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Methamphetamine TREATMENT GUIDELINES Treatment Guidelines METHAMPHETAMINE METHamphetamine METHamphetamine TREATMENT GUIDELINES treatment guidelines treatment Turning Point 110 Church St Richmond VIC 3121 Australia T: +61 3 8413 8413 E: [email protected] W: www.turningpoint.org.au Meth_Guidelines_cvr_463x300.indd 1 31/10/18 11:06 AM Methamphetamine Treatment Guidelines Practice Guidelines for Health Professionals Second Edition Jasmin Grigg Victoria Manning Shalini Arunogiri Isabelle Volpe Matthew Frei Vicky Phan Adam Rubenis Stephanie Dias Margret Petrie Michelle Sharkey Dan I Lubman Copyright © 2018 State of Victoria. Second Edition printed 2018. ISBN (print): 978-1-74001-028-3 ISBN (ebook): 978-1-74001-029-0 Copyright enquiries can be made to Turning Point, 110 Church St, Richmond, Victoria 3121, Australia Published by Turning Point, funded by the Victorian Department of Health and Human Services. The views of the authors do not necessarily reflect the views and position of the Department of Health and Human Services. The correct citation for this publication is: Grigg J., Manning V., Arunogiri S., Volpe I., Frei M., Phan V., Rubenis A., Dias S., Petrie M., Sharkey M. & Lubman D. I. (2018). Methamphetamine Treatment Guidelines: Practice Guidelines for Health Professionals (Second Edition). Richmond, Victoria: Turning Point. 1 Methamphetamine Treatment Guidelines Turning Point OVERVIEW The Methamphetamine Treatment Guidelines have been developed by Turning Point to assist Victorian health professionals in the clinical management of methamphetamine use disorder and related presentations. These guidelines also aim to improve understanding of methamphetamine use disorder in health services and the community. The first edition of these guidelines was published in 2007, and outlined acute and longer-term interventions for methamphetamine use problems available at the time. Recent changes in methamphetamine use patterns, from lower-purity powder to high- purity/potency crystal methamphetamine, has been accompanied by increases in methamphetamine-related harms and complex presentations. This shift, along with substantive changes to the diagnosis and classification of substance use disorders, has necessitated the revision of these guidelines. The 2018 updated guidelines provide recommendations based on current evidence and best practice for the management of methamphetamine use disorder (chronic use and withdrawal). These guidelines include the management of acute and complex presentations, including behavioural disturbances, polydrug use, injecting methamphetamine use, cognitive impairment and comorbid mental health symptoms, as well as recommendations for reducing harm, working with specific populations, and supporting families and carers. 2 Methamphetamine Treatment Guidelines Turning Point ACKNOWLEDGEMENTS This publication was made possible by the input of many people who willingly gave of their time and expertise. Their contributions, in the form of professional advice, suggestions and critical commentary, are greatly valued. The authors would like to thank Professor Amanda Baker for permitting the inclusion of the Brief Intervention specifically developed and evaluated for clients who use methamphetamine. In the revision of this resource, Turning Point acknowledges the considerable contribution of the authors of the previous version of these guidelines: Nicole Lee, Lisa Johns, Rebecca Jenkinson, Jennifer Johnston, Kieran Connolly, Kate Hall and Richard Cash. Turning Point also acknowledges the Clinical Expert Advisory Group who reviewed these guidelines during their original development: Amanda Baker, Catherine McGregor, Robin Fisher, Frances Kay- Lambkin, Rebecca McKetin, Ingrid van Beek, Simon Ruth, Katherine Walsh and Sue White. 3 Methamphetamine Treatment Guidelines Turning Point CONTENTS OVERVIEW 2 ACKNOWLEDGEMENTS 3 INTRODUCTION 7 What is amphetamine, and methamphetamine? 8 Prevalence and patterns of methamphetamine use in Australia 8 Properties and effects of methamphetamine 9 Impact of methamphetamine on the brain’s reward system 10 Methamphetamine dependence 11 Methamphetamine withdrawal 12 Harms associated with methamphetamine use 15 Methamphetamine and mental health 16 Mood and anxiety symptoms 16 Psychotic symptoms 16 Risk of suicide 17 Methamphetamine and cognitive functioning 17 Current evidence on stroke, cardiopathology and Parkinson’s disease 18 Barriers to accessing treatment 19 PRINCIPLES OF TREATMENT 20 Working effectively with clients who use methamphetamine 20 Stepped care 22 Harm reduction approach 22 TREATMENT MODALITIES AND SETTINGS 23 Care and recovery coordination (case management) 23 Withdrawal treatment settings 24 Post-withdrawal treatment settings 26 PRACTICE GUIDELINES 28 4 Methamphetamine Treatment Guidelines Turning Point PART I: ASSESSMENT 29 Drug use assessment 30 Assessing readiness for change 31 Assessing risk of harm 31 Mental health assessment 32 Suicide and self-harm risk assessment 33 Screening for psychosis 34 Assessing risk of harm to others 34 PART II: MANAGEMENT OF ACUTE PRESENTATIONS 36 Managing acute toxicity 37 Managing acute psychotic symptoms 38 Managing aggressive or agitated behaviour 38 PART III: MANAGEMENT OF METHAMPHETAMINE USE DISORDER 40 WITHDRAWAL MANAGEMENT 40 Withdrawal complications 42 Supportive care 42 Psychosocial approaches during methamphetamine withdrawal 43 Pharmacotherapy for methamphetamine withdrawal 43 Post-withdrawal support 45 MANAGEMENT OF CHRONIC USE (DEPENDENCE) 46 Psychological and psychosocial interventions for chronic use 46 Pharmacotherapy for chronic use 49 REDUCING HARMS 52 Interventions to reduce harms 53 Emerging risks: The Darknet 55 Harm reduction tips for clients 56 PART IV: MANAGEMENT OF COMORBID/COMPLEX PRESENTATIONS 58 Management of mood and anxiety symptoms 59 Management of psychotic symptoms 60 Pharmacotherapy for comorbid presentations 61 When and how to refer to a mental health service 65 5 Methamphetamine Treatment Guidelines Turning Point Management of cognitive impairment 67 Polydrug use 68 Injecting methamphetamine use 71 PART V: CONSIDERATIONS FOR SPECIAL POPULATIONS 74 Aboriginal and Torres Strait Islander people 74 People from culturally and linguistically diverse backgrounds 76 People who are homeless 77 People who identify as LGBTIQ+ 79 Women who are pregnant or breastfeeding 81 People from remote populations 83 Young people 85 Older people 86 Occupational groups 88 PART VI: AFTERCARE AND SUPPORTING LONGER-TERM TREATMENT GOALS 90 The role of peer support 90 The role of peer education 92 The role of support people 92 Family/support people involvement in treatment 92 PART VII: MANAGING THE NEEDS OF FAMILY/SUPPORT PEOPLE 93 Interventions that respond to the needs of family/support people 94 FUTURE DIRECTIONS AND CONCLUSION 98 APPENDICES 100 Appendix A: Brief Psychological Intervention 100 CLINICAL RESOURCES 105 REFERENCES 128 6 Methamphetamine Treatment Guidelines Turning Point INTRODUCTION In 2018, methamphetamine use remains a significant public health concern due to its high propensity for addiction, neurotoxic and neurocognitive effects, and the associated range of complex presentations that include acute mental health symptoms and behavioural disturbances. Methamphetamine use is an important contributor to the global burden of disease, and is associated with severe public health and social consequences including mortality, morbidity and criminality [1]. In Australia, methamphetamine is the second most commonly used illicit drug after cannabis [2]. Methamphetamine use occurs across the spectrum of society, though some groups (e.g. people who identify as LGBTIQ+, some occupational groups) have higher than average rates of use. While use of methamphetamine has remained relatively stable over the last decade and even declined in recent years, there has been a sharp increase in the proportion of those who are using high-potency crystal methamphetamine, or ice. Ice is now the main form of methamphetamine used, with a near three-fold increase from 22% in 2010 to 57% in 2016. In the same period, the purity of crystal methamphetamine has increased from less than 10% to more than 70%, and the proportion of individuals using weekly or more often has more than doubled from 9.3% in 2010, to 20% in 2016 [2]. These trends in use of high-purity/potency methamphetamine use have been accompanied by a visible pattern of more severe physical and psychological harms, which is having a significant impact on health service utilisation nationally, particularly emergency and psychiatric services [3]. At present, clinicians and health services are faced with a range of complex presentations of chronic methamphetamine use (dependence) and withdrawal. These cases are often complicated by polydrug use, mental health symptoms including psychosis, cognitive impairment, and acute behavioural disturbances. 7 Methamphetamine Treatment Guidelines Turning Point WHAT IS AMPHETAMINE, AND METHAMPHETAMINE? Amphetamines are a class of chemical compounds, Methamphetamine is a particularly potent compound mostly synthetic, that exert powerful central nervous in the amphetamine group, and is produced in powder system (CNS) and sympathomimetic effects. (‘speed’), paste-like (‘base’) and crystalline (‘ice’) forms. Amphetamines include substances that can be legally The crystalline form, commonly referred to as “ice” prescribed (e.g. methylphenidate for attention deficit or “crystal meth” (Table 1), can be smoked, hastening hyperactivity disorder) and those manufactured illegally the brain’s absorption of the
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