By Lynne Magor-Blatch MAPS
Adjunct Professional Associate - Alcohol and other Drug Work, Mental Health and Forensic Psychology, University of Canberra; and National Convener, APS Psychology and Substance Use Interest Group.
Lynne is the former Clinical Director of the Alcohol and other Drug Foundation ACT (ADFACT) and is now working in private practice and as a consultant to the AOD sector.
The April 1999 edition of InPsych asked the question ‘Drug dependency: social crisis or media hype?'. The cover photograph by Stuart Owen Fox was an adaptation of The Scream by Edvard Munch, illustrated by an array of drugs - licit and illicit - demonstrating our society's dependence and preoccupation with substances.
At the time, the media carried news of worrying overdose rates, discussion of medically supervised injecting places (unfortunately and erroneously referred to as ‘shooting galleries'), zero tolerance (despite the fact that we had in place a Government policy of harm minimisation¹), decriminalisation of cannabis in some jurisdictions and the proposal for a heroin trial in the Australian Capital Territory.
As a policy worker in the ACT at the time, and working to Michael Moore, the Minister who had proposed the trial, I was involved in what was then exciting and ground breaking policy development. In the final analysis the heroin trial did not proceed, nor did all of the proposed supervised injecting places. However, the Sydney Medically Supervised Injecting Centre (MSIC) was established, and some eight years later continues to reduce the harms associated with illicit drug use by supervising injecting episodes that might otherwise occur in less safe circumstances. It is attempting to do what we all strive for in the alcohol and other drug (AOD) field - save lives and provide substance users with information and the opportunity to enter a treatment program when they are ready, recognising that both readiness for change and resistance to treatment are constructs which we need to address.
So nine years on, what are the topical issues in the Australian AOD field? There is currently a great deal of discussion - and often consternation - about young people and drinking, and this is the focus of significant government attention. The Federal Government has also responded to the increased prevalence of comorbidity, or co-occurrence of mental disorders and substance use disorders, with the establishment of the National Comorbidity Initiative. Funding has been provided under the Initiative for a range of projects, particularly within the non-government, community-based AOD sector and principally focusing on amphetamine-type stimulant use. There also remains ongoing discussion about how best to engage people who are using substances with appropriate treatment and assistance. This article will focus on these three topical issues and highlight the role that psychologists can play within the AOD field.
¹Australia's harm minimisation strategy focuses on both licit and illicit drugs and preventing anticipated harm and reducing actual harm.
Professor Ann Roche, reporting in Of Substance in June this year, provides findings from the 2004 National Drug Strategy Household Survey, indicating an increase in risky behaviours for young people 14-24 years of age (Roche, 2008). The Survey found that age of initiation of alcohol consumption has been decreasing. For each successive 10-year generation over the past 50 years, initiation into drinking has occurred at earlier and earlier ages. Therefore, over twice as many young people in the 20-29 year old age group had consumed alcohol by the age of 14 years compared to the 40-49 and 50-59 years old age group. By 18 years of age, approximately 50 per cent of both males and females are risky drinkers. However, the majority (67%) of young risky drinkers classify themselves as ‘social drinkers'. Is this apparent denial of reality a consequence of the ‘bullet proof' attitudes typical of young people, a lack of reliable education and information, or both?
The proportion of 12-15 year olds consuming alcohol at risky levels for short-term harm (at least weekly) increased from 13.2 per cent in 2001 to 17.5 per cent in 2004, and the average number of standard drinks consumed in a session for this group rose from 4.7 to 5.2. In some drinking circles this would seem somewhat trivial, where consumption is reportedly as high as 38 standard drinks (a cask of wine) in a single session. The most popular beverage types for 14-24 year olds are bottled spirits, liqueurs and pre-mixed drinks in cans and bottles, along with regular strength beer for males. Females aged 21-24 also prefer bottled wine. For 12-17 year olds, the most popular types of drinks for both sexes are pre-mixed drinks in a can and bottled spirits and liqueurs. Between 2000 and 2004, there was a three and a half-fold increase in the preference of young female risky drinkers aged 15-17 for spirits. This has led to the ‘alcopops' debate, and specifically the issue of taxation and excise on alcoholic products.
The APS, in a submission to the Commonwealth Government in 2007 prepared by the Psychology and Substance Use Interest Group and the Psychology in the Public Interest team at National Office, provided a number of recommendations, including a volumetric tax (taxation on the alcohol content of drinks) and a low alcohol exemption to all alcohol products under 3.5 per cent. It was further recommended that availability of alcohol should be regulated and funding be increased to targeted education, prevention and treatment strategies, particularly through the direction of funds from excise and taxation. The submission also called for funding for the provision of effective interventions to assist parents and carers to better understand their role in the development and resolution of risk behaviour among young people.
As Professor Roche notes, today's 14-24 year olds were raised by ‘baby boomers' (or their children) who hold substantially less rigid and authoritarian views than previous generations. Modern day parenting is far more relaxed than when the baby boomers were themselves adolescents, often resulting in well-resourced, affluent young people who are used to having their expectations met and for whom instant gratification is commonplace (Roche, 2008). Family structures have also changed significantly. People marry later in life and have fewer children at a substantially older age. The proportion of single-parent families has increased considerably, and many children are today being raised in households where a father has disengaged.
Even for parents who accept that experimentation and risk-taking is the norm and the ‘rite of passage' in moving between adolescence and adulthood, the worrying issue remains: when does experimentation give way to dependence, and what are the consequences? When and how should a parent and others who are significant in the young person's life, intervene? While experimentation with both licit and illicit substances is common among youth populations, early onset or frequent use has been found to be associated with ‘developmental harm', characterised by increased risks for the development of mental health problems, as well as a range of other adverse outcomes, in late adolescence and early adulthood (Lubman, Hides, Yücel & Toumbourou, 2007).
It is generally accepted that rates of substance use are higher among those with mental illness compared to those without, and that people who use illicit drugs are more likely to experience mental illness than non-users. Results from the National Drug Strategy Household Survey 2004 report that almost two in five persons who used an illicit drug in the past month reported high or very high levels of psychological distress. The most common mental health problems experienced by people who use illicit drugs are anxiety and mood disorders. Of particular concern is the association between amphetamine-type stimulants (ATS), cannabis and mental health problems, particularly in young people.
ATS are part of the psychostimulant group of drugs and include meth/amphetamine, ecstasy, cocaine and some pharmaceuticals (such as dexamphetamine and Ritalin). Methamphetamine comes in three common forms: powder (or ‘speed'), methamphetamine base (or ‘base') and crystal methamphetamine (or ‘ice'). The Victorian amphetamine-type stimulants (ATS) and related drugs strategy 2007-2010 Discussion Paper notes that while the use of ATS in the general community remains low, these drugs are now the second most commonly used drugs after cannabis, with 3.2 per cent of the Australian population and 2.8 per cent of the Victorian population aged 14 years and over having used meth/amphetamine for non-medical purposes in the 12 months prior to the survey.
ATS stimulate central nervous system activity, producing a euphoric sense of wellbeing, wakefulness and alertness. Use of ATS is also associated with a range of potentially negative health consequences, including increased heart rate, blood pressure, sleeplessness and reduced appetite. There is also greater risk of mental health issues, aggression, violence and accidents resulting from unsafe behaviours, such as unsafe driving.
While it cannot be implied that cannabis use causes schizophrenia in people who would otherwise not have developed it, there is good epidemiological evidence of a significant association between cannabis use and the risk of meeting criteria for schizophrenia (Degenhardt & Hall, 2002). There is also good evidence to suggest that cannabis use is a more important risk factor for psychotic symptoms among those with a family history of, or pre-existing, schizophrenia (Degenhardt, Roxburgh & McKetin, 2007). Additionally, there is concern regarding the association between cannabis and ATS, especially methamphetamine, with increased admissions of young people to acute psychiatric facilities with apparent psychosis (Degenhardt, Roxburgh & McKetin, 2007).
The number of recorded hospital separations² for people with drug-induced psychosis as the primary problem among those aged 10-49 years increased from 55.5 per million population in 1993-1994 to 253.1 per million population in 2003-2004. Amphetamines accounted for the largest proportion of all drug-induced psychosis separations from 1999-2000 to 2003-2004, ranging from 41 per cent in 1999-2000 to 55 per cent in 2003-2004, while cannabis accounted for 39-45 per cent of separations over this period (Degenhardt, Roxburgh & McKetin, 2007).
The number of both cannabis- and amphetamine-induced psychosis hospital separations per million population was highest among the 20-29 year old age group, while age-specific rates among the 10-19 year old age group were lower for amphetamine-induced psychosis than for cannabis-induced psychosis (41.6-61.9 and 80.5-111.1 separations per million population, respectively). Data collected over this period, also showed that age-specific rates for cannabis-induced psychosis remained relatively stable across all age groups, compared with steady increases for amphetamine-induced psychosis (Degenhardt, Roxburgh & McKetin, 2007). While some of these presentations will remit, others will clarify into diagnoses of schizophrenia (Howard, Stubbs & Arcuri, 2007).
The Australian Government National Comorbidity Initiative aims to improve service co-ordination and treatment outcomes for people with coexisting mental health and substance use disorders and focuses on the priorities of: a) raising awareness of comorbidity among clinicians/health workers and promoting examples of good practice resources/models; b) providing support to general practitioners and other health workers to improve treatment outcomes; c) facilitating and improving access to resources and information for consumers; and d) improving data systems and collection methods within the mental health and AOD sectors to manage comorbidity more effectively. As part of the Initiative, the Commonwealth has provided improved funding to AOD non-government organisation treatment services to develop appropriate systems for working with people with comorbid mental health and substance abuse issues, and to encourage the development of partnerships with wider health networks and workers with specialist training and resources to better identify and treat people.
²Hospital 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.
It is important to note that most people experiencing harmful substance use do not initially attend specialist AOD agencies, but instead may seek no help at all or be engaged with other services within the health, welfare and criminal justice systems. For most, the GP will in fact be the first point of contact. Furthermore, evidence indicates that up to 80 per cent of people who experience drug-related problems resolve these without any treatment (Sobell, Ellingstad, & Sobell, 2000). Consequently, it is essential to recognise the potential for self-initiated change and self-help (Granfield & Cloud, 1999), and the treatment role of a wide range of sectors and professional groups (including psychologists who do not specialise in AOD treatment). People are active shapers of their own change processes, and empowering clients is fundamental to sustainable and ongoing change. A positive therapeutic relationship is a major component of effective psychological treatment.
A wide range of treatment approaches to substance use reflects the diverse and varied factors that are believed to affect its development and maintenance. Recently, the most widely-accepted treatment options have expanded to incorporate approaches based on psychological principles of behaviour change, such as cognitive behavioural therapy and motivational interviewing. There is a large and growing body of research into what constitutes effective treatment.
The diversity of evidence-based treatment options is essential for effective intervention, and is consistent with the principles of harm minimisation. Miller and Hester (1995) advocate an ‘informed eclecticism', defined as openness to a variety of approaches that is guided by scientific evidence. This approach is based upon four central assumptions:
People with co-occurring disorders present most frequently in community settings - especially when families, the judicial system, schools and work places are involved. Therefore at this point of contact it is important that eligibility criteria do not focus on one disorder exclusively (mental health or AOD) and exclude persons with the other disorder (Webster, 2008). This means that wherever the person comes to access treatment, either within an AOD, mental health or primary care setting, that there is an attitude of assistance and respectful welcoming, a policy of ‘no wrong door'. Assessment is a process of engagement, information exchange and feedback, and discussion of treatment options (Magor-Blatch & Rickwood, 2008).
Psychologists are practising and researching in the AOD field in many different capacities and bring skills from a wide variety of specialisations including clinical, counselling, forensic, health and community psychology. Psychologists work within the AOD field in a variety of roles, including:
Psychologists bring to the AOD field a unique contribution in terms of assessment and treatment planning. This may be further enhanced through the use of psychometric testing. As part of a multidisciplinary team, psychologists are able to demonstrate efficacy and effectiveness of interventions. They bring to their roles a non-judgmental approach which is respectful and compassionate, treating the client as an individual, being welcoming, empathic, understanding, and demonstrating respect and active, persistent caring. These are among the trademarks of services that ‘hang on to clients'.
So, have things changed in the AOD field - or do we have more of the same? In 2000, Shane Darke and Wayne Hall reported there was an estimated 74,000 dependent heroin users in Australia, a rate of 6.9 per 1000 adults aged 15-54 years. Three quarters of dependent heroin users were living in NSW (48%) and Victoria (27%) (Darke & Hall, 2000). In 2005, there was an estimated 72,700 dependent methamphetamine users. This represented 7.3 per 1000 population aged 15-49 years, 28,000 of whom lived in NSW - with 14,700 of these people in Sydney (McKetin, McLaren, Kelly, Hall & Hickman, 2005).
Are these essentially the same people, or do we now have more than 140,000 people dependent on opiates and methamphetamines? The likely explanation is that essentially this is the same group (assuming we are seeing attrition, as some people give up dependent use for various reasons, including entering treatment or prison, or in some cases, dying; while at the other end we will see some recruitment of new dependent users). What we understand is that people who are dependent on substances will alter their drug use depending on what is available. Therefore, the methamphetamine user is likely to also be the heroin user.
The prevalence and patterns of substance use are strongly related to a range of factors, and the use of licit substances is by far the most prevalent. However, a worrying trend in substance use is that age of initiation into most types of substance use has decreased (AIHW, 2007). The most recent data from 2004, reveal that the average age of initiation to tobacco and alcohol use among 12-24 year olds is 14.5 years and 14.7 years, respectively. For the most commonly used illicit drugs, the mean age of initiation to cannabis is 15.7 years, and 18 years for amphetamine-type substances.
The other major difference between now and a decade ago is the increased recognition and concerns relating to co-existing mental health and substance use disorders. This has led to a growing body of discussion and research into the efficacy of interventions, treatment, and service delivery. Ironically, for an AOD sector that has spent decades prising itself away from mental health in an attempt to gain recognition and adequate funding to provide evidence-based treatments and a skilled workforce, the current trends in drug use and the resulting increased incidence of mental disorders will force the sectors to once again reassess their relationship, where partnerships, collaboration and integration have become the necessary strategy.
The author can be contacted at firstname.lastname@example.org.
Australian Institute of Health and Welfare (2007). Statistics on Drug use in Australia. Canberra: AIHW.
Darke, S., & Hall, W. (2000). Drug trends Bulletin. Illicit Drug reporting System (IDRS), National Drug and Alcohol Research Centre.
Degenhardt L., & Hall W. (2002). Cannabis and psychosis. Current Psychiatry Reports, 4, 191-196.
Degenhardt, L., Roxburgh, A., & McKetin, R. (2007). Hospital separations for cannabis- and methamphetamine-related psychotic episodes in Australia. Medical Journal of Australia, 186(7), 342-345.
Granfield, R., & Cloud, W. (1999). Coming clean: Overcoming addiction without treatment. New York: New York University Press.
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Sobell, L., Ellingstad, T., & Sobell, M. (2000). Natural recovery from alcohol and drug problems: Methodological review of the research with suggestions for future directions. Addictions, 95, 749-64.
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Webster, I. (2008). The Effective Management of People with Co-occurring Mental Health and Substance Use Disorders. An ADCA Discussion Paper on Policy and Practice.