Methamphetamine is a stimulant drug available in a number of different forms. Powder form, traditionally known as 'speed', is usually of relatively low purity and can be snorted, injected or taken orally. Methamphetamine base, a damp oily substance, is of higher purity and is typically injected. Crystalline methamphetamine (crystal or "ice") is methamphetamine in its purest form and is usually smoked or injected.

Methamphetamine use can produce an initial sense of well-being and euphoria. It heightens confidence and alertness but intoxication leads to agitation.

Pseudoephedrine, available from pharmacies as a symptomatic treatment for the common cold, is the usual base for the illicit manufacture of methamphetamine.

What makes methamphetamines such a concern?

Most of the health problems related to methamphetamine use occur amongst those who have become dependent on the drug. Risk factors for dependence include smoking, injecting and frequent use, especially in those taking pure forms that produce a more intense high.

Over three quarters of dependent methamphetamine users experience serious mental health problems. The most common features are agitation or aggression, depression and anxiety, impaired concentration and motivation, and psychosis. These features sometimes, but not always, improve with abstinence.

Approximately half of dependent users have poor physical health including insomnia, poor appetite, weight loss, palpitations, nasal problems (related to snorting) and injecting site abscesses.

There is emerging evidence about the effect of methamphetamine use on cognitive functioning and memory. This has implications for prevention strategies, the design of health education programs and treatments.

Methamphetamine-induced psychosis is of particular concern to the medical profession. Out of every ten dependent users, around three will experience a psychotic episode in any one year, with paranoia and hallucinations being prominent clinical features. Such episodes may arise in people with vulnerabilities, but they also occur in people who are psychologically robust. The risk for the latter group is dose and frequency dependent. Symptoms usually last for 2-3 hours, but many users require hospitalisation for their own safety or the safety of others. They require high intensity management by Emergency Department staff and mental health teams and services.

Other methamphetamine related problems include social isolation, family disruption and relationship problems, and financial problems. Injecting users are at risk of blood-borne virus infections including hepatitis B, hepatitis C and HIV. Associated high risk sexual behaviour may lead to sexually transmitted infections or unplanned pregnancy. Many crimes and acts of violence are understood to be methamphetamine related.

Methamphetamines use in Australia

Methamphetamine is usually taken in a home environment with friends, often before going out to socialise. It is estimated that around 3% of Australians (aged 14 years and older) use methamphetamines at least once per year. Use is known to straddle all social groups.

Although the prevalence of methamphetamine use appears stable, the adverse health consequences of methamphetamine are increasing and impact across society. This is why methamphetamine use is an urgent and pressing public health problem.

Methamphetamine users appear to underestimate the risks of dependence and their health consequences. While most current users take the drug infrequently, there are estimated to be approximately 73,000 dependent methamphetamine users.This compares with approximately 45,000 regular heroin users.

A range of targeted strategies, including a comprehensive public education program, are needed to reduce the harmful effects of methamphetamine use. That is, approaches used in the workplace will be different from those used in schools.

Treatment options for severe methamphetamine dependence

The Royal Australian College of Physicians noted that the absence of an effective pharmacological treatment for severe amphetamine dependence leaves an important gap in the potential treatment options. The withdrawal and abstinence syndrome can be protracted, with sleep, for example, being disrupted for a long time. It can therefore present a major challenge to health services.

Urgent research is needed to develop suitable treatment and management options for methamphetamine dependence. While increasing numbers of methamphetamine users are presenting for treatment, the links to treatment for dependent users appear tenuous, with users being less likely to come into treatment of be retained in treatment. This indicates a need to create secure environments providing physical and emotional safety for both patients and staff.

Impact on health services

A recent Western Australian study found that amphetamine related presentations accounted for 1.2% of Emergency Department presentations. Many of those who are agitated or psychotic are also heavily intoxicated with alcohol, increasing the risks of aggression towards staff and creating clinical management challenges. Presentations related to amphetamines are typically of high acuity, result in prolonged length of stay in the Emergency Department, and consume considerable resources A third require sedation and intensive nursing, medical and security inputs to manage them safely.

Amphetamine users frequently re-attend Emergency Departments, and it can take several days to differentiate between an amphetamine induced psychosis and exacerbations of other psychiatric conditions such as schizophrenia.

Hospital presentations for methamphetamine psychosis have increased over the past five years from 1,028 in 1999-00 to 1,510 in 2004-05. Not all need the high intensity care available by admission as an inpatient. It is possible that many patients who are agitated rather than psychotic can be managed more appropriately in a low intensity environment rather than admitting them to hospital or police custody.

The number of patients attending their General Practitioner for help with methamphetamine related health problems such as sleep, mood or eating disorders or family relationship disruption is unknown. However, evidence indicates that the General Practitioner is a preferred source of help for many methamphetamine users and that early intervention within primary care may help prevent dependency and the onset of more serious health consequences.

The AMA believes that:

1. There is clear medical evidence that methamphetamine is a harmful drug, at both the individual and community level.
2. Methamphetamine psychosis is one of the most damaging health consequences of methamphetamine use. It also presents a safety issue for health care staff. Emergency Departments and other health care facilities must be adequately staffed to ensure personal safety at all times.
3. A renewed, comprehensive and sustained public education program on the health and social consequences of methamphetamine use is needed.
4. All pseudoephedrine-based medications should be scheduled at a minimum S3 (pharmacist only), with strict control of quantities supplied, in accordance with therapeutic standards and professional guidelines.
5. Methamphetamine should never be referred to in the media as a 'recreational', 'soft' or 'party' drug.
6. In order to reduce the health and social consequences arising from methamphetamine and other drug misuse, public policy should provide for generic programs, such as Life Skills, aimed at young people.
7. General Practitioners are the preferred first point of contact for most drug users, the vast majority of whom are neither in contact with the police nor with specialist drug agencies. There should be a sustained investment in the training of General Practitioners on how best to engage drug users and in the application of evidence-based brief motivational interventions that have been demonstrated to lead to positive lifestyle changes and a reduction in drug related harm. General Practitioners also need to have a range of options for referral of methamphetamine users.
8. There is a need for further research into the best treatments for those with severe methamphetamine dependence.
9. Emergency Department staffing should include a specialist drugs liaison officer, available to engage and support those presenting with methamphetamine and other drug related problems.
10. Further research is needed on the needs of patients with methamphetamine related problems presenting to Emergency Departments and their accommodation requirements. Low intensity supervised hostel-type accommodation may be most suited to the needs of medically stable but agitated users who are not psychotic, rather than admitting them to hospital or police custody.

References:

1. http://www.adca.org.au/policy/facts/ATSfactsheet.pdf. Accessed 17 April 2007

2. Australian Institute of Health and Welfare, 2007. Statistics on Drug Use in Australia, AIHW, Canberra

3. Australian National Council on Drugs, 2007. Methamphetamines: Position Paper

4. McKetin, R., McLaren J, and Kelly, E., 2005 The Sydney methamphetamine market: Patterns of supply, use, personal harms and social consequences. National Drug Law Enforcement Research Fund, Monograph No. 13.

5. Gray, S. D., Fatovich, D. M., McCoubrie, D. L. and Daly, F. F. 2007 "Amphetamine-related presentations to an inner-city tertiary emergency department: A prospective evaluation". Medical Journal of Australia. 186: 336-339

6. Degenhart, L., Roxburgh, A and McKetin, R. 2007 "Hospital separations for cannabis- and methamphetamine-related psychotic episodes". Medical Journal of Australia. 186: 342-345