Meth misconceptions

PENNY:

Good everyone and welcome to tonight’s webinar, Meth Misconceptions This is the first of a two part series. My name is Penny and I am your host for this evening. Tonight I am joined by your facilitator, Dr Tim Senior and presenter Dr Hester Wilson. Before we begin I would like to make an acknowledgement to country. We recognise the traditional custodians of the land and sea on which we live and work. Introducing our facilitator extraordinaire for this evening - Dr Tim Senior.Tim was originally trained in the UK, and is a Fellow of the RACGP. Tim is a GP working at Tharawal Aboriginal Corporation in southwest Sydney, and is also a Senior Lecturer at UWS and acts as the medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health here at the RACGP.And a big welcome to Tim.

TIM SENIOR:

Thank you very much indeed, it’s good be with you all.

PENNY:

And I’d also like to welcome our presenter for this evening, Dr Hester Wilson.  Hester is a GP in Newtown in Sydney and a staff specialist in addiction at the Langton Centre, South East Sydney local health district. Hester is also a Fellow of the RACGP and a Fellow of the Chapter of Addiction Medicine at the RACGP. Hester holds a Masters in Mental Health and is the Chair of the NSW and ACT branches GP special interest group in addiction. And Hester, a big welcome to you.

HESTER WILSON:

Thank you.

PENNY:

Now I am now going to hand over to Tim who will talk you through the learning outcome.

TIM SENIOR:

Okay, so the next slide will show the learning outcomes which is what we hope you will get out of attending tonight. So we hope for after the event that you will be able to identify what methamphetamines are, and how they are used. Then that you can recognise and understand the side-effects and harms of methamphetamines and how patients might present in general practice.  We hope that you will be initiate brief interventions and give support and evidenced based information to your patients and their families. We will refer to the DSM-V, the latest edition of the diagnostic and statistical manual to diagnose dependence and we hope to recognise how the 5As can be used to enable patients to change their behaviour.

So without further ado, I will hand over to Hester to take us through some of the information. I guess the first question really is – what exactly is ice?

HESTER WILSON:

Good evening, everybody. First of all I have to say there’s a few names out there that I recognise so hi to those people that I already know and welcome to the rest of you. It’s great to see so many people interested and wanting to learn about this important subject.

So ice. You can see it there in the picture. It’s crystalline. So that’s why it gets called ice. And it is a very pure form of amphetamine – the methylated form of amphetamine. It’s got an 80% purity. Base is another type of amphetamine which is a much gluggier one and over the page we’ve got some pretty pictures to show you what they look like, but that’s a much less potent form and the powder form is less potent. It has different names, people call it ‘Meth’, ‘Shabu’, ‘Glass’, ‘Tina’ and the really interesting thing about methamphetamine and one of the reasons that it is so potent and it is so moreish is that it’s really lipophilic. So people usually, in our community anyway, either smoke or inject it. Now it can be swallowed and it can be used anally, rectally and vaginally but in our communities it’s either smoked or injected, those are the two most common ways of using it. And they are very effective ways of getting a good amount of the drug in and because it’s highly lipophilic it gets across the blood-brain barrier very quickly. It has a very quick onset.

Most of it is excreted within a day but depending on how much you’re using it can be found in your urine for a week or longer.Now with the group of people that are using it, it’s a very wide range of use. But anywhere from 50mg to 4gm a day – 4gm a day would be a good going habit and you’d probably be – at 4gm – be spending somewhere between $400 and $600 a day on that drug. And people – it’s interesting because it’s excreted over 24 hours but it has this quick onset and then it drops away. So you use it, you get the rush, you feel fantastic and then it starts to drop away and so that encourages you to use again.

So people sometimes are using 3-4 times a day and they tend to use in binge patterns. Of course there are some people who just use it once, just have one smoke but quite often people will be using it repeatedly in a session over the day and sometimes up to days at a time. Unlike heroin, it tends not to be something that people use every day because you just get too exhausted and worn out. However I do have one patient who has a smoke of methamphetamine every morning before she goes to work. So it is used in different ways by different people.

TIM SENIOR:

And just one of the questions has come through about injecting, people use this IV do anyone inject subcut or intramuscular?

HESTER WILSON:

Not really. Usually that’s just because you’ve missed. The issue is that you want to get it straight into your blood supply so you can get the effect quickly. So just looking at these pictures, the tattoo on the left hand side of the screen, that is the chemical formula for methamphetamine. Not a tattoo that I’d want to have put my body but there you go. And you can see that the different ways, the different forms that it comes in, the really crystalline, the really pure form there of the white crystals. This blue one probably has a little bit of dye to make it look a bit cute. The powder form and the base which is that kind of waxy, ear-waxy looking stuff down the bottom.

TIM SENIOR:

Excellent, thank you.So resisting everyone to tell us about their tattoos and wondering why ice is so popular?

HESTER WILSON:

So why is ice popular?  It’s easy to make.It’s not like heroin or cocaine that has to be grown.Yeah? Or it has be imported. It can be made out of commonly available substances in Australia. So you can make it quite easily and anybody that’s watched “Breaking Bad” it’s not actually a bad portrayal of making methamphetamines or amphetamines. And you make a lot of money out of it. So it’s easy to set it up and you can set it up close to where people are going to be using it. The other thing also is that the idea here, and I should point out, my fifth point there that says - awareness ATS – that means amphetamine-type substances. And so, one of the things about this is that people may not be aware that are common chemicals that are used to make this medication. And so there’s minimal risk to operators and groups that are actually making and selling this stuff. And it’s not hard to make. It really isn’t hard to make.

So – on to the effects and harms. So why do people use it? Because it makes them feel fantastic. They feel happy. They feel strong. They feel like they can take on the world. It keeps them awake. It’s so – students use it. Truck drivers use it. Housewives use it to get round and do the cleaning. People use it to enhance the sense that they have when they’re at a party. As well, it’s the central stimulation that – that stimulation of the brain – can actually go bad. So people can become quite agitated and irritable and panicky, paranoid, have hallucinations, become quite delusional. Teeth grinding is a really common thing. And people can be really aggressive as well.

One other thing is with ice – the methamphetamine in it’s pure form, is that you don’t have to take much to get the effect. If you’re taking high doses you can get really sudden onset of toxicity which has profound effects on your brain. Most of those and the ones that we see in the ED setting, in the hospital setting, the brain effects are generally are psych effects, like delusions, paranoia, incredible aggression but also cardiovascular issues as well. Cardiovascular changes. The other things you can have from it are gastric bleeding, hepatic damage and renal failure.

The other thing of course not to forget is that it also has serotonergic effects, so people can present with serotonin syndrome, overheated and with convulsions. And as I said before, people generally don’t use it ongoing, they will have binges and then stop. Because you use up your neurotransmitters, this stuff makes you use up your happy transmitters in your brain. And you stay awake. And you get to a point where your body actually cannot, cannot continue going. And so you have to stop and then you have to drop. So for people who use this on the weekend it’s the Monday/Tuesday blues. Where you suddenly feel really miserable, really down, really fatigued. And people will have a cycle where they have a binge of use and then they have a few days of recovering, of sleeping, eating a bit better and then they’re back to it again.

One of the things, and we will talk about this a little more in the later slides, but is the idea that may well be the case that repeated or chronic use may actually lead to ongoing cognitive deficits and ongoing psychotic illness. But we’ll come back to that. Looking at this second page here, peripherally really you think about it as the opposite of opioids which are kind of your parasympathetic, slow down, go to sleep, this is your wake up, this is pupils dilate, heart beats fast, blood pressure goes up. And as I’ve got here, in terms of the cardiovascular effects, you can have arrhythmias, myocardial infarctions and rhabdomyolysis. The other thing coming out of the psychological effects can be people being injured, more likely to assault other people, more likely to have unsafe sex in unsafe situations and the risk of blood-borne viruses if you’re injecting.

TIM SENIOR:

And someone has just posted a question wondering if people use it to increase their performance in exams or in sport? Sounds like that might quite unpredictable?

HESTER WILSON:

Yes and certainly we know there are students that particularly use it so they can do an all nightery, to get in and get their studies done, get an assignment done.It’s not an uncommon thing in their study vacation for students to be using and sharing their mates Ritalin, is a really common one. But once again, it is that issue of really – for an individual person – how much can you take that’s going to improve your performance and is going to be of benefit, compared to are you going to get to a point where you are actually having side effects from it. And that is a variable thing between people. The other thing is just like any other substance, it has side effects. So you may be taking what for you was an okay amount in the past but you might start getting side effects. And we will come back to side effects. But for me, when I’m thinking about side effects, one of the really important ones not to forget is dependency, tolerance, withdrawal and addiction.

So moving on to this slide, one of the things that’s really interesting about people in our community who are using ice is that they don’t come to us as GPs very often and say “I have a problem, I’m using ice.”They’re much more likely to come to us with one of the side effects, one of the complications or one of the outcomes of their use. From psychological problems to physical health, to dependents as I mentioned before, relationship issues, financial issues, issues to do with their roles in life, looking after their kids, going to work, all those kinds of things. However there are a group of them that identified dependent use was a problem that they needed help for. And the important thing in this study, which is quite an old one, but actually people who used ice reported that they wanted to be seen by their general practitioner. They expected their GP to ask them questions. They might not actually realise that what’s going on for them, I feel anxious, I feel depressed, I’m just doing so well might be related to their ice use. But they are happy for us to ask and they expect us to ask. And they want us to be involved in their care. So it is a bit of trickiness for us as GPs because as for many of these things, it’s not always the presenting complaint and we do need to ask about it.

TIM SENIOR:

So who are the people who are using methamphetamines?

HESTER WILSON:

Yeah, so this is really interesting, I don’t know if the next slide we actually have some of the information for people but the group of people that are using it are people generally more often in the ages of 20-30 maybe 35-40. Young men. Aboriginal and Torres Strait Islanders. LGBTQI+ individuals are a part of that community. They’re also more likely to be employed. So they are a little different to the group of drug users that I might be seeing in my drug and alcohol service who are opioid dependent who tend to spend time in jail, not be working and this is a gross generalisation, it’s not the case for everyone. But they don’t see themselves as people who are drug users. They may not use as often so they don’t see themselves as having a problem, they wouldn’t see themselves as the sort of person that would go to a drug and alcohol service and they prefer to treat themselves.A lot of them don’t see that they need help but when you actually look at them and this is Quinn from 4 years ago, 50% of them when you looked at what was going on, when you compared it to the DSM, that 50% of them were actually dependent. So that there was significant issues there in this group of people that they didn’t actually recognise. They were using often more than weekly. There were injecting and they’d experienced financial issues. So there really was quite a lot of impact that was having on these subjects lives but they didn’t actually see it quite often as an issue for them. So they are a slightly different group and they are a group who we are seeing in our general practice and who want to be been in general practice rather than going to the traditional drug and alcohol services.

TIM SENIOR:

We’ve just a few questions coming through just before we move on, asking about the different between ice and other amphetamine type substances, such as MDMA and ecstasy.

HESTER WILSON:

So MDMA is a different molecule, it’s a different drug. It’s structure is different, it has slightly different effects but it’s still a stimulant. One of the issues for us in Australia that people think they’re getting MDMA but quite often they’re sold amphetamines. So MDMA tends not to make people as aggressive, it’s known as the love drug or the cuddle drug, it tends to be a more touchy-feeling drug. It has issues as well. But the problem that we have is that quite often people don’t know what they’re getting. And we’ve seen that in some recent deaths – tragic deaths – in young people in our communities, who actually didn’t know what it was that they were taking. And I’ll be controversial here for a moment but I think we really do need to think about ??cool?? testing and how we do that to protect people who choose to use these drugs. I think it’s very easy for us to say don’t use but the fact is that people do.So what can we do to actually make sure that people are safe.

There was another part to the question, did I miss a bit?

TIM SENIOR:

No – someone else has commented on the difference between ice and the version that we sometimes prescribe – occasionally Duromine – for weight loss which is another in that group.

HESTER WILSON:

Yeah, so that’s an amphetamine. So they’re in the same class, slightly different structure and as I say, with methamphetamine or the ice – which is the one that we’re seeing the issues with here, it’s much more potent and unlike Duromine where you know you’re getting a certain dose every time you take it and you know it’s not adulterated with other chemicals, there’s a minefield of unknowns in the use of illegally developed and created drugs that people buy.

TIM SENIOR:

There’s some other questions that we’re coming on to in some future slides. It would be nice to ask people – a poll next – there’s not actually off in the typical pictures that we see in the advertising.

HESTER WILSON:

And I think this is one of the things that is a worry for me. That there’s been this whole thing about the ice epidemic and photos of people absolutely losing it, destroying their lives and I’m not saying that this doesn’t happen but for many of the people that are using methamphetamines that actually come to harm – they look at this and they go “that’s not me, that’s not my friends, this is a beat up, this isn’t real”. And so it’s not a great awareness raising campaign. I think it’s much more likely to have an effect on the group of people that actually aren’t using. People who would be horrified by this. But not on the group of people that are actually using.That they don’t generally see it – “this is not me, this is not my friends”. And for us, this isn’t the patients that we see generally in the general practice setting. I’m not saying, it’s not all the time and there are many of us who see people with chronic complex illnesses and issues with their drug and alcohol use but it’s much more likely to be someone who doesn’t actually look like what these pictures portray.

TIM SENIOR:

We’ve got a poll next. Just curious as to given what you talked about, who the people who you might be seeing and the sorts of presentations, do people think that they are seeing, given that people present in diverse ways in general practice, on reflection do you think you might have patients who are using or suffering side effects from methamphetamine use? And I think the poll is open now, it would be interesting to see what the experience is of the group on the webinar?

PENNY:

I think I might close that poll off, just give maybe another 10 seconds Tim and I’ll close the poll off.

TIM SENIOR:

That’s perfect, so if you’ve not clicked one of the buttons yet, do it now before it closes.& There we go.So in which group – 69% of you say you think you have got patients.  23% of you don’t know and only 8% of you say no. Any thoughts on that poll Hester?

HESTER WILSON:

Look I think I’m interested. Yes. I would say yes. That we are seeing people and we may not realise it. For the people that are listening and looking in tonight, there’s 23% who don’t know. I really, hopefully by the end of this, you’ll have a bit more of an idea around that. For the group of 8% “nah”, you’re saying “nah I don’t see those patients”. I wonder is it a particular setting that you’re working in, but once again I would challenge you to be thinking in your patients, they’re may well be some people who are using. Now that doesn’t mean that all of them are going to come to harm and many people will use any of the illicit drugs without having any harm at all. And so they may, you may be seeing them in your practice but they’re not presenting with problems related to their use.But this is pretty common and particularly in that age group, the young guys between 20 and 35 if you’re seeing that group then you’re very likely to be seeing people who use.

So once again this comes back to some of the hype that has been around the issues with ice. Is there an ice epidemic? I think this is a really interesting question and it really annoyed me at the time because we all know what the definition of an epidemic way, and we weren’t seeing an epidemic. Certainly in the data up until 2013 there really hadn’t been a change in the prevalence of use but what we started seeing and this changed with the change to the more pure, more potent forms of ice, that we were seeing more people that were coming to harm. Now – and so what we saw in the papers was – this ice epidemic and the rise of crystal, you know, in Victoria and this is what hospitals, EDs, and police were seeing were more people were coming to harm, more people that were becoming aggressive, were becoming paranoid, and so it really is around the harm that people are having from the medications, rather than an epidemic itself. And we can see from the emergency department presentations up until 2016. And with this data, I don’t know if you can see on your page, but actually what we’ve got – the red line is women, the blue line is men and the grey line is both. And you can see a steady increase in presentations to the emergency department and a steady increase in admissions.  So this is not just people that had an injury or needed to be seen for four hours in the emergency department but actually needed to be admitted to hospital to have their conditions managed.

I guess I would say, just in terms of the hospitalisations and this data, how correct this data is, it depends on what’s put in to data from the hospital, so it would be quite variable. So it may be an underestimate, the other thing is that do hospitals or EDs always pick up that methamphetamine is the issue behind why the person’s presenting, just like we have that issue in general practice.

TIM SENIOR:

Yeah, and we’ve got a comment from someone in the audience – they work in a custodial setting and that setting is obviously very different where they’re seeing the severe effects. I think patients in the custodial setting, obviously they’ve come into contact with police and other services.

HESTER WILSON:

Yes, yes, absolutely. Absolutely. So this is a chart from Degenhardt, this is the latest data from 2016. And once again it shows you that increase in the 25-34 year olds particularly, but there is an increase in all age groups. Even older age groups, you know for example if you are thinking to yourself, most of my cohorted patients that I see are over the age of 50.We are seeing an increase in use, it’s not a huge amount but there is an increase of use of probably, what you say out of 100? Maybe, I don’t know, 0.2%?Something like that. So it is changing, there is increasing use. And the other thing that they’ve found –

TIM SENIOR:

Sorry there was a question earlier which people might be interested in – I don’t know if we have an answer – but wondering why there’s become increase in use and asking did “Breaking Bad” contribute to its rise? The audience did comment on that.

HESTER WILSON:

I don’t know whether – certainly I couldn’t watch “Breaking Bad” after the first couple of episodes because it was too much like work. But I think it’s about availability and cost.  And MDMA was a favourite before methamphetamine was very, very available. But it’s just what’s around. And as a species we have had a relationship for eons with being intoxicated. Now there may well be some in the audience and we know there are some people in our communities who don’t drink, don’t smoke, don’t ever use drugs but the majority of our community do use substances that intoxicate and as a species, we like being intoxicated.

TIM SENIOR:

We could even run a poll asking “who’s smoking, drinking or doing anything else” during the webinar!

HESTER WILSON:

So one of the other things looking at Degenhardt’s trial was that the increase in frequency of use and the increasing in smoking. In the past people would have been taking it orally.It would have been really common and it still is common, particularly in the party scene but people moving towards smoking. Now smoking is an easy thing to move towards. It’s not like injecting, there’s another step, another step into the other when people go to inject. With smoking, people will consider themselves as a recreational user. But we know particularly with the methamphetamine, because of its structure, because of how lipophilic it is, if you smoke, you probably get the same, maybe a tiny bit smaller, impact. You have very quick onset straight into the brain and get the effects as you do from injecting. The increasing impurity and the low grade speed increasing in purity. And it’s cheap. So what you could buy at which was low purity some years ago – is the same price now but it’s much more pure. So people are perhaps using the same amount and having more side effects because it is so pure.

TIM SENIOR:

The useful comment here that I think is worth drawing people’s attention to – because people are obviously seeing different effects where they are in different populations and someone is saying that in their socio-economic area where people have very little financial or educational buffer, they see more often the spiral into unemployment and dysfunctional relationships and effects on mental health, as a result of drug use.And I think we are – we do all see different things in our different communities and the statistics by their nature show a general thing with an outreach and a ranger.

HESTER WILSON:

Look and the other query I would be thinking about when working in a community that has low socio-economic status is it the ice that’s causing their issues or is the ice actually a symptom of the whole kind of – life story – history of trauma, history or poor, unstable or no employment. It’s a complex story. And there’s complex stories around why people continue to use as well.

TIM SENIOR:

I think the next slide takes us on to some of the effects of amphetamine type substances which is psychosis.

HESTER WILSON:

Yes and this is something that I briefly mentioned before. The drug induced psychosis, the positive symptoms. So it’s the positive symptoms of psychosis, the irritability, the hallucinations, the delusions and in this group of people, there’s an experience that many ambulance officers and police and ED workers have had around people kind of being Rambo charged, super strength, very very difficult to contain. And that’s psychosis is short lived. So it disappears within hours, certainly within days. But are these group of people who continue to use and have episodes of drug induced psychosis, are they actually developing a psychotic illness with continued use?

And certainly an Australian study from 10 years ago, they estimated that it had an 11 times higher risk than the general population of developing an ongoing mental illness or psychotic illness. And certainly in my drug and alcohol setting there are a number of people that I see who psychosis very clearly stared out a very short lived psychosis to do with their drug use but they’re left with ongoing symptoms after they cease use. And it’s not just the 6 months, it’s not just a year, it’s ongoing.So the question for me is what kind of damage are the amphetamine type substances doing to the brain? And we know with people that are high risk, if younger onset of use, your brains are fully formed til you’re 25, so you know – you’re going to be damaging your brain larger amounts. People who already have other mental health issues and alcohol dependence were at higher risk. And there is an interesting little article that looks at some of the permanent brain effects if you’re interested down the bottom of the page there.

TIM SENIOR:

And just before we move on, we’ve got a few people asking how much – you mentioned that it’s cheap? We’ve got a few people asking how much it costs?

HESTER WILSON:

Most people would be looking at $50 for a “point” – what they call a “point”. Don’t ask me what that is in grams, I’m sure there’s someone out there better at maths than me that can tell us.  But $50 would be a usual deal that people would buy, you might share that between 2 or 3 of you if you don’t use very often.Up to kind of $400 a day is the usual amount that we’re seeing in Sydney.

TIM SENIOR:

So 0.1gm is a point according to one of the participants. Thank you very much.