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

Methamphetamine (Ice)

A clinical guide for Primary Care Health Professionals

About Methamphetamine

Methamphetamine is a psycho-stimulant drug available in powder, paste or crystallised form.

In 2016, of Australians aged 14 or over who reported using methamphetamine in the previous 12 months, 62% reported using the ‘crystalline’ form (“Ice”) of the drug1 . Methamphetamine is usually smoked or injected and is more likely to be used intermittently rather than daily.

Methamphetamine is a powerful CNS stimulant that can induce feelings of euphoria, alertness, increased confidence and wakefulness. Acute effects can last for 8-24 hours. Continual days of use may cause significant depletion of CNS neurotransmitters, accompanied by depression, excessive tiredness and fatigue.

Did you know?

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

Start the Conversation

People may not initially present to a health practitioner with concerns about their alcohol or other drug use.

Consider screening all clients aged 14 years or older for substance use at their initial presentation/attendance and at least ever 2 years.

You could ask…

As part of my initial assessment, I generally ask all my clients about lifestyle factors 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 comprehensive assessment is vital to identify the most appropriate management.

Understanding the context of your clients’ 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 client:

  • If they currently use, or have ever used pharmaceutical drugs such as opioids or benzodiazepines?
  • Do they have concerns about their alcohol, smoking, medication or drug use?
  • Have they had any problems as a result of their alcohol, smoking, medication or drugs use?
  • Have they ever injected any drugs?
  • 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 they are using? How regularly? When did they last use?
  • At what age did they start using metamphetamine?
  • Have they had any periods of abstinence? If so, were there any precipitating factors that caused a relapse? What interventions or treatments did they use during these attempts?

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 tool4,5

Ask the following…

  • Did you use an amphetamine-type stimulant, or a stimulant medication not as prescribed?

  • Did you use a stimulant at least once each week or more often?

  • 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 client to reflect on the negative effects of methamphetamine use can lead into discussions on level of risk and readiness to change.

Negative effects include but are not limited to:

  • Hallucinations
  • Agitation
  • Sleep problems
  • Teeth grinding
  • Paranoia

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

Positive 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 is associated with tremor, sweating, dilated pupils, agitation, confusion, anxiety, seizures, hallucinations and serotonin syndrome. Chronic CNS hyperstimulation can lead to frequent headaches, tremors, choreiform/aphetoid movements and seizures.

Dermatological

Abscesses and occlusions are common with injecting drug use. Whilst compulsive scratching caused by formication is reported, which can result in skin lesions and cause bacterial cellulitis.

Respiratory

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

Cardiac

Acute Toxicity is associated with narrow-complex tachycardias, palpitation, systemic hypotension or hypertension and dyspnoea. Chronic use is associated with chronic hypertension and cardiovascular diseases, such as myocardial infarction, haemorragic/ischaemic strokes, arrhythmias and angina5.

Hepatic

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 factors associated with drug use, such as malnourishment8, 9.

Sexual Health

Heightened sexual risk-taking is reported10. In women of reproductive age, long-term use of methamphetamine can cause irregular menstruation11, which may result in unplanned pregnancy.

Consider the following

2 Social Situation Assessment

Understanding your client’s social situation is important for engagement and harm reduction, 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 usually 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 their main social support? Are they aware of their drug use? Do they usually use drugs alone or with others?

Have they 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 they ever received treatment or engaged with services about these issues?

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

Are they currently involved with any other services (i.e social services, case management)?

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

3 Mental Health Assessment

Co-morbid mood and anxiety disorders are common with methamphetamine use disorder. However, it is important to gauge whether these are methamphetamine-induced or pre-existing.

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 clients may not define their methamphetamine use as problematic. It is important to determine 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
  • Suggest smoking rather than injecting
  • Discuss safer sex e.g. condoms, lubricant and PrEP
  • Encourage eating at least one meal per day
  • Encourage adequate hydration
  • Warn about the danger of overdose if taking alcohol, opiates and benzodiazepines to help with sleep
  • Encourage them not to drive when using methamphetamine

Overdose Advice

Severe headache, psychotic symptoms; seizures; chest pain; vomiting; overheating; and extreme agitation are some of the signs of a methamphetamine overdose.

Clients 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 advise the client to perform CPR.

Discussing Treatment Options

Amphetamine-type dependence16 is defined as the problematic pattern of methamphetamine use with clinically significant impairment or distress, and 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

Methamphetamine tolerance is needing markedly increased amounts of methamphetamine for the desired effect, and diminished effect with use of the same amount of methamphetamine.

Set realistic treatment goals with your client. 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 dependence.

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 phases: crash; acute phase; and sub-acute18.

Crash
  • Lasts hours to 2-3 days
  • Characterized by: Excessive sleeping, eating and mood irritability
Acute
  • Commences 2 to 4 days after last use
  • Peaks in severity over 7 to 10 days
  • Subsides over 2 to 4 weeks
  • Characterized by: Emotional liability, mood swings, anger, aggression, intense cravings
Sub-Acute
  • Weeks to months
  • Characterized by: Depression/dysphoria, lethargy and cravings

Withdrawal Management

Withdrawal process and treatment options

Withdrawal can usually be managed as an outpatient, however if there are medical or psychiatric co-morbidities (including pregnancy), request inpatient management.

  • Treatment involves withdrawal and continuing care to reduce risk of relapse
  • Withdrawal for psychostimulants can last from 2 to 4 days, up to 2 to 4 weeks
  • Discuss limited use of medications in reducing withdrawal symptoms

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

Notes

No medication has been shown to be effective in treatment of stimulant withdrawal, however medications can assist with short­ term symptom control.

Benzodiazepines should not be prescribed for more than 3 to 7 days due to risk of dependence.

For agitation:

  • Diazepam 5 to 10 mg every 6 to 8 hours for 3 to 7 days.
  • Sedating atypical antipsychotics may have some short-term benefit.

For night time sedation:

  • Temazepam 10 to 20 mg at night for 3 to 7 days, or
  • Oxazepam 30 to 60 mg at night for 3 to 7 days.

To treat psychiatric disorders, consider using antidepressants after initial withdrawal if signs of depression and anhedonia, as these may last months after ceasing stimulant use.

Strategies for coping with methamphetamine withdrawal

Withdrawal can usually be managed as an outpatient, however if there are medical or psychiatric co-morbidities (including pregnancy), request inpatient management.

  • Environment needs to be comfortable and quiet with minimal external stimuli and dim lighting.
  • Provide handouts of links to resources as appropriate
  • Discuss limited use of medications in reducing withdrawal symptoms
    • Anxiety management
    • Sleep hygiene
    • Stress management
  • Healthy lifestyle choices e.g. relaxation, nutrition, rest, exercise
  • Multilingual resources
  • Consider additional supports e.g. counselling support, self-help or peer support groups
  • Arrange follow-up to reassess withdrawal symptoms regularly over a 2 -week period as peak symptoms may appear after a few days of abstinence. Ongoing monitoring and frequency of follow up will depend on severity of withdrawal symptoms.

If not responding to treatment in primary care, consider requesting specialised drug and alcohol treatment.

Ensure tools are in place to prevent relapse

  • Access to support services for rehabilitation
  • Addiction counselling
  • Support groups
  • Residential rehabilitation

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

  • Australian Institute of Health and Welfare 2017. National Drug Strategy Household Survey 2016: detailed findings. Drug Statistics series no. 31. Cat. No. PHE 214. Canberra: AIHW
  • McKetin, R. NDARC Fact Sheet: Methamphetamine, 2016. Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2008_011.pdf
  • 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
  • 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
  • World Health Organisation. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).< Accessed online 24th October 2019 from: https://assistportal.com.au/eassist-lite/>
  • 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.
  • Kamijo, Y., et al., Acute liver failure following intravenous methamphetamine. Vet Hum Toxicol, 2002. 44(4): p. 216-7.
  • Werb, D., et al., Methamphetamine use and malnutrition among street-involved youth. Harm reduction journal, 2010. 7: p. 5-5.
  • Shetty, V., et al., The relationship between methamphetamine use and increased dental disease. J Am Dent Assoc, 201 O. 141 (3): p.307-18.
  • 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.
  • 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
  • NSW Health. Drug and Alcohol Withdrawal Clinical Practice Guidelines. North Sydney: Mental Health and Drug & Alcohol Office, NSW Department of Health, 2008. Available from: http://www1 .health. nsw.gov.au/pds/ActivePDSDocuments/GL2008_011.pdf
  • Kessler, R.C., et al., Screening for serious mental illness in the general population. Archives of General Psychiatry, 2003. 60(2): p.184-189.
  • Bebbington, P., and Nayani, T. The Psychosis Screening Questionnaire. International Journal of Methods in Psychiatric Research, 1995. 5: 11-19.
  • 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.
  • 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
  • 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
  • NSW Health. Psychostimulant Users – Clinical Guidelines for Assessment and Management. North Sydney: Mental health and Drug & Alcohol Office, NSW Department of Health, 2006. Available from: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2006_001.pdf

Acknowledgement

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