Models of intervention and care for psychostimulant users, 2nd edition - monograph series no. 51

Chapter 12: Clinical recommendations

Page last updated: April 2004

Edited by Amanda Baker, Nicole K. Lee and Linda Jenner

This chapter presents key points of chapter authors' recommendations for clinical interventions based on findings from Chapter 4, Chapter 5, Chapter 6, Chapter 7, Chapter 8, Chapter 9, Chapter 10 and Chapter 11. A decision tree to assist clinicians with appropriate options for management and interventions is included as Figure 2 at the end of this chapter. The following criteria (National Drug and Alcohol Research Centre, 2003) have been used throughout this chapter:

  • Strength of recommendation:
    • 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.
Risks associated with psychostimulant use
Psychosocial interventions for psychostimulant users
Management of acute psychostimulant toxicity
Figure 2: Decision Tree

Risks associated with psychostimulant use

Recommendations:
  • Psychostimulant users, especially new users, should be informed of possible adverse effects of the drug even in low doses and advised to limit their intake and avoid injecting. (Strength of recommendation: fair)

  • Psychostimulant users should be informed of the potential for the context of use (e.g. rave or dance party environment) to exacerbate physiological risks, such as hyperthermia and metabolite balances. (Strength of recommendation: fair)

  • Users should be made aware of strategies to reduce health risks, including drinking appropriate amounts of water, reducing other concomitant alcohol and drug use and ensuring breaks from dancing. (Strength of recommendation: fair)

  • Users should be made aware of the legal consequences of possession and selling party drugs. (Strength of recommendation: fair) Top of page

Psychosocial interventions for psychostimulant users

Recommendations:
  • Services should offer treatment and treatment contexts that are attractive to, and appropriate for, psychostimulant users. (Strength of recommendation: fair)

  • A range of interventions should be available for psychostimulant users. (Strength of recommendation: fair)

  • Partnerships between agencies and referral networks should be developed. (Strength of recommendation: fair)

  • All users should be encouraged to practise safer sexual behaviours and use sterile injecting equipment if injecting, be informed about the symptoms of heavy use, and be provided with a self-help guide. (Strength of recommendation: fair)

  • Polydrug use is common and polydrug dependence should be assessed and addressed in the treatment plan. (Strength of recommendation: fair)

  • Hazards of injecting should be discussed with experimental users, without exaggerating the risks of occasional oral use of low doses. (Strength of recommendation: fair)

  • Advice to avoid injection and daily use should be provided to current users. (Strength of recommendation: fair)

  • CBT interventions to reduce transition to injection should be implemented for non-injectors. (Strength of recommendation: moderate)

  • Brief interventions among current injectors should be implemented to reduce initiation into injecting among their non-injecting peers. (Strength of recommendation: fair)

  • Infrequent, heavy users of psychostimulants and instrumental users should be encouraged to be aware of symptoms of adverse consequences of heavy use and the need for moderation or cessation. (Strength of recommendation: fair)

  • Brief, opportunistic interventions should be undertaken among ecstasy users to reduce harm and alert users to possible adverse consequences of use. (Strength of recommendation: fair)

  • Motivational interviewing should be a standard intervention. (Strength of recommendation: fair)

  • CBT should be a standard intervention. (Strength of recommendation: moderate)

  • Behavioural approaches, such as contingency management, may be considered. (Strength of recommendation: moderate)

  • A single concerted approach or an integrated structured approach should be used rather than an eclectic approach. (Strength of recommendation: fair)

  • Residential treatment should be enhanced with behavioural or cognitive interventions to improve their effectiveness. (Strength of recommendation: moderate)

  • The use of residential rehabilitation and therapeutic communities for psychostimulant users should be limited to those who are likely to stay for 3 months or more. (Strength of recommendation: fair)

  • Given the limited evidence of effectiveness, attendance at self-help groups should be optional not mandatory. (Strength of recommendation: fair)Top of page

Management of acute psychostimulant toxicity

General issues

Recommendations:
  • Treatment of psychostimulant toxicity should involve prompt supportive care and judicious use of specific agents. It is important to seek emergency care when any of the following symptoms are present: (Strength of recommendation: fair)

    • Chest pain.
    • Rapidly increasing body temperature.
    • Psychotic features (hallucinations, severe paranoia, delusions or thought disorder).
    • Behavioural disturbance to the extent that the individual may be at risk to themselves or others.
    • Seizures.
    • Uncontrolled hypertension.

  • Once in the Emergency Department, clinical observation of potentially toxic signs and symptoms is more relevant than estimating the ingested dose. If objective confirmation of psychostimulant use is not possible, reasonable suspicion of psychostimulant use may be inferred from: (Strength of recommendation: fair)

    • information provided by significant others or bystanders;
    • the recent activities of the patient (e.g. a dance party); and
    • clinical presentation (pupils are usually dilated and sluggishly reactive to light; the skin is usually flushed and diaphoretic; hyperthermia above 39.5 degrees C indicates severe, potentially life-threatening toxicity and mandates immediate cooling and sedation).

Behavioural emergencies and psychosis

Recommendations:
  • Urgent sedation may be indicated for extreme behavioural disturbance associated with psychostimulant toxicity or if a patient is extremely agitated or severely psychotic. (Strength of recommendation: fair)

  • If a patient requires urgent sedation, medical staff should ensure that they have sound airway management skills and access to appropriate equipment. (Strength of recommendation: fair)Top of page

Serotonin toxicity

Recommendations:
  • Diagnosis of serotonin toxicity is made by clinical examination and the Sternbach criteria may be used. (Strength of recommendation: fair)

  • Management of serious serotonin toxicity should always involve supportive measures such as IV fluids/volume resuscitation for dehydration, hypotension or rhabdomyolysis; antipyretics, external cooling, muscular paralysis with neuromuscular blocking agents, mechanical ventilation for respiratory compromise and sedation with IV benzodiazepines. Paralysis and intubation may have a role in cases of severe intractable rigidity. Management of secondary cardiac arrhythmias or seizures involves standard measures. (Strength of recommendation: fair)

  • In all patients with suspected serious serotonin toxicity, serum electrolytes, glucose, renal function, creatine kinase levels and ECG should be monitored. (Strength of recommendation: fair)

  • Hepatic function and arterial blood gases should be monitored in more severe cases. (Strength of recommendation: fair)

  • Muscle rigidity should be controlled — if unchecked, it can lead to fever, rhabdomyolysis and respiratory compromise. (Strength of recommendation: fair)

  • Patients who develop coma, cardiac arrhythmia, disseminated intravascular coagulation or respiratory insufficiency require more specific measures. (Strength of recommendation: fair)

Cardiovascular complications

Recommendations:
  • As there may be no clinical differences between those who experience myocardial infarctions and those who do not, all patients with cocaine-related chest pain should be tested for possible myocardial infarction. (Strength of recommendation: fair)

  • Diagnosis of heart attack in cocaine users with chest pain is difficult but may be assessed with electrocardiograms, measurements of creatinine kinase and cardiac troponin I. (Strength of recommendation: fair)

  • The pharmacologic treatment of patients with cocaine-related ischaemic chest pain differs in several important ways from that of patients with the usual type of myocardial ischaemia. Treatment recommendations based on the pathophysiology of cocaine-associated myocardial ischaemia must take into account cocaine's toxic effects on the CNS and other vital organs. (Strength of recommendation: fair)

  • Aspirin must be avoided in patients at risk for subarachnoid haemorrhage. If treatment strategies could be altered by the knowledge of recent cocaine use, rapid bedside toxicological assays for the drug or its metabolites may be useful, since the patient's own reporting is not entirely reliable. (Strength of recommendation: fair)

  • Beta-blockers should not be used for the treatment of acute myocardial ischaemia related to psychostimulant use, as these drugs enhance stimulant-induced vasoconstriction, increase blood pressure and may exacerbate adverse effects. (Strength of recommendation: fair)Top of page

Cerebrovascular complications

Recommendations:
  • Cerebral computed tomography should always be performed when severe headache or altered consciousness or both occur in relation to use of these compounds. Arteriography should be part of the evaluation of most young patients with non-traumatic intracerebral haemorrhage. (Strength of recommendation: fair)

  • Immediate management involves airway management, adequate oxygen, IV fluids to maintain nutritional and fluid intake and attention to bladder and bowel function. Corticosteroids may be harmful. If present, fever, hyperglycaemia, heart failure, arrhythmias, or severe hypotension must be treated. (Strength of recommendation: fair)

  • Management of cerebrovascular events secondary to psychostimulant use should follow standard procedures with early consideration of angiography. (Strength of recommendation: fair)

Psychostimulant withdrawal and detoxification

Recommendations:
  • A thorough assessment of the use of all drug classes should be undertaken. Should concomitant withdrawal syndromes occur, both should be managed simultaneously. (Strength of recommendation: fair)

  • The management of people seeking detoxification support should ensure that people are initially engaged in appropriate treatment and retained in aftercare to optimise outcomes. (Strength of recommendation: fair)

  • Due to the high rates of relapse following treatment for psychostimulant use disorders, psychosocial interventions should be offered post-detoxification. (Strength of recommendation: fair)

  • Detoxification from psychostimulants is usually undertaken outside a hospital setting unless severe psychotic symptoms or other risk factors indicate that a supervised setting would be more appropriate. (Strength of recommendation: fair)

  • A thorough mental health assessment should be undertaken by those monitoring withdrawal, focusing on psychosis and depression, and mental health staff should undertake a thorough substance use assessment. (Strength of recommendation: fair)

  • Those involved in the client's care should collaborate to coordinate their management of individuals. (Strength of recommendation: fair)

  • Detoxification from psychostimulants may proceed without the assistance of drugs. Unlike withdrawal from substances such as alcohol or opioids, pharmacotherapy for psychostimulant withdrawal is of limited value. (Strength of recommendation: strong)

  • Clients should be educated about possible withdrawal symptoms and the variable course of withdrawal, and be provided with ongoing supportive management. (Strength of recommendation: fair)

Pharmacological interventions for psychostimulant users

Recommendations:
  • Medications, including antidepressants, dopamine agonists and antagonists, disulfirum, and most CNS stimulant drugs have not been found to be useful in the treatment of psychostimulant dependence. The use of pharmacotherapies should be limited except where targeted towards accurately and appropriately diagnosed comorbid conditions. (Strength of recommendation: moderate)Top of page

Psychostimulants and young people

Recommendations:
  • A wide range of comprehensive interventions that include CBT and family therapy approaches and target a range of factors should be offered. (Strength of recommendation: moderate)

  • The use of pharmacotherapies should be limited, except for specific comorbid psychopathology. (Strength of recommendation: moderate)

  • Treatment should be readily available, accessible and attractive to young people. (Strength of recommendation: fair)

  • A comprehensive assessment should be undertaken as a first step in the treatment of young people focusing on risk and protective factors, which may be targets for intervention. (Strength of recommendation: fair)

  • The intensity of treatment intervention offered to young people should be matched to the severity of substance misuse and the level of impairment in functioning. The least intrusive options should be tried first. (Strength of recommendation: fair)

  • Co-existing mental disorders should be assessed and addressed. (Strength of recommendation: fair)

  • Detoxification by itself does little to change long-term use and should be offered as part of a comprehensive treatment program. (Strength of recommendation: moderate)

The psychiatric comorbidity of psychostimulant use

Recommendations:
  • Comorbid conditions among psychostimulant users, including drug use and psychiatric symptoms, should routinely be screened, assessed and monitored over time using valid and reliable instruments. (Strength of recommendation: fair)

  • Although it is not possible to recommend any specific interventions for comorbid conditions at this time, comorbid conditions should be diagnosed and treated in an integrated way. (Strength of recommendation: fair)

  • Psychostimulant-induced psychosis is usually treated with conventional antipsychotic medication, sedation with benzodiazepines, or a combination of both types of medication. (Strength of recommendation: fair)

  • Affective and anxiety disorders can be treated with interventions designed for these conditions. (Strength of recommendation: fair)

  • Clinicians should be provided with guidelines on screening, assessment, referral options, information on different treatment protocols available, and access to clinical evaluation tools. (Strength of recommendation: fair)Top of page

Psychostimulant use in pregnancy and lactation

Recommendations:
  • Management strategies should address both psychostimulant use and the associated risk factors. (Strength of recommendation: fair)

  • Pregnant women and mothers who use psychostimulants should be encouraged to seek pre, peri and postnatal care. (Strength of recommendation: fair)

  • The clinical environment should be non-judgmental to maintain involvement in antenatal and postnatal care. (Strength of recommendation: fair)

  • Provision of good antenatal care with interventions to improve maternal nutrition and reduce psychological distress may improve neonatal outcomes. (Strength of recommendation: moderate)

  • Even if psychostimulants have been used in the earlier stages of pregnancy, there are possible benefits for reducing or ceasing use in the later stages of pregnancy and pregnant users should be encouraged to reduce or cease use. (Strength of recommendation: moderate)

  • Pregnant users should be advised to reduce other substance use, especially nicotine and alcohol, as this can improve neonatal and early childhood outcomes. (Strength of recommendation: strong)

  • Pregnant users should be advised to avoid binge administration of psychostimulants during pregnancy. (Strength of recommendation: fair)

  • If the pregnant user continues to use, infant exposure to the drug can be minimised by breast-feeding just prior to the drug use and avoidance of feeding for a minimum of two to three hours afterwards. (Strength of recommendation: fair)

  • Pregnant users should be advised to avoid breast-feeding during periods of heavy psychostimulant use. (Strength of recommendation: fair)

  • Parenting interventions should be considered for those who continue to use as they can have a positive impact on childhood outcomes. (Strength of recommendation: fair)Top of page

Figure 2: Decision Tree

Text equivalent below for Figure 2: Decision Tree
Top of page

Text version of Figure 2

Start here

Psychostimulant and other drug use, severity of dependence, mental health disorders or symptoms including suicidal ideation, readiness to change, severity of cravings to use, special needs.

Continue to Initial Assessment below.

Initial Assessment

Are they suffering from serotonin toxicity?

Toxicity protocols

See Chapter 6: Management of acute psychostimulant toxicity, then proceed as usual.

Continue to Initial Assessment

Do they have special needs?

Young people

Focus on engagement and family involvement then proceed as for adults. (see Chapter 9: Psychostimulants and young people)

Comorbid mental health symptoms

See Chapter 10: The psychiatric comorbidity of psychostimulant use

Do they need further specialist assessment?

Do you need to refer to an external service?

  • Yes, Referral as appropriate, institute share care arrangments as appropriate, follow-up
  • No, Secondary consultation then proceed as normal
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Poly drug

Consider all drugs in treatment plan then proceed as normal

Are they dependent?

Two or more: tolerance, withdrawal syndrome, uses more than intended, difficulty cutting down, significant time spent using, impact on lifestyle, uses despite harm.

Are they a regular user?

Do they want/need detoxification?

See Chapter 7: Psychostimulant withdrawal and detoxification

Are they ready to stop or cut down?

Do they require inpatient detoxification?

  • Yes, arrange inpatient detoxification and continue to Follow up
  • No, outpatient/ambulatory detoxification or home detoxification and continue to Follow up

Motivational enhancement, cognitive behaviour therapy

See Chapter 5: Psychosocial interventions

Do they need specific pharmacotherapy? (see Chapter 8: Pharmacological interventions)

Follow up

May need to continue to Motivational enhancement, cognitive behaviour therapy