 Good evening all participants to this webinar from MHPN, working together to manage methamphetamine use and mental health issues. So far we have 53 people online over 2000 registered, so that number will climb during the evening. The webinar as you know is presented by the Mental Health Professional Network. On my panel are four, we have Associate Professor Adrian Dunlop, Ms. Vida Berghat, Associate Professor Nicole Lee and Dr. John Riley. Adrian, may I just ask you just a couple of questions about yourself. How did you first become interested in addiction medicine? Sure, look it's a long story with lots of parts. Michael, but I'll give a brief one. I was working in an emergency department in a little hospital in the northern suburbs of Melbourne. And there were many people, well many, there was at least once a week somebody would come in with heroin overdose and would give them the locks on and that wake up and run away usually. And then one time a guy had an overdose reversal and then looked at me and said, Dr, I want help. Can you give me help? I want to stop using drugs. And I had absolutely no idea what to do and nobody in the hospital said no to do either. So we simulated my interest to find out. That's great. Thanks very much Adrian. And Vida, you have an excellent CV, extensive experience as a clinical social worker, quite involved in social studies and teaching and I've worked with Eastern Health in South Australia. How did you first become interested in addiction and social work? Again, probably a long story but I suppose I actually had my heart set on aged care funny enough. Up until I found myself doing my second university degree and had to do a fourth placement and was struggling to know where to go. And I ended up working at my own place, a day drop in centre for homeless and absolutely fell in love with drugs and alcohol, mental health and homelessness and the chaos that came with it. And pretty much haven't looked back since and went on to do further studies again in addiction and mental health as well just to really try to improve and be able to serve people better. That's great, Vida. And Nicole, can you just tell us how you became interested in this area of psychology? Your CV is excellent and you obviously are quite involved in clinical medicine, clinical psychology. I'd just like to know how you became interested in addiction and psychology. Well, I wasn't actually interested in it. To start with I actually went to university to do computer science and then I hated it. So I switched to psychology to avoid having to repeat first year to do anything else. And then when I was in third year we did this lecture. I had this lecture on Q exposure and how it was just newly starting to be used with drug users. And so I came at it from a very kind of theoretical perspective and then did my, started doing my PhD in that area because I became really interested in how drugs worked and how they affected the brain and all of that kind of stuff. And while I was doing my PhD I started working as a psychologist in mental health in clinical work and in Townsville actually, Michael and John. And at the acute psychiatric unit and a lot of the clients there had drug problems and so that got me really interested in comorbidity and then here I am from here working around methamphetamine which involves both of those things. Thanks very much, Nicole. And John, you have vast experience. You're originally from Melbourne and you are now leading the mental health team in Townsville covering a vast area of North Queensland as well. And do you find much difference between the problems that people experience with managing convictions in major metropolitan cities as opposed to in the bush? Look, there's obviously always some differences when you're in regional and remote areas compared to when you're in a metropolitan area. But I think this is an area where there's still an enormous amount of overlap. And I think that the problem often is and certainly my experience has been that I was interested in drug and alcohol because that's what a lot of our patients with more severe mental illnesses often clearly have very high levels of comorbidity and yet psychiatrists back when I trained probably weren't consistently getting training in comorbid substance use disorders. It was treated as a separate kind of discipline. And I think we've realised latterly that we need to do much more in that regard. And so I think that there are still significant gaps really within psychiatry and mental health services about our links. And I think that's applicable both in metropolitan services as well as sometimes in regional and remote services. But one advantage that some regional remote services have is that you tend to work a bit more closely together between alcohol and other drug services and mental health services and sometimes primary care. Not always but again I guess small scale although large distance but fewer numbers of services sometimes leads to better linkages. That's great, John. Thanks very much. And thank you all the panellists. I'm really looking forward to tonight's presentations and discussions. You all have such interesting backgrounds. Just a few grand rules. Be respectful of other participants and panellists. If you need technical help, post in the technical help box. Be mindful that comments can be seen by everybody. If you'd like to hide the chat, click the small down arrow at the top of the chat box. Your feedback is extremely important to us. Please complete the short access survey which will appear as a pop-up on your edge of the webinar. We now have 650 people online. We have some learning outcomes for tonight. At the completion of the session participants will describe how to engage with people using methamphetamine to reduce harm, improve intervention and mental health symptoms, implement key principles of providing an integrated approach in the early identification of people with comorbid methamphetamine use and mental health issues, increase in the likelihood of a successful course of action. Thirdly, identify challenges in providing a collaborative response to people with comorbid methamphetamine use and mental health issues and share tips to overcome these challenges. You would have all received a copy of Barry's history. Basically, he's a man in his mid to late 30s who's got two children approaching puberty. His wife has just become pregnant. He's been working as a foot driver and he's recently began to use speed and has moved on to ice rather rapidly and this is causing problems with his work and with his home. We will now move on to Adrian, please, to give his presentation. Thank you, Adrian. So, thanks, Michael. Thank you. So, I guess just a couple things to start. You must have heard in the media people talking about ice. So, just to be clear, most amphetamine in Australia is methamphetamine. There's lots of different forms. Ice is one of them and is one of the purer ones, but there's also powder and base and it comes in pill forms. And I guess the key issue, just to remember, of course, is that you have to be aware of what you're talking about. And I guess the key issue, just to remember, overall, is that there's been a trend over the last five years or more for purity to increase. So, all sorts of methamphetamine, ice powder, et cetera, are all becoming purer. If you think of the effects of amphetamines, there's a range of effects, of course, and they're dependent on the dose that a person has. Milder effects, people tend to report feeling euphoria, a lot of energy, can't sit still, can't stop talking, very confident, very positive. But as the dose increase, there's the emergence of more negative effects. So, things like being unable to sleep, being unable to eat, having a sore jaw, sore teeth from grinding, anxiety, and then some of the more toxic complications as well can occur as the dose gets higher. Mental state problems are by far the most common problems that people experience as side effects with methamphetamine. Our other presenters are going to talk to you some more, so I'm not going to go in a lot of detail into mental health side effects, but the common ones would be anxiety, depression, and then this syndrome of thought disorder from very mild level where people have problems of being overly suspicious through to full-blown psychosis where people are losing touch with reality and they're seeing, hearing, or experiencing things that aren't there. And you certainly get a flavor of that in this case. Barry probably had some pre-morbid depression, and then certainly as the stimulus lease went on, he's got more paranoia which might be related to his use. There's a wide range of other medical problems as well, but it's possible for users to experience. Typically these aren't particularly common unless you happen to be working in an acute care setting and then you do see them from time to time. So different groups include ones related to hypothermia or the body being too hot, so dehydration, seizures, muscle breakdown, adrenal failure, etc. A range of cardiovascular problems from arrhythmia through to hypertension is quite common actually and then a risk of other problems including a schemer infarction, etc. Brain problems including stroke and seizures and bleeds, gastrointestinal problems including hemorrhage and necrosis, and a range of problems in pregnancy including antipartic hemorrhage. But they're not so common. We also have to think about risks like blood-borne virus injecting risks, especially hepatitis C in Australia and hepatitis B. And sexual health risks from unprotected sex. But by far the biggest group of side effects that we tend to see are those related to the social impacts of use of the drug cell effects on relationships, housing, employment, legal issues, driving issues, and Barry's case really displays this quite well. You can see his problems in his relationship with his partner have escalated, his use escalates, and the problems continue to escalate. So they are very common and clinically we see them very frequently. In terms of just trying to have a diagnostic framework, if you don't have one already for substance use, there's a range of possible experiences by people who use them. At one end of the scale you see use can be beneficial or at least perceived by the user to be beneficial. They get positive effects and they're not experiencing negative effects and people can have non-problematic use without necessarily becoming dependent or addicted. So it's not a case despite what we might hear occasionally of one hit and you're hooked to a stuff like that at all. There's a spectrum of use. And then further down the scale it's possible for people to have significant negative health problems. So harmful use or in DSM5 language a mild substance use disorder or true substance use disorders or dependent substance use disorders rather or in DSM5 language moderate or severe substance use disorder. So that's essentially increasing ability, inability to control drug use. There's quick ways to screen these. So the assist light is a tool that can be used to do a quick screen. And essentially if Barry asks these questions, is he using the last three months? Yes, is he using more than once a week? Yes, and his partner has expressed concerns so he would score on all of those. So people might present with problems or they may not present with problems and we may really need to ask. Michael just in terms of time I might hand over to the next presenter and we can come back. No actually you have a little bit of time because we saved it at the beginning. Yeah, sure. So just a familiar approach or a good approach to use with people with substance use disorders. Is that a motivational interviewing? You might be familiar with it from alcohol or to Paco. But essentially it's a balance of trying to get people to focus on exploring the things that they like about using it. For Barry it helped him work but the things that don't help him so much that aren't so good in his situation, is the amount of money he's spending and the effects that he's having on his relationship and his partner. It's really not coping. So that's a bit for me Michael and I'll pass on. Thank you very much, Adrian. That was great for plenty of time to discuss during the discussion time. Thank you very much. Now we'll just move on to you, Vita. Thank you. So I've been given the brief to talk really briefly, touch on engagement, assessment and diagnosis. And so in the first slide I guess I've listed some of the things that are common that we need to be mindful of when trying to engage clients. And I guess I just wanted to speak to number three there, keeping the humanity in the midst of the medical and explain what I meant by that. What I mean by that is I certainly had trouble myself when I swapped over from doing long-term case management and counseling into an acute setting where I only had a very short period of time to try to build some kind of trust and rapport with a client. And one of the things that I guess I found really beneficial is just trying to find something about that person that is unique to them, that's about them and their identity apart from their clinical presentation. So if on a home visit for instance I might look for things like photos, artwork or pets are a great talking point or if it's in a clinical setting then I might look for things in the collateral history about hobbies, someone's employment or their studies, that kind of thing, just to try to engage someone and prevent the assessment from becoming a bit of an interrogation process, particularly if we're doing long sort of comprehensive assessments. Apart from that, in terms of assessment, the first thing that stands to one particular embarrassed case is the need for a more comprehensive drug and alcohol assessment. And I guess I've just listed there what's the key components of a drug and alcohol assessment that we should be covering if you're doing a comprehensive assessment. If you don't have time for that, particularly if you happen to be a GP in a GP setting or an ED department, there is the Alcohol Smoking and Substance Involvement Screening Test, otherwise known as BSD. And there's information that I've added in the resource section for people who aren't aware of that where you can get a lot more detail. The other part of assessment that we'd be wanting to take into account is obviously mental health assessment and, again, I've listed what those key components are which we'd normally look for. MSC, standing for Mental State Assessment Examination, is one of the key things. Risk assessment as well as family psychiatric history and past treatment history. But I guess, again, one of the red flags that stood out to me with the case vignette was when Barry mentioned he previously felt very down but never like now. And that for me was just a real red flag to be asking, wanting to drill down there and wanting to know, well, what was the onset of that? What was the kind of symptoms he was talking about when he says he felt very down? What was the severity of those symptoms? Did it come and did it go? And how does that differ from how he's feeling now? And, again, just a reference to the importance of context there. Did he feel very down in the context of a relationship break up or a death in the family or that kind of thing? So apart from mental health assessment and drug and alcohol assessment, there's the psychosocial assessment. And it's quite important even if we're from a medical background not to forget this because this is often what is also going to inform treatment and what might be really helpful from a treatment perspective. So I've listed the key things that we normally look at, finances, isolation, relationships and so on. But I guess I wanted to highlight the last point there about identifying strength and resilience. Any periods where also of abstinence that somebody may have had in the past because so often the clients that I work with certainly present with a sense of hopelessness or helplessness about these circumstances. And I'm really aware that I think as clinicians we can sometimes add to their sense of helplessness or hopelessness depending on the approach that we take. And we can also try to build hope. And one of the ways that I found really powerful for that is identifying the strengths and those periods of abstinence in particular that they might have had before or attempts to seize. And I guess the last slide that I have is just about bringing that all together. And suggesting that if we do a really good comprehensive holistic assessment across multiple domains that's what's going to give us the best opportunity to really have a thorough diagnosis and pointing to a care and treatment plan that might be most helpful. And that's also going to be informed by, I've listed a few other things there. For instance someone's readiness for change in their personal circumstances but the only thing I really wanted to highlight there is the importance of spending time with people asking them what is their substance issues really helpful for? What does it help or assist them with or what does it make go away? Because so often that is what informs the care and treatment plan that we end up with because quite often it might start by looking like somebody needs a drug and alcohol counselor or rehab but when we actually drill down it turns out that what they might need is child sexual abuse counseling, trauma counseling, grief and loss counseling or something else. That's it for me. Thanks very much Peter. That was fantastic. Thank you very much. So it was a very, very comprehensive, very enjoyable and we'll give us much to talk about during this discussion. Now we shall move on to Nicole. Nicole Lee, our psychologist. Thanks Michael. I just wanted to first reiterate Adrian's point about not everybody needing treatment really. About 70% of users will never need treatment and Barry is kind of in that top 15% of regular users and we know that once the work use or more is associated with dependence so they're the people that are going to probably need tertiary treatment and then there's a group in the middle probably about 15% of users who need some kind of intervention but it won't be everyone dependent. In terms of thinking about Barry and treatment in general it's really important to keep in mind that the next treatment is quite a long treatment cycle. You can see here that the acute meth withdrawal starts later, it's twice as long as other drugs and it's accompanied by this really protracted readjustment period that can last 12 to 18 months for a lot of people and that will impact on how we provide treatment, not the treatment we do provide but how we provide it. And this is directly related to the action of meth in the brain. It activates the three main neurotransmitter systems that primarily acts on the dopamine system and some of the estimates of the increases in dopamine are something like 1200% on baseline levels. Most of us probably haven't tried cocaine before but a large proportion of us probably have had sex and most of us eat so you will have some sense of what it feels like when you have a nice meal or a good shag and you can see how much more dopamine meth releases under those circumstances and how incredible that must feel and that's why people use it of course. But what happens in the brain is that if you keep using meth at that level the dopamine system wears out and the crucial thing for meth users is that when the brain starts having trouble producing more dopamine the main dopamine pathways run through the frontal lobe, the prefrontal cortex which governs all our thinking and planning and decision making and goal setting and also through that limbic system which governs particularly our emotional control and also has some impact on memory and social interactions as well. So when these systems are damaged, when the dopamine system is damaged and they run through these two areas these are the kind of deficits we see, deficits in focus, attention, concentration and memory and decision making and particularly impulse control and mood and that's why we get kind of emotional outbursts of people who are long-term meth users. And that when we're in treatment and we need to think through this with Barry we get these kind of problems appearing in treatment so trouble getting to appointments and completing tasks and setting goals and stopping inappropriate behaviour and unexpected outbursts. Now the brain changes aren't permanent so that's good news after six months of abstinence, cognition is actually worse than among current users so it's a very long time to feel quite crappy while in recovery and there doesn't seem to be much improvement in long-term users in the first 12 months or so. So we just need to keep this in mind when we're thinking about treatment options and you'll see from this slide that the treatment options are identical to the treatment options that every other drug is. So if you're already treating people with meth use if Barry showed up you would know exactly what to do. It's just putting some of those brain changes and some of the physical changes into that context. So withdrawal treatment we know is not effective on its own, it's just the start of treatment and in fact for meth users there's virtually 100% relapse from withdrawal when it's not followed up with anything else. Adrian mentioned some of the significant harms associated with meth use and so it's really, really vital that we introduce harm reduction messages for everybody whatever type of treatment they're receiving particularly around nutrition and sleep and some of the physical issues. There's no pharmacotherapy and John might talk about that a bit more but there's certainly symptom management around some of the mental health symptoms but we do, the good news is that we do have very good psychosocial interventions. We know that motivational interviewing and CBT, Cognitive Behavior Therapy or relapse prevention is effective even just two sessions. Intensive CBT and contingency management such as the matrix program also Acceptance and Commitment Therapy or ACT which is a CBT therapy with mindfulness and Rezi Rehab, they've all been shown to be effective for this group. And in fact meth users have the highest success in treatment. They reduce their use by more than other drug users and they can get the small doses, they'll have quite a lot of success. But on the other hand we're trying to balance that with this data that we know you can see here after a year out of Rezi Rehab about 80% of meth users have already relapsed and by three years they're looking pretty much like people who have not had treatment before. So this is really crucial for meth users, it's much higher for meth users than for other drug users and it suggests that it's a drug that's relatively easy to get off but it's very, very difficult to stay off. So that post-treatment period, treatment's really important but it's exactly the same as all our other treatments but the post-treatment period is really crucial and that's related directly to that very long readjustment period for the brain. That's all I have to say. Thanks very much, Nicole. That was great. We'll just move on to you now, John. Thank you. So yeah, and thanks for that, Nicole. That was sort of set things up really around looking then a little bit more specifically at some of the mental health syndromes perhaps. What I wanted to emphasise also was context. So as a psychiatrist I will see people with and working in the public setting, see people in the emergency department who are amphetamine intoxicated in our acute mental health unit and then also because I work in the prison there as well as in alcohol and other drug service. And so really in any context it can be quite variable and I'm sure that each of you has your context in which you see people so it's important to think about the context within which you're seeing people. Then think about what other substances you're going to need to screen for and consider that are being used with the amphetamines sometimes to, I guess, moderate the use of the amphetamines and sometimes to help recover from them because sometimes they are contributing to problems as well. The physical health problems that it might be associated that Adrian's already touched on is very important to always consider those and then to be looking at other psychological or behavioural problems that might be associated or might be separate problems come times to the amphetamine related problems. So when you're looking at other psychological or behavioural problems again it's obviously important to consider mood symptoms in particular as Adrian highlighted they are perhaps the most common problems that people get with the significant amphetamine use disorder. So you need to think about depression and clearly people often become quite down in their mood in the day after they've come off and clearly the acute intoxication can become quite similar to a manic episode but obviously it tends to remit quickly and it's directly related to the amphetamine. So it's worth contemplating that nevertheless people with a bipolar disorder whether depressed or more often manic can also be using amphetamine. Clearly the amphetamine use and any mood syndrome it needs to then be explored fully if you identify mood syndrome. I think as Vita said thinking about that and thinking about in that context particularly how low a person is and the risk of suicide is obviously going to be important too. Psychotic symptoms we've touched on there and one of the things perhaps to particularly emphasise is whether the patient has a family history of a psychotic disorder. I'm going to just talk a little bit further about that later recognising that increased risk of psychosis in people that do have a family history of a psychotic disorder if you're using methamphetamine. And obviously Adrian again touched on impulsivity, risky behaviours and so attention deficit, hyperactivity disorder is also another issue to consider and again Adrian's touched on the functional issues. So if the amphetamine symptoms present, sorry if you're using amphetamines or psychotic symptoms going through those but particularly looking at the timelines. So just trying to understand with the person who's using, how does the substance use the link, the dose, the mode of delivery, therefore the overall impact on symptoms and how they link both leading up to the use as well as afterwards, how do they understand it and what strategies have they used to manage these symptoms thus far. Then you need to be thinking with them about their treatment plan and obviously as in any such context, thinking about the severity of the symptoms, what's the risk, what support network is available to the person to manage that risk and how cooperative are they with managing it and obviously in this context if they are acutely unwell with a mood disorder or mood symptoms or suicidality or psychotic symptoms then it might be necessary to think about more specialised mental health psychiatric intervention. One of the other issues to always be considering is is it appropriate to get some corroborative information and again that's going to depend on the context but it's going to be particularly important if there are some significant risks identified or if the patient is not cooperative. The SHIP study did look at the frequency of lifetime use of stimulants. This is amongst people who already had psychosis and it's clear that they are really quite common and the other issue to think about is that people who are chronic methamphetamine uses the likelihood of psychotic symptoms goes up markedly the more use there has been and there's also increased further if you use cannabis or alcohol. And if you look at a group of methamphetamine users accessing a needle syringe program, again over 50% of that group had a history of lifetime psychosis and 31% current psychosis, that's a recent Australian study and really there's not much to distinguish between amphetamine-related psychosis from a primary psychotic disorder but there is a significant difference in treatment so people are much less likely to be receiving treatment for a psychotic disorder if they have a substance-induced psychotic disorder. So it was just to highlight there the principles of treatment of acute psychosis are just as applicable in treating any substance-induced psychotic disorder in particular in amphetamine-induced psychotic disorder and they're not meant to be sequential. We need to be thinking about all of these issues in someone presenting with psychosis whether that psychosis has been induced by amphetamines or not. So just the only other issues to think about, the factors associated with increased use of psychosis touched on family history but also earlier use, earlier onset of use, a higher dose over time, possibly premorbid attention deficit disorder and skip to type of personality and antisocial personality disorders and people with severe mood disorders and alcohol dependence may be a greater risk that, and obviously there's impacts as we've touched on on striatal dopamine and clearly that's what we're looking at and causing psychosis in all people. And one of the issues to consider also stimulants for ADHD in adults and risks of psychosis with that group so that's not methamphetamines it can sometimes be a linked cohort. So I think the key issue is still to manage the psychosis to refer, if appropriate, to an early psychosis service or it's equivalent. If a person has a psychotic disorder and they would normally need antipsychotics or be treated with antipsychotics then that should be being considered with someone having amphetamine induced psychosis and we still need to be thinking particularly about educating and supporting the person to recognize their risks. And if they are on antipsychotics it's very important to consider a good plan for ceasing those antipsychotics if that's their plan. And so developing smart, so specific, measurable, achievable, realistic and timely thinking around what's going to be their relapse prevention strategy. Either if they continue using or if they go back to use its important future. I think that's it for me. That was great. We now move on to the part of the webinar where we have our case of searching question and answer. And the first question I'm going to actually address to Zeta, it comes from Nicole and it's in the context of what everybody was speaking about the context of context. In that we see people at different stages of illness and different stages of abuse and addiction. And Nicole wanted to say Barry has a job, family, etc. Residential rehab is probably not the best option. With the level of problem he is showing he probably needs to have a period at least of absence. How do we balance this complex need? Can I put that to you, Vita? I think that's a really, really good point because I certainly have that happen frequently to me when I get called in for consultations. I work across various mental health teams here and that happens quite a bit but once people see drug and alcohol issues flagged that the automatic assumption is that somebody needs to go to drug and alcohol rehab. There's often confusion about the difference between detox and rehab and often the assumption is that they need residential rehab and I guess that's what I alluded to as well. A, the importance of doing a comprehensive drug and alcohol assessment to establish how big a deal is it? Has it just been one off occasional experimental use? Is the person actually dependent? Because that's another thing that comes up quite a bit. I have lots of referrals particularly around alcohol where when I actually unpack it it turns out they're not actually physically dependent. They might be using a pattern which may be problematic but they're not physically dependent and therefore detox itself is not clinically indicated and nor necessarily is residential rehab. So I think the big part about that is unpacking his substance misuse history a little further. It looks like in various cases he may have developed to put its dependence on it but it's still going to be informed as said by people's circumstances. So because he is married, he's got a couple of young kids at home, he's working going away for three to six months into a residential rehab could be problematic for him and it could be problematic financially as well because most rehabs do charge so if they can't afford to pay that's another stumbling block quite often in which case I'd be talking to Barry about he's indicated he's interested in addressing his substance misuse apart from some educating him around it, I'd be talking about the treatment options around that are available to him and that includes detox it includes residential rehab it includes groups like NA it includes individual counselling and again it would depend on those underlying reasons for use and one of the big things that got out to me was a lot of this seemed to stem from the original issue that around finances and one of the things I jotted down when I first looked at this was could he benefit from some financial counselling to assist with budgeting as the family aware of emergency supports that might be available as well so that's a good question. Pretty good idea. Let's go over to you Adrian could you comment on please? I think what we do clinically a lot of the time in these sort of situations is really aimed for the least intrusive type of treatment and if that works fantastic and if that doesn't work then step up the level of intensity of treatment the phrase step care has been used by Amanda Baker and others to describe this so in this sort of situation we start by trying to engage variants in counselling look at the issues, look at possible approaches see if it's possible for him to stop by himself without too much resistance he can, great if he can't then look at a more structural withdrawal if that goes well as an outpass should fine if it doesn't go well look at residential options if that goes well continue counselling if that's not going well consider rehabilitation so just to clarify one of the slide Nicole was presenting was talking particularly about comparing some outcomes for people in residential rehab by definition they usually have more severe problems so that's not the outcome for absolutely everybody and I'm sure Nicole could talk some more about that but for many amphetamine users CBT, cognitive based therapy, motivational interviewing type approaches work quite well and you get some significant reductions 40% abstinence rates after 6 months so it's not perfect but it's not a bad honor. Thank you very much Adrian your stand just dropped out there just towards the end John may you are in charge of a very large service you must get questions from GPs and registrars and you must be dealing yourself in your alcohol and drug guide with these sort of problems what's your and you alluded to the context right all the way through your presentation would you like to comment on what's been said yeah look it is about the presentation I guess the patients that probably I still end up seeing maybe are often more at the the psychotic end of the spectrum but certainly not so much in the prison setting so I think what Adrian said with regard to the stepped care, titrating the level of support and the level of treatment offered to what the patient needs but I guess even more so what the patients prepared to accept so that's what I was emphasizing too and I think the others have highlighted that very well we have to engage the patient in recognizing the problem and clearly that's core to any motivational enhancement approach into being able to engage a person in treatment and often clearly that means that people are going to decide to continue to use the substance in a way that we might not increase in their best interests and we might be trying to point that out but we still have to work with where about the person is at that point now clearly there are sometimes red flags which mean we have to take some kind of intervention or action but in general we're still working with them at wherever they are thanks very much John I'm just going to go back to Nicole and Nicole maybe you might just want to comment on those answers that you received to your question and then I have a question for you so as you can just briefly respond to the answers to your question well yeah I agree that a step to care approach is the best practice and we want to we do want to be aiming at the lowest intervention that we think is going to be effective to start with and I think that the data is right that it would be really difficult for someone like Barry to go into residential treatment even though he seems to be having quite a lot of problems around his use and that certainly wouldn't be the first the first line of treatment for practical reasons as much as clinical reasons I think that there's a lot of things we need to think about when we think about where someone needs to go for treatment and how to figure that out now I believe that it was Vita who said in her presentation it may have been you and I apologize but I think it was Vita who said what is it about substances that makes people take them I mean apart from the huge rise in dopamine that has a hundred times better sex but you know the anxiety what are they trying to what are these patients and clients trying to what are they trying to minimize do you find that in therapy it is helpful to go down that road the first thing for me is that we need to remember that not everybody uses drugs to hide, to mask some kind of trauma or some kind of mood issue there are a group of people who have pre-existing problems and they do self-medicate or using drugs feels particularly good for them because everything else feels so crappy but there's a large group of people who just start experimenting with drugs and they may have a vulnerability to dependence or to experiencing problems with them we know that a range of trauma and mental health problems increases the likelihood of that but we shouldn't make the mistake that everybody who uses drugs and gets into trouble with it has underlying problems that we need to treat but if they do have underlying problems and there is a sizable proportion who do then we do need to treat those problems but for a lot of people the problems come as a result of their drug use as well, not prior to their drug use so it's really important I think some of the stuff that Zeta was talking about in terms of engaging people so that they can give us really detailed honest answers and we can figure out really what's going on and tailor the treatment for those people I'd just like to go ahead please yes I just wanted to really reinforce that from Nicole I think as mental health professionals and health professionals more generally there is that notion sometimes but it's all about self-medication and for some other problem and you often hear it sort of said and I think that it's actually sometimes we have to recognise it's us making a kind of easy jump or an easy assumption and we really need to drill down and understand what's going on as Nicole was suggesting rather than just assuming that and because we hear the term used often it's an easy term for particularly people working in the mental health setting to simply say self-medication I think very often there's not actually good evidence to suggest that in many situations where people use the term can I just add to that Michael just as an example I can see a few comments coming up that are more and against what we've just been talking about but just as an example about something like 70 to 80% of people who are in drug and alcohol treatment have had some kind of trauma experience at some point in their life but only about 20 to 25% of those will have any trauma symptoms so just having some traumatic experience happen to you also doesn't automatically mean that you'll be traumatised by it some people have some protective mechanisms and some people are more vulnerable to that so it is relatively small proportion of a small proportion that will be self-medicating so I don't think we should jump to that conclusion as the first line Yes Yes thank you Now just one question I had for the panel this man's driving a truck we don't know how big the truck is but I say it's one of these big big trucks and if he presents to one of us do we have a juicy of care to notify the authorities? I'm happy to answer So absolutely medically if somebody is driving under the influence of a substance we've got a responsibility to inform the relevant driving authority and that is a tiny truck a dual carriage or a dual truck Yes because of the risks to society despite this we know that driving under the influence of phenomines is common there's no great prevalence studies you hear all sorts of reports from the police about them doing testing it's usually targeted testing they get very high rates of people being testing metamphetamine positive so it's possible it's still common exactly how dangerous it is from a scientific perspective is debatable compared to alcohol for example but it's illegal so it's a meat point really So yes we have a response So would this prevent people from presenting for care? Adrian would it prevent people from presenting for care these things? Yes of course there's many things that prevent people presenting for care and probably stigma about substance use is the single biggest one so messages like unfortunately the national ice campaign about people throwing chairs through windows at emergency departments and headbutting stuff that's very rare very uncommon there's many other drugs like alcohol that are far more likely to produce results like that so stigma about drug use is very very common and is a really strong driver of people not presenting treatment and one of the issues that clinically we've got to deal with all type people are embarrassed, ashamed feel that they can't come forward and seek help and that's a problem We all talk about trying to eliminate stigma or assist stigma you know assist in getting rid of stigma in mental health Would anybody else like to comment on that? I think that's an important point Strong I'll just comment that I think as I was saying before one of the issues with psychosis in particular linked with amphetamines we just need to think of it still as psychosis so to me the term drug induced psychosis is a major problem and we need to not use it we need to be quite specific about what do we think might be an agent that might be triggering psychosis in an individual and I see one of the comments was in regard to mental health services not picking or being prepared to pick people up with psychosis and I think that's where we need to move away from a drug induced psychosis as a notion because it seems to suggest it's all about the drug whereas it's actually all about the psychosis not all but to a large extent in many of these situations and mental health services certainly need to recognise that and need to be encouraged and supported to pick people up that have psychotic disorders because it's actually core business but there is a bit of a split sometimes with the problem with them recognising that and I agree and I think that's one of the strategies and that's an issue perhaps with stigmatisation of substance use even within mental health services where you'd think there shouldn't be such stigma but I think that's one of the problems that occurs so we probably need to look within our own backyard as a mental health professional about ensuring that we're not stigmatising people because of their substance use too I agree with that John and I think that's a really important point and I think it also speaks to I think some of these campaigns and the images that we see in the media they're freaking the community out but they're also scaring practitioners as well and practitioners are feeling like they don't know they don't have the skills to deal with meth users and we inadvertently marginalise them and stigmatise them by doing that but as John said psychosis is psychosis it doesn't really matter what course it the response is the same the same with violence and aggression it's not right but that happens but in emergency departments and alcohol and drug services and mental health services we're all used to experiencing people who are aggressive and they're not all on ice and whether they're on ice or whether they're aggressive for some other reason it doesn't matter the response is the same so I think people need to just step back and get some perspective and understand that they especially practitioners have the skills to manage whatever is in front of them yep no that's a really good point the other point that's come up in a few questions that we had before the webinar from participants and it's come up again just reading down through the question is the vicarious trauma that many mental health workers suffer from dealing with with patients and clients with ice and youth independence would anybody care to discuss that? I'm happy to start from my guess from my other work mainly with the drug and alcohol workforce but also with the general health workforce and it's absolutely crucial for people who do this work to have a good supervision structure that they work under there's all sorts of risks of working with this population so having a good supervisor and ideally working as part of a modular disability team is quite desirable but even if you're working as a solo practitioner to have some sort of peer discussion of difficult patients difficult clients that's really important there are many risks that might go into all of them but that really protects yourself professionally and also protects your patients or clients and I think anybody who does this work is a major part of their work that's mandatory for their own health and for the patients themselves I would suggest that's something we have to do actual trauma by patients is rare I think it's probably far more dangerous to work in an emergency department on a Friday Saturday night when people come in drunk and it's really heavily difficult to manage Yes, I think the question was more psychological trauma than physical trauma Yes Anybody else would like to comment on the psychological trauma and amongst carers amongst family as well as amongst therapists Yeah, I think that there's a little bit of work that was done by NDARC that was looking at the alcohol and drug workers not specifically around methamphetamine but treating drug users more generally and there is a high rate of vicarious trauma and trauma related to having to deal with very complex clients quite frequently and as Adrienne said the really crucial thing for practitioners is to ensure that you've got some support networks in terms of other clinical supervision or particularly clinical supervision one-to-one clinical supervision and I think it's the same for families families really struggle with people who are using meth in their family they struggle with people who are using meth in their family that often don't know what to do they get conflicting advice that is often unhelpful but it's really helpful to access some of those family support organisations and families need to get support as well whether the person that's using meth goes into treatment or not The other question that came through quite frequently was how to get patients to engage in general practice I would tend to see more the families of ICUs than ICUs themselves they may attend once or twice and then disappear again Does anybody have any thoughts on how to engage people who are using ICUs strategies context Yeah I think Sorry Nicole Go ahead me don't I guess if I went back to my engagement last slide the thing that comes to mind I mean apart from the obvious that I think most people have heard many times taking a non-judgmental approach and being empathic Some of the key things one of the barriers that I've come across sometimes for young people is if they're concerned about confidentiality and it being reported to police maybe I've got a bit of a benefit where I see in a mental health setting the focus is around health and unless it's a major crime that they're involved in then you can avoid the mandatory reporting stuff but it depends and I think conversations, clear conversations around confidentiality and where those confidentiality lies and when you do and don't have to disclose can really help get past those particular barriers but the other thing that I find really helpful is I focus a lot with clients around neuroanatomy and neurochemistry and I find by keeping it really embedded in the biological factual side of things that that really helps people engage they're expecting to be lectured they're expecting to be told don't do this it's bad for you and I don't think that's a particularly helpful approach I think quite often we're not very good because it is not helpful for somebody and if we can talk about neuroanatomy and neurochemistry and explain what's going on biologically I find that that gets a lot of buy-in from consumers that otherwise might have walked out because they know that what I'm saying is true because they can relate to it, they've experienced I can explain why they're with the serotonin release and the dopamine release and the riddle and we can talk about why they experience effects that they do we can explain why withdrawal looks the way that it does and by avoiding that moral, legal and ethical side of things I tend to get more buy-in and acknowledging the benefits of use that's a real critical thing not pretending that all substance use is all horrible and bad we wouldn't use the reality is human beings wouldn't be misusing substances if we didn't find something enjoyable about it or something that's beneficial or something that gives us a functional gain and yeah I guess the other thing that I think a lot of times I've also come across clinicians who are scared to engage because they're not quite sure like if someone says I'm using a point of this what does that mean it's a tenth of gram but if you don't know what does an eight ball mean 3.5 grams and that scares a lot of people but sometimes I often say to clinicians that I'm training don't be afraid to ask if you're caught in a situation you're not quite sure you don't need to fudge it and pretend like if you actually say to somebody look this is an area I'm not familiar with and ask them it's just a power differential it gives power back to the client and I'm amazed at how often a client is more than happy to sit back and tell me all about how a particular drug is prepared or how they're sourcing it via the internet or whatever quite often more forthcoming than I think a lot of clinicians think they would be. Well didn't that go quickly we're coming to the end of our webinar we have about 10 or 15 minutes left and at this stage we're going to move on to a summing up from the panellists and we'll go in reverse order I believe somebody wrote on a piece of parchment many many years ago that the last shall be first. So John we will ask you to just sum up for a few minutes. Okay I think what Vita was just saying is interesting because as a psychiatrist and her talking about the neurobiology what I was actually thinking about was it takes me back to William Miller and to Oz as a strategy or a way of thinking about how to deal with the patients to motivate them and to encourage them to stay in treatment so Oz as in open questions affirmation reflection and summaries just as a way of how to approach and interview and that's something I certainly talk about with my trainees. But I think that looking at the neurobiology isn't interesting a good way to approach things because with education because really it's helping to our firm going under attack or stigmatised and I think that's a good strategy in that way as well as providing them of course with information. So I think that's excellent. I think just I suppose my overall summary would be I'd still come back to context and just going through the key point with regard to recognition of psychiatric syndromes whether it's anxiety, mood psychosis, attention deficit, hyperactivity disorder or all the other possible comorbid syndromes that we see more frequently it's clear that sometimes there's pretty complex interactions here with the substance use disorder the amphetamine use and it often does take a bit of teasing out and I think it's important that we all recognise that complexity and that when it comes to and not jump to quick conclusions about what might be causing disorders but to recognise that if there are those disorders there that they separately amphetamine use can also be treated and that it's often important to try and do that in as assertive way as possible with the patient now encouraging them to be considering that. So I think that's probably my reflection model. Thanks very much John and thank you for your contribution it was excellent and now we'll move to Nicole. Yeah I think we're just picking up on the last couple of things that were said around it's hard to engage meth users and they don't stay very long in treatment and there's quite a high relapse rate I think we have to be quite pragmatic with these groups of people I mean if you if you just think about perhaps they may only stay for one or two sessions or you may only see them once or twice I even if it's an assessment session I always do some psycho education around the brain changes just so that to put that into context for them. I always do some harm reduction intervention brief harm reduction in particular in terms of nutrition and sleep and some of the physical effects and I always do a brief motivational intervention and so if you do nothing else you'll have an opportunity at least once to do some of those things and you should do it that and the second really crucial thing I think is as Adri mentioned the step care approach if you meet the client where they are not where you want them to be and move with them then you're going to get much more likely to engage them and you can always step up the intervention as needed but if you try and put someone into Rezi Rehab when they're just not ready to go that's not going to work at all Thanks very much Nicole that was excellent we'll now move to Vita I don't know there's a few things that have stood out I guess one of the questions that came up was how long does methamphetamine stay in the system for which is roughly 2-3 days and one of the questions that came up around sort of trying to differentiate between whether or not it's methamphetamine induced psychosis or not and one is that generally speaking one of the things I look for working as a comorbidist specialist within mental health is how quickly does that psychosis resolve is it resolving within 3 days or a few more or has the person required a 2 week inpatient stay which is usually indicative that there's something else going on that was one of the things that I guess I wanted to address as we've been going through trying to keep track of some of the questions coming up in the general chat and the only other thing I think was kind of maybe missed flagging is just around drug interactions and particularly in Barry's case because I was thinking there's potential that an antidepressant might be considered and the risk of serotonin syndrome if we're combining an SSRI with methamphetamine those are probably some of the burning things that were just in my mind as we've been going through and one of the things that I would like you to comment on from your sociology background is collaboration between all the different disciplines did you just spend a minute or so on that? Yeah I think it's absolutely critical I've been specialising in this field for about 12 years and I guess part of what kept me completely engaged throughout that time is the fact there's so much to learn mental health is a complex area, drug and alcohol is a complex area you're starting to talk about comorbidity and that rarely is just those two, usually there's medical complications quite often people are also presenting with things like intellectual disabilities and ABI acquired brain injuries so I think it's so critical you'll never have the skills to necessarily address everything on your own and I know here in this state we have a triple diagnosis group that meets regularly and we have people from all different sectors attending that and from different backgrounds and it's critical and being prepared to pull knowledge and to work collaboratively to get the best possible outcomes is such a fantastic thing and if we can set that up hopefully that's working well in multidisciplinary team environments but sometimes bureaucracy can get in the way and we have our triple diagnosis group sits actually separately apart from the normal bureaucratic structures and I imagine mental health professional network also has its networks as a means that we can join in and actually pick each other's brains use each other's expertise that is sitting there I think there's an awful lot of extremely skilled people and if we can actually work collaboratively across sectors rather than picking the silos and fold to things that it's critical for the best possible outcome Thanks Peter it was really interesting and so correct and now moving to Adrian if you can just sum up Adrian you're lucky last thanks Michael so firstly thanks to the for putting on this webinar it's very timely indeed people are probably aware that the National Ice Task Force that's been going around the country for the last six or eight months or so is going to release a report I think we think it's sometime in December I hope that there will be a whole lot more resources and other information that might come out of that for people who work in this area and particularly for people in families who are affected by methamphetamine so very timely I guess for the clinicians online I really encourage you to try to engage in this area ask questions of your patients your clients about methamphetamine I showed you the assist light it's pretty simple tools that you can use engagement of course is very very important and there's a big difference between clinicians who can engage with patients with substance use problems and those who can't so we need more of you to work in this area because there's a lot of work to be done it's not always difficult and challenging in various cases it's probably slightly complex not everybody's like that and often really simple counselling approaches that it's possible to learn like community behavioural therapy anything can be useful it can make it sound too simple it can be challenging as well and if people are interested in the area definitely suggest that they need good supervisors because having good professional support is crucial and I guess for those patients that aren't going so well being aware of having good referral networks you'll see in the resources that there's the helplines for each state for patients also some states have specific helplines for professionals so where professionals can get advice so have a look at those resources and see what can be helpful to you fortunately there's two grants that were announced in the recent NHSNMRC funding grant specifically with relation to methamphetamine so there's some more research going on but we need a lot more and we need to continue to promote this area because there's much work to be done so thank you Michael Thanks very much Adrian really from the bottom of my heart I'd like to thank all our presenters this evening it is one of the best if not the best webinar that I've facilitated for MHPN so much expertise knowledge around this topic coming at it from so many different disciplines but really all saying the same thing the importance of context and how people can present at different stages of life use the importance of just the simple basic things that were all taught in our in our social work psych addiction medicine or psychiatry training you know psychoeducation harm reduction and one of the points that I took up is that psychosis is psychosis and drugs induced psychosis is not something separate I think that point came out very well from a number of other speakers that we shouldn't forget our normal toolbox that we use for treating patients and clients that we shouldn't be afraid of treating people with isodiction use of motivational therapy assist all those other little things that we drag out of our toolbox or our computer and also the recognition of other comorbidities that may need addressing during the consultation or during the time of treatment one of the things that I wasn't aware of and one of the things that came through to me was was the short physical wash out from from methamphetamines but the acedically long psychological wash out which seems to lead to that back up to that 80% after two years it's just incredible and quite frightening and I think the more webinars we have like this where we can involve speakers of such caliber as the four presenters we've had tonight the better off we will be able to to treat these people and I mean people not in a derogatory fashion but they are people just like you and I who happen to have this problem so on behalf of MHPN I thank all our participants we had over 750 at one stage for attending remembering that there will be a next webinar in 2016 you'll be able to download all the assets from tonight on the website next week and certificates of attendance will be sent out to those who need them and also remember that if you're interested in furthering the work of MHPN there are local groups that you can join at start if they don't exist in your area just again just go to the website for more information about that I'd like to thank our participants who had some minor tech problems who persisted and who stayed on and all the participants and general who made some very useful comments which contributed to the question and answer session I wish you all good night and if you're away from homeless a safe journey home good night thank you