VICTORIAN ALCOHOL & DRUG ASSOCIATION

Inquiry into the supply and use of methamphetamines, particularly ‘ice’, in Victoria

November 2013

VAADA Vision

A Victorian community in

which the harms associated

with drug use are reduced and

general health and wellbeing is

promoted.

VAADA Objectives

To provide leadership,

representation, advocacy and

information to the alcohol and

other drug and related sectors.

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The Victorian Alcohol and Drug Association

The Victorian Alcohol and Drug Association (VAADA) is the peak body for alcohol and other drug (AOD) services in Victoria. We provide advocacy, leadership, information and representation on AOD issues both within and beyond the AOD sector. As a state-wide peak organisation, VAADA has a broad constituency. Our membership and stakeholders include ‘drug specific’ organisations, consumer advocacy organisations, hospitals, community health centres, primary health organisations, disability services, religious services, general youth services, local government and others, as well as interested individuals. VAADA’s Board is elected from the membership and comprises a range of expertise in the provision and management of alcohol and other drug services and related services. As a peak organisation, VAADA’s purpose is to ensure that the issues for both people experiencing the harms associated with alcohol and other drug use, and the organisations that support them, are well represented in policy, program development, and public discussion.

Introduction

VAADA welcomes the opportunity to provide evidence to this inquiry which we hope will enable the

development of evidence informed responses to the growing issue of methamphetamine use in the

community.

VAADA has recently undertaken two consultations with the alcohol and other drug (AOD) treatment

sector to canvass issues related to methamphetamine. The feedback from the AOD treatment sector

generally noted an increase in methamphetamine presentations to treatment agencies; it was

however highlighted that other drugs, including alcohol continue to consume a much higher portion

of resources. There were varying views on the efficacy of specific treatment types; however, there

was a general consensus that additional time, resourcing and training is necessary to respond to this

issue.

The various datasets generally indicate an increase in methamphetamine use, and more strongly an

increase in the harms associated with its use.

There are a number of elements which should be considered in addressing these challenges, with

evidence informed early intervention and prevention-based activities also key to reducing the

uptake and transition to intravenous use which carries greater risk.

VAADA will not be commenting on areas related to reducing the supply of methamphetamine with

the exception that there appears to be a general over-emphasis of supply reduction approaches in

dealing with these issues which are not necessarily supported by a strong evidence base for the

reduction of harms and cost effectiveness; although supply reduction strategies play a key role,

many of them are implemented after the demand for methamphetamine has been established and

the harms have already occurred.

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Key themes

A range of data sources indicate that there has been an increase in the prevalence of harms

associated with methamphetamine use;

It is probable that there has been an increase in the number of individuals using

methamphetamine; this may include AOD treatment and harm reduction naïve cohorts;

There has been a significant increase in the purity of methamphetamine which is likely to be

a significant contributor to the increase in harms;

Methamphetamine is often consumed in tandem with other substances, which may amplify

the harms;

AOD treatment is effective in addressing methamphetamine dependency, but the current

treatment modalities need to be adapted to meet contemporary treatment expectations;

Prevention, early intervention and harm reduction initiatives are necessary to reduce the

take up methamphetamine and the associated harms;

Existing successful programs such as the Drug Court of Victoria should be rolled out state-

wide to address this and other AOD related issues; and

St Vincent’s Hospital in NSW provides a useful example of addressing the challenges from

drug induced psychosis presentations at ED.

Examine the channels of supply of methamphetamine including direct importation and local

manufacture of final product and raw constituent chemical precursors and ingredients

This question is not within VAADA’s remit of expertise.

Examine the supply and distribution of methamphetamine and links to organised crime

organisations including outlaw motorcycle gangs

This question is not within VAADA’s remit of expertise.

Examine the nature, prevalence and culture of methamphetamine use in Victoria, particular

amongst young people, indigenous people and those who live in rural areas

Methamphetamine use has featured prominently in public discussion, including media, and although

it is a problematic substance, there exists an evidence base indicating that other drugs, both licit and

illicit, are also be similarly problematic. For instance, within the general population, alcohol is far

more prevalent in causing harm than any other drug.

However, it is clear that there has been an increase in harm, and possibly the use, of

methamphetamine in recent times. It is also likely that there are a number of subpopulations which

are at higher risk. Contributions to a higher prevalence of harms include an increase in purity and

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access for this substance. The evidence supporting this increase in harms includes upward trends in

ambulance, AOD treatment, acute drug toxicity mortality and policing data involving

methamphetamine. To this end, it is unclear as to whether there is an increase in methamphetamine

use or related harms or both.

The ACC (2013) reports that the purity of methamphetamine has increased from 19.6% in 2010-11

to 60% in 2011-12; this increase in purity is likely to put upward pressure on health services, as the

risk of harm is increased.

On a global scale, Australia reports the equal third highest methamphetamine use globally (UNODC

2013)1, although this data contains limitations, the most prominent being the absence of a large

portion of jurisdictions.

It is probable that there are new cohorts of individuals using methamphetamine and that many of

these individuals, not being regular users of illicit drugs, are naïve to the harms associated with

methamphetamine and effective harm reduction strategies. These populations may be at significant

risk, as the AOD treatment sector reports that use of this substance can quite rapidly result in

dependence; however, this is evident with a range of both licit and illicit substances.

The following data provide an overview of methamphetamine use and is indicative of the associated

harms:

Slightly over 2% of Victorians aged 14 years and over had used methamphetamine in the

past 12 months (AIHW 2011);

The Illicit Drug Reporting System (Cogger, Dietze and Lloyd 2012) reports that in Victoria

during 2012, 67% of the surveyed injecting drug using population had used

methamphetamine over the past 12 months, with 64% administering intravenously;

Methamphetamine use has increased amongst drug using populations, from 32% to 59% of

those surveyed having used ice within the past six months (Cogger, Dietze and Lloyd 2012);

and

Cogger, Dietze and Lloyd (2012, p 37) note that 92% of surveyed injecting drug using

population indicated that methamphetamine was very easy to obtain.

AOD treatment – amphetamines in Victoria

The AIHW (2013) indicates that treatment presentations for amphetamines (including

amphetamines, dexamphetamine and methamphetamine) has increased in Victoria by over 80%

between 2009/10 to 2011/12 as per Figure 1 below.

1 This rating only accounts for those countries where drug consumption data is available.

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Figure 1: Amphetamine treatment episodes - Victoria2

Ambulance attendances provide another means of measuring methamphetamine related harms.

The most recent data regarding methamphetamine ambulance attendances is as follows:

Methamphetamine related attendances have increased in metropolitan Melbourne from

282 attendances in 2010/11 to 592 in 2011/12;

In regional Victoria 78 methamphetamine attendances were recorded in 2011/12 – the

Victorian total for 2011/12 is 670 (Lloyd 2013, p 41).

Figure 2: Methamphetamine Ambulances attendances 2002-03 to 2011-12

2 This graph has been developed through reference to table S7.10 from the additional material accompanying the AIHW

publication.

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

Amphetamines 2,918 2,680 2,949 3,422 3,399 2,970 2,666 3,429 4,876

-

1,000

2,000

3,000

4,000

5,000

6,000

tre

atm

en

t e

pis

od

es

Treatment episodes: Amphetamines - Victoria

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Figure 2 reveals a strong increase in methamphetamine related ambulance attendances over the

past decade. Although this increase is significant, ambulance data indicate that many other drugs are

creating a far heavier demand on ambulance services than methamphetamine, including alcohol (17

fold demand) and heroin (approximately four fold demand) (Turning Point cited in the Herald Sun

2013).

A number of factors have contributed to this increase in ambulance attendances which include:

o Reporting the use of methamphetamines when other amphetamines have been

used, therefore potentially inflating the data;

o The increase in the purity of methamphetamine;

o High levels of poly drug use; and

o Methamphetamine use in the community may have increased.

Largely, the consensus view of the Victorian AOD treatment sector is that there has been an increase

in methamphetamine treatment presentations and in a number of cases, these presentations

involve a range of complexities including:

o Challenging behaviour in the treatment setting;

o History of poly-substance use; and

o Issues with the current treatment response. For example, the duration of the funded

withdrawal period is inadequate to address methamphetamine dependence.

Further it does not accord with contemporary treatment requirements. This is

evident not only with treatment needs for methamphetamine but also for a number

of other drugs.

Regarding at risk cohorts, the Women’s Alcohol and Drug Service (which provides support for

pregnant women with AOD dependency issues) has highlighted the health implications and risks of

methamphetamine use and pregnancy as follows:

o Methamphetamine use can be harmful for pregnant women with regard to harms

associated with intoxication, withdrawal creating foetal distress and the

downstream impact methamphetamine use on self-care, which includes attending

appointments;

o Methamphetamine use can contribute to intrauterine growth restriction (IUGR) and

a preterm birth;

o Methamphetamine is similar in many ways to other substances with regard to the

risk of harms to the developing foetus; and

o The social and behavioural impacts of methamphetamine use are a significant

challenge and can impact upon the overall health of the child.

Youth services are generally citing an increase in methamphetamine presentations and ‘contacts’:

o Many of these contacts are related to misuse and do not necessarily trigger

treatment as dependency / crisis may not be evident; and

o Families are often contacting VAADA members regarding young people and

methamphetamine use.

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Examine the links between methamphetamine use and crime, in particular crimes against

the person

Illicit drugs are explicitly linked with crime, by virtue of their illegality. Regarding crimes against the

person, it is difficult for AOD treatment agencies to provide a succinct and precise assessment of this

issue. Specific agencies may be able to provide an overview on a number of behavioural issues,

especially those agencies providing forensic AOD treatment services. It should be noted, however,

that other substances demonstrate a greater prevalence in violent behaviour than

methamphetamine. For instance, Table 1 reveals a much higher prevalence of alcohol rather than

illicit drugs involved in family violence cases.

Table 1: Family violence related police callouts 2011-12 (Victoria Police 2013, pp 131-132)

definitely involving alcohol definitely involving drugs total FV episodes

12626 3598 50386

Alcohol is definitely involved in approximately one quarter of callouts; illicit drugs (including but not

limited to methamphetamine) are involved in approximately seven per cent of call outs.

Pollard et al (2011) provide longitudinal data on AOD forensic treatment presentations and highlight

the significant growth in alcohol and amphetamine related presentations between 2000 and 2010.

Alcohol related presentations have increased from approximately 1500 to 4600, and amphetamines

from approximately 200 to 1200 over that timeframe. The significant increases highlights both

substances as problematic, especially as the same report indicates an increase in AOD forensic

presentations involving violence from approximately 1600 to just under 5000 over the same time

frame.

It is difficult to pin point a causal link between methamphetamine and violence in part due to the

prevalence of polydrug use and the overwhelming acute harms associated with alcohol

consumption. Research indicates that chronic methamphetamine use can create a sense of paranoia

with users responding adopting a different response to heightened situations than they otherwise

would have had they not been using. However, there is no ‘career path’ to violence through

methamphetamine use, with ‘drug affects and outcomes mediated by the users norms, values,

practices and circumstances’ (Sommers and Baskin 2006, p 93).

VAADA’s (2012) position paper entitled Connections: family violence and AOD provides a useful

discussion on the nexus between AOD and family violence.

Examine the short and long term consequences of methamphetamine use

Methamphetamines Dependence and Treatment detail the range of long and short term physical and

psychological impacts of methamphetamine use (Lee et al 2008, p 2 – 3). These impacts may have a

deleterious effect on an individual’s social circumstances (a risk evident with problematic substance

use and dependence), including family breakdown, issues with employment and in more extreme

cases interface with the justice system (Lee et al 2008, p 7 – 8). There are mixed views regarding

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cognitive impairment related to methamphetamine use, with (Hart et al 2012) highlighting a number

of studies which demonstrated minimal variance in cognitive capacity between methamphetamine

users and control groups.

Individuals experiencing methamphetamine dependence may be reluctant to attend AOD treatment

(Kenny, Harney, Lee and Pennay 2011) which can exacerbate existing adverse circumstances.

Additionally, the Victorian AOD treatment sector has expressed concern that new cohorts of

methamphetamine using populations are emerging, with minimal ‘drug use’ experience, and

therefore naïve to both the elements of treatment as well as specific harm reduction strategies.

Evidence informed prevention and early intervention programs should be developed to address the

needs of this new cohort.

Table 2 demonstrates an increase in portion of acute drug toxicity deaths involving

methamphetamine, from one in 25 deaths in 2010, increasing to 1 in 11 deaths in 2012 (Coroners

Court 2013). Although this increase in concerning, it should be noted that the overall acute drug

toxicity death rate has increased annually since 2010, and many of these deaths would involve more

than one drug. Further, there are a number of other substances which have made significantly larger

contributions to acute drug toxicity mortality.

Table 2: Methamphetamine contributions to Victorian acute drug toxicity deaths

Year Methamphetamine contribution: total Victorian acute drug deaths

2010 14:349 one methamphetamine contribution in 25 acute drug deaths

2011 29:366 one methamphetamine contribution in 12.5 acute drug deaths

2012 34:367 one methamphetamine contribution in 10.8 acute drug deaths

The Victorian Coroners Court (2013b) provides methamphetamine related mortality over a more

extended timeframe, between 1 January 2000 and 30 June 2013; key features are as follows:

230 individuals died between 2000 and June 2013 where methamphetamine had been a

causal or contributory factor; and

214 of those deaths involved at least one additional substance.

Table 3: Methamphetamine mortality involving more than one drug

Frequent co-contributing drug groups Frequent co-contributing individual drugs

Drug Group deaths Individual drug Deaths

benzodiazepines 157 Heroin 129

Pharmaceutical opioids 141 Diazepam 126

Illegal drugs (excl amph) 139 Codeine 70

antidepressants 65 Methadone 57

Antipsychotics 35 Alprazolam 42

Alcohol 31

Oxazepam 22

Temazepam 19

Oxycodone 18

MDMA 17

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Table 3 reveals that benzodiazepines (particularly diazepam) and heroin are common co-occurring

substances in acute drug toxicity deaths with methamphetamine as a contributor. From the available

data, it is apparent that the annual death rate for methamphetamine has increased, from

approximately 14 per year from 2000 to 20010, increasing the 29 in 2011 and 34 in 2012; 2013 is

tracking on par with 2012 data, with 15 deaths recorded by June 30.

There may be a number of populations which incur elevated risk; these include populations which

interface with the justice system, with some agencies reporting an increase in methamphetamine

related forensic presentations is also quite high. Table 4 details methamphetamine contributions to

post release prisoner mortality within 2 months of release or while on a corrections order post

release.

Table 4: methamphetamine contributions to post release mortality

Methamphetamine contribution: total acute drug deaths 2 months post release

2000-2010 14:120 one methamphetamine contribution in 11.7 acute drug deaths

This data, which covers the period between 2000 – 2010 (inclusive) highlights the high prevalence of

methamphetamine contributions to these deaths. The confluence of the increasing

methamphetamine related ambulance call outs, increased amphetamine treatment episodes and

increased purity evident in recent years are likely to put upward pressure on methamphetamine

related harms in vulnerable populations, including prisoners.

The Coroners Court (2013c) provided specific information on the nexus between methamphetamine

and heroin in acute drug toxicity deaths (see Table 5). The overlap is significant with heroin evident

in approximately half of all methamphetamine deaths since 2011. This information contributes to

the knowledge base on drug trends, and should inform harm reduction and treatment activities.

Table 5: Nexus between methamphetamine and heroin in acute drug toxicity mortality – 2010 -

(June) 2013

Year heroin mortality methamphetamine mortality overlap

2010 139 14 5

2011 129 29 14

2012 109 34 18

2013 (June) 67 15 9

Examine the relationship of methamphetamine use to other forms of illicit and licit

substances

The Victorian AOD treatment sector relayed to VAADA that poly drug use is common theme with

methamphetamine dependent populations. The treatment sector has indicated that a range of

substances are often used in tandem with methamphetamines. This includes alcohol, with the harms

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exacerbated by methamphetamine use allowing for the consumption of a quantity of alcohol

beyond an individual’s standard tolerance levels.

National treatment data (AIHW 2013) reveals treatment episodes of secondary drugs where

amphetamines (including amphetamines, dexamphetamine and methamphetamine) is the principle

drug:

Cannabis – present in 30% of amphetamine related treatment episodes

Alcohol – present in 23% of amphetamine related treatment episodes

Benzodiazepines – present in 6% of amphetamine related treatment episodes

Heroin – present in 5% of amphetamine related treatment episodes

Review the adequacy of past and existing state and federal strategies for dealing with

methamphetamine use

The Victorian amphetamine-type stimulant (ATS) and related drugs strategy 2009-2012 has expired

and therefore Victorian policy in this area is not guided by a current strategy. The actions associated

with this strategy have not been reviewed and so it is unclear whether this strategy was successful.

The increase in harms associated with methamphetamine outlined in this submission is suggestive of

some shortcomings in the implementation of this strategy.

The National Amphetamine-type stimulant strategy 2008-2011 provided some resources in response

to amphetamine related issues, however, the efficacy of this strategy in guiding practice at a state

level is limited, as a number of the major stakeholders are primarily state government funded

services.

Consider best practice strategies to address methamphetamine use and associated crime,

including regulatory, law enforcement, education and treatment responses (particularly for

groups outlined above).

There are a number of strategies which should be employed to reduce the harms and prevalence of

methamphetamine use. These strategies involve a range of actions which include the development

and/or expansion of existing programmatic activity. There are specific actions which can occur at

various points of intervention, such as treatment agencies, hospital emergency departments and

Courts. Key actions are as follows:

The AOD treatment sector should receive additional funding to address the increase in

methamphetamine presentations through workforce training and capacity building as well

as increased treatment capacity;

Identify any new cohorts of methamphetamine users and target these populations with

prevention, early intervention and harm reduction initiatives;

Prohibition of the sale of methamphetamine pipes may result in individuals changing their

route of administration from smoking to intravenous use, which is more harmful and carries

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risks associated with injecting drug use. Revoking this prohibition may result in a reduction

of harms associated with intravenous drug use;

It is likely that new AOD naïve cohorts are commencing methamphetamine use. These

populations may be experiencing significant harms, in part due to a lack of knowledge on

harm reduction strategies and accessing AOD treatment. Further support for and expansion

of initiatives such as Dancewize and the NSW-based ACON Rovers to deliver harm reduction

information to these cohorts should be provided;

Mediation and treatment (if necessary) should be provided to school students in possession

or using methamphetamine within a school environment; expulsion should be used only as

an option of last resort and support needs to be provided to ensure that these children are

not ostracised from the system; and

The Drug Court model should applied to all Magistrate’s Court jurisdictions in Victoria,

commencing with those regions which are experiencing of the highest rate AOD harms and

dependence.

Methamphetamine related presentations at Emergency Departments

St Vincents Hospital in Sydney has a highly evolved process in responding to individuals who may be

experiencing drug induced psychosis. Major hospitals in Victoria should consider replicating relevant

elements of the NSW model to address problematic AOD related presentations in emergency

departments.

At St Vincent’s, NSW, individuals presenting at ED experiencing drug related psychosis are viewed as

patients requiring treatment rather than just ‘a problem to be managed’. Detailed records are

maintained for frequent flyers (patients regularly presenting with drug induced psychosis) with a

view to developing specific strategies to best address their individual health needs. This may include

retaining the details of friends and family, recording the most effective medications for treatment

and noting the likely substances which are regularly used.

Appropriate medications are administered to individuals experiencing drug induced psychosis to

‘take them down’ and a quiet space is provided to assist this process and minimise disruption to

other patients in the hospital. These patients may also be assessed and transferred to an inpatient

psych unit attached to the ED which can provide withdrawal services for up to seven days. Further

assessments can be carried out during the seven day withdrawal period to ascertain any other

health requirements.

This model could be replicated in Melbourne and to that end, it is recommended that this inquiry

establish contact with St Vincent’s in NSW to explore this program further.

AOD Treatment

The adult non-residential AOD treatment system is currently being recommissioned. This provides an

ideal opportunity to implement a number of initiatives within the treatment system which can

reduce the harms associated with methamphetamine dependence and elicit improved treatment

outcomes. This includes:

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Workforce development – the AOD treatment workforce must be provided with the capacity

to work with methamphetamine dependent individuals;

This could involve the provision of online training models for AOD workers

which can be undertaken through self-directed learning;

Enhance linkages and partnerships with mental health and community health services to

provide integrated health care to individuals experiencing methamphetamine related harm;

Flexible funding arrangements to allow for specific treatment modalities to adapt to the

treatment needs arising from methamphetamine dependency; and

Capacity for the delivery of education, health promotion and harm reduction activities

should be enabled within treatment agencies where appropriate.

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References

ACC 2013, Illicit drug data report 2011/2012, Australian Crime Commission, viewed 10 October,

http://www.crimecommission.gov.au/publications/illicit-drug-data-report/illicit-drug-data-report-

2011-12

AIHW 2013, Alcohol and drug treatment services in Australia 2011-12, Australian Institute of Health

and Welfare, viewed 11 October 2013, http://www.aihw.gov.au/publication-

detail/?id=60129544486&tab=3

Coroners Court of Victoria 2013, Drug overdose deaths in Inner North West Melbourne, viewed 17

October 2013, http://www.coronerscourt.vic.gov.au/find/publications/coroners+prevention+unit+-

+overdose+deaths+inner+north+west+melbourne+-+yarra+drug+and+health+forum+sep+2013

Coroners Court of Victoria 2013a, Parolee overdoses 2000 – 2010, viewed 17 October 2013

http://www.coronerscourt.vic.gov.au/find/publications/coroners+prevention+unit+-

+parolee+overdoses+-+7+october+2013

Coroners Court 2013b, CPU data on overdose deaths involving methamphetamine, Coroners

Prevention Unit, Victoria.

Coroners Court 2013c, Intersection between heroin and methamphetamine contribution to over dose

deaths 2010-2013, Coroners Prevention Unit, Victoria.

Department of Health 2008, Victorian amphetamine-type stimulant (ATS) and related drugs strategy

2009-2012¸ viewed 17 October 2013,

http://docs.health.vic.gov.au/docs/doc/82A4EEFAAE4188B4CA2578A000833B4E/$FILE/ats_final.pdf

Hart, CL, Marvin, CB, Silver, R and Smith EE 2012, ‘Is cognitive functioning impaired in

methamphetamine users? A critical review’, Neuropsychopharmacology, vol 37, pp 586 – 608.

Herald Sun 2013, Alcohol ties up ambulance service, 10 October ,

http://www.heraldsun.com.au/news/victoria/alcohol-ties-up-ambulance-service/story-fni0fit3-

1226736991836

Kenny, P, Harney, A, Lee, NK and Pennay, A 2011, ‘Treatment utilization and barriers to treatment:

results of a survey of dependent methamphetamine users’, Substance abuse treatment, prevention,

and policy, vol. 6, no. 3.

Lee, N, Johns, L, Jenkinson, R, Johnston, J, Connolly, K, Hall, K and Cash, R 2007 Clinical Treatment Guidelines for Alcohol and Drug Clinicians, No 14: Methamphetamine dependence and treatment. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc. Lloyd, B 2013, Trends in alcohol and drug related ambulance attendances in Victoria: 2011/12,

Fitzroy, Victoria: Turning Point Alcohol and Drug Centre.

National Drug Strategy 2008, National amphetamine-type stimulant strategy 2008-2011, viewed 7 November 2013, http://www.health.gov.au/internet/drugstrategy/Publishing.nsf/content/ATS-strategy-08

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Pollard, J, Berry, M, Ross, S and Kiehne, M 2011, Forensic AOD treatment in Victoria, Department of Health, Victoria. Sommers, I and Baskin, D 2006, ‘methamphetamine use and violence’, Journal of Drug Issues, vol 36, no 77, pp 77 – 96. UNODC 2013, Drug use statistics, United Nations Office on Drugs and Crime, viewed 10 October 2013, http://www.unodc.org/documents/data-and-analysis/WDR2011/StatAnnex-consumption.pdf VAADA 2012, Connections: family violence and AOD, Victorian Alcohol and Drug Association, Collingwood. Victoria Police 2013, Victoria Police Crime Statistics 2011/12, viewed 10 October 2013, http://docs.health.vic.gov.au/docs/doc/B7DEE775D281BE85CA25789A0081D70F/$FILE/methdeptreat.pdf

The Victorian Alcohol and Drug Association Inc. acknowledges the support of the Victorian Government.