Priority Area 4: Problems associated with amphetamine-type stimulant use

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Priority Area 1: Community awareness and understanding of amphetamine-type stimulant use and related problems
Priority Area 2: The supply of amphetamine-type stimulants
Priority Area 3: The use of amphetamine-type stimulants
Priority Area 4: Problems associated with amphetamine-type stimulant use
Priority Area 5: Organisational and system capacity to prevent and respond to amphetamine-type stimulant problems

Objective

Prevent and respond to amphetamine-type stimulant-related physical and mental health, social, familial and financial problems for individuals and the community.

Rationale

Current and emerging research indicates that ATS use is associated with a range of adverse physical, psychological and social outcomes which contribute to problems for individuals, families, the broad community and services such as emergency departments and police (see Baker et al., 2004; Baker and Dawe 2005; Dyer and Cruickshank 2005; and Maxwell 2005).
The nature and severity of adverse outcomes are generally related to frequency and quantity of use and context of use. The severity of problems increases with use and may be exacerbated by certain contexts (e.g., working or driving while intoxicated). The majority of people who use ATS do so occasionally, while a smaller proportion use frequently. Problems include:

Risks associated with injecting ATS (e.g., bacterial infection, vein collapse) - a large proportion of regular ATS users inject the drug and methamphetamine accounts for approximately one third of injecting drug use in Australia;
High levels of sexual risk taking, increasing the risk of unwanted pregnancy and sexually transmitted infection;
Mental health problems, including anxiety, depression, and psychosis;
Agitation, aggression, violence and crime, in particular when ATS are used in combination with alcohol;
Sleep and nutritional disorders that in turn can contribute to poor mental and physical health outcomes;
Oral health problems (e.g., related to dental hygiene, jaw clenching and teeth grinding);
Relationship and family disruption, which can impact on the individual user and parents, carers, children and friends/colleagues;
Polydrug use, either in combination with ATS use or, for example, to manage ‘come down’ and/or withdrawal symptoms;
Dependence; and
Cognitive impairment, which in turn has implications for treatment design and delivery.

The nature of interventions will be determined by the severity of problems. For example, the larger group of occasional users who experience comparatively lower level problems may respond to simple brief interventions, whereas regular and dependent users, who are also likely to be using a range of other drugs, may require more intensive interventions. While there is limited evidence about treatment strategies that are specific to ATS dependence, many approaches have been effectively used with other drugs and it is anticipated that these can be adapted and transferred to prevent and reduce ATS problems.

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A large proportion of people affected by ATS use seek information and advice from their peers, peer support networks, GPs, community health services, and Needle and Syringe Programs (NSPs). Developing, trialling and implementing strategies in these settings may help broaden the reach of effective interventions. Other consumers, including many people who use ecstasy, do not seek information or advice about the risks and problems associated with their drug use. Thus, it will be important to develop and trial innovative, opportunistic and targeted approaches in contexts where ecstasy use occurs. In the consultations it was suggested that:

Roadside drug detection could present an opportunity to identify and intervene with a group of individuals who may be at high risk for ATS related problems, but who otherwise are not accessing services;
A significant proportion of ATS users come into contact with law enforcement and criminal justice services, indicating the need to target interventions in these settings. It was suggested that the Illicit Drug Diversion Initiative (IDDI) should be examined to ensure its effective application to people with ATS related problems. Similarly, it was observed that the court system had an important role in responding to ATS related problems and dependence; and
Recent evidence (e.g., Allsop et al., 2001; Bywood et al., 2006) indicates that the workplace is a convenient and appropriate location to target information about ATS use and problems.

Increasing numbers of regular ATS users are being engaged in general drug treatment services. However, it was observed that other ATS consumers, who would benefit from some intervention, have either tenuous or no links at all with such services. The consultations consistently suggested the need to:

Explore innovative strategies to engage people affected by ATS use;
Explore the role of assertive outreach initiatives;
Examine the appropriateness of and gaps in current treatment options;
Examine responses to the observation that anxiety about child welfare, care and custody can act as a treatment barrier for parents (who use ATS) with dependent children; and
Enhance the accessibility and effectiveness of ATS specific interventions where indicated.

Mental health problems can precede ATS use, can be exacerbated by ATS use and may compromise treatment (e.g., some medication is contraindicated if there is concurrent ATS use). Mental health problems can also emerge as a consequence of ATS use, in vulnerable individuals and/or in otherwise psychologically robust people who regularly use ATS. Thus, psychotic symptoms are more prevalent among ATS users compared to the general community and a large proportion of ATS users entering treatment for dependence experience depression and anxiety (Dyer & Cruickshank, 2005; Kosten et al., 1998). Such symptoms are associated with poorer treatment outcome. The consultation process indicated a need to build more integrated treatment for people affected by co-existing mental health and ATS problems and to enhance the procedures for effective referral and joint management.

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The consultations indicated that there was a need to explore the value of innovative ways of communicating information about adverse outcomes of ATS use and how to seek help (e.g., using venue advertising to target particular locations or high-risk contexts of use; use of the Internet to provide quality information and to counter inaccurate information). It was also suggested that peer networks and interventions were important tools, especially in contexts and/or with individuals where there is likely to be limited contact with mainstream services. The evidence (e.g., Sansom, 2001) indicates that peer interventions can reduce HIV and Hepatitis C risk behaviour, and prevent transitions to higher risk-drug use such as injecting.

Adverse consequences are not only related to ATS use. The production and distribution of illicit ATS create a range of risks for individuals, communities and law enforcement staff. These include criminal activity, draining revenue from communities, diverting police and other law enforcement resources and risks associated with clandestine laboratories, which involve dangerous manufacturing processes and the use of toxic substances.

Recommended actions

i) Ensure that quality information is available about the context of ATS use and related adverse consequences

Support research into the context of ATS use and related problems, including risky sexual behaviour, development and management of mental health problems, impact on foetal and child development, impact of ATS use on cognitive functioning and associations with aggressive and violent behaviour.

ii) Ensure that ATS users, and others affected by ATS use, are aware of the problems associated with ATS use and know how to prevent and reduce such problems

Develop, implement and evaluate the impact of strategies to provide information about harmful patterns of use and how to obtain assistance with populations and in contexts associated with high risk use, including in juvenile justice services and prisons, high-risk entertainment venues, health services, Needle and Syringe Programs, police services and drug treatment services.

Ensure that individuals with a personal or family history of mental illness are informed that ATS use can exacerbate symptoms of anxiety, depression and psychosis. It will also be relevant to inform all target groups that even those without such histories are at risk of mental health problems, especially with regular/heavy use.

Develop, trial and adopt innovative strategies for ATS users, to provide information about risks associated with ATS use, reducing ATS problems, understanding treatment options and seeking help. Such strategies are particularly relevant for those who use ecstasy, but who do not come into contact with treatment services. Strategies/locations for interventions could include the following:

Trial and if indicated implement strategies using the Internet to communicate accurate information and counter misinformation about ATS;
Trial, and on the basis of outcome, implement advertising/communication strategies to ensure that specific messages about risks and reducing problems are targeted at venues and locations associated with high risk use;
Develop/adapt existing peer education strategies to reduce HIV and Hepatitis C risk and provide information on treatment options and how to access treatment for ATS problems;
Develop strategies and resources to enable law enforcement staff to provide information on where to access advice and treatment for ATS problems; and
Develop, trial and, where indicated, resource strategies for Needle and Syringe Programs to provide advice and referral into treatment services.

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Develop, trial and on the basis of evidence distribute self-help material for people affected by ATS use, including users and their parents/carers/families.

Resource and support Needle and Syringe Programs (NSPs) to provide information and education to reduce risk of HIV and blood borne virus transmission (such as hepatitis C). NSPs also have a role in providing information on treatment options and how to access treatment. This will include strategies to enhance access to NSPs by various groups, including Indigenous people and young people who are affected by ATS use.

iii) Implement effective brief and opportunistic interventions for ATS related problems for the large proportion of ATS users with lower levels of use and related problems

Develop, trial and, on the basis of evidence, adopt innovative and opportunistic interventions for those who occasionally use ecstasy and other ATS. Develop, implement and evaluate an ‘ATS First Aid’ strategy based on successful protocols used in ‘Mental Health First Aid’.

Develop, trial and on the basis of evidence establish screening, assessment, brief intervention and referral protocols for ATS use and related problems to implement in services/locations where initial contact may be made with people affected by ATS use. Such sites include community health services, general practitioners, police lock ups and prisons, sexual health clinics, needle and syringe programs, and emergency departments.

Develop, trial and, where indicated, implement strategies for ATS users that have been developed through the new GP Mental Health Care Plans where referrals can be made to community psychologists and clinical psychologists.

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iv) Implement effective ATS screening, assessment, management and referral protocols

Review, and where required, develop screening, assessment, management and referral protocols for ATS related problems. Implement an effective dissemination strategy for existing and new
protocols.

Develop protocols to routinely screen for mental health problems and cognitive impairment among ATS dependent clients. Use the information from such assessment to inform communication/education strategies, and to inform the design and implementation of ATS interventions, in general and for individuals.

v) Establish an adequate, effective and accessible range of ATS treatment options

Review and, where indicated, enhance pathways of care for people affected by ATS use. This will require close collaboration among police, emergency services, GPs, mental health services, drug specialist services and community-based services (e.g., Indigenous community-controlled organisations; parent-support services).

For emergency department, mental health and drug specialist services, consider establishing safe secure rooms to manage agitated behaviour associated with intoxication and ‘come down’ from ATS. This would be preferable to occupying lock-ups or emergency departments. Coincidentally, develop an evidence base to establish best practice environments and protocols to rapidly manage ATS intoxicated people who are agitated/violent/psychotic/suicidal.

Review and enhance out-of-hours access to services for people affected by ATS use. This may require assessment of particular high-risk times and development of clear referral protocols. Additional resources may need to be allocated to treatment services to specifically enhance out-of-hours access.

Identify and respond to barriers to treatment engagement and retention for people affected by ATS use. Trial and, if effective, resource and adopt assertive outreach initiatives to engage and retain in treatment people affected by ATS use.

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Review and on the basis of identified need, enhance treatment service provision to parents with dependent children.

Develop the evidence base to inform the adoption of effective treatment strategies including those to:

Manage withdrawal;
Identify and manage cognitive impairment associated with ATS use;
Manage ATS use and co-existing mental health problems, especially anxiety and depression; and
Manage severely dependent ATS users who are resistant to standard interventions. Ensure that other drug treatment populations (e.g., patients receiving methadone and buprenorphine treatments) are screened for ATS use, and where indicated receive indicated treatments for ATS related problems.
Disseminate and encourage the adoption of evidence-based stepped-care approaches for people affected by ATS use and related problems.

Build the evidence base, and consequently review clinical guidelines, on psychiatric medication for people who have mental health problems and are also regularly using ATS.

Promote and provide education on the range of effective treatments through the media, health and community services, law enforcement services and education agencies.

vi) Build on the impact of the Illicit Drug Diversion Initiative (IDDI) to link suitable offenders to health services, to provide early intervention and avoid the risks of having a criminal record for minor ATS related offences.

Support a review of the effectiveness of the IDDI for people affected by ATS use, in terms of participation, the availability of treatment and education responses, referral and participation rates and outcomes for clients, with particular reference to ATS related problems (e.g., anxiety; depression; knowledge of risks associated with ATS). If indicated, enhance the access of ATS users to police and court diversion programs.

Ensure that programs include specific information about and responses to particular problems associated with ATS use, including physical and mental health problems and legal consequences of possession, manufacture and distribution. Include specific information about the risks to children from parental ATS use.

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Identify and respond to barriers to effective diversion and retention in treatment programs associated with IDDI (e.g., exclusion criteria; treatment access).

Enhance access to diversion programs for Aboriginal and Torres Strait Islander people affected by ATS related problems. This will include enhancing access to culturally secure interventions.

Ensure that key policy decision makers, service providers and the broad community are aware of the process and benefits of diversion programs.

vii) Enhance court responses to ATS problems

Review and, where indicated, enhance the capacity of courts to:
Respond in an informed manner to ATS related offending;
Refer ATS affected offenders to treatment where indicated;
Identify and respond to risks for children where parents/carers are affected by ATS use, including enhancing the ability to monitor drug use and, where indicated, refer parents/carers to treatment services;
Provide services for offenders on court orders;
Ensure effective through-care from justice/corrective services to drug specialist services; and
Ensure that treatment services are available, appropriately skilled and resourced to respond to court referred clients.

viii) Develop and trial strategies to prevent and reduce concurrent ATS intoxication and driving

Improve knowledge about the impact of ATS on driving, including a focus on interactions with other drugs (especially alcohol) and the impact of ATS intoxication and ‘comedown’/‘hangover’ effects (e.g., fatigue).

Disseminate information about the risks of driving and ATS use (intoxication and ‘comedown’/‘hangover’ effects) for example, through school and workplace programs and through jurisdictional road and traffic authorities.

Continue to trial and evaluate the effectiveness of various methods (e.g., road-side sobriety; random/road-side drug testing) to deter and detect ATS-impaired driving.

Ensure that there are public and other transport alternatives to driving whilst drug impaired.

Explore the potential of referral to education/treatment for those drivers who are identified as ATS impaired.

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ix) Develop and trial strategies to prevent and reduce ATS use in the workplace

Improve knowledge about the workplace factors that protect from and increase the risk of ATS use.

Improve knowledge about the impact of ATS on workplace safety and health, including a focus on interactions with other drugs and the impact of ATS intoxication, ‘comedown’/‘hangover’ effects (e.g., fatigue) and withdrawal symptoms.

Develop, trial and adopt strategies to prevent and reduce work-related ATS use, targeting high-risk occupations (e.g., long-distance drivers, entertainment industry, mining) and workplaces in general. This will require improving knowledge about and expertise to deliver effective workplace interventions, including providing effective dissemination strategies on:

Drug effects;
Drugs and work (responding to workplace and occupational factors that increase/decrease the risk of ATS use);
Developing effective workplace drug policy;
Implementing effective health and safety strategies;
Creating work cultures intolerant of ATS use and impairment;
Understanding the strengths and limitations of deterrence strategies (e.g., drug testing; impairment testing) in responding to ATS use and problems; and
Understanding the strengths and limitations of workplace rehabilitation programs in responding to ATS use and problems.

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