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National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69

5.2 Initial engagement

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Many people affected by ATS use do not initially attend specialist drug treatment services, but are identified by, or present to, frontline services. These include needle and syringe programs (NSPs), police, ambulance paramedics and hospital emergency departments (EDs). As the first point of contact for many people affected by drug use, these services are in a unique position to identify use and problems and offer assistance. However, they are also confronted with several challenges and risks. With regards to ATS use, perhaps the greatest risks relate to the occurrence of amphetamine related agitation and amphetamine-induced psychosis, which can be accompanied by hostility and violent behaviour (see Chapter 3).

From 1999/2000 to 2003/04, amphetamine accounted for the largest proportion of all drug-induced psychosis separations, ranging from 41% in 1999/00 to 55% in 2003/04 (Degenhardt et al., 2007). In 2003/04, the total number of bed-days for amphetamine was 8068. The number of hospital presentations for amphetamine psychosis increased in a recent five year period, from 1028 in 1999/00 to 1626 in 2003/04 (Australian Institute of Health and Welfare, 2006a).

As indicated above, behaviours related to psychosis can be difficult to manage and pose a risk to the safety of police, ambulance and emergency health staff. Written feedback from a health worker at one of the consultations stated that:

it is frightening for doctors and nurses to have to deal with a psychotic (drug-induced) patient – the violence level is so tremendous and we do not have manpower to (manage) a psychotic person.

National guidelines have been developed specifically for police, ambulance staff, emergency departments and general practitioners on the emergency management of psychostimulant toxicity (see Jenner et al., 2004a; 2004b; 2006a; 2006b). In addition, guidelines specifically for the medical management of psychosis have been developed by the Drug and Alcohol Services Council of South Australia (DASSA): ‘Guidelines for the Medical Management of Acute Methamphetamine-induced Psychosis’ (McIver et al., 2006). The guidelines were prepared in order to aid emergency, general, medical and psychiatric staff in providing treatment in the emergency setting. The guidelines are based on the national and international literature, on clinical experience with methamphetamine-induced psychosis patients in Australia, and developed in consultation with and guided by experts from the fields of drug and alcohol treatment, emergency medicine and psychiatry. A stepped care approach is recommended, with guidelines covering assessment, medication and follow-up.

With regards to pharmacological interventions, these guidelines promote the use of benzodiazepines over antipsychotics. This is supported by recent research into the use of haloperidol in such cases. This has suggested a link of haloperidol use with the development of hyperkinetic movement disorders and seizures (Hatzipetros et al., 2007).

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ATS-related presentations may not just involve psychotic symptoms, but the burden on frontline services remains high. A recent report by Gray and colleagues (2007) attempted to estimate the impact of amphetamine use on an inner city hospital. The authors found that amphetamine-related presentations accounted for 1.2% of all admissions. Of these, over half were habitual drug users, the majority were male, and the average age was 28 years. Presentations were of high-acuity, patients were often aggressive, required prolonged emergency department admission and extensive resources. Thus, emergency situations related to high levels of agitation and sometimes psychosis, present a challenge for law enforcement, ambulance staff, emergency departments and mental health services. This was noted in the written submission received from the National Drug and Alcohol Research Centre (NDARC):

Psychiatric emergencies associated with methamphetamine use are a particular concern. Guidelines for the management of psychostimulant toxicity have been developed for emergency medical services, frontline health workers and law enforcement personnel (Jenner et al., 2004a, 2004b, 2006a, 2006b). Such protocols are important for the maintenance of staff occupational health and safety in this context. Continued efforts to improve the management of psychiatric emergencies associated with methamphetamine use are required. Adequate resources also need to be provided to emergency services to ensure that these situations are managed safely and efficiently.

The issues for frontline workers depend somewhat on the service they provide. The main issues identified for ambulance workers related to the education of paramedics, responding to personal risk, sedation of patients (used for behavioural management for those experiencing psychosis), and total care time. For police, issues focus around the management of unplanned withdrawal of ATS-intoxicated persons in custody, and appropriate diversion to health services. With specific regard to NSPs, such services can generally provide brief interventions, health promotion and service access, but have, perhaps, historically been oriented toward heroin and other opiate users and ATS dependent clients may be more chaotic. Thus, there may be a need to implement some workforce development strategies to enhance responses specific to people affected by ATS use, including skills to engage clients during binge-crash cycles.

Currently, some provisions are in place in a number of jurisdictions to meet the needs of ATS presentations to frontline services. For example, Psychiatric Emergency Care Centres (PECC) and the Mental Health Emergency Care (MHEC) program are operating in NSW. PECC provide a 24-hour brief admission service within the emergency departments of select hospitals. PECC operate according to care pathways related to: self harm/suicide; early psychosis; drug-induced psychosis; depression/anxiety; mental and physical illness; and, relapse of serious mental illness. Similarly, the MHEC program aims to provide for people presenting to hospital emergency departments with acute mental illness or disorders which contribute to people being at risk of behavioural disturbance and/or drug related problems. There are currently 4 centres in NSW, which provide an opportunity for mental health triage, assessment and behavioural management within the ED for up to 48 hours.

Much discussion during the consultations related to the burden of ATS presentations on frontline services and the associated harms. This in part related to the need for improved workforce development, particularly regarding the management of aggressive and violent behaviour and methamphetamine-induced psychosis. While there was some debate about the prevalence of such presentations and the impact the media has had in propagating this image, it was agreed that when such presentations do occur, there was a need for protocols about responding to the patient and ensuring staff safety.

Related to this was the suggestion that dealing with increased violence had an impact on the levels staff tolerance for people affected by ATS use. It was suggested that some staff exhibit prejudice toward ATS users, as mentioned earlier. It was recommended that more education was needed to counteract attitudes and behaviour that contributed to poor engagement and treatment outcomes.

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In relation to the need for specific training around ATS, in the written submission from the Australian Injecting and Illicit Drug Users League (AIVL) it was noted that:

Frontline service workers need training in defusing potentially difficult situations; communication skills to engage chaotic users; awareness of comorbid mental health issues; and available treatment options.

One of the major issues raised in all consultations related to the lack of integrated care between services. It was argued that there is a need for referral pathways to be established among all the relevant service providers (e.g., law enforcement; emergency departments, community health, drug specialist and mental health services etc.).

It was also noted in the consultations that law enforcement services are often the first point of contact for many ATS users and it was considered important to enhance behavioural management of ATS-affected people, to ensure safety for police and offenders. But there was also an identified need to build referral pathways, especially out-of-hours, when service provision was limited and when, paradoxically, ATS intoxication-related problems might be most likely expressed. Some law enforcement staff suggested that medical support is needed in the custodial environment, for example through having drug and alcohol nurses available to assist with the management and appropriate referral of ATS affected individuals. It was observed that one such initiative has been implemented in South Australia where nurses employed by DASSA have been placed at the Adelaide City Watch House.

Emergency departments were also a key initial point of contact with ATS affected patients. It was argued that emergency departments were not the best location for most presentations. A number of participants suggested that there was a need to establish an independent facility, in close proximity or adjacent to the emergency departments, that could provide a safe and supportive environment to manage intoxication and withdrawal. A number of consumers suggested that such an option was preferable to emergency departments or police lock-ups.

Managing acute ATS toxicity

As noted in Chapter 3, acute ATS toxicity can result in a range of adverse outcomes, including cardiovascular and cerebrovascular emergencies, behavioural problems, serotonin toxicity and psychosis. Such problems, usually dose dependent, can occur in relatively naive as well as regular users (Dean & Whyte, 2004). Effective management requires staff to be able to accurately assess and diagnose the condition, and needs access to a safe environment (which in some, more severe, cases may require medical management), monitoring and, in cases of severe behavioural problems and psychosis, possible sedation. Pharmacological management may be complicated by polydrug use (e.g., co-existing alcohol intoxication). Although some research on managing cocaine toxicity may be relevant, unfortunately, the evidence to guide clinical practice is limited:

… studies related specifically to the management of amphetamine and MDMA toxicity are few. (Dean & Whyte, 2004, p.100).

As described earlier, despite the paucity of specific evidence, the challenges posed by ATS toxicity and evidence regarding general management of the various conditions prompted the development of management guidelines for emergency health services, frontline health workers and law enforcement staff (Jenner et al., 2004a; 2004b; 2006a; 2006b). The effectiveness of their dissemination and adoption remains to be determined. Other guidelines have also been developed including the NSW publications, ‘Amphetamines and Other Psychostimulants – A Guide to the Management of Users’ and ‘Clinical Guidelines for Assessment and Management of Psychostimulant Users’, and the WA Drug and Alcohol Office (DAO) publication, ‘Clinical Guidelines: Management of Acute Amphetamine Related Problems’. More recently, Turning Point developed treatment guidelines for methamphetamine dependence, which included management of acute toxicity (Lee et al., 2007). The recommended steps were: observation of clinical signs of toxicity, monitoring of vital signs, verbal de-escalation of situation if necessary, sedation as required and regular hydration and observation.

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