Annabel Mayo Stimulant Treatment Program Alcohol & Drug Service St Vincent ’ s Hospital, Darlinghurst.
Methylamphetamine is a synthetic stimulant drug and a type of amphetamine-type stimulant that is illegal in all Australian jurisdictions. It comes in several forms, including tablet, powder, crystal and oil. N -methyl-alpha-methylphenethylamine The most commonly available form in Australia is crystalline ( ‘ ice ’ ) followed by powder ( ‘ speed ’ ). Image: "Racemic methamphetamine" by Boghog - Own work. Licensed under CC BY-SA 4.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Racemic_methamphetamine.svg#/media/File:Racemic_methamphetamine.svg
CR ICE IS ? 2 high profile media reports this week epidemic scourge plague 3
• ATS are the second most widely used illicit drug in the world, following cannabis. • In 2014, the United Nations Office on Drugs and Crime (UNODC) reported approx 13.9 million to 54.8 million users worldwide. • Australia has one of the highest rates of illicit stimulant use in the world – 2% • Gradual increase in ice use over last 2 decades, mostly replacing speed use (IDRIS) • Purity : Speed (10-20%) – base (40%) – ice (80%) • Perception of increased harm as a result. _____________________________________________ ○ At least one in ten people > 14 years of age have used these substances ○ Around 10% accessing treatment . 4
Changing use • Preferred amphetamine. The number of methamphetamine users who prefer ice over other types of methamphetamine has doubled, from 27% in 2007 and 22% in 2010, to 50% in 2013. The proportion of people using it at least weekly has grown, from 9.3% in 2010 to 15.5% in 2013. • More smokers. There has also been a increase in smoking as the main route of administration, from around 20% of regular users to 40%. • Purer. Other data show an increasing purity of ice, from an annual average of 21% in 2009, to 64% in 2013. The purity of traditionally lower-grade speed has also been increasing, from 12% to 37% between 2009 and 2013. • Cheaper . The price of both crystal and powder methamphetamine, based on purity, is now more similar than in previous years, making ice a more significant economical purchase for users. 5
Growing harms • increase in people seeking treatment at drug and alcohol clinics . The proportion of treatment “ episodes ” where methamphetamine was the principal drug of concern doubled from 7% in 2009- 10, to 14% in 2012-13. • More call-outs .There has been an 88% increase in ambulance call-outs in metropolitan Victoria and a 198% increase in call outs for methamphetamine-related incidents in some regional areas. • Regional crisis . People in regional areas are twice as likely to use methamphetamine as those in major cities (and are more likely to drink at risky levels and smoke cigarettes). • More hospital presentations - methamphetamine-related problems are the second-highest among the four major illicit drug types, with 182 “ separations ” per million people in 2010-11. • Legal system burden Arrests for methamphetamine-related crimes have increased by 30% between 2010-11 and 2011-12. And a review of more than 80,000 Queensland roadside drug- tests between 2007 and 2012 found methamphetamine to be present in 41% of positive results. 6
• AOD treatment focus has been on harmful use of CNS depressants like opiates, cannabis and alcohol has obscured world wide use of stimulants, with the exception of tobacco. • Many stimulants used everyday around the world: caffeine and other xanthines, betel nut, kratom, khat, sugar not seen as especially harmful until now. Cocaine and amphetamines have had a medical use. • Psychostimulants are seen as having a role in improving performance, therefore tolerated . 7 7
Amphetamines were developed in early 1800s in Germany. Methamphetamine developed late 1800s in Japan: used medically since 1920s, originally for asthma. Used in military settings to aid performance since 1940s Medically prescribed for some conditions: 1960s depression. obesity 2000s ADHD and narcolepsy. Recreational use of Amphetamine Type Stimulants (ATS) has been high in Australia for several decades : speed and ecstasy (MDMA) as well as ice. In 1990s, “speed” precursors were banned in Australia so ephedrine compounds became the major amphetamine precursor. As a result, most illicit amphetamine here is now methamphetamine . Approx. half made here and half imported. 8 8
The Public Perception A good discussion of the dynamics of this crisis. Gruen XL - Series 7 Ep 1 : ABC iview starting at 33.24 iview.abc.net.au/programs/gruen-xl/LR1513H001S00 9 9
Now let ’ s refresh your neurobiology a little 10
www.drogasycerebro.com This gives an idea of the three ways amphetamines work at the level of the synapse. 11 11
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• ‘ Crash ’ peaks in 2 to 10 days, with residual effects lasting up to 8 weeks • Symptoms include: – Feeling depressed, irritable, restless ( ‘ suicide Tuesday ’ ) – Lethargy – Increased appetite – Cramps, aches, nausea, rapid heart beat, hot and cold flushes 13
Emerging classes of stimulants • Cathoniones (eg mephadrone) • NBOMe ’ s (synthetic stimulants) • Psychostimulant “ Pre-Workouts ” e.g. 1,3-Dimethylamylamine HCL • Caffeine powder • Botanicals • Noortropics: smart drugs? e .g. IT world using modafinil piracetam gingko etc. 14
What are we going to do about ice? • Harm minimisation • Understand the user: reduce stigma • Understand the context of use: Polydrug? Comorbid ? • Look at best treatment options: Counselling/ detox /rehab Pharmacotherapy Complex / short long-term/ neuro damage Neuro-psych OT and SW inputs 15
• Experimental Irregular/infrequent/binge use, use often • Recreational normalised in peer groups/community • Performance Often early stage of “ using career ” are • “ high functioning ” Sexual • Injecting /Non-injecting Not engaged in AOD treatment and/or treatment naïve • Not dependent Many do not identify with traditional • Not considering change Alcohol and Drug Treatment Programs and organisations • Regular users • Do not feel as though Alcohol and Drug Dependent users Treatment Programs have anything to • Gambling/steroid use offer them • Polysubstance use 16 16
Practicing Harm Reduction Psychotherapy, Second Edition: An Alternative Approach to Addicons (2011) By Patt Denning, Jeannie Little The Guilford Press When SET + SETTING get stronger, the person more easily overcomes the DRUG 17 17
The Stimulant Treatment Program at St Vincent ’ s Hospital, Sydney opened in 2006. Hunter-New England STP is based at Newcastle Hospital. More STPs are being set up in Mt. Druitt, Wollongong, Taree. • Primarily a counselling service with medical support (inc. limited pharmacotherapy) • Clients: aged 18 + • Clients: current or recent user of stimulant drugs • $0 • Priority given to indigenous clients.
• Intake interview/Brief intervention • S Check (Assessment): 4 sessions with Counsellor or G.P. • Treatment offered: – Drop-in Clinic (Brief Intervention) – Counselling interventions – Counselling plus pharmacotherapy – Link Group (Strengths-based group developed by Brian Francis, based on Alan Jenkins ” Invitation to Responsibility ” ) • Hospital Inpatient Support • Community Action 19
● Assessment Therapeutic priorities: ● Counselling Eclectic Skills ● Harm Minimisation • Brief Interventions/SFT • Motivational Interviewing ● Biopsychosocial • Conversational model • Narrative Therapy ● Strengths-based • Psychodynamic Therapy • Cognitive Behaviour Therapy ● Trauma-Informed • Gestalt ● Community Link Group + ● Invitational/ membership Assertive Phone + Outreach ● Collaborative ● Psychoeducation ● Culturally aware ● Pharmacotherapy 20 20
● Understand the use and ● CBT not enough for irrational part withdrawal patterns for ice. of drug use, digging for early ● Be gentle and non- trauma too much. These clients confrontational. Your threatening often suffer PTSD and various pose may cause you harm. types of dissociation. Learn about ● Be non – judgmental. Clients will how you can help this. already feel overloaded with shame ● Rethink your use of the word ● Understand that dissociation, “ addiction ” - it can be a prophecy memory loss and confabulation are self-fulfilled. (see Marc Lewis) part of the process – your clients ● Mental Health entanglements aren ’ t always lying to you. learn the meds and Recovery ● Understand the ice economy model so you can advocate. and the financial drivers for some ● Look underneath the drug use clients. and find the person there. 21 21
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