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Methamphetamine in Australia
Challenges and responses
Steve Allsop
National Drug Research Institute
Curtin University
Last 12 month meth/amphetamine useNDSHS 2013
2007
2010
2013
1,7
1,6
1,0
0,6
0,4
1,1
Other meth/amphetamines Ice
Distribution of use is not even across the countryNDSHS 2013
0,6
0,8
1,1
1,4
1,01,2
2,9
0,8
1,1
1,0
0,8
1,2
1,6
0,8
2,2
3,0
NSW Vic All ACT SA Qld NT Tas WA
All meth/
amphetmaine*
Other meth/
amphetamine
Ice
Recent data
• Crystal methamphetamine amongst PWID increased
by additional 6% in 2015
• Increase in hospital presentations for amphetamine
problems from 145 per million (2001) to 272 per
million (2013)
Separations for meth/amphetamine diagnosesFrom 145 per million (2001) to 272 per million (2013)
National Hospital Morbidity Data
2009–10 2010–11 2011–12 2012–13 2013–14
Recent data
• Crystal methamphetamine amongst PWID increased
by additional 6% in 2015
• Increase in hospital presentations for amphetamine
problems from 145 per million (2001) to 272 per
million (2013)
• Treatment for amphetamine related problems from
10,027 (2009) to 22,265 in (2013)
Treatment episodes meth/amphetamine
principal drug of concernFrom 10,027 to 22,265 in 2013
2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013-14
Recent data
• Crystal methamphetamine amongst PWID increased
by additional 6% in 2015
• Increase in hospital presentations for amphetamine
problems from 145 per million (2001) to 272 per
million (2013)
• Treatment for amphetamine related problems from
10,027 (2009) to 22,265 in 2013
• Methamphetamine related deaths from 3.4 per
million (2001) to 8.1 per million (2011)NDARC 2015
What are some of the issues?
• So far there is limited evidence that there has been an increase in meth/amphetamine use but there is clear evidence that there has an increase in use of ‘ice’ and potency of drug used and large increases in harms
• Ice emerging in a number of rural and remote communities, some of which are particularly vulnerable
• This resulted in impact on legal, health, social systems– individual consumers
– friends and relatives
– broader community
– services (e.g. police activity, ED, ambulance call outs, specialist drug services
• There has been strong concern regarding some of the associated challenging behaviours/mental health problems and family/community disruption
Prevention
Prevention
• Evidence specific to meth limited and therefore public health action relatively neglected and limited:– … some ATS specific interventions, usually delivered in
recreational settings, mostly communicating information via the internet or in print materials, but there is no real evidence supporting their effectiveness (EMCDDA 2010).
• In WHO technical brief on principles of prevention and treatment of ATS, all nine principles addressed treatment, while none specifically highlighted prevention activity (WHO 2011).
Prevention?
• However – it is likely that key evidence about drug prevention
in general has relevance. This evidence directs us to strategies
that address:
– Family functioning/disruption/breakdown and/or parental neglect
– Childhood problems such as CD, school/community/family
connectedness
– Mental health problems
– Subjective perceptions of drug use/norms:
• subjective and objective availability
– Poor connectedness
– Social disadvantage
– Low social, cultural, psychological and economic capital
Treatment
Tenuous link to treatment?• They may be less likely to have experienced treatment and have
a more fragile connection with drug specialist services but likely to include GP’s/Primary care as potential source of advice and help
– Many users seek treatment for adverse outcomes such as sleeping or nutritional disorders, depression/anxiety, relationship problems, but not necessarily to stop use
• Challenges for community and services often arise when services least accessible
• improving access to treatment (especially out-of hours)
• need for facilities accessible to emergency departments
• safe environment for those intoxicated by or withdrawing from ATS (e.g. those who are agitated but not psychotic who nevertheless need care –currently many such individuals are managed by police and/or emergency departments)
• Consumers might not see themselves at risk, might not see the services as relevant and when a ‘treatable moment’ arises, access might not be possible
What are some of the issues for consumers and
services?
• Physical problems
• Poor eating habits, low levels of general health increased prevalence of eating disorders
• Difficulties establishing/ maintaining regular sleeping patterns
• Sepsis, skin problems, exposure to BBV’s
• Sexual risk taking
• Psychological/ psychiatric
– Scattered, scrambled, depressed, anxious, emotionally labile, psychoses, paranoia,
agitation and aggression
– Low levels of concentration, impulse control, self regulation, attention span and ability
to focus
• Social problems
– No fixed accommodation, no family, using friends, legal problems, financial problems
– Friends/ family distressed – “I’ve had enough!!!”
Treatment engagement:Importance of safety
Physical Safety– Nutrition and sleeping
requirements
– The client’s safety at home -living arrangements, relationships, support people, lifestyle
– Drug Use - knowledge and implementation of reducing risk
– Risk taking• Injecting behaviours
• Sexual risk taking
• Driving/workplace
– And clinician safety
Emotional Safety:– Mental state
• Coping with chaos, lowered capacity to cope with frustration, mood swings, strange thoughts, anxiety, depression, and paranoia
– Relationships
– Sense of safety in session or at the agency
– Trauma
Thanks to Ali Marsh
Treatment:Psychological Interventions
• Contingency management – significant reduction in meth use during application (exceeding impact of CBT for example during this time) but not sustained at one year follow up (Lee & Rawson 2008)
• CBT – reduction in meth use even with short duration CBT (Lee & Rawson 2008)
• In one Australian review: – In general counselling deemed to be more effective than
doing nothing :
… greater investment in this cost-effective strategy will produce significant cost-savings and improve health outcomes …
Ciketic et al 2014
Treatment:Pharmacotherapies
“After over 20 years of concerted effort to develop a
broadly effective medication for methamphetamine
dependence, no candidate has emerged. There is
substantial progress however. Bupropion carries
promise and … (based on emerging results) … its status
as a generic medication may increase its impact around
the world (for methamphetamine related problems)” Brensilver et al 2012 p 201
Stepped care
• Aim is to flexibly accommodate diverse symptoms using an intensive form of treatment only when less intensive form insufficient
• Based on:
– client preference
– outcome of assessment
– progress and clinical judgment and,
– carefully formulated case management plan
Illustration of a stepped care treatment planTaken from Baker et al 2012
• Step 1. Brief integrated intervention (initial session)Case formulation: methamphetamine use, other problems, linking these
Motivational interviewing and Psychoeducation
• Step 2. Methamphetamine focused treatment (4 sessions)
Motivational Interviewing
Phase I: building motivation for change;
Phase II: strengthening commitment to change
Mindfulness
Cognitive Behaviour TherapyCoping with cravings
Antecedents-Belief-Consequences
Activity log
Identifying and changing negative automatic thoughts
Negotiating a plan for change
• Step 3. Integrated Treatment (4 sessions)
MindfulnessMindfulness of pleasant events, revisiting mindfulness from Step 2 and reinforcing practice
Cognitive Behaviour Therapy
Activity scheduling of pleasant and achievement events, cognitive restructuring re use and negative thoughts, exploring the links between meth use and depression, problem solving skills
Relapse preventionStrategies to look after self, dealing with the abstinence/goal violation effect, relapse planning
Stepped care
• BI consisting of MI and CBT better outcomes than control conditions– Increase in probability of abstinence @ 6 m among those
receiving two or more sessions and short term impact on depression
• Structured assessment, self help material and role play/real life practice of skills (Baker et al 2004)
• Later study found similar outcomes to Baker et al and no better outcome comparing ACT and CBT (Smoutet al 2010)
• Both studies made comment about challenges of recruitment and attrition
Breaking the iceAustralian online brief interventionS
cre
en
ed
n =
44
6R
an
do
mis
ed
n =
16
0
BTIn = 81
BTIn = 35 (43%)
BTIn = 38 (47%)
Controln = 79
Controln = 45 (57%)
Controln = 41 (52%)
Baseline 3 months 6 months
Design: RCT Intervention versus wait list control
Target: users of amphetamine type stimulants (ATS)
Program: three modules, fully automated and self-guided
Tait, McKetin et al 2015 J Med Internet Res
Breaking the iceAustralian online brief intervention
0
5
10
15
20
25
0 months3 months6 months
BTI
Control
Days o
ut of ro
le
Inte
nded H
elp
-seekin
g
Intended help seeking
p< 0.001
0
0,5
1
1,5
2
2,5
3
3,5
4
0 months3 months6 months
BTI
Control
Days out of role p<0.001
Longitudinal prospective study
Sample:
400 methamphetamine treatment entrants
101 non-treatment controls
Recruited from 41 drug treatment agencies Sydney / Brisbane
97% dependent on methamphetamine (DSM-IV criteria)
Mostly injecting users, using several days/week, several times
per day
Follow-up 3, 12 and 36 months post-treatment
Methamphetamine Treatment Evaluation Study (MATES)
McKetin & MATES Investigators 2010 Technical Report 312, McKetin et al 2012 Addiction
Continuous abstinence by treatment type
McKetin & MATES Investigators 2010 Technical Report 312, McKetin et al 2012 Addiction
Australian Patient Pathways Study
• 796 clients from 21 treatment services in WA
and Vic
• Overall 52% of sample showed significant
reduction in use (abstinence and days used)
(highest for meth users (66%) and lowest for
alcohol)
• Non-completion of treatment and absence of
continued care associated with poorer
outcomes (Lubman et al 2014)
Conclusion• Limited specific evidence that can guide effective prevention, public
health and treatment responses but there is reason to argue:• Invest in broad based prevention strategies to enhance connectedness, respond to needs
of vulnerable families and communities and, in times of limited budgets, invest in evidence based approaches
• There is evidence about counselling and emerging evidence about pharmacotherapies – there is some thought that it may be
– comparatively harder to engage and retain meth users
– comparatively easy to give up but harder to stay stopped - ‘easier to get off than stay off’
• Some evidence about superiority of residential care but may be illustration of importance of longer term care with these clients - we probably need strategies to better engage, good retention strategies and aftercare and assertive outreach.
• We need to recognise, for some, the strong link to risk taking and address these risks for them and others
