Methamphetamine (ice) use trends in South Western Victoria and the Barwon region Produced by the SEED Consulting Group, Centre for Social and Early Emotional Development (SEED), School of Psychology, Deakin University for the Western Region Alcohol and Drug (WRAD) service and the Barwon Region Primary Health Partnership.
29 October 2015
Prepared by
David Robert Skvarc
Jay Varcoe
Rachel Leung
Jessica Hall
Professor Peter Miller
Professor John W. Toumbourou 1
This report was prepared by the SEED Consulting Group, Centre for Social and Early Emotional Development (SEED), School of Psychology, Deakin University for the Western Region Drug and Alcohol service and the Barwon Region Primary Health Partnership, October, 2015. Published by Deakin University.
October 2015
© Deakin University
This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.
Authorised by the Barwon Region Primary Health Partnership.
Recommended citation
Skvarc, D.R., Varcoe, J., Leung, R., Hall, J., Miller, P., & Toumbourou, J.W. 2015. Methamphetamine (ice) use trends in South Western Victoria and the Barwon region Prepared by the SEED Consulting Group, Centre for Social and Early Emotional Development (SEED), School of Psychology, Deakin University for the Western Region Drug and Alcohol service and Barwon Region Primary Health Partnership.
Acknowledgements Warrnambool Communities That Care, Geelong Communities That Care and Glenelg Alcohol Health Promotion Planning Committee for the use of data.
2
Glossary ADIS:
Alcohol and Drug Information System
AIHW:
Australian Institute of Health and Wellbeing
Episode of care: provider
A planned client service provided by an Alcohol and Other Drug service
SEED:
Centre for Social and Early Emotional Development; a Strategic Research Centre based at Deakin University.
3
Summary The report that follows sought to synthesise information for the Barwon South West Victoria region regarding the use of crystal methamphetamine use (ice) relating to: patterns of use; related harms; and evidence-based prevention and intervention responses. The report was completed by the SEED Consulting Group within the School of Psychology at Deakin University and commissioned by health service planning agencies across the region. The report found in overview that:
Trends and patterns of use: •
•
• • •
•
Death and disability related to amphetamine use remains at low rates across Australia and is a minor component when compared to alcohol use. National trends in amphetamine use have remained low and were relatively stable in recent years. Methamphetamine use is rare in populations over 30, hence the present report focussed on use amongst young people. Although Victoria has amongst the lowest rates of methamphetamine use in Australia, there are higher rates in non-metropolitan areas. South Western Victoria and the Barwon Region has amongst the highest rate of treatment entry for amphetamine use amongst 15-24 year olds. There appears to be a shift amongst methamphetamine users away from powdered and injectable forms of the drug, and towards the more potent crystallized form “ice”. Ice has been associated with an increasing number of hospital visits over the past 3 years. Longitudinal studies reveal that the use of amphetamines is predicted by a range of modifiable factors. Favourable attitudes and inflated perceptions of how many use a specific substance amongst communities, families, peers and individuals consistently predict increased use for that form of substance use. This suggests that discouraging favourable attitudes and inflated perceptions of use may contribute to reducing substance use. Young people that do not use alcohol are at low risk of graduating to amphetamine use and other illicit drug use, suggesting that efforts to prevent school age alcohol use may also reduce illicit drug use in future years.
Strategies to prevent and reduce use: •
•
• • •
•
Multiple strategies to reduce methamphetamine use have been examined both internationally and in Australia. The most effective strategies commonly integrate: reduction of availability of precursors; attempts to reduce favourable attitudes and inflated perceptions of use; and efforts to encourage healthy child and youth development. Illicit substance use, including methamphetamine use, can be reduced through evidence-based treatment approaches including long residential and multi-session interventions, but these approaches are expensive and there are limits on local availability. There are evidence-based approaches that can prevent youth initiation of methamphetamine use and other illicit drug use, these tend to be feasible and cost-effective. Providing targeted evidence-based support to vulnerable families can reduce early life problems that can lead adolescents to develop self-destructive motivations to use harmful drugs. Using school curricula and brief online interventions may be effective in reducing favourable attitudes and inflated perceptions of use for students, contributing to small reductions in use for large populations in a feasible and cost-effective manner. Reducing child and adolescent risk factors and enhancing protective factors using evidencebased approaches such as Communities That Care is a long-term strategy that can prevent the development of substance use and related problems across large populations in a feasible and cost-effective manner. 4
•
Strategies for prevention are more likely to succeed if they are integrated and supported across all levels of key stakeholders, such as the government, communities, and individuals.
Recommendations: Recommendation 1. Give priority to supporting youth alcohol prevention approaches. Reducing future demand using effective alcohol prevention approaches in school-aged populations is feasible and cost-effective and will reduce post-school youth illicit drug problems across the region within 5 to 10 years. The Communities That Care and Smart Generations approaches are evidence-based prevention approaches available within the region. Recommendation 2. Use screening and brief intervention approaches to encourage young alcohol and drug users to reduce substance use and to enter treatment services at an earlier point. The use of ice is associated with high rates of heavy and harmful youth alcohol use across the region. In a previous report Skvarc, Varcoe, Graetz, Bauld & Toumbourou (2015) examined catchment-based planning in the south west region and recommended that alcohol and drug services set a target to increase treatment places for young people by 20% over coming years. This is being supported by a Western Alliance funded project that aims to introduce youth alcohol and drug screening and brief intervention into South West primary care services. If this is shown to be successful a similar approach should be also considered for the Barwon region. Recommendation 3. Develop agreed protocols for managing substance users that are violent or threatening in settings such as hospital emergency rooms. Although use of ice is not common (see Department of Health, 2008; Lim et al., 2015; and Communities that Care data summarised in Table 1), the salient association of use with violent and unpredictable behaviour warrants the commissioning of expert assistance to develop agreed protocols for managing settings where contact with affected substance users is likely (Bunting et al., 2007). The early intervention target in the Skvarc et al. (2015) report for the South West region introduces the potential to trial protocols that take a low tolerance approach. For example, police could agree to attend emergency rooms when substance users are engaged in threatening behaviours and before offences are caused. While comparatively greater numbers of methamphetamine patients are accompanied by police to emergency departments as opposed to other toxicology-related patients, the majority are unaccompanied by police (Bunting et al.). Increased police visits to emergency rooms in the South West region could enable police warnings and legally enforced pressure from the courts to then be used as early interventions to encourage substance users that engage in threatening behaviours to enter treatment at an earlier point. If evaluated and found to be successful, similar substance use management protocols could be used to supplement local family violence strategies and introduced for trial in the Barwon region.
5
1. Introduction Methamphetamine (N-methyl-alpha-methylphenethylamine) is a central nervous system stimulant that is used increasingly as an illegal recreational drug in Australia and in other nations. The use of methamphetamine and its crystalline form (“ice”) are associated with dependency and potentially harmful effects such as amphetamine psychosis, aggressive behaviour, and other significant potential harms (Department of Health, 2008). In the working population, rates of use have been estimated at approximately 6.4% amongst Australians aged between 12-17, and 11.2% between the ages of 18 and 29, before sharply decreasing in older populations. Industry trends also reveal that workers within the hospitality, construction, retail, and transport sectors contain some of the highest proportions of users (9.5%, 5.4%, 4.6% and 5.4% respectively; Roche et al. 2008). At a regional meeting in March 2015 health service planning agencies and the regional alcohol and drug planning consortium received member reports that raised concerns relating to the use of ice in South West Victoria. Similar concerns were later raised relevant to the Barwon region of Victoria. The SEED consulting group based within Centre for Social and Early Emotional Development (SEED), the School of Psychology, Faculty of Health at Deakin University accepted the commission to develop the report that follows. The SEED consulting group were asked within a limited time-frame to identify and synthesise a range of data sources relating to ice including: Trends in secondary school age youth reports of illicit drug use including stimulants such as ice; Numbers entered in drug treatment service data systems; Hospital Emergency Department data; Police data; and Reviews of evidence-based prevention, treatment and intervention responses. Where possible trend comparisons were made with local government areas, the Barwon South Western Victoria region and the state and nation. Literature reviews systematically examined peer-reviewed international publications. It became apparent in completing research into ice that the drug is mainly used by people aged below 30, hence the report that follows focuses particularly on these age groups. In what follows data is initially provided on rates of use in recent primary and secondary school age student surveys completed in areas of the region.
2. Trends and patterns of use Summary: •
• • •
•
National trends of generic amphetamine use have remained low and relatively stable in recent years. Methamphetamine use is rare in populations over 30, hence the present report focussed on use amongst young people. There appears to be a shift amongst methamphetamine users away from powdered and injectable forms of the drug, and towards the more potent crystallized form “ice”. Ice is associated with an increasing number of hospital visits over the past 3 years. Victoria has amongst the lowest rates of methamphetamine use in Australia, but South Western Victoria and the Barwon Region has amongst the highest rate of alcohol and drug treatment episodes of care for amphetamine use amongst 15-24 year olds. Deaths due to amphetamine use have remained steady since 1990, whereas deaths from alcohol have increased. Death and disability related to amphetamine use remains at low rates across Australia and is a minor component when compared to alcohol use.
6
National trends and comparisons with alcohol We examined published records from the National Drug Strategy Household Survey, including the published online tables. These analyses revealed that rates of methamphetamine use in Australia across all ages have been steadily decreasing since approximately 2004, with 2.1% of the population reporting use in the past 12 months. By comparison, 78.2% of Australians reported recent alcohol use, including 15.6% who did so at least monthly at a level associated not only with single occasion harms, but also at a level that placed them at risk of lifetime harms (Australian Institute of Health and Wellbeing National Drug Survey, 2014). The rate of deaths in Australia due to amphetamine use has also remained at between 3 and 12 per year in recent decades, whereas deaths directly attributable to alcohol use have increased from 251 to 343 per year (see Figures 1-3; Institute for Health Metrics Evaluation, 2013). The economic impact of methamphetamine use is difficult to quantify, but estimates for all illicit substances (including hospital costs, loss of productivity, and forensic costs) were estimated at over $6 billion in the years 2004-2005. By contrast, alcohol alone accounted for over $11 billion dollars in costs in the same period (Collins and Lapsley, 2008).
Methamphetamine use amongst secondary school aged individuals in Australia National trends from published tables from the National Drug Strategy Household Survey indicate that methamphetamine use is historically low among the 14-19 age groups. Between 2010 and 2013, the proportion of young people aged 14-19 who had used methamphetamine in the past 12 months increased from 1.6% to 2.0%. However, this must be interpreted in light of a general overall trend for decrease in methamphetamine use among this age group over the past 20 years, and the differences between 2010 and 2013 were not statistically significant. In 1995 2.7% of 14-19 year olds reported methamphetamine use, and this rose consistently to 6.6% in 2001. Use declined to 1.6% in 2007, and remained stable until 2013. Males and females differed marginally, but remained relatively consistent with the overall proportions of use. Type of methamphetamine use has significantly altered since 2007; in 2007 powder methamphetamine (“speed”) was the most commonly used form. By 2013, powder use had decreased significantly from 51% of users to 29%, and crystal methamphetamine (“ice”) use had increased from 22% to 50% of all methamphetamine users. This indicates that in 2007 approximately 0.81% of people aged 14-19 used speed, and 0.35% of the same group used primarily ice. In 2013, 0.58% used speed, and 1% used ice (AIHW-NDS, 2014). Use of generic amphetamine amongst secondary school aged students was also examined for the present report using published data from the Australian Secondary School Alcohol and Drug Survey (ASSADS, 2011). Across all age groups (12 -17 years), the proportion of amphetamine users decreased significantly from 2005 to 2011. Of the students who had ever used amphetamines, 44% of males and 59% of females had used them only once or twice (ASSADS, 2011). Based on the most recent National Drug Strategy Household Survey, the median age of initiation into methamphetamine use was 18 (14-23) years (AIHW-NDS, 2014).
Victoria Based on published tables from the National Drug Strategy Household Survey, Victorians aged 14-19 are among the least likely to have used any illicit drug in the past 12 months, compared to other states and territories, with 16% of this age group reporting recent use. The Northern Territory was the highest with 27.3% of people aged 14-19 reporting use in the past 12 months. Greater detail comparing age groups and methamphetamine use by state or territory was not available, but it was possible to compare methamphetamine use across all age groups by state or territory. Victoria had 7
amongst the lowest proportion of methamphetamine users nationally with 1.9%, NSW was lowest with 1.4%. Western Australia and Tasmania had the highest proportions of users with 5.5% each (AIHW-NDS, 2014). For the present report we also examined estimates from the Victorian government sourced from analyses reported by Turning Point. These indicated that methamphetamine use among 12-15 year olds decreased from 2008 to 2010 (4% of males and 3% of females in 2008, both decreased to 2% in 2010; DHS, 2011).
South West Victoria We completed analyses for the present report of National Drug Strategy Household Survey data held by the Australian Institute for Health and Welfare. We estimated that the proportion of any illicit drug use across all ages in the Warrnambool and South West Statistical Area was 17.0%; the 3rd largest proportion in Victoria behind the Mornington Peninsula (17.4%) and Inner Melbourne (25.9%; AIHW, 2014). This is generally consistent with estimates that suggest rurality, remoteness, and distance from capital cities are associated with increased rates of methamphetamine and alcohol use, by a factor of two to one. However, the AIHW database did not allow further scrutiny of proportions by age or substance type. Table 1 reports surveys conducted by Deakin University on behalf of Communities that Care Geelong, Communities that Care Warrnambool and the Glenelg and Southern Grampians Primary Care Partnership that allowed comparisons in different municipal and regional areas across Geelong, Warrnambool, and the Glenelg Shire.
Table 1. Reported use of methamphetamine use in primary and secondary school aged children. YEAR 6 (n=194) % CI (%)
YEAR 8 (n=206) % CI (%)
YEAR 10 (n=137) % CI (%)
Ever used methamphetamines
0
0
0
0
2.1
0-4.6
Lifetime illegal drug use
0
0
0.5
0-14.5
5.8
1.9-9.8
0.5
0-1.5
0.5
0-1.5
2.9
0-5.8
Geelong
Used illegal drugs in last 30 days
%
YEAR 6 (n=314) CI (%)
0.3
0-0.9
0.4
0.1.1
0.2
0-0.7
Lifetime illegal drug use
0
0
0.2
0-0.6
1.3
0-2.7
Used illegal drugs in last 30 days
0
0
0
0
0.4
0-1.2
Warrnambool
Ever used methamphetamines
%
YEAR 6 (n=105) CI (%)
1.0
0-2.8
Glenelg Shire*
Ever used methamphetamines
YEAR 8 (n=466) % CI (%)
YEAR 10 (n=411) % CI (%)
YEAR 8 (n=171) % CI (%) 1.2
0 -2.8
Source: Hall & Toumbourou (2014); Hall, Smith & Toumbourou (2015a); and Hall, Smith, & Toumbourou (2015b). Note: CI (%) – 95% confidence interval. *Lifetime illegal drug use, and past 30 days illegal drug use were not collected in the Glenelg Shire.
8
Numbers entering Alcohol and Drug Information Service (ADIS) system in South Western Region for Amphetamine use Alcohol and Other Drug episodes of care: The following analyses were conducted through an examination of the Turning Point alcohol and other drug databases (Turning Point, 2014).
Victoria ADIS total amphetamine entries An analysis was completed for the present report of State Alcohol and Other Drug (AOD) episodes of care per 10,000 people recorded on the Alcohol and Drug Information Service (ADIS) database. Across the state the Mean AOD episodes of care per 10,000 people was 13.4 (SD: 6.5 Range: 28.2). The Hepburn LGA had the lowest mean rate of AOD episodes of care per 10,000 people with 4.2, and Cardinia had the highest with 32.4.
Barwon South West Victoria ADIS total amphetamine entries When including the entire Barwon region, including all LGA’s along the south coast of Victoria stretching from the Glenelg shire to the City of Greater Geelong, AOD amphetamine episode of care rates per 10,000 people were slightly above the state average.
Table 2. Amphetamine episodes of care per 10,000 people by LGAs in Barwon SW region (all ages), by year. LGA
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
Colac-Otway
14.1
11.6
9.2
12.2
11.1
14.1
19.8
44
Corangamite
3.6
-
4.2
-
-
3.2
8.9
5.2
Glenelg
10.4
5.8
3
2.4
7
13
22.5
46.4
Greater Geelong Moyne
7.7
7.1
7.3
5.4
6.2
10.2
12.8
19.7
-
-
6.5
-
5.4
4.5
6.8
13.7
Queenscliffe
0
0
0
0
-
0
-
0
Southern Grampians Surf Coast
-
3
3.6
-
-
3
7.1
11
3.2
-
3.7
6.6
6.4
4.6
8.1
7.5
Warrnambool
15.8
11.5
7.8
7
6.5
14.8
14.4
29.4
5.03
5.6
7.1
7.4
12.55
19.65
5.8
5.2
6.5
9.4
13.7
17.6
Barwon SW 7.82 6.5 Region Average Victoria 7.1 6.7 Average LGA – Local Government Area.
The majority of LGAs within the Barwon region demonstrated relatively consistent and nonsignificant increases in amphetamine use from 2004/05 until 2014/15, with the exception of the Glenelg, Colac-Otway, and City of Greater Geelong LGAs which demonstrated significant increases. 9
Across the entire Barwon region, recent trends for ages 15-24 and 25-39 indicate a general increase in AOD episodes of care within the region, largely driven by sharp increases in the Glenelg region and to a lesser degree, Colac-Otway region (See Figure 4).
Table 3. Amphetamine episodes of care per 10,000 people aged between 15-24 years, by LGAs in Barwon SW region, by year. LGA
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
Colac-Otway
19.8
46.5
58
59.5
43.8
40.6
45.2
97.5
Corangamite
-
-
-
2.3
-
0.1
26.7
2.7
Glenelg
44
-
-
0
-
44.8
60.6
168.9
Greater Geelong
17.6
14.9
15.5
10.3
15.6
34.3
35.8
49.2
Moyne
-
1.5
0
-
-
-
-
47.9
Queenscliff
0
0
0
0
-
0
-
0
Southern Grampians
-
-
-
-
0
24.6
24.5
30.4
Surf Coast
-
0.9
-
31.3
25.1
15.5
28.5
26.2
Warrnambool
38.7
25
20.9
16.5
14.3
29.9
34.9
94.4
Barwon Average
24.02
14.8
18.88
17.12
19.76
23.72
36.6
57.46
17.9
15.7
13.3
10.8
15.3
24.9
37.5
46.6
Victoria Average
The rates of episodes of care for amphetamine use in 15-24 year olds per 10,000 people in Individual regions throughout South Western Victoria have tended to fluctuate over the past ten years, although sharp increases have been observed in recent years. With the exceptions of Queenscliff LGA were no change occurred, and Corangamite and the Surf Coast LGAs where decreases where observed, the Barwon Region and Victoria in general saw a historically high average rate of episodes of care for 15-24 year olds. In 2013-2014, the Glenelg shire had the highest rate of amphetamine episodes of care per 10,000 for 15-24 year olds, and the Colac-Otway and Warrnambool LGAs rated as the 6th and 8th highest in Victoria respectively.
Hospital Separation statistics Hospital separation statistics are used in Australia to record the treatment or care provided to a patient. Patients may have more than one separation within a defined period. In many statistical analyses, separation statistics are based upon International Classification of Diseases (ICD-10) codes. These data were analysed for the present report based on their inclusion in the National Hospital Morbidity Database, which allows comparisons from 2011/12 and 2012/13. Substance use disorders are coded under “Mental and behavioural disorders due to psychoactive substance use (F10-19)”. 10
This analysis did not have data at a regional level and revealed that across Australia the total number of cases of mental and behavioural disorder due to stimulants (including caffeine but excluding cocaine; coded F15) increased from 4,388 separations in 2011/12 to 5,631 in 2012/13 (AIHW National Hospital Morbidity Database, 2014). The data collected in the National Hospital Morbidity database includes all public and the majority of private hospitals in Australia, including both inpatient and outpatient facilities.
Table 4. Hospital separation data for methamphetamine use, all ages, over 2010-2013 (Australia). 2010-
2011-
2012-
11
12
13
F15.01 Mental & behavioural disorder due to use of stimulants, acute intoxication from methamphetamines.
44
117
127
F15.11 Mental and behavioural disorders due to use of other stimulants, including caffeine, harmful use (methamphetamines).
55
113
227
F15.21 Mental and behavioural disorders due to use of other stimulants, including caffeine, dependence syndrome (methamphetamines).
499
436
856
F15.31 Mental and behavioural disorders due to use of other stimulants, including caffeine, withdrawal state (methamphetamines).
29
70
95
F15.41 Mental and behavioural disorders due to use of other stimulants, including caffeine, withdrawal state with delirium (methamphetamines).
N/A
10
8
F15.51 Mental and behavioural disorders due to use of other stimulants, including caffeine, psychotic disorder (methamphetamines).
254
531
630
F15.81 Mental and behavioural disorders due to use of other stimulants, including caffeine, other mental and behavioural disorders (methamphetamines). F15.91 Mental and behavioural disorders due to use of other stimulants, including caffeine, unspecified mental and behavioural disorder (methamphetamines).
19
5
18
9
17
18
909
1299
1979
Total
Table 5. Hospital separation data for methamphetamine use in patients aged 19 years or younger. 2010-2011
2011-2012
2012-2013
F15.01 F15.11
4 8
18 17
18 21
F15.21 F15.31
2 3
14 6
21 6
F15.41 F15.51 F15.81 F15.91 Total
N/A 51 N/A 0 68
0 41 0 1 97
0 46 1 1 114
7.48%
7.46%
5.76%
Proportion
11
Additional analyses performed upon this data reveal that over 2011-2012 and 2012-2013 the absolute number of patients presenting at hospitals for treatment related to methamphetamine use increased significantly. However, the proportion of these patients aged 19 years or younger decreased slightly too just fewer than 6%.
Emergency Department Data Analysis of emergency department data was completed for the present report based on published tables provided to the AIHW. Analyses revealed that Australian emergency departments received 376 drug reaction presentation cases over 2013-14, out of over 6 million recorded entries. This represents 0.21% of the 172,560 cases that fell under the “F00-F99” ICD-10 classification, Mental and Behavioural Disorders (AIHW, 2014a). While 90% of Victorian hospitals provided data to the AIHW, caution should be used when interpreting this data for smaller hospitals, as just under half of smaller (Category “C”) hospitals in Victoria provided data to the AIHW at the time of the report.
Great South Coast Police Data Police records for assault offences were analysed for the present report. There was great inconsistency across different regions of South West Victoria. For example, throughout Western Region Division 1 (Victoria Police delineations), assault rates decreased slightly from 2012/13 to 2013/14 overall. In Greater Geelong, a modest decrease of 5.6% was recorded, while the Surf Coast reported a decrease in per-population assaults of 15.5%, from 364 per 100,000 to 307 per 100,000. The Colac-Otway region experienced a 17.1% increase from 1011.2 to 1183.9 per 100,000 in the same period; Queenscliff remained unchanged. By comparison, Western Region Division 2 reported a significant increase in rates of assault (10.4%) over the same period. Assault rates in Warrnambool decreased 9.7% from 299 recorded offences in 2012/13 to 270 recorded offences in 2013/14, representing a per population shift from 906 per 100,000 to 810.5 per 100,000 (Victoria Police, 2014). Both statistics for Warrnambool are amongst the lowest in the state, and are below average for the Western Victoria, and are anomalous for the region. Corangamite reported a 19.8% increase in assault rates from 476 to 570.1 per 100,000; Glenelg reported a 4.2% increase from 860 to 896.5 per 100,000; Moyne reported the largest increase from 998.4 per 100,000 to 1456 per 100,000 (45.8%); and Southern Grampians reported an increase of 17.5% from 653.8 per 100,000 to 768 per 100,000. The analysis that follows examined trends across Australian causes of death data to extract trends in deaths per year for amphetamine use disorders. Trends were compared those for deaths from alcohol use disorders. These analyses were completed using data available from the Institute for Health Metrics Evaluation (2014). Figure 1 below presents trend estimates (and 95% confidence interval bars) for both males and females, Figure 2 for males only and Figure 3 for females only. The analyses show that deaths per year from amphetamine use disorders have been steady at between 3 to 12, while deaths from alcohol use disorders have risen by 37% in two decades from 251 in 1990 to 343 in 2010 (Figure 1). Males have higher rates of deaths from alcohol use disorders (Figure 2) than females (Figure 3), but the rising trend is apparent for both.
Figure 4 contains longitudinal data demonstrating a modest overall increase for AOD service episodes of care in the Barwon and South Coast region, adjusted for population (Turning Point, 2014).
12
Figure 1- Average cause of death in Australia, by disorder, by year, all ages
700
600
500
400 Average deaths per year, all ages. 300
200
Alcohol use disorders
100
Amphetamine use disorders 0
1990
1995
2000
2005
2010
Alcohol use disorders
251.497
275.144
282.697
303.903
343.227
Amphetamine use disorders
3.88377
7.30244
11.1746
10.6087
9.75881
Source: IHME (Institute for Health Metrics and Evaluation) 2014
13
Figure 2- Male cause of death in Australia, all ages
Male Cause of Death 700
600
500
400 Males, Alcohol use disorder Males, amphetamine use disorder
300
200
100
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0
14
Figure 3- Female cause of death in Australia, all ages
Female Cause of Death 200 180 160 140 120 100
Females, Alcohol use disorder Females, Amphetamine use disorder
80 60 40 20
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0
15
Figure 4 – ADIS episode of care rate per 10,000 people across the Barwon region
16
3. Preventable risk factors and promotable protective factors for methamphetamine use in Australia: a rapid review of the literature. Summary: •
• •
•
•
Young people that do not use alcohol are at low risk of graduating to amphetamine use and other illicit drug use, suggesting that efforts to prevent school age alcohol use may also reduce illicit drug use in future years. Substance use, including methamphetamine use, can be reduced by prevention strategies that target modifiable risk factors across the life-course. Desire to conform and appease (real or perceived) familial, peer, and societal expectations around a specific form of substance use consistently influence involvement in that form of substance use. Educational and Social Cognition training to address erroneous (inflated) beliefs about familial, peer, and societal levels and acceptance of substance use are amongst the effective preventative strategies available. In addition to substance specific risk factors, exposure to a cumulatively high number of risk factors in childhood is known to lead to developmental problems that can motivate harmful substance use. Strategies that effectively assist vulnerable mothers and families may prevent motivational pathways to the most severe forms of heavy drug use.
Introduction: The use of methamphetamines in Australia represents an important population healthcare concern that can be reduced through strategic intervention. The prevalence of substance use is influenced by a broad range of factors, including genetics and environmental factors. Although environmental factors are often considered malleable, some environmental factors may be resistant to change. This rapid review will summarise the available evidence documenting potentially malleable risk factors and protective factors associated with substance use. Very little data is available specifically examining risk and protective factors for methamphetamine use in Australia, although the National Drug Safety Household Survey (NDSHS, 2013) does include measures of motivations to try methamphetamine. Amongst 14-19 year olds, curiosity and availability were by far the highest reported motivations for initiating any illicit drug use. Method: The EBSCO Host database was searched using the following terms: substance use OR methamphetamine AND Australia AND risk factors. 198 academic journal articles reporting longitudinal studies published 2005-2015 inclusive were considered, and 14 papers were included. Table 6 - Results: Risk and protective factors influencing the development of various forms of substance use identified in longitudinal studies Article
Substance(s)
Risk factors
Protective factors
Hemphill et al. (2011).
Tobacco, Alcohol, Cannabis
• • • •
•
• •
Low neighbourhood attachment Community disorganisation Transitions and mobility Laws and norms favourable to drug use Perceived availability of drugs Perceived availability of handguns
• • •
Rewards for prosocial involvement Opportunities for prosocial Involvement Mother attachment Father attachment
17
Article
Substance(s)
Risk factors
Protective factors
• • • •
•
• • • • • • • • • • •
Silins et al. (2013).
Cannabis
Gazis et al. (2009)
Tobacco, Alcohol, Cannabis
Poor family management Family conflict Family history of substance use Parental attitudes favourable toward drug use Parental attitudes favourable to antisocial behaviour Academic failure Low commitment to school Rebelliousness Favourable attitudes toward antisocial behaviour Favourable attitude towards drug use Interaction with antisocial peers Friends' use of drugs Sensation seeking Peer recognition for substance use involvement Antisocial behaviour
Note: Bold indicates an OR of drug use greater than 2. • Environments of licit drug use (tobacco and alcohol) • Greater fun seeking behaviour • Psychoticism • Spend time to learn about culture increased risks of cigarette use (Indigenous Australians)
• • • • •
Opportunities for prosocial involvement Rewards for prosocial involvement Opportunities for prosocial involvement Rewards for prosocial involvement Religiosity Belief in the moral order
Note: Bold indicates an OR of drug use of 0.50.
•
Religious involvement
•
Friends that do not use tobacco, alcohol, or cannabis (Non-Indigenous Australians and Indigenous Australians only) Clear sense of cultural background protective against alcohol and cannabis use (NonIndigenous Australians) Participation in culture protective against alcohol and cannabis use (NonIndigenous Australians); and cigarettes (Other Minorities) Feel good about culture protective against alcohol and cannabis use (nonIndigenous Australians) Understand group membership protective against cannabis (NonIndigenous Australians) Pride in cultural group protective against
•
•
•
•
•
18
Article ScholesBalog et al. (2013)
Substance(s) Alcohol
Risk factors • • • • • • • • •
Kelly et al. (2014)
Patton et al. (2011) Little et al. (2012)
Patton et al. (2006) Hughes et al. (2010) Ryan et al. (2010)
Alcohol, Tobacco, Marijuana, Ecstasy, Other illicit drug use Tobacco, Alcohol, Cannabis Alcohol
Tobacco, Alcohol, Cannabis Alcohol, Cannabis, Other illicit drugs Alcohol
• •
•
• • • • • • •
•
Community normative behaviour (Grade 7) Perceived availability of drugs (Grade 6) Community enforcement of laws (Grade 6) Poor family management (Grade 6) Family history of antisocial behaviour (Grades 6 and 7) Low commitment to school (Grades 6 and 7) Friends use of drugs (Grades 6 and 7) Rebelliousness (Grade 6) Favourable attitudes to drug use (Grade 7) Sensation seeking (Grade 6) Non-completion of high school significantly increased the risks of all substance use, including poly substance use and extended use. Depressive symptoms
Protective factors • •
•
Relationship status (couples used less of all substance types.
•
Increased levels of optimistic thinking
Impulsivity (15-16 years) • Frequency of intoxication (15-18 years) Alcohol related harms (15-18 years) Risky drinking at 19-20 years Paternal drinking at 17-18 years Friends drinking at 19-20 years School and teacher driven strategies (Gatehouse) did not significantly impact upon substance use. Stress was a significant risk factor for cannabis use amongst sexual minorities • • • • •
Lloyd et al (2013)
Alcohol, Other psychotropic drugs
•
A number of risk factors are identified by the authors, but the lack of employment is likely to be the most malleable.
cigarettes (Other Minorities) Peer rewards for prosocial behaviour (Grade 7) Higher self-esteem (Grade 6)
•
Not living with parents at 19-20 years
Parental modelling, Limiting availability of alcohol to the child, Parental monitoring, Parent-child relationship quality, Parental involvement and general communication. Likewise, employment.
19
Article
Substance(s)
Risk factors
White et al. (2013)
Tobacco, Alcohol, Cannabis Ecstasy
• •
Perceived peer drug use Psychological distress
• •
Ecstasy use amongst peers Attendance at electronic dance/music events Being offered ecstasy Lifetime cannabis use Psychological distress Lower moral disengagement Lower resistive self-efficacy
Smirnov et al. (2013)
Newton et al. (2012)
Alcohol, Cannabis
• • • • •
Protective factors
Results: All of the studies listed in the Table above were published in the past nine years and most in the past four years. The majority are Australian studies. The findings highlighted in bold show that some of the strongest risk factors were: perceived availability of substances; favourable attitudes (individual, family, peers); poor family management; family history of antisocial behaviour and substance use; peer substance use; school problems; individual characteristics (rebelliousness). Discussion: Given that the selection of literature was constrained by strict time-limits, we are aware the studies identified in the above Table do not comprehensively include all longitudinal research within the capture period. The selection of research presented in the Table above indicates that there are a broad range of potentially modifiable (intervention-able) factors that predict the development of substance use in longitudinal research. While no literature was identified to specifically address these factors in relation to methamphetamine, the perception of methamphetamine as a “hard” drug (and the relative uncommonness amongst adolescents) may account for the use of tobacco, alcohol, and cannabis as antecedents to methamphetamine use (Degenhardt et al. 2007). In overview the salient risk and protective factors identified in the Table above are compatible with prior reviews of longitudinal studies. Previous systematic reviews of longitudinal studies have identified that adolescent early age use of licit drugs such as alcohol and tobacco are common risk factors for progression to heavy substance use in mid-adolescence that in turn act as risk factors for progression to young adult illicit drug use (Toumbourou & Catalano, 2009; Toumbourou et al, 2014). A consistent observation in longitudinal studies examining the development of substance use is that risk factors have a cumulative impact across childhood and adolescence. The more risk factors that are present and the longer they persist over time, the greater the subsequent developmental impact (e.g., Newcomb & Felix-Ortiz, 1992). There is no single risk factor that fully explains developmental problems, rather these problems can be regarded as having complex causes involving influences and interaction of multiple risk and protective factors. One heuristic proposed to describe the cumulative effect of risk factors is to use the analogy of a snowball (Toumbourou & Catalano, 2009; Toumbourou et al, 2014). According to this view, risk factors that emerge early in life (e.g., maternal smoking and alcohol use) can lead to subsequent risk factors that tend to ‘adhere’ and accumulate as a consequence of the experience of earlier problems (e.g., neurobiological damage due to foetal alcohol and tobacco exposure, school failure, antisocial behaviour). Social and economic mobility patterns in our society have increased socioeconomic differentials and led to a situation whereby children experiencing snowball risk trajectories tend to be disproportionately clustered within disadvantaged geographic communities and schools (Toumbourou et al, 2007). Using this analogy the solution is to invest within these targeted areas to 20
prevent the potential for an avalanching snowball by building protective solutions and reducing early life risk factors for vulnerable families. For example, by increasing support and the availability of substance use treatment to at-risk mothers before they conceive, it may be possible to prevent the sequence of events that can result in the cumulative escalation of risk factors (Catalano et al, 2012). In many cases the cumulative effect of risk is more temporal and can be better described with the analogy of a snowstorm (Toumbourou & Catalano, 2009; Toumbourou et al, 2014). According to this view a healthy child can be put at risk by temporal events such as exposure to extreme weather (or readily accessible supplies of alcohol and drugs). If such exposure continues for long enough and the child has little protection, adverse health outcomes can result. Where the adolescent has low protective factors (such as parents being unavailable to supervise activities, or poor relationships with teachers) in a community with high rates of youth drug use, the likelihood of the adolescent becoming involved in drug use may increase. The protective advantages of positive relationships with adults suggest there is potential to protect health within risky social environments by increasing healthy adult relationships or other protective factors (analogous to providing shelter in stormy weather). From this perspective solutions lie in improving social environments (by reducing peer risk factors and increasing protective social relationships) through the course of development (Catalano & Hawkins, 1996). Interventions to reduce the cumulative exposure to risk factors in combination with efforts to promote protective factors may therefore be effective in efforts to prevent future methamphetamine use. Recommendations Substance use (and subsequent progression from “softer” (licit) to “harder” (illicit) drugs) is commonly observed in longitudinal studies. This may be in some individuals and communities due to the snowball accumulation of early risk factors that leads to self-reinforcing efforts to seek relief from emotional distress. More common across individuals and communities is that substance use is motivated by snowstorm risk factors particularly inflated perceptions of peer, familial, and societal involvement in substance use and favourable attitudes. In order to assist in reducing snowstorm risk factors during adolescence, efforts to prevent methamphetamine use in young people are recommended to adopt strategies aimed at modifying perceptions of levels of use and favourable attitudes to use amongst individuals/ peers and at the family, community and school levels. Community change strategies are more likely to be successful where they integrate with strategies at the governmental levels. This suggests that successful strategies for reducing methamphetamine use are likely to include preventative interventions to enhance healthy child development (e.g., intervening in the early years to reduce snowball risk factors) and community-wide efforts to reduce supply and reduce favourable attitudes before first substance use, or at least before first methamphetamine use. Evidence from this review indicates that the relationships between each level of prevention tend to be multidirectional; as each level tends to produce some flow-on impacts at other levels (See the community level Project STOP and the interactions at an individual and governmental level described below). The next section will examine and summarise the recommended evidence-based prevention and intervention practices. Limitations None of the above included papers, and few of the review articles directly examined methamphetamine use, instead relying upon proxy indicators such as attitudes and use intention. While pragmatic, this approach complicates the evaluation of the efficacy of prevention programs. 21
4. Prevention and intervention strategies for methamphetamine use Summary • • •
Multiple strategies to reduce methamphetamine use have been examined both internationally and in Australia. Strategies commonly revolve around reduction of availability of precursors, and attempts to correct erroneous beliefs about familial, peer, and societal perceptions of substance use. Strategies for prevention are more likely to succeed if they are supported across all levels of key stakeholders, such as the government, communities, and individuals.
Introduction Methamphetamine use has been a growing concern in Australia in recent years. Given the addictive nature of methamphetamine additional research into effective prevention and treatment interventions are important. This rapid literature review will examine the evidence behind common methamphetamine prevention strategies and examine the outcomes of these strategies within Australia where possible. The efficacy of population-level prevention strategies; in particular media based strategies designed to provide information about the dangers of drug use, empower potential users about contributing to their own treatment or prevention, provide support and information about existing programs, correct erroneous normative beliefs about drug use, clarify social and legal norms, and set positive role models, was reviewed by Ferri et al. (2013), with mixed results. Mainstream media interventions specifically aimed at reducing methamphetamine use in adolescents in five US states (Colorado, Georgia, Hawaii, Idaho, and Wyoming), were not successful in reducing past-month use in 12-17 year olds, but did significantly reduce the rate of past-year use of methamphetamine (OR0.59, 95%CI: 0.42-0.84). Other age groups remained unchanged. Alternate forensic programs such as the Hawaii Opportunity Probation with Enforcement (HOPE), have proven successful in reducing methamphetamine use in prisoner populations compared to standard probation protocols, but are not applicable to the wider public due to their specialised administration requirements (Hawken & Kleiman, 2009).
Method: We completed a rapid review to examine prevention strategies for methamphetamine use in Australia. A systematic search of the evidence using the EBSCO Host database, using the search terms: “Methamphetamine AND prevention AND Australia” yielded 179 articles from academic journals. This was reduced to 96 after removal of duplicates. 3 articles met the criteria for methamphetamine prevention strategies in Australia; 93 articles were excluded after failing to meet the reviewable criteria. Additional articles were located through manual scanning of the reference lists of included articles.
22
Results: Table 7: Strategies identified through primary search Paper
Strategy
Method
Results
Australian Example
McKetin et al. (2014).
Disruption of methamphetamine precursor chemicals.
Tightening legislation around retailing of methamphetamine precursor chemicals, such as pseudoephedrine, is intended to reduce quality and quantity of overall supply of available methamphetamine.
Moderate-to-large effect sizes for the reduction in methamphetamine use and purity amongst seized quantities. Police seizure of production facilities appears to be extremely effective in the United States.
Champion et al. (2013); Teesson, (2012).
Use of computerized school-based modules to reduce substance use in students.
Educational modules generally aim to equip young people with skills to recognise and resist perceived peer and societal pressure to use substances. It is generally hypothesized that the promotion of resilience to peer pressures will reduce lifetime substance use.
Generally effective at reducing use of alcohol, tobacco, and cannabis, but this is not universal and the administration of adequately controlled studies appears difficult.
Rodriguez et al. (2014)
Use of computerized Serious Educational Games (SEGs) to reduce substance use in students.
Through the use of educational games, it is hypothesized that students can be educated about the risks of substance use. It is theorized that by providing this information to students, they will change their attitudes towards substance use.
Evidence suggests that the provision of greater information to students results in generally less favourable attitudes towards substance use of all kinds.
Webster (2015). Partnership interventions between police and pharmacists or other third-party operators can be successful in reducing methamphetamine production. Project STOP highlighted as a potentially powerful tool in monitoring pseudoephedrine sales. Vogl et al. (2014) examined the use of school-based computer module intervention among 1734 Year 10 students, comparing interventions to controls over 11 months. The intervention students demonstrated lower promethamphetamine use attitudes and use intentions compared to control students. No Australian examples were identified specifically examining the use of SEGs in Australia. However, Cheng et al. (2012) were able to use a methamphetamine use specific SEG to educate students about the impacts of use upon brain function. This in turn reduced favourable attitudes towards methamphetamine use in students.
23
Table 8: Proposed preventative measures (Roche et al. 2008; Ferri et al. 2013) Prevention Method
Study
Australian Example
Policy development and implementation
Crime and Misconduct Commission (2010); Berbatis et al. (2009).
Queensland: State and federal policies of pseudoephedrine diversion significantly reduced total estimates quantities of available methamphetamine and the purity of the substance. Increased occurrences of pharmacy break-ins to obtain pseudoephedrine. • Recommendation of a federally mandated and nationally consistent policy regarding pseudoephedrine sales, such as mandatory use of electronic monitoring through the use of Project STOP and other Linked Electronic Medical Systems (LEMS).
Education and training
Matthews et al. (2014)
Health promotion
Champion et al. (2013).
Brief interventions
Smout (2010); Humeniuk et al. (2012).
Australia: National media campaigns aimed at educating psychostimulant users about the risks (both of physical risks, and criminal outcomes) of driving under the influence appear to be effective in reducing instances of driving while intoxicated offences for cocaine, ecstasy, and methamphetamine, but not alcohol or cannabis. • Media campaigns appear to be an effect method of disseminating widespread information, although there may be a plateauing effects for more substances such as cannabis and alcohol. Australia: Online education and health promotion tools are in relatively common use amongst Australian schools. Typically, the interventions focus upon providing information about social cognition (e.g. Beliefs about peeruseage) and consist of multiple short modules focused upon one or more substances. Some examples include Consider This (tobacco); and CLIMATE schools (AOD use in general, including psychostimulants). • Computer-based health promotion tools appear to be effective in reducing substance use in young people up to 12 months, though the majority of the available evaluations were conducted by internal evaluators (CLIMATE schools). South Australia: The use of a semi-structured phone interview (The Psychostimulant CheckIn) as a brief intervention has been shown to be effective in reducing methamphetamine use amongst a sample of users from South Australia. Users were assessed at baseline and 3 months after the intervention. Number of days spent using methamphetamine in past month, number of occasions of use on using days, quantity of methamphetamine use in grams, length of longest methamphetamine binge, number of methamphetamine related consequences significantly decreased 3 months after the intervention, and the number of abstinent users increased. There was no change to past month MDMA use, health services contacts, or readiness-to-change stages. Australia: The ASSIST brief intervention tool has demonstrated efficacy in reducing psychostimulant use over 3 months in an Australian sample. In comparison to a psychostimulant using control group, users who were administered the ASSIST reported significantly reduced substance involvement scores. • Brief interventions appear to have good efficacy in reducing substance use within the short term, and require minimal training to administer.
The preceding tables identify multiple strategies to reduce methamphetamine use that have been examined both internationally and in Australia. The most effective strategies commonly integrate 24
reduction of availability of precursors; attempts to reduce favourable attitudes and inflated perceptions of use; and efforts to encourage healthy child and youth development. Efficacy in reducing methamphetamine use among young people has been demonstrated by a range of prevention and intervention strategies in Australia and internationally. Brief interventions can be effective for reducing attitudes and intentions towards use of methamphetamine in non-users, and show some promise in reducing reported use in current users. Using school curricula and brief online interventions may be effective in reducing favourable attitudes and inflated perceptions of use for students, contributing to small reductions in use for large populations. Discussion Proxy correlates of methamphetamine use such as favourable attitudes, perceived peer or societal pressure, and ease of procurement appear to be malleable to intervention strategies in Australia. However, aside from the disruption of methamphetamine precursors via police intervention, intervention approaches produce relatively small effects and may be improved through multi-arm approaches. In Victoria, these approaches could be implemented by a combination of the Primary Health Care Regions, Local Government Areas, and school and family services to influence healthy child and adolescent development.
General (Cross contextual) Strategies At the individual and family level, reduction of perceived substance use (and approval of substance use) is amongst the strongest preventative strategies for reduction of intentions and attitudes towards use, and translation of intentions and attitudes to actual use. •
•
Discussion with young people about rates of use, risks, harms, perceived benefits of substance use in order to correct misconceptions forms a component of successful intervention modules (Vogl, et al. 2014). Provision of resources to trusted facilitators (such as teachers, parents, and other peers) to encourage honest discussion is recommended even in the absence of more structured programs. Building resilience in young people may be successful in reducing problems, including those related to substance use, while also promoting positive outcomes. For example, substance use has been found to be strongly associated with higher rates of depression, anxiety, stress, lower self-esteem, and pessimistic outlook (Kelly et al. 2014; White et al. 2013; Smirnov et al. 2013; Little et al. 2012; Newton et al. 2012; Patton et al. 2011 and Hughes et al. 2010).
Individual/Family preventative strategies Strong evidence suggests that inter-personal and intra-familial relationships and attitudes towards drug use influence drug use. In addition, both real and perceived peer use or favourable attitudes toward drug use significantly increase the likelihood of a young person trying drugs. •
•
Reducing perceived societal favourable attitudes towards substance use is critical. Education and social cognition training – information that seeks to correct erroneous beliefs about substance use and attitudes in society – has been demonstrated to significantly reduce substance use in secondary school students. Attempts to reduce substance use through positive youth development programs are currently being trialled, but have less evidence. Brief interventions, whether individually driven (such as through online or survey methods), or those enacted by GPs and other healthcare professionals, are useful tools for reduction of substance use. However, their efficacy for methamphetamine has primarily been established for prevention of use (see below). 25
Community and Regional Approaches Similarly to individual and family prevention strategies, education and social cognition training has shown efficacy in reducing some types of substance use in secondary school aged students. •
•
•
•
•
The CLIMATE schools model provides computer based modules designed to provide education to school-aged populations about the risks of substance use, and also seeks to address erroneous beliefs about substance use. Prevention methodologies such as this have significantly reduced drug use in students compared to controls. CLIMATE currently has 3 modules; Alcohol Education (Year 8), Alcohol and Cannabis Education (Years 8 or 9), and Psychostimulant and Cannabis Education (Year 10). Project STOP, an electronic database used by pharmacists to track sales of products containing pseudoephedrine, has been considered critical in significantly reducing the quantity and quality of methamphetamine in jurisdictions where pharmacy participation is high. Project STOP allows pharmacists to determine if a customer has recently made multiple small purchases of pseudoephedrine products from multiple locations (“smurfing”). Industry trends also reveal that workers within the hospitality, construction, retail, and transport sectors contain some of the highest proportions of users (9.5%, 5.4%, 4.6% and 5.4% respectively; Roche et al. 2008). Roche and colleagues recommended the following work-place preventative measures to help reduce methamphetamine use: Policy development and implementation, Education and training, Health promotion and brief interventions, Counselling and treatment, and Drug testing. Media campaigns may be of some use in reducing psychostimulant use at a population level, such as advertisements explaining the introduction of drug-testing during traffic stops. However, there appears to be a plateauing effect suggesting that media campaigns need to be combined with other strategies (Matthews et al. 2014). Previous research into the impact of media campaigns to reduce substance use suggest that emotional content appears to have a greater impact compared with content focussed upon legal consequences (Elder et al. 2013). The Communities That Care process offers a method for community coalitions to assess levels of substance use and risk and protective factors in school-aged youth and to use this information to develop local prevention strategies. The Communities That Care process has been shown in US community randomised trials to increase the delivery of evidence-based prevention strategies (Hawkins et al, 2008) and to reduce population rates of youth alcohol, tobacco and illicit drug use (Hawkins et al, 2009). The Communities That Care process is currently being implemented in Warrnambool and sections of Geelong. Rowland et al (2013) developed and trialled evidence-based alcohol prevention interventions to compliment the Communities That Care process. The Smart Generation social marketing campaign and underage sales monitoring interventions currently operate in Warrnambool, the Glenelg Shire, and in Geelong and have evidence they are preventing adolescent alcohol use.
Governmental and Policy level prevention strategies The majority of governmental level prevention strategies for methamphetamine use have been concerned with disrupting the availability of precursor substances, most notably pseudoephedrine. In 2006, products in Australia containing over 800mg pseudoephedrine became “pharmacist-only” medications that required a pharmacist to directly be involved in the sale process.
26
•
The success of community-driven initiatives such as Project STOP has been demonstrated to be restricted to jurisdictions where participation rates are highest. For example, it is estimated that the number of clandestine methamphetamine laboratories in Queensland fell significantly from 2005 to 2006, while remaining relatively stable in other states. Additional government support for participation in Project STOP nationally is recommended.
A judicial approach to relapse prevention – the Hawaii Opportunity Probation with Enforcement (HOPE) method In the United States, standard drug-testing procedures during probation or parole periods for nonviolent, drug-offending criminals have failed to curb rates of relapse into substance use, particularly in the case of methamphetamine. The rationale of the HOPE method is that infrequent drug testing protocols during probation tend to involve relatively low risks of drug use detection, albeit with a chance of heavy punishment, and that this is less effective in reducing substance use than a higher frequency of drug tests with guaranteed lighter punishments that incrementally increase in severity (termed the “Swift and Certain” approach to detection and punishment). The use of the HOPE system resulted in significant reductions to positive urinalysis results for methamphetamine compared to probation as usual over 6 months, and significantly fewer instances of missed probation appointments over the same period. In addition, despite being assured of a relatively brief return to imprisonment for violations, the HOPE cohort averaged significantly fewer days in either prison (but not jail) compared to regular probation (Hawken & Kleiman, 2009).
27
5. Brief Online interventions for the treatment and prevention of methamphetamine use: a rapid literature review Background: The earlier sections of the present report briefly summarised evidence that brief interventions may be an effective component in regional intervention efforts to address methamphetamine use. The Sax institute commissioned an evidence check of the literature (Skvarc, Varcoe, Fuller-Tyskziewicz, Austin & Toumbourou, 2015). This is briefly summarised in what follows.
What this document is: This rapid literature review was completed by a SEED consultancy team as an “evidence check” commissioned by the Sax institute. The primary outcome of this review was to examine the evidence that fulfilled three criteria: (1) youth focused; (2) amphetamine prevention or treatment focused; and (3) used web or computer based brief interventions. Literature that did not fulfil all three criteria but was deemed relevant by the research team was included as part of a secondary analysis.
How this document was produced: Members of the research team conducted a systematic search of three large electronic databases to capture studies and three experts in the field of addiction science were also consulted to suggest additional resources that may have been missed. 374 non-duplicate citations were screened, and from these 18 articles were included after a full-text screen.
Outcome Results: Evidence from 4 randomised control trials and 1 non-experimental trial (Table 9) suggested that the use of computerised brief interventions can produce healthy effects on attitudes and intentions associated with methamphetamine use. Promisingly, the pooled results of included studies suggests that the use of brief online interventions can have moderate to large impacts in reducing both intent to use methamphetamine (g = 0.58, n = 109) and favourable attitudes towards future use (g = 0.98, n = 207). Two randomised trials were identified (Table 10) that evaluated the efficacy of brief treatment interventions for impacts on amphetamine-type stimulant use amongst youth. Overall these studies reported non-significant and weak effects. Marsden et al. (2006) found no intervention differences while Srisurapanont et al. (2007) found a small reduction in fewer days of use.
Findings in relation to three questions in the consultant brief: Q1. What youth focused on-line 'brief interventions' for amphetamine-type stimulants, particularly Crystalline Methamphetamine, are described in the literature? ANSWER 1: Five papers reported evaluations of on-line 'brief interventions' for youth targeting the prevention of amphetamine-type stimulant use (See Table 9). A search using broader criteria (Table 10) revealed two studies that evaluated the efficacy of brief treatment interventions for impacts on amphetamine-type stimulant use and reported non-significant and weak effects. Marsden et al. (2006) found no intervention differences while Srisurapanont et al. (2007) found a small reduction in fewer days of use. Tait et al. (2012) have published a protocol to trial the efficacy of brief online interventions for the treatment of amphetamine-type stimulant use in adults. Q2. What recruitment strategies, screening strategies, mode of delivery and intervention content are employed in the identified brief interventions? ANSWER 2: In the preventative interventions (Table 9) recruitment strategies have included: all students completing interventions as part of their 28
school curricula; recruitment through community organisations; online; and in a museum. Screening strategies are not used in preventative interventions as these are delivered universally across the target population. The intervention content has focussed: on life-skills; problem solving; and drug education. The brief treatment interventions targeting substance users in Table 10 generally screened and referred youth from treatment sites or via youth agencies. Intervention content included: motivational interviewing; and change strategies and referrals. Q3. What evidence is there for the effectiveness of the brief interventions? ANSWER 3: There is promising but inconclusive evidence that on-line brief interventions may play a role in preventing school aged youth populations from initiating illicit drug use including amphetamine-type stimulant use. There have been no trials of on-line brief interventions to treat youth methamphetamine use. Of two trials of brief interventions to treat youth methamphetamine use results are not promising. The largest trial showed no effect (Masden et al, 2006) and the smaller trial of volunteer students only a small reduction in days of use (Srisurapanont et al, 2007).
29
Table 9: Five papers that met all three criteria Author date
Intervention
Evaluation
Outcomes
Effects
NHMRC Evidence rating
Schinke, Di Noia, & Glassman (2004).
1. Computer-delivered interactive 20 minute Brief Intervention (n = 64); 2. Professional and peer guided interactive Brief Intervention program (n = 65); versus 3. No intervention Control (n = 60).
189 youth randomised by trial site to three conditions, mean age 9.6 years (SD = 1.2).
4 item Likert scale measuring attitudes towards non-alcohol, nontobacco drug use, before and immediately after intervention.
II, randomised control trial (cluster randomised by community site).
Schinke & Schwinn (2005).
1. Computer-based “Girls and Stress” (GAS) CD-ROM 20 minute stress management Brief Intervention; versus 2. 40 minute teacher-delivered “Keep a Clear Mind” (KCM) curricula (controls). 12-session web-based life skills Intervention; versus no intervention Controls.
47 participants received GAS Intervention, 44 KCM (controls). All participants were year 7 girls. Intervention was randomised by school site.
Centre for Disease Control Youth Risk Behaviour Survey; American Drug and Alcohol Survey. Preintervention and 2 weeks after.
236 girls aged 13-15, randomly assigned to either intervention or control.
Centre for Disease Control Youth Risk Behaviour Survey; pre-intervention, 6 weeks follow-up, and 6 months follow-up.
Computer-based (Serious Educational Game) autostereoscopic 3D display technology Brief Intervention.
98 students from grades 6-8. All participants received the intervention offered in the museum in Changhua City, Taiwan.
Semi-structured interviews; Attitude questionnaire. Pretest/Post-test design.
Reduction in positive perceptions towards drugs use in others (p
