Barriers to methamphetamine withdrawal treatment in Australia: Findings from a survey of AOD service providers
Amy E. Pennay BA(Hons), Research Fellow, Nicole K. Lee PhD, Head of Research. Ms Amy Pennay, Clinical Research Program, Turning Point Alcohol and Drug Centre, 54–62 Gertrude Street, Fitzroy, Vic. 3065, Australia. Tel: +61 03 8413 8460; Fax: +61 03 9416 3420; Email: email@example.com
Introduction and Aims. Despite the high prevalence of methamphetamine use and dependence in Australia, withdrawal treatment access for methamphetamine accounts for only 9.3% of total withdrawal treatment presentations. Furthermore, treatment completion for methamphetamine users is one of the lowest of all drugs. There is not a clear understanding for the reasons why methamphetamine withdrawal treatment presentations and efficacy is so low. This study examined the current practices and barriers to methamphetamine withdrawal treatment in Australia. Design and Methods. Twenty-four interviews were conducted with employees from alcohol and other drug services from around Australia. These services were questioned about a range of issues relating to methamphetamine withdrawal treatment including current treatment practices, perception of the effectiveness of current treatment and barriers to treatment. Results. The study found that current practices in the treatment of methamphetamine withdrawal are diverse and uncertain. Service providers identified a great number of barriers to the treatment of methamphetamine withdrawal that encompass personal, social, cultural and organisational barriers. Discussion and Conclusions. The results of this study suggest that alcohol and other drug service providers are not clear about the best way to respond to clients seeking methamphetamine withdrawal treatment. Furthermore, the study showed a general pessimism about withdrawal treatment for this group. Treatment services should consider improving withdrawal protocols, educating clinicians and reconsidering entry criteria to better respond to methamphetamine users who have made the important first step into withdrawal treatment.[Pennay AE, Lee NK. Barriers to methamphetamine withdrawal treatment in Australia: Findings from a survey of AOD service providers. Drug Alcohol Rev 2009]
Australia has one of the highest per capita uses of illicit methamphetamine in the world  with approximately 3% of the population using regularly (in the last 12 months)  and around 11% of regular users dependent on the drug .
Despite the high prevalence of methamphetamine use and dependence in Australia, methamphetamine accounts for only 9.3% of total withdrawal treatment presentations . Furthermore, withdrawal treatment accounts for only 13% of methamphetamine treatment accessed, and treatment completion is one of the lowest of all drugs at approximately 50% [4,5]. The reason for the low rates of withdrawal treatment seeking is unclear, but one possibility is that withdrawal services are not well oriented to meet the needs of methamphetamine users .
Engaging and retaining methamphetamine users in treatment can be difficult due to the nature of withdrawal and relapse . Methamphetamine withdrawal seems to be different from the withdrawal syndromes associated with other drugs, such as opiates and alcohol, which has significant implications for treatment services that are generally better oriented to manage the withdrawal of these other drugs . Furthermore, methamphetamine dependence might be accompanied by complications, such as polydrug use and mental health symptoms that require specific intervention [2,8,9].
Barriers to effective service delivery for illicit drugs users more generally include social stigma, perceptions about treatment effectiveness, accessibility and waiting periods [10–16]. However, methamphetamine users face specific barriers, which include not identifying themselves as ‘hard’ or dependent drug users and being unwilling to mix with heroin users . Klee and Morris  have reported that 65% of current methamphetamine users in the UK perceive treatment as wholly inappropriate.
Much of the previous work on barriers to methamphetamine treatment has been undertaken a decade ago in the UK and primarily from the service user perspective [10,16]. In early work, service providers identified a lack of methamphetamine specific services for methamphetamine users and structured appointment systems that require long periods of planning or waiting as significant barriers . There is little recent research that seeks to understand the barriers to service provision from the worker perspective. Service providers have experience with users who come into treatment and also understand the idiosyncrasies of the service system. Understanding the provider perspective might assist in the development of strategies to improve treatment access.
The current study provides a snapshot of barriers to methamphetamine withdrawal treatment in Australia from the perspective of service providers that might point to potential areas for improvement in service provision. Potential implications for practice and further research are offered.
Twenty-four alcohol and other drug (AOD) treatment workers from agencies across Australia from all States and Territories, and from metropolitan (33%), regional (38%) and rural (29%) areas participated. Thirteen (54%) of the interviewees were female and the average age of respondents was 43 years. They held a range of positions including managerial (29%), clinical leadership (29%) and practitioner (42%) roles in organisations that provided a range of services including counselling, inpatient withdrawal, outpatient withdrawal, residential rehabilitation, ‘pre-hab’ (in between detoxification and rehabilitation) and outreach.
Services were chosen on consultation with members from an Expert Advisory Group (EAG). The EAG consisted of 10 experts in medical and psychosocial aspects of methamphetamine withdrawal from around Australia. Each member of the EAG was encouraged to provide a metropolitan, regional and rural service in their State in order to gain the most comprehensive overview of Australian treatment services.
Semi-structured interviews were conducted with AOD treatment workers over the telephone by the first author. The interviews took approximately 20 min to complete. The interview included questions relating to current procedures and psychosocial and pharmacological practices. There were also open-ended questions exploring attitudes and barriers including the effectiveness of current treatment and challenges and obstacles to working with methamphetamine users. Written notes were entered and analysed using NVivo7 (QSR International, Victoria, Australia), coded by a single coder (first author).
Service provider confidence
Service providers were asked to rate the effectiveness of current methamphetamine withdrawal treatment on a scale of 0–10, where 0 was not at all effective and 10 was highly effective. The mean score was 5.
A range of treatment options exist for withdrawal management. A total of 79% of services incorporated a psychosocial intervention into their methamphetamine withdrawal treatment, 46% offered cognitive behavioural therapy and 54% offered a medicated detoxification. Medication regimes varied considerably between services. Sixteen of the 24 services (67%) reported the use of benzodiazepines for methamphetamine withdrawal. Other medications included paracetamol, quinine and hyoscine butylbromide; and anti-psychotics including olanzapine, pericyazine, haloperidol and chlopromazine.
Just over half of the services (54%) reported using a withdrawal scale to measure methamphetamine withdrawal symptoms. Of the services that reported using a withdrawal scale, four used specific methamphetamine-type scales, whereas the others used scales adapted from heroin or alcohol. There was little consistency with the methamphetamine scales used.
The most commonly cited barrier to withdrawal treatment from the service provider perspective was the behavioural characteristics of methamphetamine users (58% of respondents). Respondents used terms, such as ‘impulsive’, ‘erratic’, ‘aggressive’, ‘agitated’, ‘anxious’, ‘depressed’, ‘exhausted’, ‘lacking motivation’, ‘inconsistent’, ‘unpredictable’, ‘in denial’ and ‘chaotic’ to describe methamphetamine users.
According to one respondent, erratic behaviour at presentation means that they often turn them away initially and ask them to come back when they are in a better state. Another respondent suggested that methamphetamine users have a distinct personality type that conflicts with their tendency to seek and benefit from treatment:
Users don't understand the drug they're taking . . . they are always underestimating their dependence or completely discounting it. The personality of methamphetamine users is a belief in their own control. They do not acknowledge they are out of control.
Issues relating to mental health
A lack of understanding among treatment providers about the complications arising from co-occurring mental health problems was also raised as a significant barrier (50% of respondents). Respondents commented that clinicians with drug and alcohol as well as mental health experience are difficult to find, and another argued that:
Mental health issues complicates things but mental health won't see them because ‘it’s an AOD problem'.
Respondents also commented on poor interagency coordination between drug and alcohol services and mental health services.
Many respondents (42%) commented on the lack of services available for this client group, and number of spaces within services. One rural service commented on there being a 1 week wait for a medical officer and another was frustrated at having a great team of staff, but only four beds. The problem of access creates the problem of waiting lists and as one respondent stated:
Waiting lists are no good for this population, they need treatment immediately or risk being lost.
Nature of the drug and its use
The nature of the drug and its use, which relates to the pharmacological properties of the drug and the difficult nature of methamphetamine withdrawal and high probability of relapse, was cited by 38% of respondents. For example, one respondent suggested that the binge-type pattern of methamphetamine use makes withdrawal complex as users are already accustomed to going days without the drug, and withdrawal then becomes a longer process. Another respondent argued that methamphetamine withdrawal results in loss of pleasure, which immediately detracts from the likelihood of success:
By virtue, dopamine is the chemical affected in this use, so stopping results in massive loss of pleasure and enjoyment for life.
One respondent expressed despair at the nature of methamphetamine use:
With all other drugs, health and mental status improves after the initial hump, but this group after day 3 or 4 just relapse. And they are depressed through and after withdrawal due to messed up serotonin and dopamine levels. It just doesn't work and they know it. It's the only group who I have complete failure with. It exasperates and disheartens me.
Lack of effective pharmacotherapy
A total of 29% of respondents suggested that medication might assist with the behavioural issues of these clients. One respondent also commented that the absence of an approved pharmacotherapy might be influencing how serious methamphetamine withdrawal is perceived by service providers:
The lack of any pharmacological alternative means that the medical profession isn't involved to the same degree which actually defines it as less of a problem.
Related to this was a feeling that many services are still much more focused on other drugs, such as opiates and alcohol, with not enough emphasis on methamphetamine treatment.
Problems with the physical setting
A total of 29% of respondents suggested that more thought needs to be put into the housing arrangements of different groups of drugs users. For example:
Lumping all the clients together is ineffective, there needs to be a separation of opiate/alcohol/methamphetamine clients.
Lack of understanding about ‘what works’
A lack of understanding among treatment providers regarding the most effective withdrawal treatment approach for this client group was also frequently raised as an issue (29% of respondents):
There is a lack of understanding in treatment agencies about how to treat this group. There is sometimes still an ‘old school’ approach that believes it's all psychological and no physiological addiction.
Different approaches between services were also raised as an issue relating to the confusion surrounding ‘what works’.
Negative attitudes of staff
The negative attitudes of AOD workers towards this client group were cited as a barrier to their treatment by 25% of respondents. For example, there was a perceived generational barrier between staff and clients, whereas others suggested that attitudes relating to abstinence were unhelpful. According to one respondent:
Prejudices in the industry are a real problem, as are the traditional values of country GPs.
Other less commonly cited barriers included lack of funding and resources, accessibility to rural services, clients being unaware of what treatment options exist, stigma and judgement associated with accessing treatment, problems relating to poor interagency coordination, inadequate personal case management and follow up and the absence of a unified treatment approach for this group.
The results of this survey of treatment providers stressed a diverse and complex client group and a treatment sector at varying levels of capacity to respond. The results suggest that service providers might not be clear about the best way to respond to clients seeking methamphetamine withdrawal treatment and showed a general pessimism about treatment for this group.
There were a number of barriers to treatment identified in this study. Some were related to drug treatment more generally including lack of funding and resources, limited access to services, lack of awareness regarding treatment options, social stigma, poor interagency coordination, poor case management and inadequate follow up. Such barriers have been identified in other research [10–16].
Others related to practitioner perceptions and practices, which might need modification to better respond and for practitioners to feel more confident in responding to this group. Expectations about withdrawal length might need to be adjusted, for example.
The use of methamphetamine specific withdrawal scales was limited. Bronson et al. noted that a lack of guidelines for effective medication regimes have resulted in an ad hoc approach and the absence of a single recognised protocol means that patient management becomes dependent on individual decisions, with changes occurring between medical practitioners and other workers. From a practitioner perspective some clarity around withdrawal regimes might help to improve optimism about treatment as well as treatment outcomes.
The most commonly cited barrier to withdrawal treatment was the challenging behaviours of methamphetamine users, which reflects a generally negative view about this client group. Many respondents stressed the negative attitudes of other staff as a significant barrier to methamphetamine withdrawal treatment. Better understanding about the nature of methamphetamine withdrawal and associated behaviours is crucial in overcoming the negative attitudes from staff and fostering a more positive relationship between treatment providers and methamphetamine clients.
Similarly, a lack of understanding about ‘what works’ and the perception that treatment is not effective without a specific replacement medication, might influence responses and pessimism to methamphetamine users. The development of more effective pharmacotherapy interventions for withdrawal might serve to both increase optimism among staff about, and attract dependent users into, withdrawal treatment. At the present time, there are no pharmacotherapeutic agents approved for the withdrawal treatment of methamphetamine .
Consistent with Wright et al., practitioners identified having to wait for access to treatment as a significant barrier, as is combining methamphetamine users with other drug users in the same physical space. Furthermore, the high prevalence of mental health issues among this population complicates withdrawal for this client group and is a substantial barrier to effective treatment unless AOD and mental health improve their interagency coordination [8,9].
Overall, a general pessimism among treatment providers about treatment options and treatment outcomes as well as perceptions about the users themselves might be influencing the provision of treatment and what is communicated to users entering treatment.
Although the sample size for this study was small, there was some consistency in response. The study is, however, limited in its scope and does not include the client's perspective. Further research is required into barriers to methamphetamine withdrawal treatment, but in the meantime, services might consider improving withdrawal protocols, educating clinicians and reconsidering entry criteria to better respond to methamphetamine users who have made the important first step into withdrawal treatment.
This study was funded by the Illicit Drugs Section, Drugs Strategy Branch, Australian Government Department of Health and Ageing. The authors would like to thank the treatment services who participated and the members of the project's EAG for their guidance.