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Documente Profesional
Documente Cultură
What
Is
Known
Part
One
amphetamine
methamphetamine
The
dierence
between
amphetamine
and
methamphetamine
is
the
addition
of
a
single
methyl
group
(CH3)
to
the
amino
group
sticking
o
the
middle
carbon
atom
in
the
chain.
3
Production: Reduction of ephedrine or pseudoephedrine Reducing condensation product of BMK and methylamine Synthesis from D-phenylalanine
What
Is Going On?
In Thailand, as in much of the world, an inadequate health infrastructure and lack of professionals with the skills and training in methamphetamine use, misuse and abuse, are major obstacles to providing much needed services for stimulant users. At present, most available drug services are modeled on strategies designed specically for users of opiates and alcohol. As a result, methamphetamine users are neglected. Indeed, if not for the early evidence from needle exchange programs suggesting extremely high use by methamphetamine users (in some cases higher use of their service than opiate users), many specialist services would not be aware of the local problems.
Thailand Timeline
1972
(prior
to)
-
No
record
of
anyone
in
treatment
for
amphetamine
use.
1972
-
First
recorded
treatment
cases
in
hospitals
in
Thanyarak
and
Khon
Kaen.
1979
-
The
rst
intravenous
use
of
amphetamines
is
recorded
in
Thailand.
1995
-
New
cases
with
amphetamine
as
principle
drug
rise
from
2.69%
in
1995
to
10.6%
2002
Thai
market
said
to
be
around
700
million
pills
or
ten
pills
for
everyone
in
the
country.
Current
-
Methamphetamine
is
the
most
popular
illicit
drug.
Of
all
new
hospital
admissions
for
drug
treatment
in
in
2006,
75.6%
(n
=
29,235)
of
patients
were
admitted
for
methamphetamine
use.
Furthermore,
75.2%
(n
=
51,457)
of
all
drug-related
arrests
in
2006
were
methamphetamine
related.
8
10
11
Amphetamine
Amphetamine-type stimulants (ATS), most of which is methamphetamine, are the second most common illicit drugs used worldwide after cannabis. Amphetamine users outnumber both cocaine (2.3 to 1) and opiate users (3.5 to 1). Amphetamines can be manufactured anywhere. They are easy to make and inexpensive to produce. This training will focus on methamphetamine (ice and ya ba), as it is the amphetamine most often used illicitly in Thailand.
12
Methamphetamine
Forms:
Powder;
Crystal;
Solution;
Pill
Delivery:
Injection;
intranasal;
Smoked;
Oral;
Rectal Ingestion
Medical
Use
(not
in
Thailand):
Severe
obesity;
narcolepsy;
ADHD.
O
label:
Depression.
Aects
neurochemical
mechanisms
responsible
for
regulating
heart
rate,
body
temperature,
blood
pressure,
appetite,
attention,
mood
and
emotional
responses
associated
with
alertness
or
alarming
conditions.
The
acute
physical
eects
of
the
drug
closely
resemble
the
physiological
and
psychological
eects
of
an
epinephrine-provoked
ght-or-ight
response,
including
increased
heart
rate
and
blood
pressure,
vasoconstriction,
bronchodilation
and
hyperglycemia.
13
Dose Effects
Low Dose High Dose
Physical Psychological
Increases in blood pressure Sweating Palpitations Chest pain Shortness of breath Headache Tremor Hot and cold ushes Increases in body temperature Reduced appetite Euphoria Elevated mood Sense of wellbeing Increased alertness and concentration Reduced fatigue Increased talkativeness Improved physical performance
High
blood
pressure
Rapid
or
abnormal
heart
action
Seizures
Cerebral
hemorrhage
Jaw
clenching
and
teeth-grinding
Nausea,
vomiting
Confusion
Anxiety
and
agitation
Repetitive
motor
activity
Impaired
cognitive
&
motor
performance
Aggressiveness,
hostility,
violent
behaviour
Paranoia
including
paranoid
hallucinations
Common
delusions
include
preoccupation
with
bugs
on
the
skin
14
15
Withdrawal
The
DSM-IV
characterizes
amphetamine
withdrawal
as
including
dysphonic
mood
(sadness)
plus
two
of
the
following:
Fatigue
insomnia
Hypersomnia
(over-sleeping)
Psychomotor
agitation
Increased
appetite
Vivid,
unpleasant
dreams
16
17
18
The
release
of
dopamine
is
why
Methamphetamine
works
so
well.
Because:
Dopamine
aects
a
region
of
the
brain
that
controls
pleasure
Dopamine
is
involved
in
reward
behavior,
leading
to
continued
use
of
the
19
1. Methamphetamine enters the brain cells from the bloodstream. 2. It produces neuro-chemical activity having the brain release chemical messengers, called neurotransmitters, to stimulate sections of the brain. 3. Methamphetamine aects the cerebral cortex and cause the experiencing of heightened energy, elevated euphoria, and powers of reasoning and thinking. 4. It also targets the limbic area - or pleasure center - which controls food, ght, ight, and the sex drive.
20
1) Methamphetamine reaches the nerve cell 2) Releasing dopamine . . . 3) Which then ts into specialized receptors located on other nerve cells, creating a rush of pleasure. 4) It also targets the limbic area - or pleasure center - which controls food, ght, ight, and the sex drive.
21
22
23
No use Occasional, recreational or casual use Regular use Misuse, abuse Dependence, addiction
24
Addiction
25
26
When illicitly produced, it is commonly made by the reduction of ephedrine or pseudoephedrine. Most of the necessary chemicals are available in household products or over-the-counter cold or allergy medicines. Synthesis is relatively simple, but entails risk with ammable and corrosive chemicals, particularly the solvents used in extraction and purication.
27
28
What
follows
are
observations
formulated
from:
Experience
working
with
drug
users
and
social
workers
Interviews
with
key
informants
Focus
groups
Reviews
of
scientic
literature
29
You must not fool yourself and you are the easiest person to fool. - Richard P. Feynman
30
anxiety
Combat
HIV
fatigue
Lose
weight
Ease homelessness
31
32
injection
run
during
which
a
user
maintains
a
high,
usually
without
sleep,
for
days
or
weeks
Several
days
of
exhaustion,
sleep,
and
depression
follow
the
high
33
1.
Initial
Rush
After ingestion, user feels 5 to 10 minutes intense euphoria Intense feelings of wellbeing or pleasure Rapid ight of ideas Sexual stimulation High energy This is more intense for injectors and the most addictive component of cycle
2. The High Less intense euphoria Hyperactivity, hypersexuality Rapid ight of ideas Obsessive/compulsive activity Thought blending Hyperacute senses Dilated pupils
34
3. Binge User seeks to continue the high by using more methamphetamine. The euphoric rush diminishes after the initial dose; tolerance is experienced Users might continue to use over a 3 to 15 day period, until no rush or high is experienced, becoming mentally and physically hyperactive 4. Crash (this is dose dependent) Toward the end of the binge, some users experience: Feelings of sadness and emptiness Increased suspiciousness, paranoia Waves of craving In some, heightened paranoia and psychosis 5. Rebound After crashing and replenishing the body, a user returns to normal
35
Withdrawal
The
DSM-IV
characterizes
amphetamine
withdrawal
as
including
dysphonic
mood
(sadness)
plus
two
of
the
following:
Fatigue
insomnia
Hypersomnia
(over-sleeping)
Psychomotor
agitation
Increased
appetite
Vivid,
unpleasant
dreams
Withdrawal
symptoms
from
methamphetamine
dependence
closely
mirror
the
negative
symptoms
of
psychotic
disorders.
(Broome
et
al,
2005.
Srisurapanont
et
al,
2003.
Dyer
+
Cruickshank,
2005
+
2006.
McKetin
et
al,
Addiction.)
36
Withdrawal
The
DSM-IV
characterizes
amphetamine
withdrawal
as
including
dysphonic
mood
(sadness)
plus
two
of
the
following:
Fatigue
insomnia
Hypersomnia
(over-sleeping)
Psychomotor
agitation
Increased
appetite
Vivid,
unpleasant
dreams
Withdrawal
symptoms
from
methamphetamine
dependence
closely
mirror
the
negative
symptoms
of
psychotic
disorders.
(Broome
et
al,
2005.
Srisurapanont
et
al,
2003.
Dyer
+
Cruickshank,
2005
+
2006.
McKetin
et
al,
Addiction.)
37
How can you tell if you re using too much? First of all, too much can mean several things the amount you use, how often you use, or what happens when you use.
In each case, you probably have an idea of what feels acceptable for you. Some people set limits for their use. Going beyond these limits could have negative results that just aren t worth the price health problems, guilt, relationship stress, etc.
38
39
A philosophy, model, and set of strategies that reduces drug-related harm without creating further harm to active licit and illicit drug users, their families, and communities aected by drug use. Drug-related harms include HIV/AIDS and other infectious disease, overdose, illness, death, dysfunction, violence, and community disintegration.
40
Research
Innovation
Discovery
The norm of reciprocity is the social expectation that people will respond to each other in kind
Positive Change
Staff Experience
User Experience
Discussion
Investigation
41
Syringe
Exchange
Site
and
o-site,
secondary
exchange
Group Level Interventions (GLISU) Brief Individual Level Interventions (BILI) Access to harm reduction supplies HIV counseling and testing, other services, support, advocacy, referral
42
43
Sta works with Methamphetamine Users to Increase everyone's knowledge of Methamphetamine and to Implement Harm Reduction Strategies Specic to Methamphetamine Use. Important Topics: Smoking associated risk Injection associated risk Sexual risk Psychological and physiological issues presenting during use Health problems
44
45
Risks
and
harms
will
be
lessened
when
users
are
prepared
Help
in
setting
limits
around
length
of
use
(during
a
run)
Encourage
users
to
use
or
party
with
people
they
trust
Encourage
users
to
take
care
of
one
another
Encourage
users
to
discuss
what
is
going
on
inside
themselves
with
one
another
Help users avoid impulse spending. Users can decide how much they will
46
47
Smoking Methamphetamine
48
Time to get o: about 7-10 seconds 1)Ice is placed in a glass bowl or stem, melted and allowed to reconstitute. 2)It s then vaporized over a low ame. ice moves away from the heat as it turns into gas. 3)It's then inhaled into the lungs. The gas enters the blood stream via the lungs. 4)Users typically inhale a large amount of vapor and exhale quickly. Facts: There is no point in holding in the vapor for an extended amount of time as the drug is its active properties are released into lungs almost immediately. Methamphetamine is water soluble, which means it can be dissolved in water. Smoking ice through a water pipe reduces its strength . Using a beverage other that pure water in a water pipe is not recommended as the inhalation of sugars or other ingredients is bad for the lungs.
49
Here are a few particular risks for smoking and some suggestions: Burns from hot glass, direct ame, or a hot lighter Don t apply ame directly to the glass, keep it below and move it around Don t apply a constant ame, gradually heat the product Consider making a needle lighter Try a Pyrex pipe Injuries The vapors are pretty toxic to your lungs. Don t hold your hit in your lungs (don t hold your breath) Try not to hold the pipe with your lips Keep a drink handy to rinse your tongue between smokes Avoid plugging the pipe with your tongue Slow gradual heating of a small load, and take break
50
Risks for smoking and some suggestions (continued): Dental damage due to caustic vapors Hold the pipe with the end of the tube behind your teeth. Rinse your mouth frequently Legal problems associated with possession of smoking equipment Don t carry equipment around with you, or leave it on display Transmission of infections if sharing equipment Use your own equipment or wash it well between Keep a spare pipe handy for friends If you don t want to waste smoke, rather than pass the pipe around consider blowing extra smoke into a balloon to use later
51
52
Methamphetamine is Injected into a vein. Unlike opiates, it is never a good idea to muscle or skin pop methamphetamine. When drugs are skin popped, they slowly make their way from tissues into the blood stream. Opiates are easily absorbed into the body this way. Because of the additives in methamphetamine, it can t be absorbed by the body like opiates can. So, methamphetamine must be shot directly into the blood stream via a vein. If you were to skin pop methamphetamine, it would sit under your skin for long periods of time eventually forming an abscess or other nasty side eects.
53
veins
hard on
Drink plenty of water for healthy veins The best place to look for veins is the crook of the arm. The veins found here
are close to the skin s surface and therefore, easy to spot given their large size and distinctive, bluish color
54
If
a
user
has
trouble
nding
a
vein:
Use
a
tourniquet
to
tie
o.
It
needs
to
be
above
the
mound
of
the
bicep.
Do
not
tie
o
on
top
o
the
muscle
or
on
the
lower
arm
Hang
your
arm
lower
than
your
waist
and
clench
your
st
for
a
while
Gently
tap
or
slap
the
crook
of
your
arm
Use
a
hairdryer
-
as
heat
will
draw
veins
to
the
surface
Do
a
few
pushups.
Blood
will
rush
to
the
veins
Soak
the
site
in
warm
water
55
56
Drug Testing
Methamphetamine
can
be
detected
in
urine
anywhere
from
3
to
6
days
after
last
use.
Avoiding
a
positive
drug
screen:
Drink
several
gallons
of
uids
every
day
prior
to
taking
the
drug
test.
Water
and
pure
fruit
juice
are
the
best,
but
you
avoid
drinking
too
much
juice
because
it
is
high
in
sugars.
Avoid
salty,
fatty,
and
fried
foods,
and
do
not
consume
alcohol.
Drink
at
least
eight
large
glasses
of
water
just
prior
to
the
test.
Urinate
a
few
times
before
submitting
to
the
test.
Don t
submit
your
rst
urine
of
the
day
.
57
58
Gender
Data
has
consistently
shown
that
drug
use
is
not
equally
distributed
by
gender.
For
example,
males:
Are
more
likely
to
use
most
illicit
drugs
Report
using
such
drugs
earlier
and
longer
than
females
Use
all
illicit
drugs
more
frequently
and
in
larger
amounts
than
females
The
ratio
of
men
to
women
who
use
heroin
is
close
to
3:
1
The
ratio
of
men
to
women
who
use
cocaine
is
close
to
3:
1
Methamphetamine,
however,
is
signicantly
dierent
and
appears
to
be
a
substance
of
abuse
and
addiction
that
appeals
to
both
men
and
women
equally.
The ratio of use along gender lines is close to 1:1; admissions to treatment are approximately 50% women and 50% men.
59
Gender
Historically,
heroic
individualism
or
sensual
hedonism
has
embodied
men s
stories
of
drug
use.
Women s
drug
taking
has
been
personied
by
escapes
from
pain
or
in
psychological
drives
(i.e.
having
addictive
personalities).
Their
drug
use
is
seen
as
being
at
the
mercy
of
personalized,
inner
drives.
In
truth,
women
use
a
variety
of
substances
for
a
range
of
reasons,
including
pleasure.
Also,
In
consideration
of
gender
imbalance,
it s
important
to
note
the
correlation
between
intensity
of
stimulant
use
and
positive
experiences
of
sex
among
women
has
been
found
(Sexual
and
Injection
Risk
among
Women
who
Inject
Methamphetamine
in
San
Francisco;
J.
Lorvick,
A.
Martinez,
L.
Gee,
and
A.
Kral;
Journal
of
Urban
Health:
Bulletin
of
the
New
York
Academy
of
Medicine,
Vol.
83,
No.
3,
2006).
60
Multiple sexual partners Receptive syringe sharing Sharing of syringes with more than one person in the past six months
Sexual and Injection Risk among women who inject methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006
61
Sexual and Injection Risk among women who inject methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006
62
64
Pregnancy
Complication
for
care:
Mother
seen
as
cause
of
the
problem
that
harms
herself
and
her
unborn
child.
Further
complications:
Legal,
social
and
environmental
problems.
Caregivers
role:
To
provide
a
non-judgmental,
supportive
environment
to
minimize
risks
during
pregnancy,
the
neonatal
period
and
in
the
long
term.
To
achieve
this,
care
givers
need
to
be:
Multidisciplinary
and
tolerant
of
the
mother s
problem.
Remember
the
aim
of
antenatal
care
is
to
reduce
risk,
which
does
not
mean
that
the mother must abstain from drug use. responsibility for her situation.
The aim is to keep her within the care system and encourage her to take
Most Importantly, the specics of the care provided are probably less important than the quality of the care given and the degree of engagement of the individual.
65
Prenatal Exposure
Evidence
suggests
there
are
likely
to
be
adverse
developmental
eects
for
children
exposed
prenatally
to
methamphetamine,
either
because
of
the
drug
per
se
or
because
of
the
environment
in
which
these
children
are
raised.
At
present,
we
do
not
know
specically
what
those
eects
will
be. To
avoid
making
unfounded
judgments
about
the
development
of
infants
born
to
mothers
using
methamphetamine
during
pregnancy,
further
research
that
considers
the
impact
of
other
drug
use
and
inuence
of
the
postnatal
environment
is
needed.
What
is
known
about
the
eects
of
methamphetamine-use
during
pregnancy
on
the
developing
child
comes
from:
Studies
conducted
on
animals
Human
studies
(Few
conducted;
contain
number
of
methodological
problems)
Studies
of
cocaine
66
Prenatal Exposure
Eects
of
prenatal
methamphetamine
exposure:
Preterm
birth
Growth
retardation
Neurobehavioral
outcomes
(depending
on
extent
and
combination
of
drugs)
Developmental
domains
aected
during
infancy
and
early
childhood:
State
regulation
Arousal
Attention
Psychomotor
development
Lester, B. et al Maternal methamphetamine use during pregnancy and child outcome: what do we know? Journal of the New Zealand Medical Association, 26-November-2004, Vol 117 No 1206
67
Breastfeeding
Breastfeeding
is
contraindicated
as
signicant
amounts
of
methamphetamine
are
transferred
into
breast
milk
from
the
maternal
plasma
due
to
their
low
molecular
weight.
Few
controlled
studies
are
available
on
the
physiological
aects
of
methamphetamine
on
infants
exposed
through
breast
milk
despite
the
prevalence
of
use.
Studies
do
show
irritability
and
poor
sleep
patterns
in
infants
exposed
via
breast
milk.
Distribution
in
the
illegal
market
and
the
practice
of
mixing
drugs
with
other
toxic
chemicals
raises
additional
concerns
about
the
harmful
aects
to
the
infant.
Milk
production
may
suer
due
to
decreased
maternal
appetite
and
resulting
poor
nutrition,
common
side
eects
of
methamphetamine
use.
National
Institute
on
Drug
Abuse,
2002
68
evaluation
Provide improved stimulant trainings for service providers Investigate the local impact of stimulant use on risk behaviors Create drug specic and population specic messages for women
Create
partnerships
69
70
Women often do not know how to inject themselves, relying on others to inject them. The reasons for this are both biological and social, and include: Women sometimes have a dicult time nding a vein - as they usually have low mussel mass and less pronounced veins Women are often introduced to injection by men, and never learn how to inject themselves The stigma attached to drug use among women Issues of sexism, control, power and abuse
71
Those
who
Don t
KNOW
HOW
to
Inject
Themselves
Are
Especially
Vulnerable:
Risk
of
HIV,
HEP
C
Overdose
Physical,
Sexual,
and
Emotional
Abuse
72
73
Harm Reduction Strategies for Women Who Inject Drugs Women who inject drugs need to be separated from male partners, friends and/or running buddies, early in engagement. Sta should determine if a female client knows how to self inject All female IDUs should know how to inject themselves. Instruction in safer injection techniques should be provided.
74
75
The disinhibitory nature of methamphetamine makes it an appealing tool to aid sexual activities. Many use methamphetamine to enhance senses, increase energy and stamina, increase condence, and reduce anxiety, making sex more fullling.
76
Feeling sexier, more attractive, virile Having more vivid sexual fantasies Prolonging sexual play Prolonging erection Delaying orgasm
77
Considerations
Some
users
report
plain
old
sex
is
boring
Some
users
report
they
couldn t
have
sex
without
methamphetamine
Methamphetamine
may
increase
condence
while
lowering
inhibitions
Users
may
give
in
to
impulses
that
may
result
in
at-risk
behavior
Increased
risk
of
STDs
78
Impotence Increasing Paranoia, Psychosis Increasing use of fantasy into reality Disconnect from intimacy Total sexual objectication
79
80
Users should be reminded to periodically check for blood Users must feel comfortable discussing their sex lives with sta Who ELSE do the have to TALK with?
81
Considerations: Fluids
82
If users choose to drink alcohol while using, recommend they also drink
83
84
Concerns: tooth decay, gum problems, bone loss, tooth loss Users experience - dry mouth - which sets up a perfect environment for bacteria to grow (such as cavities and infections). Although there is a lot of information that says ice or ya ba is what causes oral problems, it is actually the dry mouth and dehydration that cause it. To prevent this problem you have to make an active choice to keep your mouth and body hydrated. Preventing oral problems means you need saliva. Without saliva your mouth cannot properly break down bacteria or help digest food. It all starts in the mouth. Tips to prevent oral problems are sucking on something sugar free, chewing sugar free gum, spraying your tongue with a squirt bottle, swish and spit after smoking, and brush/oss regularly.
85
Considerations: Sleep
86
They take some "down time" during their high to relax and be quiet from constant activity. This may take some self-training" until it becomes a habit Sometimes short naps can take the rough edges o a high Do they have a place to sleep when they need to? If their own home isn't an option, what about a friend's place? Recommend they don't mix depressants with methamphetamine. Using opiates, sleeping pills, or tranquilizers to come down can cause serious eects on one s heart and blood pressure. Sleeping for a few hours here and there signicantly reduces the crash.
87
Considerations: Appetite
88
Users
lose
their
appetites.
Sometimes
they
can
become
so
focused
on
another
activity
they
may
forget
to
eat
This
often
results
in
users
become
malnourished.
This
is
a
very
big
health
issue
for
stimulant
users
living
with
HIV,
TB
and
other
chronic
health
problems
Of
course,
it
is
dicult
to
get
users
to
eat
when
they
are
using
Remember,
women
use
methamphetamine
to
lose
weight.
Being
too
thin
can
be
unhealthy.
Also,
eating
a
little
bit
here
and
there
signicantly
reduces
the
crash.
89
90
Long-term, heavy alcohol use weakens the immune system. Other drugs may do the same, but more research is needed to know whether they do for sure. It s also not clear whether drug use causes HIV to progress faster.
91
Drug
use
may
increase
an
HIV+
person s
chances
of
getting
colds,
u,
sore
throats
and
other
infections
Alcohol
weakens
the
eects
of
some
antibiotics
and
antiviral
drugs
and
may
lead
to
oral
candida
(thrush)
methamphetamine
decrease
appetite,
possibly
leading
to
weight
loss
92
The symptoms of infections related to HIV can be mistaken for problems caused by drug use, and that confusion can interfere with the early diagnosis of illnesses related to HIV. What about HIV medications? Missing or changing a dose of HIV medication may allow resistance to develop. Users should plan ahead if they re going to be away from their pills Using can interfere with regular eating, and medications meant to be taken with food can be less eective if not taken properly
93
What
About
Drug
interactions?
Very
little
is
known
about
the
interactions
between
HIV
medications
and
methamphetamine.
It
is
know
that
mixing
the
two
can
change
the
eects
of
the
methamphetamine
and
reduce
the
medication s
eectiveness.
The
group
of
HIV
medications
called
protease
inhibitors
(PIs)
-
ritonavir,
indinavir,
nelnavir
and
saquinavir
-
aect
certain
enzymes
in
the
liver
This
can
cause
increased
levels
of
methamphetamine
in
the
body,
possibly
94
Most of the known interactions involve PIs, especially ritonavir. Other PIs don t seem to aect liver enzymes as much. Still, it s best to avoid using methamphetamine during the rst six to eight weeks of starting any new PI to allow the body to adjust. In theory, many of the medications taken could interact with recreational drugs. More research is needed to know whether they do for sure.
95
Considerations: Hepatitis C
96
Relatively
few
studies
have
looked
at
rates
of
HCV
infection
among
methamphetamine
users.
However:
Injection
drug
use
accounts
for
nearly
70
percent
of
acute
and
60
percent
to
90
percent
of
all
chronic
HCV
infections
HCV
transmission
is
primarily
facilitated
by
drug-sharing
practices
With
the
growing
prevalence
of
injection
of
methamphetamine
in
Thailand,
providers
should
incorporate
HEP
C
education
and
testing
within
their
stimulant
programs.
97
98
Polydrug
use
is
the
use
of
more
than
one
drug
at
the
same
time
-
that
is
mixing
drugs
together
Statistically,
polydrug
use
dramatically
increases
the
risks
of
harm
to
the
user,
impacting
on
their
physical
health
and
emotional/
mental
health.
Poly
drug
use
appears
to
be
common
among
methamphetamine
users
in
Thailand.
99
When methamphetamine is used with: Alcohol. Health risks increase because alcohol impairs thermal regulation and increases dehydration Alcohol. The combination may be more directly toxic to the heart and liver than either methamphetamine or alcohol alone Opiates and/or other Depressants. Methamphetamine often overpowers their eects. Mixing these can result in an overdose once methamphetamine wears o
100
Possible Risks
Cross addiction Users may not be aware of the harms of associated a drug that is not their drug of choice Recommendations Inform clients aware of the risks associated with poly-drug use
101
Considerations: Psychosis
102
Psychosis?
Psychosis is a loss of contact with reality, usually including false ideas about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations). In the general sense, psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. In a specic sense, it refers to a thought disorder in which reality testing is grossly impaired. Methamphetamine induced psychosis is usually symptomatic of use not chronic mental illness. If you have questions or concerns confer with a specialist.
103
Psychosis?
Most
acute
methamphetamine
related
problems
are
perhaps
best
understood
as
exaggerations
of
the
desired
eect
-
intoxication
Heavy
users
commonly
exhibit
substantial
levels
of
anxiety
and
paranoia.
Typically,
the
symptoms
do
not
reach
the
level
of
psychosis,
but
thinking
is
impaired,
and
users
experience
considerable
anxiety.
Care
should
be
taken
when
working
in
such
situations.
A
very
nonaggressive,
non-confrontational
counseling
approach
should
be
used
to
avoid
exacerbating
a
users
anxiety
and
fearfulness.
104
Psychosis?
There
are
many
possible
causes:
Brain
tumors
Dementia
(including
Alzheimer's
disease)
Epilepsy
Manic
depression
(bipolar
disorder)
Psychotic
depression
Schizophrenia
Stroke
And,
alcohol
and
certain
drugs
105
Psychosis?
106
107
Transition
Smoking
is
associated
with
less
severe
methamphetamine
dependence
than
injecting,
but
more
intense
use
patterns
and
similar
levels
of
other
harms.
Education
or
product
information
for
methamphetamine
users
needs
to
make
clear
the
safer
routes
of
administration
and
the
harms
associated
with
snorting,
smoking
and
injecting.
Transition
from
other
forms
of
administration
to
injecting
should
be
a
key
focus
of
services,
particularly
in
the
rst
12
months
of
smoking.
Once
the
transition
is
made
to
injection,
users
rarely
return
to
other
routes
of
administration.
Advice
about
the
risks
of
smoking
and
injecting
may
help
to
reduce
the
transition
to
injecting.
108
Transition
There are two approaches that have been developed to prevent noninjecting drug users from transitioning to injection.
One
is
to
identify
non-injecting
drug
users
-
at-risk
users
-
and
intervene
with
them
to
reduce
their
propensity
to
adopt
injecting. The second focuses on the gatekeeper role that current injectors play and seeks to reduce their influence on non-injecting drug users
109
110
111
Eventually,
a
user
runs
out
of
drugs
-
or
the
body
runs
out
Then,
a
user
starts
to
come
down
or
crash .
For
some
users
this
is
a
not
a
problem.
Many
methamphetamine
users
have
little
diculty
dealing
with
this
inevitable
period
of
their
use.
For other, this can be a dicult time, especially if the use was heavy or extreme. It s quite common for users to use alcohol, pills, cannabis and/or opiates to help ease the crash, which increases their harm.
112
113
Techniques
that
can
help
a
user
feel
more
comfortable
during
the
crash,
include:
Meditation
and
focusing
helps
relieve
the
negative
thoughts
Focusing
on
music
Watching
TV
Reading
comics
Doing
puzzles
Masturbation
Playing
cards
Games
Or
a
walk
?
114
Suggest they keep their surroundings calm They should eat foods high in carbohydrates, high in calories and low in protein. This will help them relax and get to sleep They should be drinking plenty of uids 1. Remind them to remember these feelings will pass 2. That the crash means they are coming down o of the drugs 3. Remind them to avoid making life changing decisions
115
s home A squat Near an agency? Tweeker Rooms Some agencies set aside dedicated space for users to crash in
Note: Homeless youth often use methamphetamine to stay awake at night to avoid placing themselves at risk. They crash during the day in parks, HR agencies, or other sites where youth may safely congregate.
116
Users become anchors for one another They do this for love, drugs, compassion many reasons What does an anchor do? Talks the other person down Gets the other person to sleep Talks, listens and remains calm
117
118
Most acute stimulated related problems are perhaps best understood as exaggerations of the desired eect - intoxication
119
APT describes an individual who has toxic or poisonous levels of methamphetamine in their system. Due to the eect of methamphetamine, possibly in combination with other factors, individuals may not respond to calming or directive communication. Consequently, incidents may rapidly escalate and life-threatening physical complications of methamphetamine toxicity may manifest. APT is a MEDICAL EMERGENCY and these guidelines recommend appropriate responses.
120
Acute Psychostimulant Toxicity (APT) is not the same as an opiate overdose. There are no medications that can quickly and safely reverse a stimulant overdose (APT).
121
Stay calm and positive. Use a consistently even tone of voice. Allow the individual as much personal space as possible. If the individual is paranoid or aggressive, make eye contact only
occasionally.
122
Assessment Step - Assess the cause of the individual s distress. Is it A or B? A) Mental Distress: Resulting from one or more of the following: Sleep depravation Anxiety Crashing Negative Thinking Paranoia
B) Physical Distress (APT): Physical signs and symptoms include: Limb jerking or rigidity Rapidly escalating body temperature Alteration in level of consciousness Severe agitation Severe headache Racing pulse Chest pains Sever sweating
123
Action
Step
For
Assessment
A)
Mental
Distress
(A)
If
you
are
condent
that
the
distress
is
not
medical
in
nature,
and
is
not
APT,
you
should:
u
Have
the
person
drink
lots
of
water.
u
Place
cool,
wet
cloths
under
the
armpits,
on
back
of
knees,
and/or
on
the
forehead.
u Open a window for fresh air. u Keep them comfortable and relaxed. Suggest they close their eyes. u Remain patient, kind, and supportive. u If necessary, administer a benzodiazepine (Small dose).
124
125
Physical Distress Including symptoms such as Limb jerking /rigidity escalating body temperature Alteration in level of consciousness Severe agitation Severe headache Racing pulse Chest pains sweating
Mental Distress resulting from Sleep depravation Anxiety Crashing Negative Thinking Paranoia Note: Severe Mental Distress may require medical intervention
127
Client self-reports having unprotected sex while using methamphetamine Sta discusses Harms associated with risky sexual behavior Use of latex barriers and lubricant Checking condoms for tears during marathon sexual encounters Safer sex negotiation
128
Client self-reports experiencing or seeing stimulant overdose/toxicity Sta discusses Discuss methamphetamine overdose prevention and response
129
Client self-reports an increase in sexual desire while using methamphetamine Sta discusses Discuss condoms and lubricant Discuss the importance of checking condoms for tears during marathon sexual encounters Discuss safer sex negotiation
130
Sta can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Arm The Client s Statements I think its great that you're willing to be honest with yourself and take time to look at your level of risk."
131
Sta can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Reframe You're concerned about your level of risk, but you can't see yourself being celibate, either."
132
Sta can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Roll With Resistance "You're jumping ahead a bit here. Right now, we're just getting a sense of where you are regarding using methamphetamine and unsafe sex behaviors. Later on, we can talk about what, if anything, you want to do about it."
133
Sta can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Elicit Self-Motivational statements "What do you want to do about this," "Tell me why you think you might need to make a change."
134
Sta can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example:. Elicit Self-Motivational statements Client: "I guess I didn't realize how many people I had sex with since I've been on this run." Sta: "What do you make of this?"
135
Increasing a client s knowledge of the behavioral risks associated with the use of methamphetamine can also be a motivational strategy. For example: Client Expresses Interest In Injecting methamphetamine Sta provides the client with information on how injecting increases the risk of harm from substance use
136
Help clients develop personalized plans to avoid harm and maintain safety before getting high. For example: The essential message of eat, drink water and sleep should be relayed as meeting these needs will help the body withstand highs, ease crashes and delay the onset of paranoia.
137
138
Key
Issues
A replacement therapy for methamphetamine has not been developed More research is needed to develop evidence-based practice Specialized treatment approached need to be developed for specic populations
What Works? interventions with the strongest empirical support use cognitive behavioral techniques
139
Key
Issues
Very
little
treatment
is
available
for
stimulant
users
in
most
of
the
world.
This
is
due
to:
Bad
drug
policy
Lack
of
resources
Misappropriation
of
resources
Lack
of
information
Exaggeration
of
the
eects
and
harms
of
methamphetamine
The
demonization
of
stimulant
users
140
When Someone Is Cutting Back or Trying to Stop Using It takes about 12 days from the last use for the brain chemistry and body systems to get back into normal mode. Cutting back the frequency of use may be the way to go. Cutting down frequency can mean lengthening the time between use the more time you take o from methamphetamine use the better for your body and mind.
141
Cutting
Back
Maybe
the
user
can
extend
the
time
between
injections?
Wait
1
hour
this
time
then
2
hours
the
next
time
and
so
on.
Ask
friends
who
don t
use
to
do
stu
with
on
days
they
usually
use.
Periodically
but
regularly
breaking
the
pattern
may
lead
to
less
frequent
use.
Plan
use-free
weekends.
Make
commitments
with
other
people
so
they
are
less
likely
to
change
their
mind
and
get
high.
142
143
Acknowledgments A special thank you to all drug users who consulted on this project. Very special thanks to Dr. Carl Hart, Dr. Patricia Case, Dr. Michael Siever, Dr. John Morgan, Phillip Fiuty, Paul Dessauer, and the International Harm Reduction Project of the Open Society Institute
The End Thank you very much for your attention and contributions!
144