Management of Patients With Psychostimulant Use Problems Guidelines for General

Management of patients with psychostimulant use problems Guidelines for general practitioners

Management of patients with psychostimulant use problems Guidelines for general practitioners

© Commonwealth of Australia 2004 This work is copyright. Apart from any use use as permitted under the Copyright Act 1968,, no part may be reproduced by any process without prior written permission 1968 from the Commonwealth available from the Department of Communications, Information Technology Technology and the Arts. Requests and inquiries concerning reprodu reproduction ction and rights should be addressed to the Commonwealth Copyright Administration, Intellectual Property Branch, Department of Communications, Information Technology Technology and the Arts, GPO Box 2154, Canberra ACT 2601 or posted at http://www.dcita.gov.au/cca.

ISBN: 0 642 82524 6 Publication approval number: 3516 (JN 8726)

To request copies of this document, telephone Nat ional Mailing and Marketing on To 1800 020103, extension 8654, or e-mail them at [email protected] Guidelines prepared by Linda Jenner, Amanda Baker, Ian Whyte and Vaughan Carr on behalf of the Guidelines Development Working Party. Suggest ed Citation: Suggested Citatio n: Jenner, L., Baker, Baker, A., Whyte, I., & Carr, Carr, V. V. Management of patients with psychostimulant use problems – Guidelines for general practitioners practitioners.. Canberra. Australian Government Department of Health and Ageing. Ageing. The opinions expressed in this document are those of the authors and are not necessarily those of the Australian Government.

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M ANAGEMENT

OF PATIENTS WITH PSYCHOSTIMULANT USE PROBLEMS

• GUIDELINES FOR GENERAL

PRACTITIONERS

Contents

Background

v

Purpose and scope of the guidelines

v

Target groups

v

Definition of psychostimulants

vi

Patterns of psychostimulant use

vi

Definition of acute psychostimulant toxicity

vi

Introduction

vii

Key points

vii

The role of the general practitioner

viii

Guidelines

1

Assessment

2

When a patient discloses psychostimulant use

2

When a patient does not disclose psychostimulant use

4

General principles of management

5

Experimental, recreational, occupational and non-injecting users who are not dependent on psychostimulants

5

Regular users and dependent users

5

Special issues in management

7

Amphetamine-related psychosis

7

Behavioural disturbances

7

Serotonin toxicity

8

Assisting family members and carers

9

In a nutshell

11

References

12

Appendices Appendix 1:

Decision tree for managing psychostimulantrelated disorders in general practice

14

Appendix 2:

Other resources and useful internet links

15

Appendix Appen dix 3:

Guidelines devel Guidelines development opment proc process ess and stake stakeholde holderr involvement

17

Acknowledgements and reviewers

20

Appendix 4:

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14



PRACTITIONERS

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iv

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PRACTITIONERS

Background

Purpose and scope of the guidelines

T

he purpose of this document is to provide guidelines for general practitioners throughout Australia to effectively and safely manage individuals who are experiencing problems related to the use of psychostimulants, including psychostimulant and serotonin toxicity. The aim of these guidelines is to assist general practitioners to: 1. ident identify ify patient patients s who may may be using using psychos psychostimula timulants; nts; 2. engag engage e psychost psychostimulan imulantt users users in treatm treatment; ent; and 3. identify identify and and manage manage a range range of adverse adverse conseq consequence uences s of stimulant use including acute toxicity. A brief decision tree is included as Appendix 1 to assist general practitioners to identify appropriate options for management. There already exist a number of excellent publications for general practitioners that recommend management strategies appropriate for patients with alcohol and other drug use problems in general (see Appendix 2 for a list of these resources). resources). Therefore these these guidelines refer to issues related to psychostimulant users users only. only. A detailed explanation of the process used to develop the guidelines is at Appendices 3 & 4. These guidelines should be used in conjunction with the recent publication Models of intervention and care for psychostimulant users (Second Edition),, National Drug Strategy Monograph Series Number 51. The Edition) monograph can be obtained by contacting National Mailing and Marketing on 1800 020 103, extension 8654, or is available to be downloaded from the department’s website on http://www.nationaldrugstrategy http://www .nationaldrugstrategy.gov .gov.au/publications/index.htm .au/publications/index.htm

Target groups

M ANAGEMENT

These guidelines are for use by all general practitioners and apply to all psychostimulant-affected psychostimulant-affect ed individuals including youth, Indigenous peoples, women and those with suspected co-existing mental health problems. General practitioners with little experience in the alcohol and other drugs field generally may choose to access materials related to assessment and interventions for drug and alcohol use problems in general (see Appendix 2).



PRACTITIONERS

v

Definition of psychostimulants

The range of substances collectively known as psychostimulants include:

1. MDMA (methyl (methylened enedioxy ioxymeth methamp ampheta hetamine mine)) – ‘ecst ‘ecstasy’ asy’;; 2. cocaine; 3. amp amphetam hetamine ine sulphat sulphate e or hydrochl hydrochlorid oride e – ‘speed’; ‘speed’; 4. me meth tham amph phet etam amin ine; e; a. crys crystal tal metham methamphet phetamin amine e – ‘ice’, ‘ice’, ‘crystal ‘crystal meth’; meth’; b. meth methamph amphetam etamine ine table tablets ts – ‘pil ‘pills’; ls’; c. meth methamp ampheta hetamine mine ‘base’ ‘base’,, which is a moist, moist, oily oily substance substance.. Prescription stimulants such as Ritalin, Duromine or dexamphetamine can also be misused by some patients.

Patterns of psychostimulant use

Users of amphetamines can be categorised as experimental, ‘recreational’ (those who use irregularly in a social setting), ‘binge’ users or regular daily users. Others may use psychostimulants psychostimulants to improve improve work performance, and some may use stimulants in an effort effort to reduce weight. Intranasal ‘snorting’ or oral ingestion ‘bombing’ are common routes of administration by experimental and recreational users; while a significant proportion (particularly regular users) choose to inject. Injection is typically associated with higher levels of dependence (see Table Table 1 for criteria of dependence) and other physical, psychological and social problems as is smoking of some forms of psychostimulant drugs, such as crystalline methamphetamine, ‘ice’ or crack cocaine (1).

Definition of acute psychostimulant toxicity

Psychostimulants are a group of drugs that stimulate the activity of the central nervous system, causing individuals to feel falsely or overly confident, euphoric, alert and energetic. However However,, at toxic levels, individuals may become extremely agitated, irrational, impulsive, paranoid and psychotic, which may lead the person to behave in an aggressive and/ or violent manner. The definition of ‘acute psychostimulant toxicity’ utilised by these guidelines describes an individual who has toxic levels of psychostimulants in their system, although it is recognised that levels of other drugs such as alcohol, cannabis or opioids may also be excessive. Consequences of psychostimulant toxicity include cardiovascular and cerebrovascular emergencies, acute behavioural disturbances, psychosis and serotonin toxicity of varying varying severity. severity. It is important to recognise that toxicity may occur among both experimental and regular users of psychostimulants (2).

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Introduction Key points ●

●

●

The use of psychostimulants in Australia is increasing. Many individuals will seek treatment from a general practitioner for a range of adverse consequences. The evidence relating to efficacy of amphetamine-specific treatment is sparse.

●

Current good practice recommends accurate assessment, engagement, and individual symptom management.

●

Evidence for the use of pharmacotherapies for psychostimulant dependence is lacking.

Psychostimulant toxicity has been recognised among both naive and regular users and represents a medical emergency when severe. The use and availability of psychostimulants, in particular amphetamine sulphate or hydrochloride (‘speed’) and methamphetamines (‘meth’, ‘crystal meth’, ‘ice’ and ‘base’) are increasing throughout Australia (3). Population studies estimate that more than half a million Australians had used an illicit stimulant during the year 2000 (3). Among a sample of 200 regular amphetamine users in Sydney, Sydney, many identified problems with dependent use as significant prompts for treatment seeking (4). Similarly Similarly,, many users have reported high levels of satisfaction with treatment received from a general practitioner (5). This is particularly important, as many psychostimulant users perceive alcohol and other drug treatment agencies to be largely unresponsive to their specific needs (6). Adverse consequences of regular, heavy use of psychostimulants (7, 2), can include: poor nutrition; ● skin problems (ulcers, infections, facial sores); ● engaging in high-risk behaviours (injecting, unsafe sexual activity, ● binge drinking, drug driving etc); blood borne viruses (BBVs) and sexually transmitted diseases ● (STDs); psychosis, paranoia, misperceptions; ● depression; ● anxiety; ● panic reactions; ● cardiovascular complications; ● cerebrovascular complications; and ● serotonin toxicity. ●

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PRACTITIONERS

vii

The role of the general practitioner Psychostimulant users have traditionally not sought treatment (8), and some amphetamine users have opted for self-management or self-detoxification (9). However, a range of precipitants may prompt treatment seeking by psychostimulant users (psychotic symptoms, mood disturbances, aggressive outbursts etc) and research indicates that many who do seek treatment will be regular or dependent users who are experiencing a variety of adverse consequences (4, 5). Interventions range from harm reduction messages at one end of the treatment spectrum to withdrawal management at the other other.. Polydrug use is widespread among psychostimulant users, and comorbid mental health symptoms are commonly reported. Therefore, interventions interventions will be determined by individual needs, or the needs of family members or carers who ask for assistance. Patients may disclose the use of psychostimulants and identify concerns with problematic use as a precipitant precipitant for treatment seeking. However However,, some psychostimulant users may not disclose use and instead might request prescription medications such as dexamphetamine or sedativehypnotics. In this case, vigilant observation observation and astute questioning questioning is required so an accurate initial assessment can be made. The role of the general practitioner in assisting patients with a range of problems related to psychostimulant use includes:

1. ef effec fectiv tive e en engag gagem ement ent;; 2. acc accura urate te ass assess essme ment; nt; 3. ong ongoin oing g man manage ageme ment; nt; an and d 4. referra referrall if nece necessar ssary y (particular (particularly ly for patients patients experienci experiencing ng severe psychosis). It is important for general practitioners to recognise the relapsing nature of dependence, and ongoing management will often include supporting dependent patients through several attempts to change drug use behaviours.

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Guidelines

T

he guidelines are intended to be used by general practitioners in conjunction with the recently updated National Drug Strategy Monograph No 51 Models of intervention and care for psychostimulant users (Second Edition). Edition) . A thorough thorough review review of the literature is presented presented in the monograph. monograph. Hence, these guidelines guidelines provide a synopsis of the evidence only. The current guidelines for the management of persons with problems related to the use of psychostimulants, including toxicity, toxicity, address the following areas:

1. Assessment:

a. spont spontaneou aneous s disclosur disclosure e of psychosti psychostimulan mulantt use; b. non-d non-disclo isclosure sure of psychosti psychostimulan mulantt use. 2. Management:

a. gen genera erall manage managemen mentt issues issues;; b. spe specia ciall issues issues in manageme management; nt;

M ANAGEMENT OF PATIENTS

●

amphetamine-related psychosis;

●

management of behavioural disturbance;

●

serotonin toxicity; and

●

assisting family members or carers.

WITH PSYCHOSTIMULANT USE PROBLEMS

• GUIDELINES FOR GENERAL PRACTITIONERS

1

Assessment

When a patient discloses psychostimulant use

Some patients may spontaneously disclose the use of psychostimulants. In this case, a thorough history should be taken to inform appropriate management. The following points may serve as a guide (10), although if the patient is intoxicated or exhibiting signs of agitation or other behaviours that might impact on accurate assessment, an emphasis on engagement and reassuring the patient should take priority. 1. Psychostimulant Psychostimulant use use (‘speed’, (‘speed’, ‘go-ee’, ‘go-ee’, ‘base’, ‘ice’, ‘ice’, ‘meth’, ‘meth’, ‘whizz’ etc): ●

amount of psychostimulant used1 ;

●

type of psychostimulant used (e.g. methamphetamine, amphetamines, cocaine, MDMA and prescription drugs);

●

potency of psychostimulant used (“ how long did it last?”, last?”, “was “was it strong?”) strong? ”)

●

route of administration (intranasal, intravenous, oral and inhalation);

●

frequency of use (e.g. regular daily use, binge pattern, recreational, other, etc); and

●

duration of current use and age of first use.

2. Ot Othe herr dru drug g use use:: ●

use of other drug classes (particularly alcohol, benzodiazepines, opiates and alcohol), including criteria above.

3. De Depe pend nden ence ce:: ●

meets criteria for a diagnosis of dependence for psychostimulants and/or other drugs (see Table 1 below for criteria); and

●

severity of dependence on each drug used.

4. Hi Histo story ry of wit withdr hdrawa awal: l: ●

experience of previous withdrawal symptoms, severity, severity, course and treatment outcomes (withdrawal symptoms typically include irritability,, insomnia, dysthymia, lethargy irritability lethargy,, and cravings to use, see Chapter 7: Detoxification and Withdrawal Management in Models of intervention and care for psychostimulant users monograph).

5. Cons Conseque equences nces of drug use: ●

might include physical, psychological, financial, social and legal consequences and is a good starting point for enhancing motivation to change drug use behaviours.

1 Amount can be measured in local dollar value; grams, or numbers of ‘pills’ taken.

2




6. Ot Other her con condit ditio ions ns:: ●

presence of concomitant physical illness including blood borne viruses (HCV, HBV, HIV, skin infections etc); and

●

presence of concomitant psychiatric illness or psychiatric symptoms (psychosis, paranoia, depression, suicidal ideation etc).

7. Ot Othe herr fac facto tors rs:: ●

social/family/carer situation (“do (“do they support your goals”?, “do they use too”?); too”?);

●

stressors (e.g. legal, financial, social etc);

●

employment status;

●

accommodation;

●

readiness to change drug use behaviour; and

●

patient’s patient’ s goal for treatment.

Table 1: DSM-IV diagnostic criteria for substance dependence (11) A maladaptive pattern of substance use, leading to clinically significant significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12 month period: 1. tole toleranc rance, e, as as defin defined ed by by eithe either: r:

a. a need for marked markedly ly increased increased amoun amounts ts of the substanc substance e to achieve achieve detoxification or the desired effect; or b. markedly markedly dimini diminished shed effect effect with continu continued ed use of the same amount amount of the substance; 2. withdraw withdrawal, al, as manife manifested sted by either either of the following: following:

a. a charact characterist eristic ic withd withdrawal rawal syndr syndrome; ome; or b. the same or closely related substance substance is used to relieve or avoid withdrawal withdrawal symptoms; 3. the substance substance is taken in larger amounts amounts or or for a longer longer period period than intended; 4. there is a persiste persistent nt desire desire or unsuccessful unsuccessful efforts efforts to cut cut down or control control substance use; 5. a great great deal of of time is is spent in activities activities necessary necessary to to obtain the substance, substance, use the substance, or recover from its effects; 6. important important social, social, occupational occupational or recrea recreational tional activities activities are are reduced reduced or given up because of substance use; and 7. substance substance use is continued continued despite despite knowledge knowledge of of having a persi persisten stentt or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Assessment is an ongoing process and regular evaluations of patient progress should occur as treatment progresses.




3

When a patient does not disclose psychostimulant use

There are various reasons why a psychostimulant-using patient might be reluctant to disclose drug use including fear of judgement or embarrassment. The following signs might indicate the patient has recently used psychostimulants or is moderately to severely intoxicated: ●

dilated pupils that react sluggishly to light;

●

clenched jaw;

●

restlessness, agitation (fidgety) and repetitive movements;

●

rapid speech;

●

motor agitation or pacing;

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hypertension;

●

tachycardia;

●

sweaty palms; and

●

hypervigilance and paranoia.

The following signs might indicate long-standing or regular psychostimulant use: ●

obvious signs of poor or under-nutrition;

●

sores on face, arms or legs; and

●

evidence of needle marks or thrombophlebitis.

Similarly, individuals may offer other reasons for treatment seeking such as: ●

requests for sedative-hypnotics or prescription stimulants;

●

complaints of insomnia or narcolepsy;

●

reports of feeling anxious, depressed or irritable;

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complaints of weight gain; and

●

complaints of general g eneral lethargy.

If psychostimulant use is suspected, developing rapport, raising the issue in a non-judgemental way, and assuring the patient that you are willing to help may encourage the patient to disclose use. A general practitioner might raise the issue by saying:

“Many people in Australia use drugs like amphetamines, ecstasy, ecstasy, pills or speed. speed. May I ask if this is true for you?” This type of questioning implies acceptance of the patient without condoning the use of psychostimulants. If the patient does not disclose psychostimulant use despite obvious signs and gentle questioning, this should not be considered a failed consultation as the development of a therapeutic alliance often takes time. In this case, conservative treatment of presenting symptoms should be implemented and a follow-up appointment offered. Prescription of benzodiazepines or other sedative hypnotics at this stage is not recommended.

4




General principles of management As is recommended for the management of problems related to the use of alcohol and other drugs generally, management in general practice begins with the development of an appropriate treatment treatment plan. This will be guided by the initial assessment and ongoing reviews. Family or carer involvement in the treatment process is also recommended and education and support should be offered as appropriate, particularly for parents of young people. However,, it is important However im portant to reassure the patient that strict confidentiality will be maintained until consent is given, as many psychostimulant users are hypervigilant or paranoid and the creation of a trusting, therapeutic relationship is essential for ongoing care. Management strategies for various groups of users are briefly described below.

Experimental, recreational, occupational and noninjecting users who are not dependent on psychostimulants

Harm reduction strategies are appropriate for this group, and education about the range of possible adverse consequences of regular use such as mood disturbances, paranoid ideation, irritability and health consequences has been recommended (4). Offering the patient vaccination for hepatitis B is appropriate, as is discussion regarding the appropriateness of HBV HBV,, HCV and HIV serology and the implications of findings. Brief interventions to reduce the risk of transition to regular use or injecting are also appropriate (see Appendix 2 for a list of readings and resources for brief interventions). The essential elements of brief interventions are included in the FRAMES model (16):

F eedback: Involves feedback to clients of findings from your assessment.

R esponsibility: Patient is responsible for acting on the feedback given.

A dvice: Clear advice to change behaviour that comes from a GP may be effective.

M enu: Offer the patient a menu of options for change. E mpathy: Showing empathy has been shown to enhance motivation for change.

patient’s s optimism by identifying S elf-efficacy: Reinforce the patient’ their skills and ability to change.

Regular users and dependent users


Regular psychostimulant users will probably present with a range of adverse psychological, physical and social problems. Individual management plans will be informed by the patient’s treatment goals described below.



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1. Continued use

Harm reduction strategies such as using small amounts of the drug, using in the presence of other people, alternatives to injecting (e.g. ‘snort’, swallow, etc), using sterile injecting equipment when continuing to inject (or at least not sharing any potentially blood contaminated equipment), education regarding signs and symptoms of severe adverse consequences including toxicity, recommending ‘rest’ periods from the psychostimulant to enable the body to recover, encouraging adequate nutrition, and offering ongoing reviews of physical and mental health status to ensure engagement and early intervention if problems should occur. 2. Cessation of use

If the patient is dependent on psychostimulants, an assessment of the need for supervised detoxification should be undertaken. If detoxification is required, most patients can be adequately managed in the community with regular monitoring by the general practitioner. practitioner. There is no evidence as yet to suggest that medications are effective effective in withdrawal. However However,, a benzodiazepine may be prescribed for no longer than two weeks to assist in restoring sleep and reducing withdrawal-related agitation and anxiety (10). Patients should be educated about the possible lengthy withdrawal process as mood fluctuations and irritability, which may persist for several months, have been identified as precipitants to relapse by some users (9). If dependence on other drug classes is apparent, particularly alcohol or benzodiazepines, and the patient intends to cease all drug use, a withdrawal syndrome can be reasonably expected to occur occur.. It is important to manage the concomitant withdrawal according to existing protocols for that drug class, and assessment of the need for supervised detoxification should be undertaken. Should a mood disturbance indicate the need for prescription of an antidepressant, care should be taken as relapse to psychostimulant use is common and simultaneous use of stimulants and antidepressants, particularly Selective Serotonin Reuptake Inhibitors (SSRIs), has been linked to serotonin toxicity in some patients (2). Low dose benzodiazepines, if prescribed to initiate restorative sleep, should be prescribed for no longer than two weeks, and dispensing on a daily basis is recommended (7). If the patient does not require detoxification, psychological therapies such as cognitive behavioural therapy (CBT), motivational approaches and relapse prevention strategies may assist with continued cessation. Cravings to use psychostimulants may be a considerable barrier to ongoing commitment to change and patients may benefit from a discussion of strategies to manage cravings (e.g. distraction, delay using for short manageable intervals until craving passes, review personal reasons for change etc). Cravings decline in intensity each time they are are not reinforced reinforced with drug use. Referral to a specialist alcohol and other drug treatment service may be beneficial for patients who are willing to engage with public services.

6




A list of local alcohol and other drug agencies may be obtained by telephoning the Alcohol and Drug Information Service (ADIS) in each state, or by logging on to the Australian Drug Information Network (ADIN) on www.adin.com.au

Special issues in management Amphetaminerelated psychosis

There is substantial evidence that amphetamines can produce a distinctive psychotic episode with a good short-term prognosis in people with no pre-existing mental health problems (14). Similarly, the experimental administrations of amphetamines have been reported to lead to a worsening of positive symptoms in people with a pre-existing psychotic disorder such as schizophrenia (15). Many psychostimulant users report experiencing acute or subacute symptoms of psychosis at some time (15), which are often precursors to treatment seeking. Signs of an impending psychotic episode can include: ●

increasing agitation;

●

insomnia not related to the use of psychostimulants;

●

anxiety;

●

fear;

●

suspiciousness suspiciousnes s and hypervigilance;

●

paranoia;

●

over-valued ideas; and

●

erratic behaviour.

If psychotic symptoms manifest and are able to be managed by the general practitioner in the community, an antipsychotic medication such as phenothiazine or haloperidol may be prescribed in the short term (1-2 weeks). However if symptoms persist or escalate in severity a thorough psychiatric assessment should be sought as inpatient management may be required (Jenner & Saunders). The patient should be monitored over several weeks to ensure that the psychotic symptoms resolve and to detect significant symptoms of depression if they should occur. Patients need to be informed that an amphetamine-induced psychosis leaves them vulnerable to future future psychotic episodes. Relapse prevention strategies are therefore particularly important for this group, and abstinence is the preferred goal for treatment to reduce the chance of psychotic relapse.

Behavioural disturbances


Occasionally, a patient may present to a general practitioner Occasionally, practitio ner with a request for sedative-hypnotics or prescription stimulants and become hostile or aggressive when the request is declined.



7

The primary aim of management is to reduce the risk of harm to the patient, general practitioner, practitioner, practice staff and other patients. It may be beneficial for a general practice to establish protocols for the management of behavioural disturbances so all staff, including reception staff and other general practitioners, are familiar with how to proceed in the event of such an incident. Respond to the patient in a calm and confident manner. Be aware that if the person is acutely intoxicated with psychostimulants and experiencing great fear or paranoid symptoms, unexpected stimuli such as loud noises or sudden movements may worsen the situation. So at all times use calming, de-escalating communication strategies. Individuals affected affected by psychostimulants are more likely to respond in a positive way to communication strategies that are not perceived to be aggressive, threatening or confrontational. Recommended communication techniques include: ●

Listening to the patient.

●

Using the patient’s name to personalise the interaction.

●

Calm, open-ended questioning questioning to ascertain the cause of the behaviour.

●

A consistently even tone of voice, even if the person’s communication style becomes hostile or aggressive.

●

Avoidance of the use of ‘no’ language, which may prompt an aggressive outburst. Statements like like “I’m “I’m sorry, practice policy doesn’t allow me to prescribe certain medications but I can offer you other help, assessment, referral etc ........” may encourage further communication and often has a calming effect on the patient.

●

Allow the individual as much personal space as possible and do not allow the person to block your exit from the consultation room.

●

Avoid too much eye contact if possible as this can increase fear or promote aggressive outbursts in some hostile or paranoid individuals.

These techniques will assist general practitioners to determine the individual’s individual’ s level of responsiveness to de-escalation strategies and further assess the degree of risk to all involved. However However,, if the risk to personal safety is high and the patient is unable to be calmed, it may be necessary to call for police assistance.

Serotonin toxicity

8

There have been several reports of serotonin toxicity associated with the use of psychostimulants in the recent past, particularly MDMA (ecstasy). Serotonin toxicity may be a mild, self-limiting condition or be potentially fatal with symptoms such as muscle rigidity, coma, seizures, hypertension or hypotension. When the toxicity is severe, severe, rhabdomyolysis with hyperkalaemia, acidosis and frank renal failure may result (2).




The presence of serotonin toxicity is determined by clinical assessment, and a set of criteria exists for this purpose (see points below). If the recent recent use of a serotonergic agent is suspected (peak risk time for cocaine is 20-40 minutes after administration, and peak risk time for an amphetamine is approximately two to three hours after administration) or use is confirmed and three of the following criteria are met (Sternbach 1991 cited in 2), a diagnosis of serotonin toxicity may be made (2): ●

altered mental status (confusion, hypomania);

●

agitation;

●

tremor;

●

shivering;

●

diarrhoea;

●

hyperreflexia;

●

myoclonus (may be severe enough to mimic seizure activity);

●

ataxia;

●

fever; and

●

diaphoresis.

General practice management of severe serotonin toxicity involves:

1. early identi identificat fication ion of the syndr syndrome, ome, includ including ing educatin educating g patients about early warning signs (muscle rigidity rigidity,, increasing body temperature, increasing agitation, severe headaches etc), and possibly 2. mechanic mechanical al cooling cooling (cold (cold packs, packs, fans and fluid fluids) s) until until the patient can be transported ideally via ambulance to the emergency department.

Once in the emergency department, the patient is continuously monitored, IV fluids are given and medications appropriate to the presenting symptoms are administered. In rare cases mechanical ventilation may be required if respirations are compromised (2). The general practitioner may also consider the administration of oral benzodiazepines 5-10 mg as a starting dose if circumstances or lack of available resources delay transport to the emergency department. A thorough description of the management of toxicity can be found in Models of intervention and care for psychostimulant users (Second Edition), Edition), National Drug Strategy Monograph Series No 51.

Assisting family members and carers


Family and carer disruption is frequently associated with the use of psychostimulants and other drugs. It is often difficult difficult for carers to understand why their family member continues to use substances in the face of ongoing problems with their mental health, the legal system or finances.



9

It is essential for the families of psychostimulant users to obtain information that they can understand, as well as support and practical assistance to enhance their own wellbeing during the day to day care of their family member. GPs can help family members and carers by:

a) simply simply discussi discussing ng the concep conceptt of readine readiness ss to change change to promote an understanding of relapse and ambivalence to change substance use; b) describin describing g the effects effects of psychostim psychostimulan ulants, ts, particula particularly rly symptoms of psychosis, effects on mood and anxiety and early warning signs; c) advising advising the family family of local local support support group groups s (see ADIN website); d) advi advising sing the the family family of local alcohol alcohol and and drug counsel counsellors; lors; e) listening listening to them them and and helping helping them them to clarify clarify their their issues issues and and reactions and assuring them that feelings of both distress and helplessness are shared by other families and are normal in their situation; and f)

10

giving them giving them as much info informati rmation on as poss possible ible with without out violat violating ing the patient’s rights to confidentiality.




In a nutshell

1. The use and availabil availability ity of psychosti psychostimulant mulants s is increasing; increasing; 2. Individuals Individuals are likely likely to seek assistance assistance from from a general practitioner practitioner when adverse consequences of use are experienced; 3. Management Management principles principles involve involve accurate assessment assessment and and treatment treatment planning that considers pattern of use, severity of dependence and patient’s patient’ s goal for treatment; 4. Detoxification Detoxification from from psychostimulan psychostimulants ts can often be undertak undertaken en in the community; 5. Medications, Medications, although although not empirically empirically proven proven to be of benefit, benefit, may be prescribed on an individual basis (ie. benzodiazepines, antidepressants and antipsychotics), with special attention to the risk of drug interactions such as serotonin toxicity; 6. Symptoms Symptoms of psychosis psychosis can can often be managed managed by general general practitioners; however patients should be thoroughly assessed by specialist mental health services if symptoms persist or worsen during treatment; 7. Severe seroton serotonin in toxicity toxicity should be be managed in the the emergency emergency department. However However,, general practitioners are well placed to identify the syndrome should it occur, and educate patients about early warning signs (muscle rigidity, increasing body temperature, increasing agitation, severe headaches etc); 8. Calming communicat communication ion to de-escalate de-escalate potentia potentially lly dangerous dangerous situations is recommended if a patient becomes hostile or violent in the general practice setting, although the police may need to be called to a high-risk situation; 9. Some patients patients may benefit benefit from referral referral to specialist specialist alcohol alcohol and drug services for ongoing relapse prevention and management interventions; and 10. Families and and carers can benefit benefit from from receiving receiving basic information information about about psychostimulants and support on an as needed basis.




11

References

1) Jenner, Jenner, L. & McKetin, McKetin, R. Preva Prevalence lence and Pattern Patterns s of Psychostimu Psychostimulant lant Use, in Baker, A. Lee, N.K. & Jenner, Jenner, L. (eds) Models of intervention and care for psychostimulant users (Second Edition), Edition) , National Drug Strategy Monograph Series Number 51. Canberra. 2) Dean, Dean, A., & Whyte, Whyte, I., I., Emergenc Emergencyy Manageme Management nt of Acute Acute Psychostimulant Toxicity, Toxicity, in Baker Baker,, A. Lee, N.K. & Jenner, L. (eds) Models of intervention and care for psychostimulant users (Second Edition),, National Drug Strategy Monograph Series Number 51. Edition) Canberra. 3) Australian Australian Institu Institute te of Health and Welf Welfare are (2002). 2001 Nation National al Drug Drug Strategy Household Survey, Drug Statistics Series number 1 1. Australian Government Publishing Service, Canberra. 4) Hando, J., Topp, Topp, L. & Hall, W. W. (1997), Amphetamine-related harms and treatment preferences of regular amphetamine a mphetamine users in Sydney, Sydney, Australia. Drug and Alcohol Dependence, 46, 105-113. 5) Vincent, N., Shoobridge, J., J., Ask, A., Allsop, S. & Ali, R. (1999). Characteristics of amphetamine users seeking information, help and treatment in Adelaide, South Australia. Drug and Alcohol Review, 18, 63-73. 6) Kamieniecki, G., Vincent, N., Allsop, S., Lintzeris, N. Models of intervention and care for psychostimulant users. Canberra, ACT, ACT, Commonwealth of Australia; 1998. 7) Hall, W. W. & Hando, J. (1994). Route of administration and adverse effects of amphetamine use among young adults in Sydney, Australia. Drug and Alcohol Review, 13, 277-284. 8) Klee, H. (Ed) (1997). Amphetamine Misuse: International Perspectives on Current Trends. Trends. The Netherlands: Harwood Academic Publishers. 9) Cantwell, Cantwell, B. & McBride McBride,, A.J. (1998). Self-de Self-detoxific toxification ation by amphetamine dependent patients: a pilot study. study. Drug and Alcohol Dependence (49) 157-163. 10) Jenner, Jenner, L. & Saunders, J., Psychostimulant Detoxification Detoxificatio n and Withdrawal Management, Manageme nt, in Baker, Baker, A. Lee, N.K. & Jenner, Jenner, L. (eds) Models of intervention and care for psychostimulant users (Second Edition),, National Drug Strategy Monograph Series Number 51. Edition) Canberra. 11) American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: DC: American Psychiatric Association.

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12) The AGREE Collaboration (2001). Appraisal of guidelines for research and evaluation (AGREE) instrument. http://www.agreecollaboration.org./ 13) National Health and Medical Research Council (NHMRC, 1998). A guide to the development, implementation and evaluation of clinical practice guidelines. Commonwealth of Australia. 14) Bell, D. S. (1973). The experimental reproduction of amphetamine psychosis. Archives of General Psychiatry Psychiatry,, 29(1), 35-40. 15) Dawe, S. & McKetin, R. The psychiatric comorbidity of psychostimulant use, in i n Baker, Baker, A. Lee, N.K. & Jenner, L. (eds), Models of intervention and care for psychostimulant users (Second Edition), Edition) , National Drug Strategy Monograph Series Number 51. Canberra. 16) Miller, W.R. & Sanchez, V.C. in Motivational Interviewing: Preparing People to Change Addictive Behaviour , Miller, W.R. W.R. & Rollnick, S. S . (eds) (1991). The Guilford Press, New York.




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ni sr e dr o si d d et al er -t n al u mi t s o h c ys p g ni g a n a m r of

e er ar

ci t e c t p n l oi ar si e c n e e D

g 1 xi d n e p p A

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Appendix 2

Other resources and useful internet links 1. A user’s user’s guide to to speed. speed. National Drug and Alcohol Research Centre (NDARC) http://ndarc.med.unsw http://ndarc.med.unsw.edu.au/ndarc.nsf/website/ .edu.au/ndarc.nsf/website/ Publications.resources 2. Alcohol and Other Other Drugs: A Handbook for Health Health Professionals Professionals.. Australian Government Department of Health and Ageing, 2004. 3. Australian Drug Information Network (ADIN), www.adin.com.au www.adin.com.au 4. Centre for General Practice Integration Studies, University of New South Wales. http://www.commed.unsw.edu.au/cgpis/ http://www.commed.unsw.edu.au/cgpis/ 5. Beck, A.T., A.T., Wright, F.D., F.D., Newman, C.F. C.F. and Liese, B.S. (1993). Cognitive therapy of substance substance abuse. New York: York: Guilford Press. 6. Clinical Treatment Guidelines Series, Series, Turning Turning Point Alcohol A lcohol and Drug Centre, http://www.turningpoint.org.au/service_information/ si_ctgs.html 7. Davies, J. (2000). A Manual of Mental Health Care in General Practice. Practice . Commonwealth Department of Health and Aged Care. Canberra. 8. Treatment Approaches for Alcohol and Drug Dependence: An Introductory Guide. http://ndarc.med.unsw.edu.au/ndarc.nsf/website/ Publications.resources 9. Models of intervention and care for psychostimulant users (Second Edition),, National Drug Strategy Monograph Series Number 51. Edition) Australian Government Department of Health and Ageing. 10. Clinical skills training series: effective approaches to alcohol and other drug problems, modules 1-5. 1-5. Newcastle: University of Newcastle; Training, T raining, Health and Educational Media, 1998. (National Teaching Teaching Grant held by Amanda Baker and National Centre for Education and Training T raining on Addiction). Module 1: Motivational Motivational interviewing: interviewing: how to encourage motivation motivation for change. Module 2: Relaps Relapse e prevention prevention.. Module 3: Raising the issue issue and assessment: assessment: triggers to learning. Module 4: Brief intervention: triggers to learning. Module 5: Brief intervention strategies among Aboriginal and Torres Strait Islander people. (Each module consists of 1-3 videotapes and a booklet including summation of the script, training questions and exercises, and student assessment and evaluation forms).




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11. Barry Barry,, K.L (1999). Brief interventions and brief therapies for substance abuse. Treatment Improvement Protocol (TIP) Series No. 34. US Department of Health and Human Services: Rockville, Maryland. 12. National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) – Report of Results and Recommendations, National Drug Strategy Monograph Series Number 52. Australian Government Department of Health and Ageing. 13. Treatment Options for Heroin Heroi n and Other Opioid Dependence – A Guide for Frontline Workers, Australian Workers, Australian Government Department of Health and Ageing. 14. Treatment Options for Heroin Heroi n and Other Opioid Dependence – A Guide for Users, Australian Users, Australian Government Department of Health and Ageing. 15. Treatment Options for Heroin Hero in and Other Opioid Dependence Depe ndence – A Guide for Families and Carers, Australian Carers, Australian Government Department of Health and Ageing.

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Appendix 3

Guidelines development process and stakeholder involvement

The development of these guidelines represents one component of the Update of the the National Drug Strategy Monograph No. 32: Models of intervention and care for psychostimulant users project, funded by the Australian Government Department of Health and Ageing. Guidelines for the management and treatment of individuals with psychostimulantinduced behavioural disorders and toxicity are being developed for four front-line worker groups: emergency departments, ambulance services, general practitioners, and police services. Due to a lack of available literature or evidence for management of psychostimulant users specific to the general practice setting, the development of these guidelines has been informed by the opinions of an expert panel of clinical and academic staff. The expert panel has also extrapolated from the general alcohol and other drug literature where appropriate. An Expert Reference Group who oversaw the update of the monograph publication determined the methodology that would be undertaken in developing the guidelines. It was agreed that the model would be consistent with the National Health and Medical Research Council (NHMRC, 1998) and AGREE (2001) recommendations for developing guidelines. Specifically: 1) the monograph monograph will will describe describe the the natural natural history history of psycho psychostimula stimulantntrelated presentations for the four key groups, g roups, and provide a written resource; 2) an expert expert panel panel of approp appropriate riate police, police, clinical clinical and and academic academic personnel personnel will be convened to inform the content of the guidelines; 3) various scenari scenarios os will be put to the expert panel to to determine determine if evidence for intervention and management of those conditions exist and are applicable, and rate the quality of that evidence; 4) the guidelines guidelines will will be comprehe comprehensive, nsive, flexible flexible and and adaptable adaptable for various various settings across Australia; and 5) the guidelines guidelines will will be circulated circulated to other other relevant relevant experts experts around around the the country for comment to ensure varied input and wide acceptance for the dissemination phase.




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Guidelines Development Meeting participants

Dr Amanda Baker – University of Newcastle (Chair of the Psychostimulant Monograph Group) Professor Ian Whyte – Senior Staff Specialist, Clinical Toxicology & Pharmacology, Newcastle Mater Hospital Dr Ed Heffernan – Forensic Mental Health Service Dr Bill Kingswell – Forensic Mental Health Service Ms Megan Smith – Senior Project Officer, Queensland Police Service Inspector Peter Mansfield – Drug & Alcohol Co-ordinator Senior Sergeant Damian Hansen – Drug & Alcohol Co-ordination Senior Sergeant Philippa P hilippa Woolf – Operations Resource Co-ordinator, New South Wales Police Senior Sergeant Ray Knight – Brisbane Watchhouse Sergeant Don Schouten – Fortitude Valley Sergeant Shane Turner – Brisbane City Sergeant Terry Terry Honour – Southport Sergeant Troy Troy Schmidt – Logan Central Sergeant Bruce Dimond – Surfers Paradise Mr Ron Henderson Henderson – Intensive Care Care Paramedic and Queensland State Drug Unit Coordinator Dr Richard Bonham – Queensland Ambulance Service Medical Director and Emergency Specialist Mr Gavin Leader – Intensive Care Paramedic and Regional Drug Unit Coordinator for Ipswich area Mr Christian Francois – Intensive Care Paramedic and Regional Drug Unit Coordinator for Greater Brisbane Region Mr Darrin Hatchman – Intensive Care Paramedic and Regional Drug Unit Coordinator for Gold Coast Region Dr David Spain – Emergency Department, Gold Coast Hospital Dr David Hunt – General Practitioner Practitioner,, AOD specialist Dr Wendell Rosevear – General Practitioner Practitioner,, AOD specialist Ms Kay McInnes – Queensland Health Ms Tarra Tarra Adam – St S t Vincent’s Vincent’s Hospital & National Drug and Alcohol Research Centre Mr Michael Arnold – NSW Users and AIDS Association Mr Anthony Nutting – Queensland Health Dr Wasana Pattanakumjorn – Visiting Psychiatrist, Thailand Ms Angela Dean – Queensland Health Ms Linda Jenner – University of Newcastle

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Guidelines Development Working Party

Dr Amanda Baker, Centre for Mental Health Studies, University o f Newcastle (Chair) Professor Ian Whyte, Senior Staff Specialist, Clinical Toxicology & Pharmacology, Newcastle Mater Hospital Ms Linda Jenner, Centre for Mental Health Studies, University of Newca stle Professor Vaughan Carr, Carr, Centre for Mental Health Studies, University of Newcastle Dr David Spain, Emergency Department, Gold Coast Hospital Mr Ron Henderson, Intensive Care Paramedic and Queensland State Drug Unit Coordinator, Coordinator, Queensland Ambulance Ambula nce Service Professor John Saunders, University of Queensland Dr Paul Mercer – General Practitioner, AOD specialist, RACGP Queensland representative Dr Angela Dean, Department of Psychiatry, University of Queensland Mr Michael Arnold, NSW Users and AIDS Association




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Appendix 4

Acknowledgements and reviewers

The Guidelines Development Group warmly thanks all of the participants of the development meeting day for offering their time and expertise, which was used to form the foundation for the guidelines. We also particularly thank Dr Paul Mercer for his involvement in the guidelines development process. We are also grateful to the following individuals for their expertise in reviewing the guidelines: Dr Michael Campbell-Smith – General Practitioner, AOD specialist Dr Adrian Dunlop – Turning Point Alcohol and Drug Centre Inc. Dr Stefan Goldfeder – Acting Clinical Director, The Prince Charles Hospital and District Alcohol and Drug Service Mr Ron Henderson Henderson – Intensive Care Care Paramedic and Queensland State Drug Unit Coordinator Dr Simon Holliday – General Practitioner, AOD specialist Dr David Hunt – General Practitioner Practitioner,, AOD specialist Mr Michael Lodge – Executive Officer, NSW Users and AIDS Association Dr Paul Mercer – General Practitioner, AOD specialist, RACGP Queensland representative Professor Ann Roche – Director, Director, National Centre for Education and Training Training on Addiction (NCETA), Flinders University Dr Wendell Rosevear – General Practitioner Practitioner,, AOD specialist Dr Fiona Shand – National Drug and Alcohol Research Centre (NDARC) Dr Moira Sim – Senior Medical Officer, Drug and Alcohol Office, Western Australia Dr David Spain – Emergency Department, Gold Coast Hospital Dr Jeanette Tait – Alcohol and Drug Specialist, Australian Medical Association Dr Alex Wodak – St Vincent’s Hospital, Sydney Professor Ian Whyte – Mater Hospital, Newcastle

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Management of Patients With Psychostimulant Use Problems Guidelines for General

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