MIC CAVAZZINI: Welcome to Pomegranate, podcast of the Royal Australasian College of Physicians. I'm Mic Cavazzini, and today we’re looking at crystal methamphetamine—the illicit drug “striking fear” in living rooms and emergency wards.
[NEWS CLIP MONTAGE]
MIC CAVAZZINI: This kind of media frenzy misrepresents the reality for most methamphetamine users, according to leading addiction researchers and clinicians.
Today’s guests explain how the stigma created has raised barriers to treatment, and that labelling crystal meth “the most addictive drug ever” discredits the effectiveness of available and upcoming therapies.
And are we really facing an unstoppable ice epidemic? Professor Alison Ritter of the National Drug and Alcohol Research Centre.
ALISON RITTER: Technically it’s a misnomer. An epidemic would be described as something that is affecting the whole population and that's certainly not the case. In fact, in the general population the use of methamphetamine has not increased—it’s hovering at around 2% of the general population.
And so I think it’s because the presentations are so florid that people think there’s more of it happening—and that’s how the media start this spread of panic and hysteria that this problem has become out of control. But the reality is that they’re the same people that they would have seen a few years ago, but they’re presenting very differently and they’re using more potent forms and they’re using more of it. It’s amongst existing users who have shifted from powder to crystal.
MIC CAVAZZINI: In the past, most methamphetamine users were snorting or swallowing the powder known as speed, cooked down from pseudoephedrine in the clichéd backyard bikie labs. But today more than half of all users are taking it in a purer crystalline form, as large scale imports have increased its supply on the street.
Speed only has a purity of around 10 to 20 percent, while the oily extract called base might be twice as strong and is typically injected by users. But crystal methamphetamine is produced in a more refined chemical process that gets the purity up to 80 percent or more. The shiny white crystals can be smoked in a pipe resulting in an easy hit with very rapid onset. Associate Professor Nadine Ezard Clinical Director of St Vincent Hospital’s Drug and Alcohol Service, Sydney, recounts some of the effects described by users.
NADINE EZARD: The sense that you are more powerful in every sense. That you are more confident, that your self-esteem goes up, and that you are able to interact better in the world—and if it’s in sexual context then also libido goes up and you feel more confident in your sexual interaction. So that people actually get into this period of time where sleep doesn’t cross your mind, food doesn't cross your mind, or any of those things that usually affect us as humans.
Many people are at work and they find they can get more done at work. And then they’re using at night, they’re tired, so they use a little bit in the morning to get them back to work again. So it’s this idea of increased productivity—you can even stay up for several days and then all of a sudden you just crash, you’re done, you need to sleep.
MIC CAVAZZINI: In the reward pathways of the brain, methamphetamine both boosts the release of dopamine and blocks its reuptake. Its effects on the dopamine concentrations in the synapses are four times greater than cocaine and six times greater than a natural high.
A single hit of crystal methamphetamine when smoked or injected can keep a person high for an entire day, and 200 bucks-worth might see them through the weekend. But the energy, euphoria, and disinhibition do come at a cost.
NADINE EZARD: People typically describe feeling really quite anhedonic—even suicidal—a couple of days later. And earlier on in use perhaps, if people aren't using so frequently, people present with anxiety and depression and some of those mood problems. Some people also have a problem with sleeping tablets or with benzodiazepines because they’re using that to counteract the stimulant effects.
But also most people using high dose and staying up for periods of a time eventually will develop some degree of psychosis. So usually it’s paranoia—people barricade themselves in their room, black out with the curtains—hearing your name being called. So that is something that many people will have experienced.
MIC CAVAZZINI: Over the last six years, there’s been a fourfold increase in the rate of hospital presentations associated with methamphetamine in Australia, and ambulance call-outs show an even steeper trend. Not all of these are related to mental health issues, however.
Users also present with high blood pressure and heart rate as well as profuse sweating and psychomotor agitation. These result from the drug’s effects on the sympathetic nervous system and on serotonergic brain pathways. While uncommon, cases of acute overdose can involve heart attack, stroke, seizures, and kidney failure.
So the stereotype of the deranged and violent methamphetamine user presented by the media is largely misleading, according to Professor Amanda Baker of the Calvary Mater Hospital in Newcastle.
AMANDA BAKER: Those presentations where they’re almost like “the Terminator” or something like that aren't all that common. People are edgy on methamphetamine, feeling paranoid and scared, and the hostility comes from that believing that they’re being persecuted and things like that.
There is a good correlation between the higher the dose then the more acute effects. But most people just sort of say, “I know it’s the drug. By tomorrow, you know, I’ll be OK.”
MIC CAVAZZINI: Despite the increase in stimulant related presentations to emergency departments, they still make up less than one percent of all cases in the ED. Alcohol is implicated in 30 times that number, and research shows that it’s just as likely to provoke violent behaviour.
Addiction specialist Doctor Gilbert Whitton of Bankstown Hospital says that coping with agitated patients isn't a new challenge for clinical staff.
GILBERT WHITTON: Not every patient who’s aggressive in an emergency department or aggressive towards an ambulance officer is on amphetamines. People at the frontline are trained to deal with that and are very good at it. So I often say to frontline workers, “Look, you've dealt with these problems before, maybe the cause is slightly different, but you know how to deal with them. If you just use your own basic principles, you’ll be OK.”
NADINE EZARD: Yeah, I mean it’s the same with managing any severe acute behavioural disturbance—trying to engage with people and use open body language, and don’t tower over them, and not touching someone without their consent, things that might actually escalate the situation.
If you block someone into a corner then they’re going to feel much more trapped. One of the problems that many of the ambulance officers describe is that because they’re in blue in uniform that they’re sometimes perceived as police and that then actually makes people more anxious rather than less anxious.
AMANDA BAKER: There is a huge stigma in that people have “brought this problem on themselves” so you've got to communicate that the person’s welcome to be there. Being non-judgemental, empathic with people who aren't very likeable sometimes—they’re scared, they’re looking for support.
And the evidence is in psychosis, not particularly with methamphetamine, but if you just listen to people that has a really good effect on the distress that’s associated with the symptoms.
NADINE EZARD: And acknowledging where they’re at too and not trying to deny their experiences. So if people are saying that “this is happening to me,” you listen and interact with what is happening to people—not saying “No, that’s not true there’s no one there.”
So working with people where they’re at so that you can try and connect at some level to encourage people to take the medication or whatever it is that you’re wanting to do.
MIC CAVAZZINI: While negotiating with patients, it’s best to have only one staff member do the talking and to avoid using “no” language or making promises that can’t be kept. But calming a paranoid patient can be difficult when surrounded by the hyper-stimulating lights and sounds of the emergency department. And of course even the best interpersonal approach might not be enough to pacify highly agitated patients.
GILBERT WHITTON: I try to explain to the patient that they will feel better if they take some oral diazepam or oral olanzapine and hopefully get them to realise that that it’s in their interest. But of course if the patient is irrational sometimes, you know, they won’t take oral medication, they won’t settle down, and so you are looking at trying to give them some intramuscular or intravenous sedative medication.
NADINE EZARD: One of the hospitals in Canberra got some funding to do a study and for that group of people who came in already very agitated, too late really to try and deescalate the situation, they found that provision of IM sedation by nursing staff meant that people actually got sedated sooner and ended up with less dose of sedation and less complications related to the sedation. So the point is to not delay too long either if you are going to get to the point where you need to sedate someone.
MIC CAVAZZINI: When intramuscular sedation is needed, either clonazepam or midazolam can be used. And to counter psychotic symptoms, droperidol has been shown to be a safe alternative to olanzapine. Once a patient has emerged from the effects of acute intoxication, the idea of dependence can be introduced before they slip through the system of care.
GILBERT WHITTON: The ideal is that the drug and alcohol service sees the patient as soon as they’re starting to improve. Just giving them a referral to go off to a service that they've never had any contact before is less likely to see the patient following through on that counselling and rehabilitation.
NADINE EZARD: Withdrawal—which is sleep disturbances, mood disturbances, difficulty concentrating, compulsion to use—that kicks in later and that can go for quite some time. And if people have been using methamphetamine for a long time, deficits can persist really for months, years even. And that often triggers a relapse too because people say, “I just can’t concentrate.”
MIC CAVAZZINI: The number of Australians using methamphetamine at least once a month has tripled since 2010 to almost 270,000, according to modelling by the National Drug and Alcohol Research Centre. This equates to a population rate of around two percent, which is two or three times higher than the rate picked up in household drug surveys on both sides of the Tasman.
While a significant proportion of methamphetamine use may go unreported in such surveys, they do reveal that the availability of purer forms of methamphetamine is associated with increased frequency of use. But Amanda Baker is keen to dispel the fatalistic myth that it’s the most addictive drug ever. She says it’s more important to understand the personal motivations each individual has for using.
AMANDA BAKER: So methamphetamine isn't the most, you know, dependence liability producing drug—it’s probably nicotine. What makes drugs addictive is that basically they’re nice to use, and that’s partly neuro. But what brings them back to it isn't having to restore those neurochemical deficits or whatever—it’s what it does for that person socially, emotionally.
The words of clients vary. It’ll be something mundane as, “I use it to get my housework done”—seriously—to people saying that they only feel socially confident when they use it, to people just, you know, wanting to go out and have a great time.
MIC CAVAZZINI: Just as with all classic drug and alcohol rehab, counselling is the backbone to treatment of methamphetamine addiction and research has shown remarkable results from very brief interventions.
AMANDA BAKER: We did a randomised controlled trial a few years ago and found that even two sessions of motivational interviewing and cognitive behaviour therapy doubled abstinence from methamphetamine. And if people were attending as many as four sessions they had additional benefits for depression as well. Which is good, in that we knew when we did that first study that amphetamine users probably won’t attend a lot of sessions.
But over a year’s timeframe a lot of people, as in any other drug, there’s a bit of a dabbling here and there over time. So if you follow people up, even every 3 months or so, that will be really effective.
MIC CAVAZZINI: Because it might be difficult to engage users in long and committing treatment regimes, Professor Baker describes a model of “stepped care”—presenting therapy of increasing intensity to patients only as required. While intensive residential rehab might be needed for the most addicted patient, she's keen to test phone counselling on users who might not have a clinic nearby, or the discipline to attend appointments. But whatever the mode of delivery, the first counselling tool she relies on is motivational interviewing.
AMANDA BAKER: If someone’s presenting for the first or second time, and a clinician says to them, “What is it that you like about methamphetamine?”—often no one has asked them that. So it’s a lot of listening to tease out what’s bringing them here, and so to be able to talk about, you know, what it is what it does for them, is really an important thing. And then on the other side, what's not so good.
And then you can tie those less good things into what they value the most—and that might be their relationship, or their job, or seeing their kids grow up, or whatever. And then they’ll say, “Oh, I guess I haven't been seeing this much recently, because I've been spending too much time scoring” or drinking or whatever.
NADINE EZARD: Most of the evidence is around cognitive behavioural therapies but we don’t have really good data on dose and intensity and duration—so that’s kind of a research gap. What we do know though is that people who are using less when they come into treatment do better with the talking therapies than people that are using more frequently and higher dose. So that’s one of the reasons we want people to come earlier, because what we’ve got available to us works better before they really run into major problems with it.
AMANDA BAKER: The thing with methamphetamine users is that they’re almost invariably poly-drug users. There’s no such thing, really, as a methamphetamine user. And some people are experiencing persistent psychotic symptoms these days, but not actually being diagnosed with schizophrenia.
GILBERT WHITTON: A range of different pharmacological treatments are being tried to look at the reward pathway and trying to reduce craving. So in the same way that methadone is a long-acting oral opiate used to treat a short acting injectable opiate such as heroin, if you think of methamphetamine as a short-acting injectable or smokeable amphetamine, are there long-acting oral amphetamines which we can use as replacement or substitution?
NADINE EZARD: We do use here—on a pilot basis—dexamphetamine, then those people in addition to counselling can get high dose dexamphetamine. And by high dose I mean higher than the dose that’s used for ADHD.
And when we look at treatment data the outcomes look really good, but of course that’s just the people that have remained in treatment. So that’s why we’re moving to a study a randomised controlled trial of a pro-drug called lisdexamphetamine. It’s metabolised to dexamphetamine in the red cells, so it has a slower onset and a longer duration of action than the immediate release dexamphetamine, which is what we’re using at the moment. That lasts pretty much the whole day.
MIC CAVAZZINI: Despite the current lack of a licensed replacement drug, even the most complex patients can recover with talking therapy alone.
AMANDA BAKER: You know, you hear people say, “There are no treatments for methamphetamine”—and that’s really sad because counselling works so well. Often with methamphetamine, it will be the mental health symptoms that bring them into treatment and so if you’re a drug and alcohol worker that is not confident in working with mental health symptoms, you might not gel as well with that person.
Years ago the Commonwealth did fund national dissemination of the treatment manual but what’s happened is staff turnover and people haven't stayed up with it. So I think we need to do much more with our sort of staff training. That treatment manual was published in 2003, it’s over 10 years later, that exists and it works, it’s just a matter of getting the message out there, I think.
ALISON RITTER: What’s important is having the full array of treatments available to people and where they are on their drug-using journey. So it’s a chronic relapsing condition like asthma or diabetes—that doesn’t mean that they shouldn’t be referred for a withdrawal because they've come out of one a few months before. Treatment outcomes accumulate over time irrespective of the outcome of one particular episode of care. The most common thing that people say is that they’re just sick and tired of being sick and tired.
MIC CAVAZZINI: Treatment for methamphetamine dependence does work, but there is on average a 10-year delay before people actually seek treatments once they start experiencing problems. Apart from the poor coverage in Australia of drug rehab clinics, the barriers to engagement are largely cultural. Both users and primary service providers aren't always comfortable discussing methamphetamine problems. According to Alison Ritter, the media panic only makes this worse.
ALISON RITTER: That’s what sells copy and in terms of stigma and marginalisation that’s potentially disastrous. It really reduces the likelihood that someone will tell a friend or a family member and therefore decreases the likelihood that they’ll seek appropriate treatment. I mean, in an ideal world people seeing their GP would be comfortable talking about all of the things associated with their health including drug use. But in my clinical experience, most patients actually want their GP to just treat them like a regular patient in a sense, but the disincentives are enormous on both the GP and the patient side of things. GPs have a huge responsibility as the gatekeepers into the rest of the healthcare system, so they don’t have the time to uncover a dependence that they then feel they don’t have the relevant skills or referral strategies to manage.
NADINE EZARD: There’s a whole range of reasons that people don’t present for treatment, and one reason is not recognising problem use—even for people that were scoring positive on the screen for dependence. Anecdotally, some of our clients say to us, “I didn't think I was bad enough—I didn't think recognise myself in the media representation of the crazy, scabby person in the street, therefore I didn't think I warranted or deserve treatment.” Even people that had had contact with emergency departments, the methamphetamine use is not being discussed or addressed adequately at those contact points.
MIC CAVAZZINI: Many of those presenting to the St Vincent’s Drug and Alcohol Service are injecting methamphetamine users who tend to have some understanding of the risks of needle use. But the equally-sized cohort of meth smokers is largely missing, as are users from lower socioeconomic groups. That’s because the talking therapies available for dependence are attractive mostly to people that are more verbal and likely better educated. Nadine Ezard’s team has setup a website called S Check as an easy source of information on the health risks to look out for with regular stimulant use.
NADINE EZARD: Not everyone is looking to stop using or decrease their use, so when we talk to people that were using methamphetamines people were saying, “We want just a check-up of our health.” So for example if you've got a very high cardiovascular risk profile, you’re already overweight, hypertensive, and then you’re using high-dose methamphetamine quite frequently on top, your risk will be greater.
So the idea was to help people identify those red flags or warning signs, to then maybe make more informed decisions, if you like. So we need to be detecting some of those risks in a very logical way, like for any other aspect of medicine, and not clouded by this kind of fear around this idea of drugs.
ALISON RITTER: Drug use occurs across all classes of society, across all occupations, across all demographic characteristics. The difference is those people that experience problems with it. So the people that end up increasing their use are almost without exception people who have less education, who have poorer employment prospects, and are in other ways marginalised—with mental health problems, physical ill health, and so on.
MIC CAVAZZINI: Statistics from New Zealand show no differences in the rate of methamphetamine use between the most affluent areas and the most socioeconomically deprived. In the long history of drug and alcohol use in society crystal methamphetamine is just one more page.
ALISON RITTER: There’s nothing unique about this particular drug whatsoever, it’s like all of that others. Even the drug-induced psychosis—I mean, that occurs with cannabis. And the other thing to remember is that alcohol is the primary drug that’s causing substantially more harm than any of the currently illegal drugs and there’s no media hysteria about alcohol. There are in fact, you know, much of the media at the moment is concerned with the alcohol-related restrictions, which is kind of ironic.
NADINE EZARD: We know that methamphetamine has been around since the end of the nineteenth century, that it’s had medical applications, it’s had military applications. It’s still available in the U.S. as a diet pill—5 milligrams before each meal. The advertising of it around the 50s had images of women feeding their family, shopping in the supermarket—not eating themselves, but looking very happy.
Its current incarnation is demonised in the way that heroin was demonised in the 90s, so that kind of panic instilled to parents—parents terrified that their children might come home from school one day suddenly addicted to ice.
MIC CAVAZZINI: It’s important to understand the relative social context and burden of drugs when targeting public health initiatives. In response to the National Ice Task Force, the Australian Government last year committed 240 million dollars to be distributed to primary healthcare networks on specific drug and alcohol programs as needed. This represents an important step in the right direction.
You've been listening to Pomegranate. Many thanks to Alison Ritter, Gilbert Whitton, Nadine Ezard, and Amanda Baker for their contributions to the show. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians. For more resources relating to management of patients with addiction to methamphetamine and other drugs, visit the Pomegranate website at racp.edu.au/pomcast. Please follow the links to email us some feedback or suggested topics, and join in the conversation on Twitter using the hashtag #RACPpod.
I'm Mic Cavazzini and I hope you can join me again next month, when we discuss the gender gap between different specialties and in positions of clinical leadership.