ATS Treatment Protocol
New Treatment Protocol for Amphetamine-Type Stimulants
ATS Treatment Protocol
Odyssey House McGrath Foundation 2009
AMPHETAMINE‐TYPE STIMULANT USE.
Treatment Protocol in Intervention developed for the use of staff and clinicians working with ATS clients of Therapeutic Communities.
James A. Pitts Chief Executive Officer
Odyssey House McGrath Foundation
September 2009
Introduction
A new treatment protocol has been developed to meet the particular needs of people who are dependent on amphetamine-type stimulants (ATS) and undertaking rehabilitation over several months in a therapeutic community [footnote1] (other forms of ATS treatment are usually much shorter in duration). Amphetamine-type substances are part of the psycho-stimulant group of drugsand include methamphetamine, speed, ice and ecstasy.
ATS users are increasingly presenting to drug treatment services, yet the evidence-base regarding withdrawal and treatment for ATS dependence is limited. ATS use is a unique and complex problem that presents a significant challenge to existing strategies, which in most cases are modelled on opiate and alcohol treatment despite the different physical properties to ATS. There is also a limited range of pharmacotherapies and there is often the compounding need for treatment services to address mental health issues and behaviours associated with ATS use and withdrawal.
The project is the brainchild of Odyssey House CEO James Pitts, who prepared the protocol in collaboration with consultant Clinical Psychologist Lynne Magor-Blatch. It was funded by the Commonwealth Department of Health and Ageing through their National Amphetamine-Type Stimulants Grants Program, established as part of the National Drug Strategy’s ATS Strategy 2008-2011 to enhance the capacity of non-government organisations to respond to the rising demand of users of ATS, particularly in the challenging initial phase of treatment.
The process of developing the protocol involved:
• a literature review of background issues, problems associated with ATS use and current available treatment interventions
•
consultation with National Drug and Alcohol Research Centre (NDARC),
other experts on ATS research and members of the Australasian
Therapeutic Communities Association (ATCA) through forums in Australia and New Zealand
•
the development of a draft protocol, which was trialled in 2009 in two
therapeutic communities (Mirikai at Gold Coast, Qld, and Cyrenian
House, Perth, WA). The feedback from the trials has been positive.
Participants feel they have been greatly assisted in understanding
their dependence upon ATS and have been able to learn useful strategies to help them to cope while in treatment.
A further evaluation of the efficacy and outcomes of the
protocol will be undertaken by Lynne Magor-Blatch as part of a PhD
program through NDARC. Odyssey House staff were involved in the initial consultation and development phases, and Odyssey House residents will be involved in evaluation process.
Mr Pitts presented preliminary details to the European Therapeutic
Communities Conference at The Hague, Netherlands, 2-5 June 2009,
generating significant interest from delegates and requests for copies
of the protocol once released.
The protocol was launched on 16 September at the 2009 ATCA Conference in Canberra by James Pitts, Lynne Magor-Blatch and Professor Margaret Hamilton, executive member of the Australian National Council on Drugs.
Increased ATS dependence
There has been a significant increase in people who have started to use and become dependent upon ATS over the past six to seven years. This has been due to the lack of availability of heroin, which created a vacuum in the drug market that has been filled by ATS.
•
More than 1.4 million Australians (6.3%) have tried meth/amphetamine
over the course of their lifetime, and approximately 500,000 (2.3%)
have used meth/amphetamine in the past 12 months (2007 National Drug Strategy Household Survey).
•
In 2004-2005 there were 15,000 recorded drug treatment episodes for
amphetamine or methamphetamine in Australia (AIHW, 2006). Amphetamines
accounted for the largest
proportion of all drug-induced psychosis hospital separations [footnote 2] from 1999-2000 to 2003-2004, ranging from 41% to 55% respectively (Degenhardt, Rosburgh and McKetin, 2007).
•
Amphetamine-type substances were the primary illicit drug for residents
entering the Odyssey House rehabilitation program in 2008, accounting
for 23 per cent of admissions.
The new ATS treatment protocol is designed specifically for people who are in therapeutic communities where treatment is mid- (3-6 months) to long-term (greater than 6 months) in duration. Other forms of treatment for people dependent upon ATS are usually much shorter in duration and administered in an outpatient setting as a “brief intervention” (2-4 counselling sessions). The protocol has the flexibility to be delivered in a block or as stand-alone sessions.
ATS treatment challenges
Successfully treating people dependent on ATS presents particular challenges:
•
Mental health problems are common among more than half of ATS users:
underlying the ATS use, caused by the ATS use, and/or caused by
withdrawal from ATS. This may result in challenging behaviours that
require more time and specialist attention from staff, and can impact
on the success of treatment
• The majority of ATS users are polydrug users, with the attendant treatment issues this poses
•
Staff report difficulty in engaging and motivating ATS users in
treatment, which may adversely affect up to the first 12 weeks of
treatment.
Mental illness
A large proportion of ATS-dependent users experience psychological problems, including depression, anxiety or psychosis.
While mental illness may be pre-existing, the psychiatric “bible” DSM-IV-TR describes ten amphetamine-related psychiatric disorders due to ATS intoxication or long-term use. Meth/amphetamine intoxication, particularly when alcohol and other drugs are involved, often results in agitation and aggression and impacts on frontline workers and families. Psychotic-like presentations (hallucinations, delusions) at hospital emergency departments and treatment centres are particularly worrying.
In addition, ceasing ATS use may cause psychological problems such as rebound depression, paranoid or suspicious thoughts, agitation, irritability and sleep disorders, which may persist for several weeks (usually 2-6 weeks, but sometimes up to 12 weeks).
Engagement/motivation
In addition to likely psychological issues, many ATS users have disordered thoughts, have difficulty focusing their attention, and generally need additional assistance to help them settle into a treatment environment and concentrate on recovery.
People with ATS dependence may need assistance to recognise they have a problem and the consequences of that problem on them and the people around them. In addition, many ATS users (and drug users generally) feel guilty and ashamed and may not feel worthy or deserving of recovery. It is important to address these issues early in treatment in order for clients to persist with treatment, become motivated to change, and engage fully with their therapy.
Protocol overview
Application
The new ATS treatment protocol is designed for use in therapeutic communities where treatment is usually longer than three months (e.g. Odyssey House). However, the concepts have wider applications in other treatment settings (including other residential treatment environments and outpatient services), both in Australia and overseas.
The protocol focuses on working with clients within a group setting, which is the hallmark of therapeutic community (TC) treatment, but may also be used in individual applications. While designed with ATS users in mind, the protocol may also be useful in treating clients with other drug problems, given the prevalence of co-existing mental health problems among people entering treatment.
Treatment
Due to the prevalence of psychological issues among ATS users, the protocol emphasises the importance of identifying any mental health issues on admission and treating these accordingly, taking into account the combined effect of ATS use and mental illness. The aim is not only to improve the efficacy of treatment, but also to reduce the risk to staff and other clients. Regardless of the results of initial mental health assessments, staff are also advised to be alert for rebound psychological problems, a common side effect of ceasing ATS use.
After initial assessment and screening for mental health
problems, the treatment protocol entails seven therapy sessions to be
conducted in the early stages of treatment:
1. Building motivation for change
2. Understanding and coping with cravings
3. How thoughts influence behaviour
4. Understanding feelings: mind/body connection
5. Learning how to deal with anxious thoughts and feelings
6. Understanding and acknowledging core beliefs and values
7. Relapse prevention
The emphasis on starting sessions soon after admission recognises that although the client has made a commitment to enter treatment, their continuation may be influenced negatively by a number of factors, including removal from the drug scene and possible harm, relaxation of family and court pressure, and, very importantly, the loss of coping mechanisms i.e. the drug use that has previously assisted the person to cope with the issues or situations in their lives that they felt unable to deal with.
The sessions utilise a combination of recognised therapies including:
• cognitive behavioural therapy
• motivational interviewing
• mindfulness-based stress reduction
• mindfulness-based cognitive therapy
• acceptance commitment therapy.
Some techniques would already be known to staff, while others may require further training. To assist staff in facilitating sessions, the protocol package contains an overview of each session and worksheets and tip sheets for use with clients.
For further media information or interviews, please contact:
Carol Moore, Moore Public Relations Tel (02) 9560 2826 or 0402 382 363 Email
James Pitts, Odyssey House Tel (02) 9820 9999 or 0411 144 796 Email
To view the complete ATS Protocol please right click the following links and select 'save as' to download the following PDF files.
ATS Literature Review, Consultations & Trial
Footnotes:
1 The therapeutic community (TC) model is a form of residential
rehabilitation in which clients live and work together as a small
community and actively participate in all aspects of the program to
help
themselves and each other, rather than spending their time alone in a
hospital-like setting. Self-help, responsibility and personal growth
are emphasised. Clients undertake the rehabilitation
process within
a highly structured environment, with treatment and support provided by
professional counsellors and medical staff. In order for personal
growth to replace drug dependency, clients work to change any negative
attitudes and values, confront the reasons they resorted to drug
misuse, and learn strategies for dealing with the ups and downs of
daily life.
2 Hospital separations refer to the reason for a patient's stay in hospital based on their medical records after treatment has been completed, rather than the reason for admission.