Chapter 1: Background to the monograph

Amanda Baker
Chair of the Psychostimulant Monograph Consortium, Centre for Mental Health Studies, University of Newcastle, New South Wales

In response to the growing prevalence of psychostimulant use in Australia and the need for treatment and other community services to respond, the Australian Government Department of Health and Ageing commissioned a consortium of clinicians and researchers from the Centre for Mental Health Studies, University of Newcastle, New South Wales, the University of Queensland, Queensland Health, New South Wales Health and Turning Point Alcohol and Drug Centre Inc. to update the 1998 National Drug Strategy Monograph No. 32, Models of Intervention and Care for Psychostimulant Users (Kamieniecki, Vincent, Allsop & Lintzeris, 1998) and to produce management guidelines for ambulance officers, police, emergency department personnel and general practitioners. The management guidelines are published separately to the current monograph. Consortium members were:
  • Dr Amanda Baker (Chair), Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Professor Vaughan Carr, Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Dr Stefan Goldfeder, The Prince Charles Hospital and Health Service District (TPCH&HSD) Alcohol and Drug Service, Brisbane, Queensland
  • Dr Ed Heffernan, Integrated Forensic Mental Health Services, Royal Brisbane Hospital, Queensland
  • Ron Henderson, Queensland Ambulance Service
  • Linda Jenner, Centre for Mental Health Studies, University of Newcastle, New South Wales and JenCo Consulting
  • Frances Kay-Lambkin, Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Dr Nicole K Lee,Turning Point Alcohol and Drug Centre Inc., Victoria
  • Terry Lewin, Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Professor John B Saunders, University of Queensland
  • John Sharples, Court Liaison, Hunter Mental Health Services, New South Wales
  • Associate Professor Ian Whyte, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Hospital, New South Wales
As a member of the Expert Reference Group of the 1998 monograph, I am aware of the huge amount of academic work and consultation that contributed to the production of that seminal document. It drew together a large and disparate body of knowledge for the first time in order to inform Australia's response to the growing harms associated with psychostimulant use.

The present work builds upon the foundations of the previous monograph. Since that time, there have been substantial developments in the research into treatments for psychostimulant users and this monograph focuses on these.

Aims of the monograph
Scope of the literature review
Designation of levels of evidence
Structure of the monograph
Terminology and definitions
Acknowledgements
Top of page

Aims of the monograph

The aims of this monograph were to document the prevalence and risks associated with psychostimulant use, describe the pharmacology of psychostimulants, identify best practice in detoxification and clinical interventions for psychostimulant use, identify gaps in the literature and make suggestions for interventions and further research.

Key objectives of the monograph were to:
  1. critically review existing literature in the domains of prevalence, risks, pharmacology, detoxification and treatments for psychostimulant use;
  2. obtain expert feedback from reviewers of each chapter;
  3. update recommendations for practice with psychostimulant users; and
  4. identify priority areas for further research.

Scope of the literature review

Experts in each domain were invited to contribute chapters to the monograph. Literature searches on databases, such as PsychInfo, Medline, Cochrane Database of Systematic Reviews and Addiction Abstracts were conducted. Existing review papers were obtained and reference lists reviewed. I would like to thank the following authors for their invaluable contributions to this publication:
  • Mr Anthony Arcuri,Ted Noffs Foundation, Sydney, New South Wales
  • Dr Sharon Dawe, School of Applied Psychology, Griffith University, Queensland
  • Dr Angela Dean, Department of Psychiatry, University of Queensland
  • Dr Linda Gowing, Evidence Based Practice Unit, Drug and Alcohol Services Council, South Australia (DASC)
  • Dr Leanne Hides, Substance Use Research and Recovery Focused (SURRF) Program, ORYGEN Youth Health, Department of Psychiatry, University of Melbourne
  • Dr John Howard,Ted Noffs Foundation, Sydney, New South Wales
  • Linda Jenner, Centre for Mental Health Studies, University of Newcastle, New South Wales and JenCo Consulting
  • Dr Nicole Lee,Turning Point Alcohol and Drug Centre Inc., Victoria
  • Dr Rebecca McKetin, National Drug and Alcohol Research Centre (NDARC), New South Wales
  • Treasure McGuire, School of Pharmacy, University of Queensland and Mater Pharmacy Services, South Brisbane, Queensland
  • Heather Proudfoot, NDARC, New South Wales
  • James Shearer, NDARC, New South Wales
  • Matt Stubbs,Ted Noffs Foundation, Sydney, New South Wales
  • Professor John B Saunders, Department of Psychiatry, University of Queensland
  • Dr Libby Topp, NDARC, New South Wales
  • Associate Professor Ian Whyte, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Hospital, New South Wales[
An Expert Steering Committee was established for the project. Members were asked to provide information on any previously unidentified research groups. I would like to thank the following Steering Committee members for their important contribution to the development of the monograph:
  • Professor Robert Ali, DASC
  • Michael Arnold, NSW Users and AIDS Association (NUAA)
  • Michael Lodge, NUAA
  • Professor Richard Mattick, NDARC
  • Professor Anne Roche, National Centre for Education and Training on Addiction (NCETA), Flinders University, South Australia
  • James Shearer, NDARC, New South Wales
  • Dr Libby Topp, NDARC, New South Wales
  • Dr Ingrid van Beek, Kirketon Road Centre, Sydney, New South Wales
Top of page

Designation of levels of evidence

Chapter authors were asked to employ the method of Gowing, Proudfoot, Henry-Edwards and Teesson (2001) in designating levels of evidence in clinical studies (see Table 1). Gowing and colleagues (2001) had modified National Health and Medical Research Council (National Health and Medical Research Council, 1999) designations due to the limited availability of randomised controlled trials (RCTs) in the field of drug dependence by using a scale to provide an indication of the reliability and validity of evidence.

A brief statement of the reasons for the rating was also included. Gowing and colleagues (2001) noted that the rating system enabled a distinction between 'no evidence of effect' and 'evidence of no effect', or a 'negative effect'.

Clinical recommendations have been based on the method employed by NDARC in preparing the Guidelines for the Treatment of Alcohol Problems (National Drug and Alcohol Research Centre, 2003). The strength of the recommendation is based on the best available evidence presented for the intervention or strategy in question (see Table 2), combined with clinical expertise. Three levels are used.

Table 1: Modified designation of levels of evidence (Gowing et al., 2001)

Table 1 is presented as a list in this HTML version for accessibility reasons.
  • 4 stars - Strong evidence. Supported by a systematic review that includes RCTs or more than one properly conducted (unconfounded) RCT.

  • 3 stars - Moderate evidence. Supported by qualified evidence from reviews limited by research factors OR one properly controlled RCT, or more than one qualified RCT limited by research factors, OR more than one well conducted level 111-1 or 111-2 study (see level explanation below).

  • 2 stars - Some evidence. Supported by one qualified RCT limited by research factors, or more than one level 111-3 or level 1V study from different research teams OR one or more 111-1 studies limited by research factors.

  • 1 star - A little evidence. Based on opinion (clinical anecdote or editorial) OR reviews unsubstantiated by data OR one level 111-3 or level 1V study OR 111-3 or level 1V studies limited by research factors.

  • ? - Unable to assess. No, insufficient or conflicting evidence preventing any conclusion from being drawn.

  • Level 1 - Evidence obtained from a systematic review of all RCTs.

  • Level 11 - Evidence obtained from at least one properly designed RCT.

  • Level 111-1 - Evidence obtained from well-designed, pseudo-RCTs (alternate allocation or some other method).

  • Level 111-2 - Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, or interrupted time series with a control group.

  • Level 111-3 - Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group.

  • Level 1V - Evidence obtained from case series, either post-test or pre-test and post-test.

Table 2: Strength of clinical recommendation

Table 2 is presented as a list in this HTML version for accessibility reasons.
  • Strong - The recommendation is supported by at least level 11 research and expert clinical opinion.
  • Moderate - The recommendation is supported by at least level 111 research and expert clinical opinion.
  • Fair - The recommendation is based on expert clinical opinion.
Top of page

Structure of the monograph

The monograph comprises three sections:
  1. Background.
  2. Prevalence, effects and risks (with chapters on prevalence, pharmacology and risks).
  3. Clinical considerations (with chapters on psychosocial interventions; management of acute toxicity; withdrawal and detoxification; pharmacological interventions; specific populations; clinical recommendations; and future research directions).

Terminology and definitions

In this document, psychostimulants have been defined as amphetamines, cocaine and MDMA (ecstasy). Street names for these drugs can be found in the Glossary. The Glossary also contains definitions and explanations of a number of technical and medical terms used throughout the monograph. The term ATS (amphetamine-type stimulants) when used in this monograph specifically relates to amphetamines and methamphetamine and related substances.The term does not include other psychostimulants such as cocaine or MDMA. The term is typically used when describing law enforcement and customs data.

The terms psychostimulant abuse, use, misuse and dependence are sometimes used interchangeably. In this document, the terms 'abuse' and 'dependence' refer to the criteria defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (American Psychiatric Association, 1994), which are outlined in Table 3 and Table 4. 'Use' refers to use that does not meet these criteria.We used 'misuse' only when referring to the inappropriate use of prescribed or otherwise licit psychostimulants.

Table 3: DSM-IV diagnostic criteria for substance abuse

Table 3 is presented as a list in this HTML version for accessibility reasons.
  1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period:
    1. recurrent substance use resulting in failure to fulfil major role obligations at work, school, or home;
    2. recurrent substance use in situations in which it is physically hazardous (e.g., driving while intoxicated);
    3. recurrent substance-related legal problems; and
    4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
  2. The symptoms have not met the criteria for substance dependence.

Table 4: DSM-IV diagnostic criteria for substance dependence

Table 4 is presented as text in this HTML version for accessibility reasons.

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12-month period:
  1. tolerance, as defined by either:
    1. a need for markedly increased amounts of the substance to achieve detoxification or the desired effect; or
    2. markedly diminished effect with continued use of the same amount of the substance;
  2. withdrawal, as manifested by either of the following:
    1. a characteristic withdrawal syndrome; or
    2. the same or closely related substance is used to relieve or avoid withdrawal symptoms;
  3. the substance is taken in larger amounts or for a longer period than intended;
  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use;
  5. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects;
  6. important social, occupational or recreational activities are reduced or given up because of substance use; and
  7. substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Top of page

Acknowledgements

The chapter authors are very grateful to the following expert reviewers for their important contributions to the development of the monograph:
  • Professor Robert Ali, DASC, South Australia
  • Professor Steve Allsop, Drug and Alcohol Office of Western Australia
  • Dr Lisa Amir, Centre for Women's Health in Society, University of Melbourne
  • Professor Robert Batey, Division of Medicine, John Hunter Hospital, Newcastle, Drug and Alcohol Clinical Services, Hunter Area Health Service and University of Newcastle, New South Wales
  • Dr James Bell, Langton Centre, Sydney, New South Wales
  • Associate Professor Nick Buckley, Department of Clinical Pharmacology and Toxicology, Royal Canberra Hospital and Australian Capital Territory Poisons Information Centre, Australian Capital Territory
  • Professor Vaughan Carr, Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Associate Professor Loris Chahl, Discipline of Experimental Pharmacology, School of Biomedical Sciences, Faculty of Health, University of Newcastle, New South Wales
  • Professor MacDonald Christie, Pain Management Research Institute, Royal North Shore Hospital, University of Sydney, New South Wales
  • Chris Cruickshank, Clinical Pharmacotherapies Research Group, University of Western Australia and Next Step Specialist Drug Services,Western Australia
  • Dr Sharon Dawe, School of Applied Psychology, Griffith University, Queensland
  • Dr Glenys Dore, Rozelle Hospital, Sydney, New South Wales
  • Dr Kyle Dyer, Clinical Pharmacotherapies Research Group, University of Western Australia and Next Step Specialist Drug Services,Western Australia
  • Dr Gordian Fulde, St Vincent's Hospital, Sydney, New South Wales
  • Dr Stefan Goldfeder, The Prince Charles Hospital and Health Service District Alcohol and Drug Service (TPCH&HSD), Brisbane, Queensland
  • Dr Ed Heffernan, Integrated Forensic Mental Health Services, Royal Brisbane Hospital, Queensland
  • Dr Leanne Hides, Substance Use Research and Recovery Focused (SURRF) Program, ORYGEN Youth Health, Department of Psychiatry, University of Melbourne, Victoria[
  • Greg Kamieniecki, DASC, South Australia
  • Dr Fergus Kerr, Austin and Repatriation Hospital, Melbourne, Victoria
  • Dr Simon Lenton, National Drug Research Institute, Curtin University, Western Australia
  • Dr Toni Makkai, Australian Institute of Criminology, Australian Capital Territory
  • Professor Richard Mattick, NDARC, New South Wales
  • Dr Rebecca McKetin, NDARC, New South Wales
  • Dr Alison Ritter,Turning Point Alcohol and Drug Centre Inc., Victoria
  • Carla Schlesinger,TPCH&HSD Alcohol and Drug Service, Brisbane, Queensland
  • Dr Catherine Spooner, NDARC, New South Wales
  • Michael Tarren-Sweeney, Centre for Mental Health Studies, University of Newcastle, New South Wales
  • Dr Maree Teesson, NDARC, New South Wales
  • Dr Ingrid van Beek, Kirketon Road Centre, Sydney, New South Wales
  • Dr Jason White, Pharmacotherapies Research Unit, University of Adelaide, South Australia
  • Dr Rodney Whyte, Monash Medical Centre, Melbourne, Victoria
Top of pageFinally, I would like to thank the following individuals for their kind assistance with the project:
  • Angela Bates, University of Newcastle, New South Wales
  • Anna Bacik, New South Wales Health Department
  • Frances Kay-Lambkin, University of Newcastle, New South Wales
  • Jodie Shoobridge, NCETA, Flinders University, South Australia
  • Lyndie Barrkman, Centre for Mental Health Studies, University of Newcastle, New South Wales[
  • Michael Jenner, JenCo Consulting
  • Paul Gardiner,Turning Point Alcohol and Drug Centre Inc., Victoria
  • Tarra Adam, St Vincent's Hospital, Sydney, New South Wales