National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
5.3 Treatment access and retention
- Acknowledgements
- Abbreviations
- List of Tables
- List of Figures
Chapter 1: Introduction- Chapter 2 Setting the Context
- Chapter 3: Effects of Amphetamine-Type Stimulants
- Chapter 4: Prevention and Harm Reduction
Chapter 5: Treatment and Service Provision- 5.1 Amphetamine-type stimulant treatment presentations
- 5.2 Initial engagement
- 5.3 Treatment access and retention
- 5.4 Withdrawal management
- 5.5 Psychosocial interventions
- 5.6 Pharmacotherapy
- 5.7 Other interventions
- 5.8 Managing co-occurring mental health and amphetamine-type stimulant problems
- 5.9 Workforce development
- 5.10 Summary
- Chapter 6: Law Enforcement
- Appendix 1
- Appendix 2
The evidence indicates that ATS users represent a relatively ‘volatile group’ in respect to both access to, and retention in, treatment. A number of studies (e.g., Klee et al., 2001; Hando et al., 1997; Vincent et al., 1999) have indicated that traditional drug services have not been attractive to ATS users and there remain some reasons to believe that treatment engagement of people affected by ATS use is low compared to the number of people in need. For example, Kelly and colleagues (2005) estimated that only 10% of regular amphetamine users received formal treatment in any given year. Poor engagement and retention limits the ability of treatment to have impact (McKetin & Kelly, 2007).
Recent reports indicate that the problems of limited treatment engagement and retention are still issues (e.g., Shearer, 2007). Access to treatment does not appear to be randomly distributed among those who might be affected by ATS use. For example, research investigating characteristics of amphetamine users accessing treatment in NSW during 2002-03 reported that the majority of clients were English speaking, of low socioeconomic status, unemployed and were injecting drug users (McKetin et al., 2004). Research with dependent methamphetamine users in Sydney explored socio-demographic factors associated with receiving treatment (McKetin & Kelly, 2007). After adjusting for severity of methamphetamine dependence, factors predictive of not receiving treatment included being female, being born outside Australia and being in full-time employment. Methamphetamine smokers were also less likely to receive treatment than those who consumed the drug via other methods of administration. Similarly, Hillhouse and colleagues (2007) examined individual drug use and treatment characteristics as predictors of in-treatment performance and post-treatment outcomes over a 1-year period. A sample of 420 participants, from the Methamphetamine Treatment Project (MTP), was interviewed. Poor treatment engagement was associated with being female, more frequent use of methamphetamine, shorter history of methamphetamine use, smoking as the route of administration, and baseline depression. Poor treatment retention was associated with more frequent methamphetamine use, injecting drug use history, and use of methamphetamine during treatment. Non-completion of treatment was associated with shorter history of methamphetamine use, smoking or injecting methamphetamine, and methamphetamine use during treatment.
These studies replicate earlier reports. For example, Maglione and colleagues (2000) reported on treatment retention of over 2000 methamphetamine users in public outpatient services in California from 1994-1997 (a 45 month period). Overall, only 23% completed treatment, and drop out rates were higher for males. It should be noted that the treatment programs were lengthy (drop out was defined as not completing 180 days of treatment) and thus, this may be an indication of the fact that long term treatments are unattractive.
Luchansky and colleagues (2007) found completion rates for methamphetamine users in treatment compared well to users of other drugs. This study investigated a total sample of 12,726 adults and 2,715 youths receiving treatment for substance abuse in Washington State. Participants were compared according to primary drug, defined as alcohol, marijuana, methamphetamine, or ‘other hard drugs’ (cocaine, heroin, other opiates) and tracked for 1-year following discharge from a residential or outpatient treatment. Outcomes relating to completion of and readmission to treatment, and employment and criminal activity after treatment were measured. The general finding for both adults and youth was that outcomes for methamphetamine users were similar to those of users of ‘other hard drugs’, but not as positive as those of users of alcohol or marijuana. The one exception was in regards to completion of treatment, with adult methamphetamine users found to be significantly more likely to complete treatment than users of either alcohol or ‘other hard drugs’. However, alcohol users were less likely to be readmitted to treatment than methamphetamine users.
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A current Australia-wide project, led by NDARC with collaboration from Turning Point, DASSA, University of Melbourne, Queensland Alcohol and Drug Research Centre (QADREC), Griffith University and the National Centre for HIV Epidemiology and Clinical Research, is aimed at further enhancing understanding of treatment characteristics and issues for ATS users. The project will follow a cohort of dependent methamphetamine users in order to examine the characteristics of those entering treatment, differences to those not seeking treatment, factors predictive of abstinence, psychiatric morbidity, criminal involvement and contact with the health and criminal justice systems.
Some research has suggested that the patterns of ATS use may influence decisions to seek and remain in treatment. The lifestyle of those who engage in ‘binge patterns’ of use may disincline them to attend services, especially if it is believed that the treatment goal will be unattractive (e.g., abstinence). Baker and colleagues (2001a) found that few regular amphetamine users interviewed in their study wished to reduce or abstain from drug use, which has led some to conclude that a harm reduction focus should be an important element of treatment approaches.
Attracting and retaining ATS users in treatment has been a feature of a number of studies. For example, in relation to amphetamine, Wright and colleagues (1999) suggested that better information about treatment options should be communicated to users, resources specific to amphetamine should be available to staff, drop-in centres should provide advice and a link to treatment, workforce development strategies should be implemented to enhance staff skills and partnerships should be developed between general and drug specialist services. They also noted the importance of interventions targeting families. Others (e.g., Vincent et al., 1999) have made similar recommendations, including emphasising the need to build partnerships between drug specialist services and GPs, particularly because a number of studies (e.g., Hando et al., 1997; Vincent et al., 1999) indicated that GPs were a preferred source of support for many people affected by ATS use. These various researchers and others have noted that ATS use can severely impact on relationships (e.g., impact of agitation, aggression, paranoia – see chapter on ‘Effects of ATS’) and this includes relationships with treatment services and the individuals in those services. The ability to establish a safe therapeutic alliance is central to any clinical endeavour – with people affected by ATS use, this assumes a greater importance (e.g., see Baker et al., 2004; Vincent et al., 1999; Wright, Klee & Reid, 1999; Wright & Klee, 2001). In addition, interventions need to be based on the factors that influence and underlie ATS use and the functions they perform (e.g., social functions; losing weight; self-medication of mental health problems).
One suggested option is the development of clinics that specifically provide treatment for ATS users. Turning Point Alcohol and Drug Centre in Melbourne is currently trialing two SMaRT Clinics, which are specialist methamphetamine treatment and research clinics. The clinics aim to build collaborative care relationships with a range of services to ensure smooth pathways into and out of ATS treatment, act as a training ground for alcohol and other drug (AOD) and mental health staff, and demonstrate a range of best practice interventions for ATS users. The project aims to use consumer consultation in the process of establishing the clinics which are to be staffed by community nurses, psychologists, addiction medicine specialists/GPs and psychiatrists. It is intended to conduct a detailed evaluation of the services.
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Similar trials are being conducted in NSW with the Stimulant Treatment Programme established at St Vincent’s Hospital in Darlinghurst (Sydney) and in the Hunter New England region. The program provides a brief psychosocial intervention (8 sessions) within a stepped care framework. Preliminary data report 83 clients across the two sites who are predominantly male (75%) and aged 20-37 years (65%) (Dunlop & Tulloch, 2007). Three quarters of the clients at the New Hunter site and half the clients at the Sydney site are unemployed, and 55% across the sites are self-referred. The most common route of administration reported is injecting (70%), followed by smoking (24%). The majority of the clients are polydrug users, with cannabis (61%) and alcohol (59%) the most commonly reported drugs also used. Three quarters of clients had a mental health disorder, including 65% with depression, 36 % drug-induced psychosis and 33% anxiety. Anecdotal reports from clients found that they were attracted to the service due to its stimulant-specific focus and perceived more generic AOD services as not understanding their particular issues and concerns.
During the consultations, a common theme related to the challenges of accessing treatment services for ATS users. It was suggested that this was due to limited treatment options and long treatment waiting periods. Concern was particularly expressed about limited access to withdrawal management and rehabilitation programs. Limited access to treatment was a particular concern for those located in rural and remote regions, an issue that was more evident for many Indigenous communities. The written submission from the National Indigenous Drug and Alcohol Committee (NIDAC) indicated that there was a specific need to enhance access to culturally secure drug treatment services for Indigenous people particularly in remote and regional areas. This would include providing locally accessible treatment and rehabilitation services and involve strategies that addressed not only the drug user but the broader family unit and the provision of posttreatment aftercare and support. It was proposed that a critical component of any effective approach would involve building an Indigenous workforce that could prevent and respond to ATS use amongst Indigenous people.
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