National Amphetamine-Type Stimulant Strategy Background Paper

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104 that limit brain exposure to methamphetamine; modify the effects of methamphetamine at vesicular monoamine transporter-2 (VMAT-2); or act on dopaminergic, serotonergic, GABAergic, and/or glutamatergic neurological pathways that play a role in the reinforcing effects of methamphetamine. Vocci and Appel (2007) conclude that there is evidence to support the rationale that pharmacotherapies to decrease methamphetamine use or reduce cravings following cessation of use may be developed by: ...altering the pharmacokinetics and pharmacodynamics of methamphetamine or its effects on appetitive systems in the brain (p.96). Following is a brief summary of some of this research with a focus on the main areas of investigation. Managing withdrawal As already noted, there is limited evidence about pharmacotherapies to manage withdrawal. Given the presentation of acute toxicity (outlined above), symptoms related to mood and sleep require management. Antidepressants have been used to alleviate mood-related symptoms of withdrawal with mixed results. There is some suggestion that fluoxetine could decrease cravings in the short-term, and imipramine may increase duration of adherence to treatment in the medium-term, however, the evidence is limited (Shearer & Gowing, 2004). It has also been suggested that diazepam be used to treat anxiety and temazepam for insomnia (Dyer & Cruickshank, 2005). Finally, mirtazepine (medication that helps promote sleep and alleviate depression) has also been implicated in withdrawal management. Preliminary results from a joint investigation in Western Australia and NSW found no evidence that mirtazepine improved treatment retention, alleviated withdrawal symptoms, improved sleep or reduced methamphetamine use (Cruickshank et al., unpublished). Modafinil, an agent used to treat narcolepsy, has also been suggested as having some utility in withdrawal management. The medication enhances wakefulness, vigilance and alertness, and may therefore alleviate withdrawal symptoms such as hypersomnia, poor concentration and low mood (Shearer & Gowing, 2004). A number of studies are underway, in Australia and overseas, to investigate the potential of this drug and others in managing ATS withdrawal. For example, DASSA is currently investigating the safety and efficacy of mirtazepine, modafinil and bupropion (antidepressant shown to be effective as a nicotine cessation aid) in the treatment of withdrawal symptoms following cessation of amphetamine use among dependent users. There are a number of other studies currently underway: the WA DAO and NSW Langton Centre are currently testing the efficacy of mirtazapine in the treatment of amphetamine withdrawal and narrative therapy as an adjunctive treatment; Turning Point in collaboration with DASWest, Hunter Area Health Service and University of Queensland are currently conducting a pilot randomised placebo controlled trial of Modafinil as an aid for methamphetamine withdrawal and entry into further treatment. Assessed outcomes include drug use, mental health, cognitive functioning and withdrawal symptomatology.
105 Substitution therapy Substitution therapy for ATS has most commonly involved prescribing central nervous system stimulants, in particular, dexamphetamine, especially to patients for whom other interventions have not been effective. Substitution therapies aim to replace harmful drug use with safer modes of drug use in terms of dose, route of administration and adverse effects. Effective substitutes may allow patients to stabilise on doses that prevent withdrawal and craving and to reduce the harms associated with illicit drug use. (Shearer & Gowing, 2004, p.125). The potential benefits of substitution therapy for amphetamine users were outlined by Fleming (1998) and include: • Attracting and engaging amphetamine users into treatment, particularly those who would not otherwise seek out help; • Engaging users in treatment provides a valuable opportunity to provide harm reduction information, health care interventions, and referral; • Substitution acknowledges that there are problems associated with amphetamine use and thus, conveys messages about the potential harms of amphetamine use; • By reducing amphetamine use through substitution, related harms are also reduced; and • Potential short-term risks of prescribing substitutes may outweigh the potential long-term harms of continued illicit amphetamine use. It has been suggested that substitution may be indicated for individuals who are dependent and for whom other attempts at abstinence have failed and maintenance is considered to be less risky than continued illicit use (Mattick & Darke 1995). However, it is noted that substitution therapy is not without risks, and may include the risk of relapse to psychotic episodes, risk of cardiovascular problems, risk of diversion of therapeutic doses and continued use of prescribed and illicit amphetamine (Shearer et al., 2002). In the United Kingdom, dexamphetamine has been used to treat ATS dependence since the 1990s. Despite a number of relatively large clinical trials, there is little scientific evidence to support this treatment, but rather, self-report or case note studies (Bradbeer et al., 1998). White (2000) conducted a retrospective study of 220 amphetamine users receiving dexamphetamine prescriptions in the UK and found it had an immediate effect in reducing amphetamine use, but less impact on treatment retention (White, 2000). In this study, oral and intravenous amphetamine users had similar outcomes, although intravenous users made more overall gains in treatment. The first randomised controlled trial of dexamphetamine as a substitute for methamphetamine dependence was conducted in Sydney (Shearer et al., 2001). This study compared 21 long-term dependent users receiving 60mg dexamphetamine daily to a control group of 20 similar users. Both groups received standard drug counselling and both were found to respond positively to intervention. Reductions were found in injecting behaviour, methamphetamine-positive urine samples and severity of dependence. The
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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
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48 Shoptaw and Reback (2007) review
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50 It has also been speculated that
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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 108 and 109: 98 addressed not only the drug user
Page 110 and 111: 100 Research conducted in the subse
Page 112 and 113: 102 users, data that may be general
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
Page 158 and 159: 148 Law enforcement agencies are pl
Page 160 and 161: 150 Appendix 1 National consultatio
Page 162 and 163: 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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