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Amphetamine Type Substance (ATS) use

Amphetamine Type Substance (ATS) use: Asking, Assessing, Advising, Assisting and Arranging Care in General Practice
 
 
Sammi:
 
Good evening everybody and welcome to this evening’s webinar, Amphetamine Type Substance (ATS) use: Asking, Assessing, Advising, Assisting and Arranging Care in General Practice. We are joined by our presenter, Dr Hester Wilson this evening.
 
Before we jump in, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
 
Okay, I would like to formally introduce our presenter for this evening now, Dr Hester Wilson. Hester has a Masters Degree in Mental Health and 25 years’ experience working in the primary healthcare setting. Hester is also a Staff Specialist in Addiction at Sydney’s Langton Centre Drug and Alcohol clinic and has facilitated training for doctors and other healthcare workers since 2001. So welcome, Hester and thank you for joining us this evening.
 
 
Hester:
 
Thank you so much. And welcome everybody. It is so great to have everybody here to talk about this really important issue and I really encourage you to ask questions. Let us make this as interactive as you can in this strange world of Zoom. The learning outcomes for this session, are to recognise and understand the effects and side effects of methamphetamines and the risks and safety issues that can come up for people and how they might present to general practice, and how you might kind of pick it up and consider asking about it. And developing skills using the five A’s and if anybody out there has not had a look at the SNAP Guide, which is a Smoking, Nutrition, Alcohol and Physical Exercise book which is on the RACGP website, I really encourage you to do so. And we are using the ideas from that five A’s brief intervention. The reality is, we do this every time we see someone, so we ask, we assess, we give them support and information, advise them, assist them with treatment and arrange follow up or referral. And we are particularly looking at amphetamine-type substances and their use management in general practice. And importantly for us, knowing when, where and how to provide, and how to support withdrawal or where do you refer for withdrawal and management of complex issues for people that are using amphetamine-type substances.
 
Okay, now just finding the things. So, first of all some of you in New South Wales may have been aware of the Ice inquiry, and our current Liberal Government or Coalition Government in New South Wales asked for a very distinguished judge to come and actually do a special commission into the drug Ice. And the enquiry heard that again and again, that GPs are well-placed to address harms related to mild to moderate amphetamine-type substance use, but additional supports and education is required to enable this, and this is part of what this is for. I have to say, the amount of times I have heard you know, that GPs are ideally placed, we are ideally placed to do everything and I do have some concerns that we really do need to make sure that we are well-supported. So if you have someone who has complex issues as a result of their drug use, and / or their comorbidities, you know, getting the support that you need and the referral options is really important. But tonight here, we are looking at education to ensure that you have got an understanding of the skills and the information that you need to be able to assist people in your setting.
 
So let us have a look at Nathan. Nathan is a 16-year-old who attends your surgery with his mother, Julie who comes into the consult with him. You notice Nathan looks uncomfortable. He has his headphones on. He is not making eye contact. He has a few bruises on his face. Julie hands you a discharge summary from the local Emergency Department. She says look, Nathan did not want to attend today, but we are so worried about him, we do not know what to do. And Nathan says, it is alright mum. You read the discharge summary. Nathan was brought in by ambulance in the early hours of Sunday morning accompanied by a friend. He was found by the ambulance to be very distressed and anxious, complaining of chest pain, and had smoked some methamphetamines and had some alcohol on the Saturday night. And the diagnosis was psychostimulant intoxication. He was investigated, he was medically cleared and discharged to his family for follow up by LMO, that great letter that does not ever actually have a name on it, but just has LMO. But really, I want you now in the Q and A there just to actually put, do we put it in the chat or the Q and A, wherever it goes, around you know, what do you think might be going on here? What are the issues? What are the important issues that we want to see?
 
 
Sammi:
 
Why is he drug using?
 
 
Hester:
 
Yes.  Anything else, guys? Anything else? What is going on here, and what do you need to do? Is he dependent? Thank you. Does he use other drugs? Is he interested in changing? Leonie, I cannot see your answer. I will just move it down.
 
 
Sammi:
 
Is he doing it of his own volition? Is he being coerced? Do a HEADSS questionnaire.
 
 
Hester:
 
Yes, fantastic. Fantastic. Type of drugs and quality. Level and frequency of use. You know what guys, I could go home. I reckon you guys know it. Suicidal ideation, other mental health issues. Is this his first time or it is regular? Does he have mental health issues, any psychotic symptoms? Absolutely right. Comorbidities. Yes. Yes, beautiful. Beautiful. Okay, yes. Okay.
 
So you are Nathan’s GP you know, and you have been the family GP for the last 20 years and you know the family well. You saw Nathan last year with some otitis externa from some surfing. He has no significant medical history, no allergies, no surgery. His father sought help last year for tobacco cessation and continues to occasionally smoke some cannabis. His mother has no significant history. Nathan has two younger brothers, one of whom has ADHD and is treated with methylphenidate. What else do you want to know? So once again, getting back, getting you guys to think about this. Put it in the Question and Answer. What else would you want to know, and I think we have covered some of this. So we know that he has no comorbidities, we know that you know his family very well. So we still do not know, yes, do the brothers share their medication with each other? And we do know this is an issue, particularly for high school students, university students, that Ritalin and these kinds of medications get shared because they help you to stay up. Does he have ADHD? And certainly this is an issue for young people and particularly adults who will end up using stimulants because they are treating their ADHD, and there is a whole story there about adult ADHD.
 
Moving on. So, oh sorry. You know she was worried, the mum was really worried about this and he will continue to use drugs and harm himself, you know, get into trouble and drop out of school. She says, I know I am catastrophizing, but Nathan’s uncle died of a drug overdose. So we have some family history here. And we have the husband who smokes a little bit of cannabis, the tobacco use and the uncle who has had an overdose. So thinking about for you in your setting. You have a 16-year-old who is a little bit reluctant. You have a mum who is super-concerned. What are the things that you do? I know we talked about the HEADSS assessment which is really brilliant. What other things do you think you might think of doing? We have got people interested in school, psychoeducation. Why has he got bruising? Now the bruising was because he was intoxicated and had a fall. Assess without mum in the room. Do a physical check-up. Yes. Yes. Ask whether Nathan wants to speak to me alone. So certainly that is one of the really important things with young people and it is a huge issue, and confidentially. And young people can be concerned, oh what is happening to this screen? It is not moving. Sorry. I cannot move the screen. Sorry, Sammi, the screen. Oh, anyway, confidentiality is a huge issue, you know. So the young people will be concerned. Look, the family GP is going to disclose information to my mum, to my family. And really the reality is, that both Julie and Nathan are your patients and it is important to have a chat separately to Nathan to kind of work out what has been going on for him, and there may be things he does not want to share with his mum. So, setting up those limits of confidentiality around acute, serious risk of harm to himself, to others or others causing him harm is really important and it always creates that sense of safety, so that people can start to talk to you about what is going on. And you need to be clear what might, sorry these slides are all over the place, okay. So you know, so you say thank you so much for attending today, this sounds like an issue that really concerns you, Julie. I would like to talk to Nathan on his own. So I would not ask Nathan, I would say I would like to. I am not going to put him in the position of having to kick his own mum out, I am going to kick her out. If that is okay, but first can you tell me a little bit more about your concerns and then I will ask you to step outside while I chat to Nathan.
 
So, you have acknowledged Julie’s concerns. You have said, okay, so Nathan you have heard what your mum says, tell me what is happening for you. Tell me what your concerns are and what are the other important issues. So we flag before we are worried about dependence, we are worried about comorbidities, we are worried about mental health, we are worried about whether he is sharing medications. We really want to know what is going on with this young guy.
 
Okay, Nathan said he had a couple of stubbies of beer and then was offered the Ice pipe. He said he freaked out, it was an awful experience and not one he wants to repeat. His friends are really worried about him and said he was an idiot for smoking ice. So how does that change your level of concern for this young man? Given that history that he is very clearly saying it is the first time, he did not like it, my friends think I am an idiot, I do not think it is going to happen again. Can I get a bit of a sense of what people think? Are you still highly concerned? Reduced concern? Yep, James, absolutely. Do you need to do further? How would you manage this in this case with Nathan? Yes. Yes, Amila you are absolutely right. It is a really good opportunity to counsel him about risky drug use. And once again, psychoeducation, supportive care. And saying well you know, okay so you have had this experience, what have you learnt from it, how do you want to take this forward? What else can I do to assist you? Talking about his alcohol use. So he had had a couple of stubbies, and once again it is just a good idea to suss out what else is he doing? What other drugs is he using? How much alcohol is he using and in what circumstances? How risky is that use? Because the reality is for young people, the harms from episodic drinking is a real issue.
 
Okay. Sorry, there are weird things happening with this. It is very, very slow. Okay, so here we have all the different types of methamphetamine. So you can see I have got somebody’s lovely tattoo on their wrist of the chemical symbol for methamphetamines. That really makes me feel like going out and getting one of my own. We also have the crystal, and we also have this kind of resin stuff down here which is Base, which tends to be less potent, less pure. It has a whole heap of different names. The ones I hear most are Speed, Meth, Uppers, Goeey, Go-go juice, Scooby snax sometimes, Glass. Ice is not there, there you go. But a whole heap of different names that people do use.
 
So what is Ice? And certainly when we are talking about a percentage of potency, Ice is the crystalline form, so it is a very pure form of methamphetamine, whereas Base is only 20%, powder form is 10%, so much less potent. It is an indirect agonist at dopamine, serotonin and noradrenaline receptors and activates the post synaptic monoamines. It also inhibits monoamine metabolism. It is highly lipophilic, but the metabolites are not very active. So one of the things about smoking, is smoking is just about as potent and the time to peak onset is nearly as good as injecting. And you can see that down in my little graph, down the bottom there, that people will say oh, I am not injecting, I am only smoking, I am not getting as much. Well, they probably are. And really clinically, there is very little difference in terms of the amount and the speed of effect. The majority of it is excreted in the urine pretty quickly, but you can have, depending on how much use and how often, it can be present in urine for up to a week later.
 
The amounts that people use, people will talk about it in different ways. It might be a point. It might be grams. It might be ounces. And so to my mind, generally it is somewhere from 50 milligrams to four grams, but quite often it can be difficult to know exactly how much people are using. But a really common way for people to use it if they are dependent, is that they use it three or four times a day and they do it in a binge pattern and use it for about four or five days, almost up to a week and then they crash. They have used up all their serotonin and they feel absolutely dreadful and they just cannot maintain and so they then will have some time off and then start up again. And you know, they have used up their dopamine and they are fatigued and unwell and exhausted and have not eaten and have not slept. And so they really, very few people will just go day on day on day, particularly if they are using it three or four times a day. So it does tend quite often to happen in this binge pattern. But for someone like Nathan, that was a one-off. Other people may only use it on weekends, or only use it occasionally.
 
Oh, sorry. The interesting thing about methamphetamines is it is a slightly different group of people who are using. They are more likely than perhaps the group of people who use other drugs, particularly the opioids, more likely to be employed. They do not see themselves as having an issue and they may not use often, and they do not access traditional drug and alcohol services. They prefer to treat themselves, and they look for help from their friends. And they quite often do not see that they need help, but what we are finding with the more potent forms is that 50% could be classified as dependent. Nearly 46% are using more often than weekly. Half of them have injected, and more than half of them are experiencing methamphetamine-related financial problems. So it is actually causing them problems, but they may not recognise it, and they are more likely to turn up to our general practices than they are to a drug and alcohol service. They would not see themselves as being someone that would need a drug and alcohol service. And they have issues, and they come to harm.
 
And this is a paper from 2016 looking at the prevalence of use. So the prevalence of regular use is pretty low and look really has not changed a great deal. We do hear about this Ice epidemic and we do hear about more people attending Emergency Departments and going into treatment, but my sense really is, and it is not entirely clear, but my sense is that it is more to do with the potency of what is available and the fact that you are getting much more potent drugs in the past and that therefore, and it as the same price, but you are having more side effects as a result.
 
Why is it popular? Well, bottom line is, people will use what is available. It is cheap, it is easy to obtain. It can be made locally and so it is a really common drug at the moment. People may not recognise it as being harmful. Once again, people who smoke may be less frequent users, not have a history of other drug use, and so it is kind of easy to use. You do not have to inject. It is certainly very easy to manufacture. And it is something that is therefore more available because it does not need to be imported, unlike other drugs like heroin and cocaine.
 
So what does it do when you take it? Increased alertness, increased confidence, being wakeful. Feeling happy, feeling on top of the world, feeling amazing. This amazing feeling. Other people will talk about the fact that it makes them feel normal and they can get the housework done. But too much can have significant effects and we do see this turning up to the Emergency Department, people with hallucinations and paranoia and frankly psychotic. Agitation, sweating, angina, anxiety or panic, and this is the way that Nathan presented. And it is a risk for older patients, that it can actually cause angina and cardiovascular side effects. Longer term use, people do not eat, they do not sleep, they become dehydrated and the mental health issues can be ongoing, and I do think there are a few people who I have seen who have had really significant methamphetamine dependence, who have developed an enduring psychotic illness. You know, generally if someone has a psychotic episode as a result of their stimulant use, it is short acting and once their body recovers, they get over it. But there are a group of people who continue to have enduring psychosis, and you know, that is a real issue that they give themselves a chronic illness. And as we talked about before, dependence. So the thing about dependence or addiction is that you use for longer, despite harm you cannot cut down, you might have tolerance, you might need more to get the same effect and you have withdrawal symptoms when you try to stop. It takes over your life. It becomes more important than other things in your life. It takes over everything else in your life and becomes a huge part of your life. And this does happen with methamphetamines unfortunately.
 
So if we are looking at the effects and harms, one of the ways to look at it is, what are the harms centrally, peripherally, and the other consequences? So I will not go through this in a great deal of detail. It is all there on the slide. But you know, really think about well, what might happen in terms of the central nervous system? So first of all, you know, increased alertness so you can study, you can drive your truck, you can party. But as your body becomes and your brain becomes over-stimulated, then the toxicity issues can occur including serotonin syndrome, seizures and hyperthermia. Psychosis and cognitive deficits we have talked about before. The sympathetic stimulation, so increased heart rate, increased blood pressure and dilated pupils and in overdose you can vascular collapse as well as arrhythmias, myocardial infarction and rhabdomyolysis as a result. And the other thing that is really common, is just as people are intoxicated, they do not think straight, they are more likely to get in fights, they are more likely to be sexually assaulted. They are more likely to have risky sex and they are more likely to be exposed to blood-borne viruses.
 
One of the things with the media out there is that there has been a lot of quite extreme adverts. And we do all know on the one hand that extreme adverts can actually shift some behaviours. But one of the things that I have noticed with these, is that people look at these and go, well that is not me. That is not my friends, that does not happen to us. And you know, maybe for us, this may not be the patients I see. These are very extreme examples, and for us in the general practice setting, you cannot assume that these are the only ways that people present and in the general practice setting it is much more likely to be a more diverse presentation.
 
One thing that I would like to say, and this is really important, is that this is a group of people who want to see their GP. They prefer to see their GP as compared to a drug and alcohol service. And quite often their drug use is not what they present with. It may be physical health issues, mental health issues, financial issues, relationship issues as well as dependence. There can be other issues around nutrition or skin issues. We talked about before, the high risk behaviours, unsafe sex, injecting, binge drinking, driving while under the influence. Sexually transmitted diseases. Mental health issues. Cardiovascular, cerebrovascular complications. And all of the social and family issues, financial and study, accidents and incidents.
 
We talked about this before, the effects of use. Once again, addiction, psychosis. There has been this concern about changes in brain structure and when you do MRIs on people who have used a lot of methamphetamines, their brain structure does change. What we think is once you stop, it does return to normal but it can take some time. And you do have deficits in your cognition. Memory loss, it can affect your frontal lobes, so that you actually have some personality changes and aggressive and violent behaviour. And we have mentioned weight loss before, and dentition. Huge issues with dentition because of the grinding, because of the dehydration, because of the lack of self-care as well.
 
So let us come to Darren. He is a 45-year-old man who found that his blood pressure was raised when he checked on a friend’s blood pressure monitor. He works full time in banking. He is not sleeping well. He feels a bit sad and fatigued and is missing some days at work. He is going through an acrimonious divorce, and is renting an apartment in the CBD with a flat mate. His misses his children. His father had a myocardial infarction aged 50 and his brother who is older than him had a bypass last year. So I want to come back to you guys. What do you need to know? What are the important things for Darren?
 
 
Sammi:
 
Ask about risk-taking behaviours.
 
 
Hester:
 
So the thing that he has presented with is his blood pressure.
 
 
Sammi:
 
HEADSS again.
 
 
Hester:
 
Would you do a HEADSS on a 45-year-old? I have to say, I always think of HEADSS as the sort of thing I would do with young people. But it is probably not a bad idea, it is much the same kind of things. Managing sleep, sadness, fatigue. Why is his blood pressure up? Caffeine. Is he on prescribed medicines? Check his lipids. Ask about smoking. Ask about cardiovascular risk factors. Absolutely. We know he has the family history and he is male. Social issues, drug use, his depression, is he drinking too much? Absolutely. So let us have a look at what we have got. Sorry, have we missed one? No. When you ask him, he says he is not feeling depressed and has no thoughts of suicide or self-harm. But he has been partying a bit with his new flatmate. So he has moved away from the family. He is in the CBD and he is partying a bit, so you are very right to be thinking about what other drugs is he using. One of the things that is really important when you are going to take a drug and alcohol history is that sometimes in the general practice setting, people may not be prepared for you to ask them about their drug use. You know, he has come in and he has said, I have got problems with my blood pressure. He may not think that there is a reason for you to ask about his alcohol and drug use, so it is really important to normalise and to say, look something like, as your GP I am concerned about people’s health and wellbeing and lifestyle issues like smoking, alcohol, other drugs, exercise, nutrition are very important and also we notice that your blood pressure is up and some of these can be affected by that. Is it okay if I ask you? And then to ask specifically. Yes? So do ask, you know, do you drink alcohol? How much do you drink? How many standard drinks is that? How often do you do that? In what circumstances do you do that? Do you smoke tobacco? How long after waking do you have your first one? How many years have you smoked for? With cannabis once again, do you smoke cannabis? How much do you smoke? How do you smoke it? Or do you ingest it? And the same with methamphetamines. Have you ever used methamphetamines? How much do you use, how often, by what route do you take it? And really just going through the drugs as well as medications as well as prescribed medications are very important as well. And really being clear that this is part of what you do, it is non-judgmental. It is around you doing an assessment of his health needs and what you need to intervene and how you need to talk to him about it.
 
So he drinks alcohol three nights a week and has 12-15 beers. So they are schooners, so a schooner is around and about one and a half standard drinks, so he is having somewhere between you know, 20 to 22 beers, standard drinks, three nights a week. He recently smoked Ice on weekends and shared a 50 dollar deal with his flatmate and friends. And he uses cannabis to assist with sleep. So he just has a little bud in a pipe at night to help him sleep. So what else might you want to do? What else might you want to know and what else do you want to do now? And just here, anonymous is saying, what do you do if they say they do not want you to record a drug history? Once you record it, it is available to any insurance company. It is available if they give permission for it. I think you need to explore with them what their concerns are, and certainly from my point of view, I need to be clear that I have to make notes. I have got to actually have a record of why I am doing what I am doing. And there just needs to be a conversation around how you manage that, and how you document that. Explore his reasons for insomnia. Yes. Is he having sex? Yes, absolutely. So he is recently out of a relationship and is he having sex and are there risks there? And who is he having sex with and what are their risks? Does he need an STI check? Great, okay.
 
So, you know, he is drinking a fair amount of alcohol. He has also got the Ice use and the cannabis use. It is just a bit of fun. He does not think his Ice use is a problem. So, when you have got someone who is saying I just tried it the other week, it is nice, I am having fun, I really do not think it is a problem. What do you say to them then? So you need to take it further, or can you just let it go? It is just a bit of fun, he is not worried about it. I do not need to ask any more. What are your thoughts? Yes, so are there any affects? Mohammad is absolutely right, he might think it is just a bit of fun, but really just thinking about well, what else might you need to know? How else might this be affecting you in ways that you might not have thought about? And Anil is saying to take it further. And I guess it is that question around how you do it? And absolutely, as Leon says, you know, giving them psychoeducation, giving them information about how this might be affecting them and the side effects and the risks that might come from that. And an anonymous attendee says this drug is always a problem. How do you relate to this? Look I do not actually think that it is always a problem. There are a group of people who do enjoy taking this drug and have no problems at all. Just like there are a group of people who drink alcohol and have no issues at all. But really, as Dina says, let him talk non-judgmentally, you know, let him think about how this drug affects him and how the alcohol is affecting him and what effect it might have on his cardiovascular health given his history. And really kind of helping him to think what through what the risks might be. But the bottom line is, if he is clearly saying get out of my face, just a bit of fun, I am not interested, absolutely you can ask, look I can give you some brief information. I do have some concerns about your risk given your age and your family history. You might want to hear a little bit about that. He might say no, no I have heard it all before.  Say that is okay, I am not going to lecture you, I am not going to you know, give you a hard time if you are happy with what you are doing. I want to you know, just flag my concerns, I am a little concerned about this, but having said it, it is your life. I am here to support you and help you make change with this if you want to at any stage in the future. If you have any concerns, of if anything changes, I am here. So come back anytime. So you are not pushing against his resistance in him saying it is just a bit of fun, but you are letting him know, if he does have any concerns, you are here. You are a non-judgmental GP who can support him with what he needs at the time he needs it. And you have opened the door. You have got him thinking about how this might actually not be so great for him.
 
So coming back to the five A’s, we have got the Ask, the Assess, the Advise, the Assist and Arrange. So with someone like Darren, you have screened, you have asked. You know, asked about their drug use. You have set up that permission and set up the explain why you are doing it. You have given some information, some advice around that and then you are thinking, well what treatment might he need at the moment? He is not interested in treatment, but I have given him lots of information. It may be that it becomes clear that it is more of an issue for him and you want to organise some treatment and that is something that you may do in your setting or you may like to refer him. One of the things, and we talked about this before was really assessing where people are at with their stages of change. So if someone is pre-contemplative and saying it is a bit of fun, it does not worry me, doc do not need to talk about it, do not spend a whole a heap of time pushing against them being pre-contemplative. Leave the door open, allow them to come back if and when they are ready. And you have given them that little kernel, something to think about that they can use in the future should they wish or need. If somebody is ambivalent, is concerned about their use, is not sure what they want to do about it, this is the time to use motivational interviewing techniques. Now it is beyond the scope of an hour’s conversation about amphetamines to discuss motivational interviewing techniques. I would really encourage you if you have not had any experience in this area to do some reading. There are some very, very good courses. For me, I use motivational interviewing techniques in every consult that I do with every person, and it is not just drug and alcohol, it is not just mental health. It is around exercise, it is around nutrition, it is around medication adherence. It is around working with that person where they are at and building their self-efficacy for them to actually take control of their health. So I will leave that at that, but it is a really fabulous area, and if you have not read much or had much experience with it I really encourage you to take it further.
 
So we talked a little bit about the asking, the permission, the normalising. Do not skirt around it, actually ask it. It is okay. People expect us to ask. It is okay. We are much more cautious about asking than our patients are concerned about being asked. We talked about how you assess it. You know, how do you use it? What level of use? Any side effects? Any dependence? Any problematic use? Is it causing you any harm? Giving that psychoeducation, information, brief advice. Looking at a management plan. Self-monitoring. Are there medications that could help? And we will come back to that. And then arranging for follow up. Arranging to see them if they change their behaviour and supporting them to change that behaviour with relapse prevention or referral on for other services. You do need when you are looking at the drugs to have a little bit of drug-specific information at your fingertips. But once again, if somebody comes in and they tell you they are using some drug you have never heard of, it is okay to say, gee I have never heard of that, can you tell me about it? Do you know what it is? What it is related to? What effects it has for you? Are there any issues that you are having with that? You are not expected to know everything, and certainly with my patients who have longer history of significant drug use, they really like teaching me stuff, you know because this is their area of expertise, and it is a really lovely way to actually level that playing field between doctor and patient so you can actually work collaboratively.
 
So when we are thinking about the management of methamphetamines, and some of you have asked these questions already, do they use regularly? Are they dependent? Are they acutely unwell? Is there serotonin toxicity or another acute medical condition going on? Do they need urgent transfer to the Emergency Department? So coming back to, that is your aside, you need to really suss out is there an acute issue that they need to go to hospital for? But coming back to the unfolding issues, are they dependent? And when you are looking at dependence, we use these days the DSM 5 and there are 11 criteria that help you to understand, is this an amphetamine use disorder? And tolerance and withdrawal are important, but so are the other dimensions of that which are about craving, continued use despite harm, trying to cut down unsuccessfully, not doing what is expected of you in your life, not looking after your kids as well as you could, not going to work, not doing your studies. And the word for me around addiction that makes so much sense, is the salience that it has in your life. It is the percentage of time and energy that it takes up in your life, that it becomes more important than other things, more important than your work and your family and the other things you used to enjoy in your life. So it is really important to work through that with people. And people can have a little bit of substance use disorder and a moderate amount or a severe amount. And that really gives you an idea of how much it affects their function. If they are dependent, do they want or need a detox? And where would you do that detox? Do they need an inpatient detox? Are they high risk? Are they homeless? Do they have unstable mental health? Do they need a high level of support to safely change this behaviour? Or can you manage this in your setting? And then arrange appropriate care. We will come back to the management of detox in your setting. Do they use regularly? Are they ready to change this behaviour? So this comes back to where Darren was at. Are they ready to change this? Do they want to continue what they are doing? Do we work with them around minimising the harm while they continue the behaviour? Is there a role for medication? And we will come back to that. Do they need referral again and then follow up?
 
Okay. I think I will go back to this slide. So in terms of the management and treatment of amphetamine use disorder. Unfortunately, unlike opioid use disorder where we have highly evidence based treatments in the form of methadone and buprenorphine, and unlike alcohol where we have very well-defined management for withdrawal and managing relapse prevention, the medicines are not as good in alcohol disorder as they are in the management of opioids. But we do have medicines. In withdrawal, detox and changing this behaviour, there are some medications that have been trialled, but there is not a great deal of evidence, and I do not think at the moment, that unless you are someone who has a lot of experience using the medications that sometimes I use, that this is what we would be doing in the general practice setting. Having said that, if someone has anxiety, if someone has depression, if someone has psychosis, we can manage their mental health issues and you know, that is really important in terms of supporting someone who is using amphetamine-type substances. There are some trials looking at things like dexamphetamine and also modafinil, but really the evidence is not there and so if you are thinking this might be an option or you have a patient who has used those as an option in the past and they have helped, then I would encourage you to get some advice from your drug and alcohol service. And here in New South Wales, we have DASAS which is the Drug and Alcohol Specialist Advisory Service that is run through St. Vincent’s Hospital. 24/7 advice and they are really good people to talk to. So you may have someone who comes in and says, look I used modafinil before, it really helped me to stop and to stay stopped. But you might think, well I do not have any experience with modafinil, it is not listed for the treatment of amphetamine-type substance disorders. Get some advice on how to manage that, or refer them on to specialist services.
 
Certainly for some people, if they have had a binge and they are coming down, they can feel pretty blue and pretty sad. Sometimes, you might consider using an SSRI. There is not any evidence that the antidepressants work in that setting, and the reality is they have used up all their neurotransmitters and they actually need to stop and have a break. But you may well see people come in looking for SSRIs. Once again, it is always a case by case basis and there would need to be very good clinical reasons to prescribe, but there is once again not a great deal of evidence.
 
Just follow up in our setting. Okay. Sorry, Henry, you have dexamphetamine works in the ADD group which is… well, the ADD group, uh-huh, really in terms of the incidence of amphetamine use disorder, the prevalence of use is pretty low. So the incidence per year, I do not have that figure in my head. But it would be 0.2%, something like that. It is pretty low. Dexa, modafinil we do not have we do not have good evidence that they work in this group, however it may be that someone actually has attention deficit disorder or ADHD and that treating them medically is a much better way than them using illicits to try and manage their disorder.
 
Sorry, I will get out of here. What I really want to put a plug in in terms of GPs and the local services. Finding your local drug and alcohol service for where you are working. Do you know what is available? Do you know the services that are available? What is available through your PHN and your local health district website? Do you know what is out there? Now I would like to flag that we do have an online stimulant treatment service through New South Wales, and also some specialist stimulant services in the Hunter and in Sydney. But for those of you working outside those areas, there is an online service. And also drug and alcohol services, your local drug and alcohol services in your area do do this work as well. And you know, really encourage you to find where your local service is and sort out how they can actually support you. You know, people that have a stimulant disorder, it is a chronic, relapsing condition, and they will need ongoing support and treatment, and it may well be that it is mild enough so that you can actually manage it. Or it could be that they need more intense case management and support, and that might be through a drug and alcohol and a mental health service, depending on what is happening for them. Do not feel that you as a GP have to manage someone who is very, very complex. They require a team of people with specific skills and capabilities, and working in services that allow those capabilities to support them, to make change. Look at what your local PHN has got. There are quite a few of the PHNs around New South Wales that have GP and drug and alcohol liaison services that can support you and help you to access care that you need for your patients. And look, some of the LHDs do have, the local health districts, do have websites. Generally they are not terrific, but the St. Vincent’s one does have the DASAS service up on it and does have the stimulant treatment programs as well.
 
I will just go back to the chat. Is there anything there? So Henry is asking about the incidence of ADD in the AUD group. So I am assuming that ADD is Attention Deficit Disorder and in the Alcohol Use Disorder group. I actually do not know. But we do know that comorbidity with mental health and drug and alcohol issues is very common, particularly in men, and ADD is more common in men. So Henry, I am sure you could google that and find out what the actual incidence was, but they do occur.
 
Amila, you have asked about treating amphetamine-induced psychosis with Seroquel? Well, quetiapine is an anti-psychotic, so it is one that you can use, and it is sedating. Once again, it is really thinking about the level of distress and how acutely unwell the person that you are seeing is, whether they do need an inpatient admission and more support. I have certainly used anti-psychotics to help people manage psychotic symptoms, but if they are quite unwell, I would tend not to do it in the general practice setting and I get them engaged with the mental health service and ideally an admission for a period of time to ensure that they remain well.
 
Aneel has made a comment, follow up in our setting. I am kind of not sure, Aneel. Can you send me a little bit more information? Was that about a previous part of the conversation I am wondering? But if there is more information I am not entirely sure what that comment was about.
 
I am going to go back to anonymous attendee, who said I have a patient who was severely depressed and suicidal, started using Ice and no longer wanted to kill himself. Yes, look, once again, what are people treating? What are they trying to manage? And if you have severe depression and suicidal ideation, perhaps something that makes you feel a little bit lighter can be useful. There is however no evidence that stimulants are a treatment for severe depression or suicidal ideation.
 
Leon, you have asked, how long for brain structure and function to return to something like normal? Oh look, how long is a piece of string? It really does depend on the individual and the amount that they have been using and the amount that has actually affected their brain. I will talk to people and say, it is a bit like you have overheated your brain, you know, it needs to calm down and you need some space and it needs just to rest and get over it and build up your supply of neurotransmitters, your happy hormones in your brain, because you have overused them. You know, certainly in terms of psychosis, people will return pretty rapidly if they have got a drug-induced psychosis, and stimulants are one of the main ones, they will return very, very quickly within hours to days back to non-psychotic state. You know, but for other people who have used methamphetamines over an extended period of time and high levels as I say, can take an extended period of time, some months before they actually resolve symptoms.
 
Okay, so thanks, Aneel, it was part of a previous conversation.
 
And Jayanthi is asking about mirtazapine. So, mirtazapine is an anti-depressant. It is not a particularly, in my view, a particularly effective one. It is sedating, so it can help people who need some sleep. I think we do need to be careful about the use of off-label medicines to manage people’s insomnia. And certainly you know, we do find that quetiapine is over-prescribed for insomnia and it is a high-risk medication and has significant metabolic and weight, it is obesogenic, so you do need to be careful, and same with mirtazapine, it is obesogenic as well. People will put on weight. But it is something that we do try occasionally, particularly when people are withdrawing, if they are not able to sleep. If they are irritable a small dose of mirtazapine for a short period of time at night for some people can perhaps help. The issue there is, would it have improved anyway? Or is the mirtazapine doing anything itself? So, we do not have a lot of evidence for the use of it. We sometimes use it. You could try, once again it is on a case by case basis, and really being clear what you are trying to treat, the outcomes that you are looking for, and they do not end up on the medication long term.
 
Now, Yanksia, could you briefly explain the detox process in the GP setting? Okay. So, when people stop, if they are dependent, they will go through withdrawals and in methamphetamines, this is craving, wanting to use, irritability, not being able to sleep. And the issue that we have is that we do not have a nice detox medicine that will manage it, unlike opioid use disorder where you can use benzodiazepines, you know, once again it is over five to seven days. I will Oxazepam if they have impaired liver or diazepam long-acting if they do not, you know, you can use that to really help people manage their cravings and successfully stop. We do not have good evidence for the use of benzodiazepines in their treatment of amphetamine withdrawal. It really is supportive, a calm, safe place, good food and water, distracting, supporting and helping that person through. And so, if people do not have a space where they can do that, do not have the support that can help them do that, then an inpatient detox within a drug and alcohol detox rehabilitation can be really useful. If people have private health cover, it can be done in a private health setting. And it is over a matter of days, and always it is around looking at, what are the supports? What are the skills and the structures that my individual patient has? And how can I support them through this? And I would see them frequently. I would help them. If they had family, I would support their family and them to actually manage this, and understand that it is a chronic relapsing illness. Detoxing is not the end of treatment, it is the beginning of a journey towards actually changing the way someone lives their lives. And it is really possible that people will lapse back into their drug use, and the important thing there is to support them to keep accessing your support and your care, and the other care that they need to enable them to make long-lasting change.
 
Fahdi, you have been talking about CBT. CBT we know is really useful with mental health issues. We do know that talking therapies can support people to make changes that they want to make. And CBT can be really useful in terms of helping them with their thoughts and their feelings and their actions, as is motivational interviewing.
 
James is asking, are there any medications that are absolutely contraindicated in people who use methamphetamines? The first ones that come to mind with me for that is the SSRIs. You do need to be careful because if you have got good amounts of methamphetamine on board and good amounts of SSRIs, it does increase your risk of serotonin syndrome. I think apart from that, it is just thinking about the individual risks of that person. You know, are they an older person? Do they have some cardiac of you know, some cardiovascular disease, or diabetes, and you know using methamphetamines, is that actually going to affect their and you know, possibly destabilise their other medical conditions?
 
Mohammad has said haloperidol helps for psychosis. Haloperidol? Yes, you know, olanzapine or risperidone, you know, all the antipsychotics can be helpful. But once again my caveat would be you really need to be clear that they have the level of support to help them manage that period of psychosis in their setting and do they need to be hospitalised. But certainly antipsychotics and sedatives including benzodiazepines in a supervised setting are very, very helpful in drug induced psychosis in the short term.
 
I am just going to move down to Amila. What is the difference between amphetamine withdrawal and coming down off amphetamines? So amphetamine withdrawal and coming down are probably a little bit similar, however it can be that people episodically using amphetamines who binge use, who may or may not be dependent, that they will still have the come down. And the come down is because they have used up their dopamine and their serotonin. They feel very down, very depleted and it takes them a day or two to recover. So amphetamine withdrawal is in the context of dependence.
 
Bromocriptine for cocaine withdrawal. Once again, not a great deal of evidence, and it has some side effects.
 
Anthony. Advise on oral hygiene?  Great question, thank you for raising that. It is so important. And you know, the issues with people who, because they are dependent and the focus of their lives is around their drug use, they do not always look after themselves. So, you know, once again, brushing, seeing the dentist, flossing, those kinds of things. But also the fact that you can get the clenching and grinding which are a real issue for dentition as well.
 
Are there any physical fatality risks from methamphetamine withdrawal? Not so much from withdrawal. I mean, we do have the toxicity effects, but not withdrawal itself. The toughest thing really about withdrawal is how hard it is to maintain, and that people lapse back to using because they feel so terrible and their symptoms are relieved by using the drug. So really, in terms of it is not like alcohol were there are a group of people who would come to harm because of the DTs or seizures. So, no, but you know, you have really got to look at it on a case by case basis in terms of the risks that person has, because of their history, their medical history and the environment that they are in.
 
So we are up to 8:29, and that is time to finish. There might be another slide here that I have forgotten. My Superlab Playset. So, this is a nod to I have forgotten the name of it.
 
 
Sammi:
 
Breaking Bad.
 
 
Hester:
 
Breaking Bad! I just thought it was the most cute thing having kids that have lots of Lego. I am not about to buy them a Superlab Playset, but I thought it was kind of cute. So, thank you everybody for your attendance today, and look if there are any questions that do come up for you, please do send them on to Sammi. And I will hand back.
 
 
Sammi:
 
Thanks, Hester. And I just want to thank you again for joining us and presenting this evening, and also to everyone that has joined us online. We do hope you enjoyed it. That brings us to the end of our presentation this evening. Thank you and good night everybody.
 
 
Hester:
 
Good night.

Other RACGP online events

Originally recorded:

10 March 2021

This webinar will provide GPs with the skills to screen for ATS use, provide brief interventions, and refer patients into treatment where appropriate. GPs will also be shown how to provide ambulatory withdrawal services for ATS in clinically appropriate circumstances.

Learning outcomes

  1. Recognise and understand the effects and side effects of methamphetamines, the risks and safety issues and how patients present in general practice.
  2. Develop skills using the 5As of brief intervention (ask, assess, advise, assist and arrange) for amphetamine-type substance (ATS) use management in general practice.
  3. Know when, where and how to provide withdrawal services for ATS.
This event attracts 2 CPD points

This event attracts 2 CPD points

Presenter

Dr Hester Wilson
(FRACGP, FAChAM)

Dr Hester Wilson is a GP, addiction specialist and Chair of the RACGP’s Specific Interests Addiction Medicine network. Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings. She also works in a public Drug and Alcohol Service in South East Sydney Local Health District. She is a Conjoint Lecturer and PhD candidate, School of Public Health and Community Medicine, University of New South Wales, NSW.

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