National Amphetamine-Type Stimulant Strategy Background Paper

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98 addressed not only the drug user but the broader family unit and the provision of posttreatment aftercare and support. It was proposed that a critical component of any effective approach would involve building an Indigenous workforce that could prevent and respond to ATS use amongst Indigenous people. 5.4 Withdrawal management The nature of ATS dependence, and coincidentally the nature of a withdrawal syndrome, has been debated until relatively recently. This has contributed to a situation where: The literature pertaining to psychostimulant withdrawal is inconsistent and of mixed quality. … no studies that describe the natural history of methamphetamine withdrawal among dependent individuals could be located and as a result that particular process is still poorly understood (Jenner & Saunders, 2004, p.103). Although there have been some advances since this conclusion, there is still a dearth of information. What is known is that ATS withdrawal is distinguished from that which occurs with central nervous system depressant drugs such as alcohol or the opioids. The latter drug withdrawal syndromes generally result in symptoms that are the opposite of the drug effects, whereas for ATS, the symptoms might be similar to symptoms of intoxication, including for example agitation and arousal (Jenner & Saunders, 2004). The amphetamine withdrawal syndrome appears to consist of three primary symptom clusters: hyperarousal symptoms, composed of drug craving, agitation, and vivid/unpleasant dreams; reversed vegetative symptoms, consisting of decreased energy, increased appetite and craving for sleep; and anxiety-related symptoms, comprising anxiety, slowing of movement, and loss of interest or pleasure (Srisurapanon et al., 2001). A prospective study of methamphetamine withdrawal syndrome found moderate levels of depression during the first several days of abstinence, with minimal levels thereafter. The most prominent symptoms were anhedonia (inability to experience pleasure from normally pleasurable experiences), irritability and poor concentration (Newton et al., 2004). More recently, McGregor and colleagues (2005) conceptualised the methamphetamine withdrawal syndrome as comprised of two phases: an acute phase lasting 7-10 days and a subacute phase lasting at least a further 2 weeks. The acute phase was characterised by increased sleeping and eating, a cluster of depression-related symptoms and less severe anxiety and craving-related symptoms (McGregor et al., 2005). Symptoms of mood lability, irritability, sleeping difficulties and cognitive deficits may persist for several months (Volkow et al., 2001). From their review of the literature, Grabowski and colleagues (2004) concluded that there was a lack of clear protocols for appropriate withdrawal management of methamphetamine users. This was largely due to differing opinions among medical practitioners as to the most effective regimens and available research not supporting one medication over another. The role of pharmacotherapy in withdrawal management is outlined in a subsequent section. An important clinical challenge has been to differentiate the symptoms of ‘crash’ (or the immediate ‘come down’ effects of ATS) from withdrawal. The former, not inconsistent with the ‘hangover effects’ of drugs, such as alcohol, occurs in the ensuing few days after
99 intoxication – the latter tend to commence towards the end of this period and are more enduring. The experience of withdrawal is generally related to the frequency and duration of ATS use, potency of drugs consumed, mode of use, severity of dependence and coexistence of physical and psychiatric conditions (e.g., see Jenner & Saunders, 2004). Symptoms include, in order of most frequently reported, irritability, aches and pains, depressed mood, and impaired social functioning (Cantwell & McBride, 1998). Symptoms can be protracted over several days to several weeks. Jenner and Saunders (2004) suggested that ATS withdrawal: • Can generally be managed on an outpatient basis (except where unsuitable home conditions or co-existing health concerns exist); • Provision of safe psychosocial support in a non-threatening environment; and • Can involve pharmacological symptom relief. These authors also suggested a range of assessment protocols for assessing the potential risks of withdrawal to inform treatment planning and protocols to monitor and respond to the withdrawal syndrome. However, as with other researchers and clinicians, they note that there is a lack of a good evidence base to guide withdrawal management, and in particular, despite a range of current studies, their counsel that there is limited evidence about indicated pharmacotherapies still stands: Recommendations for psychostimulant detoxification and withdrawal management … tend to be based on clinical opinion and therefore management strategies may vary from setting to setting. The role of pharmacotherapies is currently limited, however benzodiazepines, antipsychotics and antidepressants if necessary are currently considered by clinicians to be the major components of a medicated psychostimulant withdrawal program (Jenner & Saunders, 2004, p.117). These and other researchers (e.g., Vincent et al., 1999) also note that a significant proportion of people dependent on ATS may also be dependent on other drugs (e.g., alcohol, opioids), and therefore, the more established withdrawal management strategies for these drugs could be employed. 5.5 Psychosocial interventions Psychosocial treatment modalities have most commonly been used to treat ATS users, in part because of the absence of a strong evidence base demonstrating the effectiveness of pharmacotherapies. Kamieniecki and colleagues (1998) reported that the following non-pharmacological interventions had been used with psychostimulant users: inpatient programs, therapeutic communities, 12-step programs, peer interventions, behavioural strategies, cognitive-behavioural interventions, multimodal treatment packages, and non-traditional methods such as acupuncture. Those which demonstrated the most efficacy were relapse prevention, cue exposure/response prevention, and multifaceted behavioural treatment. However, it was noted that many of the interventions had not been properly evaluated.
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National Amphetamine-Type Stimulant
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ii Acknowledgments This research wo
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iv Table of contents Acknowledgemen
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vi List of tables Table 1.1: Amphet
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viii
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2 The NDS framework and the Law Enf
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4 Table 1.1: Amphetamine-type stimu
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6 particularly on the Pacific Coast
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8 Figure 1.1: MDMA (ecstasy) tablet
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10 a 10-year period. While some of
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12 Figure 1.4: Forms of methampheta
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14 Figure 1.5: Median purity of met
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16 As noted, the route of administr
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18 Chapter 2: Setting the Context T
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20 Figure 2.2: Prevalence of ecstas
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22 19 years (Dunn et al., 2007). Th
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24 The use of MDMA among police det
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26 this survey is conducted with th
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28 models might be useful. On the o
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30 the questionnaire in February 20
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32 2.5 Summary According to the lat
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34 anxiety, agitation, tremor, teet
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36 may be stronger than the link wi
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38 Srisurapanot and colleagues (200
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40 Psychiatric problems appear to o
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42 In 2005, there was a total of 68
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44 The most recent EDRS survey foun
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46 same reasons they use the drugs
Page 58 and 59: 48 Shoptaw and Reback (2007) review
Page 60 and 61: 50 It has also been speculated that
Page 62 and 63: 52 Parental ATS use In addition to
Page 64 and 65: 54 The Minnesota Department of Heal
Page 66 and 67: 56 Chapter 4: Prevention and Harm R
Page 68 and 69: 58 should cover the full range of d
Page 70 and 71: 60 specific drug (Spoth et al., 200
Page 72 and 73: 62 be applied regularly and systema
Page 74 and 75: 64 Strategies targeting vulnerable
Page 76 and 77: 66 Examples of particular periods t
Page 78 and 79: 68 At-risk workplaces There is incr
Page 80 and 81: 70 The consultation forum with Abor
Page 82 and 83: 72 young people was noted in the su
Page 84 and 85: 74 and/or others); mental health ef
Page 86 and 87: 76 of the fact that frequently peop
Page 88 and 89: 78 Sexual risk behaviour is a furth
Page 90 and 91: 80 • Cleaning up; • Transport o
Page 92 and 93: 82 Assessing the risks of illicitly
Page 94 and 95: 84 4.4 Challenges of applying preve
Page 96 and 97: 86 but a number of studies are now
Page 98 and 99: 88 The pack included a video, train
Page 100 and 101: 90 Chapter 5: Treatment and Service
Page 102 and 103: 92 to the occurrence of amphetamine
Page 104 and 105: 94 In relation to the need for spec
Page 106 and 107: 96 These studies replicate earlier
Page 110 and 111: 100 Research conducted in the subse
Page 112 and 113: 102 users, data that may be general
Page 114 and 115: 104 that limit brain exposure to me
Page 116 and 117: 106 only significant difference was
Page 118 and 119: 108 through the use of antipsychoti
Page 120 and 121: 110 to develop the capacity of the
Page 122 and 123: 112 It was also suggested that link
Page 124 and 125: 114 as new evidence emerges. New ps
Page 126 and 127: 116 border in 2000 (McKetin et al.,
Page 128 and 129: 118 Table 6.1: Number of clandestin
Page 130 and 131: 120 Table 6.2: Examples of domestic
Page 132 and 133: 122 Tasmania In 2004, strengthened
Page 134 and 135: 124 Recommendations from the consul
Page 136 and 137: 126 Although there are a number of
Page 138 and 139: 128 illegal drugs. When incarcerate
Page 140 and 141: 130 heroin) (Payne et al., 2007). I
Page 142 and 143: 132 Some examples of diversion prog
Page 144 and 145: 134 Other research has compared psy
Page 146 and 147: 136 Rehabilitation in Corrections T
Page 148 and 149: 138 Synthetic Drugs measure will im
Page 150 and 151: 140 • Stealing from motor vehicle
Page 152 and 153: 142 criminal offences There continu
Page 154 and 155: 144 • Increase international coll
Page 156 and 157: 146 • Ensuring offence and penalt
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148 Law enforcement agencies are pl
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150 Appendix 1 National consultatio
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152 Appendix 2 Written submissions
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154 Australian Institute of Health
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156 Bowers, J. & Johnson, S. (2003)
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158 Crits-Christoph, P., Siqueland,
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160 Drug & Alcohol Services South A
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162 Halkitis, P.N., Parsons, J.T.,
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164 Hull, P., Rawstorne, P., Zablot
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166 Leek, L., Seneque, D., & Ward,
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168 McKetin, R., McLaren, J., Kelly
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170 NSW Health (2006). Psychostimul
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172 Ressler, K.J., & Nemeroff, C.B.
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174 Small, W., Kerr, T., Charette,
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176 United Nations Office for Drug
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178
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