Crystal Meth (Ice): Myths and Realities

VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities, and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au That!|s upclose.u-n-i-m-e-l-b.edu.au.

SIAN PRIOR
Hello and welcome to Up Close coming to you from Melbourne University, Australia, I!|m Sian Prior. Here in Australia, there has been a wave of recent media interest in the use of the illegal drug, crystal methamphetamine, or !¢FDice!| as it is commonly called. Some have even described it as an epidemic. And Australia is not alone in this. There has also been growing public anxiety about the effects of the drug on users and the communities in the UK, the USA and parts of Asia. In the USA, the most significant federal policy response has been the !¢FDCombat Meth Act!|, signed into effect by President Bush, back in March, 2006. Here in Australia, there have been coordinated national initiatives, to reduce the availability of precursor chemicals used in the manufacture of crystal methamphetamine. According to the Australian National Council on Drugs, almost one in ten Australians have used methamphetamine at least once. And, there are currently over 70,000 regular users; almost double the number of regular heroin users. So, are we really in the grip of an ice epidemic, or has the problem been overstated? Well, to answer this question and to fill us in on the latest research into the use of ice in the Australian community, we are joined today by Associate Professor John Fitzgerald, Principal Research Fellow at the School of Population Health, here at the University of Melbourne, Australia. And, Dr. Frances Bramwell, a medical clinician with many years of experience working in public health with drug users. Dr. Bramwell is also doing post-graduate research here at Melbourne University. Welcome both of you, to Melbourne University Up Close.

JOHN FITZGERALD
Hi Sian.

FRAN BRAMWELL
Thanks Sian.

SIAN PRIOR
Now, John, if we can start with the absolute basics, what is ice and how does it differ from other illegal drugs and in particular other forms of amphetamines?

JOHN FITZGERALD
Ice is methamphetamine. It is a chemical. It acts on the brain. It also acts on other parts of the body; directly on blood vessels and on the heart. It is generally called a stimulant. It stimulates the release of neuro-transmitters. And it generally, in terms of its acute effects, effects that happen straight away, it increases alertness. It increases the capacity for work. It increases your heart rate and it can also create a sense of euphoria, as well.

SIAN PRIOR
And Fran, what effect does ice have on users and how do those effects differ from, say, other illicit drugs such as heroin?

FRAN BRAMWELL
Well, that will depend on the frequency, obviously. And the amount that is used. And, the spacing of that use. So, the more severe, adverse consequences of regular heavy use of, really, any psycho-stimulant relate to things like nutrition, the indirect effects of perhaps injecting, such as blood born viruses But the main concern, is really, in terms of the mental health effects. And, certainly heavy regular use of methamphetamine can have a very deleterious effect on your mental health and the main concern is that it can cause a psychosis-like reaction. So, that can have effects, obviously on themselves and also on those around them.

SIAN PRIOR
And this psychotic behaviour that you describe, is it just in the instant, or are there long term effects on the mental health, that we are starting to see?

FRAN BRAMWELL
Yeah, the long term effects, you need to distinguish between things like psychosis, but fortunately, that is not as common as you might think, and I guess, the more important things for me, are, I guess, are secondary depression and anxiety.

SIAN PRIOR
And, presumably there are consequent effects on family, friends, workmates, of people who are regular users of ice.

FRAN BRAMWELL
Yeah, I think, ice, if you put aside perhaps, the relatively severe violent episodes, what you are talking about are the effects on family and friends of any addiction.

SIAN PRIOR
So, there are no particular differences between the effects on family and friends of regular ice use to say regular heroin use?

FRAN BRAMWELL
There obviously are some differences. Because a person who uses heroin quite functional, while they can continue to get that supply of the opiate, they can actually function okay for a period, until the addiction gets so severe that there whole life is actually revolving around that. Whereas, with amphetamine or any stimulant use, it may be cognitively more difficult to function.

JOHN FITZGERALD
I think the experience, in a number of places around the world, is that people, who use methamphetamine, generally will be using other substances at the same time. And certainly in Australia, what we saw from 2001, was when we previously had a glut in heroin in Australia, which was actually seen in a number of countries around the world, but in 2001, the glut, the supply was reduced and what we saw was a large number of heroin users who actually took up the use of methamphetamines.

SIAN PRIOR
As a cheaper alternative, presumably.

JOHN FITZGERALD
As a replacement. And generally what we see now also, is this movement between substances, amongst a relatively stable population of people. Either people who are disadvantaged or homeless or in some way struggling with the pressures of the world, that they will use a range of substances depending on their availability. And I think that this is one of the issues with methamphetamine around the world that we are struggling with, is that we tend to see it as a new drug, a new epidemic, but essentially, often it is the same population of people.

SIAN PRIOR
John, could you put the ice issue in an international context for us? How does Australia compare with the USA in terms of numbers of users, and with Asian countries where it is popular? You!|ve recently had information about its use in Myanmar, for example.

JOHN FITZGERALD
One of the main production centers for ice and methamphetamines for South East Asia is Myanmar and noticed that the production actually increased around 1998-1999 and peaked 2001 to 2002. What we are noticing in the intelligence reports at the moment, is that the local price of ice and methamphetamines locally in Myanmar is actually going up which is an indicator that availability and production might not be as extensive as it was in the past. So what that would signal to us in Australia and to other parts of South East Asia, is perhaps we have seen the peak of production of ice and that production might be in a much more stable level.

SIAN PRIOR
So, that is production, what about use? How does Australia compare, for example, with the USA, in terms of numbers of users and in particular regular users of crystal meth?

JOHN FITZGERALD
I think this is the critical thing about how we appreciate the methamphetamine crisis around the world. One of the aspects and key characteristics of methamphetamine use is that it tends to be patchy. The population surveys of methamphetamine use, if you look at high school student surveys in the United States in 2005-2006, it showed over a time series of about four or five years that methamphetamine use was very stable and actually wasn!|t going up. But what we were aware of was small-scale studies, small reports that showed in very specific locations that methamphetamine use did go up in certain places. Places like Montana, in Oregon, that they did have large increases in very, very small pockets of users. In Australia, what we have seen is a peak in use, which peaked around 2001-2003. Certainly in terms of population estimates, we know that in 1998, there were 3.7% of the Australian population, based on National Survey data, were regular users of methamphetamines. Now, in 2004, that has actually gone down. In terms of the number of people that have actually died from a methamphetamine related incident, in 2001, nationally, there were 90 deaths in Australia and in 2005 that had gone down to 60. So, what we are seeing in Australia in the last two years is again, this patchy experience, where we know that in Sydney, in New South Wales, that they report increased arrests of people producing methamphetamines. We also know that admissions to emergency departments and pysch institutions for methamphetamine related problems increased in New South Wales. But we are not seeing those changes in different parts of Australia. And certainly, at a national level, all the population data suggests that, in terms of mortality and morbidity, that the methamphetamine so-called epidemic, has not really happened.

SIAN PRIOR
My guests today in Melbourne University Up Close are Associate Professor John Fitzgerald and Dr. Fances Bramwell.
So, John, essentially what you are saying is that, in Australia there is no epidemic of ice use.

JOHN FITZGERALD
Yeah, and it is not to say that ice use is not problematic. We know that there is a proportion of drug users who get into trouble, that actually do become violent at different points in their drug use. And actually, the spectrum of violence and problems associated with ice use is different to that which is associated with other illegal drugs. That is not at issue. What is at issue is whether the extent of use and the extent of problems that are being experienced has changed over time. And certainly most of the indicators would suggest that we are not in the midst of an ice epidemic in Australia. The pressures, as to actually why we think we are, are things we really should talk about. We should talk about it with people like Fran, who are at the coalface, and the people who are actually looking at population data. We should actually be talking about it with people who are in the media, about how readily we accept the notion that there is a new drug epidemic on the basis of very little information and very little evidence. I suppose, this is a great opportunity to actually talk about the role of evidence-based approaches, population based approaches, to actually dealing with some of these problems.

SIAN PRIOR
Well, you mentioned people working at the coalface, such as Fran, we have also spoken recently to a doctor, who works in a clinic in Broadmeadows, which is an economically depressed outer-suburb, of Melbourne, Australia, Dr. Chris Towie is his name. We might just have a quick listen to what Chris has to say about his experiences.

CHRIS TOWEY
Between the alcoholics, the heroin addicts, and the ice users, we have incidents here most days. Probably twice a week, they!|d be violent. Mostly, they!|re verbal. Ice users are not the majority. The majority of problem people are alcoholics. But the severity of the violence with the ice users is the issue. Probably, at the moment, once every three months I get physically assaulted and have to take fairly drastic measures to defend myself. But I!|m a fairly big fellow and I can deal with it. It really troubles me, what happens to other doctors who are less burly and self-confident. The level of violence is so terrifying. The worst attack I had, I really thought I was going to get killed. I was absolutely ready to die. And that was just in the waiting room, in the clinic. I shouldn!|t be feeling like that. And so, it takes on more importance than the alcoholics, who are rarely violent to that degree. But these people are on adrenalin rush !V it!|s an adrenalin rush on steroids, if you like !V they!|re really 'suped' up and they don!|t stop.

SIAN PRIOR
That!|s Dr. Chris Towie, a medical doctor, who has had some experience of dealing with drug users, including crystal methamphetamine or ice users in his clinic in Broadmeadows, an economically depressed suburb of Melbourne, Australia. Fran Bramwell, you also work, as a medical doctor, dealing with drug users, do Chris!|s experiences match yours?

FRAN BRAMWELL
Well, fortunately I can say I haven!|t experienced something like that and I hope that I don!|t. And I think it is really unfortunate when incidences like that happen. We don!|t have enough general practitioners working with drug users. And quite often, these isolated but quite serious incidences do add to GPs!| reluctance to engage with this group of people.

SIAN PRIOR
Well, John mentioned the issue of violence and this is certainly one of the reported effects of regular ice use and one of the things that the media in particular has focused on, that people who regularly use ice, exhibit unusually violent behaviour compared to other drug users. Is this one of the main problems with ice?

JOHN FITZGERALD
Well, the difficulty at the moment, there is a relationship between how we perceive a problem and the intensity of the problem. Because there has been such extensive media coverage of this purported relationship between violence and ice use, what we get now when we talk to service providers, is a reproduction of the messages that the media are portraying. So, when someone walks into the service and they might be agitated or violent, very quickly the service provider says, !!!OOh, they must be on ice.!!L And so, you get this reproduction of the message that is actually communicated in the media, rather than one that is based on evidence and based on good clinical practice. We weren!|t receiving news amongst the service providers of high levels of violence related to methamphetamine use five years ago, when the peak of methamphetamine use was occurring in Australia. We are seeing that now.

SIAN PRIOR
How is that measured? How is it reported? Is it numbers of police attendances, ambulance attendances?

JOHN FITZGERALD
One of the key indicators, that we have in terms of the contribution of stories about ice to the media, are police. We know, absolutely, that the intensity of police operations relating to methamphetamine use has increased dramatically over the last five years. For instance, in 1998, there were 14,000 heroin related arrests in Australia. In 2004, that 14,000 heroin-related arrests, had actually dropped down to 4,000. We also know that in terms of amphetamine related arrests, it actually increased over the same period from about 4,000 to about 10,000.

SIAN PRIOR
But, John, to an outsider, that would sound like evidence that there is a growing problem, an epidemic?

JOHN FITZGERALD
Absolutely, and the problem with that is the assumption that police arrests reflect the natural changes in the drug market. What we do know concretely is that drug arrests are what they call !¢FDdiscovery crimes!|. They!|re not naturally reported each time a drug crime occurs. Drug arrests, are actually a measure of how intense the policing is. It is a discovery crime. So when police stop policing heroin, they actually police amphetamines more. And so that increase in amphetamines arrests is actually more as a result of increased policing, not an increase in amphetamine use.

SIAN PRIOR
And is that increase in policing of amphetamine use, a direct result of particular policy initiatives or government responses to this problem?

JOHN FITZGERALD
No, it is probably what they!|d call !¢FDa displacement!|. It is called a !¢FDcategory displacement!|. If you are arresting people related to heroin use, and heroin use actually goes down, then the policing activity still needs to occur and so they displace their activity to amphetamine use. And so what you see, is actually a displacement of people and resources to start concentrating on amphetamine users and that is why we saw an increase in amphetamine related over this time period.

SIAN PRIOR
Well, Fran Bramwell, you mentioned a little earlier, that one of the things you!|d like to see in response to the issue of ice use is more support for GPs. What kinds of useful responses have we seen from policy makers, from government, from public health authorities here in Australia in the last few years that are actually having an impact?

FRAN BRAMWELL
I don!|t know that the impact has actually been assessed. But there certainly have been some genuine attempts at several different levels. Predominantly around increasing general practitioners!| awareness of the problem with amphetamine use. There was the development of national guidelines for general practice management, and personally I found those very clear and presented in a very reasonable and in a harm reduction framework which I think, is very important.

SIAN PRIOR
And can you give us just a couple of quick examples of what is contained within those, that really helps doctors at the coalface?

FRAN BRAMWELL
Okay, and this, in some respects relates back to the general practioner!|s experience, and it would be important for GPs to actually have some awareness of how to detect someone who might be in some sort of crisis related to amphetamine use. So, for instance, it lists things like, !¢FDthe following signs might indicate the patient has recently used psycho-stimulants, or is moderately to severely intoxicated: clenched jaw, restlessness, agitation, rapid speech, etc, etc!|. And then, just general markers of chronic amphetamine use: poor nutrition, sores. We!|ve all become very, very aware of people that may be need to be seen quicker, and not made to wait an hour because they do so seem to be very agitated. And so, if we do think that someone is really agitated, we would never take that person into a room by ourselves, and we would certainly never take them into a room without a personal alarm on.

JOHN FITZGERALD
One of the really interesting things that Fran!|s service provides and one that is actually being modeled in different parts of the world, is the notion that we have a holistic approach to the drug user. That it is not just a substance-specific approach. That we actually create a support network around the clinician. That involves people who are doing outreach services, who can talk about what is going on in the street environment where people are purchasing the drugs that have a relationship with the police. Certainly that kind of support network, can actually be provided to clinicians that can actually give them the information to allow them to assess the client in a much more holistic way.

SIAN PRIOR
My guests today, in Melbourne University Up Close are Associate Professor John Fitz and Dr. Fances Bramwell.
John, I wanted to ask you also about the production of crystal meth because this term !¢FDhome labs!| keeps coming up. Which creates an image in your mind that there is a whole bunch of people out there in their sheds making their own supply of this drug. Is that the case and what is being done about reducing the supply of materials that you need in order to make this drug?

JOHN FITZGERALD
There has been some really important legislation passed in Australia which has actually been replicated in the United States and in parts of South East Asia, which is called precursor Legislation. The precursors which are used to make methamphetamine have been pretty readily available from a range of sources. And it is actually reducing access to those by creating a licensing system for people who might be using them for a range of industrial or chemical purposes. The kind of volume of precursors that are needed to produce the volumes that methamphetamines that are required to sustain the population of drug users is quite extraordinary. And not a volume that can be sustained through retail sales of cold tablets, which essentially contain pseudoephedrine which is a precursor. We have had a lot of focus on reducing access to pseudoephedrine across pharmacies and chemists. That is not the main source of precursors. It is a 14:1 conversion of pseudoephedrine. So, 14 kilograms of pseudoephedrine are needed to produce one kilo of methamphetamine.

SIAN PRIOR
Industrial quantities.

JOHN FITZGERALD
That!|s right. So, we are actually talking about restricting industrial quantities, rather than retail quantities. And so, in terms of ... internationally, when we are talking about reduction of access to precursors, it!|s actually about access at an industrial level, rather than through a retail level. The other parts of the American response, as part of the Combat Meth Act were probably a good indication of where policy could have been informed by data and by practice, a little bit more effectively. So, for instance, one of the strategies, which is being used in Australia, North America, in Europe and in the UK, is the use of diversion strategies, where, if somebody is caught or arrested for a drug offence, instead of sending them to prison, they actually divert them away from prison and into drug treatment. It is seen to be very cost effective and produces better outcomes in the long term.

SIAN PRIOR
It is a medical approach, rather than a legalistic approach.

JOHN FITZGERALD
Absolutely. But part of the Combat Meth Act was to actually reduce the availability of diversion strategies specifically for methamphetamine users. So, it was actually because of this perception that methamphetamine was a far more pernicious and far more damaging substance that they actually reduced the capacity for methamphetamine users when they were arrested to actually get access to diversion. And the rationale for that was that they believed that methamphetamine users were less amenable to treatment !V which is actually not borne out in the evidence.

SIAN PRIOR
Fran, what!|s your experience of that?

FRAN BRAMWELL
Well, I guess the distinguishing thing is that there is no current pharmoco-therapeutic agent that one can use to assist drug rehabilitation for a chronic amphetamine user.

SIAN PRIOR
In contrast to heroin use, where!Kmethadone is the most commonly!K

FRAN BRAMWELL
Well, now in Australia we have three options of pharmoco-therapy agents. There!|s methadone, which has been around for decades, bupamorphine and more recently a combination of bupamorphine with naltraxone. But that is not to say that there aren!|t other approaches that couldn!|t be used with stimulant users. And there is quite good evidence that even two to four sessions of cognitive behaviour therapy can have quite a dramatic impact.

SIAN PRIOR
So a psychological approach rather than a pharmacological approach?

FRAN BRAMWELL
Yes.

SIAN PRIOR
So, John, from your perspective what are the key policy responses that we need from our legislators, our public health authorities in order to effectively deal with the problems caused by the regular use of crystal meth?

JOHN FITZGERALD
I think Fran has covered some of it already. But I think there are some really concrete things that we can do. In terms of direct service providers, people who are at the coalface, who need to deal with this issue, we need to take seriously their experiences of fear and their experiences of violence. We can!|t just turn around say, !!!OLook, at a population level it!|s not happening, so we just ignore it.!!L I think we do need to take that on and actually skill people up in issues of conflict resolution, skilling clinicians up in how to deal with agitated clients, whether they!|re alcohol users, methamphetamine users or people engaged in domestic violence. We need to have proper assessment procedures, like where people are given time. Time in observation, so that idea that in a service, we actually create an environment where a person can be observed. And to give them time to actually engage with the service in a much more equitable way, rather than being given a number and being told to sit down and wait.

SIAN PRIOR
And Fran Branwell, what about the drug users themselves? Presumably these are the people who can tell us what would help them.

FRAN BRAMWELL
Well, I think we!|ve got very good examples from previous harm reduction success stories in Australia whereby drug users have been intimately involved in, for instance, reducing the risk of HIV transmission amongst drug users, such that we!|ve got an incredibly low rate, compared to other countries like the USA. And that has largely been due to the needle and syringe exchange programme. In any response to concerns about methamphetamine use, it is vitally important to engage the people that are actually affected. So the drug users themselves, in terms of thrashing out the problems, coming up with some designs for research, trialling interventions. Basically involving them as much as possible. Because we can come up with some fantastic ideas, but they really won!|t work unless they!|re acceptable to the group.

SIAN PRIOR
Well, many thanks to both of you for joining us here today. I!|m Sian Prior and my guests have been Associate Professor John Fitzgerald, Principal Research Fellow at the School of Population Health, here at the University of Melbourne, Australia. And, Dr. Francis Bramwell, a medical clinician with many years of experience, working in public health in particular with drug users. Fran is also doing postgraduate research here at Melbourne University. We also heard today from Dr. Chris Towie, a medical doctor who works in the outer Melbourne suburb of Broadmeadows.

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute of the University of Melbourne, Australia. Relevant links, a full transcript and more information on this episode can be found on our website, at upclose.unimelb.edu.au
We also invite you to leave your comments or feedback on this or any episode of UpClose. Simply click in the add new comment link at the bottom of the episode page. This program was produced by Kelvin Param, Eric Van Bemmel and myself Sian Prior. Audio recording is by Dean Collett and the theme music is performed by Sergio Ercole. Melbourne University Up Close is created by Eric Van Bemel and Kelvin Param. Until next time thanks for joining us. Goodbye.

VOICEOVER
You!|ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au, that!|s upclose.u-n-i-m-e-l-b.edu.au. Copyright 2007 University of Melbourne.