National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
5.10 Summary
- 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
Treatment for ATS use and associated problems is impeded by relatively low rates of access by ATS users and tenuous links with services. Research suggests that those least likely to receive treatment are females, persons born outside Australia and those in fulltime employment. Furthermore, poor treatment retention is associated with frequent use, injecting and use during treatment. Nevertheless, recent Australian national data suggest that approximately 11% of those seeking treatment for drug use reported amphetamine as the principal drug of concern. Of this group, the most common form of treatment was counselling.
The first point of contact for many ATS users is with frontline services, often due to intoxication or related problems including violence and psychotic behaviours. The high burden on frontline services posed by ATS use, particularly methamphetamine, is largely due to the nature of the presentations rather than the actual numbers of ATS-related presentations. As a result, national guidelines have been developed for police, ambulance staff, emergency departments and general practitioners in managing psychostimulant users, including pharmacological management of toxicity. The extent of dissemination and utilisation of these guidelines remains unclear.
A related issue is that of withdrawal management for ATS. Current research suggests the amphetamine withdrawal syndrome is comprised of hyperarousal symptoms, reversed vegetative symptoms and anxiety-related symptoms. Symptoms of depression have also been found during the first several days of withdrawal. At present there appears to be a lack of clear protocols for appropriate withdrawal management for dependent meth/amphetamine users. Pharmacotherapies currently being trialled include various antidepressants, mirtazepine and modafinil.
Several psychosocial interventions have been used in treatment for ATS users. These include brief interventions, inpatient programs, therapeutic communities, 12-step programs, peer interventions, contingency management, behavioural strategies, cognitive-behavioural interventions, multimodal packages (such as the Matrix Model used in the United States) and non-traditional methods such as acupuncture. Research to date suggests that cognitive behavioural therapy (CBT) applied in a stepped care approach is the treatment of best practice for ATS use. CBT is typically comprised of motivational interviewing, instruction in cognitive-behavioural coping strategies and relapse prevention. However, there is a limited evidence base and consideration of what is best practice may be confirmed or change as new evidence emerges. New psychological approaches to treatment currently being investigated in Australia for ATS use include mindfulness therapy, narrative therapy and acceptance and commitment therapy.
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Pharmacotherapy has also been used in treatment of ATS use. In addition to its role in withdrawal management, it has also been investigated as substitution therapy. This typically involves the use of prescribed dexamphetamine, particularly for those users for which other interventions have not been effective. More recently, methylphenidate and bupropion have been studied as potential amphetamine substitutes. Although there may be risks associated with substitution therapy, it is viewed by users as an attractive incentive into treatment and clinical trials show it may be effective when used in conjunction with psychosocial intervention. There may also be some adverse outcomes that compromise the value of substitution therapies, at least for some patients. Unfortunately, the evidence base is limited.
An issue to consider in treatment for ATS use is co-occurring mental health problems. Co-morbidity of alcohol and drug use and psychological difficulties is common, and ATS use is no exception. While the research is limited, depression, anxiety and psychosis have all been identified as associated with ATS use. Given this, an integrated approach to treatment that involves coordination and collaboration across sectors is indicated. In addition, health professionals need education, training and supervision specific to the issues of ATS use. The research and opinion at consultations indicates that dissemination of existing guidelines and development of further professional resources is needed.
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