Recognising and addressing the harmful mental health impacts of methamphetamine use

Purpose

Methamphetamine is one of the most commonly used amphetamine-type stimulants (ATSs) and is associated with a range of acute and long-term mental and physical health-related adverse effects. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises the impact that methamphetamine is having on those who use it, their families, communities, whānau¹, health services, employers, educational institutions and beyond as a serious public health issue. While there is growing awareness of the issues associated with methamphetamines amongst communities, policy-makers, the media and health services, there is a significant amount of work still to be done in order to translate this into evidence-based, clinically informed and effective responses. This position statement explores the issues associated with methamphetamine use from a mental health perspective, and provides recommendations as to how these issues could be addressed.

Key messages

• Methamphetamine use is associated with high rates of negative physical, psychological, behavioural and interpersonal affects including psychosis, suicide, violence, stroke and cardiovascular risk.
• Methamphetamine-associated psychosis can transition to long-term mental illness, and presents an opportunity for early intervention.
• Indigenous and rural communities are particularly vulnerable to methamphetamine-related harms.
• Public health campaigns should be evidence-based and should focus on harm minimisation messages and strategies to destigmatise, rather than sensationalise, substance use disorders.
• The family and support networks of people with methamphetamine use disorder require improved access to appropriate supports.
• Psychiatrists have a key clinical leadership role in informing and coordinating preventative, early intervention and treatment approaches to methamphetamine use.
• Further efforts and research are required to improve evidence-based treatments.

Definition

The term amphetamine type-stimulants (ATS) refers to a class of drugs that includes a variety of central nervous system stimulants, including dexamphetamine and methylphenidate (found in some prescription medications), amphetamine (also known as speed), methcathinone, methylenedioxymethamphetamine (MDMA) and methamphetamine. Methamphetamine commonly comes in the form of tablets, crystal, base or powder. Due to slight structural differences, methamphetamine produces a stronger nervous system response than amphetamine, and can lead to acute short term and long-term effects (ACC, 2014).

In recent years, the way methamphetamines are used in Australia and New Zealand has undergone a qualitative and quantitative change. In Australia this is largely due to increases in the proportion of people using purer forms of the substance, particularly crystalline methamphetamine (commonly known as ‘ice’) (AIHW, 2016). In New Zealand, methamphetamine is more commonly used in its powder or paste form (known as ‘pure’, ‘base’ or ‘P’) (DPMC, 2010), although crystalline methamphetamine is becoming increasingly available (Bradley, 2018). These purer forms of methamphetamine are associated with a higher risk of acute physical and mental health harms, and higher rates of use disorder.

Prevalence

In 2016, around 6.3% of the Australian population had used a substance from the ATS group in their lifetime, and 1.4% in the last 12 months. These figures have been in decline, particularly since 2013 (AIHW, 2016). At the same time, there has been a sharp and continuing increase in the portion of this group who are now using crystal methamphetamine, rather than other, less pure variations, such as amphetamine in powdered form. In 2016, 57% of the Australian population who had used an ATS substance in their lifetime had used crystal methamphetamine as the main form, more than doubling from 22% in 2010. Along with the rise in the portion of people using methamphetamine, the frequency of use, rates of dependence, and rates of treatment-seeking have also increased. Whereas in 2010 the percentage of Australians who described their methamphetamine use as frequent (daily or weekly) was 12.4%, in 2016 it had risen to 32% (AIHW, 2016). The rate of dependent use has increased from 0.74% in 2009–10 to 1.24% in 2013–14 (Degenhardt et al., 2016); and treatment episodes have risen by 123% over 2012-2017 (AIHW, 2018). Furthermore, people using methamphetamine use other substances at higher rates than the general population, exposing them to further risks including polysubstance use disorders, overdose and other related physical and mental health problems.

In 2015, it was estimated that just under 1% of the New Zealand population had used methamphetamines in the last 12 months (DPMC, 2015). This is a decrease from 2010 where that rate was over 2%. While this is a small portion of the population, the impacts of this type of substance use are known to be widespread, including on family, whānau, the wider community, schools, health services and beyond (Te Puni Kōkiri, 2011). Māori were also found to be much more likely to have used methamphetamines in the last year, indicating that the impacts on these communities would be even more pronounced (MoH, 2010).

Impacts

The trends in rising rates of dependent use and harms are of concern to the RANZCP due to the link between the purity and frequency of methamphetamine use and mental health problems. A significant proportion of the mental health harms related to methamphetamine use are due to psychosis. Methamphetamine use is implicated in ambulance attendances for psychosis more than all other illicit drugs combined, accounting for 6.1% of all ambulance attendances for psychosis, and 93% for ATS-related psychosis in Victoria (Arunogiri et al., 2015).

Research shows that people with methamphetamine dependence are five times more likely to develop psychotic symptoms during periods of drug use in comparison to periods of abstinence (McKetin, 2014). These substance-induced psychotic reactions can look similar to acute paranoid schizophrenia, including persecutory delusions and hallucinations (McKetin et al., 2013) and can actually be a barrier to identifying longer term mental illness. Importantly, up to a third of people hospitalised with a methamphetamine-induced psychotic episode go on to be diagnosed with schizophrenia later (Arunogiri et al., 2018), highlighting that this is a critical opportunity for early intervention to prevent progression to long-term mental illness (Lappin, Sara and Farrell, 2017).

Agitation and behavioural disturbance associated with methamphetamine use has seen emergency departments, acute psychiatric inpatient units and other frontline services increasingly having to grapple with significant and unique challenges (McKetin et al., 2018). Methamphetamine use is linked to increased risk of violence, with studies suggesting that there is a dose-related relationship between methamphetamine use and hostility and violence (McKetin et al., 2014). This can lead to acute and mental health services being placed under significant strain as they are required to manage increasing numbers of people presenting with complex psychiatric presentations, as well as challenging behaviours, related to methamphetamine use. For example, the number of methamphetamine-related ambulance call outs rose 88% in metropolitan Melbourne and 198% in regional Victoria between 2011–12 and 2012–13 (Lloyd et al., 2014). Neither mental health nor alcohol and other drug (AOD) health services are resourced to respond to these complex presentations (Lee et al., 2007), or the considerable burden on frontline workers who are placed at a risk of occupational exposure to violence.

The rates of death in people using methamphetamine doubled in Australia between 2009 and 2015, and death rates from suicide are substantially higher in this population, with estimates that suicide comprised 18% of all methamphetamine deaths (Darke et al. 2017). A range of other salient physical health harms include cardiovascular risks, increased risk of stroke, and the risk of potential Parkinson’s disease (Lappin, Darke and Farrell, 2018).

Due to the range of physical, social and mental harms experienced by those with methamphetamine use disorder, a multi-disciplinary team approach in intervention and care is recommended, particularly in cases involving co-morbid diagnoses (Lappin, et al, 2017; Hamilton & Dunlop, 2016). This includes psychiatric services and drug and alcohol service treatment.

The range of issues related to an individual’s methamphetamine use are also of key concern to family, community and whānau. When a person using methamphetamine is intoxicated or in withdrawal, their care needs and the unpredictability of their behaviour can become such that their support networks are unable to continue engaging with them. This can create a vicious cycle whereby the individual experiences increased isolation, loss of safety nets and associated hardships, which can in turn precipitate increased drug use (Te Puni Kōkiri, 2011).

One solution that has had success in New Zealand and which the RANZCP recommends for consideration in Australia is a mechanism whereby money seized and confiscated from criminal syndicates by law enforcement is redirected into support and prevention programs. This creates a sustainable mechanism for resourcing essential programs (DPMC, 2010; DPMC, 2015). Programs to provide preventative and supportive measures can assist those with methamphetamine use disorder avoid the justice system.

While some jurisdictions have implemented compulsory treatment for substance use disorder, there is ambiguous evidence as to the effectiveness of compulsory treatment (Werb, et al, 2016; Lunze, et al, 2016) and it is important that programs are appropriately evaluated and reviewed.

At-risk population groups

Some population groups disproportionately experience the impacts of methamphetamine use. For example, recent rates of methamphetamine use are higher in rural Australia than in metropolitan areas (Riche and McEntee, 2017). These increased rates, compounded by limited service access, leads to increased hospital admissions (Monahan and Coleman, 2018; Ridley and Coleman, 2015). Tailored interventions are required to address the unique needs of rural populations.

In Australia, the availability of methamphetamine in Aboriginal and Torres Strait Islander communities is incurring a significant physical, emotional and spiritual toll. For some groups, methamphetamines are exacerbating existing mental and physical health problems and contributing to disproportionate incarceration rates. Given that Aboriginal and Torres Strait Islander adults are experiencing high or very high psychological distress at three times the proportion of non-Indigenous adults, and that the incarceration rate of Aboriginal and Torres Strait Islander peoples is 13 times that of non-Indigenous Australians, there is significant concern regarding how increasing methamphetamine use will play out in these communities (Productivity Commission,
2014).

In New Zealand, Māori communities are also vulnerable to the availability of methamphetamine. Approximately 9.8% of the Māori population have tried ATS substances in their lifetime, compared with 7.9% of Europeans, 3.7% of Pacific people and 1.8% of Asian people (Cook, 2013). Over the past decade a number of innovative programs have been implemented in Māori communities to address this. For example, as part of the New Zealand Government’s Effectiveness Interventions policy packages, the Programme for Action for Māori was developed and implemented across a number of locations. The approach involved strong engagement with whānau and was informed by the principle of kaupapa Māori². The project has been evaluated and found to have built capacity in affected areas and facilitated whānau to lead their own journeys of recovery (Te Puni Kōkiri, 2011). Particular care must be taken in Aboriginal and Torres Strait Islander and Māori settings to divert people away from the justice system and into treatment wherever possible. The Programme of Action for Māori in New Zealand is an example of an effective approach to this, which has had significant success. Strengths-based, community-led, capacity-building and culturally relevant approaches are key in engaging Aboriginal and Torres Strait Islander and Māori communities, families and whānau and affecting real change.

Recommendations

The RANZCP calls for a coordinated, multidisciplinary, long-term approach to addressing the harmful impacts of methamphetamine use, which is evidence-based, clinically informed and recovery-focused. Treatment of any substance use disorder involves the management of issues that may underlie harmful use (such as developmental trauma or other major life events), as well as the associated physical, psychological and social effects arising from the substance use disorder itself. As such, psychiatrists have a key clinical leadership role in informing and coordinating preventative, early intervention and treatment approaches to methamphetamine use.

The RANZCP has a number of specific recommendations for how to address methamphetamine use and related harms in Australia and New Zealand, as follows:

Provision of adequate resources

• Address shortages in the addiction psychiatry workforce in order to enhance the capacity of the mental health sector to treat substance use disorders, and for the AOD sector to identify and address complex mental health issues.
• Support resources which increase coordination and flexibility between mental health and AOD services to provide a better continuum of care with a focus on early intervention.
• Enhance opportunities for undergraduate and post-graduate medical trainees to work in AOD
  programs, with funding for addiction trainee and consultant positions to support these roles.
• Increase resources for AOD services in general, with effective referral pathways to mental health services, and vice versa, necessary to effectively and holistically address
  methamphetamine-related issues.
• Fund integrated welfare and social support services to address the social determinants of health in people with methamphetamine use disorder.
• Support programs where funds confiscated by law enforcement from criminal syndicates are
  then redirected to support and prevention programs.

Acute psychiatric inpatient units and other frontline services

• Increase access to training, resources and clinical supervision for acute psychiatric inpatient units and other frontline service workers to support them to manage methamphetamine-related challenging behaviours effectively and safely and to avoid burnout.
• Increase resources in acute psychiatric inpatient units, as well as emergency departments, at a level commensurate with the level of need in the community so as to be able to respond effectively to the mental health implications of acute methamphetamine use.

Developing evidence-based treatments

• Fund research into minimising the treatment gap and enhancing engagement of people with
  methamphetamine use disorder; as well as research into the efficacy of treatment, impact on
  comorbid mental health issues, and long-term outcomes for substance use, associated
  comorbidity and quality of life (Coggers et al., 2008).
• Support further research in pharmacotherapies which are effective in addressing methamphetamine use disorder.
• Support tailored interventions for population groups with unique needs such as people living in rural and remote locations.
• Indigenous communities
• Ensure responses to methamphetamine use in Aboriginal and Torres Strait Islander and Māori communities are led by local people, and in particularly community leaders and elders, who already have insight into the issues and potential solutions and divert people away from the justice system as much as possible.
• Ensure funding to Aboriginal and Torres Strait Islander and Māori communities where successful programs already exist.

Public education

• Address stigma and methamphetamine use in the community of drug use disorders as an
  illness, and a respect for its treatments.
• Focus public health campaigns on evidence-based primary, secondary and tertiary harm
  minimisation messages and avoid fear tactics.
• Support public education campaigns which provide more information on early recognition of the
  potential effects of methamphetamine use, as well as harm minimisation messages such as
  safe injecting practices, how to respond to an overdose, aggression, suicidal thoughts and
  psychosis.

Family, community, whānau and carers

• Provide family and support networks of people with methamphetamine use disorder access to confidential supports, training and resources to assist them to care for their loved ones without compromising their own mental health and personal safety.
• Research distance-based interventions such as real-time online interventions and telephone support which may offer effective solutions for the support networks of methamphetamine users who themselves require guidance.

Responsible committee: Faculty of Addiction Psychiatry 

References

1 ‘Whānau’ (pronunciation: fa:naᵾ) is a Māori word used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui).

2 Kaupapa Māori relates to a key Māori philosophy incorporating the principles of self-determination, spiritual
and cultural awareness, the right to socioeconomic equality, the principle of whānau, collective philosophy,
the Treaty of Waitangi and nurturing respectful relationships.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.