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Concerned about your own or
someone else’s drug use?

The National Alcohol and Other Drug Hotline

For free and confidential advice about alcohol and other drugs, call the National Alcohol and Other Drug hotline: 1800 250 015. It will automatically direct you to the Alcohol and Drug Information Service in your state or territory. Click here for more information

Counselling online

An online text-based counselling for people concerned about their own drinking or drug use. The service is equally available to people concerned about a family member, relative or friend. Click here for more information

Cracks in the ice

An online toolkit providing evidence-based and up-to-date information and resources about crystal methamphetamine (ice) for the Australian community. Click here for more information

Methamphetamine (Ice)

A clinical guide for Primary Care Health Professionals

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About Methamphetamine

Methamphetamine is a psycho-stimulant drug available in powder, paste or crystalline form and is typically snorted, smoked or injected.

In 2019, of Australians aged 14 or over who reported using methamphetamine in the previous 12 months, 50% reported using the ‘crystalline’ form (“Ice”) of the drug, of whom 30% were using at least once a week or more1 .

Methamphetamine is a powerful central nervous systems (CNS) stimulant that can induce feelings of euphoria, alertness, increased confidence and wakefulness. Acute effects can last for 8-24 hours.

Repeated use of methamphetamine may cause significant depletion of CNS neurotransmitters, accompanied by depression, excessive tiredness and fatigue.

Did you know?

Meth, Ice, Crystal, Shabu, Tina and Glass refer to the crystalline form, which is of highest purity.

Start the Conversation

People who use methamphetamine may present initially with sleep problems, anxiety or low mood/depression.

Consider asking about stimulant use when assessing sexually transmitted infection and blood borne virus risk, or working up hypertension and cardiac disease, particularly in a young person.

You could ask…

As your GP/Healthcare worker, I am concerned about all aspects of your health, such as nutrition, physical activity, weight, smoking, alcohol and drug use. Is it ok if I ask you about these things?

Assessment of Drug Use

Methamphetamine is often used in conjunction with other drugs. A substance use history is vital to identify the most appropriate management.

Understanding the context of your patients’ drug use will inform an appropriate plan of care.

Did you know?

In Australia, among people who report recent methamphetamine use, 74% use canabis and 73% engage in risky drinking1.

Start by asking the patient:

  • If they currently take, or have ever taken pharmaceutical drugs such as opioids or benzodiazepines?
  • Do they smoke tobacco? Do they vape? Do they smoke anything else?
  • Do they have any concern/have they had any problems as a result of their alcohol, smoking, medication or drug use?
  • Have they ever used stimulants?
  • What type of stimulant they are using e.g pills, powder, base or ice; and how they are administering it – oral, nasal, smoked, injected?
  • How much are they using? How regularly? When did they last use?
  • At what age did they start using methamphetamine, when did they start using it regularly and when did they start this route of administration?
  • Have they had any periods of abstinence? If so, were there any precipitating factors that caused a relapse? What interventions or previous treatments did they use during these attempts?
  • Are there any other drugs that you want to talk about e.g. GHB, sleeping tablets, benzodiazepines….?

Did you know?

Other forms of methamphetamine include Base (a waxy substance, known as Pure, Point or Wax, which is medium to high potency) and Speed (a powder, which is now almost always methamphetamine and is of lowest purity)2,3.

Consider using the eASSIST-Lite ultra-rapid screening tool (Age 18+)4,5

Ask the following…

  • In the last 3 months did you use an amphetamine-type stimulant, or a stimulant medication not as prescribed?

  • In the last 3 months did you use a stimulant at least once each week or more often?

  • In the last 3 months has anyone ever expressed concerns about your use of a stimulant?

A score of 2 or more strongly suggests stimulant use disorder

Effects of Methamphetamine Use

Asking your patient to reflect on the negative effects of methamphetamine use can lead into discussions on level of risk and readiness to change.

Adverse effects include but are not limited to:

  • Anxiety
  • Low mood
  • Weight loss
  • Poor appetite
  • Hallucinations
  • Agitation
  • Sleep problems
  • Teeth grinding
  • Paranoia

The reasons a patient uses methamphetamine may impact where, when, how much and how often they use it.

Desired effects include:

  • Euphoria
  • Increased confidence
  • Increased concentration
  • Increased focus
  • Ability to stay awake for longer periods

Assessment Types

1

Stimulant-specific Health Assessment

2

Social Situation Assessment

3

Mental Health Assessment

1 Stimulant-specific Health Assessment

Neurological

Acute Toxicity can present with tremor, sweating, dilated pupils, agitation, confusion, anxiety, seizures, hallucinations and serotonin syndrome. Chronic CNS hyperstimulation can lead to frequent headaches, tremors, choreoathetoid movements and seizures, irritability, apathy, depression, anxiety, insomnia, increased impulsivity and impaired judgement.

Dermatological

Injecting can be associated with skin abscesses. Very heavy daily use can be associated with delusion of parisitosis or formication, causing compulsive scratching and risking skin lesions and bacterial cellulitis.

Respiratory

Smoking methamphetamine can lead to respiratory problems, lung damage and disorders such as pulmonary oedema, bronchitis, pulmonary hypertension and granuloma6.

Cardiovascular

Acute Toxicity is associated with narrow-complex tachycardias, palpitation, systemic hypotension or hypertension and dyspnoea as well as haemorrhagic strokes in young people. Chronic use is associated with chronic hypertension, aortic dissection, acute coronary syndromes, pulmonary arterial hypertension and methamphetamine-associated cardiomyopathy and strokes.

Hepatic

Acute kidney injury, rhabdomyolisis and acute liver injury including hepatic necrosis, has been reported, even in the absence of hepatitis7.

Dental/Oral Health

Severe tooth decay, oral soft­ tissue inflammation and breakdown is reported. Although evidence suggests this is largely due to lifestyle factors associated with drug use, such as malnourishment8, 9.

Sexual and Reproductive Health

Methamphetamine use has been associated with increased transmission of sexually transmitted infections10. In women of reproductive age, long-term use of methamphetamine can cause irregular menstruation11, which may result in unplanned pregnancy. Psychostimulants can cross the placental barrier to affect the foetus during gestation, and may also be present in breast milk. Women who use methamphetamine regularly are advised not to breastfeed.

Consider the following

2 Social Situation Assessment

Understanding your patients family and social situation is important when working with your patient to make changes in relation to their methamphetamine use, and can help with identifying factors which would benefit from a referral to external agencies (such as housing or other social services etc.)

Did you know?

Methamphetamine is typically measured in ‘points’ (1 point is 0.1 of a gram), ‘grams’, or money (1 point is approximately $50, 1 gram is approximately $30012).

Ask Questions

Ask the following…

What is your main social support? Are they aware of your drug use? Do you usually use drugs alone or with others?

Have you ever experienced any type of abusive behaviour (e.g physical violence, sexual assault, emotional abuse, social or financial control) from a current or previous partner family or friend? If so, have you ever received treatment or engaged with services about these issues?

If a carer for children, do you feel your drug use is having any impact on your parenting? Where are you living? Do you feel safe?

Are you currently involved with any other services? (e.g counsellor, social services, case management)

Are you working or studying? If so is your drug use having an adverse effect on these commitments?

3 Assessment of Mental Health

Mood and anxiety disorders may coexist with methamphetamine use disorder, and may be pre-existing, exacerbated by or induced by methamphetamine use.

Methamphetamine-induced depressive disorders or anxiety are characterized by prominent disturbance in mood and panic attacks, causing significant distress and impaired functioning.

Mood disorders that are pre-existing will require different treatment planning, to prevent potential interactions and relapse. There is the potential for drug interactions, and symptoms can be exacerbated by lack of sleep or the drug.

Methamphetamine-associated psychosis is typically transient, but can present as misperception, hallucinations, extreme agitation, delusions, suspiciousness, and paranoia.

Consider using...

  • The Kessler Psychological Distress Scale (K10)13 as a brief screening tool for measures of mental health symptoms in the past 30 days.
  • The Psychosis Screen14 if you suspect psychotic symptoms.
  • A general psychiatric history to assess if your client requires referral to a mental health service.

The screening tools linked above are subject to copyright with acknowledgement to the authors

Management

Many patients may not define their methamphetamine use as problematic. Consider assessing the persons readiness and motivation to change.

1
Precontemplation
2
Contemplation
3
Preparation
4
Action
5
Maintenance

Stages
of Change

(Prochaska and DiClemente, 1992)

Ask Questions

Ask the following…

On a scale of 1-10, how worried are you about your methamphetamine use?

How important is it for you to make changes to your use?

Why did you give these scores?

What would it take for your score to go up or down?

Studies show that 1/4 to 1/2 of Methamphetamine users would like to reduce their use, rather than abstain. Motivational interviewing techniques and tools such as ‘The stages of change’15 can be used as a guide to monitor engagement.

Harm reduction education and interventions can be provided at any stage.

Harm Reduction

  • Encourage engagement with health services
  • Discuss safer sex, e.g. condoms, lubricant and PrEP/PEP
  • Discuss safer injecting techniques and provide advice on local Needle & Syringe Programs (NSP’s)
  • Encourage eating at least one meal per day
  • Encourage adequate hydration
  • Advise patients to plan how much they will use and tell a friend they trust what their plans are
  • Advise patients to try and get some sleep daily, and if not possible, to rest in a darkened room for a few hours each day
  • Warn about the danger of overdose if taking alcohol, opiates and benzodiazepines to help with sleep
  • Encourage patients not to drive when using methamphetamine

Overdose Advice

Signs of methamphetamine overdose include severe headache, psychotic symptoms, chest pain, vomiting, overheating and extreme agitation.

Patients should be advised to call triple zero (000) and ask for ‘AMBULANCE’.

The police will not be called unless they are at risk of danger. Demonstrate the recovery position and give advice on when it is appropriate to perform CPR.

Discussing Treatment Options

Stimulant Use Disorder16  (which includes amphetamine-type substances such as methamphetamine) is defined as a pattern of amphetamine-type substance, cocaine or other stimulant use leading to clinically significant impairment or distress, as manifested by at least 2 of the following in the past year:

  • Using larger amounts or over a longer period than intended
  • Persistent desire to cut down
  • A great deal of time spent obtaining the drug or recovering from use
  • Strong desire of craving to use
  • Failure to fulfil major work, home, educational roles
  • Continued use despite persistent or recurrent physical or psychological problems caused or exacerbated by use
  • Important social, occupational, or recreational activities are given up or reduced because of stimulant use
  • Recurrent stimulant use in situations in which it is physically hazardous
  • Continued use despite knowledge of physical or psychological problems known to likely be caused or exacerbated by the stimulant
  • Tolerance as defined by either needing markedly increased amounts of methamphetamine for the desired effect, or a diminished effect with use of the same amount of methamphetamine
  • Withdrawal, as manifested by the characteristic withdrawal syndrome (as outlined below) or the stimulant is taken to relieve or avoid withdrawal symptoms

Set realistic treatment goals with your patient. Some individuals may feel that a goal to control their use is more achievable than abstaining. In this instance harm reduction advice and brief motivational interviewing may be appropriate.

Consider using the Severity of (Methamphetamine) Dependence Scale (SDS)17

  • Did you think your methamphetamine use was out of control in the past week?

  • During the past week, did the prospect of missing a hit/dose of methamphetamine make you anxious or worried?

  • Did you worry about your use of methamphetamine in the past week?

  • Did you wish you could stop using methamphetamine in the past week?

  • How difficult did you find it to stop, or to go without methamphetamine in the past week?

A score of 4 and above is indicative of clinically significant dependence19.

Treatment planning and withdrawal care

Treatment planning

People who are dependent on methamphetamine (score of 4 or greater on the SDS) and/or people who use regularly may experience a typical withdrawal syndrome on cessation or reduction of use, and will benefit from support and symptomatic treatment of the withdrawal period. Withdrawal itself is not a treatment and does not change substance use outcomes. Attempts at reducing or ceasing methamphetamine use are marked by profound cravings and high rates of lapse and relapse. Post-withdrawal treatment planning should begin at commencement of a supported withdrawal episode to entrench lasting change and recovery. This includes:

  • Assessment and treatment of co-existing conditions
  • Addiction counselling
  • Support groups
  • Residential rehabilitation
Crash
  • Can occur after cessation of use even in those without methamphetamine dependence/severe methamphetamine use disorder
  • Usually 12-24 hours post last use
  • Chacterized by: exhaustion and fatigue, dysphoric mood, anxiety, agitation, cravings and non-specific aches and pains
  • Symptoms typically persist for 2-3 days18,19.
Acute
  • Peak withdrawal symptoms will likely occur within the first 7 days
  • Characterized by: mood fluctuations, restlessness, irritability, anxiety, agitation, poor concentration, increased appetite, muscle tension and fatigue.
  • Disturbance of thought (e.g. psychosis, paranoia, delusions) and perception (e.g. auditory hallucinations, misperceptions) may emerge throughout this phase20.
Sub-Acute
  • Can last for weeks to months
  • Characterized by episodic fluctuations of mood, levels of craving and quality of sleep20.

Methamphetamine Withdrawal

Methamphetamine withdrawal occurs upon cessation, or reduction in dependent, prolonged and/or heavy use. Withdrawal is generally more protracted than for other drugs and is characterized by three distinct phases: Crash; Acute; Sub-Acute18

Notes

There is currently no evidence-based pharmacotherapy for withdrawal management and medicines should be used in conjunction with supportive care strategies to manage withdrawal. Benzodiazepines should not be prescribed for more than 3 to 7 days due to risk of dependence.

Antidepressants may be indicated for symptoms of depression that persist after stimulant withdrawal (although this may take several weeks or months to determine). Psychiatric assessment and a treatment plan that includes counselling should be considered.

  • Mild psychosis can be managed with short-term (up to 7 days) prescription of antipsychotics e.g., Olanzapine 2.5-5mg PO prn TDS.
  • Anxiety can be treated with short-term (up to 7 days) prescription of benzodiazepines e.g., Diazepam 5-10mg QID prn.

Assess carefully for risk of withdrawal from other substances as methamphetamine use disorder may coexist with other substance use disorder (including benzodiazepines, GHB, alcohol, z-drugs).

Withdrawal care

Withdrawal can usually be managed as an outpatient, however if there are medical or psychiatric co-existing conditions (and/or pregnancy), inpatient management may be indicated.

Withdrawal care involves:

  • Education and coping techniques for withdrawal symptoms (eg relaxation techniques, sleep hygiene, advice regarding diet).
  • Education regarding the nature of cravings and strategies for coping with them during withdrawal.
  • Specific strategies for addressing agitation, anger and sleep disturbances.
  • Frequent orientation, reassurance and explanation of procedures to clients with thought or perceptual disturbances.
  • Crisis intervention, addressing accommodation, personal safety or other urgent welfare issues

 

If managing withdrawal in the community setting, provide ongoing support and consultation in your practice

Advice & Treatment

Getting into drug treatment can reduce the risk of dying from an overdose. Call the National Alcohol and other Drug Information Service (ADIS) on 1800 250 015.

You will be automatically directed to the ADIS State or Territory you are calling from.

Need Help? Call ADIS on:

1800 250 015

Further Information & Resources

For Health Professionals

For Clients

References

  1. Australian Institute of Health and Welfare 2020. National Drug Strategy Household Survey 2019. Drug Statistics series no. 32. Cat. No. PHE 270. Canberra: AIHW
  2. McKetin, R. NDARC Fact Sheet: Methamphetamine, 2016. Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2008_011.pdf
  3. National Drug and Alcohol Research Centre. Methamphetamine: forms and use patterns, 2015. Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2006_001.pdf
  4. Ali, R., et al., Ultra-rapid screening for substance use disorders: the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-Lite). Drug Alcohol Depend, 2013. 132(1-2): p. 352-61
  5. World Health Organisation. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).< Accessed online 24th October 2019 from: https://assistportal.com.au/eassist-lite/>
  6. Rose, M.E. and J.E. Grant, Pharmacotherapy for methamphetamine dependence: a review of the pathophysiology of methamphetamine addiction and the theoretical basis and efficacy of pharmacotherapeutic interventions. Ann Clin Psychiatry, 2008. 20(3): p. 145-55.
  7. Kamijo, Y., et al., Acute liver failure following intravenous methamphetamine. Vet Hum Toxicol, 2002. 44(4): p. 216-7.
  8. Werb, D., et al., Methamphetamine use and malnutrition among street-involved youth. Harm reduction journal, 2010. 7: p. 5-5.
  9. Shetty, V., et al., The relationship between methamphetamine use and increased dental disease. J Am Dent Assoc, 201 O. 141 (3): p.307-18.
  10. Shoptaw, S. and C.J. Reback, Methamphetamine use and infectious disease-related behaviors in men who have sex with men: implications for interventions. Addiction, 2007. 102 (1): p. 130-5.
  11. Wen-Wen, S., et al., Long-term Use of Methamphetamine Disrupts the Menstrual Cycles and Hypothalamic-Pituitary-Ovarian Axis. J Addict Med, 2014. 8(8): p.183-8
  12. Peacock, A., et al, Australian Drug Trends 2019: Key Findings from the National Illicit Drug Reporting System (IDRS) Interviews. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney
  13. Kessler, R.C., et al., Screening for serious mental illness in the general population. Archives of General Psychiatry, 2003. 60(2): p.184-189.
  14. Bebbington, P., and Nayani, T. The Psychosis Screening Questionnaire. International Journal of Methods in Psychiatric Research, 1995. 5: 11-19.
  15. Prochaska, J.O., Redding CA, and Evers, K. The Transtheoretical Model and Stages of Change. In Glanz, K, Rimer, B.K., and Lewis, F.M, (Eds) Health Behaviour and Health Education: Theory, Research, and Practice, 2002 (3’” Ed.). San Francisco, CA: Jossey- Bass, Inc.
  16. American Psychiatric Association. & American Psychiatric Association. DSM-5 Task Force 2013. Diagnostic and statistical manual of mental disorders: DSM-5 American Psychiatric Association Arlington, VA
  17. Gossop, M., et al., The Severity of Dependence Scale (SOS): psychometric properties of the SOS in English and Australian Samples of heroin, cocaine and amphetamine users. Addiction, 1995. 90(5); 607-614
  18. McGregor, C., et al., The nature, time course and severity of methamphetamine withdrawal. Addiction. 2005;100(9):1320-9
  19. Newton, T.F., et al., Methamphetamine abstinence syndrome: preliminary findings. The American journal on addictions. 2004;13(3):248-55
  20. Shoptaw, S.J., et al., Treatment for amphetamine withdrawal. Cochrane Database of Systematic Reviews. 2009(2).
  21. Topp, L. and Mattick, R.P. Choosing a cut-off on the Severity of Dependence Scale (SDS) for amphetamine users. Addiction, 1997. 92(7): 839-845.

Acknowledgement

Rodgers, C. Methamphetamine. In: Health pathways South Eastern Sydney, 2018 (Eds). Christchurch (NZ): Stream liners NZ.Available from: https://sesydney.communityhealthpathways.org/

National Centre for Clinical
Research on Emerging Drugs

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