Good evening and welcome to our slightly delayed start and to the 262 participants who've joined us for tonight's webinar and the viewers who are watching this podcast. MHPN wishes to acknowledge the traditional custodians of the lands across Australia upon which this webinar, our presenters and participants are located. We wish to pay our respects to the elders past, present and future for the memories, the traditions, the culture and the hopes of Indigenous Australia. Hello, I'm Katherine Bolland and I'll be facilitating tonight's session. I'm a clinical psychologist with expertise in child and family, but not quite in the area that tonight's presentation is, which is methamphetamine use and working collaboratively to manage comorbid mental health and methamphetamine use. Thankfully, this webinar has been provided by the support and funding provided by the New South Wales Ministry of Health and we thank them for that. There's some information there if you'd like some more information about the Ministry of Health. Tonight I'm joined by an expert panel and you can read more about them in detail on the information on the website. I'd like to introduce each of our panelists and tell you a little bit about their background. First of all, I'd like to introduce Associate Professor Adrienne Dunlop. Adrienne is one of those unique individuals that has expertise in both medicine and academia. He has a litany of awards and has been involved in addiction research and medicine for several decades. Adrienne, you've done some other webinars on ICE. Can you tell us why it's such a particular topic of interest for you? I think there's no doubt that we've heard a lot about it, especially over the last year or two. Interestingly, it was one of the first drugs I started to see patients with clinically going back into the early mid-1990s. So some things have changed and some haven't over time, but certainly it's a patient group I've seen over a long period of time. Right. Well, we're looking forward to tapping into your expertise. Next, I'd like to introduce Dr. Grant Sarah, who is a psychiatrist who too has an expertise and interest in the area of ICE. And Grant, you're conducting some studies on the impact of amphetamines and other stimulants. Can you tell us a little bit about the nature of your studies? Sure. I mean, I have a clinical role working with young people with psychosis, and a large proportion of them have had ICE problems. But I think it's one of the areas where large data sets and epidemiology can help show an light on clinical problems, because so many young people who use ICE also use cannabis. And so we've been using New South Wales data and Australian population data to look at and to untangle the effects of amphetamines and cannabis from each other. Yeah. That's absolutely of interest. And some of the participants have already asked us some questions about young people, the use of ICE, and the comorbidities with other substances. So we'll be tapping into your expertise in that area also. All right. I'd now like to introduce Dr. Hester Wilson. Hester is a general practitioner who works at the Langdon Centre amongst other incredible professional accomplishments in the area of addictions, as she's a specialist in addiction medicine. Hester, can you tell us a little bit about the work that you do in general practice? So I work in a general practice setting in metropolitan Sydney as well as in a specialist drug and alcohol setting. But from the primary care point of view that my particular interest in terms of methamphetamine is the fact that we in general practice are seeing patients with methamphetamine issues. But quite often the general practice setting, that's not what they present with. They'll present with other issues and it takes some digging on the part of the clinician to actually work out the role that drug use might be having. And it's an area that is quite important for us in general practice. We see 85% of the population in the year. We have relationships with our patients and this is a group of patients that we are seeing and maybe not picking up on. Yeah. I think that's such an important perspective and the real front line of presentation. All right. Last but certainly not least, I'd like to welcome Professor Amanda Baker who is a clinical psychologist. Amanda, you're a senior research fellow working in the research area of substance use amongst many other things. Can you tell us a little bit about your research work? Yeah. So I work mainly in clinical treatment outcome research. So over the years I've done some work on motivation that you're doing in CBT with people who use methamphetamine and what I want to talk about tonight is how successful that can be and really hope to increase people's confidence in that area because we've had a lot of success with that. That's absolutely great to hear and really segue as well with some of our other expertise on the panel tonight. All right. I'd like to go through a couple of things to ensure that everyone has the most games, the most from the live webinar. So I'd like to all of you to consider the following ground rules. First of all, to be respectful of other participants and panelists and behaviors if this was a face-to-face activity. Please post your comments and questions for the panelists in the general chat box and we'll be following along with those and trying to answer those where we can. If you need help with technical issues and I know there have been a few, if you post in the technical help chat box, just be mindful that all the comments posted in the chat boxes can be seen by all the participants and the panelists. So try to keep those comments on topic and it's fantastic to get your feedback. If that's all too distracting and you'd like to hide the chat, just click the small drop down arrow at the top of the chat box. Your feedback is also very important to us so we really like you to complete the short exit survey which will appear as a pop-up when you exit the webinar. And the other thing is just to be mindful of self-care where if you're dealing with any of the issues that are raised tonight which we understand can be difficult and ensure that you get some support. This is not designed as a personal resource to help you but as a professional platform for a discussion. If you would like some support services or phone numbers, you can access the resource document on your platform for phone numbers of support services. So that in mind, I'd like to turn our attention to some of the learning outcomes for tonight's webinar. First of all, through an exploration of comorbid mental health and methamphetamine use, the webinar will provide you with an opportunity to recognize the clinical effects and harms related to methamphetamine use and comorbid mental health. To increase your skills and understanding of managing methamphetamine users and improve awareness of evidence-based interventions and to identify strategies and to engage specialist services when treating someone using methamphetamine. What we'd like to do now is turn over to Adrian who's going to give us some information from an addiction medicine perspective. Great, thanks Catherine. So you've seen the case and essentially we're going to talk about different elements of it but a young man in rural Australia who has had an escalating pattern of amphetamine use over a period of time and I'm going to pick it up from the moment that he's in the emergency department. So just thinking a little bit about how somebody like Andrew might be managed in the emergency department and understand the majority of you will probably be working in community-based settings, not in hospital settings but I think it's important to have an understanding of what goes on. But the first thing I want to stress is a bad public health message. What happened on the ad that I'm sure everyone's seen run last year about the young boy smashing the chair at the emergency department staff is not the most typical presentation for amphetamine use and it is not what most hospitalers have to deal with but they do have to deal with people from time to time presenting in acutely agitated states. So just quickly to summarise somebody who's methamphetamine intoxicated what will they look like because it's a stimulant, their body's essentially overstimulated. So they won't be able to sit still. If you do their vital signs they'll all be elevated. They'll often look sweaty and have to add pupils and their mental state there's a range of presentations. Grant's going to talk to you a little bit more about some of these in particular but along a spectrum of anxiety, agitation, paranoia, through to delusions, magical thinking, hallucinations and even psychosis. And sometimes this presents by people being socially drawn so they're so paranoid they're not willing to engage with anyone and sometime we'll be presented and they're looking acutely agitated. So fortunately for emergency department staff being aware that people can present like this and need rapid sedation there is a protocol that's been disseminated to all New South Wales hospitals. Not all hospitals are yet using this protocol but there's a strategy to get the information out there so it's available on the New South Wales website. It's the management of cutesphere behavioural disturbance. It can be used for other drugs other than amphetamine could be used for alcohol could be used for other reasons for amphetamine with for intoxicated presentation but essentially it's to assess somebody try to verbally de-escalate them if they'll tolerate old medication then diazepam or arazapam. Generally the first line drugs of choice if somebody wanted to accept oral medication then paratol and repeat dose of up to two doses of 10 milligrams paratol are indicated. And the key issue is not so much the medications but it's having a structured response of somebody is acutely agitated there's a structured response to emergency departments which start switching to gear as they would for other emergency presentations and have a good acute response. In terms of the medical complications there's a number of medical complications some of them are in common the more common ones are certainly injury related to the intoxication state risk of hepatitis in particular or hep B if injecting endocardialis for injecting drug users and then a range of cardiovascular problems seeing this or brain problems hyperthermia is a risk and gastrointestinal problems are a risk to and they're some of the things that would be assessed in an acute setting. The flowchart might be too small to see but essentially it's saying and again this has been developed by Sydney LHD can be can be used by others though it's assessing somebody for signs of acute toxicity if there's acute toxicity you've got a screen and assess it so any of those acute risks that I'm just talking about if there's not then the management is to refer them to our patient drug and alcohol services and essentially counselling is the mainstay there. Amanda will be talking to you more about that so I won't talk too much about counselling interventions. So who else might need to be involved in somebody's care presenting with this sort of presentation to an emergency department clearly Andrew's got some acute mental state problems and that's going to have to be followed up we just talked about drug and alcohol after care counselling being first fine treatment and the other thing that clearly can be need to be managed is Andrew's social and family problems. I've put up the DASIS help number that's a 24 hour a day seven day a week 365 day a year number for health professionals to call 1-800-02-3687 and you're welcome to access that so I'll stop there Catherine. Wonderful thanks Adrian it's an excellent perspective from the emergency department. I should have mentioned earlier that you can find the information about our case study in the resources folder and was also sent to you on registration and so I'd like to now turn to to Dr. Grant-Sara who's going to give us the perspective from the psychiatrist. Thanks very much Catherine and look I think the case history that was provided is a very realistic one and this scenario that you know we certainly often see I'm sure many people on the webinar tonight would recognize so the first thing I was going to discuss was just that link between amphetamine and psychotic symptoms and particularly hallucinations and that's been amphetamines were first marketed in the 30s and the first reports of psychosis really followed on within a year or two but particularly from the 1950s there was quite a literature looking at this and a very interesting series of studies in the 60s and 70s of giving healthy volunteers high doses of amphetamines and finding that for the majority it can induce psychosis if given enough and there's also a large body of research showing high rates of psychotic symptoms usually brief and transient but potentially going on to more enduring psychosis in recreational stimulant users and particularly associated with higher doses higher frequency intravenous use and also with the use of high potency forms like crystal methamphetamine or ice as opposed to others probably one of the mechanisms one of the reasons that amphetamines are such potent triggers of acute psychosis you can see the picture there of amphetamine compared to dopamine and amphetamine is a very strong analog of dopamine which is one of the brain's key neurotransmitters involved in our reward systems hence the pleasure and there was a question on the chat earlier from Vicky Fisher about you know whether there's a relationship between amphetamine dependence and that kind of a rush that we search for and in some ways you know that relationship between with dopamine and the brain's reward systems is probably part of that. So one with a situation like Andrew one diagnosis that will often come up is that idea of drug induced psychosis and I did want to make the point that that idea that there's two very distinct forms of psychosis drug induced psychosis which is sort of benign and other sorts of psychosis which are more serious is probably not well supported by the evidence and certainly there's a reason to be very cautious about a diagnosis of drug induced psychosis it's got poor reliability it's a poor predictor of outcome and a higher proportion of people who have a psychotic episode or even brief psychotic symptoms serious enough to bring them to hospital will go on to have other disorders we did a study in New South Wales looking at more than 7000 people with brief a typical or drug induced psychosis and most of those were drug induced and nearly half went on to have a later admission with a diagnosis schizophrenia so it's really critical not just to look at the individual episode in front of you but the person's broader risk factors and I'll talk more about that in a second moving on to the next slide so instead of that very binary view increasingly psychosis is seen as very much a continuum of disorders that relate to brain development and what's important to understand is the individual combination of risk factors and typically there will be genetic and family risk factors and some evidence of early insult to the brain in its development in utero or in early childhood head injury or psychosocial trauma and evidence in childhood of learning and sensory and motor problems and then psychosis emerging during that critical period of brain development in adolescence and substance has been potentially a great trigger for that so the view of psychosis therefore is a spectrum where up to about 10 to 20 percent of the population might have a broad spectrum of vulnerability to psychosis and that brief psychotic symptoms are common in that in that group so Andrew is by the fact that he's there is automatically in that higher risk group and so it's really critical to then understand what's his unique the other thing that's important is that psychosis are more than just hallucinations and you know while they're a classic and characteristic symptom that that psychosis have many dimensions and different diagnostic systems talk about four or five or even up to eight different dimensions but the hallucinations and paranoia are what's typically called positive symptoms but there's also other symptoms so there's symptoms in a broader psychosis of drive defecting drive and volition symptoms of cognitive problems and symptoms of mood and it's one of the challenges with methamphetamines is that the effect of methamphetamines can mimic and you know appear to cause all of those sorts of problems so if we come back to Andrew then really what are the implications of this for Andrew so I think he needs careful assessment about the broad spectrum of psychotic symptoms that may or may not be there there's a very useful tool that's been widely used in mental health services in headspace called the calms the the clinical assessment of at-risk mental state and that term at-risk mental state is increasingly replacing the idea of pro-drone or psychosis and so it's important to look for the range of symptoms it's important to look for risk factors in the rest of healthcare we increasingly know to look for family history if we're looking at someone's risk of skin cancer or or you know other conditions we it's important to know what their family history is and that's increasingly the evidence is to support that approach also in psychosis and look for those other symptom dimensions not just the positive symptoms corroborative history is critical and you know in that scenario you'd be you'd be keen to talk to his girlfriend Amy you'd be keen to talk to his parents and you'd be really wanting to try and tease out the different possible reasons for his recent decline some of that might be drug effects some of that might be depression or some of that might be the the evolution of an at-risk mental state for psychosis it's critical as well as identifying that to identify his strengths and his supports and his usual strategies for coping some of the studies we've done have shown that amphetamine related psychosis have some of the best outcomes but that's only true if people stop using and so that it's really important to not therefore neglect that this really critical opportunity for intervention and that you know substance use amphetamines and cannabis are one of the few risk factors that you can now modify at that point where Andrew has crossed your path in the health system so it's really important to really focus on assessing and following him up assertively so I'll stop there. Thanks Grant that's a really comprehensive overview and I think there's lots of panel discussion and questions particularly about the link between schizophrenia and drug induced psychosis and some of the pathways which we might get you to comment on a little bit later. All right I'd like to now turn our attention to the primary care response and that of the general practitioner and so I'll leave you over to Dr. Hester Wilson. So I think one of the interesting things for me having seen people that have used schizophrenia for many years has been the sense that things have changed recently that there is methamphetamine which is more common which is which is purer, there's a whole heap of speed up in the media about there being a nice epidemic and while there has been some evidence that perhaps that prevalence of use has increased a little bit there's some reason that's an epidemic isn't an epidemic but one of the things that's interesting is that the individuals who are using it are a bit different to the ones that I would have seen in the past and this is from some work done in 2012 so one of the things about the people that we're seeing and we're seeing them in the primary care setting as well is that they're slightly different groups and there are groups that wouldn't perhaps think of accessing a special drug and alcohol services they're more likely to be employed they see themselves as recreational users they don't see this as harmful they don't use it often and they prefer to see to see GPs or self-trade but the interesting thing is when you look at them they actually are there are real issues for them in terms of they're quite likely to be dependent they are using it more than they they think perhaps and and there is injecting and so people have experienced harm as a result of their use so we've got this disconnect between how people see themselves and the harms that they're coming to and I think that that's one of the things that really drives the whole media frenzy about it's the fact that we are we are seeing people and it does seem to be more of a problem the police are talking about it needy they're talking about it because the nature of the drug has changed the nature of use of the change and the individuals that are using it are slightly different groups sorry just changing the page and we are in the other primary care setting you see it with us and as I said before it is one of the issues this is generally in terms of drug and alcohol use in the primary care setting is that people don't present saying I have a drug and alcohol problem but they're very likely to come for issues like psychological issues, depression, anxiety, fatigue, insomnia, you know withdrawal, dependent, financial issues, personal issues and so it's one of the trickinesses for us in general practice to go beyond what the person is talking about and actually take a history lesson to a drug and alcohol history to really tease out what's going on here. Now the other really interesting thing I think here is that they do come seeking help and they want to be seen by the GTs, they want to be seen by the GTs and they report high levels of satisfaction with being treated in the primary care setting and you can understand this if your person already has a relationship with a general practitioner, if there is a therapeutic alliance there already it's something that we are happy to continue we are seeing as the go-to people for our patients. And once again just this listing the kind of things that people can present with. Now in the case that we've got with Andrew he's presented to the emergency department and as a GP you might work in the rural region area where you are, the doctor in the emergency department in which case you will see this but it's not a common presentation in your surgery or your setting in the community. But as I say it's much more likely to be other things that they're having problems with, whether it be problems with FTIs or viruses or nutrition as we said the psychological stuff, the physical stuff and the other thing is that someone like Andrew it's likely that they might be seen in the emergency department, things settled down, they're sent home and they may well be following up with us in a general practice setting so that the role that we have in the general practice setting is following up with them afterwards and supporting them and helping them to understand that they do have this risk in the symptoms that they've had and helping them to change that. The other thing in terms of us in general practice is that capacity to intervene earlier. So is there a possibility that Andrew might have been seen by a general practitioner that we put it into being early or another really common way that people present in my practice is mum and dad coming or Amy the girlfriend comes in and says I'm really worried this is what's happening, what do I do and that's a really important place to intervene. So I just wanted to from the point of view of general practice just you know the five days that we use in general practice part of the SNAP guide which is Smoking, Nutrition, Alcohol and Physical Activity can be applied in terms of how you talk to your patients about this and this is something that we do in general practice already so it's not rocket science to do with the methamphetamine. There may be some aspects of methamphetamine that us in general practice don't have a great deal of experience with but we can still use this term five days. I think I'll leave it there, I think I might have talked for long enough. Thanks Hester that was great in giving us the insight into the complex presentations to a general practitioner that lead to the assessment that you know one needs to do and it really rings through about how complex the role is that a general practitioner has to undertake. Alright last and certainly not least I'd like to turn over to Professor Amanda Baker who's going to talk to us from the perspective of a clinical psychologist. Thanks Amanda. Hello everyone. So I think what I want to mainly focus on tonight is the importance of the personal relationship in working with people who use methamphetamine. There has been a lot of vilification in the media and I think there's a lot of uncertainty on the part of staff around how best to handle the co-increasing mental health problems sometimes the cognitive issues as well as the substance use problems. So methamphetamine is the drug that kind of brings comorbidity together so it highlights all those issues that are so hard for clinicians and I think it's something that that we work hard to keep skilled in working with say depression, anxiety and substances but if you work in drug and alcohol often you get de-skilled in working with the mental health problems and conversely if you're working in a mental health setting sometimes you get de-skilled in you know working with substance use. So methamphetamine is the drug that you know really brings comorbidity to the fore and I think that is why it gets so much publicity from time to time. So the good news is that counseling is very effective when you look at studies in people who are regular methamphetamine users, counseling interventions are effective and they should be in place of course in conjunction with needle and syringe programs and HIV, anti-viral vitro therapy but it's very important to keep an optimistic attitude because we do know and we've done three randomized control trials in Australia to hear a new castle and those two trials have shown that even two sessions of motivational interviewing and cognitive behavior therapy can be effective and if you do two sessions of CBT that doubles abstinence compared to the control condition but if you do four sessions of CBT, if the person can stay as long as four sessions then they'll have additional benefits and those benefits will be in terms of reduced depression as well. So the longer someone stays in counseling the more benefit we tend to see from the mental health symptoms. There has been another study done by some people in Adelaide and they compared acceptance and commitment therapy with CBT and they found that CBT was actually more effective than acceptance and commitment therapy in terms of methamphetamine. So in the early days that's only one study but we have got a gold standard therapy here in Australia and that treatment manual from that trial is on the Commonwealth website and I urge you to have a look at that and use it. So we've done a recent randomized control trial with young people who have those early sort of at risk symptoms not quite psychosis but some early hints of psychotic symptomatology and we compared a CBT intervention with reflective listening and people were encouraged to come along for at least eight sessions but they could come along for as many as 24 if they wanted to and what we found was that the distress associated with the psychotic symptomatology was actually significantly more reduced by the reflective listening approach. So if someone is coming along to you and they're experiencing these symptoms often the best thing to do is to listen and to show understanding and to use our good clinical skills and certainly the human relationships very very important with methamphetamines is particularly given their tendency to feel a bit paranoid. So the first step is really to use our good counseling skills and then if needed maybe step up to CBT. So there I've got a slide showing what are the good counseling skills being empathic, compassionate. Often there has been some bad press around methamphetamine users so making them feel as so they deserve to be able and have a good counseling relationship being respectful of the person and optimistic about change is really important. So brief CVT can work in terms of methamphetamine used at summarizing there but if you give more sessions in terms of CVT then you'll have a better effect in terms of mental health symptomatology and those are all psychiatric severity. There is a problem with methamphetamine use and relapse as there is with any drug use so that although we have found that in our counseling trials some abstinence can be maintained in the longer term just typically in a clinical scenario people tend to weave in and out of drugs is not only with methamphetamine use but alcohol, panacea and other drugs so it's not just the one treat them once and people abstain forever. So there needs to be a context either ask to care if someone's been in residential rehab or there needs to be some sort of neutral aid attendance whether that's NA or smart recovery or something like that and I think just if you're working in an outpatient setting letting people know that they can come back whether they're continuing to use or whether they're stopped and you know worried that they'll use again so it's very important to help people to improve over the longer term knowing that it might take several change attempts before abstinence or significant reduction is reached. So that's it from me. Wonderful thanks Amanda that was a really a comprehensive overview of the sort of psychological and counseling interventions and I think dovetails are quite nicely in some of the medical treatments that we heard about earlier. I just wanted to ask a couple of questions that people from the panel have been asking and some people already asked us previously and I guess first I'd like to ask either Grant or Adrian to give their perspective about why is it that ICE is so addictive could you talk a little bit about the sort of biological mechanisms of that are you getting a number of questions about that Adrian or Grant? Sure I'm happy to start and happy to hear from you too Grant. There's nothing particularly magical about methamphetamine being addictive tobacco is probably by far the most addictive drug in our country and alcohol is probably not that far behind it but there's a few things that that make a drug I think use more commonly or more problematically by people in our society so one of them is availability and price is part of availability but if a drug's available then people are more likely to use it that's why we make it difficult for young people to purchase tobacco for example. The thing that we've seen in the last few years and we saw it in the 2000s as well with amphetamine we saw it in the 1990s with heroin is if you have a rapid escalation so there's more availability and purity increases as well then it's a perfect storm for there to be increased use and increased harms related to that so it was heroin overdoses in the in the late mid to late 1990s and it's a range of problems including mental health problems related to methamphetamine in the 2010s. Grant say anything you'd like to add? Okay I agree that the sort of broader social and context issues are probably critical does the pharmacology probably helps I mean it gives substances tend to have that component of a very rapid onset of action and that issue that we've already discussed before about the way in which amphetamines you know like some other substances really do tap into the same chemical pathways that are involved in our reward systems so you know it's intrinsically a rewarding drug. Yeah thanks thanks Adrian and Grant that was wonderful. I guess I'd like to now ask Kesta you mentioned earlier some of the sort of presentations that I theaters have in that they're not that they're a certain age group or they're more likely to be employed. Can you tell us a little bit about the types of individuals and the comorbidities that you're seeing from a mental health perspective in general practice? Yeah yeah in general practice I mean certainly we do see people who've had episodes of psychosis and occasionally people will present into general practice so they'll tend to present into the general practice setting with milder symptoms but the other thing as I said before is that we may well see them in follow-up after their presentation in the emergency department. It's particularly in rural regional areas where specialist psychiatric services are seen on the ground it may be that they are settled down in the emergency department and they come out with their letter from the emergency department to their local medical officer so we do see people in that in that time afterwards. I think the other things though that we've seen more commonly is people who are presenting with the high prevalence of mental health conditions like anxiety, low mood, depression but also the interpersonal conflict so not getting on with family. I mean I think as was mentioned before with our case study that he's had this time of decline here you know as an engineering student who's not managing his studies, who's arguing with his family you know what is happening there is this is this part of an unfolding mental health issue that he's trying to treat with his units because he's used them in the past and they made him feel good there's a young man who likes to experiment and so it's I think for us in the general practice setting when we're more likely to see people that have the high prevalence conditions like anxiety and depression or just not coping you know so often in the general practice setting we don't get a full blown psychiatric syndrome but we get people who are not coping not doing well not happy and that's and it's really important in that setting to actually dig down and take that drug and alcohol history to assess whether the drug use is contributing faster. Yeah and and I guess I'll open this up to the rest of the panel. There's been a little bit of a discussion about it. What sort of numbers of people do you see who have also got ADHD who are presenting and are using methamphetamine? That's an interesting one. It is one of the interesting things because of course we know that ADHD is treated with stimulants and are there a group of people out there who are actually self-treating their ADHD with a stimulant or is it the medicalization of drug use you know so that people will get a history of something sounds like ADHD in order to access the drugs. I'd be interested to hear what the other panelists have to say about that. Sure I'm happy to comment. Here's Adrian here. So there's around about 110-120,000 Australians currently prescribed stimulant medication for ADHD. The bulk of those are young people but maybe a third above the age of 16. Methylphenidates the most common drug prescribed with methamphetamines, the second one after that. There's now three controlled trials of treating people with stimulant use disorder and ADHD using stimulants, different stimulants but dexamphetamine as an example and essentially those trials, one of them is with methamphetamine, two of them with cocaine populations. There's a consistent result but in three RCTs so we haven't seen it beyond RCTs at this stage and that's the two things happen. One people's ADHD gets better, surprise, surprise probably not but secondly that their stimulant use seems to decrease as well. So it's an area for further exploration but at this stage not certainly not at the stage where we should say beyond people with comorbid ADHD and stimulant use disorder to be prescribing that. Now it's a difficult area to diagnose and Grant and or Amanda be interested in your thoughts on that but it's a challenging diagnosis to diagnose ADHD in somebody with concurrent stimulant use disorder. Yeah and it's Grant here, I agree with you Adrian, it is extremely challenging and trying to tease them apart. I mean there's been certainly some population studies also looking at whether there has been a rise in the prevalence of psychosis associated with stimulant treatment in ADHD and you know the doses that are being used in therapeutic treatment are in orders of magnitude lower than what people are using in recreational use and it doesn't appear that those lower doses that there's a great increase in risk. Certainly most adult psychiatrists are nervous about prescribing stimulants and I think that sort of research you're talking about is really important but on the whole it's a sort of some specialty within adult psychiatry that some people are willing to and registered to prescribe stimulants and the main concern is the risk of psychosis and you know for people with an established psychotic illness that's a very real risk you know for others that may be less so. Can I just make a comment headed to here? I've certainly had a small number of patients who I've been treating in the drug and alcohol settings who have been opioid dependent, had a history of flexionary use and become clear on the history that it seems like they may have an ADHD that's long-standing from childhood into adulthood and they're really struggling in their lives and I think if there is I understand that many of the people on this webinar are in the drug and alcohol sector it's very easy for us to just kind of say well that's just you know you're a type of stimulant user but in this group of people going through that process and getting them assessed by two consultants, psychiatrists and for a number of them actually getting on to prescribed stimulant treatment has made a huge difference in their lives and just because somebody has like a stimulant disorder doesn't mean that they don't have ADHD as well and I've seen some really good outcomes from that but it takes a very detailed and comprehensive assessment and follow-up and also making sure that they're stable in terms of the drug use before proceeding. Thanks Hester and Adrienne and Grant such an interesting link between methamphetamine use and ADHD which is clearly a complex issue and I think some people are commenting that like a separate webinar on the topic. I just want to turn attention to other comorbidities and Amanda if I can come to you, you use this great phrase that methamphetamines bring comorbidity to the fore. Can you tell us a little bit about that in the sort of therapeutic session and how a clinician might sort of tease out prioritizing treatment, presuming you're engaged with someone in a longer term relationship, how you might tease out what to treat first and what modality? Yes so the short answer is it's best to treat the methamphetamine use either together with the depression or the methamphetamine use first and then the depression but if you just treat the depression alone then you have less of an effect on the methamphetamine use. So often people will say that if you give them a choice which we did in one trial they'll say they really want to work on their depression but when you do that you'll find that the outcome isn't so good so it's really better to offer an integrated approach or to look at reducing their methamphetamine use. It just depends on what they would like to do. There's quite a big improvement it does, there is a delay and people do have this sort of long-standing time where they experience some cognitive deficits and problems with low mood but there is a big improvement as people reduce so they notice that it inspires them to come back for more sessions. I guess I mean the other thing I would like your opinion about Amanda and I'll open this up to the other panelist also thinking a lot of our participants telling us that they're working with young people as young as 12 who are using ICE and I guess I want to hear first from you Amanda about how you might approach a young person how that might be different from the treatment approach with an adult user and then open up to the rest of the panelists to tell us a little bit about the impact of ICE on the developing adolescent brain and any particular considerations with young people and methamphetamine use. Yeah so with our child with people at risk of psychosis they were aged from 12 and it's really very important to establish a good working relationship with people there's no sort of shortcut to that it's really about them feeling as though they can open up and talk with you and you've got a good relationship with them so that relationship is more important really than what you do with people and especially with young people they're they're not going to come back unless you know they think they're being understood and listened to and I think a harm reduction approach is very important with young people that you know if you go in for the same you know they've got to stop using and stop using yeah so good then that's not going to go well you really need to spend time on that relationship and talk with them about reducing the use. And I guess I'll ask some of our other panelists to comment about generally the sort of use of the impact of the use of ICE on the adolescent brain and treatment considerations when when working with young people. So I might jump in first Catherine. Certainly yeah a 12 year old methamphetamine use absolutely there's a very high risk that there's multiple other problems and the methamphetamine use may not even be the most sticky one to try to manage so usually it would need somebody that young multiple clinicians and multiple backgrounds being involved. In terms of effects on the adolescent brain certainly not something that we'd advise is being a good thing there's an enormous study going on in the US the ABCD study which is scanning thousands of young brains seriously over a number of years and will look probably they'll see a lot more on other drugs like cannabis use than amphetamine use and so in the future we'll know more about it. So not something that that's advised but not enough yet to say that there's say the neurotoxicity that we might see with alcohol for example. Could I agree with Adrian emphatically that in that scenario of the 12 year old you'd certainly be concerned about the range of other issues that are probably accompanying that. There's very good evidence looking at cannabis that the age of first use and particularly use early in adolescence is a really strong moderator of the relationship between cannabis use and psychosis and I haven't seen any studies that have looked at adolescent early adolescent amphetamine use in quite that way because it is less common but there'd be every reason to expect that the same would apply it's really about that effect on the brain at those earlier and more critical stages of development. Could I just add something as well as has to hear the issue with the child. So a child's definitely under the age of 14 and one of the things that I would be struggling with that you know Fernanda saying hey you know you really want to have a harm minimization approach and create a therapeutic relationship but at the same time as a mandatory reporter to our family community services that is that is a trickiness in a way for us and you know it's a little bit easier to see our older adolescents but with a child there we do have that that mandatory reporting issue and you're absolutely right that once again it is about it's part of the drug use is the symptom of much broader things going on in that young person's life. So I think it's reasonable to say that the likely effects of trauma in a 12 year old who's using a methamphetamine that's likely you know you'd imagine there's likely lots of trauma involved that's going to have a neurotoxic effect and that's going to be probably a long-term problem for that person. Right all right thanks I mean complex I can hear lots of conversation about the need to work in multi-disciplinary teams and the need for not only acute care in the hospital setting as is the case in our case study with Andrew but really having follow on with the GP or perhaps vice versa and and also with clinicians in the community what are the ways that particularly in remote and rural areas that drug and alcohol workers or GPs can skill themselves and become more confident in working with individuals who are using methamphetamine? Can this webinar? Of course. So the basic skills and Amanda you'll be interested in your take on this too but the basic skills around trying to work with somebody with amphetamine use is no different to alcohol use or tobacco use even the you know principles of motivational interviewing and trying to engage people get them to look at their substance use get them to look at the harms get them to identify what they want to do look at strategies it's it's not particularly complex but what people might not feel comfortable or familiar with is the fact that there's a range of other mental health problems that people present with but again there's a spectrum of severity not everybody's super complex and super severe so you know we'd encourage people to to ask their current patients and more clients and and try to engage in conversations about their substance use. The other important thing to remember is there's also a lot of people out there that use methamphetamine but never have any problems and I think that sometimes we get caught up on GPs you know some people do come to harm but not everybody does sometimes it is the recreational drugs that many people have fun with and it's not an issue for them. Yeah I think I think what is challenging potentially is that people present fairly in a fairly complex way even though as Adrian says fairly basic counseling really helps a lot so lots of people well just most people who use methamphetamine use other drugs as well and if they're experiencing some early sort of psychotic symptomatology if the condition isn't confident in handling that then I think you know people just kind of lack confidence but like Adrian says people do tend to respond to like a general counseling approach and CBT which is mainly focused on the drug use so I think it's just a complexity of the presentation is a challenge and it's hard to communicate how effective counseling is unless you see that through and I think a lot of people are just tempted to refer people on. But once again not everybody is complex you know so once again in the primary care setting we perhaps see a bigger spectrum of people some of whom that their drug use is not a problem for them but I'm coming back to Adrian's point you know I know in talking to other primary care providers that they're concerned I don't know very much about our eyes this is a scary drug I've seen the things on television about people going crazy but it the skills that you use are the same as you use to help you hear their medication to help them lose weight maintain a physical or improve a physical activity lose weight you know stop smoking it's the same basic skills there and yet there are some people who are more complex and in the primary care setting ideally you will have a have connections or have a thorough pathway so that you can refer on to specialist services that can deal with the more complex presentation and that is I think one of the real challenges particularly for people working in rural regional and remote areas that gaining access to those specialist services is problematic they used to be for GPs they used to be GP psych support where you could actually ring up and talk to a psychiatrist if you're seeing someone we don't have that anymore but we do have dancers which is the drug and alcohol specialist advice service and so as a GP or anybody working in New South Wales and there are numbers in other other states as well just in case if you're from a different state listening where you can actually ring enough advice from a drug and alcohol specialist and that is one way of getting advice quite quickly is very responsive but there is a real issue around how do regional and remote practitioners actually improve their confidence and skill up in this area. Great, great thanks Hester. I'll put one more question to the panel and then we'll then it will be time to wrap up. I guess there's been some conversation on the chat about you know the concept of harm minimization versus drug substitution therapy can we have a little bit of could I get your feedback about some of the long-term proposals therapeutically for individuals using methamphetamine. Adrian do you want to talk to that one? Yeah yeah sure sorry. So look certainly in terms of substitution therapy unlike nicotine replacement therapy or buprenorphine or methadone for opiate dependence we don't really have at this stage and even a space medication that we can promote for amphetamine dependence it's one that there's clearly a lot of interest in but for Charles to date have not have not been promising enough. In terms of you know so really our therapeutic strategies are counselling, counselling and counselling. Some people who have high level dependent use need help with stopping the drug, need help with withdrawal. Some people need intensive support to be able to stay off the drug so they need residential support as well. In terms of you know promising interventions on the horizon there's a lot of interest in internet based or smartphone based or other modes of trying to deliver counselling so that's one beyond that you know it's I think still early days. Now I've been with Charles looking at dexamphetamine and the Daphnil but really the results from the trials aren't good. I mean there's certainly been some work looking at using those medications in the come down period after a after a amphetamine binge but once again not great evidence to support the effectiveness. Right that's really state of the nation as it is with treatment I guess at the moment. I guess we've sort of reached the time of night where I'd ask everyone to just give me a little bit of a summary about you know what they've made of tonight's discussion and some of the take home messages for our participants. I'll start with you Adrian. So I guess you know one of the key issues I'm trying to get across is clearly there's the potential for mental health complexities, medical complexities and social many social problems and we haven't probably focused on them beyond the young person scenario but there's many social problems that can be related to methamphetamine use but the key thing I think for attendees to the webinar would be to encourage them to talk to their patients or clients about substance use. As Hester said a number of times still it's not all problematic they're not all the most severe end of the scale and certainly her experience in primary care backs that up so to encourage people to ask their clients or the patients about it and offer support and there's ways of referring even rural areas. We've talked about that a couple of times now and suggest people can use that too. All right I'll now turn over to you Grant can you give us a bit of a summary about the main messages in your presentation tonight and what you've heard. Look I think I've enjoyed listening to the other panelists and to me there's a common theme through a number of the presentations that even though there are some specific things around amphetamines a lot of the approach is really shared broadly it's about good engagement with the person, good assessment trying to maintain a relationship and that really challenging kind of magical part of any treatment which is about trying to motivate people and find the things that help people want to change and make sensible decisions for themselves and it's a challenge in young people with psychosis but it's really a challenge for everyone so and you know that the main take home message for me I guess would be to think broadly about psychosis as a spectrum of disorders and to be really thinking as we would with you know with skin cancer about what's your personal range of risk factors including your... Such an important message and so well expressed Grant I really like that and with the diagram you gave about something I'm going to certainly take away like that and with the diagram you gave about something I'm going to certainly take away from this. All right Hester can you tell us a little bit about your take home messages that you'd like the participants in tonight's webinar to be left with? Yeah I think there's three factors for me that there's a really important part of that non-judgmental approach and really going to where the person is seeing where they're at they may not actually want to stop using but you want to engage with them and make an assessment around well is there use a problem? Is it causing them problems? Is it causing the family problems? Is there some way you can actually intervene and assist in order to reduce their risk and minimize their harm and also that that thing and it's particularly an advantage we have in primary care that we see people over a period of time you know long term many of my patients I've been seeing for longer than I would care to give my age away but it's that ability to have that ongoing engagement you know I'm hearing that you're having these issues I'm hearing that you're using this drug I'm concerned for you I want you to be well please come and see me when you're ready please you know I do want to assist you and keep the door open and be ready to intervene and support and as needed when when when it hasn't really all right thanks Hester that's wonderful and finally over to you Amanda can you tell us a bit of your summary and take home messages from tonight's webinar okay so most important messages I think I've heard tonight from the panel are that most people who use methamphetamine don't experience problems with it if they do experience problems then like Adrian said counseling counseling counseling so do keep that in mind I think it's really important to have some optimism around that we know it works and give it a go. Thanks Amanda that is an optimistic and hopeful message for us all and I think hearing all of you that convergence of sort of medical social psychological overall health perspective and really person focus treatment the onus is on all of us as clinicians and experts in various areas to work collaboratively with one another with methamphetamine people are using methamphetamine particularly with the comorbidities that are brought to the fore as you say Amanda so I would you know spectacularly like to thank all of you for your expertise and input on tonight's webinar from my perspective it's been fantastic I can see that participants have enjoyed your informative presentations and response to the case there's lots of questions that many of you are being asked about specific niche areas based on people's experiences and what they would like to do so thank you again and thank you to our wonderful participants for your encouraging comments for your productive and useful comments and for the questions and interest you've shown in the topic the webinar as you know has been made possible through funding provided by the New South Wales Ministry of Health we would encourage you to fill out the exit survey before you log out it will appear on your screen after the session closes and certificates for attendance for this webinar will be issued within two weeks and you will be sent a link to the online resources which are associated with this webinar within one week so again please fill out the exit survey and you will be receiving those resources. I'd also like to tell you about an upcoming webinar the Department of Veterans Affairs has engaged MHPN to produce a series of six webinars focused on supporting the mental health of veterans the first webinar in the series understanding the military experience from warrior to civilian will be held on Tuesday the 16th of August. I'd also like to encourage you based on some of the discussions and questions that have come up tonight to consider setting up your own special interest network or to enjoy drawing an existing one where there is one in your area and finally before I close I'd like to acknowledge the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present thank you again everyone for your participation and contribution