotransmitters in certain parts of the brain. In addition, brain cells themselves
can be killed (neurotoxicity) as they struggle to break down excess dopamine.
The result is chronic dopamine underactivity, resulting in damage to memory,
concentration, decision-making, impulse control, and emotional balance.
The recovery period after long-term use, during which complete avoidance
of methamphetamine should be maintained, can take many months or even
years. Some researchers believe that certain individuals, particularly long-term
regular users who began using methamphetamine at an early age, may never
recover completely (see Chapter 2, Effects, risks and harms, and how these can
be reduced).About methamphetamine 17
Information for clients
The following explanation could be helpful for some clients. Workers could also
use visual images or drawings to aid understanding:
Methamphetamine causes the brain to release a huge amount of
certain chemical messengers, which, as you probably know, make
people feel alert, confident, social, and generally great. Some of
these messengers help us to respond to threats by preparing us to
either fight or run away, so they increase energy, keep us awake,
stop hunger and raise blood pressure and heart rate.
The problem is that there are only so many of these messengers
stored at any one time. Think of a glass full of ‘happy’ messengers,
so when people have been using methamphetamine for a while,
the glass empties and no matter how much methamphetamine
they use, they just can’t get the ‘rush’ they want and will still feel
awful. There are just too few messengers left to tell the brain to
feel good. It’s like overdrawing a bank account — no matter how
many times you go back to the bank, the balance is still zero until
a deposit is made.
It takes rest, a good diet, and most of all TIME for the glass to
become full again. During this period, people can feel flat, moody,
irritable, forgetful, and restless, but exhausted, which is opposite
to the feelings people have while using. This is when people often
get strong cravings to use methamphetamine because these
cravings are caused by the same brain chemical messengers,
which are being produced, but in only small amounts.
Researchers think that, after using methamphetamine regularly
over several years, some people experience a long-term or chronic
lack of these ‘happy’ messengers, which can cause people to feel
moody, have trouble concentrating and making decisions, and
either lack motivation to do usual things or behave in reckless
ways. This can sometimes last for months or even a year or two.
The main issues in treatment are to make sure that your mood
doesn’t get too low; improve your general health by eating a good
diet and getting plenty of rest; manage cravings; and take things
day by day so you don’t get frustrated with your progress and go
back to using.18 Treatment Approaches for Users of Methamphetamine
References Chapter 1: About methamphetamine
Australian Institute of Health and Welfare (2008). 2007 National Drug Strategy Household
Survey: First Results. Drug Statistics Series number 20. Cat. no. PHE 98. AIWH,
Canberra.
Davidson C, Gow AJ, Leea TH and Ellinwood EH (2001). Methamphetamine neurotoxicity:
necrotic and apoptotic mechanisms and relevance to human abuse and treatment. Brain
Research Reviews 36:1–22.
Dean A (2004). Pharmacology of Psychostimulants In Models of Intervention and Care for
Psychostimulant Users, 2nd edition, Baker A, Lee N and Jenner L (eds), Commonwealth
of Australia Monograph Series, 35–50. Australian Government Department of Health and
Ageing, Canberra.
Dolan K, MacDonald M, Silins E and Topp L (2005). Needle and Syringe Programs: A Review
of the Evidence. Australian Government Department of Health and Ageing, Canberra.
Jenner L and McKetin R (2004). Prevalence and patterns of psychostimulant use, In Models
of Intervention and Care for Psychostimulant Users, 2nd edition, Baker A, Lee N and Jenner
L (eds), Commonwealth of Australia Monograph Series, 13–34. Australian Government
Department of Health and Ageing, Canberra.
Lee N, Johns L, Jenkinson R, Johnston J, Connolly K, Hall K and Cash R (2007).
Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14: Methamphetamine
Dependence and Treatment. Turning Point Alcohol and Drug Centre Inc, Fitzroy.
McKetin R, McLaren J and Kelly E (2005). The Sydney Methamphetamine Market: Patterns
of Supply, Use, Personal Harms and Social Consequences, National Drug and Alcohol
Research Centre, Sydney.
National Drug and Alcohol Research Centre (2006). Methamphetamine: Forms and
Use Patterns
http://ndarc.med.unsw.edu.au/NDARCWeb.nsf/resources/NDLERF_Methamphetamine/$file/NDLERF+ICE+FORMS+AND+USE.pdf (Accessed May 2008).
Volkow ND and Li TK (2004). Drug addiction: the neurobiology of
behaviour gone awry. Nature Reviews Neuroscience 5:963–970.
http://www.nature.com/reviews/neuro doi:10.1038/nrn1539 (Accessed January 2008).19
2
Effects, risks and harms, and how these can
be reduced
What are the short-term effects?
The effects of methamphetamine depend upon a range of factors including
the quality and purity of the drug; amount used; how it is used; the person’s
tolerance to methamphetamine (eg new or regular user); where it is used (eg
crowded, hot dance party or person’s home); and the person’s general physical
and mental health. Although there is individual variation in the effects of the drug,
the following points serve as a guide:
During intoxication
During intoxication, the person usually feels a sense of wellbeing or euphoria and
is alert, energetic, wakeful, extremely confident — sometimes invincible— with
a sense of heightened awareness and increased concentration. Libido (sex drive)
and blood pressure often increase. The person may be talkative and fidgety or
restless, and will have large (dilated) pupils. Appetite is reduced. Wakefulness
varies, but might continue for 12 hours or more.
At higher doses
At higher doses, the person might experience tremors, anxiety, sweating,
palpitations (racing heart), dizziness, tension, irritability, confusion, teeth grinding,
jaw clenching, increased respirations (breathing); auditory (hearing), visual or
tactile (touch) illusions; paranoia and panic state; loss of behavioural control; or
aggression.
In overdose
In overdose (toxicity), the person can experience intense paranoia involving
hallucinations (hearing or seeing things that are not there) and delusions (eg
having a fixed false belief often that people or things mean the person harm). The
person can also experience chest pain and shortness of breath; severe headache;
tremors; hot and cold flushes; dangerously increased body temperature; muscle
spasms; brain haemorrhage; heart attack; or seizures (fits) (see Chapter 4:
Recognising and managing overdose).20 Treatment Approaches for Users of Methamphetamine
What are the long-term effects?
Long-term use of methamphetamine can result in a number of physical and
psychological effects, which are often related to poor diet, lack of sleep,
dehydration and ongoing (chronic) neurotransmitter disruption including:
• weight loss and dehydration relating to poor nutrition or malnutrition;
irregular or absent menstrual periods; renal (kidney) problems caused by
the lack of adequate fluid intake; chronic sleeping problems; and probable
methamphetamine dependence
• extreme mood swings including depression and possibly suicidal feelings;
anxiety; paranoia; and psychotic symptoms including hallucinations and
delusions (see Chapter 5: Identifying and responding to a person with mental
health problems)
• cognitive (thinking) changes including memory loss, difficulty concentrating,
and impaired decision-making abilities.
What are the other risks and harms?
Users of methamphetamine are at risk for a range of other potential harms
including:
• blood-borne viruses (BBV), including hepatitis B and C and human
immunodeficiency virus (HIV) from sharing injection equipment
• infections and damage to veins (cellulitis)
• heart problems such as irregular heart beat, weakened heart muscle
(cardiomyopathy), bacterial infections of the lining of the heart (endocarditis),
and heart attack (myocardial infarction)
• burst blood vessels in the brain (stroke, ruptured aneurysm, brain
haemorrhage)
• shortness of breath and dizziness in smokers of ice
• sexually transmitted diseases including HIV and syphilis linked to sexual risk
taking
• poor oral health such as gum inflammation (gingivitis) and cavities caused by
methamphetamine-induced dry mouth, and damaged teeth due to grinding
and jaw clenching
• feelings that ‘bugs’ are crawling under the skin (tactile hallucinations)
• compulsive skin picking and scratching, particularly on the face and arms,
which can increase vulnerability to skin and other infections
• family and other relationship breakdown; financial problems; loss of
employment; and legal problems related to drug driving, dealing, or engaging
in other crimes to support continued use.Effects, risks and harms, and how these can be reduced 21
How can the risks and harms be reduced?
A harm reduction approach should be taken with all methamphetamine users
who intend to continue to use and will not consider stopping.
Users come to services with a wealth of knowledge about drug use already,
so it is important for workers to ask what clients already know and what they
would like to know so harm reduction advice can be tailored, appropriate and
engaging.
As well as the usual safer injecting and safer sexual practices advice, which is
freely available in a wide range of resources, some harm reduction strategies
specifically for users of methamphetamine have been recommended (see
http://www.aivl.org.au or
http://www.hepatitisc.org.au) or contact the local
alcohol and drug information service.
Workers should encourage clients to do the following.
Eat and drink enough
• Drink plenty of water — keep a water bottle handy and take frequent sips
because people tend to forget to drink when they are intoxicated and on the
go, and can easily become dehydrated.
• Eat a balanced diet including dairy products, meat and fish (or non-animal
protein for vegetarians), fruit, vegetables, rice, grains, nuts, etc. Workers can
help by checking a client’s weight regularly.
• Drink milk, high protein drinks, shakes or fruit smoothies if solid food cannot
be tolerated. (You wouldn’t run a long distance marathon without eating or
drinking so you need to put some fuel into your body.)
Rest sufficiently
• Get adequate rest. (Going more than two nights without sleep isn’t good for
anyone.) Encourage regular users to have regular non-using days each week,
or plan a ‘crash’ period when they can rest and sleep undisturbed for several
days to ‘come down’.
• Get into regular patterns of eating, drinking and resting as detailed above.
Even if users do not feel hungry, a little food and good hydration helps.
Understand the actions and effects of methamphetamine
• Understand how methamphetamine works (see Chapter 1 About
methamphetamine).
• Be clear about individual signs and symptoms of psychosis. If psychotic
symptoms are experienced, take a total break from using methamphetamine
and seek professional help from the person’s GP, local emergency department,
or local mental health service (see Chapter 5, Recognising and responding to a 22 Treatment Approaches for Users of Methamphetamine
person with mental health problems).
• Call on friends or family who are stable supports in the person’s life if he or
she is feeling scared, paranoid or panicky. Support people can often help the
client calm down or can call for specialist help if needed. Users could make
an emergency plan and have names and numbers of support people handy.
• Be clear about signs and symptoms and overdose including advice to call an
ambulance immediately if overdose occurs (see Chapter 4, Recognising and
managing overdose).
Attend to other health and lifestyle issues
• Brush and floss teeth regularly, and chew sugar-free gum to increase saliva
and to take some pressure off the enamel if teeth grinding is a problem. Dental
health can suffer due to a lack of bacteria-fighting saliva in the mouth.
• Plan for the week ahead and make sure that the person does not use (or be in
the middle of ‘coming down’) just before an important event or commitment
(workers might need to assist clients to brainstorm alternatives to using). This
will help to keep life a little more on track.
• Consider if the person is doing things that they would not normally do to buy
methamphetamines. Sometimes a person does not realise that his or her life
is out of control, and a client’s own moral compass is a good indicator.
• Avoid discussing sensitive topics or making important decisions if partners
are coming down together. Social or romantic relationships can suffer when
people are feeling irritable, so encourage partners to be patient with each
other.
• Avoid driving when intoxicated or ‘coming down’, particularly if alcohol has
also been consumed.
What about pregnancy?
Workers in the drug and alcohol field are sometimes asked for advice about
drug use during pregnancy. There is only limited evidence about the specific
effects of methamphetamine on the developing foetus in humans, and most
evidence comes from animal studies or is derived from studies on cocaine or
‘crack’ use.
The most important thing for a pregnant woman is to have regular, supportive
antenatal care, which improves outcomes for both the mother and baby. The
specialists in the antenatal team can assess each woman and offer individual
advice and guidance throughout the pregnancy. It is not uncommon for women
to be reluctant to disclose drug use, as they often fear criticism, or dread having
the baby removed from their care. However, antenatal teams focus on the
best interests of the mother and child,
November 11, 2015, 07:10:35 AM
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