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Psychostimulants

Trainer Notes& Activities

Overview

KEY POINTS1. Psychostimulants comprise a family of related compounds that share similar

properties. Several psychostimulants (such as caffeine and Ritalin®) are legal. The psychostimulant Ecstasy (MDMA) is often referred to as a ‘party drug’ due to its pattern of use and association with the party drug scene, rather than due to its psychostimulant effects (see Topic 4.4 Ecstasy & Party Drugs).

2. Although amphetamine use is increasing, most users are not dependent. Users may present to a GP in the first instance with a variety of issues (e.g., insomnia, ‘speed hangover’).

3. Regular users may need a break from use for a day or two following a binge (‘run’).

4. Psychostimulant-related harms may include those related to obtaining, using, coming down from, or ceasing the use of, drugs.

5. Although amphetamine withdrawal is a well-described clinical entity, there is little evidence-based information (or medications) that will ameliorate withdrawal discomfort in the short- or long-term, or facilitate long-term abstinence (as per opioids).

6. Mental health problems may arise as a direct result of using psychostimulants (see Topic 3.7 Comorbidity).

Resource Kit for GP Trainers on Illicit Drug IssuesPart B4 Drugs: Psychostimulants

4.6: Psychostimulants

SUGGESTED OBJECTIVESTo enable GPs to: identify the effects and consequences associated with using psychostimulants

apply skills gained in other topics (such as Assessment and Brief Intervention) to identify, assess, and respond to, psychostimulant-related harms

identify and implement harm reduction strategies relevant to the use of psychostimulants

identify, treat and refer patients with problems requiring specific care, such as cardiovascular problems, paranoia or symptoms of psychosis associated with psychostimulant use.


Please check that these objectives are relevant for the particular group you are about to train. If not, write down alternatives.

Topic Contents

SLIDESThe slides with slide notes cover: forms of psychostimulants (content refers primarily to methamphetamine and

cocaine)

patterns of use

effects and harms associated with use

pharmacology

clinical practice issues (assessment, brief intervention, harm reduction, withdrawal).

The slides are on the Resource Kit CDROM under this topic. Trainers are encouraged to select and/or adapt this slide set to meet the focus of the training and information needs of their participants.

ACTIVITIESThe activities complement skill-based learning activities provided in other topics, especially those in B3: Clinical Process. These activities provide opportunities for GPs to: identify issues related to the use of psychostimulants within the general practice

context

identify relative benefits and harms (as perceived by society and users) related to psychostimulant use

plan and implement harm reduction strategies specific to psychostimulant use.



HANDOUTS1. Australia’s Dynamic Methamphetamine Markets

Topp, L. & Churchill, A. 2002, ‘Australia’s Dynamic Methamphetamine Markets’, Drug Trends Bulletin, IDRS June 2002, National Drug and Alcohol Research Centre (NDARC), Sydney.

2. Amphetamine Dependence and WithdrawalMcKetin, R. & McKenna, S. 2000, Amphetamine Dependence and Withdrawal, GP Drug and Alcohol Supplement No. 12, http://www.health.nsw.gov.au/public-health/dpb/supplements/supp12.pdf.

3. Amphetamines SDS Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W. & Strang, J. 1995, ‘The Severity of Dependence Scale (SDS): Psychometric Properties of the SDS in English and Australian Samples of Heroin, Cocaine and Amphetamine Users’, Addiction, vol. 90, pp. 607–614.Dawe, S., Loxton, N., Hides, L., Kavanagh, D., & Mattick, R. 2002, Review of Diagnostic Screening Instruments for Alcohol and Other Drug Use and Other Psychiatric Disorders 2nd edn, Commonwealth Department of Health and Ageing, Canberra.

4. Amphetamine Withdrawal ScaleDASC Amphetamine Withdrawal Scale. Cited in DeCrespigny, C. et al. 2003, Alcohol Tobacco and Other Drugs Guidelines for Nurses and Midwives: Clinical Guidelines. Flinders University and Drug and Alcohol Services Council, Adelaide. Also available at wwww.dasc.sa.gov.au

Please refer to the Resource Kit CDROM for a copy of handouts in PDF and Word.


Slides, Activities & Handouts from other topics may be useful. Please refer to Part A3 for: Examples of Potential Links to Other Slides, and for a Listing of Activities and Handouts.

Sources of Additional Information

PATIENT RESOURCESAustralian Drug Foundation 2000, Cocaine: How Drugs Affect You, Australian Drug Foundation, North Melbourne.

Lintzeris, N., Dunlop, D. & Thornton, D. 1999, Getting Through Amphetamine Withdrawal, (revised), Turning Point Alcohol & Drug Centre Inc., Fitzroy, Victoria.

Topp, L., McKetin, R., Hando, J., & Dillon, P. no date, A User’s Guide to Speed. National Drug and Alcohol Research Centre (NDARC), Sydney.

KEY READINGSBaker, A., Lee, N. & Jenner, L. 2004, Models of Intervention and Care for Psychostimulant Users, National Drug Strategy Monograph Number 51. Australian Government Department of Health and Ageing. http://www.nationaldrugstrategy.gov.au/publications/monographs.htm

Baker, A., Kay-Lambkin, F., Lee, N., Claire, M. & Jenner, L. 2003, A Brief Cognitive Behavioural Intervention for Regular Amphetamine Users. Australian Government Department of Health and Ageing. http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

Latt, N., White, J., McLean, S., Lenton, S., Young, R. & Saunders, J. 2002, ‘Central Nervous System Stimulants. Disorders’ in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, Oxford University Press, South Melbourne, pp.124-140.

Todd, F. 2002, ‘Coexisting Alcohol and Drug Use and Mental Health Disorders’ in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems ch. 20, Oxford University Press, South Melbourne, pp.359–373.



Patient resources are a valuable GP tool in the clinical setting. They can be obtained through ADIS or the publisher; free or at nominal cost.

http://www.nationaldrugstrategy.gov.au/publications/illicit.htm

http://www.nationaldrugstrategy.gov.au/publications/monographs.htm

ADDITIONAL RESOURCESAlliance of NSW Divisions GP Liaison Project Tip Sheet Series. Available from: http://www.answd.com.au/

Amphetamines: A general information guide for the General Practice setting Amphetamines: Other drugs, pregnancy, the law, driving and those ‘most at risk’ Effects of amphetamines Treatment for amphetamine dependence and withdrawal in the General Practice

setting Amphetamines – overdose, tolerance, dependence and withdrawal Cocaine: a general information guide for the General Practice setting Cocaine: other drugs, pregnancy, the law, driving and those ‘most at risk’ Effects of cocaine Cocaine – overdose, tolerance, dependence and withdrawal Treatment matching for alcohol and other drugs in General Practice Treatment matching after detoxification in General Practice

Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W. & Strang, J. 1995, The Severity of Dependence Scale (SDS): Psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users, Addiction, 90, 607–614.

Pead, J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues. The Trainer’s Package for Health Professionals, Commonwealth Department of Human Services and Health, Canberra.

Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Mornington, Victoria.

WHO (World Health Organisation) 2001, Systematic review of treatment for amphetamine-related disorders, [paper], Management of Substance Dependence Review series, Geneva.


PsychostimulantsActivities

Activity 1: Recognising Psychostimulant Intoxication

PURPOSETo increase recognition of the symptoms of psychostimulant intoxication and its management through the use of the video and associated discussion.

PROCESS1.1 Show Vignette 1: ‘Thunderbirds are go’ (2:40min) from the video ‘From Go to

Whoa’ (See Part C2 in this Resource Kit for details of this training package)

1.2 Request participants to form pairs/small groups and discuss the main features of intoxication, such as: behaviour demonstrated in the video other behaviours or features you might expect this person to display is this behaviour consistent with your experience? how might you manage a person who is intoxicated with amphetamines in

your practice?

Refer to the table below (if needed) to assist you to elicit responses from participants.

Features of intoxication may include:

Talkative Vague concerns Fidgety

Scratching Twitching/shaking Ambivalent

Nervous Tension Rocking

Sniffing Feeling great Tangential thinking

Stereotypical motor behaviour

Decreased appetite

Repetitiveness/pressure of speech

1.3 Discuss findings as a whole group. Facilitate discussion of: types of support GPs have, or may need, in order to appropriately manage a

person affected by amphetamines.For example, do you have safety and management policies and procedures in place for your practice? These may include the management of intoxication in general practice settings, managing and organising referrals, policies on managing patients who present with inappropriate behaviours.



Activity 2: Amphetamine Users’ Concerns

PURPOSETo increase GP awareness of the typical concerns of people experiencing amphetamine-related harms.

PROCESS2.1 Show Vignette 5: ‘Lets Party’ from the video ‘From Go to Whoa’

2.2 Ask participants to describe the patient and identify her concerns

2.3 From this description discuss the ‘typical’ features of presentation for amphetamine use.

The following notes, adapted from Pead et al.1996, may assist you to elicit responses from participants.

Note: Amphetamine related problems can be fairly stereotypical, and may include those who:

are young (late teens to mid 20s), shift work (diversity of occupation) display features of intoxication, withdrawal and crash experience some health problems experience some social problems experience some mental state problems are possibly drug-seeking (benzodiazepines, codeine, opioids) have infected injection sites, lesions.

People with amphetamine problems look like anyone else presenting for help. The person in the video could just as well have problems with drinking, cannabis use, be depressed as a consequence of some life event, or be physically unwell.

Many people with amphetamine problems will present with health, social or mental state problems associated with, or exacerbated by, amphetamine intoxication, regular use, dependence or withdrawal. These associated problems may be emphasised by the patient rather than their amphetamine use. The patient may be unaware that these problems are associated with amphetamine use. Some people will seek medications such as benzodiazepines or opioids like codeine to come down from amphetamines, or to deal with features of amphetamine intoxication, crash or withdrawal.

Source: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues. The Trainer’s Package for Health Professionals, Commonwealth Department of Human Services and Health, Canberra, p. 44.


Activity 3: Psychostimulant Use and Related Harms

PURPOSETo assist GPs to identify and respond to possible harms that may result from using methamphetamine.

This activity requires Slide 12 from the Psychostimulants slide set: Psychostimulant Cycles of Use

PROCESS3.1 Optional: Provide a short anecdote of a case in which a patient using

methamphetamine reduced his/her intake through interaction with his/her GP, or alternatively, invite GPs to outline a case

3.2 Use the slide to highlight use and the five areas of harm

3.3 Divide participants into small groups

3.4 Instruct participants to brainstorm specific strategies to reduce methamphetamine-related harm for one of the five areas of harm. Advise them to: limit these strategies to those they can undertake in the course of their daily

work estimate how much time they think these ideas would take in practice list possible human or physical resources they may be able to use, and how

they would monitor the outcome

3.5 As a whole group, compile a comprehensive list of strategies using the feedback provided by each group (complete with time and resource estimates)

3.6 Select a few key ideas and encourage a critique in terms of the realities of the general practice setting – the course of a consultation

3.7 Provide the Activity 3 Handout ‘Potential Amphetamine Harms Checklist’ if needed (for verification or as additional information)

Topic Link: Please refer to ‘Brief Intervention’ and ‘Harm Minimisation’ slide sets


4.6: psychostimulants

Psychostimulants

Psychostimulant Cycles of Use

Acquisition

Intoxication Intoxicatedbehaviour

AdministrationCrash /

Withdrawal

CessationHow, and wherecan GPs assist inreducing harms?

ACTIVITY 3 HANDOUT

Potential Psychostimulant Harms Checklist

Acquisition Insufficient moneyPolice and jailCriminal underworldPoor relationshipsUnknown drug quality

‘Ripped off’ by dealersDealingUncertain supplyAlienationSecrecy/stigma

Administration Vein abscessVein scarringThrombosisContaminants

Bloodborne virusesNasal infectionsNeedle and equipment sharing

Intoxication AgitationWeight lossTachycardiaDehydrationHyperthermiaPoor immunity

ParanoiaDelusionsHallucinationsSleeplessnessSeizuresTeeth grinding

Intoxicated Behaviour

Increased aggressionIntoxicated drivingParenting difficultiesRisk takingWork accidents

Unsafe sexInjuriesFightsSocial avoidanceOther drug use

Crash/Withdrawal DepressionRestlessnessCravingsSuicidal ideas

Lapse to drug useJobBizarre thoughtsFlat mood

Source: Pead. J., Lintzeris, N. & Churchill, A. 1996, From Go to Whoa: Amphetamines and Analogues. The Trainers Package for Health Professionals, Commonwealth Department of Human Services and Health, AGPS, Canberra.


The page reference above provides case studies that address cannabis, hallucinogens, and CNS stimulant issues related to young people, as well as injection-related harms, harm reduction, drug-seeking behaviour, and treatment and management issues.

Full citation: Johnson, S., Martin, J., Liew, D., Cape, G., Edmonds, C., Baigent, M., Dunn, C., Bucci, S., Baker, A., & Cohen, M. 2004, ‘Cannabis, Hallucinogens, and CNS Stimulants’ in Hulse, G. (ed.), Alcohol and Drug Problems; A Case Studies Workbook, ch. 3, Oxford University Press, South Melbourne.


4.6: psychostimulants

For case studies refer to ‘Cannabis, Hallucinogens, and CNS Stimulants’ in Hulse, G. 2004, Alcohol and Drug Problems: A Case Studies Workbook, ch. 3, pp. 61–98.

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