Amphetamine-type stimulants (ATSs), particularly in purer forms such as methamphetamine, can be associated with acute mental and physical health-related adverse effects, and result in long-term harm. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has serious concerns about the impact this group of illicit drugs is having on those who use it, their family, community, whānau1, health services, employers, educational institutions and beyond. While there is growing awareness of the issues associated with methamphetamines amongst communities, policy-makers, the media and health services; there is a significant amount of work still to be done in order to translate this into evidence-based, clinically-informed and effective responses. This position statement explores the issues associated with methamphetamine use from a mental health perspective, and provides recommendations as to how these issues could be addressed.
ATSs stimulate the central nervous system and speed up messages travelling between the brain and the rest of the body. ATSs come in a variety of forms, including dexamphetamine and methylphenidate (found in some prescription medications), amphetamine (also known as speed), methcathinone, methylenedioxymethamphetamine (MDMA) and methamphetamine. Methamphetamine commonly comes in the form of tablets, crystal, base or powder. Due to slight structural differences, methamphetamine produces a stronger nervous system response than amphetamine, and can lead to acute short and long term effects (ACC, 2014).
In recent years the way ATS substances have been used in Australia and New Zealand has undergone a qualitative and quantitative change. This is largely due to increases in the proportion of people using purer forms of the substance, particularly methamphetamine in its powder or paste form in New Zealand (known as ‘pure’, ‘base’ or ‘P’) (DPMC, 2010), and crystalline methamphetamine in Australia (commonly known as ‘ice’) (ACC, 2014). These purer forms of ATS substances (henceforth referred to collectively as methamphetamines) are associated with more acute side effects, behavioural issues and violence, and higher rates of dependency.
In 2013 around 7% of the Australian population had used a substance from the ATS group in their lifetime, and 2.1% in the last 12 months. These figures have remained relatively stable since the 1990s (AIHW, 2014). What has changed in recent times is the sharp increase in the portion of this group who are now using crystal methamphetamine, rather than other, less pure variations, such as amphetamine in powdered form. In 2013 50% of the Australian population who had used an ATS substance in their lifetime had used crystal methamphetamine, more than doubling since 2010 when 22% of those who had used ATSs had used crystal methamphetamine. Over this same period the portion of people using less pure, powdered forms such as amphetamine fell, from 50% in 2010 to 29% in 2013 (AIHW, 2014).
Along with the rise in the portion of people using purer forms of ATS, the frequency of use has also increased. Whereas in 2010 the percentage of Australians who reported using ATS described their use as frequent (daily or weekly) was 9.3%, in 2013 it had risen to 15.5%. Amongst those who use crystal methamphetamine, the percentage of daily or weekly use was 25% (AIHW, 2014).
Similarly, in New Zealand, it is estimated that just over 2% of the population had used methamphetamines in 2010 (DPMC, 2010). Whilst this is a small portion of the population, the impacts of this type of substance use are known to be widespread, including on family, whānau, the wider community, schools, health services and beyond (Te Puni Kōkiri, 2011). Māori were also found to be much more likely to have used methamphetamines in the last year, indicating that the impacts on these communities would be even more pronounced (MoH, 2010).
These trends are of concern to the RANZCP due to the link between the purity and frequency of ATS use and adverse physical and mental health-related side effects. Research shows that people with methamphetamine dependence are five times more likely to develop psychotic symptoms during periods of drug use in comparison to periods of abstinence. These substance-induced psychotic reactions can look similar to acute paranoid schizophrenia, including persecutory delusions and hallucinations (McKetin et al, 2013). Methamphetamine use is also linked to increased risk of violence, with studies suggesting that there is a dose-related relationship between methamphetamine use and hostility and violence (McKetin et al, 2014).
The disordered behaviour associated with methamphetamine use has seen emergency departments, acute psychiatric inpatient units and other frontline services having to grapple with significant and unique challenges. Commonly, consumers present in the first instance for treatment of mental health issues, rather than methamphetamine dependency. This can lead to mental health services being placed under significant strain as they are required to manage increasing numbers of consumers presenting with complex and often acute psychiatric presentations, as well as challenging behaviours, related to methamphetamine use. Neither mental health nor Alcohol and Other Drug (AOD) Health services are resourced to respond to the current numbers of consumers with complex behaviours, including aggression, polydrug use and acute toxicity (Lee et al, 2007).
The way the increase in methamphetamine use has impacted upon frontline services is demonstrated in a report on drug-related ambulance attendances in Victoria. Between 2011/12 – 2012/13 the number of methamphetamine-related ambulance call outs rose 88% in metropolitan Melbourne and 198% in regional Victoria (Lloyd et al, 2014). Methamphetamines are also implicated in ambulance attendances for drug-induced psychosis more than all other illicit drugs combined, accounting for 6.1% of all ambulance attendances for psychosis, and 93% for ATS-related psychosis in Victoria (Arunogiri et al, 2015).
The acuity of the side effects and behavioural issues associated with methamphetamine use are also of key concern to family, community and whānau. When a person using methamphetamine is intoxicated or in withdrawal, their care needs and the unpredictability of their behaviour can become such that their support networks are unable to continue engaging with them. This can create a vicious cycle whereby the user experiences increased isolation, loss of safety nets and associated hardships, which can in turn precipitate increased drug misuse (Te Puni Kōkiri, 2011).
In Australia, the availability of methamphetamines in Aboriginal and Torres Strait Islander communities is incurring a significant physical, emotional and spiritual toll. For some groups, methamphetamines are exacerbating existing mental and physical health problems and contributing to high incarceration rates. Given that Aboriginal and Torres Strait Islander adults are experiencing high or very high psychological distress at three times the proportion of non-Indigenous adults, and that the incarceration rate of Aboriginal and Torres Strait Islander peoples is 13 times that of non-Indigenous Australians, there is significant concern regarding how increasing methamphetamine use will play out in these communities (Productivity Commission, 2014).
In New Zealand, Māori communities are also vulnerable to the availability of methamphetamine. The most recent New Zealand Drug Survey found that 9.8% of the Māori population had tried ATS substances in their lifetime, compared with 7.9% of Europeans, 3.7% of Pacific people and 1.8% of Asian people (MoH, 2010). Over the past decade a number of innovative programs have been implemented in Māori communities to address this. For example, as part of the New Zealand Government’s Effectiveness Interventions policy packages, the Programme for Action for Māori was developed and implemented across a number of locations. The approach involved strong engagement with whānau and was informed by the principle of kaupapa Māori.2 The project has been evaluated and found to have built capacity in affected areas and facilitated whānau to lead their own journey of recovery (Te Puni Kōkiri, 2011).
The RANZCP calls for a coordinated, long-term approach to addressing the harmful impacts of methamphetamine use, which is evidence-based, clinically informed and recovery-focused. Treatment of any substance dependency involves the management of issues that may underlie use and abuse (such as using drugs to cope with developmental trauma or other major life events), as well as the associated physical, psychological and social effects of regular use, withdrawal and recovery. As such, psychiatrists have a key clinical leadership role in coordinating preventative, early intervention and treatment approaches to methamphetamine use.
The RANZCP has a number of specific recommendations for how to address methamphetamine use and related harms in Australia and New Zealand, as follows:
Developing key sectors of the workforce
- The disconnect between AOD and mental health services is regularly identified as an impediment to effective referral and holistic treatment. There are currently significant shortages in the addiction psychiatry workforce. This must be addressed in order to enhance the capacity of the mental health sector to treat substance dependency, and for the AOD sector to address mental health issues. This is essential given the high frequency of substance dependence and other mental health issue comorbidity.
- Enhanced opportunities for under- and post-graduate medical trainees to work in AOD programs are required, with funding for addiction trainee and consultant positions to support these.
- Methamphetamine use cannot be addressed in isolation of other factors, including comorbid mental health disorders or the problematic use of other substances. Adequately resourced AOD services in general, with effective referral pathways to mental health services, and vice versa, are necessary to effectively and holistically address methamphetamine-related issues.
- One solution that has had success in New Zealand and which the RANZCP recommends for consideration in Australia is a mechanism whereby money seized and confiscated from criminal syndicates by law enforcement is redirected into support and prevention programs. This creates a sustainable mechanism for resourcing essential services (DPMC, 2010).
Acute psychiatric inpatient units and other frontline services
- Acute psychiatric inpatient units and other frontline service must have access to training, resources and clinical supervision to support them to manage methamphetamine-related challenging behaviours effectively and safely and to avoid burnout.
- Acute psychiatric inpatient units, as well as emergency departments, must be resourced at a level commensurate with the level of need in the community so as to be able to respond effectively to the mental health implications of acute methamphetamine use.
Developing evidence-based treatment
- Whilst early research has indicated that people treated for methamphetamine dependency tend to respond well to treatments currently available, more support for research into this area is required. Specifically, more research is needed into the people using methamphetamines who present for treatment, efficacy of the treatment, impact on comorbid mental health issues and long term outcomes for both the substance dependency and any associated comorbidity (Coggers et al., 2008).
Aboriginal and Torres Strait Islander and Māori communities
- Particular care must be taken in Aboriginal and Torres Strait Islander and Māori settings to divert people away from the justice system and into treatment wherever possible. The Programme of Action for Māori in New Zealand is an example of an effective approach to this, which has had significant success. Strengths-based, capacity-building and culturally relevant approaches are key in engaging Aboriginal and Torres Strait Islander and Māori community, family and whānau and effecting real change.
- As an extension of the above point, responses to methamphetamine use in Aboriginal and Torres Strait Islander and Māori communities must engage local people, and in particularly community leaders and elders, who already have insight into the issues and potential solutions.
- In addressing methamphetamine use in Aboriginal and Torres Strait Islander and Māori communities, it is also important to take stock of what has been working well. In many instances, successful programs already exist, though their outcomes may be limited by inadequate or uncertain funding.
- Effective public health campaigns should focus on primary, secondary and tertiary harm minimisation messages and avoid fear tactics, which do not have an evidence base. This is reflected in the New Zealand Government’s New National Drug Policy which focusses on the following three pillars: supply control, demand reduction and problem limitation (MoH, 2013).
- The stigmatisation of drug use disorders can be a significant barrier to people accessing treatment, and contributes to the marginalisation and discrimination of people who use methamphetamines. Addressing methamphetamine use in the community must begin with an understanding of drug use disorders as an illness, and a respect for its treatments.
- Treating substance use disorder can often be a lengthy and complex process. Prevention and early intervention are the most effective and efficient approaches to curbing methamphetamine misuse. The RANZCP supports public education campaigns which provide more information on the potential side effects of methamphetamine use, as well as harm minimisation messages such as safe injecting practices and how to respond to an overdose, aggression and psychosis.
- Targeted public health messages are also effective, for example, education on the dangers of mixing alcohol and methamphetamines. Excessive alcohol consumption is a common pathway to methamphetamine use, and it is often when alcohol use is problematic that individuals may begin experimenting with other substances. Such messages are often considered more applicable to a person’s life than campaigns which focus on more general or extreme outcomes of methamphetamine use.
Family, community, whānau and carers
- The family and support networks of people with methamphetamine use disorder require access to confidential supports, training and resources to assist them to care for their loved one without compromising their own mental health and personal safety.
- Distance-based interventions such as real-time online interventions and telephone support may offer effective solutions for the support networks of methamphetamine users who themselves require guidance.
1 ‘Whānau’ (pronunciation: fa:naᵾ) is a Māori word used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui).
2 Kaupapa Māori relates to a key Māori philosophy incorporating the principles of self-determination, spiritual and cultural awareness, the right to socioeconomic equality, the principle of whanau, collective philosophy, the Treaty of Waitangi and nurturing respectful relationships.