Key points in the provision of interventions for psychostimulant users1
- There are clear signs that amphetamine use is increasing; however, there are few services in Australia that offer amphetamine-specific interventions.
- The literature is limited in the number of well-conducted, controlled studies, however the available evidence suggests that outpatient cognitive behaviour therapy (CBT) appears to be current best practice for psychostimulant users.
- The service context in which interventions are provided is important in attracting and retaining people who present to intervention facilities.
- Psychosocial approaches to psychostimulant dependence include outpatient interventions, residential intervention and therapeutic communities (TCs).
- Completion of treatment is associated with improved client outcomes.
- Enhancement of residential treatment with behaviour therapy or cognitive behaviour therapy is also associated with improved client outcomes.
- Service delivery may be enhanced by considering the following issues: attracting and retaining clients; establishing treatment partnerships; and monitoring and evaluating services.
ContextThe use of psychostimulants is increasing in Australia and internationally (see Jenner & McKetin for a thorough review of these studies). In 2000, nearly one and a half million Australians reported using amphetamines at least once in their lives, and half a million people reported use of these drugs at some time during that year (Australian Institute of Health and Welfare (AIHW), 2002). Currently, amphetamines are the second most frequently used illicit drug after cannabis (AIHW, 2002).
Psychostimulants include amphetamine sulphate and amphetamine hydrochloride ('speed'), and the more potent methamphetamine ('base', 'ice', 'pills'). Cocaine and MDMA (ecstasy) are also classed as psychostimulants but as the current intervention was evaluated among regular amphetamine users its efficacy cannot be generalised to users of other psychostimulants. Hence this guide refers to amphetamines, including methamphetamine, only.
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Amphetamines increase activity of the neurotransmitters dopamine, noradrenaline and serotonin in the central nervous system and cause a range of effects both sought after and adverse. Sought after effects of amphetamines include euphoria, mood elevation, a sense of well-being and confidence, increased energy and wakefulness, and increased concentration and alertness (Dean). Adverse effects include severe restlessness, tremor, anxiety, dizziness, tenseness, irritability, insomnia, confusion, and possibly aggression (Dean). At toxic doses amphetamines can produce psychosis, delirium, auditory, visual and tactile illusions, paranoia, hallucinations, loss of behavioural control, alterations in consciousness and severe medical complications such as serotonin toxicity and cardiovascular and neurological events (Dean, Dean & Whyte).
Amphetamine users report a reluctance to seek treatment and a level of dissatisfaction with services currently provided (Kamieniecki, Vincent, Allsop, Lintzeris, 1998). Adverse consequences of amphetamine use such as symptoms of dependence, aggression, depression, hallucinations and panic attacks have been identified as prompts for intervention seeking (see Baker, Gowing, Lee & Proudfoot, for a review of relevant studies).
Clinicians and researchers have identified the need for specific intervention approaches for this group to attract and engage clients into treatment (Baker et al.). This guide details a brief intervention specifically designed for regular amphetamine users that may be utilised by practitioners working in a wide range of treatment settings.
A flow-chart2 that visually depicts the context in which the current CBT intervention could be offered is presented in Figure 1. For further detail please refer to the National Drug Strategy Monograph Models of Intervention and Care for Psychostimulant Users.
Figure 1: Flow-chart for clinical decision making in offering interventions for psychostimulant users
Larger version of Figure 1 (GIF 136 KB) Top of page
Text version of Figure 1Figure 1 displays a flow chart for decision making in offering interventions for psychostimulant users:
- Initial assessment (Amephetamine and other drug use, mental health disorders or symptoms including suicidal ideation, readiness to changes, cravings, case formulation (SDS, speed use ladder))
- Are they acutely intoxicated?
- Yes - Medical assessment for potential toxicity is required, then proceed as normal when no longer intoxicated
- No - Proceed to Step 3.
- Do they have special needs?
- Yes -
- Young people - Focus on engagement and family involvement, then proceed as for adults (Step 4)
- Comorbid mental health symptoms -
- Do they need further specialist assessment?
- No - Ensure integrated treatment and proceed as normal (Step 4).
- Yes - Proceed below
- Do you need to refer to an external service?
- No - Secondary consultation, then proceed as normal (Step 4).
- Yes - Referral as appropriate, institute shared care arrangements as appropriate, follow-up.
- Do they need further specialist assessment?
- Polydrug - Consider all drugs in treatment plan then proceed as normal (Step 4).
- No - proceed to Step 4.
- Yes -
- Are they dependent? (Two or more: tolerance, withdrawal syndrome, uses more than intended, difficulty cutting down, significant time spent using, impact on lifestyle, uses despite harm).
- Are they a regular user?
- No - Harm minimisation, brief psycho-educational intervention & follow-up.
- Yes - Proceed to Step 6.
- Are they ready to stop or cut down?
- Do they want/need detoxification?
- Are they suitable for outpatient detoxification?
- Yes - Proceed to outpatient detoxification or home detoxification; follow-up; offer CBT intervention.
- No - Arrange inpatient detoxification; follow-up; offer CBT intervention.
1 These points have been adapted from Baker, Gowing, Lee & Proudfoot, Psychosocial Interventions for Psychostimulant Users, in Baker, Lee & Jenner (eds), Models of Intervention and Care for Psychostimulant Users, National Drug Strategy Monograph Series.
2 Adapted from Chapter 12, Clinical Recommendations in Baker, Lee & Jenner (eds), Models of Intervention and Care for Psychostimulant Users, National Drug Strategy Monograph Series No 51.