Methamphetamine Use: Presentations & Responses in Mental Health Settings. methamphetamine. Ann Roche. Professor and Director

Transcription

1 Methamphetamine Use: Presentations & Responses in Mental Health Settings methamphetamine Ann Roche Professor and Director National Centre for Education and Training on Addiction (NCETA) Central Adelaide Local Health Network Mental Health Directorate 9 December 2015

2 Current Context Increasing concern in Australia about methamphetamine use, often framed as ice use Strong media interest An Epidemic of Negative Headlines Pressure on health, community services and workplaces to respond appropriately Family impact and social disruption

3 Final Report: National Ice Taskforce 3

4 What s the current situation? This presentation provides an overview of the current data to inform our understanding of patterns, problems and potential responses. Data will provide only part of the insight and understanding required. Best available data is limited. The community, families and users, and service providers need to complement the available data with first hand knowledge and experience.

5 Key Questions and Considerations What is Methamphetamine? What is Ice? What has changed? What is the concern? Who is most likely to experience problems? What are the best evidence-based intervention options? What strategies are being developed to respond to ice?

6 Meth/amphetamine & performance

7 A brief history of Ice 1887 & 1893: Amphetamine & methamphetamine first synthesised 1932: Amphetamine Benzedrine (over-the-counter bronchial dilator) 1937: Amphetamine available in prescription in tablet form (narcolepsy & hyperactivity - ADHD) : Meth/amphetamine used extensively by troops to combat fatigue 1950s: Increased use in US (diet aid & depression treatment), widespread nonmedical use 1960s: Increased availability leads to increased non-medical use 1970: Use regulated in the US (Controlled Substances Act) : Growth in illegal production & supply 1990: Emergence of more potent illicit forms such as ice 1991: Ice identified as a new Australian drug threat by AFP 2001: Increase in use in Australia noted by Illicit Drug Reporting System : Australian Crime Commission reports ice is becoming a large-scale problem for law & health Meth/amphetamine are both Schedule 8 drugs in Australia Amphetamine (dexamphetamine) still regularly prescribed for ADHD & narcolepsy in US & Australia (eg., Ritalin) Methamphetamine no longer prescribed in Australia and very rarely in US

8 Methamphetamine belongs to the stimulant class of drugs, which also includes amphetamine, ecstasy, and cocaine. They stimulate the brain and central nervous system; can result in a range of physiological and psychological changes including: a) increased alertness/euphoria/energy/enhanced mood.. b) anxiety/panic/agitation/hallucinations aggression/violence. 3 main forms of methamphetamine: powder (speed) base crystal (ice)

9 Types of Methamphetamine

10 Base Sticky, oily paste First step in cooking process Low purity Cheaper than Crystal Meth Use of base has declined in Aust SA has the higher % of use Average amount used is 1 point per session Ephedrine is extracted from Pseudoephedrine via the use of Ammonia. Then Nitrate, Hydrochloric Acid & Red Phosphorous are added this is the Base!

11 Hydrochloride Salts / Powder Commonly known as Speed Smokable in this form Continuation of the cooking process from Base with more chemicals & processes added Most commonly used form until 2014 in Aust 60% is produced in backyard labs Remainder is shipped from South East Asia Overall Meth users % %

12 Crystalline Also known as Crystal Meth/Ice Purer form than Salts/Powder Highly Addictive Highly Corrosive Generally Smoked High risk of volatile off gassing when produced The most talked about form in 2015 Now the most commonly used form of Meth 2013

13 Figure 2.10: National annual median purity of methamphetamine

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15 Long Term Effects / Complications Central Nervous System Meth causes the most damage to the brain Neurons, receptors & neurotransmitters Significantly large amounts of Dopamine into synapse cause: - Twitching & repetitive movement - Tearing of skin and itching - Schizophrenia, hallucinations & paranoia - Neuronal damage or death - Parkinson's Significantly large amounts of Serotonin into synapse cause: - Weight Loss & Malnutrition - Serotonin toxicity Respiratory System Vessel Constriction Pulmonary Artery Hypertension APO Pneumothorax Chronic Coughing Reactive Airways Disease Granulomas Cardiovascular System Significant, prolonged vessel constriction & narrowing Inc HR, BP & inc workload on cardiac muscle Systolic Dysfunction CCF Endocarditis Cardiomyopathy Cardiac Arrhythmias & AMI Aortic Dissection

16 Long Term Effects / Complications Peri-natal Complications Pre term labour Seizures & Death Liver / Kidney Damage Lead Poisoning Repetitive Motor Activity Anorexia / Malnutrition Peripheral Neuropathies Skin Abscesses * Paranoia / Psychosis * Mood Disturbances * Hallucinations * Addiction * Schizophrenia * STD s * Teeth Grinding * Jaw Clenching * Dental Erosion

17 Methamphetamine effects Low dose elevated mood, & increased alertness, concentration, & energy Increased confidence, affect on risk perception High dose can induce psychosis, rhabdomyolysis & cerebral hemorrhage Regular use high potential for addiction, psychosis or post-acute-withdrawal syndrome Can result in a range of negative physiological, emotional & cognitive outcomes Ice Increased potency & method of use (smoking or injecting) increases risk of these negative outcomes

18 Immediate psychological effects (Majumder & White 2012) Euphoric state Increase in energy levels Enhancement of mood Increased self-esteem Alleviation of fatigue Increased attention

19 Immediate physiological effects (Majumder & White 2012) Signs of activation of the adrenergic system: Increased HR & resp rate Hypertension Decreased appetite Psychomotor stimulation Euphoric state Increase in body temperature

20 4 broad types of adverse health effects (Degenhardt & Hall 2012) (i) (ii) Acute toxic effects, OD Acute effects of intoxication Accidental injury Violence (iii) SUD (iv) Sustained chronic use Chronic disease, eg CVD Blood-borne bacterial & viral infections Mental disorders

21 Polydrug use (Darke et al, 2008) Increases toxicity: ETOH/MA HR, BP Heroin/MA O 2 demand with respiration (cardiac failure) MA/cocaine vasoconstrictive & cardiotoxic effects Multiple substances are detected in around half of fatal MA toxicity cases

22 Ice, the crystalline form of methamphetamine, is of particular concern. Ice (also known as crystal meth, meth, crystal, shabu, batu, d-meth, glass, or shard): most potent form of methamphetamine, usually smoked or injected.

23 Patterns of use and Manifestation of Problems Multiple sources.anecdote, media, observation, service providers, law enforcement 1. National Drug Strategy Household Survey (NDSHS) 2. National Minimum Data Set ( AOD Treatment Specialists) 3. Hospital Morbidity Data 4. Other (IDRS, EDRS, ED, specific targeted studies)

24 What s Changed? 1. Price 2. Purity 3. Form 4. Mode of administration 5. Frequency of Use

25 Scott et al., 2014 Reported: Increase in purity Decline in purity-adjusted price per gram Extreme purity variation

26 Local Production & Risks to Workers

27 The Production Line Clandestine Labs Houses, offices, roof spaces, & cars may be used 60% of Australian Methamphetamine is produced in a Lab

28 Shake n Bake Method Fast Portable Do it in the car Produce small amounts Dispose of container easily Produced whilst driving around

29 Recent methamphetamine use in Australia, Source: Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey

30 Methamphetamine use in the Australian population, % 2% 0.8% 0.4% Lifetime Past 12 months Past month Past week Frequency of Methamphetamine Use Source: Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey (NCETA secondary analysis, 2015).

31 Main form of meth used in last 12 mnths, % 59% 50% 39% 27% 22% 12% 12% 8%* 5% 8% 4% Speed Ice Base Other Form of Methamphetamine Used Source: Australian Institute of Health and Welfare (AIHW). 2007, 2010, 2013 National Drug Strategy Household Survey (NCETA secondary analysis, 2015). * Estimate may be unreliable due to small sample size

32 Frequency of methamphetamine use, % 68% 64% 14% 9% 22% 16% 16% 17% Weekly Monthly Yearly Frequency of Methamphetamine Use

33 Figure 2.11: Estimated number of Australians aged 14 and over using ice in the past 12 months and using at least once a week

34 Main method of meth use, % 35% 36% 33% 34% 17% 19% 26% 23% 16% 11% 10% 0.2%* 0% 0.5%* Smoked Swallowed Snorted Injected Other Mode of Methamphetamine Administration Source: Australian Institute of Health and Welfare (AIHW). 2007, 2010, 2013 National Drug Strategy Household Survey (NCETA secondary analysis, 2015). * Estimate may be unreliable due to small sample size

35 Gender differences in frequency of methamphetamine use, % 66% 53% 47% 35% 34% Weekly Monthly Yearly Frequency of Methamphetamine Use Male Female Source: Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey 1 (NCETA secondary analysis, 2015).

36 Do Ice Users Differ From Other Meth Users? (2013 NDSHS data) Ice users had a significantly different demographic profile to other methamphetamine users. Ice users were: younger, and less likely to be married, heterosexual, or to have finished high school. more likely to use frequently, be psychologically distressed, and be drug dependent. twice as likely to engage in risky activities while under the influence of an illicit drug (OR: 2.52, 95%CI: ).

37 Figure 2.13: Average age of Australians aged 14 and over reporting meth/amphetamines use in the past 12 months, by main type used

38 Mean age of methamphetamine users, Trend Ice Users 29.5 years 28.9 years 28.8 years* Other Methamphetamine Users 28.6 years 30.0 years 30.9 years* All Methamphetamine Users 28.9 years 29.6 years 30.1 years* Source: Australian Institute of Health and Welfare (AIHW). 2007, 2010, 2013 National Drug Strategy Household Survey (NCETA secondary analysis, 2015).

39 Frequency of use by form: ice vs all forms of methamphetamine, NDDHS 2013 Weekly/monthly meth (ice) users % Yearly meth (ice) users % Male 60 (62) 66 (62) Married 24 (20) 35 (31) Employed 49 (46) 71 (69) Heterosexual 81 (77) 91 (87) Live in major cities 73 (76) 72 (74) Psychologically distressed 41 (46) 28 (18) Worked under the influence of drugs 60 (62) 24 (22) Drove under the influence of drugs 63 (62) 34 (48) Drink at risky levels 70 (78) 68 (59) Smoke tobacco 72 (83) 59 (57) Source: Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey (NCETA secondary analysis, 2015).

40 Less frequent (yearly) users of methamphetamine, including ice users, tend to be: employed, heterosexual, male, low levels of psychological distress. Frequent (weekly/monthly) methamphetamine users, including ice users, tend to: comprise more females, be less likely to be married fewer heterosexual. Frequent users are also more likely to be: unemployed, psychologically distressed, engage in various risk taking activities Likely to be a non-treatment seeking population

41 Methamphetamine harms in AOD meth treatment episodes 2009/ /13: 326% increase from (1,240 to 4,043) in meth related hospitalisations 2008/ /13: 19% to 35% in Ice related ambulance callouts (hi % violence/mh issues) Melbourne Metro 2011/ /13: 88% (592 to 1116) 2012/ /14: 10% (1116 to 1237) Regional Victoria 2011/ /13: 198% (77 to 231) 2012/ /14: 27% (231 to 295)

42 AOD Treatment Specialist Services Report growing episodes of care for methamphetamine In 2009/10, <1% of episodes of AOD specialist treatment were for meth (n=1,240) In 2012/13, >3% of episodes of AOD specialist treatment were for meth (n=4,043)

43 Figure 6.8: Number of completed treatment episodes where meth/amphetamines was the principal drug of concern

44 Methamphetamine treatment: Indigenous status by age, 2012/13 25% 10% 8% 19% 20% 21% 21% 19% 15% 13% 13% 16% Indigenous Non-Indigenous Source: Australian Institute of Health and Welfare (AIHW). 2012/13 Alcohol and Other Drug Treatment Services National Minimum Data Set (NCETA secondary analysis, 2015).

45 Figure 3.3: Number of completed treatment episodes where meth/amphetamines was the principal drug of concern, by main method of use

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47 Crystal methamphetamine-related ambulance attendances in Victoria by year /05 to 2013/14 Ambo Project:

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49 Figure 6.2: Quarterly hospital separations with a methamphetamine-related principal diagnosis

50 Hospital separations: stimulants, 2008/ /13 Source: Australian Institute of Health and Welfare (AIHW) National Hospital Morbidity Database (NCETA secondary analysis, 2015).

51 Figure 3.1: Annual number of hospital separations where the principal or additional diagnosis was methamphetamine related

52 Hospital separations: poisonings due to psychostimulants, 2008/ /13 Source: Australian Institute of Health and Welfare (AIHW) National Hospital Morbidity Database (NCETA secondary analysis, 2015).

53 Hospital separations: psychotic disorders due to methamphetamines, 2008/ /13 Source: Australian Institute of Health and Welfare (AIHW) National Hospital Morbidity Database (NCETA secondary analysis, 2015).

54 Hospital separations: psychotic disorders due to methamphetamines by age, 2008/ /13 Source: Australian Institute of Health and Welfare (AIHW) National Hospital Morbidity Database (NCETA secondary analysis, 2015).

55 Figure 2.1: Percentage of Australian adult detainees who tested positive to methamphetamine at DUMA sites

56 Other Considerations Important not to see either the causes or the responses to meth/ice issues in isolation Comprehensive/holistic responses needed Consideration given to concurrent patterns of use: Alcohol: - high levels of stimulant use associated with risky drinking and night time economy Wide-awake drunkenness (Pennay et al 2014) Cannabis: Potential displacement effect, shifting from cannabis to meth to avoid drug detection.

57 Intervention/Treatment principles? Prevention Early intervention De-escalation Critical incident management Medical management Police intervention Treatment, long term recovery and relapse

58 Agitation in stimulant use Agitation is not necessarily aggression or violence The inability to achieve relaxation or a state of rest Often co-operative but unable to control need for gross motor movement EXAMPLE A patient may not be capable of sitting still; they will co-operate by remaining on the stretcher, but they cannot remain still.

59 Acute Behavioural Change Sedation may need to be considered Low sensory environment Reducing agitation reduces HR, BP, Temp, RR and associated chest pain Restraint use / MHA 2009

60 Rx for the critically ill stimulant patient

61 What about the workplace?

62 The workplace as an intervention setting The workplace is an ideal intervention setting Access to large numbers of drug users Most drug users are employed Employees spend a lot of time at work Maximises exposure Employers support safety/productivity improvement & worker wellbeing initiatives Existing IR & WH&S frameworks exist to support prevention & intervention strategies Workplace prevention/intervention efforts extend to the wider community

63 Workplace interventions & barriers to treatment Workplace interventions can overcome many common barriers to treatment Drug use not perceived as a problem Lack of motivation Work commitments Lack of support Lack of awareness of treatment options

64 The statistics: Prevalence of use among workers

65 % methamphetamine users (last 12 months) by employment status 2.1% Total Population Data source: 2013 National Drug Strategy Household Survey

66 Number of methamphetamine users (last 12 months) by employment status Data source: 2013 National Drug Strategy Household Survey

67 Number of methamphetamine users (last 12 months) by paid labour force status Data source: 2013 National Drug Strategy Household Survey

68 Prevalence by occupation Data source: 2013 National Drug Strategy Household Survey

69 Prevalence by industry Other industries <2.0% Data source: 2013 National Drug Strategy Household Survey

70 Methamphetamine use in the workforce

71 Workplace harms Meth Other illicit Sig diff Absenteeism due to injury* Absenteeism due to illness* Absenteeism due to drug use* Absenteeism due to alcohol use* 16.9% 10.3% p< % 39.5% ns 7.3% 1.3% p< % 6.4% p<.01 Usually use at work 9.7% 3.8% p<.01 Worked under influence# 31.6% 6.0% p<.01 * at least 1 day off in past 3 months # at least once in past 12 months Data source: 2013 National Drug Strategy Household Survey

72 High risk workforce groups Workers aged Males Trades/blue collar Industry Wholesale Construction Mining Manufacturing Hospitality

73 Workplace risk factors Workplace environment Availability Workforce demographic, location, supervision level, policy response Working conditions Shift work, long hours, fast paced work, FIFO/DIDO work Workplace motivations Reduce fatigue Increased productivity, increased alertness Reduce risk of positive drug test

74 Implications for prevention/treatment Access to large numbers of at risk individuals Young males Recreational/occasional users Opportunity for prevention & early intervention Onsite awareness & brief intervention Referral to counselling Provides treatment pathway Employment as motivator

75 Prevention/intervention strategies Supervisor/manager training Signs & symptoms of use Referral/supporting affected employees Factors that contribute to use Employee awareness Physical & mental health risks of use Factors that contribute to use Treatment pathways EAP/Community AOD (and other) services

76 Summary the workplace provides an opportunity for cost effective prevention/early intervention strategies that can each large numbers of drug users these strategies are likely to receive substantial employer support AOD agencies/service providers can play a significant role

77 Frontline Online Training Package NCETA and its consortium partners commissioned by the Victorian Government Department of Health and Human Services to: Develop and implement a standard online training package for frontline workers most likely to be providing services and support to Ice-affected individuals. The training package forms part of the Victorian Government s Ice Action Plan. 77

78 Acknowledgements Consortium Partners: Australasian College for Emergency Medicine Greater Green Triangle University Department of Rural Health Harm Reduction Victoria South Australian Network of Drug and Alcohol Services (SANDAS) We also acknowledge the support of the Victorian Alcohol and Drug Association (VAADA). 78

79 Training Package Overview The training package contains seven independent, but complementary, modules: 1. About Ice 2. Effects of Ice 3. Communicating with Ice Users 4. Ice Users and Critical Incidents 5. Interventions 6. Prevention 7. Organisational Responses to Ice. 79

80 Training Package Features Each module: Contains up to eight different topics Is designed for adult independent and individual learners to work through at their own pace. Features include: Learning Flexibility learners can work on any module or topic of interest to them Tailored and interactive learning contains written information, data, graphs and videos, and exercises to enhance learning and skill development. 80

81 Training Package Features Intended for different audiences & can be used in several ways: 1. Individual workers independent learning to upskill their knowledge. 2. Supervisors / managers examine & reflect on program and service structures. 3. Train-the-trainer guide / support mechanism for other trainers including face-to-face training. 4. Integration into existing accredited training programs content can be extracted & utilised across different disciplines. 81

82 Status Finalising the foundation modules SCORM (Sharable Content Object Reference Model) - compatible Learning Management System (LMS) (able to be exported to other LMS) Users will be able to pick and chose topic content and level of complexity. Initially available to Victorian-based workers potential for national availability. Ongoing monitoring and updating. 82

83 Existing training resources We want to know if there are there existing methamphetamine training resources (e.g. hard copy, PDF, videos, online) currently available that you would like to bring to our attention and/or recommend for inclusion in the Training Package? Contact: Allan Trifonoff T: (08) E: Roger Nicholas T: (08) E:

84 Whole rvices rimary health care,

85 Summary Increasing prevalence of ice use Increasing impact on law & health services Increasing risk of dependency & long term physical & mental health issues Increasing risk of harm to others

86 Thank you

87