cohealth’s response to the Commonwealth Government inquiry into ice use in Australia recommended a harm minimisation approach to addressing ice alongside increased engagement with people using the substance to capacity amongst this population group.
Harm reduction has been the overall policy framework for alcohol and drug services since the 1980s and the program response has seen many thousands of lives saved as a result of community and user education, needle and syringe programs and diversion programs. As the ongoing policy of the Australian Government it would be expected that the Taskforce’s report continues to embrace harm reduction in framing recommendations and future work.
Methamphetamine does not damage in isolation, rather harm can be increased through the impact of many factors. These factors may result from or contribute to poor self-management and drug use in the first instance. These factors can also include access to secure housing, strong personal relationships and networks, ability to participate in employment, training or education, and access to health services or support when required.
It is also clear that some of the harms associated with methamphetamine can be mitigated through user education and appropriate use strategies. These strategies include encouraging users to sleep, eat and drink water regularly and encouraging them to use in a safe environment with people that they know and trust.
From the understanding and experience gained through implementation of the harm reduction approach we know it is the most effective way to reduce harm and illness as a result of the impact of alcohol, licit and illicit drugs.
The challenge of methamphetamine use is that it requires us to understand how harm reduction can be delivered across the service and support spectrum as the nature of harms may be different. This is particularly the case for long term mental health impacts as a result of chronic long term use and in some instances casual use.
In October 2014 cohealth conducted three facilitated discussion groups with regular methamphetamine users to explore their personal experiences. Groups were held in Collingwood, Footscray and Braybrook and recruited from Needle and Syringe Program attendees in those places.
Following is the presentation that was given to a conference based on the findings of this consultation.
Three questions were put to each group for general discussion:
From all workshops, participants identified safer using strategies such as:
There is no doubt that methamphetamines have great destructive potential. There is evidence that it can have long term health consequences, though this is not the case for all users. For those using occasionally or irregularly there may be little long term or ongoing impact. This of course will vary from person to person with underlying illnesses / conditions being relevant.
Service users report a history of trauma from early childhood neglect, physical and sexual abuse and limited education, many have undergone prison sentences related to drug use. They also report a high level of polydrug use – both opiates and stimulants, these practices require increased flexibility from the alcohol and drug treatment sector.
Different population groups have varying service response requirements – this is core to the understanding that drug use occurs within the context of the user’s life. This requires a commitment to respecting the human rights of people who use drugs and ensuring that they are not subject to discrimination as a result. The stigmatisation of people who use drugs results in increasing isolation within the community, lower levels of engagement with support services and greater harms done to themselves and the broader community as a result. .
For people who are Aboriginal and Torres Strait Islanders issues of grief / loss and related mental health issues play a specific role, which when combined with lower health service access can increase harm and result in poorer self management – increasing risks for the broader community. For lesbian, gay, bisexual or transgender people in addition to traditionally lower levels of service access and higher levels of mental illness the use of methamphetamine as a party drug can exacerbate risk taking behaviours which have flow on health impacts.
It is of note that the service presence of refugees and asylum seekers is increasing, though not necessarily among recent arrivals (last 1 or 2 years), rather as a result of settlement failure over the previous decades. This is particularly prevalent among young men who are experiencing housing insecurity, low rates of employment, disengagement with education / training and detachment from their cultural communities.
Across these groups the diverse needs and relatively low engagement with the health service system generally may require additional formats of service delivery and understanding how to engage with these populations.
The existing service system for people who inject or use illicit drugs was set up to deal with opiate based drugs. The impact of these drugs on health outcomes, on user behavior and experience and the possible harms to be minimised have different characteristics. Risk taking behaviours can be made worse as a result of long term use and poor self management – this plays out for example through long periods of alcohol use without sleep and food. Sleep deprivation alone can have significant behavioural impacts.
Current primary health services for people who use drugs have developed mainly for people who inject drugs. This is historically the result of the development of the Needle and Syringe Programs to reduce the spread of blood borne viruses and the associated development of primary health services that flow from this. As a result the targeting for many of these services is people who inject drugs.
There are a number of administration methods for methamphetamine with little evidence that harm, risk taking or self-management issues vary depending on the method (smoking, injecting, snorting etc). It is clear that different modes of administration involve different risks and therefore responses. Across population groups there may be different modes that have prevalence and support for users needs to give consideration to this.
This requires greater investment in additional community based health services is required to improve capacity to support people who use drugs, rather than just people who inject drugs. This additional investment is required to provide a better service response to a broader population.
The service continuum should be built on the recognition that there is great diversity in the experiences and pathways for people who use methamphetamine and this requires a diverse range of service responses.
There are those for whom methamphetamine is a substitution drug for other substances (for example other stimulants or heroin) and the use forms a continuation of substance use. While there are many within this cohort who are fully engaged in employment, education and have secure housing there is a sub-cohort for whom attention to whole of life conditions may require attention to support safe use acknowledging that factors such as housing, employment, experience of abuse / violence, or access to education and community networks require consideration. The service response for this latter group is of necessity likely to require specialist skills / and be delivered through the existing network of primary health services for people who use / inject drugs.
People who use methamphetamine report that there are not many services that were particularly effective in engaging them. They also indicated that many of the information resources that were used were identified as either being informal or not specifically focused on addressing methamphetamine use. In discussions with people who use methamphetamine there was a level of frustration that much of the service response was focused on issues that they have not actually experienced and there has been little engagement around the actual harms that they identified. This appears to be a reference to the focus on the very acute ‘psychotic violent’ behaviours that get highlighted through media; rather than on the varying and lower level harms which with support / advice / engagement can be managed appropriately.
The most significant population of users includes people who use substances only irregularly or occasionally. For the latter, more ‘social’ group of users entry to use may be a result of peer engagement or be opportunistic as a result of the social environment – there will be many reasons that could exist that will bring someone to the point where they decide to use a substance – licit or illicit for the first time. Though there will be exceptions this group are likely to feature users who are still engaged with employment, education and have secure housing and social networks. The service response for this population is likely to be facilitated through mainstream health services.
Mainstream capacity building is particularly important for this population of users as their use has been described as starting off ‘socially’ and so people neither regard themselves as requiring a specialist service response and are not likely to access specialist services, rather they may seek advice through anonymous forums (for example online) or general practitioners or other primary health services.
This requires additional attention and capacity building within the mainstream health service system so that advice and education can be given to support this user group to maintain good health, reduce harm and risk taking, improve self management and lower the potential for use to move from occasional / irregular to chronic and ongoing – where the risk of harm is greater.
One of the key learnings from decades of experience in service delivery for people who use drugs is the importance of engaging and training a peer workforce to deliver education on harm reduction and options available for support.
The peer workforce generally appears to have more experience in the opiod substance range and so further development and eduction of the peer workforce will improve safety of users and the community – through better self-management and allow a better earlier more relevant form of support.