Amphetamine-Type Stimulant (ATS) Use

Treatment Protocol: An interventiondeveloped for the use of staff and

clinicians working with ATS clients inTherapeutic Communities

Lynne MagorLynne Magor--BlatchBlatch

Project OfficerProject Officer

James PittsJames Pitts

Chief Executive OfficerChief Executive Officer

Odyssey House McGrath FoundationOdyssey House McGrath Foundation

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WHAT IS THE AMPHETAMINE TYPESTIMULANTS (ATS) GRANTS PROGRAM?

$22.9 million committed in AustralianFederal budget to enhance capacity ofNGOs to respond to rising demand of usersof ATS.

Reduce harms caused by ATS toindividuals, their families and the Australiancommunity.

Intended to be one off funding to allowNGO’s to:

• Cater for and treat

• Attract ATS users and/or

• Increase referrals of ATS users in treatment

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WHAT IS THE AMPHETAMINE TYPE STIMULANTS(ATS) GRANTS PROGRAM?

Achieved by provision of targeted grants to:

Existing AOD NGO treatment services to meet theincreasing demand for users dependent on ATS;and

NGOs who wish to expand or establish newtreatment services to address growing need fortreatment programs targeted specifically to usersdependent on ATS.

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KEY PRINCIPLES

Treatment interventions should:

1. Reduce and treat the use of illicit drugs.

2. Be informed by evidence and use models of goodpractice.

3. Reduce the risk of infectious disease.

4. Improve physiological and psychological health.

5. Reduce criminal behaviour and

6. Improve social functioning.

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WHAT IS THE PROJECT?

To develop a treatment protocol specific to therapeuticcommunities for people who are adversely affected dueto their use of ATS.

Phase 1 –

A literature review including:

Prevalence rates of ATS use, current availabletreatment interventions and TC programs,including context, populations and outcomes;

EvidenceEvidence--based treatment approaches inbased treatment approaches inAustralia and abroad, current Australian researchAustralia and abroad, current Australian research

Consultation with members of the National Drug andAlcohol Research Centre and other researchinstitutes and clinicians with expertise on ATS.

Consultation with members of the ATCA throughforums in Queensland, New South Wales, Victoria,Western Australia, South Australia and theAustralian Capital Territory; and with New Zealand.

WHAT IS THE PROJECT? Phase 2 – Development and trial of the draft treatment protocol in

two selected TCs that have populations with high ratesof ATS use.

Trial included youth, family and adult populations inselected TCs in Western Australia, which has beenidentified as having highest prevalence in Australia,and Queensland, which has high rates of ATS amongyoung people.

Phase 3 – Development and roll out of the final Treatment

Protocol for use by staff & clinicians working with ATSclients of Therapeutic Communities, following trialperiod.

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EXPECTED OUTCOMES

A treatment protocol specific to the TCA treatment protocol specific to the TCenvironment.environment.

A product which has both national andA product which has both national andinternational implications.international implications.

The overall project will enhance the efficacy ofThe overall project will enhance the efficacy ofthe TC in working with this complex clientthe TC in working with this complex clientgroup.group.

Products are a manual and CDProducts are a manual and CD--Rom for use byRom for use byTC clinicians and workers.TC clinicians and workers.

AUSTRALIAN USE OF ATS

7.7% of males (0.7 million) and 4.9% of females (0.47.7% of males (0.7 million) and 4.9% of females (0.4million) over 14 years of age have triedmillion) over 14 years of age have triedmeth/amphetamine.meth/amphetamine.

3% of males and 1.6% of females aged 14 years3% of males and 1.6% of females aged 14 yearsand over had used meth/amphetamine for nonand over had used meth/amphetamine for non--medical purposes in the 12 months prior to themedical purposes in the 12 months prior to thesurvey.survey.

A total of 6.3% of the general population has usedA total of 6.3% of the general population has usedmeth/amphetamine.meth/amphetamine.

These figures translate to approximately 1.1 millionThese figures translate to approximately 1.1 millionAustralians having used meth/amphetamine in theirAustralians having used meth/amphetamine in theirlifetime.lifetime.

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AUSTRALIAN USE OF ATS

Just 2.3% of the population have usedJust 2.3% of the population have usedmeth/amphetamine in the past 12 months.meth/amphetamine in the past 12 months.

Lifetime use of ecstasy is higher thanLifetime use of ecstasy is higher thanmeth/amphetamine use, at 8.9% of themeth/amphetamine use, at 8.9% of thepopulation, and recent use is 3.5%.population, and recent use is 3.5%.

Therefore, approximately 1.5 million AustraliansTherefore, approximately 1.5 million Australianshave used ecstasy at some time in their life, andhave used ecstasy at some time in their life, andapproximately 0.6 million have used ecstasy inapproximately 0.6 million have used ecstasy inthe past 12 months.the past 12 months.

(The 2007 National Drug Strategy Household Survey, 2008).(The 2007 National Drug Strategy Household Survey, 2008).

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Proportion of IDU reporting recent use ofcrystalline methamphetamine, by Australianjurisdiction, 2000-2005

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ATS USE IN NEW ZEALANDATS USE IN NEW ZEALAND

2007 Illicit Drug Monitoring System (IDMS)2007 Illicit Drug Monitoring System (IDMS)interviewed 324 frequent drug users, includinginterviewed 324 frequent drug users, including110 frequent methamphetamine users, 105110 frequent methamphetamine users, 105frequent ecstasy (MDMA) users and 109 frequentfrequent ecstasy (MDMA) users and 109 frequentinjecting drug users in Auckland, Wellington andinjecting drug users in Auckland, Wellington andChristchurch.Christchurch.

Use patterns were:Use patterns were:

Methamphetamine (97%),Methamphetamine (97%),

Cannabis (87%),Cannabis (87%),

Tobacco (84%),Tobacco (84%),

Alcohol (79%),Alcohol (79%),

Crystal methamphetamine (66%),Crystal methamphetamine (66%),

Ecstasy (MDMA) (52%),Ecstasy (MDMA) (52%),

BZP party pills (43%), andBZP party pills (43%), and

LSD (34%).LSD (34%). 11

Frequent drug users by gender, 2007:New Zealand

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ISSUES FOR SERVICE PROVISIONISSUES FOR SERVICE PROVISION

ATS users are poorly connected with servicesATS users are poorly connected with servicesand retention rates are therefore low.and retention rates are therefore low.

Many of the treatments used for other drugMany of the treatments used for other drugrelated problems have relevance for peoplerelated problems have relevance for peopleaffected by ATS useaffected by ATS use --

However, there are gaps in knowledge aboutHowever, there are gaps in knowledge aboutATS specific withdrawal and treatmentATS specific withdrawal and treatmentstrategies; andstrategies; and

The infrastructure to support effective responsesThe infrastructure to support effective responsesto ATS related problems is limited in someto ATS related problems is limited in someareas. This includes the lack of coordination ofareas. This includes the lack of coordination ofresponse among services, including lawresponse among services, including lawenforcement, AOD specialists and other healthenforcement, AOD specialists and other health(including mental health) networks.(including mental health) networks.

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Methamphetamine TreatmentEvaluation Study (MATES)

11stst Australian longitudinal study.Australian longitudinal study.

Included 5 TCs in QueenslandIncluded 5 TCs in Queensland –– Fairhaven, Goldbridge,Fairhaven, Goldbridge,Logan House, Mirikai and Moonyah Detoxification Unit.Logan House, Mirikai and Moonyah Detoxification Unit.

Methamphetamine was the primary or secondary drugMethamphetamine was the primary or secondary drugof choice; no inpatient meth/amphetamine treatment inof choice; no inpatient meth/amphetamine treatment inthe month prior.the month prior.

44% Major Depression and further 45% reported44% Major Depression and further 45% reportedSubstanceSubstance--Induced Major Depression.Induced Major Depression.

31% Social Phobia.31% Social Phobia.

22% had Substance22% had Substance--Induced Social Phobia.Induced Social Phobia.

31% met the criteria for Panic Disorder.31% met the criteria for Panic Disorder.

58% Agoraphobia.58% Agoraphobia.

10% Substance10% Substance--Induced Panic Disorder.Induced Panic Disorder.

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Methamphetamine TreatmentEvaluation Study (MATES)

TC sample showed greater impairment, 91% scoringTC sample showed greater impairment, 91% scoringbelow 40 on the SFbelow 40 on the SF--12.12.

TC participants more likely to be unemployed, withTC participants more likely to be unemployed, with

92% of the TC sample compared with92% of the TC sample compared with 74% of the74% of theOther sample &Other sample & 86% of the Total sample (p<0.05 cf.86% of the Total sample (p<0.05 cf.

other treatment agencies).other treatment agencies).

TC participants more likely to have exhibited clinicallyTC participants more likely to have exhibited clinicallysignificant symptoms of psychosis in the month priorsignificant symptoms of psychosis in the month priorto treatment.to treatment.

Significantly greater number of TC participants metSignificantly greater number of TC participants metthe DSMthe DSM--IV criteria for panic disorder (31% TotalIV criteria for panic disorder (31% Totalsample, compared to 14 % Others and 40% TC).sample, compared to 14 % Others and 40% TC). 15

Methamphetamine TreatmentEvaluation Study (MATES): Outcomes

Treatment outcomes showed marked reductionsTreatment outcomes showed marked reductionsin all measures of methamphetamine use atin all measures of methamphetamine use atboth three and 12 month follow up.both three and 12 month follow up.

61% abstinent from methamphetamine use at61% abstinent from methamphetamine use atboth three and 12 month followboth three and 12 month follow--up (comparedup (comparedwith 2% at baseline).with 2% at baseline).

Major Depression was, however, the same at 12Major Depression was, however, the same at 12month followmonth follow--up as it was at baseline (44%).up as it was at baseline (44%).

Significant decrease in SubstanceSignificant decrease in Substance--InducedInducedMajor Depression.Major Depression. 16

Effects of ATS use on psychopathology,aggression and cognitive function

among clients within TCs

20% of people receiving treatment for ATS use from20% of people receiving treatment for ATS use from20052005--2007 were treated in a TC2007 were treated in a TC (National Minimum Data Set).(National Minimum Data Set).

Recent study of 104 participants (67 males and 37Recent study of 104 participants (67 males and 37females, with ages ranging from 19 to 60 years) fromfemales, with ages ranging from 19 to 60 years) fromKarralika (Australian Capital Territory), Odyssey HouseKarralika (Australian Capital Territory), Odyssey House(New South Wales), Mirikai (Queensland), and(New South Wales), Mirikai (Queensland), andGoldbridge (Queensland).Goldbridge (Queensland).

Study investigated differences in executive function andStudy investigated differences in executive function andthe prevalence of cothe prevalence of co--occurring mental healthoccurring mental healthproblemsproblems——psychopathology and aggressionpsychopathology and aggression—— amongamongparticipants who identified as being ATS usersparticipants who identified as being ATS userscompared with noncompared with non--ATS usersATS users (Gunn & Rickwood, 2009).(Gunn & Rickwood, 2009).

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STUDY RESULTS

ATS users in TCs showed markedly greater levelATS users in TCs showed markedly greater levelof impairment in overall global executive functionof impairment in overall global executive functionand subcomponents of behavioural regulationand subcomponents of behavioural regulationand metacognitive abilities to manage attentionand metacognitive abilities to manage attentionand solve problems.and solve problems.

Impairment most evident in impulse control;Impairment most evident in impulse control;

Ability to move freely from one situation, problemAbility to move freely from one situation, problemor activity to another as the situation demands;or activity to another as the situation demands;

Capacity to monitor social behaviour;Capacity to monitor social behaviour;

Ability to hold information in the mind in order toAbility to hold information in the mind in order tocomplete a task;complete a task;

Capacity to initiate a task and independentlyCapacity to initiate a task and independentlygenerate ideas; andgenerate ideas; and

Being able to organise personal effects.Being able to organise personal effects.18

IMPLICATIONS OF STUDY FOR TCsIMPLICATIONS OF STUDY FOR TCs

Aspects of executive functioning shown to beAspects of executive functioning shown to beaffected relate to:affected relate to:

Reflective functioning, which involves selfReflective functioning, which involves self--monitoring and selfmonitoring and self--evaluation of performance,evaluation of performance,

Impaired functioning in these areas is likely toImpaired functioning in these areas is likely toinhibit reflecting on behaviour,inhibit reflecting on behaviour,

Ability to make objective decisions,Ability to make objective decisions,

Learn to control impulses, and toLearn to control impulses, and to

Learn from past mistakes.Learn from past mistakes.

Need to consider process for ATS users forNeed to consider process for ATS users forlearning and reflecting, decisionlearning and reflecting, decision--making andmaking andimpulse control in order to gain benefits ofimpulse control in order to gain benefits oftreatment, and most importantly, totreatment, and most importantly, to remainremain inintreatment.treatment.

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SUMMARY OF TC CONSULTATIONS

With few exceptions, ATS was identified as theWith few exceptions, ATS was identified as theprincipal illicit drug of concern by TCs.principal illicit drug of concern by TCs.

3 main drugs of concern were most usually identified3 main drugs of concern were most usually identifiedas alcohol, ATS and cannabis; although heroin wasas alcohol, ATS and cannabis; although heroin wasnominated as the second illicit drug of concern afternominated as the second illicit drug of concern afterATS at Odyssey House (NSW).ATS at Odyssey House (NSW).

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SUMMARY OF TC CONSULTATIONS

Assessment process more complex, need to collectAssessment process more complex, need to collectmore information, especially relating to MH history.more information, especially relating to MH history.

PrePre--admission extended to gather information, and toadmission extended to gather information, and toensure the person has been stabilised, often onensure the person has been stabilised, often onmedications.medications.

Development of early intervention programs, activeDevelopment of early intervention programs, activecase management in consultation with other services.case management in consultation with other services.

Assessment and earlier phases of treatment have hadAssessment and earlier phases of treatment have hadto change in order to cope with this population group.to change in order to cope with this population group.

TCsTCs havehave introduced new programs including waitingintroduced new programs including waitinglist support, early intervention and day programs, andlist support, early intervention and day programs, anddetoxification to assist the transition into treatment.detoxification to assist the transition into treatment.

Provide an opportunity for a steppedProvide an opportunity for a stepped--care approach,care approach,which is particularly valuable where a personwhich is particularly valuable where a personexperiences an episode requiring intensive support orexperiences an episode requiring intensive support ora period away from the wider TC community.a period away from the wider TC community. 21

SUMMARY OF TC CONSULTATIONS

Increased concerns in relation to violence, threats ofIncreased concerns in relation to violence, threats ofviolence and aggression amongst this client group.violence and aggression amongst this client group.

Need for tolerance and latitude, conversely there wasNeed for tolerance and latitude, conversely there wasa view that TCs needed to be clear about theira view that TCs needed to be clear about theirexpectations of behaviour, especially in relation toexpectations of behaviour, especially in relation toviolence or threats of violence.violence or threats of violence.

The need for boundary setting was emphasised, whileThe need for boundary setting was emphasised, whileat the same time appreciating that impulse control asat the same time appreciating that impulse control aspart of executive functioning, was often apart of executive functioning, was often aconsiderable issue of concern for this client group.considerable issue of concern for this client group.

Woolshed in SAWoolshed in SA -- Use of contingency management,Use of contingency management,modelled on themodelled on the ‘‘star chartstar chart’’ and training of seniorand training of seniorresidents as mediatorsresidents as mediators -- receive areceive a ‘‘mediator licencemediator licence’’..

Rewards for successful mediation and resolution ofRewards for successful mediation and resolution ofconcerns.concerns.

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SUMMARY OF TC CONSULTATIONS

Increased incidence of comorbidity.Increased incidence of comorbidity.

Need for more individualised work, which in turn placesNeed for more individualised work, which in turn placesgreater stress on other aspects of the program.greater stress on other aspects of the program.

Prescribed antiPrescribed anti--psychotic medications.psychotic medications.

High prevalence of depression & anxiety, also increasedHigh prevalence of depression & anxiety, also increaseddiagnoses: schizophrenia, bipolar disorder & others.diagnoses: schizophrenia, bipolar disorder & others.

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Mirikai:Primarydiagnoses2007-2008Residentsalso haveSecondarydiagnoses,adding tocomplexity

SUMMARY OF TC CONSULTATIONS

Lack of sexual boundaries has sometimes been a partLack of sexual boundaries has sometimes been a partof a personof a person’’s behaviour prior to entering treatment .s behaviour prior to entering treatment .

Issues relating to sexual assault, including PTSD andIssues relating to sexual assault, including PTSD andsignificant issues relating to shame, guilt and grief.significant issues relating to shame, guilt and grief.

First stage of treatment vitalFirst stage of treatment vital –– need for more activityneed for more activity--based interventions, fewer cognitivelybased interventions, fewer cognitively--based educationbased educationinterventions and didactic teaching.interventions and didactic teaching.

Use of contingency management.Use of contingency management.

Development of peer support and mediation skillsDevelopment of peer support and mediation skillsamongst residents, leading to greater selfamongst residents, leading to greater self--management and internal locus of control, rather thanmanagement and internal locus of control, rather thanexternal systems.external systems.

As TCs have modified to include moreAs TCs have modified to include morepsychoeducation, tendency to reduce the amount ofpsychoeducation, tendency to reduce the amount oftime residents spend in traditional work programs.time residents spend in traditional work programs.

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TREATMENT PROTOCOL

Consultations with TCs overwhelmingly supported theneed for an intervention that concentrated on the pre-treatment and early treatment stages of the TC program.

The use of interventions incorporating CognitiveBehavioural Therapy (CBT), Motivational Interviewing (MI),Acceptance Commitment Therapy (ACT), andMindfulness-Based Cognitive Therapy (MBCT) werestrongly endorsed..

There was strong recognition of the TC as providing astepped-care approach, together with workskills programs,which were found to be efficacious in working with thisclient group.

There was strong support for a flexible model whichincluded Tip Sheets, Clinical information for Assessmentand Withdrawal, Treatment Intervention and Worksheets.

TREATMENT PROTOCOL

The development of the Treatment Protocol: An interventionTreatment Protocol: An interventiondeveloped for the use of staff & clinicians working with ATSdeveloped for the use of staff & clinicians working with ATSclients of Therapeutic Communitiesclients of Therapeutic Communities has utilised thehas utilised theinformation from all consultations with TCs in Australia andinformation from all consultations with TCs in Australia andNew Zealand, and has incorporated materials from:New Zealand, and has incorporated materials from:

Baker, A., Kay-Lambkin, F., Lee, N.K., Claire, M. & Jenner,L. (2003). A brief cognitive behavioural intervention forregular methamphetamine users. Canberra: AustralianGovernment Department of Health and Ageing.

Lee, N., Johns, L., Jenkinson, R., Johnston, J., Connolly,K., Hall, K. & Cash, R. (2007). Clinical Treatment Guidelinesfor Alcohol and Drug Clinicians. No 14: Methamphetaminedependence and treatment. Fitzroy, Victoria: Turning PointAlcohol and Drug Centre Inc.

TREATMENT PROTOCOL

The Treatment Protocol has been enhanced throughattendance at three valuable experiential workshops, fromwhich information has been sourced and utilised withpermission of the authors:

Liana Taylor, Mindfulness-Based Cognitive Therapy,experiential intensive course and professionaldevelopment, Canberra, 12 – 15 February, 2009.

Dr Chris Wagner, Adapting Motivational Interviewing to aGroup Counselling Setting, Sydney, 9-10 March, 2009.

Dr Russ Harris, ACT MINDFULLY: Acceptance &Commitment Therapy Training, Canberra, 23-24 March,2009.

TREATMENT PROTOCOL

The treatment package has been divided into four sections:

Section 1: Clinical Assessment

Comprehensive assessment, Assessing readinessfor change, Mental Health assessment, Screeningfor depression & Anxiety, Information on thePsyCheck Screening Tool, Psychosis ScreeningTool

Section 2: Tip Sheets

12 Tip Sheets covering clinical information,withdrawal, motivation for change, coping withcravings, recovery metaphors, managing feelings,coping with anxiety & relapse dangers.

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TIP SHEETS

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Designed for usewith clients,professionals &families.

Learning to dealwith Cravingsthrough UrgeSurfing –Understandingthat you have thepower overfeelings providesa sense ofControl

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TIP SHEETS

Use ofMetaphors isparticularlypowerful –

AcceptanceCommitmentTherapy.

TC Concepts

TREATMENT PROTOCOL

Section 3: Treatment Modules – 7 modules:

Module 1: Building motivation for change

Module 2: Understanding and coping with cravings

Acceptance & Commitment Therapy

Module 3: Understanding how thoughts influence

behaviour

Module 4: Understanding feelings and making the

Mind/Body connection

Module 5: Learning to deal with anxious thoughts

and feelings

Module 6: Understanding and acknowledging core

beliefs and values

Module 7: Relapse Prevention

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TREATMENT PROTOCOL

Section 4: Worksheets

The treatment intervention includes 21 differentworksheets covering:

• Timeline follow-back and stages of change ladder;

• Psychosis screener;

• Lifestyle issues causing problems; Decisionalbalance;

• Vitality & Suffering Diary; Unhelpful thinking patterns;Self-monitoring record; Understanding how weexperience feelings; Feelings of Anger, Loss, Shameand Guilt; Pleasant thoughts calendar; Anxiousthoughts questionnaire;

• Values worksheets, including Personal Values CardSort;

• Positive Affirmations; Relapse dangers and GoalSetting. 32

WORKSHEETS

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Buildingmotivation forchange first stepin change process

WORKSHEETS

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ACT Exercise:Think about themain thoughts andfeelings youstruggle with – theones that get youdown, interfere withyour life, or set youup for a strugglewith yourself &others.BODY – write downthe urges, cravings,sensations you feelin your body.MIND – write downyour thoughts,memories youstruggle with.

WORKSHEETS

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Now you have achoice.VITALITY is what weare aiming for: asense of wellbeing.Write down all thepositive things youhave done whenthese difficultthoughts & feelingshave shown up.SUFFERING is whatwe are aiming toreduce. What are thestrategies you’veused in the past thathave actually madethings worse?

TRIAL OF TREATMENT PROTOCOL

The initial trial of the Treatment Protocol was conductedwithin selected TCs that are geographically located inareas with high ATS prevalence and are working with ATSclients.

Cyrenian House (Perth) working with adults & women withchildren and Mirikai (Gold Coast) working with youngpeople.

The initial short trial (1 – 2 months) sought information fromparticipants and clinicians on their response to theintervention, use of Tip and Worksheets and flow ofsessions.

This was largely a qualitative study.

Some adjustments were then made to the TreatmentProtocol, prior to its release at the ATCA Conference inCanberra in September 2009.

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INTERVENTION FOR AMPHETAMINE-TYPE STIMULANT (ATS) USE IN THETHERAPEUTIC COMMUNITY

The Treatment Protocol will now be tested through a 3 yearPhD study with the University of NSW to assess theeffectiveness of the specialist ATS intervention in atherapeutic community setting.

This will be a quasi-experiment comparing process andoutcomes of treatment for clients with ATS as a principal orsecondary drug of concern in the TC setting receiving theATS intervention compared with treatment as usual in otherTC settings.

125 participants will be recruited in each of the groups(intervention in 5 TCs, compared with treatment as usual inanother 5 TCs).

Participants will be interviewed at treatment entry,discharge data (records/interview if planned), 3 months and12 months post entry.

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INTERNATIONAL APPLICABILITYINTERNATIONAL APPLICABILITY

Expected the Treatment protocol will translate wellExpected the Treatment protocol will translate wellinto European & American TCs.into European & American TCs.

Information from 1st Global MethamphetamineInformation from 1st Global MethamphetamineConference in Prague in 2008 confirmed findingsConference in Prague in 2008 confirmed findingsof Australasian consultations.of Australasian consultations.

Issues are similar, therefore it is likely theIssues are similar, therefore it is likely thesolutions will also be similar.solutions will also be similar.

Enquiries: James Pitts, CEOEnquiries: James Pitts, CEO

Odyssey House McGrath Foundation,Odyssey House McGrath Foundation,

PO Box 459, Campbelltown,PO Box 459, Campbelltown,

NSW, Australia 2560.NSW, Australia 2560.

The authors would like to acknowledge the support of the AustralThe authors would like to acknowledge the support of the AustralianianGovernment Department of Health & Ageing in the funding of thisGovernment Department of Health & Ageing in the funding of thisproject.project.

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