CSIRO PUBLISHING
Australian Journal of Primary Health, 2015, 21, 384–390 http://dx.doi.org/10.1071/PY14126
Review
Primary health-care responses to methamphetamine use in Australian Indigenous communities Sarah MacLean A,B, Angela Harney A and Kerry Arabena A A
Indigenous Health Equity Unit, Melbourne School of Global and Population Health, The University of Melbourne, 207 Bouverie Street, Vic. 3010, Australia. B Corresponding author. Email: [email protected]
Abstract. Crystal methamphetamine (commonly known as ‘ice’) use is currently a deeply concerning problem for some Australian Indigenous peoples and can cause serious harms to individual, families and communities. This paper is intended to support best practice responses by primary health-care staff working with Australian Indigenous people who use methamphetamine. It draws on a systematic search of relevant databases to identify literature from January 1999 to February 2014, providing an overview of prevalence, treatment, education and harm reduction, and community responses. The prevalence of methamphetamine use is higher in Indigenous than non-Indigenous communities, particularly in urban and regional settings. No evidence was identified that specifically related to effective treatment and treatment outcomes for Indigenous Australians experiencing methamphetamine dependence or problematic use. While studies involving methamphetamine users in the mainstream population suggest that psychological and residential treatments show shortterm promise, longer-term outcomes are less clear. Community-driven interventions involving Indigenous populations in Australia and internationally appear to have a high level of community acceptability; however, outcomes in terms of methamphetamine use are rarely evaluated. Improved national data on prevalence of methamphetamine use among Indigenous people and levels of treatment access would support service planning. We argue for the importance of a strength-based approach to addressing methamphetamine use, to counteract the stigma and despair that frequently accompanies it. Received 20 August 2014, accepted 22 November 2014, published online 23 February 2015
Introduction Methamphetamines are part of the ‘amphetamine’ group of stimulant drugs. While illicit amphetamines and ‘speed’ commonly comprised amphetamine sulfate in the past, methamphetamine is currently the most common type of amphetamine available in Australia (Department of Health 2012). Crystalline methamphetamine is a particularly potent form of the drug and can be smoked or injected; it is also known as ‘ice’, ‘crystal’, ‘crystal meth’ and ‘shard’. An apparent rise in methamphetamine use (MU) in Victoria has prompted a Parliamentary Inquiry, which published a report in September 2014 (Law Reform Drugs and Crime Prevention Committee 2014). Over recent years, Indigenous people, particularly those in urban and regional centres, have expressed deep concern about MU and its effects. The purpose of this article is to review available literature to provide primary health-care (PHC) staff with advice to support best practice responses to methamphetamine use (MU) among Indigenous people. We identify prevalence and trends in MU, reasons for use and associated harms, evidence-based interventions and treatment access, harm reduction and community responses. Each section briefly considers evidence regarding the general population and any available studies specifically concerning Indigenous people. We conclude Journal compilation Ó La Trobe University 2015
by offering recommendations for PHC service responses to MU. In this review, we use the term ‘methamphetamine’ or ‘ice’ to include amphetamines currently used in Australia; however, when citing a particular data source, we replicate the terms used there. The term ‘Indigenous’ is used to denote Aboriginal and Torres Strait Islanders, except where we describe research that was conducted with one of these groups of peoples, but not the other. Methods A broad systematic search was conducted to identify published and unpublished international literature concerning MU and associated interventions, with a focus on resources and information developed to meet the needs of Australian Indigenous people, or which is likely to be relevant to Australian Indigenous people. Searches were undertaken using a range of relevant databases including Medline, PsychInfo, Web of Science, Scopus, Cochrane Collaboration library and the Australian Indigenous HealthInfoNet. Additional searching was then done using the Grey Literature Report, relevant websites and Google search engine. Databases were searched using the terms ‘methamphetamine’ and ‘amphetamine’, combined with other keywords including www.publish.csiro.au/journals/py
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‘treatment’, ‘Aboriginal’, ‘Indigenous’, ‘community’ and ‘education’. For manageability and to reflect the relatively recent increase in reports of MU in Australia, searches were limited to English language articles, published in the period January 1999 to February 2014. We identified a total of 705 citations for this paper, and after initial screening of titles and deleting duplicates, we then reviewed 228 abstracts and retrieved 90 relevant articles for further review. A total of 45 papers are discussed in this paper; 31 research and review articles and 14 relevant government reports and/or grey literature sources. Abstracts were screened to exclude dissertations, older individual studies already summarised in major reviews, older review articles where more recent reviews were available and other papers considered less relevant to the focus of the project. The search was designed by all three authors and conducted by AH. The search involved identifying a diverse range of documents. As we were interested in providing a broad overview, we utilised a narrative approach towards the literature review (Booth et al. 2012). Quality assessment for included papers was managed through discussion and evaluation by the authors. We focus here on papers in peer-reviewed publications and comprehensive summaries and systematic reviews of the evidence, as well as peer-reviewed articles and clinical treatment guidelines with Australian- and Indigenous-focussed content. Hand searching these documents identified further relevant articles. Findings from our review of responses to methamphetamine use are summarised in Table 1. A list of treatment guidelines and information resources compiled from a wider search is available elsewhere (Harney et al. 2014). Reasons for methamphetamine use and associated harms Methamphetamine offers users short-term effects including reduced fatigue, euphoria, positive mood, reduced appetite, reduced inhibition and temporary improvements in concentration (Cruickshank and Dyer 2009; Panenka et al. 2013). These effects commonly last for ~8–10 h. Alongside the cheap cost and availability of methamphetamine, these effects make it an appealing drug for a range of people, from those
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who use occasionally to enhance their enjoyment of events, to those who are motivated to use for a specific purpose or occupational task, to daily dependent users (Jenner and Lee 2008). Like other Australians, Indigenous people have diverse reasons for using methamphetamine. A small qualitative study with 12 Aboriginal methamphetamine users in urban NSW included both very regular users and some occasional methamphetamine users, and it was reported that among this group, the most common motivations identified for first trying ice or speed were pressure from friends and the desire to try something new (Blue Moon Research and Planning 2008). Other drivers for use were family break-up, the price and accessibility and a few women reported being encouraged by family members to use ‘ice’ to achieve weight loss. The positive effects of use were considered to include the enjoyment, feeling good, confidence, temporarily forgetting problems, weight loss and social aspects. Short-term harms associated with MU, particularly involving higher doses, include anxiety, panic, paranoia, teeth grinding, high blood pressure, rapid heartbeat and palpitations, itching skin, sleep problems and a tendency to aggression. Stroke, heart attack and seizures also occur (Panenka et al. 2013; Rawson 2013). Longer-term effects can include organ damage, cognitive impairment, increased risk of contracting blood-borne viruses and psychosis (Darke et al. 2008; Cruickshank and Dyer 2009; Panenka et al. 2013; Rawson 2013). Compared with the powder or base forms, ‘ice’ or crystal methamphetamine is stronger and is associated with a greater likelihood of developing dependence (Cruickshank and Dyer 2009). Dependence may be chronic or involve bingeing with brief drug-free periods and dependent users can experience withdrawal symptoms (Rawson 2013). Methamphetamine is rarely the only drug an individual has tried or uses regularly (Jenner and Lee 2008). Harms are frequently increased when methamphetamines are used in combination with alcohol and other drugs (AOD) (Darke et al. 2008; Jenner and Lee 2008), with concurrent use of cannabis and/or alcohol significantly increasing the chance of psychotic symptoms (McKetin et al. 2013b).
Table 1. Responses to methamphetamine use Strongest evidence: psychosocial interventions supported by findings of multiple randomised trials and/or longitudinal studies *
*
*
Cognitive behaviour therapy (CBT) has demonstrated effectiveness in assisting methamphetamine users to reduce their use and increase rates of abstinence. CBT can involve a range of interventions such as relapse prevention and coping skills therapy and is effectively supported by motivational interviewing. It may be delivered as outpatient counselling therapy, group or individual treatment or within residential rehabilitation treatment; CBTbased brief interventions also found to be effective. Contingency management uses incentives for abstinence or treatment attendance (e.g. money or vouchers) and demonstrates significant increases in treatment retention and reductions in methamphetamine use. Strong evidence for short-term effects; longer-term effects less clear. Longer-term residential rehabilitation programs have been found in longitudinal studies to improve treatment retention and achieve positive effect in reducing methamphetamine use.
Promising approaches: strategies with limited evidence but potential for positive effect Community-wide and multi-pronged approaches to preventing methamphetamine use and related harms are provided some support by program evaluations and government reports for other substance use issues and public health concerns, and by positive outcomes from a multi-agency governmental approach to methamphetamine use in New Zealand. Comprehensive education programs to reduce methamphetamine use and related harms among occasional and regular users have been demonstrated to be effective based on a small number of quasi-experimental and controlled studies. Indigenous-specific, culturally targeted education campaigns and family support resources have been identified in individual program evaluations as having potential to strengthen community responses to methamphetamine use. *
*
*
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The potential for methamphetamine abuse and dependence to severely damage family and social relationships is well documented, including the increased risks that parents will come to the attention of child protection services or that families will experience violence (Watanabe-Galloway et al. 2009). Indigenous Australians are hospitalised as a result of mental or behavioural disorders stemming from the use of stimulant drugs at almost three-fold the rate of non-Indigenous Australians (Cussen et al. 2014). Indigenous injecting drug users are overrepresented in terms of rates of blood-borne viruses such as HIV and hepatitis C, and sexually transmissible infections (Mapfumo et al. 2010). Research emphasises the distress experienced by Indigenous methamphetamine users’ families. In turn, conflict and isolation from family have negative effects for these users themselves (Blue Moon Research and Planning 2008; Kratzmann et al. 2011). Prevalence Australia has one of the highest rates of MU in the world and high rates of methamphetamine injecting (Lee and Rawson 2008). In 2010, 7% of a representative sample of Australians aged 14 years and over reported that they had ever tried methamphetamine and ~2% had used it in the previous 12 months (Australian Institute of Health and Welfare 2011). MU is more common among males and younger age groups. Victorians aged 22–24 years are around four-fold more likely to report past year MU than the overall national average (Department of Health 2012). A small decrease in the recent use of meth/amphetamines was evident between 1998 and 2010 (Australian Institute of Health and Welfare 2011); however, there is a clear indication of subsequent increases in use in some populations, including police detainees (Sweeney and Payne 2012). Early data from the 2013 national survey show no significant increase in meth/ amphetamine use, but a significant reduction in the use of the drug in a powder form, with a corresponding increase in the use of crystal methamphetamine, from 22% in 2010 to 50% in 2013 (Australian Institute of Health and Welfare 2014b). Prevalence of MU appears to be higher among Indigenous than non-Indigenous Australians, with Indigenous Australians more likely to report past year use (3.6% compared with 1.9%). MU among Indigenous Australians rose from 2.3% in 2007 to 3.6% in 2010 (Australian Institute of Health and Welfare 2011); however, these findings should be interpreted with caution due to comparatively small sample sizes of Indigenous respondents. The 2012–13 National Australian Aboriginal and Torres Strait Islander Health Survey reported that 2.7% of Indigenous Australians living in non-remote areas reported past year use of ‘speed or amphetamine’ (Australian Bureau of Statistics 2013). Recent reports from service providers indicate that the use of ‘ice’ in particular has increased among young Indigenous Victorians and among Indigenous offenders, with particularly high rates in some regional centres (Australian Community Support Organisation 2013). Statewide estimates of MU among clients of the Victorian Aboriginal Legal Service indicate a very high prevalence of use; an estimated 15–60% of clients
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used ‘ice’ at the time of offending, and 20–70% of all clients used ‘ice’ (Victorian Aboriginal Legal Service 2013). Treatment and treatment access Systematic reviews of the evidence for methamphetamine dependence treatment options have found that psychological interventions can be effective, with particular support for cognitive behaviour therapy (CBT) and contingency management (CM) (Lee and Rawson 2008; Ciketic et al. 2012). CBT may involve a range of interventions such as relapse prevention and coping skills therapy. Delivered as outpatient counselling therapy or within residential rehabilitation treatment, CBT has demonstrated effectiveness in assisting methamphetamine users to reduce their use and increase rates of abstinence (Ciketic et al. 2012). CM reinforces desired behaviours such as attendance at treatment or returning a drugfree urine sample with rewards such as vouchers or money. It appears to increase treatment retention and support significant reductions in MU during the treatment period (Lee and Rawson 2008). However, its longer-term effects on use and other outcomes are not clear and CM is not commonly used in Australia. Motivational interviewing and stepped care treatment models have been effectively used to address low motivation to cease MU and increase treatment access among methamphetamine users (Kay-Lambkin et al. 2010; McKetin et al. 2013a). For example, stimulant treatment clinics established in NSW involving outpatient counselling tailored to individual users’ needs and levels of dependence were effective in reducing MU and a range of mental health-related symptoms. Younger users who have had no previous treatment experience showed the greatest reductions in these measures (McKetin et al. 2013a). While no treatment outcome evidence specific to methamphetamine users in self-help and mutual support groups is available, there is early limited evidence supporting the use of gender-specific Aboriginal support groups for substance use issues (Lee et al. 2012; Lee et al. 2013). CBT-based support groups for substance users (SMART Recovery) and methamphetamine-specific 12-step groups (similar to Narcotic Anonymous) are now operating in Australia (Jenner and Lee 2008). Residential rehabilitation also appears to have some positive effects (Ciketic et al. 2012). A recent Australian study found that residential rehabilitation produced large reductions in MU at up to 3 months after treatment, although this was substantially reduced at 1- and 3-year follow up (McKetin et al. 2012). Inpatient detoxification was not found to reduce MU at any follow-up point, when compared with receiving no treatment. Inpatient detoxification is recommended only as a first step in a structured treatment program (McKetin et al. 2012). Residential treatment interventions may be more suitable for some methamphetamine users, such as injecting drug users and individuals experiencing greater levels of disadvantage (Ciketic et al. 2012), and may be a practical option for some Indigenous substance users who have less stability in their lives and thus are at higher risk of relapse (Gray et al. 2010). No broadly effective pharmacotherapy options have been identified in clinical trials for methamphetamine users (Lee and
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Rawson 2008; Brensilver et al. 2013) and as yet, no medications have been approved for use in withdrawal from methamphetamine (Shoptaw et al. 2009; Pennay and Lee 2011). Current medical management of withdrawal involves medications to help reduce symptoms of insomnia and anxiety experienced during early withdrawal stages, with support often provided in home-based or outpatient withdrawal settings (Shoptaw et al. 2009; Pennay and Lee 2011). However, a recent systematic review of medication treatment options for amphetamine-type stimulants found that there was no evidence to support the use of benzodiazepines to help manage sleep disturbance and agitation during withdrawal (LeeJenn Health Consultants 2014). Australian methamphetamine treatment guidelines are available. These guidelines provide specific advice in relation to Indigenous clients, including provision of culturally appropriate assessment and information resources and liaison with available support agencies (Jenner and Lee 2008). Other treatment manuals and reviews offer suggestions on treatment for Indigenous AOD users without specifically considering methamphetamine (Teasdale et al. 2008; Gray et al. 2010; Lee et al. 2012; Victorian Dual Diagnosis Education and Training Unit 2012). Collaborative, culturally sensitive, strengths-based and family inclusive approaches are commonly recommended. Despite the prevalence of MU, treatment access is low, particularly for those who smoke rather than inject (Australian Institute of Health and Welfare 2013; Quinn et al. 2013). National data shows that during 2011–12, Indigenous service users participated in nearly 10% of episodes where amphetamines were the principal drug of concern and most treatment episodes for this group involved counselling (Australian Institute of Health and Welfare 2013). It is probable, however, that most of these figures under-estimate the number of Indigenous clients accessing treatment for substance use issues. Data from the National Minimum Dataset does not include statistics on treatment accessed in agencies funded by the Office for Aboriginal and Torres Strait Islander Health, which in 2012–13, included 205 Indigenous-specific PHC and 63 substance use services. Approximately one-quarter of these services were located in the Northern Territory and 22% in New South Wales (Australian Institute of Health and Welfare 2014a). Nationally, in 2012–13, 43% of services providing AOD treatment for Indigenous people and 28% providing PHC to Indigenous people reported responding to amphetamine use issues (Australian Institute of Health and Welfare 2014a). Education and harm reduction Education directed at reducing drug use and minimising drugrelated harms is important for people who are unlikely to cease MU entirely. For example, smoking and injecting methamphetamine are more strongly associated with the development of dependence than using the drug by snorting or swallowing (Rawson 2013). Harm-reduction education might discourage transition to these routes of administration (Pennay and Lee 2008). Nonetheless, some Indigenous communities are wary of harm reduction and this must be kept in mind when implementing any such interventions (van der Sterren et al. 2006).
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Recent evidence supports the effectiveness of comprehensive education programs in reducing MU and related harms among occasional and regular users, particularly where peers disseminate messages. An Australian project used peers to deliver psychostimulant-related health and drug education messages to ecstasy users at music festivals, dance events and nightclubs in three Australian cities. This was associated with reductions in both ecstasy and MU. The study suggests that health messages should be simple to convey and comprehend (Silins et al. 2013). In Thailand, young, regular methamphetamine users attended either a peer educator and social network intervention, or a best practice life-skills education program on MU, sexual behaviours and sexually transmissible infections. Engagement in either of these interventions was associated with significant declines in self-reported MU and consistent condom use (Sherman et al. 2009). While little evidence is available on effective approaches to education for Australian Indigenous people who use methamphetamines, Indigenous people in other countries have successfully used culturally targeted education and social marketing campaigns. In the US, the ‘Indian Country Methamphetamine Initiative’, involved multifaceted approaches to prevention, including culturally relevant multi-media campaigns (e.g. ‘Meth addiction is NOT our tradition’). This reportedly contributed to reductions in methamphetaminerelated arrests and incidents (Walker et al. 2011). New Zealand’s Patua te Ngangara, provided a Maori community drug education program focussed on extended family members (whanau) effected by MU. An evaluation of the program does not describe outcomes in terms of reducing use and related harms, but indicates the program developed and disseminated effective, family-specific resources based on a ‘best practice’ approach. This involved working with whanau and ex-users to identify their strengths and the strategies they have used to deal with MU, and collating these as a resource (Te Puni K okiri 2008). Community action on methamphetamine No one strategy is enough on its own to produce long-term changes in MU within any community, and multiple reinforcing prevention interventions are likely to have the greatest impact (Birckmayer et al. 2008; Goldberg 2007). Community-wide responses to substance use problems may be developed at a local level but are generally most successful when they involve coalitions and broad participation across individuals and organisations in the community. They may, for instance, combine school-based education, community education and mobilisation and work in collaboration with local police units, courts and law enforcement activities (Birckmayer et al. 2008). A local example of an urban Indigenous community response to MU and increasing levels of drug-related violence involved essentially ‘banning’ the use of methamphetamine in ‘The Block’; Redfern in NSW (Blue Moon Research and Planning 2008). This Aboriginal community enforcement strategy was argued to be more effective as a deterrent to MU than policing approaches in the neighbourhood, although there is limited available information on how it was implemented or the extent of its impact.
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Despite widespread agreement that responses to AOD use within Indigenous communities should be community owned and driven, there are few formal evaluations of community responses to MU. The Indian Country Methamphetamine Initiative in the US provides an example of a coordinated education, treatment and law enforcement campaign (Walker et al. 2011). At a national level, the New Zealand government initiative Tackling Methamphetamine: An Action Plan demonstrates a multi-agency approach involving government departments and agencies responsible for health, police, corrections and customs and Maori affairs. The project reports positive outcomes including increased rates of treatment and information seeking and access and a significant reduction in prevalence of MU for 16–64 year olds (from 2.2% in 2009 to 0.9% in 2013) (State Services Commission New Zealand 2013). Evaluation of a multi-agency taskforce initiative in San Diego, US, indicated that sustained efforts are required in communities with a high prevalence of MU (Goldberg 2007). The Victorian consortium ‘Project Ice: Mildura’ is a current example of a coordinated response and community awareness program. This project involves local police, mainstream and Aboriginal health and substance use treatment services, local council and community members. It is currently being evaluated (Maisner 2014). Conclusions: implications for PHC responses to methamphetamine use Methamphetamine is relatively cheap, widely available and offers powerful psychotropic effects. This makes it an appealing drug for a range of people, and particularly those who have limited access to money or compelling reasons to be intoxicated due to difficult life circumstances. Indigenous people appear to be over-represented among Australian methamphetamine users and this form of drug use may have particularly distressing effects in Indigenous communities where many other social and health issues are also pressing. No evidence was identified through this review that specifically related to effective treatment and treatment outcomes for Indigenous Australians experiencing methamphetamine dependence or problematic use. While studies involving methamphetamine users in the mainstream population suggest that psychological and residential treatments show short-term promise, longer-term outcomes are unclear. Clinical treatment guidelines formulated for the general community should guide treatment until more specific advice is available. Experience from New Zealand provides a model for a response aimed specifically at supporting family members of Indigenous MU, and this kind of intervention could usefully be developed for use with Australian Indigenous communities. Public health-care workers should also offer culturally sensitive information and educational resources to Indigenous methamphetamine users. Peer education models are worthy of further exploration here. Many examples of culturally specific flyers and posters are available. While controversial in some Indigenous communities, harm reduction has a role to play, particularly in encouraging people not to transition from powder forms of meth/amphetamine to ‘ice’ use, or to more
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harmful methods of use (e.g. from ‘snorting’ to smoking or injecting). Indigenous community-driven responses have been an effective way to demonstrate concern and act on other forms of substance use (MacLean and d’Abbs 2002). Multi-agency programs frequently involve PHC workers as representatives of a range of agencies and have been associated with increased treatment seeking and even reductions in MU. As with treatment and education, any intervention of this nature should include careful evaluation wherever possible, so others can learn from the experience. Some responses to MU require broader action than can be achieved by the PHC workforce. For example, improved data collection is required that reflects treatments provided through Indigenous community-controlled services, as well as mainstream AOD agencies. In areas of high need, it would be appropriate to develop and evaluate Indigenous-specific treatment responses to MU. This should occur alongside tracking outcomes for Indigenous people who use methamphetamine and seek treatment through mainstream services. Methamphetamine use can be deeply distressing for affected communities, whether Indigenous or not. This can lead to despair about the likely effectiveness of any kind of action. While MU is associated with serious harms for individuals and communities, it is not inevitable that any person using methamphetamine will progress to dependence, injury and social dislocation, or that no one will be able to help them. The strength-based approach adopted in the New Zealand Patua te Ngangara program offers a useful way forward here. It is important that stories of successful intervention addressing MU be available to Australian Indigenous communities. Publically available accounts of people’s journeys towards reduction or cessation of MU would also help to counteract the stigma and sense of powerlessness that MU too often generates. Conflicts of interest None declared. Acknowledgements SM is supported by a Senior Research Fellowship funded by VicHealth.
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Australian Journal of Primary Health, 2015, 21, 384–390 http://dx.doi.org/10.1071/PY14126
Review
Primary health-care responses to methamphetamine use in Australian Indigenous communities Sarah MacLean A,B, Angela Harney A and Kerry Arabena A A
Indigenous Health Equity Unit, Melbourne School of Global and Population Health, The University of Melbourne, 207 Bouverie Street, Vic. 3010, Australia. B Corresponding author. Email: [email protected]
Abstract. Crystal methamphetamine (commonly known as ‘ice’) use is currently a deeply concerning problem for some Australian Indigenous peoples and can cause serious harms to individual, families and communities. This paper is intended to support best practice responses by primary health-care staff working with Australian Indigenous people who use methamphetamine. It draws on a systematic search of relevant databases to identify literature from January 1999 to February 2014, providing an overview of prevalence, treatment, education and harm reduction, and community responses. The prevalence of methamphetamine use is higher in Indigenous than non-Indigenous communities, particularly in urban and regional settings. No evidence was identified that specifically related to effective treatment and treatment outcomes for Indigenous Australians experiencing methamphetamine dependence or problematic use. While studies involving methamphetamine users in the mainstream population suggest that psychological and residential treatments show shortterm promise, longer-term outcomes are less clear. Community-driven interventions involving Indigenous populations in Australia and internationally appear to have a high level of community acceptability; however, outcomes in terms of methamphetamine use are rarely evaluated. Improved national data on prevalence of methamphetamine use among Indigenous people and levels of treatment access would support service planning. We argue for the importance of a strength-based approach to addressing methamphetamine use, to counteract the stigma and despair that frequently accompanies it. Received 20 August 2014, accepted 22 November 2014, published online 23 February 2015
Introduction Methamphetamines are part of the ‘amphetamine’ group of stimulant drugs. While illicit amphetamines and ‘speed’ commonly comprised amphetamine sulfate in the past, methamphetamine is currently the most common type of amphetamine available in Australia (Department of Health 2012). Crystalline methamphetamine is a particularly potent form of the drug and can be smoked or injected; it is also known as ‘ice’, ‘crystal’, ‘crystal meth’ and ‘shard’. An apparent rise in methamphetamine use (MU) in Victoria has prompted a Parliamentary Inquiry, which published a report in September 2014 (Law Reform Drugs and Crime Prevention Committee 2014). Over recent years, Indigenous people, particularly those in urban and regional centres, have expressed deep concern about MU and its effects. The purpose of this article is to review available literature to provide primary health-care (PHC) staff with advice to support best practice responses to methamphetamine use (MU) among Indigenous people. We identify prevalence and trends in MU, reasons for use and associated harms, evidence-based interventions and treatment access, harm reduction and community responses. Each section briefly considers evidence regarding the general population and any available studies specifically concerning Indigenous people. We conclude Journal compilation Ó La Trobe University 2015
by offering recommendations for PHC service responses to MU. In this review, we use the term ‘methamphetamine’ or ‘ice’ to include amphetamines currently used in Australia; however, when citing a particular data source, we replicate the terms used there. The term ‘Indigenous’ is used to denote Aboriginal and Torres Strait Islanders, except where we describe research that was conducted with one of these groups of peoples, but not the other. Methods A broad systematic search was conducted to identify published and unpublished international literature concerning MU and associated interventions, with a focus on resources and information developed to meet the needs of Australian Indigenous people, or which is likely to be relevant to Australian Indigenous people. Searches were undertaken using a range of relevant databases including Medline, PsychInfo, Web of Science, Scopus, Cochrane Collaboration library and the Australian Indigenous HealthInfoNet. Additional searching was then done using the Grey Literature Report, relevant websites and Google search engine. Databases were searched using the terms ‘methamphetamine’ and ‘amphetamine’, combined with other keywords including www.publish.csiro.au/journals/py
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‘treatment’, ‘Aboriginal’, ‘Indigenous’, ‘community’ and ‘education’. For manageability and to reflect the relatively recent increase in reports of MU in Australia, searches were limited to English language articles, published in the period January 1999 to February 2014. We identified a total of 705 citations for this paper, and after initial screening of titles and deleting duplicates, we then reviewed 228 abstracts and retrieved 90 relevant articles for further review. A total of 45 papers are discussed in this paper; 31 research and review articles and 14 relevant government reports and/or grey literature sources. Abstracts were screened to exclude dissertations, older individual studies already summarised in major reviews, older review articles where more recent reviews were available and other papers considered less relevant to the focus of the project. The search was designed by all three authors and conducted by AH. The search involved identifying a diverse range of documents. As we were interested in providing a broad overview, we utilised a narrative approach towards the literature review (Booth et al. 2012). Quality assessment for included papers was managed through discussion and evaluation by the authors. We focus here on papers in peer-reviewed publications and comprehensive summaries and systematic reviews of the evidence, as well as peer-reviewed articles and clinical treatment guidelines with Australian- and Indigenous-focussed content. Hand searching these documents identified further relevant articles. Findings from our review of responses to methamphetamine use are summarised in Table 1. A list of treatment guidelines and information resources compiled from a wider search is available elsewhere (Harney et al. 2014). Reasons for methamphetamine use and associated harms Methamphetamine offers users short-term effects including reduced fatigue, euphoria, positive mood, reduced appetite, reduced inhibition and temporary improvements in concentration (Cruickshank and Dyer 2009; Panenka et al. 2013). These effects commonly last for ~8–10 h. Alongside the cheap cost and availability of methamphetamine, these effects make it an appealing drug for a range of people, from those
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who use occasionally to enhance their enjoyment of events, to those who are motivated to use for a specific purpose or occupational task, to daily dependent users (Jenner and Lee 2008). Like other Australians, Indigenous people have diverse reasons for using methamphetamine. A small qualitative study with 12 Aboriginal methamphetamine users in urban NSW included both very regular users and some occasional methamphetamine users, and it was reported that among this group, the most common motivations identified for first trying ice or speed were pressure from friends and the desire to try something new (Blue Moon Research and Planning 2008). Other drivers for use were family break-up, the price and accessibility and a few women reported being encouraged by family members to use ‘ice’ to achieve weight loss. The positive effects of use were considered to include the enjoyment, feeling good, confidence, temporarily forgetting problems, weight loss and social aspects. Short-term harms associated with MU, particularly involving higher doses, include anxiety, panic, paranoia, teeth grinding, high blood pressure, rapid heartbeat and palpitations, itching skin, sleep problems and a tendency to aggression. Stroke, heart attack and seizures also occur (Panenka et al. 2013; Rawson 2013). Longer-term effects can include organ damage, cognitive impairment, increased risk of contracting blood-borne viruses and psychosis (Darke et al. 2008; Cruickshank and Dyer 2009; Panenka et al. 2013; Rawson 2013). Compared with the powder or base forms, ‘ice’ or crystal methamphetamine is stronger and is associated with a greater likelihood of developing dependence (Cruickshank and Dyer 2009). Dependence may be chronic or involve bingeing with brief drug-free periods and dependent users can experience withdrawal symptoms (Rawson 2013). Methamphetamine is rarely the only drug an individual has tried or uses regularly (Jenner and Lee 2008). Harms are frequently increased when methamphetamines are used in combination with alcohol and other drugs (AOD) (Darke et al. 2008; Jenner and Lee 2008), with concurrent use of cannabis and/or alcohol significantly increasing the chance of psychotic symptoms (McKetin et al. 2013b).
Table 1. Responses to methamphetamine use Strongest evidence: psychosocial interventions supported by findings of multiple randomised trials and/or longitudinal studies *
*
*
Cognitive behaviour therapy (CBT) has demonstrated effectiveness in assisting methamphetamine users to reduce their use and increase rates of abstinence. CBT can involve a range of interventions such as relapse prevention and coping skills therapy and is effectively supported by motivational interviewing. It may be delivered as outpatient counselling therapy, group or individual treatment or within residential rehabilitation treatment; CBTbased brief interventions also found to be effective. Contingency management uses incentives for abstinence or treatment attendance (e.g. money or vouchers) and demonstrates significant increases in treatment retention and reductions in methamphetamine use. Strong evidence for short-term effects; longer-term effects less clear. Longer-term residential rehabilitation programs have been found in longitudinal studies to improve treatment retention and achieve positive effect in reducing methamphetamine use.
Promising approaches: strategies with limited evidence but potential for positive effect Community-wide and multi-pronged approaches to preventing methamphetamine use and related harms are provided some support by program evaluations and government reports for other substance use issues and public health concerns, and by positive outcomes from a multi-agency governmental approach to methamphetamine use in New Zealand. Comprehensive education programs to reduce methamphetamine use and related harms among occasional and regular users have been demonstrated to be effective based on a small number of quasi-experimental and controlled studies. Indigenous-specific, culturally targeted education campaigns and family support resources have been identified in individual program evaluations as having potential to strengthen community responses to methamphetamine use. *
*
*
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The potential for methamphetamine abuse and dependence to severely damage family and social relationships is well documented, including the increased risks that parents will come to the attention of child protection services or that families will experience violence (Watanabe-Galloway et al. 2009). Indigenous Australians are hospitalised as a result of mental or behavioural disorders stemming from the use of stimulant drugs at almost three-fold the rate of non-Indigenous Australians (Cussen et al. 2014). Indigenous injecting drug users are overrepresented in terms of rates of blood-borne viruses such as HIV and hepatitis C, and sexually transmissible infections (Mapfumo et al. 2010). Research emphasises the distress experienced by Indigenous methamphetamine users’ families. In turn, conflict and isolation from family have negative effects for these users themselves (Blue Moon Research and Planning 2008; Kratzmann et al. 2011). Prevalence Australia has one of the highest rates of MU in the world and high rates of methamphetamine injecting (Lee and Rawson 2008). In 2010, 7% of a representative sample of Australians aged 14 years and over reported that they had ever tried methamphetamine and ~2% had used it in the previous 12 months (Australian Institute of Health and Welfare 2011). MU is more common among males and younger age groups. Victorians aged 22–24 years are around four-fold more likely to report past year MU than the overall national average (Department of Health 2012). A small decrease in the recent use of meth/amphetamines was evident between 1998 and 2010 (Australian Institute of Health and Welfare 2011); however, there is a clear indication of subsequent increases in use in some populations, including police detainees (Sweeney and Payne 2012). Early data from the 2013 national survey show no significant increase in meth/ amphetamine use, but a significant reduction in the use of the drug in a powder form, with a corresponding increase in the use of crystal methamphetamine, from 22% in 2010 to 50% in 2013 (Australian Institute of Health and Welfare 2014b). Prevalence of MU appears to be higher among Indigenous than non-Indigenous Australians, with Indigenous Australians more likely to report past year use (3.6% compared with 1.9%). MU among Indigenous Australians rose from 2.3% in 2007 to 3.6% in 2010 (Australian Institute of Health and Welfare 2011); however, these findings should be interpreted with caution due to comparatively small sample sizes of Indigenous respondents. The 2012–13 National Australian Aboriginal and Torres Strait Islander Health Survey reported that 2.7% of Indigenous Australians living in non-remote areas reported past year use of ‘speed or amphetamine’ (Australian Bureau of Statistics 2013). Recent reports from service providers indicate that the use of ‘ice’ in particular has increased among young Indigenous Victorians and among Indigenous offenders, with particularly high rates in some regional centres (Australian Community Support Organisation 2013). Statewide estimates of MU among clients of the Victorian Aboriginal Legal Service indicate a very high prevalence of use; an estimated 15–60% of clients
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used ‘ice’ at the time of offending, and 20–70% of all clients used ‘ice’ (Victorian Aboriginal Legal Service 2013). Treatment and treatment access Systematic reviews of the evidence for methamphetamine dependence treatment options have found that psychological interventions can be effective, with particular support for cognitive behaviour therapy (CBT) and contingency management (CM) (Lee and Rawson 2008; Ciketic et al. 2012). CBT may involve a range of interventions such as relapse prevention and coping skills therapy. Delivered as outpatient counselling therapy or within residential rehabilitation treatment, CBT has demonstrated effectiveness in assisting methamphetamine users to reduce their use and increase rates of abstinence (Ciketic et al. 2012). CM reinforces desired behaviours such as attendance at treatment or returning a drugfree urine sample with rewards such as vouchers or money. It appears to increase treatment retention and support significant reductions in MU during the treatment period (Lee and Rawson 2008). However, its longer-term effects on use and other outcomes are not clear and CM is not commonly used in Australia. Motivational interviewing and stepped care treatment models have been effectively used to address low motivation to cease MU and increase treatment access among methamphetamine users (Kay-Lambkin et al. 2010; McKetin et al. 2013a). For example, stimulant treatment clinics established in NSW involving outpatient counselling tailored to individual users’ needs and levels of dependence were effective in reducing MU and a range of mental health-related symptoms. Younger users who have had no previous treatment experience showed the greatest reductions in these measures (McKetin et al. 2013a). While no treatment outcome evidence specific to methamphetamine users in self-help and mutual support groups is available, there is early limited evidence supporting the use of gender-specific Aboriginal support groups for substance use issues (Lee et al. 2012; Lee et al. 2013). CBT-based support groups for substance users (SMART Recovery) and methamphetamine-specific 12-step groups (similar to Narcotic Anonymous) are now operating in Australia (Jenner and Lee 2008). Residential rehabilitation also appears to have some positive effects (Ciketic et al. 2012). A recent Australian study found that residential rehabilitation produced large reductions in MU at up to 3 months after treatment, although this was substantially reduced at 1- and 3-year follow up (McKetin et al. 2012). Inpatient detoxification was not found to reduce MU at any follow-up point, when compared with receiving no treatment. Inpatient detoxification is recommended only as a first step in a structured treatment program (McKetin et al. 2012). Residential treatment interventions may be more suitable for some methamphetamine users, such as injecting drug users and individuals experiencing greater levels of disadvantage (Ciketic et al. 2012), and may be a practical option for some Indigenous substance users who have less stability in their lives and thus are at higher risk of relapse (Gray et al. 2010). No broadly effective pharmacotherapy options have been identified in clinical trials for methamphetamine users (Lee and
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Rawson 2008; Brensilver et al. 2013) and as yet, no medications have been approved for use in withdrawal from methamphetamine (Shoptaw et al. 2009; Pennay and Lee 2011). Current medical management of withdrawal involves medications to help reduce symptoms of insomnia and anxiety experienced during early withdrawal stages, with support often provided in home-based or outpatient withdrawal settings (Shoptaw et al. 2009; Pennay and Lee 2011). However, a recent systematic review of medication treatment options for amphetamine-type stimulants found that there was no evidence to support the use of benzodiazepines to help manage sleep disturbance and agitation during withdrawal (LeeJenn Health Consultants 2014). Australian methamphetamine treatment guidelines are available. These guidelines provide specific advice in relation to Indigenous clients, including provision of culturally appropriate assessment and information resources and liaison with available support agencies (Jenner and Lee 2008). Other treatment manuals and reviews offer suggestions on treatment for Indigenous AOD users without specifically considering methamphetamine (Teasdale et al. 2008; Gray et al. 2010; Lee et al. 2012; Victorian Dual Diagnosis Education and Training Unit 2012). Collaborative, culturally sensitive, strengths-based and family inclusive approaches are commonly recommended. Despite the prevalence of MU, treatment access is low, particularly for those who smoke rather than inject (Australian Institute of Health and Welfare 2013; Quinn et al. 2013). National data shows that during 2011–12, Indigenous service users participated in nearly 10% of episodes where amphetamines were the principal drug of concern and most treatment episodes for this group involved counselling (Australian Institute of Health and Welfare 2013). It is probable, however, that most of these figures under-estimate the number of Indigenous clients accessing treatment for substance use issues. Data from the National Minimum Dataset does not include statistics on treatment accessed in agencies funded by the Office for Aboriginal and Torres Strait Islander Health, which in 2012–13, included 205 Indigenous-specific PHC and 63 substance use services. Approximately one-quarter of these services were located in the Northern Territory and 22% in New South Wales (Australian Institute of Health and Welfare 2014a). Nationally, in 2012–13, 43% of services providing AOD treatment for Indigenous people and 28% providing PHC to Indigenous people reported responding to amphetamine use issues (Australian Institute of Health and Welfare 2014a). Education and harm reduction Education directed at reducing drug use and minimising drugrelated harms is important for people who are unlikely to cease MU entirely. For example, smoking and injecting methamphetamine are more strongly associated with the development of dependence than using the drug by snorting or swallowing (Rawson 2013). Harm-reduction education might discourage transition to these routes of administration (Pennay and Lee 2008). Nonetheless, some Indigenous communities are wary of harm reduction and this must be kept in mind when implementing any such interventions (van der Sterren et al. 2006).
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Recent evidence supports the effectiveness of comprehensive education programs in reducing MU and related harms among occasional and regular users, particularly where peers disseminate messages. An Australian project used peers to deliver psychostimulant-related health and drug education messages to ecstasy users at music festivals, dance events and nightclubs in three Australian cities. This was associated with reductions in both ecstasy and MU. The study suggests that health messages should be simple to convey and comprehend (Silins et al. 2013). In Thailand, young, regular methamphetamine users attended either a peer educator and social network intervention, or a best practice life-skills education program on MU, sexual behaviours and sexually transmissible infections. Engagement in either of these interventions was associated with significant declines in self-reported MU and consistent condom use (Sherman et al. 2009). While little evidence is available on effective approaches to education for Australian Indigenous people who use methamphetamines, Indigenous people in other countries have successfully used culturally targeted education and social marketing campaigns. In the US, the ‘Indian Country Methamphetamine Initiative’, involved multifaceted approaches to prevention, including culturally relevant multi-media campaigns (e.g. ‘Meth addiction is NOT our tradition’). This reportedly contributed to reductions in methamphetaminerelated arrests and incidents (Walker et al. 2011). New Zealand’s Patua te Ngangara, provided a Maori community drug education program focussed on extended family members (whanau) effected by MU. An evaluation of the program does not describe outcomes in terms of reducing use and related harms, but indicates the program developed and disseminated effective, family-specific resources based on a ‘best practice’ approach. This involved working with whanau and ex-users to identify their strengths and the strategies they have used to deal with MU, and collating these as a resource (Te Puni K okiri 2008). Community action on methamphetamine No one strategy is enough on its own to produce long-term changes in MU within any community, and multiple reinforcing prevention interventions are likely to have the greatest impact (Birckmayer et al. 2008; Goldberg 2007). Community-wide responses to substance use problems may be developed at a local level but are generally most successful when they involve coalitions and broad participation across individuals and organisations in the community. They may, for instance, combine school-based education, community education and mobilisation and work in collaboration with local police units, courts and law enforcement activities (Birckmayer et al. 2008). A local example of an urban Indigenous community response to MU and increasing levels of drug-related violence involved essentially ‘banning’ the use of methamphetamine in ‘The Block’; Redfern in NSW (Blue Moon Research and Planning 2008). This Aboriginal community enforcement strategy was argued to be more effective as a deterrent to MU than policing approaches in the neighbourhood, although there is limited available information on how it was implemented or the extent of its impact.
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Despite widespread agreement that responses to AOD use within Indigenous communities should be community owned and driven, there are few formal evaluations of community responses to MU. The Indian Country Methamphetamine Initiative in the US provides an example of a coordinated education, treatment and law enforcement campaign (Walker et al. 2011). At a national level, the New Zealand government initiative Tackling Methamphetamine: An Action Plan demonstrates a multi-agency approach involving government departments and agencies responsible for health, police, corrections and customs and Maori affairs. The project reports positive outcomes including increased rates of treatment and information seeking and access and a significant reduction in prevalence of MU for 16–64 year olds (from 2.2% in 2009 to 0.9% in 2013) (State Services Commission New Zealand 2013). Evaluation of a multi-agency taskforce initiative in San Diego, US, indicated that sustained efforts are required in communities with a high prevalence of MU (Goldberg 2007). The Victorian consortium ‘Project Ice: Mildura’ is a current example of a coordinated response and community awareness program. This project involves local police, mainstream and Aboriginal health and substance use treatment services, local council and community members. It is currently being evaluated (Maisner 2014). Conclusions: implications for PHC responses to methamphetamine use Methamphetamine is relatively cheap, widely available and offers powerful psychotropic effects. This makes it an appealing drug for a range of people, and particularly those who have limited access to money or compelling reasons to be intoxicated due to difficult life circumstances. Indigenous people appear to be over-represented among Australian methamphetamine users and this form of drug use may have particularly distressing effects in Indigenous communities where many other social and health issues are also pressing. No evidence was identified through this review that specifically related to effective treatment and treatment outcomes for Indigenous Australians experiencing methamphetamine dependence or problematic use. While studies involving methamphetamine users in the mainstream population suggest that psychological and residential treatments show short-term promise, longer-term outcomes are unclear. Clinical treatment guidelines formulated for the general community should guide treatment until more specific advice is available. Experience from New Zealand provides a model for a response aimed specifically at supporting family members of Indigenous MU, and this kind of intervention could usefully be developed for use with Australian Indigenous communities. Public health-care workers should also offer culturally sensitive information and educational resources to Indigenous methamphetamine users. Peer education models are worthy of further exploration here. Many examples of culturally specific flyers and posters are available. While controversial in some Indigenous communities, harm reduction has a role to play, particularly in encouraging people not to transition from powder forms of meth/amphetamine to ‘ice’ use, or to more
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harmful methods of use (e.g. from ‘snorting’ to smoking or injecting). Indigenous community-driven responses have been an effective way to demonstrate concern and act on other forms of substance use (MacLean and d’Abbs 2002). Multi-agency programs frequently involve PHC workers as representatives of a range of agencies and have been associated with increased treatment seeking and even reductions in MU. As with treatment and education, any intervention of this nature should include careful evaluation wherever possible, so others can learn from the experience. Some responses to MU require broader action than can be achieved by the PHC workforce. For example, improved data collection is required that reflects treatments provided through Indigenous community-controlled services, as well as mainstream AOD agencies. In areas of high need, it would be appropriate to develop and evaluate Indigenous-specific treatment responses to MU. This should occur alongside tracking outcomes for Indigenous people who use methamphetamine and seek treatment through mainstream services. Methamphetamine use can be deeply distressing for affected communities, whether Indigenous or not. This can lead to despair about the likely effectiveness of any kind of action. While MU is associated with serious harms for individuals and communities, it is not inevitable that any person using methamphetamine will progress to dependence, injury and social dislocation, or that no one will be able to help them. The strength-based approach adopted in the New Zealand Patua te Ngangara program offers a useful way forward here. It is important that stories of successful intervention addressing MU be available to Australian Indigenous communities. Publically available accounts of people’s journeys towards reduction or cessation of MU would also help to counteract the stigma and sense of powerlessness that MU too often generates. Conflicts of interest None declared. Acknowledgements SM is supported by a Senior Research Fellowship funded by VicHealth.
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